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Comparative Study
. 2014 Oct 1:349:g5459.
doi: 10.1136/bmj.g5459.

Safety, effectiveness, and cost effectiveness of long acting versus intermediate acting insulin for patients with type 1 diabetes: systematic review and network meta-analysis

Andrea C Tricco  1 , Huda M Ashoor  1 , Jesmin Antony  1 , Joseph Beyene  2 , Areti Angeliki Veroniki  1 , Wanrudee Isaranuwatchai  1 , Alana Harrington  1 , Charlotte Wilson  1 , Sophia Tsouros  1 , Charlene Soobiah  1 , Catherine H Yu  1 , Brian Hutton  3 , Jeffrey S Hoch  1 , Brenda R Hemmelgarn  4 , David Moher  3 , Sumit R Majumdar  5 , Sharon E Straus  6
Affiliations
Comparative Study

Safety, effectiveness, and cost effectiveness of long acting versus intermediate acting insulin for patients with type 1 diabetes: systematic review and network meta-analysis

Andrea C Tricco et al. BMJ. .

Abstract

Objective: To examine the safety, effectiveness, and cost effectiveness of long acting insulin for type 1 diabetes.

Design: Systematic review and network meta-analysis.

Data sources: Medline, Cochrane Central Register of Controlled Trials, Embase, and grey literature were searched through January 2013.

Study selection: Randomized 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.

Results: 39 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.

Conclusions: Long 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 registration: PROSPERO CRD42013003610.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: this was work funded by the Canadian Institutes for Health Research; no financial relationships with any organization that might have an interest in the submitted work in the previous three years; no relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Study flow
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Fig 2 Network meta-analysis estimates for glycated hemoglobin (26 randomized clinical trials including 6776 patients). bid=twice daily; od=once daily; qid=four times daily
See this image and copyright information in PMC

References

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    1. Vardi M, Jacobson E, Nini A, Bitterman H. Intermediate acting versus long acting insulin for type 1 diabetes mellitus. Cochrane Database Syst Rev 2008;3:CD006297. - PMC - PubMed
    1. Cameron CG, Bennett HA. Cost-effectiveness of insulin analogues for diabetes mellitus. CMAJ 2009;180:400-7. - PMC - PubMed

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