Insulin Pump Therapy in �Type 2 DM

Teresa Nimmo, MD, FACE,

September 19, 2026

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Objectives

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• Review of insulin use for type 2 DM
• Discuss why would insulin pump therapy would be necessary
• Myths surrounding insulin pump therapy
• Therapy available
• How to have that conversation
• Tips for the prescriber

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Insulin requirements in Type 2 DM

Insulin resistance develops before glucose is abnormal.

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Over time insulin secretion drops and glucose levels rise.

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Longer duration of diabetes or very poorly controlled

Why would insulin therapy be necessary?

• Glucose excursions
• Hypoglycemia limiting titration of oral meds
• Intolerance/Contraindications to current therapy
• Need for better control
• Wounds
• Nephropathy
• Pre-op
• Steroids

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Why would insulin pump therapy be necessary?

• Many patients with T2D fail to reach glycemic targets.
• Two major barriers to intensifying insulin therapy are hypoglycemia and weight gain (Hespanhol et al, Diabetes Care 2026)
• MDI requires MULTIPLE DAILY INJECTIONS, complex dose timing and sometimes calculations and is subject to adherence limitation.
• A tool is needed to lower Hb1c without increasing hypoglycemia and or weight

Components of an insulin pump

• Pump
• Reservoir
• Tubing
• Infusion set
• Cannula
• CGM
• PDM/Smart phone controller/watch

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Components of an insulin pump

• Pump – delivery device, may have a screen to input data: carbs, glucose and to confirm delivery or needs compatible device manager

Components of an insulin pump

• Reservoir – chamber that holds insulin

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Components of an insulin pump

• Tubing – thin plastic tube connecting infusion set to the pump

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Components of an insulin pump

• Infusion set – adheres to the skin and connects the cannula to the tubing

Components of an insulin pump

• Cannula – part of the infusion set that is inserted subcutaneously, can be flexible and soft at a variety of angles for entry (90, 45, 30) or a small thin needle at 90 degrees.

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Continuous Glucose Monitors

• Dexcom G7, 10-15 days
• Minimed
• Instinct (Abbott) 15 days
• Simplera – 7 day
• Freestyle Libre 2+ or 3 + 10, 14, 15 day
• Eversense – 365 days

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Controller

• Minimed Flex – compatible phone
• 780 G
• Tandem Mobi – compatible phone
• Tandem X2
• Omni Pod – Personal Device Manager (In Starter Kit)
• Can use compatible phone
• Beta-Bionics
• Twiist – compatible phone/Apple watch

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Review of insulin pump therapy – CSII ��continuous subcutaneous insulin infusion

• Insulin type - filled with short/rapid/mealtime insulin, will d/c long acting/basal/bedtime insulin

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• Basal Delivery
• Short acting insulin delivery, every 5 minutes of programmed basal rate
• Example: 1 unit/hour doses 0.083 units, every 5 minutes x 12.
• Bolus delivery – larger doses for meals or corrections infused in quickly
• Carb ratio: programmed/learned/preset
• Correction factor/sensitivity
• Targets – goal
• IOB/AIT programmed/standard

Automated insulin delivery (AID)

• Hybrid closed loop pump – pump is paired with the CGM and delivers insulin according to its propriety algorithm.
• The goal is to adjust insulin delivery in real time (Kalyani, et al., JAMA, 2025)
• AIM: mimic physiologic insulin secretion more closely than injections.

Available AID therapy

• Minimed 780 G/Flex system
• Tandem X2/Mobi
• Omnipod 5
• Betabionics current trial for type 2 PREPARE 4 AID
• Twiist – type 2 Data presented at ADA 2026

Having that Conversation

• Myths
• Expectations
• Results

Audience Poll

• What questions should you be prepared for when discussing insulin pump therapy?

Insulin pumps myths/truths

• It’s a punishment
• It’s a reward
• Reduces hypoglycemia
• Hard to learn to use
• Dangerous
• It’s a last resort
• Only for poorly controlled patients
• Only for well controlled patients

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Insulin pumps myths/truths

• It’s a punishment
• It’s a reward
• Reduces hypoglycemia
• Hard to learn to use
• Dangerous
• It’s a last resort
• Only for poorly controlled patients
• Only for well controlled patients

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TRUE OR FALSE?

• Implanted, needs a Surgical procedure
• Runs itself – NO need to interact
• Do not need to check blood sugars*
• Not covered by insurance
• Only for Patients with Type 1 diabetes
• Only for young patients
• Obvious when wearing

TRUE OR FALSE?

• Implanted, needs a Surgical procedure
• Runs itself – NO need to interact
• Do not need to check blood sugars
• Not covered by insurance
• Only for Patients with Type 1 diabetes
• Only for young patients
• Obvious when wearing

Myth busting – Only for T1DM

• OpT2mise (Lancet 2014)
• Multinational open-label RCT
• 331 Adults with T2DM, HBA1C >8 despite optimized MDI, randomized to CSII vs continued MDI
• Primary Outcome @ 6 months: Hba1c reduction of 1.1% vs 0.4%.
• Insulin dose lower with CSII – 20%
• Weight – no significant between group difference
• Safety – no DKA and one severe hypo in the MDI group

Used the Medtronic pump, now Minimed, sensor augmented pump

CGM Substudy

• Compared with MDI, CSII produced significantly greater reductions in 24-h meals sensor glucose
• More time in range
• Greater reductions in post prandial area under the curve after breakfast and dinner
• No increase in time < 70 and no increase in glucose variability

SECURE-T2D Pivotal Trial

Automated Insulin Delivery in Adults With Type 2 Diabetes A Nonrandomized Clinical Trial

Francisco J. Pasquel, MD, MPH¹; Georgia M. Davis, MD¹; David M. Huffman, MD²

 et al

JAMA Netw Open

Published Online: February 14, 2025

2025;8;(2):e2459348. doi:10.1001/jamanetworkopen.2024.59348

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Omnipod insulin pump

Myth Busting – Only for Young people �

Who are our Type 2 patients?

