Comparative Efficacy of Insulin Delivery Modalities on Glycaemic Control in Adults With Type 2 Diabetes: A Systematic Review and Network Meta-Analysis

Aims: To compare insulin delivery modalities for glycaemic control, body weight and insulin dose in adults with insulin-treated Type 2 diabetes. Materials and Methods: We searched eight databases and two trial registries until 27 April 2026 for parallel-group randomised trials comparing pre-specified insulin delivery modalities. The primary network meta-analysis excluded the clinically heterogeneous residual Other node. Outcomes were changes in HbA1c, time in range (TIR), time above range (TAR), time below range (TBR), body weight and insulin dose; certainty was assessed with CINeMA. Results: Thirty-seven reports describing 36 independent trials with 4157 participants were included. Median follow-up was 12 weeks. In the primary no-Other analysis, hybrid closed-loop (HCL) reduced HbA1c versus multiple daily injections (MDI; MD −0.79%, 95% CI −1.33 to −0.25), increased TIR (MD +16.00 percentage points, 95% CI +8.77 to +23.22), reduced TAR (MD −13.48 percentage points, 95% CI −23.05 to −3.91) and reduced insulin dose (MD −15.69 U/day, 95% CI −31.33 to −0.06). Continuous subcutaneous insulin infusion also reduced HbA1c (MD −0.47%, 95% CI −0.74 to −0.20) and insulin dose. Fully closed-loop yielded larger TIR/TAR estimates, but from one short trial only and should be considered hypothesis-generating. HCL increased body weight (MD +1.58 kg, 95% CI +0.75 to +2.40). Most trials had risk-of-bias concerns and low-risk sensitivity analysis was infeasible. Conclusions: HCL showed the most consistent glycaemic benefit, but body-weight and sparse safety evidence warrant caution. FCL findings require larger, longer confirmation. Trial Registration: PROSPERO registration: CRD420261381231. © 2026 John Wiley & Sons Ltd.