Automated Insulin Delivery Versus Daily Injections for Hospital Diabetes Care

Inpatient Diabetes Management With Automated Insulin Delivery Systems Compared to Multiple Daily Injections With a Basal-bolus Regimen - a Randomized Controlled Trial

Aim

The investigators aim to investigate if automated insulin delivery systems (AID) improve in-hospital glycemic and clinical outcomes in patients with type 2 diabetes compared to standard-of-care with a pen-basal-bolus insulin regimen manually titrated by general staff at Herlev-Gentofte Hospital and a clinical decision support system (GlucoTab) titrating the basal-bolus regimen automatically daily at Graz University Hospital.

Population

Hospitalized patients with type 2 diabetes in non-intensive care units (non-ICU) at medical wards at Copenhagen University Hospitals of Herley-Gentofte (affiliated with Steno Diabetes Center Copenhagen) and Medical University Hospital of Graz (N = 92).

Design

This is an investigator-initiated, two-armed, two-site, prospective, randomized, open-label, blinded endpoint (PROBE) trial.

Objectives

The objective is to determine the glycemic and clinical effects of inpatient AID systems in non-ICU patients with type 2 diabetes. Participants will be randomized in a usual-of-care and an AID arm. Diabetes management will be performed by usual care in the control arm based on a basal-bolus insulin regimen and point-of-care (POC) glucose testing. A continuous glucose monitoring (CGM) system (Abbott FreeStyle Libre 3) will be used in all groups for outcome analysis and comparison between the groups. The CGM will be blinded for the control arm, to not interfere with the usual of care because of the higher amount of glucose data. The AID-arm will be managed by an AID system with real-time CGM data transmitted to nursing stations.

Outcomes

Primary outcome: The primary outcome is the difference in CGM-recorded time in range (TIR) (70-180 mg/dl (3.9-10.0 mmol/l)) between the POC- and the CGM-arm according to the 2023 in-hospital CGM consensus during the entire hospital stay.

Secondary outcomes: Outcomes are reported according to the 2023 in-hospital CGM consensus and specified in the protocol during the entire hospital stay, including three levels of time above range (TAR) 180-250mg/dl (10.0-13.9 mmol/l), >250mg/dl (>13.9 mmol/l), and >180mg/dl (>10.0 mmol/l); three levels of time below range (TBR) 54-70mg/dl (3.0-3.9 mmol/l), <54mg/dl (<3.0 mmol/l), and <70mg/dl (<3.9 mmol/l); events of hypoglycemia in three levels, 54-68mg/dl (3.0-3.8 mmol/l), <54mg/dl (< 3.0 mmol/l), and <70mg/dl (<3.9 mmol/l), where the glucose values between the two hypoglycemic events must all be >70mg/dl (>3.9 mmol/l) for at least 15 consecutive minutes(1), including prolonged hypoglycemic events (> 120 minutes), recurrent hypoglycemic events (events preceded by another hypoglycemic event), and recurrent hypoglycemic days (percentage of days with at least one hypoglycemic event on separate days that is preceded by another in-hospital day with hypoglycemia(1)); mean glucose level; standard deviation (SD) of the CGM glucose distribution; coefficient of variation (CV); and insulin doses during hospitalization.

Clinical outcomes: The investigator assess the length of hospital stay as calculated from time of admission until discharge; in-hospital mortality; admissions to intensive care unit; any in-hospital-related complications occurring at least one day after randomization and until discharge, as documented and defined by the treating physician in the electronic health record (e.g., acute kidney injurie, sepsis, etc.)

Method

For the usual-of-care-arm, glucose assessment is done by standard POC glucose testing and insulin is manually titrated by general staff at Herlev-Gentofte Hospital and the glucose assessment is done by standard POC glucose testing and insulin is manually titrated by the GlucoTab system titrating the basal-bolus regimen automatically daily at Graz University Hospital. For the AID-arm, CGM data informs in real time the mylife Ypsopump for automated insulin delivery.

Device

The investigational device is the AID system, containing of the mylife YpsoPump and the FreeStyle Libre 3 sensor.

