Intensive insulin therapy today: 'basal-bolus' using multiple daily injections or CSII?

Intensive insulin therapy aiming at normoglycemia in order to prevent long-term complications is not questionable for the management of type 1 diabetes mellitus nowadays. The gold standard mode of insulin therapy in this view is CSII using fast-acting analogues. Whether this reference method can be challenged by MDI using recently available long- and fast-acting analogues remains an open question. Use of fast-acting analogues provides similar benefits on post-meal glucose control either by MDI or by CSII. Long-acting analogues glargine and detemir have shown better effectiveness on basal blood glucose control, including improved stability and reduced occurrence of hypoglycemic episodes, than NPH and ultralente. Reported comparisons between CSII and MDI using glargine have been limited until now. While some of them have shown that CSII allowed both lower HbA1(c) and incidence of hypoglycemia, similar effects have been obtained in other experiences. From present data, it appears that CSII remains the most effective mode of intensive insulin therapy although it may be challenged in patients with stable basal insulin needs. Nevertheless, individual factors seem to be decisional in the choice between CSII and MDI using long-acting analogues, among which patient ability and will to use an insulin pump are critical.