Endocrine News Podcast ENP102: Insulin Delivery Systems

Date: September 17, 2025
Host: Aaron Lohr
Guests: Dr. Grazia Aleppo (Northwestern University Feinberg School of Medicine) and Dr. Diana Isaacs (Cleveland Clinic)

Episode Overview

This episode focuses on the evolving landscape of insulin delivery systems for type 1 diabetes, highlighting current challenges, recent advancements, and the implications for both providers and patients. Host Aaron Lohr speaks with expert endocrinologists Dr. Grazia Aleppo and Dr. Diana Isaacs, who share their experiences and research insights on misdiagnosis, automated insulin delivery (AID) systems, emerging technologies, patient education, and the ongoing struggle for accessible diabetes care.

Key Discussion Points & Insights

1. Challenges in Type 1 Diabetes Treatment

Timestamps: 01:45 – 05:43

• Diagnosis Difficulties: Diagnosis often occurs in a crisis (e.g., DKA), or adults are misdiagnosed with type 2 diabetes, leading to delayed and improper care.
  • “Many people are diagnosed in DKA and are hospitalized. It's like, all right, now you need to learn everything. … There’s actually several people now that are misdiagnosed, think that they have type 2 diabetes for a period of time.”
    — Dr. Isaacs [01:53]
• Narrow Therapeutic Window: Insulin must be closely tailored to avoid hypoglycemia (dangerously low sugar) or DKA (dangerously high).
• Daily Burden: Patients must constantly monitor, adjust, and care for their condition, which is both mentally and physically demanding.

Importance of Early Identification

• Clinical Trial Access: Early and correct diagnosis is crucial; most trials require enrollment within 45–90 days of diagnosis.
• Misconceptions: "50% of people today diagnosed with type 1 are over the age of 25." Weight and BMI expectations mislead providers; simple antibody tests can clarify.
  — Dr. Aleppo [03:45]

2. Insulin Delivery Systems: Current Options and Innovations

Timestamps: 05:43 – 10:19

• Traditional Injections: Multiple daily injections with long-acting and rapid-acting insulins remain a standard.
• Automated Insulin Delivery (AID) Systems: Integration of pumps and CGMs with intelligent algorithms.
  • Examples: MiniMed 780G, Control IQ, Omnipod 5 (tubeless), Tandem Mobi, the iLet, and new programs inspired by DIY “looping.”
  • Distinct Features: Some systems require detailed settings; others (e.g., iLet) need only basic input like weight.
  • Patient Experience: Some require meal announcements or carbohydrate counting, while innovation aims for full automation in the future.
• Simple Wearable Devices: “Simplicity” and “VGO” deliver basal and bolus insulin via small wearable gadgets for straightforward use.
• Connected Pens: Record doses and help calculate insulin needs.
• Inhaled Insulin: Acts quickly and is more physiologic, offering an alternative for those wishing to avoid injections or devices.

“With the islet, all you do actually is you put in a person's weight, you connect them to CGM, and then you press go bionic ... All the person is asked to do is actually to announce their meals.”
— Dr. Isaacs [07:50]

3. Efficacy & Safety: What Does the Latest Data Show?

Timestamps: 10:19 – 14:24

• Inhaled Insulin: Recent trials show impressive post-meal glucose control without increased hypoglycemia; conversion dosing is key.

  “The response post meal was dramatic. … The group that was doing inhale took the dosamine help insulin for the post challenge glucose were much lower … There were no hypoglycemic episodes, people were just fine.”
  — Dr. Aleppo [11:37]

• AID Systems: Large-scale, real-world studies (up to 100,000 users) reinforce safety and efficacy shown in controlled trials, often showing even better outcomes in practice.
  • Benefits across ages, insurance types; AID systems reduce both high and low glucose incidents, improve time-in-range, and reduce psychosocial distress, especially in children through easier dosing.

  “The beauty is that we also have real world numbers … It tells us that if the systems work well in the super controlled environment … they work even better [in real life].”
  — Dr. Aleppo [12:20]

4. Educating Providers and Patients

Timestamps: 14:24 – 21:41

• Need for Ongoing Education: Keeping up with rapid advances is challenging, especially outside endocrinology settings.
  • Resources like DiabetesWise (for both providers and patients), Panther tools, and DANA Tech provide side-by-side system comparisons, feature overviews, and objective guidance.

