Aug 2026· Endocrine Practice· 0 citations· 51 references
Medicine
TL;DR
Randomized and real-world studies demonstrate that AID systems significantly improve A1C and time in range while minimizing hypoglycemia, without increasing treatment complexity or patient burden, and position AID as a practical and effective strategy to overcome long-standing therapeutic inertia in type 2 diabetes.
Abstract
Despite major advances in therapeutics, many adults with type 2 diabetes do not achieve recommended glycemic targets, driven by progressive beta cell dysfunction and persistent therapeutic inertia. Insulin therapy is commonly delayed for years, exposing patients to prolonged hyperglycemia and substantially increasing complication risks. Although automated insulin delivery (AID) systems have transformed outcomes for people with type 1 diabetes, their adoption in type 2 diabetes has been limited. Emerging evidence and recent updates to the American Diabetes Association Standards of Care now support AID as the preferred insulin delivery method for adults with type 2 diabetes on multiple daily injections of insulin or for whom basal-only insulin is not sufficient to achieve glycemic targets, reflecting a paradigm shift toward addressing the burdens and limitations of manual insulin delivery. Randomized and real-world studies demonstrate that AID systems significantly improve A1C and time in range while minimizing hypoglycemia, without increasing treatment complexity or patient burden. By dynamically adapting insulin delivery to real-time continuous glucose monitoring data, AID mitigates common barriers to intensification, including fear of hypoglycemia and increased regimen complexity associated with multiple daily injections. In addition, AID enables more efficient diabetes care through standardized glucose reporting, remote data review, and team-based management. Together, these advances position AID as a practical and effective strategy to overcome long-standing therapeutic inertia in type 2 diabetes. Earlier consideration of AID during insulin intensification could improve glycemic outcomes, reduce diabetes-related complications, decrease cognitive burden, and modernize insulin delivery for people living with type 2 diabetes.
A practice-oriented evaluation of the indications, clinical benefits, and safety of modern diabetes technologies and suggests that technologies should be offered according to individual needs, abilities, preferences, and life circumstances and implemented early, including at the time of diagnosis.
Achieving glucose targets without hypoglycaemia is the treatment goal in type 1 diabetes. Structured education, intensified insulin injection regimens, continuous glucose monitoring, automated insulin delivery, and ongoing support from a multidisciplinary team all support people with type 1 diabetes to achieve this goal. Despite these advances, significant barriers to achieving optimal management remain. Continuous intraperitoneal insulin infusion has comparable or better glucose outcomes to continuous subcutaneous insulin infusion and may reduce the frequency of hypoglycaemia, including severe episodes. Intraperitoneal insulin may be considered as a treatment modality for children and adults with type 1 diabetes using optimised intensive insulin therapy for whom subcutaneous insulin has failed due to lipoatrophy, -dystrophy or -hypertrophy, local allergy, subcutaneous insulin resistance or co-existing skin conditions. Failure of subcutaneous insulin may result in recurrent or unexplained severe hypoglycaemia or hyperglycaemia. Intraperitoneal insulin may also be considered as a treatment modality for people with type 1 diabetes with severe needle-phobia, and for those being considered for islet cell or pancreatic transplantation, or where transplantation is not available. This paper summarises current intraperitoneal insulin delivery technology, its potential risks and benefits, and an expert position statement. It is intended for use by diabetes specialist healthcare professionals, and as a reference for other healthcare professionals, commissioners, payors, people with diabetes, their carers, and advocates.
Nick S. Oliver, B. Gehr, R. Lal et al.· Diabetes, obesity and metabo...· 0 citations
For decades, type 2 diabetes (T2D) pharmacotherapy has followed a reactive, stepwise approach, typically initiated with metformin monotherapy and intensified only after glycemic deterioration. This so-called wait-to-fail strategy may prolong hyperglycemia and increase the cumulative risk of microvascular and macrovascular complications. Early combination therapy (ECT) has been proposed as an alternative strategy to achieve faster glycemic control, improve glycemic durability, and enable timely use of glucose-lowering agents with cardiovascular, renal, and metabolic benefits. This narrative review examines the rationale for ECT in newly diagnosed T2D and summarizes evidence from landmark clinical trials. Recent updates to major international guidelines, including the 2026 American Diabetes Association Standards of Care in Diabetes and National Institute for Health and Care Excellence NG28, are also discussed, reflecting a shift toward individualized, comorbidity-focused treatment selection. While ECT represents an important evolution in T2D management, current clinical evidence supports its use mainly in selected patients rather than as a universal default strategy.
