Herts Valleys Clinical Commissioning Group
CONTINUOUS GLUCOSE MONITORING
IN ADULTS AGED 19 AND OVER WITH TYPE 1 DIABETES
Please complete this proforma to provide evidence of consistency with NICE guidance
www.nice.org.uk/guidance/ng17
Date of Referral: …/…/….
Please complete all fields or attach patient sticker
Name of Patient:
D.O.B:
NHS No.
Address
Hospital No.
G.P Name:
G.P Address:
Yes
(tick)
No
(tick)
Comments
NICE recommendation
Do not offer real-time continuous glucose monitoring routinely to adults with
type 1 diabetes.
Consider real-time continuous glucose monitoring for adults with type 1
diabetes who are willing to commit to using it at least 70% of the time and to
calibrate it as needed, and who have any of the following despite optimised use of
insulin therapy and conventional blood glucose monitoring :

More than 1 episode a year of severe hypoglycaemia with no obviously
preventable precipitating cause OR

Complete loss of awareness of hypoglycaemia OR

Frequent (more than 2 episodes a week) asymptomatic hypoglycaemia that
is causing problems with daily activities OR

Extreme fear of hypoglycaemia OR

Hyperglycaemia (HbA1c level of 75 mmol/mol [9%] or higher) that persists
despite testing at least 10 times a day (see recommendations 1.6.11 and
1.6.12).
Continue real-time continuous glucose monitoring only if HbA1c can be
sustained at or below 53 mmol/mol (7%) and/or there has been a fall in
HbA1c of 27 mmol/mol (2.5%) or more.
Version 1.0
September 2016
Herts Valleys Clinical Commissioning Group
YES
(tick)
NO
(tick)
COMMENTS
CGM in pregnancy NICE guidance NG3
Do not offer continuous glucose monitoring routinely to pregnant women
with diabetes.
Consider continuous glucose monitoring for pregnant women on insulin therapy:

Who have problematic severe hypoglycaemia (with or without
impaired awareness of hypoglycaemia) OR

Who have unstable blood glucose levels (to minimise variability)
OR

To gain information about variability in blood glucose levels
If a patient does not meet the criteria above then
funding will be considered on an exceptional basis.
Please provide a clinic letter with descriptive clinical details of exceptionality.
Name of Provider:
CGM Model:
Cost (if available)
PLEASE SUPPLY CONTACT DETAILS TO ENABLE US TO REPLY VIA PHONE/EMAIL OF DECISION MADE.
Name of Consultant:
Signed By Consultant:
Hospital/Trust Name:
OR Name of Specialist Nurse;
Contact Email:
Telephone Number:
Request Date:
Fax Number:
We would expect a re-application for funding after a clinical review
of the appropriateness of this treatment in line with NICE guidance
every 6-12 months
Please send completed forms to [email protected]
Contact IFR Team 01707 369 681
Version 1.0
September 2016