Diabetes Core Update – Special Edition: AID Part 3 – Cases Feb 2026
Podcast: Diabetes Core Update
Episode: Special Edition — AID Part 3: Cases
Date: February 5, 2026
Hosts: Dr. Neal Skolnick, Dr. John J. Russell (not present in this episode)
Guests:
- Davida Kruger, NP (Henry Ford Health)
- Dr. Susan Kuchera (Jefferson Health Abington Family Medicine)
Overview
Main Theme:
This third and final part of the special Diabetes Core Update series explores the practicalities, decision-making, and common questions around prescribing Automated Insulin Delivery (AID) systems for people with type 2 diabetes. The conversation moves from evidence and theory to the messy and complicated real world, offering both specialist and primary care perspectives. Two real-world cases are discussed to show how AID can fit into patient management.
Purpose:
To bridge the gap between clinical trial data and primary care clinic realities, discuss operational/logistic barriers, review ADA Standards of Care updates, and explore practical strategies for integrating AID systems into diabetes treatment for adults with type 2 diabetes.
Key Discussion Points and Insights
1. Primary Care Realities & The State of Insulin Pump Use
- Dr. Susan Kuchera describes her busy primary care practice, which has many uninsured/underinsured patients and clinicians who rarely initiate or manage insulin pumps (03:04).
- Quote:
“We have a fair number of patients who are on insulin… with very significant access issues to get in with endocrinology… We do a lot of troubleshooting… but we don’t really manage an awful lot of [insulin pumps].” (03:04, Dr. Susan Kuchera)
- Observation: Most of primary care still does not routinely use or manage AID, but frequently supports patients when specialist access is limited.
2. Recent Evidence & Broader Inclusion in AID Trials
- Dr. Skolnick summarizes two major, recent trials (JAMA Network Open, NEJM) showing significant A1C reductions (from 8.2% to 7.4%; difference of 0.6-0.8%) without increased hypoglycemia risk in diverse populations on AID vs. standard insulin regimens (05:03).
- Davida Kruger highlights deliberate inclusion of older adults, racially diverse patients, those with high insulin needs, and varied socioeconomic backgrounds in these studies (07:20).
- The higher the baseline A1C, the greater the reduction seen (often >2% for double-digit A1Cs).
- Quote:
“We took all comers… so we could say, OK, we did the research, we proved this. Now how do we share it in the primary care world?” (07:20, Davida Kruger)
3. Advantages of AID Over Multiple Daily Injections (MDI)
- Adherence Transparency: AID provides visibility into actual insulin delivery and use, as opposed to the uncertainty of MDI adherence (10:01).
- Safety: The data allow real-time troubleshooting and monitoring, which can minimize risks of missed doses or incorrect insulin administration.
- ADA Standards:
- New recommendation:
“Automated insulin delivery systems should be offered to all adults with type 1 and type 2 diabetes on insulin, depending on the person or caregiver’s needs and preferences.” (A-level recommendation) (11:54)
- New recommendation:
- Quote:
“With the pump, we have a high degree of confidence that they are actually getting the insulin that’s prescribed.” (10:01, Dr. Skolnick)
4. Primary Care Barriers: Logistical & Operational Issues
- Cloud Integration & Time:
- Even with CGMs becoming more common, integrating and actually reviewing data routinely in busy clinics remains rare and challenging (12:35).
- Training & Support: Many primary care physicians feel they lack the exposure to get comfortable with pump technologies in real practice, especially with integration and troubleshooting (13:41).
5. Case Discussions: Translating Evidence Into Practice
Case 1: 55-year-old man, Type 2 Diabetes
- Background: On multiple agents (metformin, SGLT2, GLP-1 agonist, basal and bolus insulin), A1C 8.2%.
- Primary Care Approach (Kuchera):
- Typical: optimize lifestyle, adherence, consider CGM; would refer to endocrinology when insulin requirements seem “high” or patient is not at goal (15:32).
- Quote:
“This is starting to teeter on the amount of insulin that I’m like, yeah, I don’t know… comfortable with… probably would refer to endocrine at this point.” (15:32, Dr. Kuchera)
- Specialist Approach (Kruger):
- This is a textbook pump candidate; AID minimizes concerns about missed doses, improves control, and reduces risk of hypoglycemia by modulating insulin dynamically (16:55).
- “Even if the patient misses his mealtime insulin, that pump will correct.” (18:26, Kruger)
- Compelling rationale:
- AID confers both safety (mitigating hypoglycemia risk) and efficacy in real-world adherence situations, as the device ensures appropriate insulin titration, unlike self-administered MDI. (19:54)
Case 2: 60-year-old woman, Type 2 Diabetes, CKD3A
- Background: On metformin, SGLT2, GLP-1, well-tolerated, lost weight, A1C still 8.6%.