Study Overview

• Status: Not yet recruiting
• Conditions: Diabetes Mellitus Type 2; Infection; CGM
• Intervention / Treatment: Device: automated insulin delivery system; Procedure: GlucoTab; Procedure: Control-arm

• Study Type: Interventional
• Enrollment (Estimated): 92
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Austria
  • Styria
    • Graz, Styria, Austria, 8036
      • University Hospital of Graz
      • Contact: Julia Mader, Prof. PD Dr.; Phone Number: +43 318 385 80254; Email: julia.mader@medunigraz.at
      • Contact: Paul Klopf; Phone Number: +4331638526176; Email: paul.klopf@stud.medunigraz.at
      • Principal Investigator: Julia Mader, Prof. PD Dr.
• Denmark
  • Copenhagen, Denmark, 2730
    • Steno Diabetes Center Copenhagen
    • Contact: Mikkel Thor Olsen, MD, PhD; Phone Number: +45 31 49 72 95; Email: mikkel.thor.olsen@regionh.dk
    • Principal Investigator: Mikkel Thor Olsen, MD, PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• A documented history of Type 2 diabetes mellitus (T2DM) which requires subcutaneous insulin therapy
• acute infectious disease of any kind
• age ≥ 18 years old
• willingness and ability to comply with theclinical investigation plan
• ability to communicate with the trial personal
• an expected length of hospital stay for at least 2 days after enrolment

Exclusion Criteria:

• Patients already using AID for their glycemic management
• Patients in use of an insulin pump
• Skin pathologies that hinder application of a FreeStyle Libre-3 CGM and mylife YpsoPump
• Participation in another trial, which could influence the outcome of the trial
• Any mental condition rendering the patient incapable of giving informed consent
• Known or suspected allergy to adhesive material/tape of the Libre-3-sensor and/or YpsoPump
• Any disease or condition which the investigator or treating physician feels would interfere with the trial or the safety of the patient

• Diagnoses/treatments/clinical parameters prohibiting use of Insulin/AID such as

  • Estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2 OR
  • Treated with hydroxyurea/hydroxycarbamide OR
  • Nutritional therapy (continuous enteral or parenteral feeding) OR
  • Clinically relevant pancreatic disease OR
  • Aystemic glucocorticoid treatment with prednisone equivalent dose >5 mg/day OR
  • Expected to require admission to the intensive-care unit OR > Patients in dialysis

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: AID-arm; In the AID-arm, participants will be equipped with a Freestyle libre-3 CGM to collect the glucose data and communicated with the mylife YpsoPump for insulin application. As part of the AID system, the participants will also be equipped with the CE-marked mylife Ypsopump to administer the needed insulin dose during the day. The insulin used for the pump for the glycaemic control of the participants will be insulin aspart.(6) The Freestyle libre-3 CGM and the YpsoPump will be coupled together in an AID system via the the mylife CamAPS HX app on a smartphone.	Device: automated insulin delivery system; To date, no randomized controlled trials have evaluated inpatient use - including bolus insulin - in patients with infectious disease.; Other Names: AID; cloosed-loop system
Placebo Comparator: Control-Arm; In the control-arm, glucose levels are assessed with POC glucose testing at 03:00 h, pre-prandial at breakfast, lunch, and dinner, and before bedtime (22:00 h) or for subjects not eating at 03:00 h., 08:00 h., 12:00 h., 17:00 h., and 22:00 h as per standard of care. A blinded CGM is mounted for outcome analysis. At admission, non-insulin antidiabetic medications will be paused, and the control-arm participants will be treated by usual-of-care with a pen based a basal-bolus regimen Participants at Graz University Hospital are ordered the same basal-bolus insulin regimen as in the usual-of-care arm at Steno Diabetes center Copenhagen, however, insulin is not manually titrated, but titration is based daily on the GlucoTab system, a clinical decision support validated for the inpatient setting in titrating insulin for patients with type 2 diabetes as this is the usual of care at Graz University hospital.	Procedure: GlucoTab; Participants at Graz University Hospital are basal-bolus insulin regimen , however, insulin is not manually titrated, but titration is based daily on the GlucoTab system, a clinical decision support validated for the inpatient setting in titrating insulin for patients with type 2 diabetes as this is the usual of care at MUG. The GlucoTab-arm will be titrated initially by the principal Investigator or sub principal investigator and afterwards by the general ward nurses of MUG.; Procedure: Control-arm; In the control-arm, glucose levels are assessed with POC glucose testing at 03:00 h, pre-prandial at breakfast, lunch, and dinner, and before bedtime (22:00 h) or for participants not eating at 03:00 h, 08:00 h, 12:00 h, 17:00 h, and 22:00 h. Those collected glucose levels will be automatically transferred to the EHR. If POC glucose testing is not prescribed or performed five times daily as standard of care, the research staff may encourage usual ward nurses to do so. The investigat will also mount a FreeStyle Libre-3 CGM on each participant like descripted in the section above to be able to have a better comparison of the glucose levels throughout the day in both arms. This glucose data will be blinded and as such only be available for the diabetes research team in the end of the trial and not for the general wards. At admission, non-insulin antidiabetic medications will be paused, and the control-arm participants will be treated by usual-of-care with a pen based a basal-bolus regimen

