Diana Isaacs, PharmD, is an endocrine clinical pharmacist, director of Education and Training in Diabetes Technology, and codirector of Endocrine Disorders in Pregnancy at the Cleveland Clinic.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES

Diabetes Dialogue: Technology, Therapeutics, & Real-World Perspectives!

Diabetes Dialogue: Updates for T1D Treatment in Pregnancy and Pediatrics

In this episode of Diabetes Dialogue, cohosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, discuss a slew of advances in diabetes technology and treatments, starting with the US Food and Drug Administration (FDA)’s recent approval of the Tandem automated insulin delivery system for use during pregnancy in individuals with type 1 diabetes.

The conversation centers on findings from the CIRCUIT trial, which demonstrated significant improvements in time in range among pregnant patients, a population historically challenging to manage because of stringent glycemic targets. Isaacs and Bellini review practical considerations from the study, including the use of continuous sleep mode to target tighter glucose ranges and proactive optimization of basal rates, correction factors, and carbohydrate ratios to improve outcomes. They emphasize that FDA approval now allows clinicians and manufacturers to openly discuss evidence-based best practices for pregnancy management using automated insulin delivery systems.

The hosts also highlight the importance of clinician comfort with aggressive insulin automation during pregnancy, noting that increased basal modulation, suspensions, and automated adjustments should be expected as physiologic insulin needs fluctuate throughout gestation. Bellini stresses the importance of reducing patient burden while maintaining intensive glycemic management, tying this theme into Tandem’s newly announced compatibility with the Dexcom G7 15-day sensor. Both hosts note strong patient enthusiasm for extending sensor wear time, framing reduced device maintenance as an important quality-of-life improvement even when the practical change appears modest.

The discussion then shifts to immunotherapy in type 1 diabetes, focusing on the expanded approval of teplizumab to include children as young as 1 year old for delaying progression from stage 2 to stage 3 disease. Isaacs and Bellini underscore how broader eligibility may strengthen adoption of autoantibody screening among relatives of patients with type 1 diabetes. They review evidence showing that screening substantially lowers rates of diabetic ketoacidosis at diagnosis and discuss the broader clinical significance of delaying symptomatic disease onset, even when delays are shorter than the median duration reported in trials. The hosts note that many families value the possibility of a more gradual transition into insulin dependence, often requiring only minimal insulin therapy initially rather than presenting with severe metabolic decompensation.

The conversation also addresses ongoing regulatory developments surrounding teplizumab for newly diagnosed stage 3 type 1 diabetes. Although the anticipated expedited review pathway has been withdrawn, the hosts remain optimistic about eventual approval, citing encouraging data and the growing role of precision medicine approaches in identifying patients most likely to benefit from immune intervention.

To conclude the episode, Isaacs and Bellini examine a post hoc analysis from the SURMOUNT-5 trial comparing tirzepatide and semaglutide in adults with obesity and prediabetes. They discuss findings showing high rates of reversion to normoglycemia in both treatment groups, with tirzepatide demonstrating greater efficacy overall. The hosts frame these data within the broader movement to reconceptualize prediabetes as an earlier stage of type 2 diabetes and cardiovascular disease risk rather than a benign precursor state. They emphasize the potential value of earlier therapeutic intervention to prevent progression and reduce long-term cardiometabolic complications while also acknowledging the importance of maintaining multiple treatment options because of variability in medication tolerability and patient response.

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.

Tandem Diabetes Care. Tandem Diabetes Care’s Control-IQ+ Automated Insulin Delivery Technology Now FDA Cleared for Pregnancy in Type 1 Diabetes. April 27, 2026. Accessed May 8, 2026. 

https://investor.tandemdiabetes.com/news-releases/news-release-details/tandem-diabetes-cares-control-iq-automated-insulin-delivery

Sanofi. Press Release: Sanofi’s Tzield approved in the US to delay the onset of stage 3 type 1 diabetes in young children. April 22, 2026. Accessed May 8, 2026. 

https://www.sanofi.com/en/media-room/press-releases/2026/2026-04-22-05-05-00-3278650

Galindo RJ, Aronne LJ, Horn DB, et al. Reversion to normoglycemia with tirzepatide vs semaglutide in participants with obesity and prediabetes: a post hoc analysis of SURMOUNT-5. J Endocrinol Invest. Published online April 20, 2026. 

