A Comparison of the Effectiveness of

Multiple Daily Injections vs. Continuous

Subcutaneous Insulin Infusion
Throughout the Lifespan with Persons
with Type 1 Diabetes
Mindy Smith
12/6/12
Type 1 Diabetes Mellitus
Only accounts for about 5% of diabetes cases
Autoimmune destruction of insulin-producing beta
cells of pancreas
Abrupt onset
Exogenous insulin required
Decision of whether to use CSII or MDI is crucial and
must be weighed thoroughly


Centers for Disease Control and Prevention, "National diabetes fact sheet: national estimates and general informaiton on diabetes and prediabetes in the United States," U.S.
Department of Health and Human Services, Atlanta, 2011.
Intensive Therapy
CSII: continuous
subcutaneous insulin infusion
Rapid-acting insulin for
basal and bolus

MDI: multiple daily injections
Rapid-acting insulin for
bolus
Long-acting insulin for
basal

Glycemic Control
Purpose: avoid long-term complications
retinopathy, neuropathy, nephropathy, heart disease,
stroke

Measurement:
HbA1C: hemoglobin A1C 3 month average
Target: <7% for optimal control
Self-monitoring blood glucose
Ideal range: pre-prandial between 90 120 mg/dL

American Diabetes Association, "Diagnosis and classification of diabetes mellitus," Diabetes Care, vol. 33, no. Suppl 1, pp. S62-69, 2010
Diabetes Quality of Life Questionnaire
Questionnaires developed by the Diabetes Control
and Complications Trial Research Group
Pediatric Quality of Life Inventory
Diabetes Quality of Life Youth
Diabetes Quality of Life
Higher score indicates better quality of life
Four subscales: life satisfaction, diabetes impact,
worries about diabetes, and social concerns
Methods

Inclusion Criteria
Type 1 diabetes
Multiple daily injections
Continuous subcutaneous
insulin infusion

Exclusion Criteria
Type 2 diabetes
Gestational diabetes
Pregnancy
Sensor-augmented therapy
PubMed search
Key words:
Type 1 Diabetes Mellitus
Intensive Insulin Therapy
Glycemic Control
Quality of Life

Author Design Length Location Sample
Size
Inclusion
Criteria
Outcome Measures
Opipari-
Arrigan
RCT
Parallel
Arms 6 mo US 18 (16)
T1DM
Very Young
HbA1c, Glucose Variability
Quality of Life
Adverse Events
Nuboer
RCT
Crossover 14 mo Netherlands 39 (38)
T1DM
Very Young
HbA1c
Quality of Life
Adverse Events
Weintrob
RCT
Crossover 7 mo Israel 23
T1DM
8-14 yrs
HbA1c
Quality of Life
Adverse Events
Doyle
RCT
Parallel
Arms 16 wks US 32
T1DM
Very Young
8-21 yrs
HbA1c and BMI
Quality of Life
Adverse Events
Hoogma
RCT
Crossover 8 mo Europe 272
T1DM
Adults
18-65 yrs
HbA1c , Glucose Variability
Quality of Life
Adverse Events
Hanaire-
Broutin
RCT
Crossover 8 mo France 41
T1DM
Adults
21-65 yrs
HbA1c and BMI
Hypoglycemic Events
Satisfaction
L. Opipari-Arrigan, E. Fredericks, N. Burkhart, L. Dales, M. Hodge and C. Foster, "Continuous subcutaneous insulin infusion benefits quality of life in preschool-age children with type 1 diabetes mellitus," Pediatric
Diabetes, vol. 8, pp. 377-383, 2007.
Nuboer, G. Borsboom, J. Zoesthout, H. Koot and J. Bruining, "Effects of insuiln pump vs. injection treatment on quality of life and impact of disease in children with type 1 diabetes mellitus in a randomized,
prospective comparison," Pediatric Diabetes, vol. 9 (Part I), pp. 291-296, 2008.
N. Weintrob, H. Benzaquen, A. Galatzer, S. Shalitin, L. Lazar, G. Fayman, P. Lilos, Z. Dickerman and M. Phillip, "Comparison of Continuous Subcutaneous Insulin Infusion and Multiple Daily Injection Regimens in
Children with Type 1 Diabetes: A Randomized Open Crossover Trail," Pediactrics, vol. 112, no. 3, pp. 559-565, 2003.
D. A. Elizabeth, S. A. Weinzimer, A. T. Steffen, J. A. H. Ahern, M. Vincent and W. Tamborlane, "A Randomized, Prospective Trial Comparing the Efficacy of Continuous Subcutaneous Insulin Infusion With Multiple Daily
Injections Using Inuslin Glargine," Diabetes Care, vol. 27, no. 7, pp. 1554-1558, 2004.
R. M. Hoogma, P. Hammond, R. Gomist, D. Kerr, D. Bruttonmesso, K. Bouter, K. Wiefels, H. d. l. Calle, D. Schweitzer, M. Pfohl, E. Torlone, L. Krinelke and G. Bolli, "Comparison of the effects of continuous subcutaneous
insulin infusion (CSII) and NPH-based multiple daily insulin injections (MDI) on glycaemic control and quality of life: results of the 5-nations trial," Diabetes UK, vol. 23, pp. 141-147, 2005.
H. Hanaire-Broutin, V. Melki, S. Bessieres-Lacombe and J.-P. Taubert, "Comparison of Continuous Subcutaneous Insulin Infusion and Multiple Daily Injection Regimens Using Insulin Lispro in Type 1 Diabetic Patients on
Intensified Treatment," Diabetes Care, vol. 23, no. 9, pp. 1232-1235, 2000.