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time in range	The difference in CGM-recorded time in range of 70-180 mg/dl (3.9-10.0 mmol/l) between the control-arm and the AID-arm	From inclusion in the trial until discharge from hospital (up to 30 days)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time above range level 1	The difference in CGM-recorded time in range of 181 - 250 mg/dl (10.1 - 13.9 mmol/L) between the control-arm and the AID-arm	From inclusion in the trial until discharge from hospital (up to 30 days)
Time above range level 2	The difference in CGM-recorded time in range of > 250 mg/dl (> 13.9 mmol/l between the control-arm and the AID-arm	From inclusion in the trial until discharge from hospital (up to 30 days)
Time below range level 1	The difference in CGM-recorded time in the range of 54 - 70 mg/dl (3.0 - 3.9 mmol/L) between the control-arm and the AID-arm	From inclusion in the trial until discharge from hospital (up to 30 days)
Time below range level 2	The difference in CGM-recorded time in the range of < 54 mg/dl (< 3.0 mmol/l) between the control-arm and the AID-arm	From inclusion in the trial until discharge from hospital (up to 30 days)
Hypoglycemic events level 1	Hypoglycemic events (defined as three consecutive CGM measures) in the range of 54-70 mg/dl (3.0-3.9 mmol/l).	From inclusion in the trial until discharge from hospital (up to 30 days)
Hypoglycemic event level 2	Hypoglycemic events (defined as three consecutive CGM measures) in the range of <54 mg/dl (<3.0 mmol/l).	From inclusion in the trial until discharge from hospital (up to 30 days)
Recurrent hypoglycemic event	Recurrent hypoglycemic events, defined as events preceded by another hypoglycemic event. The glucose values between the two episodes must all be > 70mg/dl (>3.9 mmol/l) for at least 15 consecutive minutes between the sentinel and recurrent hypoglycemic events to count.	From inclusion in the trial until discharge from hospital (up to 30 days)
Time at High Risk for Hypoglycemia	The difference in CGM-recorded time in range of 70 - 100 mg/dl (3.9 - 5.6 mmol/l) between the control-arm and the AID-arm	From inclusion in the trial until discharge from hospital (up to 30 days)
Glycemia risk index	Defined by the formula [3.0 × % time below 54mg/dl (3.0 mmol/l)] +[2.4 × % time below 70mg/dl (3.9 mmol/l)] + [1.6 × % time above 180mg/dl (10.0 mmol/l)] + [0.8 × % time above 250mg/dl (13.9 mmol/l)].	From inclusion in the trial until discharge from hospital (up to 30 days)
Prolonged hypoglycemic events level 1	A hypoglycaemic event 54 - 70 mg/dl (3.0 - 3.9 mmol/l) continuously for at least 120 minutes.	From inclusion in the trial until discharge from hospital (up to 30 days)
Prolonged hypoglycemic event level 2	A hypoglycaemic event <54 mg/dl (<3.0 mmol/l) continuously for at least 120 minutes.	From inclusion in the trial until discharge from hospital (up to 30 days)
Severe hypoglycemia	Patient requires assistance to correct hypoglycemia.	From inclusion in the trial until discharge from hospital (up to 30 days)
Mean sensor glucose	Mean sensor glucose from the CGM in mg/dl (mmol/l).	From inclusion in the trial until discharge from hospital (up to 30 days)
Standard deviation of the glucose distribution	The standard deviation mg/dl (mmol/l) from the CGM glucose measurements.	From inclusion in the trial until discharge from hospital (up to 30 days)
Coefficient of variation	The standard deviation of the glucose distribution divided by the mean glucose level.	From inclusion in the trial until discharge from hospital (up to 30 days)
Length of stay	The amount of time spent in the hospital from admission untill discharge from the hospital	From admission untill discharge from the hospital (up to 30 days)
In-hospital complications	Any in-hospital related complications occurring at least one day after randomization (e.g. acute kidney injury, sepsis, etc.)	One day after randomisation until discharge from the hospital (up to 30 days)
Total daily insulin doses	The amoun of daily insulin given.	From inclusion in the trial until discharge from hospital (up to 30 days)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Questionnaires	The validated Diabetes Treatment Satisfaction Questionnaire for Inpatients (DTSQ-IP) will be used. The questionnaires will assess the patient satisfaction level and staff satisfaction level in managing patients on either control-arm patients vs AID systems. Exploratory, the investigators will identify which patients might benefit from AID and in-hospital diabetes teams by heterogeneity of treatment effect analyses.	From inclusion in the trial until discharge from hospital (up to 30 days)
Time management	Time management for setting up the AID system and maintaining it is compared to usual-of-care (time spent monitoring POC glucose testing and administering basal-bolus regimen insulin daily).	From inclusion until discharge from hospital (up to 30 days)

