The use of technology in type 2 diabetes and prediabetes: a narrative review

Abstract

The increasing incidence of type 2 diabetes, which represents 90% of diabetes cases globally, is a major public health concern. Improved glucose management reduces the risk of vascular complications and mortality; however, only a small proportion of the type 2 diabetes population have blood glucose levels within the recommended treatment targets. In recent years, diabetes technologies have revolutionised the care of people with type 1 diabetes, and it is becoming increasingly evident that people with type 2 diabetes can also benefit from these advances. In this review, we describe the current knowledge regarding the role of technologies for people living with type 2 diabetes and the evidence supporting their use in clinical practice. We conclude that continuous glucose monitoring systems deliver glycaemic benefits for individuals with type 2 diabetes, whether treated with insulin or non-insulin therapy; further data are required to evaluate the role of these systems in those with prediabetes (defined as impaired glucose tolerance and/or impaired fasting glucose and/or HbA1c levels between 39 mmol/mol [5.7%] and 47 mmol/mol [6.4%]). The use of insulin pumps seems to be safe and effective in people with type 2 diabetes, especially in those with an HbA1c significantly above target. Initial results from studies exploring the impact of closed-loop systems in type 2 diabetes are promising. We discuss directions for future research to fully understand the potential benefits of integrating evidence-based technology into care for people living with type 2 diabetes and prediabetes.

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Vol.:(0123456789)
Diabetologia (2024) 67:2059–2074
https://doi.org/10.1007/s00125-024-06203-7
REVIEW
The use oftechnology intype 2 diabetes andprediabetes: anarrative
review
AlexandrosL.Liarakos1,2 · JonathanZ.M.Lim3 · LalanthaLeelarathna3,4,5 · EmmaG.Wilmot1,2
Received: 5 March 2024 / Accepted: 9 May 2024 / Published online: 29 June 2024
© The Author(s) 2024
Abstract
The increasing incidence of type 2 diabetes, which represents 90% of diabetes cases globally, is a major public health concern.
Improved glucose management reduces the risk of vascular complications and mortality; however, only a small proportion of
the type 2 diabetes population have blood glucose levels within the recommended treatment targets. In recent years, diabetes
technologies have revolutionised the care of people with type 1 diabetes, and it is becoming increasingly evident that people
with type 2 diabetes can also benefit from these advances. In this review, we describe the current knowledge regarding the role
of technologies for people living with type 2 diabetes and the evidence supporting their use in clinical practice. We conclude
that continuous glucose monitoring systems deliver glycaemic benefits for individuals with type 2 diabetes, whether treated
with insulin or non-insulin therapy; further data are required to evaluate the role of these systems in those with prediabetes
(defined as impaired glucose tolerance and/or impaired fasting glucose and/or HbA1c levels between 39 mmol/mol [5.7%]
and 47 mmol/mol [6.4%]). The use of insulin pumps seems to be safe and effective in people with type 2 diabetes, especially
in those with an HbA1c significantly above target. Initial results from studies exploring the impact of closed-loop systems in
type 2 diabetes are promising. We discuss directions for future research to fully understand the potential benefits of integrat-
ing evidence-based technology into care for people living with type 2 diabetes and prediabetes.
Keywords Automated insulin delivery· Closed loop· Continuous glucose monitoring· Continuous subcutaneous insulin
infusion· Diabetes technology· Insulin pump· Prediabetes· Review· Type 2 diabetes
Abbreviations
AID Automated insulin delivery
CGM Continuous glucose monitoring
CSII Continuous subcutaneous insulin infusion
DKA Diabetic ketoacidosis
HCL Hybrid closed-loop
isCGM Intermittently scanned continuous glucose
monitoring
MD Mean difference
MDI Multiple daily injections
pp Percentage points
QoL Quality of life
rtCGM Real-time continuous glucose monitoring
SMBG Self-monitoring of blood glucose
TAR Time above range
TBR Time below range
TIR Time in range
Introduction
Diabetes mellitus is a major public health issue character-
ised as a worldwide pandemic. A total of 537 million adults
live with diabetes globally, with 90% of all cases diagnosed
as type 2 diabetes [1]. This figure is predicted to rise by
Alexandros L. Liarakos and Jonathan Z. M. Lim are joint first
authors.
* Emma G. Wilmot
emma.wilmot@nottingham.ac.uk
1 Department ofDiabetes andEndocrinology, University
Hospitals ofDerby andBurton NHS Foundation Trust,
Royal Derby Hospital, Derby, UK
2 School ofMedicine, Faculty ofMedicine andHealth
Sciences, University ofNottingham, Nottingham, UK
3 Diabetes, Endocrinology andMetabolism Centre,
Manchester University NHS Foundation Trust, Manchester
Royal Infirmary, Manchester, UK
4 Department ofDiabetes, Imperial College Healthcare NHS
Trust, London, UK
5 Faculty ofMedicine, Department ofMetabolism, Digestion
andReproduction, Imperial College London, London, UK
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2060 Diabetologia (2024) 67:2059–2074
almost 50% in the next 20 years, which will be associated
with increased rates of vascular complications [1]. Improved
glucose management reduces the risk of vascular complica-
tions and mortality in people with type 2 diabetes [2–5].
However, data suggest that only around 50% of people with
type 2 diabetes achieve the recommended HbA1c target of
<53 mmol/mol (7%) [6, 7], highlighting the need for better
therapeutic options.
Technologies such as continuous glucose monitoring
(CGM), insulin pumps and automated insulin delivery
(AID) therapies have been shown to improve HbA1c, reduce
hypoglycaemia and diabetes distress, and improve quality
of life (QoL) in people with type 1 diabetes [8–10], and it is
becoming increasingly evident that type 2 diabetes popula-
tions can also benefit from these advances [11, 12].
The aim of this review is to describe the current evidence
regarding the role of technologies in people with type 2 dia-
betes, based on randomised trials, observational studies, sys-
tematic reviews and meta-analyses. We used the keywords
‘type 2 diabetes’, ‘diabetes technology’, ‘continuous glucose
monitoring’, ‘flash glucose monitoring’, ‘intermittently-
scanned continuous glucose monitoring’, ‘real-time continu-
ous glucose monitoring’, ‘continuous subcutaneous insulin
infusion’, ‘insulin pump’, ‘closed-loop’, ‘automated insulin
delivery’, ‘artificial pancreas’, ‘connected insulin devices’,
‘smart insulin pen’ and ‘smart insulin pen caps’ alone and
in combination to retrieve available literature from PubMed
from inception until January 2024. The current evidence and
research gaps in the use of technology in type 2 diabetes and
prediabetes (defined as impaired glucose tolerance and/or
impaired fasting glucose and/or HbA1c levels between 39
mmol/mol [5.7%] and 47 mmol/mol [6.4%]) are illustrated
in Fig.1.
