Diabetes, obesity & metabolism · 2026
Diagnosis and Management of Adult Type 1 Diabetes Mellitus: Systematic Reviews of Biomarkers, Insulin Regimens and Insulin Delivery Devices Highlighting Evidence Gaps in Emergency and Humanitarian Settings.
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Patwa Niyati, Bennett Alexandria, Shaver Nicole, Dahroug Lama, Skidmore Becky, Kelly Shannon E, Wells George, Tricco Andrea C, Lochnan Heather, Little Julian, Brouwers Melissa
Аннотация
AIMS: Supporting the World Health Organization's (WHO) 2021 Global Diabetes Compact's goals, we conducted three systematic reviews on type 1 diabetes (T1D) in adults concerning (1) diagnostic biomarkers, (2) insulin regimens and (3) insulin delivery devices, focusing on emergency and humanitarian settings.
MATERIALS AND METHODS: Multiple databases were searched in October 2024 without language or date restrictions. Two reviewers independently selected studies, extracted data and assessed risk of bias using study-specific tools. Critical outcomes included Haemoglobin A1c (HbA1c), hypoglycaemia, microvascular and macrovascular complications, diabetic ketoacidosis, mortality, adverse events, alongside diagnostic accuracy measures and patient-centred outcomes. Where appropriate, random-effects meta-analyses were performed, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
RESULTS: The biomarkers review (n = 15 studies) found C-peptide and other autoantibodies showed high specificity but variable sensitivity for T1DM diagnosis. The insulin regimen review (three reports from one small trial) suggested possible differences in glycaemic control and nephropathy outcomes between multiple daily and twice-daily regimens. The insulin delivery devices review (n = 8 studies) showed strong patient preference for pens; pooled analyses of HbA1c, hypoglycaemia and quality of life demonstrated outcomes comparable to syringes. Overall, the evidence was sparse, low quality and limited to high-income countries, with none of the studies addressing emergency or humanitarian settings. Certainty of evidence was very low for the biomarkers and delivery devices reviews and low for the insulin regimen review.
CONCLUSIONS: Evidence for T1D care in emergency and humanitarian settings remains very limited. Evidence for biomarker use for diagnoses is constrained by very low-certainty evidence and infrastructure barriers. Multiple daily insulin regimens may confer glycaemic benefits, whereas pens and syringes yield similar outcomes despite patients' preference for pens. Evidence gaps underscore the need for pragmatic, context-sensitive guidance balancing clinical and logistical considerations.
TRIAL REGISTRATION: PROSPERO (CRD420250649000).
MATERIALS AND METHODS: Multiple databases were searched in October 2024 without language or date restrictions. Two reviewers independently selected studies, extracted data and assessed risk of bias using study-specific tools. Critical outcomes included Haemoglobin A1c (HbA1c), hypoglycaemia, microvascular and macrovascular complications, diabetic ketoacidosis, mortality, adverse events, alongside diagnostic accuracy measures and patient-centred outcomes. Where appropriate, random-effects meta-analyses were performed, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
RESULTS: The biomarkers review (n = 15 studies) found C-peptide and other autoantibodies showed high specificity but variable sensitivity for T1DM diagnosis. The insulin regimen review (three reports from one small trial) suggested possible differences in glycaemic control and nephropathy outcomes between multiple daily and twice-daily regimens. The insulin delivery devices review (n = 8 studies) showed strong patient preference for pens; pooled analyses of HbA1c, hypoglycaemia and quality of life demonstrated outcomes comparable to syringes. Overall, the evidence was sparse, low quality and limited to high-income countries, with none of the studies addressing emergency or humanitarian settings. Certainty of evidence was very low for the biomarkers and delivery devices reviews and low for the insulin regimen review.
CONCLUSIONS: Evidence for T1D care in emergency and humanitarian settings remains very limited. Evidence for biomarker use for diagnoses is constrained by very low-certainty evidence and infrastructure barriers. Multiple daily insulin regimens may confer glycaemic benefits, whereas pens and syringes yield similar outcomes despite patients' preference for pens. Evidence gaps underscore the need for pragmatic, context-sensitive guidance balancing clinical and logistical considerations.
TRIAL REGISTRATION: PROSPERO (CRD420250649000).