biocybernetics and biomedical engineering 36 (2016) 18

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/bbe

Review Article

Treatment of patients with type 1 diabetes Insulin

pumps or multiple injections?
Janusz Krzymien a, Monika Rachuta a, Iwona Kozlowska a,
Piotr Ladyzynski b,*, Piotr Foltynski b
a
b

Clinic of Gastroenterology and Metabolic Diseases, Medical University of Warsaw, Warsaw, Poland
Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland

article info

abstract

Article history:

In theory, the continuous subcutaneous insulin infusion (CSII) has a few advantages over the

Received 3 July 2015

multiple daily insulin injections (MDI) that should lead to improved glycemic control and lower

Received in revised form

risk of hypoglycemia. In practice, both treatment regimens allow for adequate control of

30 September 2015

glycemia. The objective of this review is to discuss the most important factors contributing

Accepted 3 October 2015

to this situation. We made a comprehensive evidence-based review of the factors affecting

Available online 23 October 2015

effectiveness of CSII and MDI, with a special attention to algorithms for insulin dose adjustments
and the automatic bolus calculators. Regardless of the treatment regimen that is used a few

Keywords:

different interdependent factors inuence the nal result of the intensive insulin therapy. These

Diabetes mellitus

factors comprise: patients' education, attitude, emotional stability and compliance, and careful

Type 1 diabetes

analysis of the treatment results by a physician establishing the appropriate rate of basal insulin

Continuous subcutaneous insulin

infusion or the basal dose of insulin and adjusting insulin doses to: the meals, the planned

infusion

physical activity and the actual and target glucose levels. Our study implies that good glycemic

Multiple daily insulin injections

control in patients with type 1 diabetes requires not only a thorough patient education and

Automatic bolus calculator

complying with medical recommendations, but also an individual determination of therapy

goals and ways of achieving them. That is why, regardless of the treatment method that is
applied, it is the choice of appropriate algorithms and adjusting them to the patient's way of life
what allow for achieving pre-specied therapeutic goals. Technical means such as automatic
bolus calculators might supplement but they cannot replace patients education and compliance.
# 2015 Nacz Institute of Biocybernetics and Biomedical Engineering. Published by
Elsevier Sp. z o.o. All rights reserved.

* Corresponding author at: Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, 4 Trojdena Street,
02-109 Warsaw, Poland.
E-mail addresses: janusz.krzymien@wum.edu.pl (J. Krzymien), m.rachuta@op.pl (M. Rachuta), iko2@interia.pl (I. Kozlowska),
pladyzynski@ibib.waw.pl (P. Ladyzynski), pfoltynski@ibib.waw.pl (P. Foltynski).
Abbreviations: ABC, automatic bolus calculator; ADA, American Diabetes Association; BGa, actual blood glucose concentration; BGt,
target blood glucose concentration; BW, body weight; CAMIT, Computer Assisted Meal Related Insulin Therapy; CF, glucose correction
factor; CHO, carbohydrates; CSII, continuous subcutaneous insulin infusion; cTDD, corrected total daily insulin dose; DCCT, Diabetes
Control and Complications Trial; GL, glucose load; HbA1c, glycated hemoglobin A1c; ICR, insulin to glucose (carbohydrates) ratio; Ins,
preprandial insulin dose; IOB, insulin on board; MAGE, mean amplitude of glycemic excursions; MDI, multiple daily insulin injections; PFC,
protein-fat coefcient; TBD, total basal insulin dose; TDD, total daily insulin dose.
http://dx.doi.org/10.1016/j.bbe.2015.10.002
0208-5216/# 2015 Nacz Institute of Biocybernetics and Biomedical Engineering. Published by Elsevier Sp. z o.o. All rights reserved.

1.