CGM intype 2 diabetes
Current glucose monitoring technology enables intermit-
tently scanned CGM (isCGM) and real-time CGM (rtCGM).
isCGM involves sensors that need to be scanned to provide
glucose values, while in rtCGM the sensors display glucose
data on a reader or app automatically, without the need for
scanning.
A meta-analysis of 26 RCTs (17 rtCGM, nine isCGM),
involving 2783 people with type 2 diabetes, showed that,
compared with self-monitoring of blood glucose (SMBG),
rtCGM and isCGM reduced HbA1c by 0.19 percentage
points (pp) (2 mmol/mol) (95% CI −0.34, −0.04 pp) and
0.31 pp (3 mmol/mol) (95% CI −0.46, −0.17 pp), respec-
tively. Time in range (TIR) increased significantly in
isCGM users (three RCTs) and non-significantly in rtCGM
users (six RCTs) [13]. CGM did not significantly impact
glucose concentrations, glucose variability, measures
of body composition, blood pressure or lipid levels [14,
15]. There was no difference in risk of hypoglycaemia
between CGM and SMBG [14, 16–19]. Treatment satis-
faction improved with CGM use, especially with newer
generation systems, compared with SMBG [13, 17, 20,
21]. A more recent systematic review of CGM in adults
with type 2 diabetes, which excluded studies investigat-
ing professional CGM and those combining CGM with
additional glucose-lowering treatment, identified 12 RCTs
(eight rtCGM, four isCGM) involving 1248 people [22].
Compared with SMBG, CGM (isCGM or rtCGM) resulted
in a reduction in HbA1c (mean difference [MD] −3.43
mmol/mol [−0.31 pp], 95% CI −4.75, −2.11 mmol/mol;
p<0.00001). The effect size was comparable between stud-
ies including individuals on insulin ± oral therapy (MD
−3.27 mmol/mol [−0.30 pp], 95% CI −6.22, −0.31 mmol/
mol; p=0.03) and studies including those on oral therapy
only (MD −3.22 mmol/mol [−0.29 pp], 95% CI −5.39,
−1.05 mmol/mol; p=0.004). Using rtCGM showed a
trend towards a larger effect (MD −3.95 mmol/mol [−0.36
pp], 95% CI −5.46, −2.44 mmol/mol; p<0.00001) than
using isCGM (MD −1.79 mmol/mol [−0.16 pp], 95% CI
−5.28, 1.69 mmol/mol; p=0.31). CGM compared with
SMBG was also associated with increased TIR (+6.36%,
95% CI +2.48%, +10.24%; p=0.001) and decreased time
below range (TBR) (−0.66 pp, 95% CI −1.21, −0.12 pp;
p=0.02). No significant differences in severe hypoglycae-
mia or macrovascular complications were found between
CGM and SMBG. No trials reported data on microvascular
complications [22]. Table1 summarises the main findings
of the key RCTs on CGM use in type 2 diabetes.
CGM use in people with type 2 diabetes on intensive insulin
therapies The DIAMOND RCT [15] showed that, compared
with SMBG, rtCGM resulted in a greater HbA1c reduction
(MD −0.3 pp [–3 mmol/mol]) in a type 2 diabetes popula-
tion treated with multiple daily insulin injections (MDI).
However, the study did not incorporate structured diabetes
education to optimise self-management and included people
undertaking SMBG at least twice daily at baseline, while
the control group were asked to perform SMBG four or
more times daily. This may have resulted in underestima-
tion of the impact of rtCGM on plasma glucose levels. In
the REPLACE RCT, isCGM resulted in no difference in
HbA1c compared with SMBG. Nevertheless, the hypoglycae-
mia burden decreased and treatment satisfaction improved
in isCGM users. An inclusion criterion of SMBG at least
twice daily at baseline was reported and no education on
data interpretation was provided [17], suggesting possible
underestimation of the impact of isCGM on HbA1c. Another
RCT of isCGM vs SMBG in a type 2 diabetes population on
MDI showed that, although the primary outcome of treat-
ment satisfaction was not met (p=0.053), users reported
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2061Diabetologia (2024) 67:2059–2074
more flexibility (p=0.019) and would recommend isCGM
to others (p=0.023) [23].
Overall, using CGM in those on intensive insulin ther-
apy is beneficial. Several RCTs and real-world retrospective
studies support CGM use, demonstrating improvements in
HbA1c and decreased frequency and severity of hypoglycae-
mia [24–27]. However, to date, no studies have investigated
the impact of CGM in people with type 2 diabetes treated
with mixed insulin; further research is required to evaluate
the potential benefits in this group.
