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SIGN decision support

Glucose-lowering and glucose-monitoring technologies

Optimising glycaemic control in people with type 1 diabetes (SIGN 170)
Healthcare Improvement Scotland

Make single-hormone closed-loop systems available to all eligible patients

 

Applies to adults, children, and young people

To minimise inequalities in accessing diabetes technologies, clinicians should proactively initiate meaningful discussions with all patients with type 1 diabetes about the suitability of a closed-loop system for their individual circumstances.

 

Single-hormone closed-loop systems should be available to people with type 1 diabetes (paediatric and adult) who:

  • under their current diabetes care plan continue to have suboptimal glycaemic control, a high risk of severe hypoglycaemia, or impaired awareness of hypoglycaemia, or
  • experience diabetes-related distress, measured using a validated tool, that adversely affects their quality of life or ability to manage diabetes, and which is likely to be improved by moving to a closed-loop system.

People who can achieve the desired glycaemic targets using finger prick testing, flash glucose monitoring or continuous glucose monitoring plus multiple daily insulin injections, or flash glucose monitoring plus an insulin pump, should be supported to remain on their current diabetes care plan subject to their circumstances and quality of life. People who are currently using continuous glucose monitoring in combination with an insulin pump (non-integrated) should be offered a closed-loop system, which may provide them with additional clinical benefits at lower costs.

In their discussions, people with type 1 diabetes and clinicians must consider the day-to-day requirements of managing closed-loop systems, for example, responding to alerts or replacing sensors when required. Support on how to use the closed-loop system effectively should be provided to everyone offered the technology.

The Scottish Care Information (SCI)-Diabetes database should be used to collect clinical and person-reported outcomes data from people with type 1 diabetes using closed-loop systems to inform quality of care improvements.

 

 

 

The last decade has seen developments in the functionality of diabetes technologies to optimise glycaemia in people with type 1 diabetes. Ensuring timely access to technologies remains a Scottish Government priority as set out in the Diabetes Improvement Plan. There are undoubted challenges in the implementation of this recommendation due to workforce pressures, staff expertise and funding. Some of the challenges may be overcome by engagement in national procurement processes and the Closed-Loop Systems workstream being developed by the Accelerated National Innovation Adoption team. All healthcare teams involved in care of people with type 1 diabetes are encouraged to ensure they maintain knowledge and experience in all available diabetes technologies.

Diabetes UK has developed a practical guide to promote awareness of, and communication about, psychological problems affecting adults with diabetes. It includes a section on diabetes distress which contains information on formal assessment tools, case studies and tips for supporting affected individuals.

See section on the social determinants of health.

Offer a choice of continuous glucose monitor (CGM) to adults

 

Applies to adults

Offer adults with type 1 diabetes a choice of continuous glucose monitoring based on their individual preferences, needs, characteristics, and the functionality of the devices available. See box 1 for examples of factors to consider as part of this discussion.

 

 

 

Box 1: NICE's criteria to consider in recommending a CGM device:

  • Accuracy of the device
  • Whether the device provides predictive alerts or alarms and if these need to be shared with anyone else (for example, a carer)
  • Whether using the device requires access to particular technologies (such as a smartphone and up-to-date phone software)
  • How easy the device is to use and take readings from, including for people with limited dexterity
  • Fear, frequency, awareness and severity of hypoglycaemia
  • Psychosocial factors
  • The person's insulin regimen or type of insulin pump, if relevant (taking into account whether a particular device integrates with their pump as part of a hybrid closed-loop or insulin-suspend function)
  • Whether, how often, and how the device needs to be calibrated, and how easy it is for the person to do this themselves
  • How data can be collected, compatibility of the device with other technology, and whether data can be shared with the person's healthcare provider to help inform treatment
  • Whether the device will affect the person's ability to do their job
  • How unpredictable the person's activity and blood glucose levels are and whether erratic blood glucose is affecting their quality of life
  • Whether the person has situations when symptoms of hypoglycaemia cannot be communicated or can be confused (for example, during exercise)
  • Clinical factors that may make devices easier or harder to use
  • Frequency of sensor replacement
  • Sensitivities to the device, for example local skin reactions
  • Body image concerns

Note that individuals who do not have access to a compatible smartphone can still use CGM using a device reader.

