A Cochrane review [Abstract] 3 included 26 RCTs. Compared with NPH insulin, there was a reduction in severe hypoglycaemia in favour of insulin detemir: (8.5% vs 11.5%; RR 0.69, 95% CI 0.52 to 0.92; 8 studies, n=3219) and insulin glargin (10.2% vs 12.5%; RR 0.84, 95% CI 0.67 to 1.04; 9 studies, n=2350).
A review and network meta-analysis 2 included 27 randomized controlled trials including a total of 7469 subjects assessing long acting (glargine, detemir) and intermediate acting (NPH, lente) insulin for adults with type 1 diabetes. Glargine once daily, detemir once daily, and detemir once/twice daily significantly reduced hemoglobin A1c compared with NPH once daily in network meta-analysis (mean difference -0.39%, 95% CI -0.59% to -0.19%; -0.26%, -0.48% to -0.03%; and -0.36%, -0.65% to -0.08%; respectively; 26 RCT). Differences in network meta-analysis were observed between long acting and intermediate acting insulin for severe hypoglycemia (detemir once/twice daily versus NPH once/twice daily: OR 0.62, 95% CI 0.42 to 0.91; 16 RCT) and weight gain (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; 13 RCT). 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
A Cochrane review [Abstract] 1 included 23 studies with a total of 6 787 subjects. 11 studies compared glargine with NPH, 8 studies compared detemir with NPH, and 4 studies compared ultralente with lente or NPH, as basal insulins. Only two of the studies involved non-NPH intermediate acting insulin.
The weighted mean difference (WMD) for the level of glycosylated haemoglobin was -0.08 (95% CI -0.12 to -0.04) in favour of the long acting insulin arm. The WMD between the groups in fasting plasma and blood glucose levels was -0.63 (95% CI -0.86 to -0.40) and -0.86 (95% CI -1.00 to -0.72) in favour of the long acting insulins. The odds ratio for a patient on long acting insulin to develop any type of hypoglycaemia was 0.93 (95% CI 0.8 to 1.08) compared to that of a patient on intermediate acting insulins. The OR for severe hypoglycaemic episodes was 0.73 (95% CI 0.61 to 0.87), and 0.70 (95% CI of 0.63 to 0.79) for nocturnal episodes. The WMD between the long and intermediate insulin groups for hypoglycaemic events per 100 patient follow up days was -0.77 (95% CI -0.89 to -0.65), -0.0 (95% CI -0.02 to 0.02) and -0.40 (95% CI -0.45 to -0.34) for overall, severe, and nocturnal hypoglycaemic episodes. No difference was noted in the quantity or quality of severe adverse events or deaths. The presumed mitogenic effect of long acting insulins could not be addressed, nor could their long term reduction of diabetic complications.
Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment and lack of blinding).
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