CGM use in people with type 2 diabetes on basal insulin The
MOBILE RCT [14] found that, compared with SMBG,
rtCGM resulted in a greater HbA1c reduction (MD −4 mmol/
mol [–0.4 pp]), improved TIR and decreased time above
range (TAR) and TBR in a type 2 diabetes population treated
with basal insulin (p<0.05 for all). The total dose of insulin
and body weight did not differ between groups, which raises
the possibility that rtCGM use may be directly associated
with dietary and activity changes. This is an area that needs
to be addressed in future research to gain a more detailed
Current evidence
CGM systems deliver glycaemic
benefits for individuals with type
2 diabetes, whether treated with
insulin or non-insulin therapy
CGM systems are associated
with reductions in diabetes
related hospitalisations and
acute complications
CGM systems are cost-effective
in insulin-treated type 2 diabetes
Insulin pump therapy is safe and
effective in people with type 2
diabetes, especially in those with
an HbA1c significantly above
target despite intensive insulin
therapy
Diabetes technology
21
10
3.9
0
0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00
Time
mmol/l
CGM
Insulin pump therapy
AID systems
Connected insulin devices
People living with type 2
diabetes
Prevalence of multimorbidity
increasing
High proportion of people not
achieving glycaemic targets
Increase in socioeconomic
burden and diabetes-related
complications
Increasing prevalence of type 2
diabetes in young adults
Research gaps
Fig. 1 The use of technology in type 2 diabetes and prediabetes. This
figure describes the current evidence and research gaps in the use of
technology in type 2 diabetes and prediabetes. CGM improves glu-
cose management in insulin- and non-insulin-treated type 2 diabetes,
while the role of CGM in prediabetes requires further research. Insu-
lin pumps improve glucose management in individuals with type 2
diabetes, especially in those with high HbA1c despite intensive insu-
lin therapy. The impact of CGM on behaviour changes and vascular
complications, and the evidence base on connected insulin devices
and closed-loop systems in type 2 diabetes, require further investiga-
tion. This figure is available as a downl oadab le slide
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2062 Diabetologia (2024) 67:2059–2074
Table 1 Evidence on the use of CGM in type 2 diabetes from key randomised trials
Study (first author,
year, trial name)
Study details Participant characteristicsaMedication use (%)aPrimary outcome and results
Aronson 2023,
IMMEDIATE [11]
• Two-arm RCT
• Intervention duration: 16 weeks
• Study duration: 16 weeks
• Interventionb vs comparator:
isCGM + DSME vs DSME
• No. of participants: 58/58
• Mean age: 59.2/57.6 years
• Baseline HbA1c:
69/72 mmol/mol (8.5/8.7%)
Non-insulin-treated T2D
• Metformin: 100/96
• SU: 55/43
• SGLT2i: 35/43
• DPP-4i: 43/47
• GLP-1RA: 28/35
• Primary outcome: % TIR in the final 2 week period
• isCGM + DSME arm had a greater mean TIR by 9.9 pp (2.4
h) (95% CI −17.3, −2.5 pp; p<0.01) and lower TAR by 8.1
pp (1.9 h) (95% CI 0.5, 15.7 pp; p=0.037) than DSME group
• isCGM + DSME arm had a greater reduction in mean HbA1c
by 0.3 pp (3 mmol/mol) (95% CI −0.7, 0 pp; p=0.048) than
DSME arm
• Glucose monitoring satisfaction was higher in the interven-
tion group than the control group (MD +0.5, 95% CI +0.3,
+0.7; p<0.01)
Ajjan 2023, LIBER-
ATES [18]
• Two-arm RCT
• Intervention duration: 12 weeks
• Study duration: 12 weeks
• Interventionb vs comparator:
isCGM vs SMBG
• No. of participants: 69/72
• Mean age: 62/63 years
• Baseline HbA1c:
75/73 mmol/mol (9.0/8.8%)
• Insulin: 52.2/47.2
• SU: 47.8/52.8
• Metformin: 72.5/77.8
• DPP-4i: 21.7/15.3
• GLP1-RA: 7.2/6.9
• SGLT2i: 10.1/20.8
• Thiazolidinedione: 2.9/0.0
• Primary outcome: TIR on days 76–90 post randomisation
• isCGM was associated with increased TIR by 17 min/day
(95% credible interval −105, +153), with 59% probability of
benefit
• Lower hypoglycaemic exposure on days 76–90 (−80 min/day,
95% CI −118, −43) and days 16–30 (−28 min/day, 95% CI
−92, 2) in isCGM users
• Similar HbA1c reduction (~7 mmol/mol [0.7 pp]) in isCGM
and SMBG groups vs baseline
• Glycaemic emergencies and mortality rates were not
increased in isCGM users
• QoL measures marginally favoured isCGM
Moon 2023 [29] • Three-arm RCT
• Intervention duration: 1–2 weeks
• Study duration: 24 weeks
• Interventionsb vs comparator:
group 1 – one session of rtCGM at
week 1; group 2 – two sessions of
rtCGM at weeks 1 and 12; control
group – SMBG
• No. of participants: 18/15/15
• Mean age: 55.6/53.9/50.7
years
• Baseline HbA1c: 67/66/65
mmol/mol (8.3/8.2/8.1%)
Non-insulin-treated T2D
• Metformin: 100/100/100
• SU: 66.7/73.3/40.0
• DPP-4i: 72.2/80.0/86.7
• SGLT2i: 44.4/26.7/13.3
• Thiazolidinedione:
38.9/40.0/66.7
• Primary outcome: change in HbA1c at 6 months
• At 6 months, only group 2 achieved significant HbA1c reduc-
tion (adjusted difference −0.68 pp [–7 mmol/mol], 95 CI
–1.23, –0.13 pp; p=0.018) vs control group
• HbA1c reduction was observed in group 1 (adjusted difference
−0.60 pp [–6 mmol/mol], 95% CI –1.19, –0.02 pp; p=0.044)
and group 2 (adjusted difference −0.64 pp [–6 mmol/mol],
95% CI –1.15, –0.14 pp; p=0.014) vs control group at 3
months
Choe 2022, PDF [12] • Two-arm RCT
• Intervention duration: 12 weeks
• Study duration: 12 weeks
• Interventionb vs comparator:
isCGM + structured education vs
conventional diabetes care
• No. of participants: 63/63
• Mean age: 58.6/57.5 years
• Baseline HbA1c: 63/63 mmol/
mol (7.9/7.9%)
• Insulin: 32.8/22.6
• Number of non-insulin
therapies:
- 1: 13.8/12.9
- 2: 48.3/46.8
- 3: 34.5/38.7
