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A Review of A Detailed Comparison of Continuous Subcutaneous Insulin Infusion and Multiple-

Daily Injection Treatments on Type 1 Diabetic Children

Jane Student

Fayetteville Technical Community College

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Abstract

A comparison of two different types of insulin therapies in Type 1 diabetic children

revealed more than glycemic control and quality of life through data gathered by many health

care professionals and etymologists in Poland. Treatment involving continuous subcutaneous

insulin infusion (CSII) and multiple daily injections were used to compare glycated hemoglobin

levels (HbA1c) in children with Type 1 diabetes. Hospital visits, acute sickness and HbA1c

levels were documented within a three year span. The associated risk of hypoglycemia (low

blood sugar) and Diabetic Ketoacidosis (severe high blood sugar) in CSII and MDI therapies has

been previously documented but were outdated due to the introduction of new types of fast and

slow acting insulin along with newer models of insulin pumps (CSII). It made the new study

necessary to analyze the risks and benefits of both uses. The new results debunked the previous

consensus of CSII insulin pumps having a higher risk of DKA and hypoglycemia. The new pump

models were documented for comparison and MDI stood relatively the same as it only uses

syringes or pens to insert insulin directly into the bloodstream. Unfortunately there was not

enough variables to fine tune MDI usage to improve HbA1c levels and left this particular therapy

to feel a bit outdated.

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A Detailed Comparison of Continuous Subcutaneous Insulin Infusion and Multiple-Daily

Injection Treatments on Type 1 Diabetic Children

With the accessibility of insulin in the 1920s the once deadly Type 1 diabetes has been

dramatically changed and has improved the lives of millions. It is commonly confused with Type

2 diabetes, a metabolic disease that accounts for over 90% of diabetics (Chase, 2002). Although

the disease itself has not been cured, medical advancements have brought us closer to a future

where diabetes related complications are minimized thus vastly improving the lives of diabetics

(Russell, 2014). Diabetes Type 1 is a chronic condition that causes the pancreas to produce little

to no insulin (Chase, 2002). It was formerly known as insulin-dependent diabetes or juvenile

diabetes. Although it is typically discovered during adolescence and childhood, adults are also

susceptible to the disease. Various factors that cause the disease have made it difficult to find a

cure. These factors range from genetics or an exposure to a certain virus that has not yet been

documented. All factors are part of an ongoing study to find a cure and due to these

circumstances the current priority is HbA1C (also referred to as hemoglobin A1c or simply A1C)

control. For individuals with diabetes this is vital as the higher the HbA1c, the greater the risk of

developing diabetes-related complications (Fendler, 2011). There are two main forms of insulin

therapy that is used to control the persons A1C. Continuous subcutaneous insulin infusion (CSII)

and multiple daily injections (MDI) are forms of therapy that allow insulin to enter the

bloodstream. They have been vastly studied mainly to find the best way possible to treat the

disease to an individual. Both have risks and benefits associated with the treatment but it is

important to focus on the quality care of these patients. As a mother of a Type 1 diabetic I have

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used both treatments on my daughter and although I have personal experience to compare the

different types of insulin therapies, I want more information using a controlled environment with

well documented results to compare my hypothesis to those who have studied the disease for

years.

Methods

Patients were treated with CSII or MDI under a controlled three year study that involved

90% of the Polish population’s diabetic children (Fendler, 2011). The study was supervised by

the Lodz region center’s diabetes epidemiology database and later manually curated. There were

no restrictions to patients and they were given the choice between therapies they or their

guardian saw fit, but were later encouraged to CSII if management or related complications

became an issue. Candidates were encouraged to used CSII as opposed to MDI when faced with

high A1C levels, recurrent hypoglycemia, chronic illness, or willingness to improve their quality

of life. The introduction to CSII for parents or patients that were using MDI allowed them to

choose a different therapy in view of more freedom in their lifestyles and less scrutiny with food

intake to insulin ratios. The CSII patients used insulin pumps manufactured by, Roche, Deltec

and Medtronic using either human or analogues insulin. At the end of the three year study

HbA1c levels, hospital visits and diabetes related illnesses were documented. Other scholarly

journals related to CSII and/or MDI were used to supplement and compare the advancements of

current therapies, even those currently going through a trial period. Current advancements are

focusing on CSII as opposed to MDI although successful A1C control is based on the individual

managing the disease.