A. Janež, Tanja Smid, Manfredi Rizzo et al.· Journal of diabetes and its...· 0 citations
BACKGROUND
This study examined how automatic correction boluses (ABs) vary according to active insulin time (AIT) and glucose target settings, and how these parameters impact glycemic control in individuals with type 1 diabetes.
METHODS
Retrospective data from 287 individuals with type 1 diabetes using the MiniMed 780G system in auto-mode for at least 80% of the time over a minimum period of 6 months were analyzed. The AB delivery was evaluated in relation to different AIT and glucose target settings. Glycemic outcomes, including time in range (TIR 70-180 mg/dL), were assessed.
RESULTS
Automatic correction boluses accounted for 33.1% of bolus insulin and 18.3% of the total daily insulin dose (TDD). Active insulin time settings significantly influenced AB delivery: individuals using a 2-hour AIT showed higher percentages of ABs relative to both TDD and bolus insulin, as well as higher AB doses expressed in IU/kg/day. Shorter AIT settings were also associated with improved TIR. In contrast, glucose target settings ranging from 100 to 120 mg/dL did not significantly affect AB delivery or TIR.
CONCLUSION
Active insulin time is a key modifiable parameter influencing AB delivery and glycemic outcomes. Shorter AIT settings were associated with increased AB administration and improved TIR, whereas glucose target settings had no significant impact on these outcomes.
Giuseppe Papa, R. Cannarella, C. Gusmano et al.· Journal of Diabetes Science...· 0 citations
The successful management of type-1 diabetes (T1D) and insulin-dependent type-2 diabetes depends on the ability to accurately calibrate bolus and basal insulin doses, and minimize the time spent with high postprandial blood glucose (BG) levels while avoiding dangerously low hypoglycemic excursions. Precise calibration of the insulin pump helps with successful disease management; however, people with T1D may still experience prolonged, potentially damaging BG levels due to postprandial highs. Insulin pumps offer large, currently underexploited degrees of freedom in insulin delivery, which can have a dramatic impact on average postprandial BG levels. Building on existing models of the glucose-insulin system, we first propose a simple, automated, and individualized insulin-pump calibration system based on a series of measures taken before and a few hours after carbohydrate ingestion. We then modulate the shape of pre-meal insulin dosing to explicitly reduce postprandial BG levels while minimizing the likelihood of dangerously low BG. Such an optimal insulin delivery time course can potentially improve postprandial BG levels and rapidly bring BG to the target level. We evaluated our methods in 20 patients over 4 days, with BG levels sampled frequently.
I. Aganj, N. Bryant, Leah (Morgan) Panaro et al.· medRxiv· 0 citations
ackground: Type 2 diabetes mellitus (T2DM) is fundamentally characterised by a progressive, inexorable
decline in pancreatic beta-cell function superimposed on peripheral insulin resistance. Although initial
management relies on lifestyle modifications and non-insulin antihyperglycemic therapies, a substantial
proportion of patients eventually require exogenous insulin to achieve and maintain optimal glycemic
targets.
Aims: This review synthesises current clinical evidence, international consensus guidelines, and recent
therapeutic breakthroughs to provide an operational framework on the clinical triggers ("when"),
physiological rationales ("why"), and practical algorithms ("how") of initiating insulin therapy.
Methods: A comprehensive literature search of electronic databases, including PubMed, MEDLINE, and
Embase, was conducted to identify English-language, peer-reviewed literature, clinical guidelines, and
landmark trials concerning insulin therapy in T2DM. This review evaluates data from foundational clinical
trials (UKPDS, ACCORD, ADVANCE, and the GRADE study) alongside current consensus
recommendations from the American Diabetes Association (ADA) and the European Association for the
Study of Diabetes (EASD). Literature tracking clinical thresholds for initiation, comparative data on
traditional insulin regimens (basal, biphasic, basal-bolus), and Phase 3 clinical trial data for once-weekly
basal insulins and digital health technologies published between 2019 and 2026 were extracted and
evaluated.
Conclusions: Overcoming clinical inertia requires proactive clinician intervention, structured patient
education to address psychological insulin resistance, and the early adoption of advanced monitoring
technologies. Timely and tailored implementation of insulin therapy remains a cornerstone in altering the
long-term microvascular and macrovascular trajectory of patients with T2DM.
Keywords: Type 2 Diabetes Mellitus; Insulin Initiation; Basal Insulin; Clinical Inertia; Hypoglycemia.
Manal Mekki· Journal of Medical Science A...· 0 citations