biocybernetics and biomedical engineering 36 (2016) 18

Introduction

Since the release of the Diabetes Control and Complications

Trial (DCCT) [1] results, the treatment of patients with type 1
diabetes has intensied, with multiple daily insulin injections
(MDI) or the use of an insulin pump. Both treatment regimens
allow for adequate control of glycemia. The appropriate
titration of the daily insulin dose, skilful dosage of the basal
insulin or the basic insulin delivery, adjusting doses to the
meals by calculating the carbohydrate equivalents or to the
exercise level, the use of correction doses all these elements
of treatment inuence the results. Most patients with type 1
diabetes require the use of insulin analogues [2].
It is still a matter of debate, which patients should be
treated with the insulin pump and whether treatment with
continuous subcutaneous insulin infusion (CSII) is superior to
the MDI in terms of the level of glycemic control that can be
achieved.
The American Diabetes Association (ADA) presented its
position regarding both advantages and disadvantages of
insulin pumps [3]. The former encompass elimination of
frequent injections, precise dosage, decrease of the glucose
levels' uctuations, easier bolus administration, easier adjustment of insulin doses to different meal times. In many patients
there is an improvement in glycemia control described by the
glycated hemoglobin A1c (HbA1c) concentration, and a
reduction in severe hypoglycemia episodes. Another advantage is more foreseeable effect of the basal infusion than after
an injection of a prolonged-release or long-acting insulin.
Changes in the basal infusion rate allow for exercising without
the need of an extra high-carbohydrate meal. Disadvantages
according to ADA encompass increase of a body weight,
possibility of ketoacidosis in case of a catheter slip, treatment
costs, problems linked with permanent pump presence and a
need of long-term, repeated education.
Recapitulating, in theory treatment with CSII has a few
important advantages over MDI that should result in the
improved glycemic control and lower risk of hypoglycemia.
However, no proof of these theoretical advantages was
found in numerous, randomized clinical trials conducted to
date [4]. The objective of this review was to identify and
characterize the most important factors contributing to this
situation.

2.
Glycemic control in patients treated using
CSII and MDI regimens
An analysis performed in 2012 by Yeh et al. [5] showed that
neither in children nor in adults differences occurred in the
effects of treatment, either measured by the number of severe
hypoglycemia episodes or by HbA1c, between MDI and CSII
treatments. Recent publications do not conrm earlier reports
indicating possible benets of the insulin pump use [6,7]. An
introduction of long-acting insulin analogues to diabetes
treatment further reduced possible differences in treatment
results between patients treated with MDI and those treated
with CSII. Boli et al. have compared, although in a small group,
the effect of starting treatment with insulin pump or with

peakless insulin analogue glargine in patients treated

previously with NPH insulin. This trial showed no signicant
differences in the improvement of glycemic control, or the
number of hypoglycemic episodes, and at the same time
indicated that the cost of treatment with insulin pump was
3.9 times higher. However, it must be stressed that wider
introduction of continuous glucose measurements in
patients with type 1 diabetes improves treatment results
in terms of HbA1c and hypoglycemic episodes, especially
at night [8,9].

3.
Factors affecting effectiveness of CSII and
MDI treatments
Persons who treat the pump as a device and not a panacea for
diabetes, achieve better glycemic control. Daily self-control,
realistic approach to the use of the pump, emotional stability
all these elements affect the course of treatment [10].
Publicizing standards for 2014 the ADA presented its
position regarding treatment of patients with type 1 diabetes
and commented on the effects of intensive insulin therapy
[11]. In the published standards of care for patients with
diabetes we read:
Recommended therapy for type 1 diabetes consists of the
following components: (1) use of MDI injections (three to
four injections per day of basal and peri-prandial insulin) or
CSII therapy; (2) matching of peri-prandial insulin to
carbohydrate intake, pre-prandial blood glucose, and
anticipated activity; and (3) for most patients (especially
if hypoglycemia is a problem), use of insulin analogues
There are excellent reviews available that guide the
initiation and management of insulin therapy to achieve
desired glycemic goals. Although most studies of MDI
versus pump therapy have been small and of short duration,
a systematic review and meta-analysis concluded that
there were no systematic differences in A1C or rates of
severe hypoglycemia in children and adults between the
two forms of intensive insulin therapy.
One may ask, why treatment with CSII, which is as close as
possible to the natural, physiological insulin secretion, offers
no marked improvement in glycemic control as compared
with multiple insulin injections. One may also ask, how many
patients really make the most of the possibilities offered by the
pump.
Decreasing glucose level uctuations in many cases depend
on adjusting insulin doses to the meals and the planned
physical activity. It requires appropriate patients' education,
both at the start of the treatment and during yearly reeducation courses. For example, the Polish Diabetes Society
recommends spending 915 h on initial education course and
repeating it every year at 7 to 14-h course [12]. An adequate
glycemic control depends also on the patient's dexterity in
calculating carbohydrate exchange. Results of a questionnaire
conducted among patients with type 1 diabetes showed that
most of them had no refresher course in a very long time and
had signicant difculties in calculating carbohydrate exchange. In patients with long-term diabetes (i.e. over 10 years)

biocybernetics and biomedical engineering 36 (2016) 18

Table 1 Dexterity in calculating carbohydrate exchange in patients referred to the Chair and Clinic of Gastroenterology and
Metabolic Diseases because of inadequate glycemic control [13].
Parameter
Number of patients
Duration of diabetes (years)
Time since the last education course (years)
Difference in evaluating carbohydrate
equivalents in daily diet (bread exchange units)
Number of hypoglycemic episodes per week

