Diabetes Dialogue: Twiist AID Data and the New ADA/EASD Type 2 Algorithm

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Automated insulin delivery (AID) is becoming the standard approach for insulin-requiring type 2 diabetes (T2D), and new pivotal data suggest a fourth system may soon join the 3 already cleared for this population.

On a recent episode of Diabetes Dialogue, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, reviewed 2 updates in T2D care. The discussion covered the Twiist AID trial and the new joint management algorithm from the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD).

The single-arm, multicenter trial, published in Diabetes Care, enrolled 307 adults aged 19 to 85 years with insulin-treated T2D who used the system for 13 weeks. Mean HbA1c fell 0.7%, from 8.1% to 7.4%, while continuous glucose monitoring time in range rose from 57% to 73%. Because every 5% gain in time in range carries clinical weight, a 16-point increase represents a substantial shift.

Similar benefits appeared in adults older than 65 years, those using >100 units of insulin daily, and those taking glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose cotransporter 2 (SGLT2) inhibitors. Participants kept background therapy, and few counted carbohydrates at baseline. Fixed meal announcements, such as 45 g per meal with carbohydrate ratios adjusted behind them, and an extended-absorption bolus for gastroparesis or grazing patterns may simplify use.

The ADA/EASD algorithm now integrates comorbidity assessment with glycemic and weight goals rather than splitting them into parallel pathways. Medical nutrition therapy, 24-hour physical activity behaviors, self-management education, and social determinants of health sit at the top. Directly below, the algorithm calls for early SGLT2 inhibitor and/or GLP-1-based therapy to modify disease and complication risk, a position metformin once held.

A footnote extends the atherosclerotic cardiovascular disease recommendation to dual glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonists such as tirzepatide (Mounjaro), reflecting SURPASS-CVOT. Metabolic dysfunction-associated steatotic liver disease and steatohepatitis now sit beside chronic kidney disease and heart failure, with GLP-1-based therapy, low-dose pioglitazone, or SGLT2 inhibitors as options. An evidence graphic also links each additional 500 to 1,000 daily steps with lower all-cause and cardiovascular mortality.

Collectively, the updates mark a move away from stepwise treat-to-fail escalation toward earlier organ-protective therapy and, once insulin is needed, automated delivery as the default.

Editors’ Note: Isaacs reports disclosures with Dexcom, Abbott, Lilly, Novo Nordisk, Medtronic, Insulet, and others. Bellini reports disclosures with Abbott Diabetes Care, MannKind, Povention Bio, and others.

References

1. Levy CJ, Kanapka L, Graham TE, et al. A Multicenter 13-Week Evaluation of the twiist Automated Insulin Delivery in Insulin-Treated Type 2 Diabetes: The twiist-T2D Pivotal Trial. Diabetes Care. 2026 Oct 7:dc261270. doi: 10.2337/dc26-1270.

2. Davies MJ, Aroda VR, Bajaj M, et al. Management of type 2 diabetes, 2026. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2026 Oct 2. doi: 10.1007/s00125-026-06855-7.