Objective: To review the effectiveness of multiple daily injections versus continuous

subcutaneous insulin infusion in children, adolescents and adults with type 1

diabetes, as measured by glycemic control, quality of life, and satisfaction.
Methods: A broad search of English language research articles was conduction in
PubMed. Further articles were found from paper citations and systematic reviews.
Results: Six articles were chosen, all of which were randomized controlled trails. For
children and adolescents, four studies found no difference in the effect of CSII and
MDI on HbA1c and overall quality of life scores; however at the end of the studies
they chose CSII by preference. For adults, two studies found CSII to have an
improved effect on HbA1c and overall quality of life scores. At the end of the
studies, the adults chose CSII by preference.
Conclusions: For children and adolescents with type 1 diabetes, CSII has comparable
effects to MDI on glycemic control and quality of life; however it has a higher level
of satisfaction which leads to patient preference of CSII as a treatment option. For
adults with type 1 diabetes, CSII may offer an improvement on glycemic control and
quality of life when compared with MDI. It also has a higher level of satisfaction,
which leads to patient preference of CSII over MDI.

Author

Study
Design

OpipariArrigan

RCT
Parallel
Arms

Nuboer

RCT
Crossover

Weintrob

RCT
Crossover

Doyle

RCT
Parallel
Arms

Hoogma

RCT
Crossover

HanaireBroutin

RCT
Crossover

Study Design Characteristics

#
Included
Particpant Populatio
Duration
Location
s
n

6 mo

14 mo

7 mo

16 wks

8 mo

US

Netherlands

Israel

US

Europe

18 (16)

39 (38)

T1DM
Very
Young

23

T1DM
8-14 yrs

32

272

Background: In type 1 diabetes, glycemic control is of the upmost importance

because uncontrolled diabetes is associated with long-term complications such as
retinopathy, neuropathy, nephropathy, heart disease and stroke. All of which
contribute to the morbidity and mortality of the disease.
Objective: The purpose of this review is to examine which method of intensive
therapy, CSII or MDI, has the best glycemic control, as measured by A1C, and quality
of life and if these results are the consistent throughout the lifespan.
Design: A broad search of English language research articles was conduction in
PubMed. Further articles were found from paper citations and systematic reviews.
Inclusion criteria comprised of intensive therapy that consisted of only multiple daily
injections and continuous subcutaneous insulin infusion, and populations included
only persons with type 1 diabetes. Exclusion criteria comprised of type 2 diabetes,
gestational diabetes, pregnancy and comparisons of sensor-augmented therapy with
self-monitoring blood glucose. Key words included: T1DM, MDI, CSII, adults,
pediatrics, children, and adolescents.

8 mo

France

T1DM
Very
Young

41

Population

Exclusion Criteria

Interventi
on, n

T1DM history < 1yr serious

med. condition sig. develop. CSII, 9
delay psychiatric illness
MDI, 9
HbA1c < 8.0%
age < 4 or > 16 , mental
retardation, chronic
complications , pysch
CSII, 20
problems
MDI, 19

unable to cope w/
procedures
HbA1c > 11%
HbA1c
T1DM < 6.5%
Previous Use
Very
of Pump
Serious Med
Young Condition Unwilling to Test
8-21 yrs
BG 4x/D
No Contraception Used
Hypoglycemia Unaware.
Progressive Retinopathy
T1DM
Renal Insufficiency
Adults
Uncontrolled HTN
18-65 yrs
Autonomic Neuropathy
HbA1c > 10%
not
current CSII or MDI
Untreated Retinopathy
Impaired Renal Function
Gastric Neuropathy
BMI
T1DM > 30
Hypglycemia
Adults
Unaware.
Severe
21-65 yrs
Disease

Age (yrs)
Male %
CSII: Mean 4.4
62
MDI: Mean 4.4
50

Outcomes

Baseline HbA1c %

Baseline BMI

Duration Diabetes

Duration of
Therapy

CSII: Mean 8.26

MDI: Mean 7.98

CSII: Mean 17
MDI: Mean 15.9

NR

6 mo

Results
CSII: HbA1C: B: Mean 8.26 (SD 1.37) / F: Mean 8.39 (SD 0.83) /
F-B: 0.13 / CSII-MDI: -0.9 QOL: Satisfaction:
MDI: HbA1C: B:Mean 7.98 (SD 0.76) / F:Mean 8.24 (SD 0.4) / P:
NS / F-B: 0.26
QOL: Satisfaction:

NR

CSII: Mean 5.6

MDI: Mean 4.7

14 mo

CSII: HbA1C: B: Mean 7.66 (SD 0.56) / F: Mean 7.49 (SD 0.5) /
F-B: -0.17 / CSII-MDI: -0.16
QOL: Satisfaction:
MDI: HbA1C: B: Mean 7.98 (SD0.57) / F: Mean 7.97 (SD 0.78) /
F-B: -0.01
QOL: Satisfaction:

NR

CSII: Mean 5.3

MDI: Mean 6.3

3.5 mo

HbA1C: QOL: Satisfaction:

16 wks

HbA1C: QOL: Satisfaction:

CSII, 11
MDI, 12

CSII: Mean 10
35
MDI: Mean 10
52.6
CSII: Mean 11.9
36
MDI: Mean 11.6
50

CSII, 16
MDI, 16

CSII: NR
38
MDI: NR
50

CSII: Mean 8.1

MDI: Mean 8.2

NR

CSII: Mean 6.8

MDI: Mean 5.6

CSII, 127
MDI, 129

CSII: NR
48
MDI: NR
47

CSII: Mean 8.2

MDI: Mean 8.3

CSII: Mean 24.8

MDI: Mean 24.9

CSII: Mean 15.4

MDI: Mean 14.4

6 mo

HbA1C: QOL: Satisfaction:

CSII, 41
MDI

Mean: NR
51

CSII: NR
MDI: Mean 8.39

NR

NR

4 mo

HbA1C: QOL: Satisfaction:

CSII: Mean 7.66

MDI: Mean 7.98

CSII: Mean 7.9

MDI: Mean 8.6

For children and adolescents with type 1 diabetes, CSII has comparable effects to MDI on glycemic control and quality of life; however it has a higher level of
satisfaction which leads to patient preference of CSII as a treatment option. For adults with type 1 diabetes, CSII may offer an improvement on glycemic control and
quality of life when compared with MDI. It also has a higher level of satisfaction, which leads to patient preference of CSII over MDI.

Main outcome variables:

Glycemic control
Quality of life
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.
R. 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.

Children and Adolescents: four studies found no difference in the effect of CSII and
MDI on HbA1c and overall quality of life scores; however at the end of the studies
they chose CSII by preference.
Adults: two studies found CSII to have an improved effect on HbA1c and overall
quality of life scores. At the end of the studies, the adults chose CSII by preference.

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.