Long-term diabetes

Short-term diabetes

Statistical signicance

27
21.7  8.4
12.0  7.9
6.7  6.1

10
5.6  1.5
4.0  0.5
4.2 13.5

<0.05
<0.05
>0.05

5.9  4.8

3.3  1.3

>0.05

mistakes in calculations were signicantly more frequent than

in those with freshly diagnosed disease (Table 1). A conrmation of this observation can be found in reports of other
researchers [14,15].
In the future, automatic or semi-automatic systems
should become available, that will be able to estimate
carbohydrate contents in the meal based on an analysis of:
the digital picture of the meal [16,17], the verbal description of
the meal [18,19] or the monitoring of the activities related to
consumption of the meal, e.g. chewing or swallowing [20,21].
Such systems should positively inuence on accuracy of bolus
calculations and reliability of the patient-collected data [22],
however, a proper education of the patients must never be
underestimated.
A very important element of treatment, linked with the use
of short-acting insulin analogues, is a bolus before every
snack. Many patients skip injections before snacks, what leads
to hyperglycemia [23]. The glycemic control is affected also by
a choice of a type of bolus either simple or composite before
a meal. A meal with low glycemic index should be preceded by
a complex bolus [24]. When eating fat-loaded meals, demand
for insulin rises and doses based on carbohydrate exchange
calculations need a correction [25].
From our long-term observations there is a group of
patients with type 1 diabetes, who get marked benets from
the treatment with insulin pump. However, apart from those
who comply with medical directions and gradually achieve
good glycemic control, two groups of persons treated with
insulin pumps deserve particular attention because of the way
of conducting therapy. In the rst group, there are patients
who increase the basal infusion rate, aiming at compensating
not only for the basal requirement but also for daily snacks.
This group rarely measures blood glucose levels, uses 12 meal
boluses daily and does not achieve desirable glycemic control
levels. In the other group, there are persons striving for perfect
glycemic control, measuring glucose levels very frequently
(1020 times daily), and injecting boluses before meals and
snacks but also using frequent correction doses. In one such
patient we have reported 33 boluses in a day! One can say that
these persons dedicate their life to their disease. Diagnosing a
particular type of behaviour is possible if a physician at every
visit takes time to get a good history and reads the pump's
memory.
Patients' education should be directed at explaining the
goals and mechanisms of intensive insulin therapy. Achieving
therapeutic goals is possible only with daily self-control,
becoming dexterous with principles of the diet, calculating
carbohydrate exchange, knowing the effects of exercise,
preventing hypoglycemic episodes.

4.

Calculation of the insulin dosage

There are helpful formulas allowing for choosing the right

basal insulin dose, adjusting the insulin doses to the meals
and calculating correction boluses. Unfortunately, most of
the algorithms used today to calculate doses of insulin
boluses (either simple or complex) during CSII therapy or to
calculate insulin doses used during MDI therapy does not
take into account differences between children and adults,
while in fact differences between these two groups are
enormous regarding insulin doses used, insulin sensitivity,
kind of meals and duration of digestion, e.g. rate of gastric
emptying.
In treatment with insulin pumps a very important element
is establishing the rate of basal insulin infusion and in people
treated with MDI the dose of a basal insulin (a long-acting
analogue). On the one hand, if the dose of the basal insulin is
too high, the insulin-exchange and the correction coefcients
are weakened and administered boluses do not prevent
postprandial hyperglycemia. On the other hand, if the basal
infusion dose is too low, the insulin-exchange coefcient
becomes too strong and the risk of hypoglycemia rises.
A representative, average total basal insulin dose (TBD) may
be calculated based on the total daily insulin dose (TDD) using
the following formula [25]:
TBD U=day 0:48  TDD U=day
Eating low-carbohydrate meals increases TBD, while highcarbohydrate diet requires lowering TBD. As a result, the usual
TBD ranges from 39.6% to 54.9% of TDD [26]. The effective TBD
rarely goes below 40% and only incidentally rises above 60%
of TDD. Basal infusion of about 60% of the daily dose is often
seen in people with psychogenic eating disorders [27]. In such
cases a number of boluses usually decreases (to 12 daily)
as well as the dose of meal boluses, what in turn can lead to
keto- and lactoacidosis [28].
In 2010, King reevaluated insulin dosing estimation
formulas using post hoc analysis of the data from 4 previously
published studies with continuous glucose monitoring and
proposed the following formulas to calculate TBD based on
TDD or based on the body weight (BW) [29]:
TBD U=day 0:4  TDD U=day
TBD U=day 0:2  BW kg
An appropriate adjustment of the basal infusion rate
should lead to maintaining glycemic control at night and
between meals. Adequately set basal infusion rates allow for

