School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
Monash Health, Melbourne, Australia.
Diabetes Technol Ther. 2020 May;22(5):411-421. doi: 10.1089/dia.2019.0417. Epub 2020 Feb 5.
Existing technologies for type 1 diabetes have not been compared against the full range of alternative devices. Multiple metrics of glycemia and patient-reported outcomes for evaluating technologies also require consideration. We thus conducted a systematic review, network meta-analysis, and narrative synthesis to compare the relative efficacy of available technologies for the management of type 1 diabetes. We searched MEDLINE, MEDLINE In-Process and other nonindexed citations, EMBASE, PubMed, All Evidence-Based Medicine Reviews, Web of Science, PsycINFO, CINAHL, and PROSPERO (inception-April 24, 2019). We included RCT ≥6 weeks duration comparing technologies for type 1 diabetes management among nonpregnant adults (>18 years of age). Data were extracted using a predefined tool. Primary outcomes were A1c (%), hypoglycemia rates, and quality of life (QoL). We estimated mean difference for A1c and nonsevere hypoglycemia, rate ratio for severe hypoglycemia, and standardized mean difference for QoL in network meta-analysis with random effects. We identified 16,772 publications, of which 52 eligible studies compared 12 diabetes management technologies comprising 3,975 participants in network meta-analysis. Integrated insulin pump and continuous glucose monitoring (CGM) systems with low-glucose suspend or hybrid closed-loop algorithms resulted in A1c levels 0.96% (predictive interval [95% PrI] 0.04-1.89) and 0.87% (95% PrI 0.12-1.63) lower than multiple daily injections with either flash glucose monitoring or capillary glucose testing, respectively. In addition, integrated systems had the best ranking for A1c reduction utilizing the surface under the cumulative ranking curve (SUCRA-96.4). While treatment effects were nonsignificant for many technology comparisons regarding severe hypoglycemia and QoL, simultaneous evaluation of outcomes in cluster analyses as well as narrative synthesis appeared to favor integrated insulin pump and continuous glucose monitors. Overall risk of bias was moderate-high. Certainty of evidence was very low. Integrated insulin pump and CGM systems with low-glucose suspend or hybrid closed-loop capability appeared best for A1c reduction, composite ranking for A1c and severe hypoglycemia, and possibly QoL. Registration: PROSPERO, number CRD42017077221.
现有的 1 型糖尿病技术尚未与各种替代设备进行全面比较。评估技术的多种血糖指标和患者报告的结果也需要考虑。因此，我们进行了系统评价、网络荟萃分析和叙述性综合，以比较 1 型糖尿病管理中现有技术的相对疗效。我们检索了 MEDLINE、MEDLINE 正在处理的文献和其他非索引引文、EMBASE、PubMed、所有循证医学评论、Web of Science、PsycINFO、CINAHL 和 PROSPERO（从开始到 2019 年 4 月 24 日）。我们纳入了比较 1 型糖尿病管理中各种技术的持续时间≥6 周的 RCT，研究对象为非妊娠成年人（年龄>18 岁）。使用预先设定的工具提取数据。主要结局为 A1c（%）、低血糖发生率和生活质量（QoL）。我们在网络荟萃分析中使用随机效应估计了 A1c 和非严重低血糖的平均差异、严重低血糖的率比以及 QoL 的标准化均数差。我们共识别出 16772 篇文献，其中 52 项符合条件的研究比较了 12 种糖尿病管理技术，涉及网络荟萃分析中的 3975 名参与者。具有低血糖暂停或混合闭环算法的集成胰岛素泵和连续血糖监测（CGM）系统使 A1c 水平分别降低了 0.96%（预测区间[95%PrI]0.04-1.89）和 0.87%（95%PrI 0.12-1.63），低于多次每日注射加闪光葡萄糖监测或毛细血管葡萄糖测试。此外，在利用累积排序曲线下面积（SUCRA-96.4）进行 A1c 降低的评估中，集成系统的排名最佳。尽管许多技术比较在严重低血糖和 QoL 方面的治疗效果没有统计学意义，但聚类分析和叙述性综合同时评估结果似乎更倾向于集成胰岛素泵和连续血糖监测。整体偏倚风险为中高度。证据确定性非常低。具有低血糖暂停或混合闭环功能的集成胰岛素泵和 CGM 系统似乎最适合降低 A1c、A1c 和严重低血糖的综合排名，以及可能的 QoL。注册：PROSPERO，编号 CRD42017077221。
