This systematic review and meta-analysis assessed the efficacy and safety of the newer ultra-rapid-acting insulins in people with type 1 and type 2 diabetes. Nine studies were analysed. Ultra-rapid insulins were compared against placebo in one trial and against rapid-acting insulins in the remaining eight. Five of the trials enrolled a total of 3207 people with type 1 diabetes (mean age, 43.5 years; mean HbA1c, 60 mmol/mol [7.6%]; mean diabetes duration, 43.5 years). Four enrolled a total of 2441 people with type 2 diabetes (mean age, 60.0 years; mean HbA1c, 60 mmol/mol; mean diabetes duration, 15.0 years).
Over a study follow-up ranging from 16 weeks to 1 year, the primary outcome of change in HbA1c was not significantly different between the treatment groups (weighted mean difference [WMD], 0.02% for both type 1 and type 2 diabetes). Similarly, no difference was observed in terms of fasting plasma glucose, self-measured plasma glucose, body weight or daily insulin requirements. Serious adverse events and hypoglycaemia rates were also similar between the groups. A modest increase in total daily insulin dose (WMD, 4.64 units) was observed in people with type 2 diabetes.
The only other difference observed between the treatment groups was in 1-hour and 2-hour postprandial glucose levels, which were significantly reduced with ultra-rapid-acting insulins (1-hour glucose WMD, –0.94 mmol/L and –0.56 mmol/L for type 1 and type 2 diabetes, respectively). Evaluation of postprandial glucose was based on liquid meal tests in all studies, which the authors point out as a limitation, as the results may have differed from those of solid mixed meals which participants would typically eat.
The authors conclude that ultra-rapid-acting insulins are as efficacious and safe as rapid-acting insulins, providing a beneficial effect solely on postprandial glucose levels. However, there was no evidence of superiority in terms of overall glycaemic control.
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Attempts to achieve remission, or at least a substantial improvement in glycaemic control, should be the initial focus at type 2 diabetes diagnosis.
9 May 2024