biocybernetics and biomedical engineering 36 (2016) 18

keeping blood glucose level in the range of 30 mg/dL

(1.7 mmol/L) during an 8-h sleep or a 5-h meal break. In
case of frequent hypoglycemic episodes the daily dose should
be lowered by approx. 5%.
In young adults and adolescents there is a marked increase
in insulin demand early in the morning. It is a physiological
response caused by a growth hormone surge. Physiologically
this surge occurs about 3 a.m., leading to hyperglycemia. This
early morning rise in blood glucose level is even called a dawn
phenomenon. In middle-age and older people this phenomenon becomes less and less pronounced until it fades
completely. Prolonged deterioration of glycemic control and
lowered insulin sensitivity lead to an early-morning blood
glucose level increase [30].
In clinical practice the basal insulin infusion rate is changed
frequently although similar changes are not seen in nondiabetic population. Such changes make treatment evaluation
signicantly more difcult. It has to be noted that although
changes in the insulin level appear already 1530 min after
changing the infusion rate, the marked effect on blood glucose
level occurs only after 24 h [31].
When treating patients with type 1 diabetes applying MDI
therapy one has to take into account the type and dose of a
long-acting analogue. An administration of insulin glargine in
the dose of 0.30.35 U per kilogram of the body weight secures
its effective action for about 24 h (22  4 h). An injection of the
same dose of insulin detemir gives a much shorter action time
of about 14 h [32,33]. The duration of action of insulin and its
analogues (such as glargine) differs substantially among
patients [33]. The effective action time for insulin detemir is
assumed to be dose dependent and ranges from 5.7 h at lowdose injections to 23.2 h at high doses [34]. It can be concluded
that with low doses of long-acting insulin analogues one has
to either increase the frequency of meal boluses at the same
time slightly increasing their doses or as it is frequently
recommended in case of using insulin detemir administer the
long-acting insulin analogue twice daily. Apart from establishing the appropriate basal infusion rate or the long-acting insulin
dose, the most signicant for achieving an adequate glycemic
control is the best possible adjustment of the insulin dose to
the particular meal. Since about 2002 to facilitate therapeutic
decisions an automatic bolus calculator (ABC) has been
introduced in persons treated with insulin pumps. Having such
an ABC the patient has only to input the current blood glucose
value and to estimate the carbohydrate exchange values in a
given meal as precisely as possible. The ABC is pre-programmed
with such parameters as the ideal or target blood glucose levels,
the insulin-exchange coefcient, the correction coefcient
and the insulin time of action [35]. Bolus calculators can also
account for daily uctuations of the insulin sensitivity.