Podcasts

This episode covers recent advancements in treating type 1 diabetes, including the Tandem AID system for pregnant women and teplizumab for adolescents.

Implementing Automated Insulin Delivery in Type 2 Diabetes, With Diana Isaacs, PharmD

Despite relatively limited uptake, recent research has shown the efficacy of automated insulin delivery (AID) systems in patients with 

Association of Clinical Endocrinology (AACE) Annual Meeting 2026

 in Las Vegas, Nevada, Diana Isaacs, PharmD, director of education and training in diabetes technology at Cleveland Clinic, presented a statement on the benefits of implementing AID devices in T2D care – and the importance of knowing the full breadth of options available for a given patient.

“With T2D, we have 3 algorithms that have been approved; however, we actually have 5 algorithms total, and we have 6 different insulin pumps that can be options,” Isaacs told 

 in an exclusive interview. “There are definitely a lot of choices, and I believe that we as healthcare professionals shouldn’t necessarily choose for the person. But it is up to us to know what’s out there, so we can present the different options.”

Clinical guidelines have lately begun including AID devices among treatment recommendations for patients; recently, the American Diabetes Association released the 2026 Standards of Care in Diabetes, which included a series of revisions to the prior document. Among these was a statement that AID systems are the preferred delivery system for both adult and child patients with T2D on multiple daily injections or sensor-augmented pump therapy. Additionally, the new guidelines recommend the consideration of AID systems in patients with T2D on basal insulin who fail to meet individualized glycemic goals.

Additionally, in a recent 13-week multicenter trial, investigators determined that adults with T2D treated with AID saw a greater reduction in glycated hemoglobin levels than via continuous glucose monitoring (CGM) alone. The study enrolled 319 patients, randomly assigned in a 2:1 ratio to receive either AID or to continue their pretrial insulin delivery method. Both groups received CGM throughout the trial.

Ultimately, glycated hemoglobin dropped by 0.9 percentage points (from 8.2+/-1.4% at baseline to 7.3+/-0.9% at week 13) in the AID group and by 0.3 percentage points (from 8.1+/-1.2% to 7.7+/-1.1%) in the control group (mean adjusted difference, -0.6 percentage points; 95% CI, -0.8 to -0.4; 

 <.001). The mean time in range for patients also increased in the AID group and control group, respectively. All other multiplicity-controlled outcomes measured substantially better in the AID group as well. The trial ultimately displayed the efficacy of AID devices in T2D, underscoring the revised treatment guidelines.

Isaacs also discussed the interplay between AID pumps and more prominent T2D treatments, such as GLP-1 RAs and SGLT2 inhibitors. Given their substantial and well-established efficacy, Isaacs notes that these medications are in no way being superseded by insulin – rather, clinicians should manage these treatments in tandem.

“In T2D, we want to optimize GLP-1 agonists and SGLT2 inhibitors,” Isaacs said. “When you look at the guidelines, GLP-1 drugs should be offered and used before insulin is even started. These drugs are essential, and we’re not suggesting that pumps would ever replace them. The beautiful thing about these pumps is that they’re constantly adjusting insulin, so they’re very good at being able to back off the insulin as needed as these drugs are added.”

Editors’ Note: Isaacs reports disclosures with Abbott, Sanofi, Insulet, Mannkind, Lilly, Novo Nordisk, and others.

Aleppo G, Isaacs D. Insulin Pumps for Type 2 Diabetes. Presented at the American Association of Clinical Endocrinology Annual Meeting 2026, Las Vegas, NV. April 22-24, 2026.

American Diabetes Association Professional Practice Committee for Diabetes*. Summary of Revisions: Standards of Care in Diabetes-2026. Diabetes Care. 2026;49(1 Suppl 1):S6-S12. 

