• 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, and Sherita Hill Golden.
• The Johns Hopkins University, Baltimore, Maryland, USA.
• Ann. Intern. Med. 2012 Sep 4; 157 (5): 336-47.

BackgroundPatients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring.PurposeTo 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 SourcesMEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through February 2012 without language restrictions.Study Selection33 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 Extraction2 reviewers independently evaluated studies for eligibility and quality and serially abstracted data.Data SynthesisIn 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.LimitationMany studies were small, of short duration, and limited to white persons with type 1 diabetes mellitus.ConclusionContinuous 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 SourceAgency for Healthcare Research and Quality.

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