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Insulin Delivery and Glucose Monitoring Methods for Diabetes Mellitus: Comparative Effectiveness

Slide: 14 of 25

Insulin Delivery With MDI Versus CSII in Adults With Type 1 Diabetes

A meta-analysis of four randomized controlled trials (RCTs) showed that HbA1c decreased more with CSII when compared with MDI, although results were heavily influenced by one study (combined mean between-group difference from baseline, -0.30%; 95% CI, -0.58 to -0.02). The strength of evidence for this finding was rated low.

There was low strength of evidence for a lack of significant difference in frequency of nocturnal hypoglycemia, severe hypoglycemia, other nonsevere hypoglycemia, hyperglycemia, and weight gain with CSII versus MDI in adults with type 1 diabetes.

  • Of the three studies reporting nocturnal hypoglycemia, two found no statistically significant difference in nocturnal hypoglycemic episodes between the two intervention groups. In the third study, the proportion of patients experiencing nocturnal hypoglycemia was similar between the MDI and CSII intervention arms (relative risk [RR], 0.98; 95% CI, 0.83 to 1.17).
  • A meta-analysis of three RCTs indicated no difference in the incidence of severe hypoglycemia with CSII when compared with MDI treatment (combined RR, 0.74; 95% CI, 0.30 to 1.83; p = 0.52).
  • Six studies evaluated the incidence of other nonsevere hypoglycemia. One RCT found no significant difference in asymptomatic hypoglycemia between the CSII and MDI arms. In two studies, the incidence of mild hypoglycemia was higher in the CSII arm; in a third study, the incidence of mild hypoglycemia was higher in the MDI arm. Two other studies found no difference in the incidence of biochemical hypoglycemia during CSII when compared with MDI treatment.
  • Fasting glucose did not vary significantly by treatment with CSII or MDI across three RCTs. In two of these studies, fasting glucose showed a greater decrease in the CSII arm at 4 and 6 months when compared with the MDI arm. In the third study, CSII and MDI similarly lowered fasting glucose.
  • A meta-analysis of two studies suggested no difference in weight gain when CSII was compared with MDI (combined between-group difference, -0.25 kg; 95% CI, -3.14 to 2.64 kg; p = 0.86).

 There was a small decrease in postprandial glucose and an increase in symptomatic hypoglycemia with CSII versus MDI in adults with type 1 diabetes. Strength of evidence for this finding was low.

  • Results from three studies reporting on symptomatic hypoglycemia were combined in a meta-analysis. Results revealed a significant increase in the incidence of symptomatic hypoglycemia events/person-years when CSII was compared with MDI (combined incidence rate ratio, 1.30; 95% CI, 1.18 to 1.42; p < 0.001). However, there was substantial statistical heterogeneity (I2 = 96%).
  • Three RCTs reported lower postprandial glucose levels with CSII when compared with MDI treatment.

There was low strength of evidence for a significant improvement in diabetes-specific quality of life favoring CSII over MDI in adults with type 1 diabetes.

  • A meta-analysis of those studies using the Diabetes Quality of Life Questionnaire as a measure, including only those studies that gave confidence intervals, favored CSII (mean between-group difference, 2.99; 95% CI, 0.006 to 5.97; p = 0.05).

Abbreviations: 95% CI = 95-percent confidence interval; CSII = continuous subcutaneous insulin infusion; MDI = multiple daily injections