Should You Be Using Automated Insulin Delivery (AID) for Type 1 Diabetes?

“These systems can be life-changing for people with type 1 diabetes, but there’s a huge learning curve for the first month or two,” explains James Thrasher, MD, the founder of the Arkansas Diabetes and Endocrinology Center in Little Rock.

AID systems don’t do everything yet, says Dr. Thrasher. Users still need to tell their pump when they’re eating, and they may experience better results during exercise by making manual adjustments to their insulin delivery rates. Relative to a manual pump or daily injections, however, an AID system can require significantly less work than insulin management usually does.

There are a number of different AID models available, each with different features. Thrasher stresses that every AID system also works a bit differently, and one device might work better than another.

No method of delivering insulin is perfect, and AID systems come with their share of benefits and flaws.

The major benefits are related to improved blood sugar results and less work managing treatment.

• Fewer issues with low blood sugar: AID systems aim to reduce your risk of low blood sugar (hypoglycemia) by suspending insulin delivery when the data suggests your blood sugar is going to drop below your target range.

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   This can also lead to better quality sleep and safer sleep.

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• Fewer issues with high blood sugar: AID systems anticipate rising blood sugar levels, too. While users must still tell their app when they’re having a meal, the system will automatically adjust insulin doses to try to prevent or correct high blood sugars.

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• Improved time-in-range: In a real-world setting, younger people with type 1 diabetes enjoyed significantly improved time-in-range after starting with an AID system.

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• Less math: An AID system does most of the insulin dosing calculations for you, but most systems still require you to count the carbohydrates on your plate, or at least estimate the size of your meal. After the meal, the system can also compensate for any miscalculations or other food-related challenges, like a slow-digesting high-fat meal.

The downsides are generally related to technology concerns and affordability.

• Cost: Both insulin pumps and CGMs can be pricey: Users of both devices may spend nearly $1,000 more per year out-of-pocket than people using neither technology.

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  Insurance coverage can play a big role in the financial feasibility of an AID system.
• Learning curve: While AID technology does take a lot of the brainwork out of managing insulin, the user still needs to understand how the algorithm technology works and be comfortable manipulating a complex device.
• Less control over dosing: Trusting an AID system means giving up some control, and the technology may be a poor choice for people who prefer to maintain fastidious control over their insulin dosing decisions.
• Technology failures: Like any technology, insulin pumps and CGMs aren’t perfect. Pumps and CGMs can both malfunction, potentially leading to extremely low or high blood sugar levels.

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Although AID systems seem to promise almost effortless diabetes management, there can be a learning curve, especially if you’re not already using an insulin pump.

“Once they’re on it and they learn how to troubleshoot when things go wrong,” says Hall, “the results are mostly really good. That’s the biggest hurdle: getting through the initial education.”

For people with long-standing diabetes, it may be scary to reduce your own monitoring and to trust an app to manage your blood sugar levels.

“The hardest thing to do is trust the system,” says Thrasher. “You’re asking people with type 1 diabetes to let go of the control they have been so used to over the years, of having to manage diabetes themselves. Giving up that control and letting a system do it for you is something that’s new, and it can be frightening.”

Hall also says some people are simply more ready than others for the complexities of diabetes education and the technology that comes with it.

“Some people are just ready from the moment they are diagnosed to start using a CGM and get on a pump and do what they need to do,” says Hall. “I would say a highly motivated person who wants to learn an AID system is going to learn how to do anything. If you see they have that level of medical literacy, they have support at home, they’re able to troubleshoot and know how to ask for assistance, that’s someone who could definitely get started early on this technology.”

If you’re interested in using AID, you might need to initiate a discussion about it at your doctor’s office.

Despite the many benefits, Thrasher says many healthcare providers only rarely prescribe AID systems to their patients, sometimes because the clinicians themselves are not very familiar with this advanced tech.

“If you’re not trained on how to use these systems, you’ll be reluctant to suggest it to your patients, and these companies really don’t have an efficient way of educating clinicians,” he says.

Hall says that in her experience, different clinics vastly differ in how quickly they prescribe newer technology like AID systems.

“I’ve worked in a practice where you get put in the pipeline as soon as you’re diagnosed to see a diabetes educator within a month, which is critical to first learn how insulin works,” says Hall. “And then they progress to learning about CGMs and pumps very quickly. Having a good system in place makes a big difference in helping people learn about their options.”

Some clinicians also worry about losing the ability to intervene and make adjustments based on patient data. “These systems give providers less control, and fewer levers to pull, as they often say,” says Hall. It’s not just the person with diabetes who needs to feel comfortable giving up control, Thrasher says, but also their provider.

• Automated insulin delivery systems combine an insulin pump with a continuous glucose monitor to automatically adjust insulin dosing throughout the day, easing the burden of manual diabetes management.
• Some endocrinologists aren’t comfortable recommending these systems; if you want one, you may need to advocate for yourself. Success depends on user motivation, support, and readiness to manage the technology.
• AID systems can improve time-in-range and reduce fluctuating blood sugar levels, but they may be expensive and can fail if technical issues arise.