  “There are several good resources ... Diabetes Wise ... You can do side-by-side comparisons ... Panther tools ... outline their specific features.”
  — Dr. Isaacs [14:35]

• Practical Tips: Providers benefit from printable/PDF guides for office use.

  “I hang it in my office because I have residents, I have fellows, I have students.”
  — Dr. Aleppo [18:39]

• Patient Resources: DiabetesWise (patient version), Diatribe, Diabetes Sisters, Beyond Type 1/2, and Tackling Control of Diabetes (TCOYD) encourage informed choices and peer learning.
  • “I don't buy your shoes, I don't buy your phone. Why would I buy your pump or decide what you should choose? ... it has to be something that resonates with you.”
    — Dr. Aleppo [21:20]

5. Access and Insurance Barriers

Timestamps: 21:41 – 26:09

• Medicare/Medicaid Obstacles:
  • Strict, sometimes outdated rules require unnecessary or impossible proof (e.g., antibody/C-peptide levels decades post-diagnosis).
  • Different coverage rules for tubed vs. tubeless pumps (Medicare Part B vs. Part D).
  • Frequent documentation (A1C/charts every 3 months) to maintain supplies; if appointments are missed, patients risk running out.

  “He's wearing an AID system. Now he's going to turn 65 and now he has to explain to Medicare that yes, he still has type 1 ... rules that make the patient really go through a major change.”
  — Dr. Aleppo [21:51]

• Pharmacy Distribution: Emerging trend toward pumps via pharmacy rather than durable medical equipment (DME) simplifies access and reduces contract lock-in.

  “There has been a trend toward more pumps starting to go through pharmacy ... it has been a little easier for pumps that don’t go through DME to be able to get them.”
  — Dr. Isaacs [24:55]

6. Personalized Choices: Matching Tech to the Individual

Timestamps: 26:09 – 30:55

• Customization Matters:

  • Some patients love tinkering and custom settings; others need simplicity (e.g., iLet or Omnipod).
  • Physical considerations: reservoir size, tubing, dexterity.
  • Providers should guide but not dictate; patients must feel comfortable, as contract terms may bind their choice.

  "You need to look at the patient and say, are you the kind of person who wants to customize everything? ... If you give them a system where you can customize nothing, they might be frustrated."
  — Dr. Aleppo [26:17]

• Respecting Patient Preference:

  • Tools like simulation apps and informational websites help patients choose.
  • Inhaled insulin remains valuable for those wanting to avoid hardware.

  “I never thought about that. So, okay, maybe they say, no, I don't want to have anything attached. And I needed to respect his choice.”
  — Dr. Aleppo [30:12]

Memorable Quotes

• “It's always walking this fine line…you gotta get the right amount of insulin for what you're eating, for what your activity level is.”
  — Dr. Isaacs [02:34]

• “50% of people today diagnosed with type 1 are over the age of 25. So we need to have a greater awareness.”
  — Dr. Aleppo [04:03]

• “There is no better time to be a person interested in diabetes care because it really is fantastic.”
  — Dr. Aleppo [10:33]

• “You were mentioning before the way that they show the software...there are 30 reports for each system. You need to focus in your limited time with the patient so you can get the best out of it and make the right changes.”
  — Dr. Aleppo [18:39]

• “I don't buy your shoes, I don't buy your phone. Why would I buy your pump or decide what you should choose?”
  — Dr. Aleppo [21:24]

Useful Timestamps

• 01:45: Challenges and misdiagnosis in type 1 diabetes treatment
• 05:43: Overview of current insulin delivery systems
• 10:19: Data on efficacy and safety of new delivery methods
• 14:24: Continuing education for providers; key resources
• 19:21: Patient education resources
• 21:41: Access challenges with Medicare and Medicaid
• 26:09: How providers and patients choose the right technology
• 30:12: Importance of patient-centered choice

Conclusion

The episode provides a thorough and practical overview for providers and patients navigating insulin delivery in type 1 diabetes. The conversation emphasizes the evolving technology, the complexity of matching devices to needs, the importance of ongoing education, and persistent access issues—especially for those with Medicare/Medicaid. Both experts highlight that empowered, individualized choice is essential for successful diabetes management: “There are so many out there, one for each need. ... Help the patient understand.” [Dr. Aleppo, 27:44]