Episode Overview

Podcast: Diabetes Core Update
Episode Title: Automated Insulin Delivery Part 2
Date: January 13, 2026
Host: Dr. Neil Skolnik
Guests: Davita Kruger, NP & Ashlyn Smith, PA-C

This episode focuses on practical, clinical steps for initiating automated insulin delivery (AID) systems in people with type 2 diabetes—moving from theory and evidence to real-world application. The discussion details patient selection, updates to diabetes care standards, the logistics of prescribing AID in primary care, tips for onboarding, troubleshooting common issues, and strategies for integrating AID into routine practice. The goal is to empower frontline clinicians with clear, actionable steps and to demystify new technology so more patients can benefit from AID systems.

Key Discussion Points and Insights

1. Why Should Primary Care Clinicians Consider AID in Type 2 Diabetes?

• Poor Goal Attainment: Less than 50% of US patients on insulin reach targets despite modern medications.
• Major Studies: Recent trials (JAMA Network Open, NEJM 2025) showed about 2.1% A1C lowering with AID, including for patients already on GLP-1 therapy and diverse backgrounds.
• Reduced Distress/Effort: “People just felt better and had less diabetes distress.” (Kruger, 05:28)
• AID vs. MDI: AID mitigates missed doses, hyper/hypoglycemia—unlike injectable basal/bolus regimens.
• Primary Care’s Role: Most type 2 patients are treated in primary care; success depends on engaging these providers.

Quote:
"Diabetes is so much work. If I can take some of that away, I think it's a win-win." (Kruger, 06:31)

2. Patient Selection for AID in Type 2 Diabetes

• Eligibility: Willingness to wear a CGM is the main prerequisite; “CGM is a right, not a privilege.”
• Inclusivity: Studies included patients across insulin doses (>100 units/day), diverse backgrounds, income, education; no requirement for carbohydrate counting.
• Practical Advice: Offer AID broadly to anyone on insulin and interested in an easier, more effective approach.
• Key Principle: Don't restrict access—patients did well regardless of prior concerns about medication adherence or technical sophistication.

Quote:
"The diversity was phenomenal... At the end of the day, it didn't matter. Everyone did well." (Kruger, 08:22)

3. Shifting Standards: ADA Recommendations (2026)

• Major Policy Change: ADA now formally recommends offering AID to all adults with type 1 or type 2 diabetes on insulin, including adolescents and children with type 2.
• Barriers Removed: No longer require C-peptide testing, antibody screening, or minimum insulin duration for pump eligibility.
• Insurance Lag: ADA leads; payers may follow with time.

Quote:
"Automated insulin delivery systems should be offered to all adults with type 1 and type 2 diabetes on insulin... Grade A recommendation." (Skolnik quoting ADA section 9.27, 15:31)

4. Making AID Manageable in Primary Care

a. Getting Started—It’s Simpler Than Expected

• Mindset Shift: Reframe “challenging” patients as opportunities for AID success.
• Order & Initiation:
  • Prescription sent—company provides straightforward forms.
  • Most settings filled automatically from total daily insulin dose and patient weight.
  • Company-certified trainers teach patients and provide clinician feedback.
  • Recommend using company trainers, even in specialist practices.
• Selection Tips: Learn one pump system in depth before branching out.

Quotes:
"The majority of the aid systems now have these... pre-filled forms. For some of them you only have to put in the total daily dose of insulin and the patient’s weight and it fills the rest of it out for you." (Smith, 18:52)

"You don't have to be a master of every pump. Start with one..." (Smith, 23:09)

b. Workflow and Follow-Up

• First Follow-up: Within 2–4 weeks; trainers also follow up and report to clinician.
• Data Access: Cloud-based platform setup with company trainers is recommended; essential for reviewing data and troubleshooting.
• Outcomes: Time-in-range improves, hypoglycemia reduced, often lower total insulin dose by 13 weeks.

5. Troubleshooting and Practical Pearls

• Infusion Set Issues: Malfunction or kinking can cause unexplained hyperglycemia; check and change site if needed.
• Sensor-Pump Communication: Ensure devices have a “line of sight” for reliable Bluetooth connection (e.g., don’t place on opposite sides of body).
• AID Safety: The pump’s automation protects against hypoglycemia, allowing flexible initial settings.
• Workflow Simplification: Tubeless/pod systems may be easier for primary care to start with since tubing and infusion sets aren’t needed.

Quotes:
"If I give somebody an insulin pump, that pump manages the hypoglycemia... If a primary care person is going to be afraid, it's by MDI, not the pump." (Kruger, 30:41)

6. Available AID Systems for Type 2 Diabetes (as of recording)

• Omnipod 5 (tubeless/pod)
• Tandem t:slim X2 (tubed)
• Medtronic 780G (tubed)

Quote:
"We have three that are currently approved... Omnipod 5, T Slim X2, and Medtronic 780G." (Smith, 37:08)

Notable Quotes & Memorable Moments (with timestamps)

• On clinical inertia and primary care’s crucial role:
  "Who is going to do this if we don't engage you? The majority of people with type 2 diabetes are in your practice, not mine. So I'm happy to partner with you." (Kruger, 06:46)

• On technology anxiety for providers:
  "The ease of how these pumps function will really surprise the person who's not had the ability or the opportunity to utilize them." (Kruger, 25:28)

• On teamwork and sharing the load:
  "You are not alone in managing this… utilize those colleagues. It’s really important to understand that you, as a sole provider, are not responsible for doing every piece of it." (Smith, 38:34)

Timestamps – Key Segments

• [03:51] — The value of AID for type 2 diabetes
• [05:34] — AID vs. traditional insulin titration
• [07:43] — Patient selection for AID
• [11:36] — The paradigm shift: primary care and AID accessibility
• [13:08] — 2026 ADA Standards: expanded AID recommendation
• [16:38] — Prescribing and onboarding workflow
• [20:00] — Simplifying device setup and training
• [23:08] — Choosing and getting comfortable with one system
• [24:03] — Trainer’s role and initial patient follow-up
• [28:19] — Importance of cloud-based data access
• [31:47] — Prescribing, onboarding, and follow-up recap
• [32:29] — Common troubleshooting scenarios
• [35:47] — Simpler systems: pods versus tubing
• [37:08] — List of currently approved AID systems
• [37:42] — Final thoughts on supporting primary care
• [38:34] — Emphasis on teamwork and using office champions

Takeaway Messages

• AID is now guideline-endorsed for all insulin-treated adults and children with type 2 diabetes.
• Primary care teams can and should initiate AID—trainers and educators are there to help.
• Starting with one system, leveraging company support, and focusing on simplicity ensures clinical success and reduced burden.
• Don’t let technology anxiety or inertia prevent patients from better outcomes and quality of life.

For more information, visit www.diabetesjournals.org.