Diabetes patients who are genuinely needle-phobic will be among the few to be given Pfizer's inhaled insulin product Exubera on the NHS.

NICE has just issued its final guidance on the drug, which Pfizer had strongly opposed because it means most diabetes patients will not have access to Exubera.

The company has achieved one small victory, however. NICE had originally demanded that patients be assessed by mental health doctors to decide whether they were truly needle-phobic or not.

NICE has now dropped this stipulation, allowing diabetes patients' own doctors to assess them instead.

Diabetes campaigners say the decision is a sensible one, and will avoid any stigma attached to the psychiatric consultation originally proposed.

The final guidelines say Pfizer's drug can be used for patients who show evidence of poor glucose control despite other treatment options and are unable to inject insulin due to an injection phobia, or who have severe and persistent problems with injection sites.

NICE also states Exubera should only be used for a six-month period - unless there is an improvement in blood glucose control significant enough to reduce the risk of complications.

Exubera costs on average around £1,100 per patient per year, more than double the estimated cost for injected short-acting insulin.

Cathy Multon, care advisor at Diabetes UK, admitted that some doctors might be put off prescribing the drug because of Exubera's high cost.

She said: "I am sure there are many clinicians who might think twice about prescribing it on grounds of cost," but added: "We still believe the potential benefits in reducing the risk of complications for those who delay moving on to insulin to avoid injections still have not been adequately recognised.

"The decision to prescribe Exubera should lie with the individual patient and his or her diabetes specialist."

Multon said the number of clinicians prescribing the drug would not be known until at least the end of the year, when prescription numbers were available. However, Diabetes UK was currently carrying out a number of small surveys of diabetes clinics to try to establish some idea of inhaled insulin prescription patterns.

Dr Kate Lloyd, medical director of Pfizer UK slated NICE last year when it announced its initial decision, calling it "perverse and shortsighted".

Exubera is the world's first inhaled insulin and although not suitable for all kinds of diabetes, analysts have predicted it could reach peak sales in excess of $1 billion globally.

pharmafocus@wiley.co.uk