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12 month RTC of 107 adults > 60 years with type 2 DM CSII vs MDI, reduction of Hba1c 1.7% with CSII to 6.6% - similar rates of severe hypo and similar rates of treatment satisfaction Herman et al. (Diabetes Care, 2005)

ORACL trial – 30 older adults (> 60, mean age 67) AID system, improved time in range, and 3 fold reduction in overnight hypoglycemia (closed loop vs sensor augmented – Minimed)

AIDE T1D – 82 adults aged > 65, less hypoglycemia, and 91% chose to keep the AID in the extension phase. (Tandem CIQ vs Basal IQ)

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Insulin pumps myths/truths

• It’s a punishment
• It’s a reward
• Reduces hypoglycemia
• Hard to learn to use
• dangerous
• It’s a last resort
• Only for poorly controlled patients
• Only for well controlled patients

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Insulin pumps myths/truths

• It’s a punishment
• It’s a reward
• Reduces hypoglycemia
• Hard to learn to use
• dangerous
• It’s a last resort
• Only for poorly controlled patients
• Only for well controlled patients

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Who will benefit?

• In T2D patient uncontrolled on optimized MDI, CSII and AID:
• Lower HbA1c by 0.6-1.3%
• Increase time in range by 14-16% points,
• Use less than or equal insulin
• No weight gain
• Benefit greatest in the poorest controlled, highest insulin dosed patients

Reznick, et al, 2014, Kudva et, al 2025:, Hespanol et al, 2026

Souce: Beta Bionics Website

Real World Data

Meta- Analysis (2026)

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• Systematic review/meta-analysis of 9 studies, 1,530 adults with insulin-requiring T2D (Hespanhol et al., Diabetes Care, 2026):
• Time in range +16.1% (95% CI 10.5 to 21.7)
• Time above range −15.9%
• HbA1c −1.27% (95% CI −2.06 to −0.48)
• Mean glucose −21.3 mg/dL
• Modest but significant reduction in time below range (improved safety)
• No change in body weight, BMI, or total insulin dose
• Benefit was consistent across different AID systems and, notably, larger in magnitude than seen in Type 1 diabetes.

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High Dose/Insulin-Resistance patients: VIVID Study

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• In adults with T2D requiring high-dose insulin, CSII delivery of concentrated U-500 regular insulin produced significantly greater HbA1c reduction than MDI, while requiring substantially less insulin, and more patients reached HbA1c <7% and <7.5% (Grunberger et al., Diabetes, Obesity & Metabolism, 2020).
• Supports a role for pump therapy in severe insulin resistance, though caution and further data are advised above ~200 U/day (Ekanayake and Edelman, Diabetes, Obesity & Metabolism, 2023).

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Omni Pod DASH

Important reminders in selecting insulin pump candidates

Safety

Adequate Cognitive function

Visual acuity

Adequate Literacy

Carb Awareness

Trouble Shooting

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Manual Dexterity – filling reservoir, placing

CGM and infusion sets.

Technical capability

Realistic Expectations

Social Support

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Special considerations

• Pharmacy vs DME
• Use of a smart phone, PDM or pump for control
• Insulin use for reservoir, #units/day
• Qualifying c-peptide for traditional Medicare patients

Special considerations

• Always have a back up plan
• Basal insulin
• Know how to dose for meals
• Supplies: pen needles, syringes, test strips
• Travel
• Able to troubleshoot failures
• No need for large abouts of carbohydrates for corrections since the pump may be suspended/basal reduced for 30+ minutes before the low, can try 5-10 grams.

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Retrieving data

• All systems have cloud based and manual retrieval software
• Professional accounts can be set up for a clinic
• Personal accounts can also be used to share data
• Great for telehealth
• Opportunities for remote monitoring
• Practice interpretation of the data for adjustments
• Not all created equal depending on how specific you need to go for trouble shooting.

Summary

• Insulin pump therapy can benefit a variety of patients with type 2 DM
• There are several products that can be used and therapy individualized to meet the needs of patients.
• Identify appropriate candidates
• Prescribers need to be able to assist with any malfunctions that may occur.

Summary

• Automated insulin delivery systems are safe, effective alternate method of insulin delivery that allows for flexible, accurate dosing.
• They have successfully improved glycemic control by improving A1c, reducing variability and keeping blood sugars in target range more often
• Goal is to reduce long term complications
• have a variety of systems to meet patient need and comorbidities
• Need to be aware of the limitations of adjustments
• Adjust manual settings to reflect the HCL
• Available to many patients!
• reduce the burden on patients, families and friends

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Trouble Shooting