Where Do We Stand with Closed-Loop Systems and Their Challenges?

Practical Guidance on Open Source and Commercial Automated Insulin Delivery Systems: A Guide for Healthcare Professionals Supporting People with Insulin-Requiring Diabetes

As increasing numbers of people with insulin-managed diabetes use automated insulin delivery (AID) systems or seek such technologies, healthcare providers are faced with a steep learning curve. Healthcare providers need to understand how to support these technologies to help inform shared decision making, discussing available options, implementing them in the clinical setting, and guiding users in special situations. At the same time, there is a growing diversity of commercial and open source automated insulin delivery systems that are evolving at a rapid pace. This practical guide seeks to provide a conversational framework for healthcare providers to first understand and then jointly assess AID system options with users and caregivers. Using this framework will help HCPs in learning how to evaluate potential new commercial or open source AID systems, while also providing a guide for conversations to help HCPs to assess the readiness and understanding of users for AID systems. The choice of an AID system is not as simple as whether the system is open source or commercially developed, and indeed there are multiple criteria to assess when choosing an AID system. Most importantly, the choices and preferences of the person living with diabetes should be at the center of any decision around the ideal automated insulin delivery system or any other diabetes technology. This framework highlights issues with AID use that may lead to burnout or perceived failures or may otherwise cause users to abandon the use of AID. It discusses the troubleshooting of basic AID system operation and discusses more advanced topics regarding how to maximize the time spent on AID systems, including how to optimize settings and behaviors for the best possible outcomes with AID technology for people with insulin-requiring diabetes. This practical approach article demonstrates how healthcare providers will benefit from assessing and better understanding all available AID system options to enable them to best support each individual.

The current schemes of insulin therapy: Pro and contra

Insulin regimens have been evolving for a century. The schemes used for type 1 (T1D) and type 2 (T2D) diabetes differ due to differences in pathophysiology but share important features. Insulin is required for both types of diabetes when other means of controlling glucose are insufficient. For T1D this requires multiple daily injections or continuous subcutaneous infusion assisted by CGM, whereas in early T2D basal insulin together with oral agents or GLP-1RA is usually effective. In both cases current schemes typically maintain HbA1c levels between 7 and 8%, a range that limits but does not eliminate the long-term complications of diabetes, but do not restore glycemic control to a fully protective level. Inability to control postprandial hyperglycemia without problematic weight gain and hypoglycemia is a leading obstacle in both T1D and long-duration T2D. A greater share of prandial dosing decisions will have to be provided by smart electronic systems. Further changes in the structure or formulation of insulin are of uncertain potential, but schemes including delivery of amylin, GLP-1, and glucagon show promise. More reliable access to insulins, delivery devices, and capable medical advisors will be needed to optimize replacement of this essential hormone.