- 4: 1.7/1.6
• Primary outcome: change in HbA1c from baseline
• isCGM was associated with greater improvement in HbA1c than
standard care (risk-adjusted difference −0.50 pp [–5 mmol/mol],
95% CI −0.74, −0.26 pp; p<0.001)
• Greater reduction in fasting blood glucose (−0.9 mmol/l [–16.5
mg/dl], 95% CI –1.7, –0.2 mmol/l [–30, –3 mg/dl]; p=0.017)
and body weight (−1.5 kg, 95% CI −2.7, −0.3; p=0.013) in
intervention group
• Diabetes Self-Care Activities Questionnaire score (Korean
version) increased in both groups but to a greater extent in the
intervention group (MD +4.8, 95% CI +1.7, +8.0; p=0.003)
No severe hyperglycaemia/hypoglycaemia reported in either group
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2063Diabetologia (2024) 67:2059–2074
Table 1 (continued)
Study (first author,
year, trial name)
Study details Participant characteristicsaMedication use (%)aPrimary outcome and results
Martens 2021,
MOBILE [14]
• Two-arm RCT
• Intervention duration: 32 weeks
• Study duration: 32 weeks
• Interventionb vs comparator:
rtCGM vs SMBG
• No. of participants: 116/59
• Mean age: 56/59 years
• Baseline HbA1c: 76/75 mmol/
mol (9.1/9.0%)
Insulin: one or two daily injec-
tions of long- or interme-
diate-acting basal insulin
without prandial insulin,
with or without non-insulin
glucose-lowering medica-
tions
• Primary outcome: HbA1c at 8 months
• Mean HbA1c decreased by 1.1 pp [12 mmol/mol] (from 9.1%
[76 mmol/mol] to 8.0% [64 mmol/mol]) in rtCGM group and
by 0.6 pp [7 mmol/mol] (from 9.0% [75 mmol/mol] to 8.4%
[68 mmol/mol]) in SMBG group (MD −0.4 pp [–5 mmol/
mol], 95% CI −0.8, −0.1 pp; p=0.02)
• TIR increased (adjusted difference +15 pp, 95% CI +8, 23;
p<0.001), TAR (>13.9 mmol/l [>250 mg/dl]) decreased
(adjusted difference −16 pp, 95% CI −21, −11; p<0.001)
and hypoglycaemia (<3.9 mmol/l [<70 mg/dl]) decreased
(adjusted difference −0.24 pp, 95% CI −0.42, −0.05;
p=0.02) in rtCGM group vs SMBG group
• Severe hypoglycaemic events were not increased in rtCGM
group
Price 2021 [28] • Two-arm RCT
• Intervention duration: three ses-
sions (baseline, week 4 and 8)
• Study duration: 12 weeks
• Interventionb vs comparator:
rtCGM vs SMBG
• No. of participants: 46/24
• Mean age: 59/61 years
• Baseline HbA1c: 68.3/69.4
mmol/mol (8.4/8.5%)
Non-insulin-treated T2D
• Treated with two or more
non-insulin therapies
• Primary outcome: change in HbA1c from baseline
• No difference in mean HbA1c reduction from baseline
between rtCGM and SMBG groups (−0.5 pp [–5 mmol/mol]
vs −0.3 pp [–3 mmol/mol]; p=0.74) at week 12
• 34.1% of rtCGM users vs 17.4% of SMBG users achieved a
target HbA1c <7.5% [<58 mmol/mol] (between-group differ-
ence p=0.12)
• Mean TIR at week 8 vs baseline increased for rtCGM group
(56.3% vs 63.1%) but decreased for SMBG group (68.4% vs
55.1%)
Cox 2020 [20] • Two-arm RCT
• Intervention duration: 8 weeks
• Study duration: 24 weeks
• Interventionb vs comparator:
rtCGM vs SMBG
• No. of participants: 20/10
• Mean age: 54/51 years
• Baseline HbA1c: 74/73 mmol/
mol (8.9/8.8%)
Non-insulin-treated T2D
• No details on types of non-
insulin glucose-lowering
medications reported
• Primary outcome: change in HbA1c
• rtCGM was associated with reduction in HbA1c (from 8.9%
to 7.6% [from 74 to 60 mmol/mol]) vs reduction from 8.8% to
8.7% [from 73 to 72 mmol/mol] for SMBG (p=0.03)
• rtCGM was associated with improved QoL (p=0.01) and
diabetes knowledge (p=0.001) and reduced diabetes distress
(p=0.02)
Wada 2020 [30] • Two-arm RCT
• Intervention duration: 12 weeks
• Study duration: 24 weeks
• Interventionb vs comparator:
isCGM vs SMBG
• No. of participants: 49/51
• Mean age: 58.1/58.7 years
• Baseline HbA1c: 61.1/62.3
mmol/mol (7.83/7.85%)
Non-insulin-treated T2D
• SU: 32.7/27.5
• Metformin: 69.4/62.7
• DPP-4i: 81.6/78.4
• SGLT2i: 42.9/37.3
• GLP-1 RA: 2.0/5.9
• Glinide: 20.4/21.6
• α-Glucosidase inhibitor:
26.5/35.3
• Pioglitazone: 8.2/13.7
• Primary outcome: change in HbA1c
• Mean HbA1c decreased from baseline to 12 weeks in isCGM
users (−0.43 pp [−4.7 mmol/mol]; p<0.001) and SMBG
users (−0.30 pp [−3.3 mmol/mol]; p=0.001)
• Mean HbA1c decreased from baseline to 24 weeks in isCGM
users but not in SMBG group (isCGM: −0.46 pp [−5.0
mmol/mol], p<0.001; SMBG: −0.17 pp [−1.8 mmol/mol],
p=0.124; between-group difference: −0.29 pp [−3.2 mmol/
mol], p=0.022)
• DTSQ score improved in isCGM group vs SMBG group
(difference in adjusted means +3.4, 95% CI +1.9, +5.0;
p<0.001)
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2064 Diabetologia (2024) 67:2059–2074
Table 1 (continued)
Study (first author,
year, trial name)
Study details Participant characteristicsaMedication use (%)aPrimary outcome and results
Ajjan 2019 [19] • Three-arm RCT
• Intervention duration: 24 weeks
• Study duration: 24 weeks
• Interventionsb vs comparator:
group 1 – isCGM (two wears) +
SMBG; group 2 – isCGM (four
wears) + SMBG; control group –
SMBG
• No. of participants: 46/50/52
• Mean age: 63.9/61.7/65.0
years
• Baseline HbA1c: 71/71/71
mmol/mol (8.7/8.7/8.7%)
• Insulin (basal only):
52.2/42.0/40.4
• Insulin (basal–bolus):
41.3/50/50
• Insulin (biphasic):
6.5/8.0/9.6
• Primary outcome: TIR in group 2 comparing baseline with
follow-up
• In group 2, TIR was similar between baseline and follow-
up (days 172–187) (15.0±5.0 h/day vs 14.1 ± 4.7 h/day;
p=0.159)
• HbA1c decreased by 4.9 mmol/mol (0.44 pp) (p<0.001) from
baseline to study end in group 2
• HbA1c was lower in group 2 than control group at study end
by 5.4 mmol/mol (0.48 pp) (p=0.004), without increased time
in hypoglycaemia (p=0.178)
• Treatment satisfaction scores improved in group 2 vs control
group (p=0.023)
Yaron 2019 [23] • Two-arm RCT
