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Ann Intern Med. 2012 Sep 4;157(5):336-47.

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

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  • 1The Johns Hopkins University, Baltimore, Maryland, USA.

Abstract

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.

PMID:
22777524
[PubMed - indexed for MEDLINE]
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