Insulin Delivery and Glucose Monitoring Methods for Diabetes Mellitus: Comparative Effectiveness
Insulin Delivery With MDI Versus CSII in Children and Adolescents With Type 1 Diabetes
There was moderate strength of evidence that CSII was associated with a small, statistically nonsignificant HbA1c-lowering effect when compared with MDI in children and adolescents with type 1 diabetes.
- A meta-analysis of seven randomized controlled trials (RCTs) showed a nonsignificant difference between the MDI and CSII intervention groups in how the HbA1c level changed from baseline after 16 or more weeks of followup, decreasing slightly more with CSII than with MDI (mean difference from baseline ranged from -1.7 to 0.43 in the MDI group and from -1.7 to 0.03 in the CSII group for the time period assessed; combined mean between-group difference, -0.14%; 95-percent confidence interval [95% CI], -0.48 to 0.20; p = 0.41).
No significant difference was found in the frequency of daytime hypoglycemia, the frequency of nocturnal hypoglycemia, the rate of severe hypoglycemia, or general quality of life with CSII versus MDI in children and adolescents with type 1 diabetes. The strength of evidence was rated low for these findings.
- Analyses of three RCTs showed that the frequency of daytime hypoglycemia did not differ significantly between the MDI and CSII intervention groups (mean between-group difference in perceived hypoglycemic events over 104 weeks, 0; 95% CI, -1.1 to 1.1). For nocturnal hypoglycemia, in one study there were four events/patient/study period (95% CI, 0.3 to 7.7) for MDI versus three events/patient/study period (95% CI, 1.0 to 5.0) for CSII over 52 weeks. In a second study, there were two patients with one or more events in the CSII arm but no events reported in the MDI arm over 16 weeks.
- A meta-analysis of five RCTs did not find a significant difference in severe hypoglycemia event rates between the two intervention arms (combined mean incidence rate ratio for CSII vs. MDI, 0.99; 95% CI, 0.57 to 1.71; p = 0.97).
- Two studies examined general quality of life in children and adolescents with type 1 diabetes using the Pediatric Quality of Life Inventory; a meta-analysis did not favor CSII or MDI in this population (mean between-group difference, 2.3; 95% CI, -6.9 to 11.5).
- Two studies examined the comparative effectiveness of CSII versus MDI on diabetes-specific quality of life. These studies used the Diabetes Quality of Life–Youth instrument; while one study showed improvement in quality of life favoring CSII, the other study did not find a difference in quality of life between the two intervention arms.
CSII was associated with a significant improvement in diabetes treatment satisfaction, when compared with MDI, in children and adolescents with type 1 diabetes. The strength of evidence was rated low for these findings.
- The mean between-group difference in body mass index was -0.12 units, decreasing slightly more with CSII than with MDI (95% CI, -0.55 to 0.30 units).
- A meta-analysis of two studies favored CSII over MDI for improving diabetes treatment satisfaction (mean between-group difference in the Diabetes Treatment Satisfaction Questionnaire, 5.7; 95% CI, 5.0 to 6.4; p < 0.001).
Abbreviations: 95% CI = 95-percent confidence interval; CSII = continuous subcutaneous insulin infusion; MDI = multiple daily injections; rt-CGM = real-time continuous glucose monitoring; SMBG = self-monitoring of blood glucose
Keywords: adolescents strength of evidence | children | CSII | insulin delivery | MDI | outcomes | diabetes
- Golden SH, Brown T, Yeh HC, et al. Insulin Delivery and Glucose Monitoring Methods for Diabetes Mellitus: Comparative Effectiveness. Comparative Effectiveness Review No. 57 (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 290-2007-10061-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-EHC036. Available at www.effectivehealthcare.ahrq.gov/glucose.cfm.
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