• Intervention duration: 10 weeks
• Study duration: 10 weeks
• Interventionb vs comparator:
isCGM vs SMBG
• No. of participants: 53/48
• Mean age: 67.6/65.9 years
• Baseline HbA1c: 71.4/67.7
mmol/mol (8.68/8.34%)
• Insulin (MDI): 100/100
• SU: 0.0/4.2
• Metformin: 71.7/72.9
• DPP-4i: 7.5/14.6
• SGLT2i: 24.5/27.7
• GLP-1 RA: 35.8/31.3
• Primary outcome: treatment satisfaction
• Compared with SMBG group, isCGM group found the treat-
ment significantly more flexible (p=0.019) and would recom-
mend it to their counterparts (p=0.023)
• HbA1c decreased by 0.82 pp (9 mmol/mol) and 0.33 pp (3.6
mmol/mol) in the isCGM and SMBG groups, respectively
(p=0.005)
Ilany 2018 [16] • Two-arm RCT
• Intervention duration: 16 weeks
• Study duration: 24 weeks
• Interventionb vs comparator:
isCGM + glulisine before a meal
with the highest glucose elevation
based on sensor data vs SMBG +
pre-breakfast glulisine
• No. of participants: 60/61
• Mean age: 63/63 years
• Baseline HbA1c: 68/69 mmol/
mol (8.4/8.5%)
• Insulin: 100/100 (glar-
gine: 65.0/68.3; detemir:
30.0/25.0; glulisine:
40.4/82.7)
• Primary outcome: HbA1c at week 24
• No difference in HbA1c reduction from baseline to follow-up
between isCGM and SMBG groups (−0.54 pp [6 mmol/mol];
95% CI −0.79, −0.3 pp vs −0.48 pp [5 mmol/mol]; 95% CI
−0.76, –0.2 pp; p=0.75)
• Frequency of hypoglycaemic events did not differ between
isCGM and SMBG groups (52% vs 36%; p=0.08)
Beck 2017, DIA-
MOND [15]
• Two-arm RCT
• Intervention duration: 24 weeks
• Study duration: 24 weeks
• Interventionb vs comparator:
rtCGM vs SMBG
• No. of participants: 79/79
• Mean age: 60/60 years
• Baseline HbA1c: 69/69 mmol/
mol (8.5/8.5%)
• Insulin (MDI): 100/100 • Primary outcome: change in HbA1c at 24 weeks after ran-
domisation
• HbA1c decreased to 7.7% (61 mmol/mol) in the rtCGM group
and 8.0% (64 mmol/mol) in the control group at 24 weeks
(adjusted difference in mean change −0.3 pp [−3 mmol/mol],
95% CI −0.5, 0.0 pp; p=0.022)
• No difference in CGM-measured hypoglycaemia or QoL
outcomes between rtCGM and SMBG groups
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2065Diabetologia (2024) 67:2059–2074
Table 1 (continued)
Study (first author,
year, trial name)
Study details Participant characteristicsaMedication use (%)aPrimary outcome and results
Haak 2017,
REPLACE [17]
• Two-arm RCT
• Intervention duration: 24 weeks
• Study duration: 24 weeks
• Interventionb vs comparator:
isCGM vs SMBG
• No. of participants: 149/75
• Mean age: 59.0/59.5 years
• Baseline HbA1c: 72.0/73.5
mmol/mol (8.7/8.8%)
• Insulin (intensive insulin
therapy): 100/100
• Primary outcome: difference in HbA1c at 6 months
• No difference in change in HbA1c between isCGM and
SMBG groups (−3.1 mmol/mol [–0.29 pp] vs −3.4 mmol/
mol [–0.31 pp] ; p=0.822)
• In people aged <65 years, rtCGM group had a greater
improvement in HbA1c than SMBG group (−5.7 mmol/mol
[–0.53 pp] vs −2.2 mmol/mol [–0.2 pp]; p=0.03)
• Time in hypoglycaemia (<3.9 mmol/l ([<70 mg/dl]) reduced
by 43% (0.47 ± 0.13 h/day) (p <0.001) and time in hypogly-
caemia (<3.1 mmol/l [<55 mg/dl]) reduced by 53% (0.22 ±
0.07 h/day) (p=0.0014) in isCGM group vs SMBG group
• Treatment satisfaction was higher in isCGM group than
SMBG group (DTSQ 13.1 ± 0.5 vs 9.0 ± 0.72; p<0.0001)
Tang 2014 [21] • Two-arm RCT
• Intervention duration: 24 weeks
• Study duration: 24 weeks
• Interventionb vs comparator:
rtCGM vs SMBG
• No. of participants: 40 in total
• Mean age: 59/60 years
• Baseline HbA1c: 68/73 mmol/
mol (8.4/8.8%)
• Insulin alone or in combina-
tion with oral agent
• Primary outcome: treatment satisfaction
• SMBG group reported higher overall treatment satisfaction
than rtCGM users (DTSQ 33.41 vs 24.80; p<0.001)
a Data are presented for intervention/control or group 1/group 2/control, unless stated otherwise
b Type of CGM
DPP-4i, dipeptidyl peptidase 4 inhibitor; DSME, diabetes self-management education; DTSQ, diabetes treatment satisfaction questionnaire; GLP-1RA, glucagon-like peptide-1 receptor agonist;
MDI, multiple daily insulin injections; pp, percentage points; SGLT2i, sodium-glucose co-transporter-2 inhibitor; SU, sulfonylurea; T2D, type 2 diabetes; TAR, time above range
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2066 Diabetologia (2024) 67:2059–2074
understanding of how CGM may drive glycaemic improve-
ments in this group.
CGM use in people with type 2 diabetes on non‑insulin ther‑
apy A pilot RCT of a structured diabetes education pro-
gramme with episodic rtCGM use in a non-insulin-treated
type 2 diabetes population demonstrated no significant
HbA1c improvement compared with SMBG [28], while an
RCT of intermittent short-term use of rtCGM compared
with SMBG found a 0.64 pp (6 mmol/mol) HbA1c reduction
(p=0.014) [29]. In another RCT [30], isCGM users showed
a higher HbA1c reduction than SMBG users at 24 weeks
(MD –3.2 mmol/mol [−0.29 pp]; p=0.022). The IMMEDI-
ATE RCT explored the glycaemic efficacy of isCGM plus
diabetes self-management education compared with educa-
tion alone in a type 2 diabetes population on at least one
non-insulin therapy [11]. TIR at 4 months was higher in
isCGM users (p=0.009), with little change in medication
use (non-insulin glucose-lowering therapies were added for
<10% of participants in each arm). This raises the possibility
that CGM use may change behaviours, impacting glycaemic
outcomes. The effect of CGM use on behaviour change is an
area ripe for future research.
A retrospective analysis of 728 people with type 2 diabe-
tes on non-insulin therapies using isCGM found a 1.6 pp (16
mmol/mol) HbA1c reduction (p<0.001); a limitation of this
analysis was the lack of a control group [31].