Kudva YC, Raghinaru D, Lum JW, et al. A randomized trial of automated insulin delivery in type 2 diabetes. New England Journal of Medicine. 2025;392(18):1801-1812. 

Videos

Isaacs covers the range of AID devices currently available and approved for T2D, providing suggestions for implementation and continuous glycated hemoglobin monitoring.

Diabetes Dialogue: Expanding GLP-1 Usage Into Type 1 Diabetes With Viral Shah, MD

In this episode of Diabetes Dialogue, recorded on-site at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026 in Las Vegas, Nevada, cohosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, welcome Viral Shah, MD, professor of endocrinology at Indiana University, for a discussion centered on the evolving role of GLP-1 receptor agonists and broader diabetes classification in type 1 diabetes care. Shah challenges the traditional distinction between type 1 and type 2 diabetes, emphasizing that type 2 diabetes lacks a definitive diagnostic test and is instead a diagnosis of exclusion based on phenotypic characteristics. He explains that patients with type 1 diabetes can also exhibit features of type 2 diabetes, making these categories non–mutually exclusive and supporting the rationale for dual diagnoses when clinically appropriate.

The group explores how this framework informs the use of GLP-1 receptor agonists in type 1 diabetes, particularly for patients with obesity, cardiovascular disease, heart failure, or chronic kidney disease. Shah notes that while obesity provides a clear indication for GLP-1 therapy, he is also comfortable using these agents in patients with lower BMI when cardiovascular or renal protection is the primary goal, with careful attention to dose adjustment and avoidance of excessive weight loss or muscle mass reduction. He adds that SGLT2 inhibitors may be preferable in some leaner patients, particularly when renal indications predominate, and highlights recent clarification that SGLT2 inhibitor use for CKD in type 1 diabetes is not considered off-label when prescribed for kidney protection rather than glycemic control.

The conversation then shifts to Shah’s broader view that type 1 and type 2 diabetes differ more in pathophysiology than in long-term disease course. He argues that both conditions share progressive beta cell dysfunction and overlapping complication risks, suggesting the field should move away from rigid separation and toward a more unified understanding of diabetes progression.

This perspective leads into a discussion of “prediabetes,” a term Shah critiques as outdated and insufficient. He reviews its historical origins as a label for intermediate hyperglycemia and argues that it has unintentionally minimized urgency by framing the condition as merely a risk factor rather than part of the disease continuum. Citing evidence of significantly elevated cardiovascular, kidney, and mortality risk in people with prediabetes, he advocates for staging type 2 diabetes similarly to type 1 diabetes, rather than maintaining an artificial threshold between “no disease” and diabetes. He notes that while therapies such as metformin, semaglutide, and tirzepatide have demonstrated benefit in delaying progression, regulatory limitations persist because prediabetes is not formally recognized as a disease state.

The episode concludes with a discussion of autoantibody screening in adults labeled with prediabetes. Shah supports broader antibody testing, particularly in younger adults, to identify individuals with early-stage type 1 diabetes who may otherwise be misclassified and present later with DKA. He emphasizes that accessible antibody testing and therapies such as teplizumab make earlier identification increasingly meaningful, while also acknowledging the importance of patient preference and individualized decision-making. Across the discussion, Shah calls for greater flexibility in diabetes classification, earlier intervention across the disease spectrum, and a more proactive approach to preventing complications rather than waiting for traditional diagnostic thresholds to be crossed.

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. Shah reports disclosures with Sanofi, Novo Nordisk, Lilly, Dexcom, Insulet, Tandem Diabetes Care, and others.

Shah V. Beyond Type 2: Evaluating GLP-1 Use in Type 1 Diabetes and Obesity. Presented at the American Association of Clinical Endocrinology Annual Meeting 2026 in Las Vegas, NV. April 22-24, 2026.

Viral Shah, MD, joins the show to break down his AACE 2026 presentation on the benefits of using GLP-1 RAs in patients with T1D.

