This systematic review and economic evaluation on continuous subcutaneous insulin infusion (CSII) provides an assessment of evidence published since the previous NICE appraisal (TA 151) in 2007, taking into account developments in therapies such as the long-acting analogue insulins.
Of the 74 papers used for analysis, there were 8 RCTs of CSII versus analogue-based MDI in either type 1 diabetes mellitus (T1DM) or type II (T2) DM, 8 new (since last NICE appraisal) RCTs of CSII versus neutral protamine Hagedorn (NPH) based multiple daily injection (MDI) in T1DM, 48 observational studies of CSII, 6 studies of CSII in pregnancy, and 4systematic reviews.
The following benefits of CSII were reported:
• Better control of blood glucose levels, as reflected by glycated haemoglobin (HbA1c) levels, with the size of improvement depending on the level before starting CSII.
• Reduction in swings in blood glucose levels, and in problems due to the dawn phenomenon.
• Fewer problems with hypoglycaemic episodes.
• Reduction in insulin dose per day, thereby partly off-setting the cost of CSII.
• Improved quality of life, including a reduction in the chronic fear of severe hypoglycaemia.
• More flexibility of lifestyle – no need to eat at fixed intervals, more freedom of lifestyle and easier participation in social and physical activity; and benefits for the patients’ family.
The main cost of CSII is for consumables, such as tubing and cannulas, and is about £1800 to 2000 per year. The cost of the pump, assuming 4-year life, adds another £430–720 per annum. The extra cost compared with analogue-based MDI averages £1700. Most studies, assuming a reduction in HbA1c level of 1.2%, found CSII to be cost-effective.
The main limitation of the review was the very small number of randomised trials of CSII against the most modern forms of MDI, using analogue insulins, but based on the he current evidence, it was concluded that “CSII provides some advantages over MDI in T1DM for both children and adults. However, there was no evidence that CSII is better than analogue-based MDI in T2DM or in pregnancy.”