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Results

231 CSII and 233 MDI patients were studied and documented for any hospitalizations

due to A1C control, hyperglycemia with diabetic ketoacidosis (DKA) and hypoglycemia (severe

low blood sugar). Assessments were observed solely on age of initial visit. MDI patients saw a

rise in their A1C levels while CSII users had no significant change in their A1C. Hospital visit

rates due to acute causes did not differ between CSII and MDI treated patients as well as the

average duration of their stay although those treated with CSII had significantly less total

hospitals visits annually. CSII offered better metabolic control but did not translate into the risk

of future hospitalizations. Although earlier studies suggested that CSII added an additional risk

to hypoglycemia or DKA (Nathan, 1982), current studies show no difference between those

therapies. As the study progressed, some patients using insulin pumps added more challenging

approaches like the dual wave bolus, but the effects of the combinations was not studied and the

factor was refrained from the CSII group.

Discussion

The study gave me sufficient evidence that shows CSII therapy is beneficial to those

suffering from Type 1 diabetes. It has become more common and is now the standard of

treatment for young children recently diagnosed (Nabhan, 2008). It proved that CSII is a safe

form of intensive insulin therapy with similar A1C glycemic effects as MDI users have, but a

significantly lower rate of Hypoglycemia and DKA even with a lower insulin requirement. Even

though it is common and almost expected for diabetic patients to increase their insulin dosage

(Jakisch, 2008) the CSII patient’s dosage remained significantly less than MDI users. Although it

can be argued that the use of dual wave boluses and changes in pump settings to fine tune their

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insulin needs changed the results in favor of CSII pumps, there was not enough documentation

and evidence to make a conclusion based on this particular study. Using other resources further

proved the advancements of pump therapy are on the rise and MDI cannot be completely

eliminated as they are used by CSII pump users in an emergency in case their pump malfunctions

(Chase, 2002). New ways of CSII are being tested at this moment in the form of a bionic

pancreas and being introduced through trials and controlled studies (Russell, 2014) but have not

been used in unrestricted outpatient conditions. The bionic pancreas would have been a great

supplement in favor of CSII, showing glycemic improvement even compared to CSII insulin

pumps (Russell, 2014), but could not be included in the study without further studies and

approval for public use. There was also a comparison to past uses of CSII using an older model

of insulin pumps that were too big and complex to use in an uncontrolled setting (Nathan, 1982).

It was often discussed amongst experts if these forms of therapy were vital to the discussion of

insulin therapy advancement (Rizza, 1986). It has become apparent to me that CSII is here to

stay and new medical advances are making room for a higher quality of life to diabetics and

reduced complications caused by this horrible disease.

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References

Chase, H. (2002). Understanding diabetes (10th ed.). Denver, Colo.: Barbara Davis Center for

Childhood Diabetes, University of Colorado Health Sciences Center:.

Fendler, W., Baranowska, A. I., Mianowska, B., Szadkowska, A., & Mlynarski, W. (2012).

Three-year comparison of subcutaneous insulin pump treatment with multi-daily

injections on HbA1c, its variability and hospital burden of children with type 1

diabetes. Acta diabetologica, 49(5), 363-370.

Jakisch, B. I., Wagner, V. M., Heidtmann, B., Lepler, R., Holterhus, P. M., Kapellen, T. M., ... &

Holl, R. W. (2008). Comparison of continuous subcutaneous insulin infusion (CSII) and

multiple daily injections (MDI) in paediatric Type 1 diabetes: a multicentre matched-pair

cohort analysis over 3 years. Diabetic Medicine, 25(1), 80-85.

Nabhan, Z. M., Kreher, N. C., Greene, D. M., Eugster, E. A., Kronenberger, W., & DiMeglio, L.

A. (2009). A randomized prospective study of insulin pump vs. insulin injection therapy

in very young children with type 1 diabetes: 12-month glycemic, BMI, and

neurocognitive outcomes. Pediatric diabetes, 10(3), 202-208.

Nathan, D. M., LOU, P., & AVRUCH, J. (1982). Intensive conventional and insulin pump

therapies in adult type I diabetes: a crossover study. Annals of internal medicine, 97(1),

31-36.

Rizza, R. A. (1986). New modes of insulin administration: do they have a role in clinical

diabetes?. Annals of internal medicine, 105(1), 126-129.

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Russell, S. J., El-Khatib, F. H., Sinha, M., Magyar, K. L., McKeon, K., Goergen, L. G., ... &

Damiano, E. R. (2014). Outpatient glycemic control with a bionic pancreas in type 1

diabetes. New England Journal of Medicine, 371(4), 313-325.