Comparison of Insulin Titration Strategies for Glycemic Control in Type 2 Diabetes: A Systematic Review and Network Meta-analysis

BACKGROUND: Adjusting basal insulin doses is essential for lowering blood glucose while minimizing the risk of hypoglycemia. Despite various basal insulin titration strategies being available, their comparative effectiveness remains unclear. PURPOSE: To compare the effectiveness of different basal insulin titration strategies on glycemic control in patients with type 2 diabetes. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and EBSCO Open Dissertations were searched from inception to January 2024. STUDY SELECTION: We included published trials with evaluation of basal insulin titration strategies for glycemic control in type 2 diabetes. DATA EXTRACTION: Data on HbA1c and severe hypoglycemia were extracted. DATA SYNTHESIS: Studies were categorized with the theme, intensity, and provider/platform (TIP) framework. "Theme" referred to conventional titration (Conv) or self-titration (ST), "intensity" was categorized as high (Conv, >1/month; ST, ≥2/week) or low (Conv, ≤1/month; ST, <2/week), and for "provider/platform" categories included supported by health care provider (HCP for Conv or S-HCP for ST), patient led (Pt), and supported by application (S-App). The ST/High/S-HCP strategy resulted in the greatest HbA1c reduction in comparison with all others (e.g., ST/High/S-App, mean difference -0.75 [95% CI -1.26, -0.25], and Conv/Low/HCP, -1.19 [95% CI -1.67, -0.72]). Severe hypoglycemia risk did not differ significantly across strategies. LIMITATIONS: The number of studies per network meta-analysis was limited, and not all TIP combinations were evaluated. CONCLUSIONS: Self-titration at least twice a week with health care provider support leads to superior HbA1c reduction in comparison with other strategies, without increasing the risk of severe hypoglycemia. This approach should be considered for clinical practice, where appropriate, to achieve optimal glycemic control in patients with type 2 diabetes.