- Primary Care Approach (Kuchera):
- Would have considered adding basal insulin, delay complex regimens (26:53).
- Specialist Approach (Kruger):
- Strongly recommends offering AID earlier, since advanced agents and weight loss still leave her above target; AID can facilitate tighter control, minimize risk, and ease future insulin intensification (24:24).
- Quote:
“Why would you use four syringes a day when you can give somebody an insulin pump that makes decisions for them, that helps them with high blood sugars and prevents low blood sugars?” (24:24, Kruger)
- Earlier AID initiation is both patient-friendly and clinically effective.
6. Bridging Primary and Specialty Care: Collaboration Models
- Referral-Start-Return Model:
- Kruger advocates for initiating AID in specialty clinics, then returning the patient to primary care once stable (29:36). This shares workload and accelerates learning.
- Quote:
“If you want me to help you start them, then take them back into your practice and work with me.” (24:24, Kruger)
- Support From Device Companies:
- Companies offer substantial training, support with logistics, cloud account set-ups, and ongoing education, reducing practice burden (33:55).
- “We don’t train pumps on our site either. We use all of the companies, trainers who come in and train our patients.” (33:55, Kruger)
7. Practical Questions & Troubleshooting With AID
- Sick Day/Contingency Planning:
- Always have basal insulin as backup in case of device failure, plus glucagon and ketone monitoring supplies (31:43).
- Cloud Data:
- Device trainers typically set up and administer cloud accounts; integration for primary care can be made seamless (34:22).
- Patient Self-Management:
- After initial period, most patients manage their own diabetes care with AID, reducing provider workload (33:55).
Notable Quotes & Memorable Moments
-
On Inclusion in Trials:
“We took so many all comers that we really wanted to be able to say, OK, we did the research, we proved this…”
(07:20, Davida Kruger) -
On Real-World Adherence & Safety:
“With the pump, we have a high degree of confidence that they are actually getting the insulin prescribed.”
(10:01, Dr. Skolnick) -
On Primary Care Learning Curve:
“You’re troubleshooting… I think you are closer to using insulin pumps than you think.”
(13:41, Davida Kruger) -
On Default Referrals:
“I would probably say, why don’t we get you in with endocrine and see what they think… I would love to know what you would do with him.”
(15:32, Dr. Kuchera) -
On AID for Specialists:
“If you want me to help you start them, then take them back into your practice and work with me… even the partnership, and you’re already troubleshooting, the pump is making the decisions for you.”
(24:24, Kruger) -
On Backup Plans:
“We always have them have a basal insulin as a backup. If your pump fails… you can take a basal insulin.”
(31:43, Kruger) -
On Change & Patient Agency:
“The number one reason when you ask a patient why they’re not on a pump, they’ll say, ‘nobody asked me if I would be interested.’”
(36:22, Kruger) -
On Real-World Titration:
“In theory, theory and practice are the same. In practice, they’re not.”
(30:23, Skolnick quoting Yogi Berra)
Key Timestamps
- 03:04 – Dr. Kuchera describes the primary care perspective and challenges
- 05:03 – Dr. Skolnick recaps recent key AID trials
- 07:20 – Kruger on study inclusion, broad representation, and real-world relevance
- 10:01 – Discussion on adherence and data confidence with AID
- 11:54 – ADA standards update quoted verbatim
- 13:41 – Primary care ‘halfway there’ on technology use
- 15:32 – Case 1 introduced and discussed
- 18:26 – Kruger on safety, insulin titration by AID
- 24:24 – Case 2 introduced and discussed; referral and partnership model
- 31:43 – Managing sick days and device failures
- 33:55 – Practice logistics, using device company trainers
- 36:22 – Final thoughts (“No patient asked” quote)
- 37:27 – Dr. Kuchera’s closing thoughts on operationalizing AID in primary care
Episode Takeaways
- AID is rapidly becoming the recommended insulin delivery option for many adults with type 2 diabetes, backed by high-level clinical evidence and ADA recommendations.
- Primary care clinicians should be aware of AID systems as an option—offering them can be as simple as informing, referring, or collaborating with endocrinology and leveraging training/support from device companies.
- Safety, efficacy, and patient empowerment are improved with AID, but each clinic must tackle operational complexities relevant to their setting.
- Ultimately, most barriers can be addressed with partnership, training, and a willingness to gradually adopt new workflows—“offer and discuss” is the mantra.
For further reading, see ADA Standards of Care, Diabetes Care, Section 9.27 (AID) and 7.25 (tech).