calculation of the insulin-exchange coefcient called also

insulin to glucose (carbohydrates) ratio (ICR). To evaluate how
many grams of carbohydrates (CHO) is compensated by a
single unit of fast-acting insulin analogue a 500 rule has
been proposed and for short-acting insulin a 450 is being
used [36]. According to King [29], a 300 rule should be used
for short-acting insulin.
The 500/450/300 rules are linked with daily insulin
demand, i.e. with the total daily insulin dose (TDD), in the
following way:
ICR g CHO=U W=TDD U=day
where W is equal to 500, 450 or 300 depending on the rule that
is used.
For example, with a daily insulin demand of 40 U an
application of the 500 rule leads to:
ICR 500=40 U 12:5 g CHO=U
The 500 rule works best in patients in whom the basal
insulin accounts for 5060% of the daily insulin demand.
Apart from the 500 rule and suchlike there are formulas,
which include not only the daily insulin demand but also
patient's body weight. In 2003 Davidson et al. [37] presented
a 2.8 rule:
ICR g CHO=U 2:8  BW lb=TDD U=day
Walsh et al. [25] proposed slightly different formula:
ICR g CHO=U 2:6  BW lb=TDD U=day
ICR g CHO=U 5:7  BW kg=TDD U=day
However one has to bear in mind that in case of lowcarbohydrate diet (<50%) the basal insulin dose increases
while the meal boluses decrease. In case of high-carbohydrate
or vegetarian diet the preprandial insulin dose increases while
at the same time the basal insulin dose decreases. In the work
of Japanese authors, in patients with type 1 diabetes the basal
infusion amounted only to about 30% of the daily insulin
demand [38].
In many patients with type 1 diabetes marked uctuations
in daily insulin demand levels are observed in subsequent
days. That is why the daily dose fed into formulas should be
the average calculated from several days. Davidson et al. [39]
used the average from the previous 6 days when calculating
the insulin-carbohydrate coefcient. If recently average blood
glucose levels exceeded 144 mg/dL (8 mmol/L) the TDD should
be increased. To calculate the corrected TDD (cTDD) one can
use the following formula [25]:

cTDD U=day TDD U=day 2:5  MBG  144 mg=dL=1960 mg=dL=TDD U=day
cTDD U=day TDD U=day 2:5  MBG  8:0 mmol=L=109 mmol=L=TDD U=day

It is assumed that the administration of an insulin dose

calculated by ABC should allow for achieving an average
postprandial blood glucose values of about 144 mg/dL
(8.0 mmol/L), i.e. from 109 to 163 mg/dL (from 6.1 to
9.1 mmol/L). The treatment effect depends on appropriate

where MBG stands for the average blood glucose concentration.

The cTDD can be then used in place of TDD in the
previously stated formulas to calculate more appropriate
value of ICR.

biocybernetics and biomedical engineering 36 (2016) 18

Widely accepted standards calculate insulin doses compensating meals only on the basis of the carbohydrate content
of meals, not taking into account proteins and fats. In 2010,
Pankowska and Blazik [40] proposed to include a protein-fat
coefcient (PFC) in calculating preprandial insulin doses.
PFC 4:0  Protein kcal 9:0  Fat kcal=100
Depending on the planned consumption of carbohydrates,
proteins and fats an appropriate (simple or complex) bolus is
administered. In case of MDI treatment the composition of a
meal can determine whether to administer a fast-acting or a
short-acting insulin.
To date no unequivocal recommendations allowing for
calculating the dose of insulin and the bolus action time
preventing the rise in blood glucose level after a composite
meal have been prepared. Most agree that the prolonged phase
of a complex bolus should last for at least 3 h [41]. However, in
case of a low-glycaemic-index diet, a complex bolus acting
within 2 h has been administered [23]. In healthy individuals
after eating a composite meal the rise in insulin concentration
is signicantly faster, higher and lasts for shorter period of
time than in patients with type 1 diabetes after the
administration of 18 U of a fast-acting insulin analogue (Fig. 1).
It must be stressed that under experimental conditions in
large animals the high-carbohydrate or high-fat diets do not
lead to signicant differences in insulin secretion [44].
There is still an open question, whether prolonging the
complex bolus action time after high-fat meals up to 8 h is
physiologically justied.
Patients treated with MDI have to consider the kind of basal
insulin they use. Treatment with low doses of a long-acting
analogue shortens its action time as compared with treatment
with high doses (of the same analogue), leading to the increase
in preprandial bolus doses.
When becoming hyperglycemic, patients often need an
extra injection of a correction dose of insulin. Patients should
know by how much would an injection of one unit of insulin
lower his/her blood glucose level, i.e. glucose correction factor
(CF) and what should be his/her target blood glucose values

