Diabetes Core Update – Special Edition: Automated Insulin Delivery for Type 2 Diabetes (Part 1)

Released: December 9, 2025
Host: Dr. Neil Skolnick
Guest: Davida Kruger, NP

Episode Overview

This special edition kicks off a three-part series examining the emerging use of automated insulin delivery (AID) systems in people with Type 2 diabetes. While AID is well-established for Type 1, its use in Type 2 is both novel and promising. Neal Skolnick and guest Davida Kruger—a renowned diabetes nurse practitioner and researcher—explore the rationale, recent clinical evidence, system mechanics, impact on patient and provider burden, and challenges for wider adoption in primary care.

Key Discussion Points & Insights

Why AID for Type 2 Diabetes?

• Challenging Assumptions:

  • Kruger contests the view that pumps are only for Type 1 or highly motivated Type 2 patients. She asserts, “Everyone should be on a sensor. I always think of CGM as a right, not a privilege.” (03:01)
  • There’s a misconception that AID systems are too complex for people with Type 2, or that they require advanced skills like carb counting.

• Insulin Therapy in Type 2:

  • 7.9 million Americans are on insulin; current manual approaches are “imperfect” due to variability in absorption, timing, and compliance.
  • Insulin pumps are just another delivery tool and may reduce complications and burdens associated with injections.

What Is Automated Insulin Delivery and How Does It Work?

• Core Components:

  • AID requires a continuous glucose monitor (CGM) integrated with an insulin pump; the devices communicate, adjusting insulin in real time. (05:10)
  • All pumps use rapid-acting insulin only—no long-acting (basal) insulin.

• Algorithmic Adjustments:

  • The pump and CGM “talk” constantly. Based on trends, the system can increase or decrease basal rates or deliver boluses to prevent highs and lows.
  • Example: Some newer pumps, like Twist, predict where glucose should be hours ahead and adjust dosing accordingly. (06:55)

• Ease of Use:

  • Changing the setup (infusion site, cartridge) every 2–3 days is now easily managed by most patients, regardless of prior experience.

• Bolusing with AID:

  • Most people now bolus discreetly using their smartphones, making insulin delivery less stigmatizing and more practical when eating out. (13:01)

Landmark Clinical Studies on AID in Type 2 Diabetes

Insulet Trial (JAMA Network Open)

• Design: Single-arm study—all participants used AID pump.

• Results:

  • Those starting with A1C 6.5% remained stable, while higher-baseline A1C individuals (e.g., 9–10%) dropped by an average 2%. (09:41)
  • The higher the starting A1C, the bigger the improvement.

• Insulin Usage:

  • 31% of participants started with >100 units/day; by week 13, only 10% remained at this level, likely reflecting better absorption and adherence.

• Bolusing & Carb Counting:

  • Minimal difference in outcomes whether participants bolused one or four times daily—contradicting the myth that carb counting is essential.
  • “You do not have to carb count with any of these insulin pumps...we also have proven that you don’t have to take a mealtime bolus.” (11:50)

New England Journal of Medicine Trial

• Similar findings to the Insulet study: robust A1C improvement, no reliance on carb counting, and good outcomes regardless of initial therapy.

Time-in-Range and Hypoglycemia

• Time-in-Range: Both studies saw >70% of time spent in target glucose range. Lowering target from 150 mg/dl to 110 mg/dl further improved time-in-range without increasing hypoglycemia. (15:23)
• Protection from Lows: AID systems anticipate trajectories and preemptively reduce insulin, minimizing risk of hypoglycemia—a key concern for both clinicians and patients. (05:55)

Real-World Considerations

• Therapeutic Inertia:

  • Automated systems can facilitate earlier and safer insulin initiation, potentially even for those only on basal insulin.
  • GLP-1 use delays, but does not eliminate, the eventual need for insulin; AID systems show equal benefits for those on stable GLP-1 therapy.
  • “The magnitude of A1C lowering was the same in patients on stable GLP-1 as in people that weren’t...” (19:30)

• Burden & Diabetes Distress:

  • Consistent reduction in psychological and practical burden, especially for those previously requiring multiple injections daily.
  • Family and patient stress was “significantly decreased” post-AID adoption. (25:40)
  • “...their burden came down, their personal distress came down.” (24:55)

• Primary Care Adoption:

  • The major barrier is not patient ability, but provider discomfort.
  • “We have to move it into primary care...there’s no way Endo can manage it all.” (17:54)

• Choosing a System:

  • Several FDA-approved options: Tandem (Control IQ), Insulet (OmniPod 5), Medtronic (780G), and soon, SQL’s Twist. (27:43)
  • Providers need familiarity with at least one device; expertise in all is ideal but not necessary at the outset.

Notable Quotes & Memorable Moments

• On Patient Capability:
  • “After two or three days...they change the whole setup. The patient is responsible for changing the whole setup. And they can do it. It’s amazing.” (07:55)
• On Carb Counting:
  • “For years and years we’ve said you can’t have a pump unless you carb count. And that's a misnomer.” (11:55)
• On Burden Reduction:
  • “You have to fill this device every three days and you have to wear it, but that's better than four injections a day.” (25:00)
• On Clinical Inertia:
  • “Less than half the people with type 2 diabetes have an A1C less than 7...if I can put you on a sensor and I can put you on a pump, that will protect you from hypoglycemia...why am I not going to help you get an A1C of less than 7%?” (22:24)
• On Bringing AID to Primary Care:
  • “I really think it beholds us all to spend the time to explain this to the primary care world...so we have a place for all people with diabetes that can get the kind of care they deserve.” (26:45)
• On System Choice:
  • “If you put someone on an insulin pump and you can see what they’re doing and what’s not happening, it makes your job so much easier.” (28:40)

Timestamps for Key Segments

• 00:02 – 02:15: Intro, guest bio, and purpose of the episode
• 02:15 – 04:32: Why consider AID in Type 2 diabetes; overcoming preconceptions
• 04:32 – 07:17: Mechanics of AID—what it is, how it works, rapid-acting insulin only
• 07:17 – 08:10: Patient ability and setup, overcoming provider fear of complexity
• 09:06 – 11:54: Clinical trials—Insulet (JAMA) and primary findings on A1C, insulin use
• 12:05 – 13:20: Mealtime insulin and bolus delivery with pumps
• 13:39 – 15:23: New England Journal study, hypoglycemia, time-in-range improvements
• 17:54 – 20:21: Real-world barriers to AID and integrating into primary care
• 22:24 – 26:45: Clinical inertia, distress reduction, and implications for care delivery
• 27:33 – 29:13: FDA-approved pump systems and next steps for clinicians
• 29:13 – 29:45: Final thoughts from guest
• 29:45 – 31:26: Recap and tease for next episode (practicalities of patient selection and implementation)

Tone & Style

The episode is frank, enthusiastic, and often conversational—Kruger is especially passionate and practical, challenging entrenched views and bringing a sense of optimism about simplifying diabetes management for both patients and providers. Dr. Skolnick’s tone is curious, reflective, and collaborative, modeling the questions and doubts of his clinician audience.

Final Takeaways

• The latest trials and real-world experience suggest AID is safe, effective, and life-changing even for people with Type 2 diabetes, not just Type 1.
• Patients manage AID well, regardless of their prior experience or skills, and experience less distress.
• The primary barrier is no longer technology or patient factors—but provider familiarity and willingness to adopt AID in primary care.
• Several AID systems are FDA approved for Type 2, with more options on the way.
• Next episode will cover practical aspects of patient selection and onboarding.

[For access to referenced studies, visit www.diabetesjournals.org.]