Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring for diabetes mellitus: a systematic review and meta-analysis.
BACKGROUND
Patients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring.


OBJECTIVE
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.


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


METHODS
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).


METHODS
2 reviewers independently evaluated studies for eligibility and quality and serially abstracted data.


RESULTS
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.


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


CONCLUSIONS
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.


BACKGROUND
Agency for Healthcare Research and Quality.
The Johns Hopkins University, Baltimore, Maryland, USA.
Hsin-Chieh
HC
Yeh
Todd T
TT
Brown
Nisa
N
Maruthur
Padmini
P
Ranasinghe
Zackary
Z
Berger
Yong D
YD
Suh
Lisa M
LM
Wilson
Elisabeth B
EB
Haberl
Jessica
J
Brick
Eric B
EB
Bass
Sherita Hill
SH
Golden
D001786:Blood Glucose / Q000378:metabolism*; D015190:Blood Glucose Self-Monitoring; D057186:Comparative Effectiveness Research; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000188:drug therapy*; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy*; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D007328:Insulin / Q000009:adverse effects / Q000627:therapeutic use*; D007332:Insulin Infusion Systems; D008991:Monitoring, Physiologic / Q000379:methods*; D016896:Treatment Outcome
D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin