Recommended Insulin Delivery Device
Automated insulin delivery (AID) systems are the preferred first-line insulin delivery method for patients with type 1 diabetes and other insulin-deficient conditions who can safely operate the device, while insulin pens are recommended over vial-and-syringe for patients with type 2 diabetes or those not candidates for AID technology. 1, 2
For Type 1 Diabetes and Insulin-Deficient Conditions
Primary Recommendation: Automated Insulin Delivery Systems
AID systems should be the preferred insulin delivery method because they improve time-in-range (70–180 mg/dL) substantially, reduce hypoglycemia exposure, and enhance quality of life compared to all other delivery methods. 1, 2
The American Diabetes Association issues a Grade A recommendation—the highest evidence level—for AID systems in all adults with type 1 diabetes. 2
AID systems increase time-in-range by providing real-time automated insulin adjustments based on continuous glucose monitoring, a capability that conventional pumps lack. 2
These systems significantly lower the low-blood-glucose index and time spent below 70 mg/dL, directly reducing mortality risk. 2
Automation of basal insulin adjustments reduces treatment burden and cognitive load while improving glycemic outcomes. 2
Patient Capability Requirements
The patient must be capable of using the device either independently or with caregiver assistance, as all current AID systems remain "hybrid" and require user input for meal announcements and carbohydrate counting. 1, 2
Verify that adequate caregiver support exists when the patient cannot independently manage technology tasks such as carbohydrate entry and device troubleshooting. 2
Alternative: Conventional Insulin Pump with CGM
If AID is not feasible, offer insulin pump therapy combined with continuous glucose monitoring (sensor-augmented pump) as a second-line option. 1
Conventional insulin pumps achieve only a modest HbA1c reduction of approximately 0.30% compared with multiple daily injections, underscoring AID's superior efficacy. 2
Insulin pump therapy has modest advantages for lowering A1C levels and reducing severe hypoglycemia rates in children and adults. 1
For Type 2 Diabetes
Primary Recommendation: Insulin Pens
Insulin pens are recommended over vial-and-syringe for patients with type 2 diabetes requiring insulin therapy. 1
Pens deliver insulin safely and effectively with equivalence or small improvements in glycemic outcomes compared to vial-and-syringe. 1
Patients strongly prefer pens over vial-and-syringe (74% preference rate), and healthcare providers strongly recommend pens for initiating basal insulin treatment. 3
Pens offer greater ease of use, improved discretion in public settings (85% of patients), easier-to-read dose scales (85% of patients), and better adherence compared to vial-and-syringe. 4, 5
Pen devices provide more accurate dosing than syringe-and-vial and are associated with cost savings in the long term despite higher per-unit cost. 6, 5
When to Consider Pump Therapy in Type 2 Diabetes
Insulin pump therapy, preferably with CGM, should be offered to patients with type 2 diabetes on multiple daily injections who can use the device safely. 1
One AID system has recently been approved for use in type 2 diabetes. 1
Special Populations and Situations
Patients with Dexterity or Vision Impairment
Insulin pens or insulin injection aids are specifically recommended for patients with dexterity issues or vision impairment to facilitate accurate dosing and administration. 1
The tactile and auditory feedback from pen dosing dials particularly helps patients with impaired manual dexterity or vision. 5
Patients on Multiple Daily Injections
Offer connected insulin pens for patients taking multiple daily insulin injections to enhance monitoring and adherence. 1
FDA-approved insulin dose calculators and decision support systems may help calculate insulin doses. 1
Children and Adolescents
Pump therapy may be the preferred mode of insulin delivery for children under 7 years of age with type 1 diabetes. 1
Based on shared decision-making, insulin pumps may be considered in all children and adolescents with type 1 diabetes. 1
Older Adults
- Access to insulin pump therapy, including AID systems, should be allowed or continued in older adults as it is in younger people. 1
Critical Implementation Points
Needle Selection for Pen and Syringe Users
The shortest needles (4-mm pen needles and 6-mm syringe needles) should be first-line choice in all patient categories because they are safe, effective, and less painful. 7
Intramuscular injections must be avoided, especially with long-acting insulins, because severe hypoglycemia may result. 7
Injections should not be given into lipohypertrophy lesions, as this distorts insulin absorption; correct site rotation prevents these complications. 7
Needle Reuse Caution
- Needle reuse is not recommended by manufacturers and is associated with lipohypertrophy, though patients who reuse needles should not be subjected to alarming claims of excessive morbidity. 7
Device Sharing Prohibition
- One pen should be used by only one patient to prevent cross-contamination and infection risk. 6
Ongoing Education
- Regular counseling on proper use of the pen device or pump system is required to maintain optimal technique and outcomes. 6
Access and Continuity
Individuals with diabetes who have been using continuous subcutaneous insulin infusion should have continued access across third-party payors. 1
Patients already using any insulin pump should retain access across insurance payors when transitioning to or from AID systems. 2
Device Selection Factors
When choosing among delivery systems, consider:
- Individual preferences regarding device type, number of wearables, and discretion needs 1
- Cost and insurance coverage implications 1, 2
- Insulin type availability, as some insulins are available only in pen or vial form 1
- Self-management capabilities and technology literacy 1
- Caregiver availability for patients requiring assistance 2