Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring for diabetes mellitus: a systematic review and meta-analysis

Hsin-Chieh Yeh, Todd T Brown, Nisa Maruthur, Padmini Ranasinghe, Zackary Berger, Yong D Suh, Lisa M Wilson, Elisabeth B Haberl, Jessica Brick, Eric B Bass, Sherita Hill Golden
Annals of Internal Medicine 2012 September 4, 157 (5): 336-47

BACKGROUND: Patients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring.

PURPOSE: To review how intensive insulin therapy (multiple daily injections [MDI] vs. rapid-acting analogue-based continuous subcutaneous insulin infusion [CSII]) or method of monitoring (self-monitoring of blood glucose [SMBG] vs. real-time continuous glucose monitoring [rt-CGM]) affects outcomes in types 1 and 2 diabetes mellitus.

DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through February 2012 without language restrictions.

STUDY SELECTION: 33 randomized, controlled trials in children or adults that compared CSII with MDI (n=19), rt-CGM with SMBG (n=10), or sensor-augmented insulin pump use with MDI and SMBG (n=4).

DATA EXTRACTION: 2 reviewers independently evaluated studies for eligibility and quality and serially abstracted data.

DATA SYNTHESIS: In randomized, controlled trials, MDI and CSII showed similar effects on hemoglobin A1c (HbA1c) levels and severe hypoglycemia in children or adults with type 1 diabetes mellitus and adults with type 2 diabetes mellitus. In adults with type 1 diabetes mellitus, HbA1c levels decreased more with CSII than with MDI, but 1 study heavily influenced these results. Compared with SMBG, rt-CGM achieved a lower HbA1c level (between-group difference of change, 0.26% [95% CI, 0.33% to 0.19%]) without any difference in severe hypoglycemia. Sensor-augmented insulin pump use decreased HbA1c levels more than MDI and SMBG did in persons with type 1 diabetes mellitus (between-group difference of change, 0.68% [CI, 0.81% to 0.54%]). Little evidence was available on other outcomes.

LIMITATION: Many studies were small, of short duration, and limited to white persons with type 1 diabetes mellitus.

CONCLUSION: Continuous subcutaneous insulin infusion and MDI have similar effects on glycemic control and hypoglycemia, except CSII has a favorable effect on glycemic control in adults with type 1 diabetes mellitus. For glycemic control, rt-CGM is superior to SMBG and sensor-augmented insulin pumps are superior to MDI and SMBG without increasing the risk for hypoglycemia.

PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

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