when using the correction dose. Here also we have a number of

formulas (for fast-acting analogues or short-acting insulin)
based on an empirically chosen values: 1500 [29], 1700 [36],
1800 [45] or 1960 [25], allowing for an approximate
calculation how much can one unit of insulin lower the blood
glucose value. To obtain a result we divide the chosen value
by the present daily insulin demand:
CF mg=dL=U V=TDD U=day
where V is equal to 1500, 1700, 1800 or 1960 depending on the
formula being used.
For example, with the demand of 40 U/day the CF will be:
37.5, 42.5, 45.0 and 49.0 mg/dL/U for a 1500, 1700, 1800
and 1960 rule, respectively.
If a patient measures his/her blood glucose level and the
result is 300 mg/dL while the desired target level is 140 mg/dL,
depending on the formula used he/she will have to administer
34 U of insulin.
In King's paper [29] there is a simple formula shown that
represents a relationship between all 3 insulin dosing factors,
i.e. TBD, ICR and CF:
100=TBD ICR CF=4:5120=TBD ICR CF=5
The interrelationships between ICR, CF, TBD and TDD
suggest that any adjustment in one of these parameters
require an appropriate change in the others.
Based on the above mentioned factors the preprandial
insulin dose (Ins) can be calculated that is suppose to
compensate glucose load (GL) and correct the actual blood
glucose concentration (BGa) bringing it to the target level (BGt)
[46]:
Ins U GL g CHO=ICR g CHO=U fBGa mg=dL
 BGt mg=dL=CF mg=dL=Ug  IOB U
In this formula IOB stands for insulin on board and
corresponds to the amount of insulin from the last dose that
remains active in the patient's body. The IOB is subtracted
from the dose calculated based on the carbohydrates load and
a deviation of the blood glucose from its target value to avoid
hypoglycemia.

5.

Fig. 1 Insulin level in healthy controls and in patients with

type 1 diabetes after ingesting a composite meal (55%
carbohydrates, 30% fats and 15% proteins) and after the
administration of 18 units of a fast-acting insulin analogue.
Chart is drawn based on the data reported by Basu et al.
[42] and Mader et al. [43].

Efcacy of the automatic bolus calculators

The above-described rules and algorithms can be implemented in automatic bolus calculators to facilitate estimation of
the appropriate meal-compensating insulin doses. Such
systems have been available for patients treated with CSII
and MDI methods for at least last decade. A few studies have
been conducted up to date comparing results of MDI or CSII
treatments in patients with type 1 diabetes who estimated
insulin boluses unaided or applying ABC systems. Results of
the rst such study concerning MDI were published by
Schrezenmeir et al. in 2002 [47]. In 25 patients using ABC
called the Computer Assisted Meal Related Insulin Therapy
(CAMIT) the mean blood glucose, the glucose variability
described by the mean amplitude of glycemic excursions

biocybernetics and biomedical engineering 36 (2016) 18

(MAGE) and the hypoglycemia frequency reduced signicantly

in contrast to 25 control patients where these parameters
stayed unchanged. The HbA1c after 6 months of the ABC use
was reduced signicantly. The relative reduction of HbA1c in
comparison with the initial value was equal to 15.6  2.2% in
the study group and 3.7  3.7% in the control group. Since 2002
several other studies comparing results of the MDI or CSII
treatments supported or not supported by an application of
ABC have been reported [4859]. In some of these studies
[50,54,57,58] patients using ABC for 612 months were
achieving better glycemic control, i.e. lower HbA1c values,
than patients treated without such an assistance but in other
studies [49,51,55] no differences in HbA1c reduction were
noted. Among other benets of ABC usage the following
results were listed: signicant improvement of postprandial
glucose levels or signicant improvement of daily glucose
variability [48,51,52,5557], signicant improvement in treatment satisfaction or quality of life [49,52,58] and signicant
reduction of errors or improved attitude to calculate proper
insulin dose with an ABC [57,59]. According to results of a
survey conducted on a group of 1412 patients treated with MDI
method of whom 588 responded positively, the ABC usage
reduces the fear of hypoglycemia [60]. However, an effect of the
ABC usage on frequency of hypoglycemia is not clear. In one
study more severe hypoglycemia among ABC users were
reported [50] while in another no increased frequency of
hypoglycemia was noted [57]. In general, it can be stated that
consistent use of ABC may help to improve metabolic control
in patients using MDI or CSII.

6.

Conclusion

Good glycemic control in patients with type 1 diabetes requires

not only a thorough patient education and complying with
medical recommendations, but also an individual determination of therapy goals and ways of achieving them. That is why
regardless of the treatment method (insulin pump or multiple
injections) it is the choice of appropriate algorithms and
adjusting them to the patient's way of life what allow for
achieving pre-specied therapeutic goals. Technical means
such as automatic bolus calculators might supplement but
they cannot replace patients education and compliance.

Acknowledgements
This study was nancially supported from the project No.
PBS1/B9/13/2012 granted by the National Centre for Research
and Development.

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