Results: Children Ages 4-8
8.26
7.66
7.98 7.98
8.39
7.49
8.24
7.97
Opipari-Arrigan CSII Nuboer CSII Opipari-Arrigan MDI Nuboer MDI
HbA1c: No Significant Changes
Baseline Post-Intervention
Results: Children Ages 4-8
64.1
82.5
67.1
78.6
70.6
86.2
67
79.9
Opipari-Arrigan CSII Nuboer CSII Opipari-Arrigan MDI Nuboer MDI
PedsQL: No Significant Changes
Baseline Post-Intervention
Results: Adolescents Ages 9-18
8.1
8
8.2
8.3
7.2
7.9
8.1
8.2
Doyle CSII Weintrob CSII Doyle MDI Weintrob MDI
HbA1C: Significant Change with Doyle CSII (p< 0.02)
Baseline Post-Intervention
Results: Adolescents Ages 9-18
71.9 71.9
74.8
73.5
Doyle CSII Weintrob CSII Doyle MDI Weintrob MDI
DQOL-Y: No Significant Changes
Baseline Post-Intervention
Results: Adults Ages 18-65
8.39
7.65
8.39
7.63
7.98
7.45
8.24
7.67
Hanire-Broutin CSII Hoogma CSII Hanire-Broutin MDI Hoogma MDI
HbA1c: Significant Improvement with CSII
Baseline Post-Intervention
Discussion: Children
CSII has comparable effect to MDI on glycemic control
and quality of life

Only parents completed PedsQL questionnaire
Dependence on adults to make decisions
Stress on caregivers
MDI requires less education
CSII is more expensive
Higher satisfaction with CSII



Discussion: Adolescents
CSII has comparable effect to MDI on quality of life.
Doyle found a significant reduction in HbA1c with CSII.

Type of insulin
Frequent telephone contact with CSII group
Duration of study
Novelty of insulin pump
Concerned with weight gain
Higher satisfaction with CSII


Discussion: Adults
CSII may offer an improvement on glycemic control
and quality of life

Flexibility of eating habits
Adaptability to lifestyle
Greater concern for preventing long-term
complications
Higher Satisfaction with CSII


Discussion
Strengths Weaknesses

Randomized-controlled
trials
Similar findings from
previous reviews
Represent the lifespan

6 articles
No baseline data for QOL
Poor adherence previous to
intervention
Conclusion
Children and Adolescents with Type 1 Diabetes:
CSII has comparable effect to MDI on glycemic control
and quality of life
Higher satisfaction with CSII

Adults with Type 1 Diabetes:
CSII may offer an improvement on glycemic control
and quality of life
Higher satisfaction with CSII
Questions???