Diabetes Dialogue: Nutrition, Medication, and Treatment in Obesity With Elizabeth Bauer, MD

In this episode of Diabetes Dialogue, recorded on-site at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026 in Las Vegas, Nevada, cohosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, welcome Elizabeth Bauer, MD, a clinical endocrinologist and obesity specialist, to discuss key updates in obesity management presented during her “Year in Review” session at the AACE Annual Meeting. Bauer opens by highlighting AACE’s updated obesity algorithm, released in late 2024, which builds on the organization’s prior adiposity-based chronic disease framework and shifts obesity care further away from BMI-centered diagnosis toward a more comprehensive, disease-centric model. She explains the algorithm’s emphasis on anthropometric assessment, adiposity distribution, and obesity staging, noting that clinicians must move beyond weight alone to better identify obesity-related complications and personalize treatment decisions.

The discussion focuses on the algorithm’s practical value, particularly its structured staging system and medication tables that help clinicians match pharmacotherapy to obesity-related comorbidities such as diabetes, MASLD, and obstructive sleep apnea. Bauer emphasizes that treatment goals should be complication-specific—for example, modest weight loss may improve glycemia, while greater total body weight reduction is needed for meaningful improvement in MASH. She and the hosts stress that obesity management should prioritize whole-person health rather than weight alone, drawing parallels to the evolution of diabetes treatment toward complication-driven care.

The group then turns to emerging pharmacotherapies, with Bauer reviewing several phase 2 and 3 obesity trials involving newer incretin-based agents. She highlights mazdutide, a once-weekly GLP-1–based therapy studied in Chinese populations using lower BMI thresholds more reflective of Asian obesity risk, as well as combination therapies such as semaglutide plus cagrilintide, which demonstrated greater efficacy than semaglutide alone but with substantially higher gastrointestinal adverse effects. Bauer notes that while these agents show impressive weight loss potential, tolerability remains a major clinical challenge, particularly with nausea and dose escalation.

A significant portion of the conversation centers on management of GI side effects from GLP-1 receptor agonists. Bauer explains her clinical philosophy of treating obesity like any other chronic disease—avoiding the routine practice of prescribing one medication to manage side effects caused by another whenever possible. While she may prescribe small, limited quantities of ondansetron during titration, she emphasizes that persistent nausea should prompt dose adjustment or medication changes rather than indefinite antiemetic use. The hosts discuss how slower titration strategies in real-world practice often improve tolerability compared with rigid clinical trial protocols and may help optimize long-acting monthly GLP-1 agents currently in development.

The episode also reviews bariatric surgery data, including randomized trials comparing laparoscopic banding, sleeve gastrectomy, and Roux-en-Y gastric bypass. Bauer notes that both sleeve gastrectomy and Roux-en-Y demonstrated superior efficacy and fewer complications compared with lap band procedures, while long-term comparisons between sleeve and bypass showed strong outcomes for both, with Roux-en-Y numerically favoring weight loss but often without statistically significant superiority. She also discusses higher reoperation rates among patients initially undergoing sleeve gastrectomy, often due to inadequate weight loss or significant reflux requiring conversion to bypass.

The conversation concludes with an important discussion on post-bariatric surgery weight regain and the growing use of GLP-1–based therapies after surgery. Bauer challenges the misconception that surgery “cures” obesity, emphasizing that obesity remains a chronic disease driven by persistent biology, inflammation, and environmental factors even after anatomical intervention. She notes emerging evidence suggesting that GLP-1 therapies used before or after bariatric surgery may improve long-term outcomes and reduce weight regain. She closes by reinforcing the need for clinicians to approach obesity with the same chronic disease mindset applied to diabetes—recognizing that durable management requires ongoing treatment, not a one-time intervention.

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. Bauer reports no relevant disclosures.

Bauer E. DSN Year in Review: Nutrition & Obesity. Presented at the American Association of Clinical Endocrinology, Las Vegas, NV. April 22-24, 2026.

Elizabeth Bauer, MD, joins the show to discuss her AACE 2026 presentation on key updates in obesity management and nutrition.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES

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