Multiple Daily Injections OR Insulin Pump Therapy: Choosing the Best Option for Your Patient-An Evidence-based Approach.

Achieving optimal glucose control with minimal hypoglycemia and minimizing the impact of diabetes on quality of life are the aims of management of type 1 diabetes. The main therapeutic options for patients include multiple daily injections (MDI) and continuous subcutaneous insulin therapy (CSII). It is important to differentiate fixed dose MDI with more flexible use, based on carbohydrate counting and structured education programmes, often termed functional insulin therapy (FIT), shown to deliver better outcomes. A significant proportion of patients can achieve optimal glucose control with either therapy, and for those who are unable to achieve desired glucose control with MDI, there is a large body of observational data showing CSII enables them to reduce HbA1c and hypoglycemia, with associated improvements in diabetes-related quality of life. However, in many healthcare systems, guidelines restrict the use of CSII on the basis of cost, with only 20-35 % of patients with type 1 diabetes across Europe using CSII. Although data support improved glucose control and quality of life with CSII, we must recognize that insulin pump therapy is not for everyone and has some downsides such as being attached to a device or issues with cannulas. When we sit down with our patients, we have a responsibility to support those patients with the therapeutic strategy that is best suited to them. In this paper, we review some of the literature that informs this decision-making, highlighting areas where CSII offers clear benefits and also some areas where it may not be appropriate.