Table 7.

Summary of recommendations: initiating AID use

Make AID systems available to all people with T1D (2, 3, 7, 8). Initiation of AID can be done with in-clinic or digital/virtual training; further research is warranted on how to design, implement, and evaluate individual training programs, including required follow-up and long-term glycemic outcomes. Ensure that the PwD and their care partners can demonstrate proficiency in intensive insulin therapy knowledge and skills before initiating AID.
Individualize training in AID based on each PwD’s current therapy: MDI + blood glucose monitoring MDI + CGM CSII + blood glucose monitoring CSII + CGM (as nonintegrated and integrated components) AID system Personalize training and follow-up based on the PwD/family, health care settings, etc.
Consider starting people with T1D who are “technology naïve” on either an insulin pump or CGM before transitioning to AID. In some cases, the insulin pump and CGM can be initiated simultaneously.
Advise people with T1D who are transitioning from prior insulin pump therapy to AID to use current pump settings if glycemic control is acceptable; however, pump parameters (basal rate, bolus settings) may need reassessment. Address insulin to carbohydrate ratios (ICRs), correction doses, basal rates, accounting for ratio of basal/TDD as well carbohydrate intake (eg, low carb diets). Individualize the approach to AID depending on the AID system, considering target glucose, active insulin time, etc.
Provide fundamental guidance regarding hypoglycemia and hyperglycemia treatment with AID, exercise management, switching to open loop or MDI (for “pump vacation”), sick day management, etc (see “Clinical Recommendations for AID Use” section).
Particular attention should be paid to use of adjunctive therapies (eg, SGLTs), and whether continuing such therapy is safe or feasible.
The diabetes care team should discuss limitations and benefits for AID use: Set realistic expectations for AID system user requirements: handling mealtime boluses/timing; handling CGM and pump use; handling exercise with pre-, during, and post- exercise adjustment as needed; manual insulin delivery during CGM warm-up, loss of connectivity, etc. Review published data on the expected benefit on glycemic outcomes, improvement in overnight glucose control, restful sleep.
Considerations should be made when initiating AID for people with long diabetes duration (especially those with eating disorders) and/or suboptimal control: Potential transient worsening of retinopathy with need for ophthalmologic care prior to initiation of AID along with close follow-up with ophthalmology. Potential temporary neuropathic pain, insulin edema, increase in microalbuminuria and other microvascular complications.