What Clinicians Should Know About Today’s Insulin Pump Options

At the 2025 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting & Exhibition, Diana Isaacs, BCACP, BC-ADM, CDCES, from the Cleveland Clinic Diabetes Center, discussed how shifting perspectives have expanded eligibility for insulin pump therapy among individuals with type 2 diabetes. She explained that modern automated insulin delivery systems no longer require strict carbohydrate counting skills and instead focus on carbohydrate awareness, affordability, and basic problem-solving abilities. Isaacs also compared key pump options, highlighting differences in algorithms, insulin capacity, sensor compatibility, and workflow simplicity. She emphasized that with improved insurance coverage and more accessible technology, many patients transitioning from multiple daily injections can now achieve significantly better outcomes using automated insulin delivery systems.

Pharmacy Times: When considering insulin pump therapy for type 2 diabetes, what criteria help identify the most appropriate candidates for transitioning off multiple daily injections?

Diana Isaacs, PharmD, BCACP, BC-ADM, CDCES: This is something that's really changed over time. We used to have all this strict criteria. We wanted someone to show that their A1C was at or near goal. We used to want people to know how to count carbohydrates and be pretty good at it. But now our thinking has really shifted, and we see that this technology is so beneficial, and we don't want to promote disparities in use by saying, “Oh, you need to have this education level, or you need to know how to do this before you can get the technology.” So now really, who's eligible? Any person with type 2 diabetes that is not at goal with basal insulin, and we should be using our non-insulin therapies. So we definitely want to be using metformin and GLP-1 drugs and SGLT2 inhibitors. But many people with type 2 diabetes are not at their goal on those therapies. And so if we've added a long-acting insulin—and in many cases, we try using mealtime insulin—someone is on multiple daily injections; at that point, we can be offering this technology.

I think some key things to keep in mind are that, number one, you do need to make sure the person can afford it. Fortunately, the coverage now has gotten to be very, very good, but someone does need to have access to be able to use their supplies. And then instead of needing to know how to count carbohydrates, what's really important is carbohydrate awareness—understanding what foods could increase glucose levels versus ones that don't. And as long as someone has carb awareness, we can teach them how to bolus for their foods without having to know exactly how to do precise carbohydrate counting.

Then the other thing is we want someone to have basic problem-solving skills, because when you use a pump, generally it is replacing your long-acting insulin, and so it's possible to experience hyperglycemia and severe events much more quickly. So we want someone to have the basic skills to, if they find that their glucose levels are not coming down, check their site, see if it is possible that their pump is out of insulin or that it's leaking insulin, and be able to think through what the strategy would be to take action so that their glucose levels come into range. And as long as someone can do those things, they generally do very well, and our studies show they do much better on these new automated insulin delivery systems compared to multiple daily injections.

Pharmacy Times: How do the major insulin pump options differ, and what factors should clinicians consider when selecting the right device for a patient with type 2 diabetes?

Isaacs: Well, we're really fortunate. We have six insulin pumps that are part of automated insulin delivery systems, and we have five different algorithms. We also have two patch pumps that are not, quote-unquote, smart pumps, but they offer a simple way to be able to bolus without having to take out a pen or a vial and insulin each time.

There are definitely different factors. Currently, of our automated systems, there's one that is tubeless, and that is often appealing for people with diabetes, especially people with type 2 diabetes, for whom the concept of wearing a pump is new. So this idea of not having to fill tubing and priming the insulin and inserting the tubing is often a little bit easier to start.

I think another important consideration is how much insulin the pump holds. Some pumps hold more than others. For example, the tubeless pump, the Omnipod 5, holds 200 units. But we have several options that hold 300 units, like the Medtronic 780G, the Tandem t:slim X2, and also the Sequel Twist. So if someone needs more insulin, that could definitely be appealing.

The other factor is the algorithm itself—how it adjusts insulin—and some require more fine-tuning than others. There are some algorithms where someone really does better if they’re bolusing regularly. There are others that are a little bit more hands-off, where even if you don’t bolus on your own, someone can often still have a higher time in range. And we actually, in our talk, showed an example of this with the Control-IQ+ algorithm, which works with the t:slim X2 as well as the Mobi. With this, there are automatic corrections that can occur every hour. This person was barely ever putting carbohydrate entries in but still achieved 55% time in range. For a lot of people on multiple daily injections, if we can achieve at least 50% time in range and an A1C less than 8%, often that means our goal is met.

The other thing is compatibility with different CGM sensors. They’re not all compatible with every sensor. For example, the Medtronic 780G works with its own sensors, which previously was only the Guardian 4, but more recently now includes the Simplera as well as the InPen-linked Libre 3. Some work with Libre only, like the Sequel Twist. Others work with both. So depending on what sensor someone wants to use, that could steer them.

Then there is one called the iLet—the Beta Bionics iLet—and this is a pretty unique pump in that there are actually no settings to program. It's just programming the person's weight and then connecting them to CGM. All they have to do is announce when they're eating, and they don't need to put carbohydrates in—it's simply stating whether it’s usual, less, or more. That often makes it easier. And even though this pump only holds up to 180 units, which is less than the others, it works with prefilled insulin cartridges, so it makes filling easier.

Another factor is which pumps are FDA-approved for type 2 versus type 1. Currently, there are three approved algorithms: Control-IQ+, the 780G, and the Omnipod 5. Sometimes that could dictate insurance, based on which ones have coverage and which ones don't.

Then the last thing is how you obtain them. Some go through pharmacy benefits, and some go through durable medical equipment. When you go through durable medical equipment, or DME, usually you're in a four- or five-year contract. That's quite a commitment versus pharmacy, where there is no long-term contract. Right now, Omnipod 5 and the Sequel Twist both only go through pharmacy, so that's sometimes why those can be appealing. Others sometimes can go through pharmacy; they're all trying to go through pharmacy more, but historically they've typically gone through DME.