Background: Comparisons of new technologies for type 1 diabetes through synthesis of randomized controlled trial (RCT) evidence are critical to guiding device selection. We thus conducted a systematic review and network meta-analysis to compare and rank the efficacy and safety of technologies for the treatment of type 1 diabetes.

Methods: We searched MEDLINE, MEDLINE In-Process and other non-indexed citations, EMBASE, PubMed, All Evidenced Based Medicine Reviews, Web of Science, PsycINFO, CINAHL and PROSPERO. We included RCTs ≥6 weeks duration comparing technologies among non-pregnant adults (≥18 years of age). We assessed risk of bias using a validated tool and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. Primary outcomes were HbA1c, rates of severe and non-severe hypoglycemia, and quality of life.

Findings: We identified 15,691 publications of which 50 eligible studies compared 12 technologies, with 3,885 participants. Integrated insulin pump and continuous glucose monitoring (CGM) systems resulted in HbA1c levels 0·95% (95% predictive interval 0·02-1·87) and 0·86% (0·10-1·61) lower than multiple daily injections (MDI) with either flash glucose monitoring or capillary glucose testing, respectively. Integrated systems also had the best overall ranking for HbA1c reduction. MDI with flash glucose monitoring was ranked as the best treatment for prevention of non-severe hypoglycemia with event rates significantly lower than any other intervention. The best treatment rankings for severe hypoglycemia and quality of life were MDI with flash glucose monitoring and CGM, respectively. The overall risk of bias rating was moderate-high for all outcomes. The certainty of evidence was very low.

Interpretation: Integrated insulin pump and CGM systems appeared superior for lowering HbA1c while glucose sensing devices appeared superior for preventing hypoglycaemia and improving quality of life.


A.J. Pease: None. C. Lo: None. A. Earnest: None. V. Kiriakova: None. D. Liew: Advisory Panel; Self; AstraZeneca, Bayer AG. Research Support; Self; AbbVie Inc., AstraZeneca, Bristol-Myers Squibb Company, CSL Behring, Pfizer Inc. S. Zoungas: None.

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