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Clinical review: Hypoglycemia with intensive insulin therapy: a systematic review and meta-analyses of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections.
J Clin Endocrinol Metab 2009; 94(3):729-40JC

Abstract

CONTEXT

Hypoglycemia limits the efficacy of intensive insulin therapy. The extent to which continuous insulin infusion (CSII) overcomes this limitation is unclear.

OBJECTIVE

The aim was to summarize evidence on the effect of CSII and multiple daily injections (MDIs) on glycemic control and hypoglycemia.

DATA SOURCES

We searched electronic databases between 2002 and March 2008.

STUDY SELECTION

We selected published randomized trials of CSII vs. MDI.

DATA EXTRACTION

Reviewers working in duplicate and independently extracted study characteristics and quality and differences in glycosylated hemoglobin (HbA1c) and hypoglycemic events.

DATA SYNTHESIS

We found 15 eligible randomized trials of moderate quality, with elevated baseline and end-of-study HbA1c levels. Patients with type 1 diabetes using CSII had slightly lower HbA1c [random-effects weighted mean difference, -0.2%; 95% confidence interval (CI), -0.3, -0.1, compared with MDI], with no significant difference in severe (pooled odds ratio, 0.48; 95% CI, 0.23, 1.00) or nocturnal hypoglycemia (pooled odds ratio 0.82, 95% CI 0.33, 2.03). Adolescents and adults with type 1 diabetes enrolled in crossover trials had nonsignificantly fewer minor hypoglycemia episodes per patient per week (-0.08; 95% CI, -0.21, 0.06) with CSII than MDI; children enrolled in parallel trials had significantly more episodes (0.68; 95% CI, 0.16, 1.20; P(interaction) = 0.03). Outcomes were not different in patients with type 2 diabetes.

CONCLUSIONS

Contemporary evidence indicates that compared to MDI, CSII slightly reduced HbA1c in adults with type 1 diabetes, with unclear impact on hypoglycemia. In type 2 diabetes, CSII and MDI had similar outcomes. The effect in patients with hypoglycemia unawareness or recurrent severe hypoglycemia remains unclear because of lack of data.

Authors+Show Affiliations

Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

19088167

Citation

Fatourechi, Mitra M., et al. "Clinical Review: Hypoglycemia With Intensive Insulin Therapy: a Systematic Review and Meta-analyses of Randomized Trials of Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections." The Journal of Clinical Endocrinology and Metabolism, vol. 94, no. 3, 2009, pp. 729-40.
Fatourechi MM, Kudva YC, Murad MH, et al. Clinical review: Hypoglycemia with intensive insulin therapy: a systematic review and meta-analyses of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections. J Clin Endocrinol Metab. 2009;94(3):729-40.
Fatourechi, M. M., Kudva, Y. C., Murad, M. H., Elamin, M. B., Tabini, C. C., & Montori, V. M. (2009). Clinical review: Hypoglycemia with intensive insulin therapy: a systematic review and meta-analyses of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections. The Journal of Clinical Endocrinology and Metabolism, 94(3), pp. 729-40. doi:10.1210/jc.2008-1415.
Fatourechi MM, et al. Clinical Review: Hypoglycemia With Intensive Insulin Therapy: a Systematic Review and Meta-analyses of Randomized Trials of Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections. J Clin Endocrinol Metab. 2009;94(3):729-40. PubMed PMID: 19088167.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Clinical review: Hypoglycemia with intensive insulin therapy: a systematic review and meta-analyses of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections. AU - Fatourechi,Mitra M, AU - Kudva,Yogish C, AU - Murad,M Hassan, AU - Elamin,Mohamed B, AU - Tabini,Claudia C, AU - Montori,Victor M, Y1 - 2008/12/16/ PY - 2008/12/18/entrez PY - 2008/12/18/pubmed PY - 2009/4/8/medline SP - 729 EP - 40 JF - The Journal of clinical endocrinology and metabolism JO - J. Clin. Endocrinol. Metab. VL - 94 IS - 3 N2 - CONTEXT: Hypoglycemia limits the efficacy of intensive insulin therapy. The extent to which continuous insulin infusion (CSII) overcomes this limitation is unclear. OBJECTIVE: The aim was to summarize evidence on the effect of CSII and multiple daily injections (MDIs) on glycemic control and hypoglycemia. DATA SOURCES: We searched electronic databases between 2002 and March 2008. STUDY SELECTION: We selected published randomized trials of CSII vs. MDI. DATA EXTRACTION: Reviewers working in duplicate and independently extracted study characteristics and quality and differences in glycosylated hemoglobin (HbA1c) and hypoglycemic events. DATA SYNTHESIS: We found 15 eligible randomized trials of moderate quality, with elevated baseline and end-of-study HbA1c levels. Patients with type 1 diabetes using CSII had slightly lower HbA1c [random-effects weighted mean difference, -0.2%; 95% confidence interval (CI), -0.3, -0.1, compared with MDI], with no significant difference in severe (pooled odds ratio, 0.48; 95% CI, 0.23, 1.00) or nocturnal hypoglycemia (pooled odds ratio 0.82, 95% CI 0.33, 2.03). Adolescents and adults with type 1 diabetes enrolled in crossover trials had nonsignificantly fewer minor hypoglycemia episodes per patient per week (-0.08; 95% CI, -0.21, 0.06) with CSII than MDI; children enrolled in parallel trials had significantly more episodes (0.68; 95% CI, 0.16, 1.20; P(interaction) = 0.03). Outcomes were not different in patients with type 2 diabetes. CONCLUSIONS: Contemporary evidence indicates that compared to MDI, CSII slightly reduced HbA1c in adults with type 1 diabetes, with unclear impact on hypoglycemia. In type 2 diabetes, CSII and MDI had similar outcomes. The effect in patients with hypoglycemia unawareness or recurrent severe hypoglycemia remains unclear because of lack of data. SN - 1945-7197 UR - https://www.unboundmedicine.com/medline/citation/19088167/Clinical_review:_Hypoglycemia_with_intensive_insulin_therapy:_a_systematic_review_and_meta_analyses_of_randomized_trials_of_continuous_subcutaneous_insulin_infusion_versus_multiple_daily_injections_ L2 - https://academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2008-1415 DB - PRIME DP - Unbound Medicine ER -