Practical considerations for using concentrated U200 insulin in automated insulin delivery systems

The use of automated insulin delivery systems (AID) is standard of care for people with type 1 diabetes. However, the limited capacity of insulin pump cartridges, which can hold 1.6-3.0mL or the equivalent of 160-300 units of U100 insulin, can be a barrier to AID use for individuals with high total daily insulin (TDI) requirements. With the rising prevalence of obesity, expansion of AID use to type 2 diabetes, and trends towards smaller cartridge volumes to decrease the size of devices, practical solutions to reduce barriers to AID use for those with high TDI requirements are needed. U200 concentrated rapid-acting insulin (U200) has a similar pharmacokinetic and pharmacodynamic profile to U100 insulin, provides the same dose of U100 insulin in half of the volume, and has been used off-label to facilitate AID use for those with high TDI needs. In this perspective piece we provide practical considerations for clinical implementation of U200 use in AID systems, including identification of candidates, unique considerations in filling pumps with U200 insulin, guidance on programming appropriate AID settings for the different algorithms, concepts to address in patient education, and recommendations for standardized documentation in the electronic health record.