CGM use and acute diabetes‑related complications and hos‑
pitalisation The RELIEF [32] retrospective study evaluated
40,846 people with type 2 diabetes (and 33,165 individuals
with type 1 diabetes) in the first 12 months following isCGM
initiation. Most within the type 2 diabetes cohort were
treated with MDI, while a small proportion were treated
with basal insulin or oral agents only. Twelve months fol-
lowing isCGM initiation, hospitalisation for acute diabetes
complications decreased by 39% [32]. Specifically, in the
type 2 diabetes population, the annual percentage of hospi-
tal admissions decreased for diabetic ketoacidosis (DKA)
(from 1.7% to 0.82%), hypoglycaemia (from 0.7% to 0.62%),
diabetes-related comas (from 0.23% to 0.16%) and hyper-
glycaemia (from 0.12% to 0.09%). The 2-year follow-up
showed a persistent reduction in acute diabetes-related hos-
pitalisations, from 2.0% before initiating isCGM to 0.75%
at 1 year and 0.6% at 2 years follow-up [33]. Similarly, in
a retrospective study carried out in the Netherlands, use of
isCGM reduced diabetes-related hospital admissions from
13.7% to 4.7% (p<0.05) [34].
The LIBERATES RCT [18] investigated the effect of
isCGM vs SMBG on blood glucose levels in a type 2 dia-
betes population with acute myocardial infarction, already
treated with therapies that may result in hypoglycaemia.
Although there was no significant difference in HbA1c or
TIR between groups, isCGM significantly reduced the sub-
sequent risk of hypoglycaemia (Table1).
CGM use in prediabetes An RCT in individuals with predia-
betes showed that isCGM combined with lifestyle coaching
improved blood glucose levels and reduced carbohydrate
intake and body weight [35]. A pilot RCT in 13 individuals
with prediabetes or type 2 diabetes suggested that rtCGM
may facilitate self-monitoring behaviour and increase exer-
cise adherence accompanied by improvements in health-
related QoL [36]. Similarly, a qualitative study in 26 individ-
uals at moderate to high risk of developing type 2 diabetes
suggested that using a combination of isCGM and a physical
activity monitor may increase self-awareness regarding the
impact of lifestyle on short-term health and guide behav-
iour change [37]. However, the feedback provided by the
devices lacked meaning for several individuals, posing bar-
riers to making changes to diet and physical activity levels.
Hence, these findings highlight the need for further research
to explore potential modifications required to digital health
technologies, including CGM, to sustain engagement and
behaviour change in individuals with prediabetes.
In summary, high-quality evidence demonstrates that
both isCGM and rtCGM deliver glycaemic benefits for
people with type 2 diabetes, whether treated with insulin
or non-insulin therapy. The available data suggest that the
mechanisms for improvements in blood glucose levels in
response to CGM may not be directly reacted to therapeutic
change, as one might assume. Further studies are required to
provide a detailed understanding of the impact of CGM on
dietary intake and physical activity, in addition to exploring
the potential benefits of CGM in those with type 2 diabetes
treated with mixed insulins.
Continuous subcutaneous insulin infusion
intype 2 diabetes
Continuous subcutaneous insulin infusion (CSII), also
known as insulin pump therapy, has a clear place in the man-
agement of type 1 diabetes [38]. In contrast, the guidelines
for using CSII in type 2 diabetes are less consistent [39–41].
The OpT2mise RCT, which included 331 individuals
with MDI-treated type 2 diabetes, found that, compared with
MDI, CSII resulted in a significant 0.7 pp (7 mmol/mol)
HbA1c reduction after 6 months, without increased rates of
hypoglycaemia, DKA or hospitalisation [42]. In another
RCT, individuals randomised to the CSII arm achieved a
significant 0.9 pp (9 mmol/mol) HbA1c reduction compared
with 0.3 pp (3 mmol/mol) in the MDI arm. After 6 months,
the MDI arm crossed over to CSII and at 12 months the indi-
viduals continuing CSII had an additional 0.7 pp (7 mmol/
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

2067Diabetologia (2024) 67:2059–2074
mol) reduction in HbA1c and those switching from MDI to
CSII experienced a 0.5 pp (5 mmol/mol) HbA1c reduction
[43]. Similarly, the VIVID study demonstrated that, com-
pared with MDI, CSII improved HbA1c without increasing
body weight or severe hypoglycaemia [44].
Real-world data suggest that using CSII in type 2 diabetes
can be safe and effective for improving blood glucose levels,
particularly in those individuals with higher HbA1c levels,
and is associated with high user satisfaction [45–47]. In one
study, the HbA1c reduction was sustained for 6 years, indi-
cating the potential long-term benefits of CSII therapy for
those with type 2 diabetes [46].
Initiating CSII in type 2 diabetes has been associated with
improved patient-reported outcomes and user satisfaction [48].
A recent real-world study demonstrated that, compared with
MDI, use of a tubeless insulin pump in adults with type 2 dia-
betes contributed to significant behavioural and psychosocial
benefits, including improvements in overall well-being, diabe-
tes distress, hypoglycaemia-related concerns and QoL, as well
as greater glycaemic improvement [49]. User satisfaction and
improved glycaemic outcomes have also been shown in studies
exploring the use of simplified CSII systems with no need for
pump programming or detailed education sessions [50, 51].
Overall, CSII is safe and effective in populations with
type 2 diabetes, especially in those with an HbA1c signifi-
cantly above target despite MDI. CSII may also be associ-
ated with decreased healthcare costs as a result of lower rates
of diabetes-related complications [51–54].
AID systems intype 2 diabetes
AID systems, also known as closed-loop systems, include
‘hybrid’ closed-loop (HCL) therapies, which require carbo-
hydrate counting and user-initiated, pump-delivered meal
boluses, and fully closed-loop systems, which eliminate the
need for manual mealtime boluses.
An RCT in 136 individuals with type 2 diabetes showed
that, compared with subcutaneous insulin therapy, a fully
AID system resulted in a significant 24.3 pp TIR increase
and 25.9 pp TAR reduction without increasing hypoglycae-
mia. User satisfaction was also high in the closed-loop group
[55]. Similar results were observed in other RCTs performed
in inpatient settings [56, 57].
Randomised trials conducted in outpatient settings also
suggest glycaemic benefits of fully closed-loop systems
[58–60]. A randomised crossover study in 26 adults with
type 2 diabetes compared a fully closed-loop system with
standard insulin therapy and a masked glucose sensor (con-
trol). The authors demonstrated a significant 15 mmol/mol
(1.4 pp) HbA1c reduction and 35.3 pp TIR increase without
elevated hypoglycaemia rates following closed-loop therapy
compared with control [59].