Offer CGM to all children and young people

 

Applies to children and young people

Offer real-time continuous glucose monitoring (rtCGM) to all children and young people with type 1 diabetes, alongside education to support children and young people and their families and carers to use it. See box 1 for examples of factors to consider as part of this discussion.

 

 

 

 

Box 1: NICE's criteria to consider in recommending a CGM device:

  • Accuracy of the device
  • Whether the device provides predictive alerts or alarms and if these need to be shared with anyone else (for example, a carer)
  • Whether using the device requires access to particular technologies (such as a smartphone and up-to-date phone software)
  • How easy the device is to use and take readings from, including for people with limited dexterity
  • Fear, frequency, awareness and severity of hypoglycaemia
  • Psychosocial factors
  • The person's insulin regimen or type of insulin pump, if relevant (taking into account whether a particular device integrates with their pump as part of a hybrid closed-loop or insulin-suspend function)
  • Whether, how often, and how the device needs to be calibrated, and how easy it is for the person to do this themselves
  • How data can be collected, compatibility of the device with other technology, and whether data can be shared with the person's healthcare provider to help inform treatment
  • Whether the device will affect the person's ability to engage with school or further education.
  • How unpredictable the person's activity and blood glucose levels are and whether erratic blood glucose is affecting their quality of life
  • Whether the person has situations when symptoms of hypoglycaemia cannot be communicated or can be confused (for example, during exercise)
  • Clinical factors that may make devices easier or harder to use
  • Frequency of sensor replacement
  • Sensitivities to the device, for example local skin reactions
  • Body image concerns

Note that children and young people who do not have access to a compatible smartphone can still use CGM using a device reader.

Support people to use the CGM device if there are any concerns

 

Applies to adults, children, and young people

If there are concerns about the way a person is using the CGM device:

  • ask if they are having problems using their device
  • look at ways to address any problems or concerns to improve their use of the device, including further education and emotional and psychological support.

 

 

 

 

Applies to children and young people

If the child or young person is not using their CGM device at least 70% of the time:

  • ask if they are having problems with their device
  • look at ways to address any problems or concerns to improve their use of the device, including further education and emotional and psychological support.

 

 

 

Diabetes care teams are encouraged to review the use of CGM at all consultations and provide support for patients using CGM devices.

  • Ensure people with type 1 diabetes are trained in the use of their chosen CGM device and data interpretation.
  • Support patients with practical issues in wearing CGM devices and assist in troubleshooting (common issues include skin reactions or adhesive problems which may be rectified by barrier creams, secondary dressings etc)
  • Recognise when patients may be struggling, explore reasons and consider further training or psychological support.


Support should be offered by the diabetes care team as part of clinic care or in group education sessions, in person or online.
Diabetes care teams should offer training in the interpretation of CGM data including during the delivery of  structured education programmes on type 1 diabetes. Training can also be in the form of in-person or online group ‘standalone CGM data sessions’ including treatment adjustment discussion and practice.
The CGM industry partners can support clinical teams in delivering technical training in the use of CGM devices.

 

 

See the sections on structured education and psychological and behavioural interventions.

Consider continuation of CGM and/or insulin pumps in hospitalised patients

 

Applies to adults, children, and young people

The continuation of CGM and/or continuous subcutaneous insulin infusion should be considered in hospitalised patients with diabetes without cognitive impairment and ideally with the presence of a family member who is knowledgeable and educated in the use of these devices or with a specialised inpatient diabetes team available for advice and support.

 

 

 

Hospital admission is a challenging time for any individual and their family or carers. There is also a limited understanding amongst most non-specialist staff as to the different types of insulin pumps and CGM. As such, managing diabetes technologies in an inpatient setting requires the individual or their family or carers to operate the device. While support is often available from inpatient diabetes teams, this is not available 24 hours per day in most Scottish hospitals.

NHS Lanarkshire has developed a document to support staff to assess whether it is suitable for a patient to continue using diabetes technology whilst in hospital.