Initiating Insulin Pump and Automated Insulin Delivery in Type 1 Diabetes

Glycemic Goals and Targets

The American Diabetes Association recommends target A1C <7.0% for most adolescents, though <7.5% is acceptable if hypoglycemia risk is high 2
Time in range (70-180 mg/dL) should be >70% of the time 2
Time below range (<70 mg/dL) should be <4% and time <54 mg/dL should be <1% 2
Time above range (>180 mg/dL) should be <25% 2

Start with 0.5-1.0 units/kg/day, with adolescents typically requiring doses toward the higher end (closer to 1.0 units/kg/day) due to pubertal insulin resistance 2
Split approximately 50% as basal insulin and 50% as bolus insulin 2, 4
Divide the total basal dose by 24 hours to establish the initial hourly basal rate 2
Program multiple basal rates to account for dawn phenomenon (typically increased rates from 3-8 AM) and nocturnal insulin sensitivity 2
Adjust basal rates in 0.05-0.1 unit/hour increments based on fasting glucose patterns observed over 3-5 days 2
Use rapid-acting insulin analogs exclusively (lispro, aspart, or glulisine) - never use NPH or regular human insulin in pumps 2, 5

The American Diabetes Association recommends that choice of AID system should be based on the individual's circumstances, preferences, and needs 1
Beta Bionics iLet requires the least technical skill due to minimal user input requirements (only body weight), making it suitable for patients who struggle with carbohydrate counting 3
Tandem Control-IQ and Omnipod 5 require carbohydrate counting and understanding of insulin-to-carb ratios but offer more user control 3
All FDA-approved AID systems automatically adjust basal insulin delivery and deliver automatic correction boluses based on CGM values 3

Carbohydrate counting as the foundation for bolus dosing 2
Infusion set changes every 2-3 days to prevent site infections and lipohypertrophy 2, 5
Site rotation across abdomen, thighs, buttocks, and upper arms to prevent lipohypertrophy and erratic insulin absorption 2, 3
Recognition and management of pump malfunctions, including occlusions, disconnections, and infusion set failures 2, 6

Within 1-2 weeks after pump start to review downloaded data and adjust settings 2
Every 3 months with A1C measurement 2
Download pump and CGM data at each visit to assess basal rates, bolus patterns, and glycemic trends 2

The American Diabetes Association's 2025 guidelines explicitly state that AID systems should be the preferred insulin delivery method for youth and adults with type 1 diabetes who are capable of using the device 1
Meta-analyses demonstrate that AID systems are superior to sensor-augmented pump therapy for increased time in range and reduction of hypoglycemia 1