What are Canadian automated insulin delivery systems for individuals with type 1 diabetes?

Automated Insulin Delivery Systems in Canada for Type 1 Diabetes

Automated insulin delivery (AID) systems should be considered for children aged >7 years and adults with type 1 diabetes to improve glycemic control, reduce hypoglycemia, and enhance quality of life. 1

System Components and Mechanism

AID systems consist of three integrated components that work together to mimic physiologic insulin delivery 1:

• Insulin pump that delivers rapid-acting insulin subcutaneously
• Continuous glucose monitor (CGM) that measures glucose levels every 1-5 minutes
• Control algorithm that automatically adjusts insulin delivery based on real-time glucose readings

These systems automatically suspend, increase, or decrease basal insulin delivery based on sensor glucose values 1. Some systems also deliver automatic correction boluses, while all current systems require manual meal announcements for prandial dosing 1, 2.

Clinical Benefits and Outcomes

Glycemic Control Improvements:

• AID systems reduce HbA1c by 0.2-0.5% compared to basal-bolus therapy 1
• Time in range (70-180 mg/dL) increases by approximately 18.7% 3
• HbA1c reductions of 0.6-1.0% have been demonstrated in adolescents and adults 1
• Meta-analyses show pump therapy reduces HbA1c by approximately 0.30% compared to multiple daily injections 4

Hypoglycemia Reduction:

• AID systems reduce exercise-induced hypoglycemia 1
• Time below range (<70 mg/dL) decreases significantly 1
• Nocturnal hypoglycemia is particularly reduced 1

Quality of Life Benefits:

• Psychosocial benefits have been demonstrated across multiple studies 1
• Improved treatment satisfaction compared to conventional therapy 1
• Greater flexibility in meal timing and content 4

Available Systems and Selection

Current FDA-approved AID systems include 4, 5:

• Beta Bionics iLet: Requires only body weight input with minimal carbohydrate announcements; most automated option suitable for patients struggling with carbohydrate counting 4, 5
• Tandem Control-IQ: Requires carbohydrate counting and insulin-to-carb ratios; offers more user control 4, 5
• Omnipod 5: Tubeless hybrid closed-loop system with automatic basal adjustments requiring meal announcements 4
• Twiist AID: Newer system with automated basal rate adjustments when integrated with CGM 4

All these systems demonstrate superior A1C reduction and time-in-range improvement compared to multiple daily injections or non-automated pumps 4.

Canadian Context

The Canadian Agency for Drugs and Technologies in Health reviewed intermittently scanned CGM (a component of AID systems) and concluded it could replace self-monitoring of blood glucose in patients requiring frequent testing 1. This review assessed performance, accuracy, effects on HbA1c and hypoglycemia, patient satisfaction, and quality of life 1.

Critical Implementation Considerations

Patient Selection:

• AID systems are appropriate for children >7 years and adults with type 1 diabetes 1
• Selection depends on patient capability to safely and effectively use the devices 1
• Beta Bionics iLet requires the least technical skill, while Tandem systems require more diabetes management knowledge 4, 5

Essential Education Requirements 5:

• Carbohydrate counting remains foundational for bolus dosing
• Infusion set changes every 2-3 days to prevent infections and lipohypertrophy
• Site rotation across abdomen, thighs, buttocks, and upper arms
• Recognition and management of pump malfunctions

Common Pitfalls to Avoid 4:

• Failure to rotate infusion sites leads to lipohypertrophy and erratic insulin absorption
• Even the most automated systems still require meal announcements—no system is truly "set and forget"
• CGM accuracy limitations at extreme glucose values can affect all AID system performance
• All systems require backup supplies and knowledge of transitioning to injections in case of device failure

Important Caveats

Pregnancy Considerations:

None of the current FDA-approved AID systems have pregnancy-specific glucose goals or algorithms designed to achieve pregnancy-specific targets 1. Initiating or continuing AID during pregnancy requires careful assessment with expert guidance 1.

Do-It-Yourself Systems:

Some patients create do-it-yourself closed-loop systems using FDA-approved devices with online community guidance 1, 6. These systems are not FDA-approved, and the FDA has warned of risks associated with unapproved devices 1. Healthcare professionals cannot prescribe these systems but should assist in diabetes management to ensure patient safety 1, 6.

Cost and Access:

AID systems are more expensive than multiple daily injections 4. Insurance coverage varies significantly by system and geographic location, with some plans preferring specific manufacturers 4. Both consumer and professional versions are generally covered by most commercial insurance carriers and eligible Medicare programs 1.

Follow-Up Protocol

Monitoring schedule 5:

• Within 1-2 weeks after pump start to review downloaded data and adjust settings
• Every 3 months with HbA1c measurement
• Download pump and CGM data at each visit to assess basal rates, bolus patterns, and glycemic trends