A recent meta-analysis of seven RCTs assessing the effi-
cacy of fully closed-loop systems compared with conven-
tional insulin therapy in 390 people with type 2 diabetes
showed that fully closed-loop systems improved TIR (MD
+22.40 pp, 95% CI 12.88, 31.91 pp; p<0.01) and reduced
TAR (MD −22.67 pp, 95% CI −30.87, −14.46 pp; p<0.01)
without a significant difference in hypoglycaemia [61].
The literature on HCL therapies in type 2 diabetes is
limited [62, 63]. A feasibility trial in 24 adults with type 2
diabetes managed in an outpatient setting found that HCL
was associated with a 14 mmol/mol (1.3 pp) HbA1c reduc-
tion, 21.9 pp TIR increase, 16.9 pp TAR reduction and 0%
of time at glucose <3 mmol/l (<54 mg/dl), without a sig-
nificant change in total daily insulin dose or body weight
[62]. Similarly, a prospective single-arm trial demonstrated
a substantial glycaemic improvement (TIR increased by 15
pp) without increased hypoglycaemia in 30 adults with type
2 diabetes using HCL therapy [63].
In summary, small studies suggest that closed-loop sys-
tems could be a potential future therapeutic option in type 2
diabetes.More long-term follow-up studies are required to
assess their clinical and cost-effectiveness.
Connected insulin devices intype 2 diabetes
Missed and late insulin injections negatively impact blood
glucose levels [64]. Connected insulin devices, including
tracking insulin pens, and smart insulin pens and caps, can
record and transfer data about insulin doses and timing to
smartphone applications, as well as provide reminders to
bolus and facilitate insulin dose calculations [65]. These
features support decision making and inform counselling
strategies for the diabetes care team [65–68].
In a randomised trial that aimed to assess the efficacy
of a smart insulin pen cap for the management of individu-
als with suboptimally controlled type 2 diabetes (interven-
tion group: feedback and alarm notifications; control group:
masked device without alarm notifications), compared with
the control group (n=40), the intervention group (n=40)
experienced a greater HbA1c reduction (−0.98 pp [–10
mmol/mol] vs −0.72 pp [–7 mmol/mol]; p=0.006) and lower
blood glucose levels (8.2 ± 1.9 vs 8.7 ± 2.3 mmol/l [147.0
± 34 vs 157.6 ± 42 mg/dl]; p<0.01). The device was also
associated with high user satisfaction [69]. In the STYL-
CONNECT study, people with type 2 diabetes showed a
strong interest in using a device that could automate the
collection of their insulin data and integrate data from glu-
cose measurement devices [70]. Another study demonstrated
that people with type 2 diabetes preferred connected over
non-connected insulin pens because of the capability for
automated recording of insulin dose and glucose levels [71].
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2068 Diabetologia (2024) 67:2059–2074
Evidence around the use of connected insulin devices in
type 2 diabetes is still in an early phase. However, existing
literature suggests that these systems may have the potential
to improve plasma glucose and user satisfaction, highlight-
ing the importance of further research in this area [72].
Special groups
Early‑onset type 2 diabetes Type 2 diabetes in young people
is associated with an excess lifetime risk of vascular compli-
cations and premature death [73–76]. Improving HbA1c is
crucial to reduce long-term diabetes-related complications
and mortality rates [3, 4]. Despite emerging evidence sug-
gesting the glycaemic benefits of technologies such as CGM
in older adults with type 2 diabetes [11, 12], research around
the use of such systems in young individuals is scarce and
limited to small studies [77, 78]. Small pilot studies suggest
that rtCGM is acceptable and feasible and associated with
significant improvements in QoL and glycaemic outcomes in
adolescents and young adults with type 2 diabetes [77, 78].
To date, there are no studies exploring the impact of CSII or
closed-loop systems in young people with type 2 diabetes.
Further studies assessing the use of technologies in people
with early-onset type 2 diabetes are needed to explore the
potential benefit of these therapies in this high-risk cohort.
Pregnancy and type 2 diabetes Pregnancy complicated by
type 2 diabetes is associated with adverse maternal and fetal
outcomes [79]. Maternal hyperglycaemia is a major modifia-
ble risk factor for pregnancy outcomes [79], and it seems log-
ical that CGM could improve blood glucose levels and opti-
mise the care of pregnant women with pre-existing diabetes.
rtCGM reduces the risk of adverse fetal outcomes in women
with type 1 diabetes [80] and may support the management
of women with pre-existing diabetes, including the high-risk
type 2 diabetes population [81, 82]. Non-randomised stud-
ies suggest that isCGM can be useful for improving blood
glucose levels in pregnant women with type 2 diabetes and is
accurate and well-received [83, 84]. However, RCT-derived
data assessing the efficacy of CGM for maternal glucose
management and perinatal outcomes in women with type 2
diabetes are currently lacking, while existing studies involve
small numbers of individuals [85–87]. The ADA clinical
practice recommendations for the management of diabetes
in pregnancy state that there are insufficient data to support
CGM use in all individuals with type 2 diabetes and that the
decision to use CGM should be individualised [88]. NICE
guidelines on the management of diabetes in pregnancy indi-
cate that rtCGM should be considered in pregnant women
with insulin-treated type 2 diabetes if they have problematic
severe hypoglycaemia or unstable blood glucose levels caus-
ing concern despite efforts to optimise plasma glucose [89].
Although the International Consensus on Time in Range
defines CGM target ranges for people with diabetes, there are
currently no internationally agreed goals for pregnant women
with type 2 diabetes [88, 90].
Future research should aim to investigate the impact
of CGM in pregnant women with type 2 diabetes, assess
associations of CGM metrics with pregnancy outcomes and
identify the appropriate amount of time spent within defined
glucose targets for this population.
End‑stage renal disease and type 2 diabetes The evidence
for using technologies in the type 2 diabetes population
with end-stage renal disease on dialysis is scarce. Observa-
tional studies suggest that CGM is an accurate and efficient
method of monitoring interstitial glucose levels in individu-
als receiving haemodialysis [91–95]. Data suggest that there
is increased glucose variability during dialysis days, which
could be an additional risk factor for cardiovascular compli-
cations [96, 97]. CGM can capture glucose variations, guide
insulin therapy optimisation and improve glucose levels and
hypoglycaemia detection in individuals with insulin-treated
type 2 diabetes receiving dialysis [98–100]. However, these
outcomes should be interpreted with caution as most of the
existing studies are observational with short-term follow-
up, include small numbers of participants and no control
group, and provide very limited evidence on peritoneal dial-
ysis. RCTs and studies with longer follow-up are therefore
needed.