Collaborators and Investigators

• Sponsor: Steno Diabetes Center Copenhagen

Publications and helpful links

General Publications

• Thabit H, Hartnell S, Allen JM, Lake A, Wilinska ME, Ruan Y, Evans ML, Coll AP, Hovorka R. Closed-loop insulin delivery in inpatients with type 2 diabetes: a randomised, parallel-group trial. Lancet Diabetes Endocrinol. 2017 Feb;5(2):117-124. doi: 10.1016/S2213-8587(16)30280-7. Epub 2016 Nov 9.
• Bally L, Thabit H, Hartnell S, Andereggen E, Ruan Y, Wilinska ME, Evans ML, Wertli MM, Coll AP, Stettler C, Hovorka R. Closed-Loop Insulin Delivery for Glycemic Control in Noncritical Care. N Engl J Med. 2018 Aug 9;379(6):547-556. doi: 10.1056/NEJMoa1805233. Epub 2018 Jun 25.
• Bertoni AG, Saydah S, Brancati FL. Diabetes and the risk of infection-related mortality in the U.S. Diabetes Care. 2001 Jun;24(6):1044-9. doi: 10.2337/diacare.24.6.1044.
• Shah BR, Hux JE. Quantifying the risk of infectious diseases for people with diabetes. Diabetes Care. 2003 Feb;26(2):510-3. doi: 10.2337/diacare.26.2.510.
• Sampson MJ, Singh H, Dhatariya KK, Jones C, Walden E, Bradley C. Psychometric validation and use of a novel diabetes in-patient treatment satisfaction questionnaire. Diabet Med. 2009 Jul;26(7):729-35. doi: 10.1111/j.1464-5491.2009.02754.x.
• Spanakis EK, Cook CB, Kulasa K, Aloi JA, Bally L, Davis G, Dungan KM, Galindo RJ, Mendez CE, Pasquel FJ, Shah VN, Umpierrez GE, Aaron RE, Tian T, Yeung AM, Huang J, Klonoff DC. A Consensus Statement for Continuous Glucose Monitoring Metrics for Inpatient Clinical Trials. J Diabetes Sci Technol. 2023 Nov;17(6):1527-1552. doi: 10.1177/19322968231191104. Epub 2023 Aug 17.
• Olsen MT, Klarskov CK, Jensen SH, Rasmussen LM, Lindegaard B, Andersen JA, Gottlieb H, Lunding S, Pedersen-Bjergaard U, Hansen KB, Kristensen PL. In-Hospital Diabetes Management by a Diabetes Team and Insulin Titration Algorithms Based on Continuous Glucose Monitoring or Point-of-Care Glucose Testing in Patients With Type 2 Diabetes (DIATEC): A Randomized Controlled Trial. Diabetes Care. 2025 Apr 1;48(4):569-578. doi: 10.2337/dc24-2222.
• Benfield T, Jensen JS, Nordestgaard BG. Influence of diabetes and hyperglycaemia on infectious disease hospitalisation and outcome. Diabetologia. 2007 Mar;50(3):549-54. doi: 10.1007/s00125-006-0570-3. Epub 2006 Dec 23.
• YPU_eIFU_REF_700009439_BE-de_V01.pdf [Internet]. [cited 2024 Nov 23]. Available from: https://www.mylife-diabetescare.com/files/media/03_Documents/01_YpsoPump/IFU/1.5/YPU_eIFU_REF_700009439_BE-de_V01.pdf
• Rubin R, Khanna NR, McIver LA. Aspart Insulin. 2024 Jun 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from http://www.ncbi.nlm.nih.gov/books/NBK500030/
• ART41641-001_rev-A-web.pdf [Internet]. [cited 2024 Nov 23]. Available from: https://freestyleserver.com/payloads/ifu/2023/q3/ART41641-001_rev-A-web.pdf
• Boughton CK, Hartnell S, Hobday N, Lake A, Davenport K, Daly A, Ward C, Taylor C, Hovorka R, Bansiya V. Implementation of fully closed-loop insulin delivery for inpatients with diabetes: Real-world outcomes. Diabet Med. 2023 Jun;40(6):e15092. doi: 10.1111/dme.15092. Epub 2023 Mar 28.
• Boughton CK, Bally L, Martignoni F, Hartnell S, Herzig D, Vogt A, Wertli MM, Wilinska ME, Evans ML, Coll AP, Stettler C, Hovorka R. Fully closed-loop insulin delivery in inpatients receiving nutritional support: a two-centre, open-label, randomised controlled trial. Lancet Diabetes Endocrinol. 2019 May;7(5):368-377. doi: 10.1016/S2213-8587(19)30061-0. Epub 2019 Mar 29.
• Thabit H, Schofield J. Technology in the management of diabetes in hospitalised adults. Diabetologia. 2024 Oct;67(10):2114-2128. doi: 10.1007/s00125-024-06206-4. Epub 2024 Jul 2.
• Hochfellner DA, Rainer R, Ziko H, Aberer F, Simic A, Lichtenegger KM, Beck P, Donsa K, Pieber TR, Fruhwald FM, Rosenkranz AR, Kamolz LP, Baumann PM, Mader JK, Plank J. Efficient and safe glycaemic control with basal-bolus insulin therapy during fasting periods in hospitalized patients with type 2 diabetes using decision support technology: A post hoc analysis. Diabetes Obes Metab. 2021 Sep;23(9):2161-2169. doi: 10.1111/dom.14458. Epub 2021 Jun 22.
• Davis GM, Hughes MS, Brown SA, Sibayan J, Perez-Guzman MC, Stumpf M, Thompson Z, Basina M, Patel RM, Hester J, Abraham A, Ly TT, Chaney C, Tan M, Hsu L, Kollman C, Beck RW, Lal R, Buckingham B, Pasquel FJ. Automated Insulin Delivery with Remote Real-Time Continuous Glucose Monitoring for Hospitalized Patients with Diabetes: A Multicenter, Single-Arm, Feasibility Trial. Diabetes Technol Ther. 2023 Oct;25(10):677-688. doi: 10.1089/dia.2023.0304. Epub 2023 Aug 28.

