• Andrea C Tricco, Huda M Ashoor, Jesmin Antony, Joseph Beyene, Areti Angeliki Veroniki, Wanrudee Isaranuwatchai, Alana Harrington, Charlotte Wilson, Sophia Tsouros, Charlene Soobiah, Catherine H Yu, Brian Hutton, Jeffrey S Hoch, Brenda R Hemmelgarn, David Moher, Sumit R Majumdar, and Sharon E Straus.
• Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, M5B 1T8, Canada.
• BMJ. 2014 Jan 1;349:g5459.

ObjectiveTo examine the safety, effectiveness, and cost effectiveness of long acting insulin for type 1 diabetes.DesignSystematic review and network meta-analysis.Data SourcesMedline, Cochrane Central Register of Controlled Trials, Embase, and grey literature were searched through January 2013.Study SelectionRandomized controlled trials or non-randomized studies of long acting (glargine, detemir) and intermediate acting (neutral protamine Hagedorn (NPH), lente) insulin for adults with type 1 diabetes were included.Results39 studies (27 randomized controlled trials including 7496 patients) were included after screening of 6501 titles/abstracts and 190 full text articles. Glargine once daily, detemir once daily, and detemir once/twice daily significantly reduced hemoglobin A1c compared with NPH once daily in network meta-analysis (26 randomized controlled trials, mean difference -0.39%, 95% confidence interval -0.59% to -0.19%; -0.26%, -0.48% to -0.03%; and -0.36%, -0.65% to -0.08%; respectively). Differences in network meta-analysis were observed between long acting and intermediate acting insulin for severe hypoglycemia (16 randomized controlled trials; detemir once/twice daily versus NPH once/twice daily: odds ratio 0.62, 95% confidence interval 0.42 to 0.91) and weight gain (13 randomized controlled trials; detemir once daily versus NPH once/twice daily: mean difference 4.04 kg, 3.06 to 5.02 kg; detemir once/twice daily versus NPH once daily: -5.51 kg, -6.56 to -4.46 kg; glargine once daily versus NPH once daily: -5.14 kg, -6.07 to -4.21). Compared with NPH, detemir was less costly and more effective in 3/14 cost effectiveness analyses and glargine was less costly and more effective in 2/8 cost effectiveness analyses. The remaining cost effectiveness analyses found that detemir and glargine were more costly but more effective than NPH. Glargine was not cost effective compared with detemir in 2/2 cost effectiveness analyses.ConclusionsLong acting insulin analogs are probably superior to intermediate acting insulin analogs, although the difference is small for hemoglobin A1c. Patients and their physicians should tailor their choice of insulin according to preference, cost, and accessibility.Systematic Review RegistrationPROSPERO CRD42013003610.© Tricco et al 2014.

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