A post hoc analysis of an RCT in a type 2 diabetes popu-
lation undergoing inpatient haemodialysis showed that, com-
pared with subcutaneous insulin therapy, a fully closed-loop
system was associated with a significant 37.6% increase in
the proportion of time when blood glucose was within the
target range (5.6–10.0 mmol/l [100–180 mg/dl]), without
increasing hypoglycaemia [101]. Similarly, an RCT in 26
adults with type 2 diabetes requiring dialysis in an outpa-
tient setting showed that a fully AID system significantly
increased TIR by 14.6 pp without increased hypoglycaemia
compared with standard insulin therapy [58], suggesting
that closed-loop systems could be a novel way to achieve
safe and effective glucose management in this vulnerable
population.
Older people and type 2 diabetes The adoption of diabetes
technologies in older people remains at an early stage and
clinical knowledge is currently modest. Cognitive impair-
ment, multimorbidity and sensory deficits due to increasing
age are important challenges in this group [102, 103], while
the significance of reducing hypoglycaemia is emphasised
in international recommendations [90].
Two RCTs including people with type 2 diabetes on MDI
over the age of 60 years found that CGM was associated with
a 0.3–0.5 pp (3–5 mmol/mol) HbA1c reduction compared
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

2069Diabetologia (2024) 67:2059–2074
with SMBG [15, 23]. Additional data suggesting that pump
therapy may be beneficial in older people with type 2 dia-
betes on MDI were described in the OpT2mise trial, which
included individuals aged up to 75 years [42]. Another RCT
demonstrated that, compared with MDI, a fully closed-loop
system resulted in a significant 27.4 pp TIR increase, a 27.7
pp TAR reduction and an unchanged TBR of <1% in 30
people with type 2 diabetes (mean age 69.5 years) requiring
nursing support at home. There were no episodes of severe
hypoglycaemia or ketoacidosis and both participants and
caregivers were highly satisfied with the AID system [60].
A recent review from the International Geriatric Diabetes
Society described the low uptake of diabetes technologies
in older adults because of individual and healthcare system-
related barriers [104]. Future studies should aim to explore
the efficacy, safety, role, cost implications and potential
barriers of using technologies in older people with type 2
diabetes, including those with multimorbidity and cognitive
and functional impairment and those living in supervised
facilities.
Cost‑eectiveness oftechnologies intype 2
diabetes
The increasing prevalence of type 2 diabetes globally, par-
ticularly in younger individuals who will live longer with
their disease and have an increased risk of costly diabetes-
related complications, is expected to result in several chal-
lenges for healthcare systems and clinicians. Increased rates
of emergency department use and hospital admissions due
to diabetes-related complications are associated with sig-
nificant healthcare costs [105]. Hence, using cost-effective
technologies, which improve HbA1c and thereby reduce
complications, is imperative.
The cost–benefits of CGM in type 2 diabetes have been
described previously [106, 107]. A recent retrospective anal-
ysis showed that the mean per-patient per-month cost for dia-
betes-related medical costs in a type 2 diabetes population
decreased by US$424 following ≥6 months of rtCGM use.
A decrease in hospital admissions was also reported [108].
Other studies have also demonstrated that CGM use in type
2 diabetes is associated with a reduction in diabetes-related
admissions, which would imply cost savings for healthcare
systems [24, 33]. A base-case analysis showed that long-
term isCGM use was cost-effective compared with SMBG in
individuals with type 2 diabetes receiving intensive insulin
treatment [109]. Similarly, another analysis demonstrated
that rtCGM was likely to be cost-effective compared with
SMBG in a type 2 diabetes population receiving insulin ther-
apy, with HbA1c reduction and QoL benefit from reduced
fingerstick testing being the main drivers of the outcomes
observed [110]. Taken together, the available data suggest
that CGM is cost-effective, which has led to the inclusion
of such systems in guidelines for the management of type 2
diabetes [40, 111].
Evidence suggesting the cost-effectiveness of CSII in
type 2 diabetes is scarce. Compared with MDI, CSII was
associated with a gain in quality-adjusted life-years ranging
between 0.17 and 0.43 and a 15–20% reduction in diabetes-
related complication costs, which mitigated the higher mean
lifetime costs [53, 54, 112]. Sensitivity analyses showed that
insulin pump therapy was most cost-effective in individuals
with the highest baseline HbA1c, suggesting that CSII may
represent a cost-effective therapeutic alternative for MDI-
treated type 2 diabetes populations who have HbA1c levels
above target [112].
To date, there are no cost-effective analyses of closed-
loop systems in type 2 diabetes, and studies comparing the
cost-effectiveness of such systems with that of the available
glucose-lowering therapies are needed. Lastly, connected
insulin devices in this population are potentially cost sav-
ing, but further data are required [72].
Conclusion
People with type 2 diabetes face several challenges in achiev-
ing glycaemic targets. Advances in diabetes technologies
have provided tools that can facilitate self-management in
this high-risk group, especially those on insulin therapy with
HbA1c values above target. Further research will indicate the
best place within treatment guidelines of newer technolo-
gies such as closed-loop therapies, which have shown very
promising results at this initial stage.
Supplementary Information The online version contains a slide
of the figure for download available at https:// doi. org/ 10. 1007/
s00125- 024- 06203-7.
Funding This review received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Authors’ relationships and activities ALL has received support to
attend conferences from Eli Lilly and Novo Nordisk and research sup-
port from the Association of British Clinical Diabetologists. LL has
received research support from Abbott Diabetes Care and Dexcom,
participated in advisory groups for Abbott Diabetes Care, Insulet,
Dexcom, Medtronic and Roche Diabetes, and received fees for speak-
ing from Sanofi, Insulet, Medtronic and Abbott. EGW has received
personal fees from Abbott, AstraZeneca, Dexcom, Eli Lilly, Embecta,
Glooko, Insulet, Medtronic, Novo Nordisk, Roche, Sanofi, Sinocare
and Ypsomed, research support from the Association of British Clinical
Diabetologists, Abbott, Diabetes UK, Embecta, Insulet, Novo Nordisk
and Sanofi, and medical writing support from Abbott, Eli Lilly and
Embecta, and has participated in consultancy/been an advisory board
member for Abbott, Dexcom, Eli Lilly, Embecta, Insulet, Medtronic,
Novo Nordisk, Roche and Sanofi. JZML declares that there are no rela-
tionships or activities that might bias, or be perceived to bias, this work.
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2070 Diabetologia (2024) 67:2059–2074
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