Study record dates

Study Major Dates

• Study Start (Estimated): July 1, 2026
• Primary Completion (Estimated): July 15, 2027
• Study Completion (Estimated): July 30, 2027

Study Registration Dates

• First Submitted: February 6, 2026
• First Submitted That Met QC Criteria: June 8, 2026
• First Posted (Actual): June 12, 2026

Study Record Updates

• Last Update Posted (Actual): June 12, 2026
• Last Update Submitted That Met QC Criteria: June 8, 2026
• Last Verified: October 1, 2025

More Information

Terms related to this study

• Keywords: type 2 diabetes mellitus; CGM; diabetes mellitus type 2; automated insulin delivery systems; GlucoTab; AID; continouse glucose monitoring; infectiouse disease
• Additional Relevant MeSH Terms: Endocrine System Diseases; Metabolic Diseases; Glucose Metabolism Disorders; Diabetes Mellitus; Nutritional and Metabolic Diseases; Diabetes Mellitus, Type 2; Infections; Investigative Techniques; Therapeutics; Surgical Equipment; Equipment and Supplies; Reproductive Techniques, Assisted; Reproductive Techniques; Reproduction; Reproductive Physiological Phenomena; Reproductive and Urinary Physiological Phenomena; Insemination, Artificial; Insemination; Artificial Organs; Insemination, Artificial, Heterologous; Pancreas, Artificial
• Other Study ID Numbers: Inpatient-AID

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No