Recommendations for Diabetes-Treatment with systems for Automated Insulin Delivery

The principle of Automatic Insulin Dosing (AID) has shown excellent treatment results in pivotal studies and real-world experience. With AID, an insulin pump is interconnected with a continuous glucose monitoring system, while an algorithm takes over the control of insulin administration as needed. Ideally, the system would be a closed-loop system in which people with diabetes would no longer need to provide input. However, the systems available today require various basic settings and inputs (especially of carbohydrate amounts of meals or physical activity), which differ from the previous recommendations of sensor-augmented pump therapy in several aspects. For example, the traditional concepts of "basal" and "bolus" become less useful with AID, as the algorithm uses both types of insulin delivery to bring glucose levels closer to the set target. Therefore, instead of discussing "basal" and "bolus", a distinction should be made between a "user-initiated" and an "automatic" insulin dose in these systems. Common therapeutic principles of the different AID systems include the precise fitting of the carbohydrate ratio, the importance of timing the user-initiated pre-meal insulin boluses, the correct handling of a delayed or missed meal bolus, new principles in dealing with exercise or alcohol intake, and the timely switch from AID to manual mode when elevated ketone levels occur. The team from the Diabetes-Zentrum AUF DER BULT in Hannover has compiled practical recommendations for the application and training of the systems, both, for those currently and those soon to be commercially available in Germany from their own study experience and the underlying international literature. For the success of AID treatment, the right expectation management seems to be of great importance for the treatment team as well as for the user.