Cited by 90Diabetes Management and ResearchDiabetes and associated disordersDiabetes Treatment and Management

Insulin Resistance in Type 1 Diabetes: Pathophysiological, Clinical, and Therapeutic Relevance

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Apostolopoulou, Maria, Lambadiari, Vaia, Roden, Michael, Dimitriadis, George D·2025·Endocrine Reviews

Abstract

People with type 1 diabetes (T1D) are usually considered to exclusively exhibit β-cell failure, but they frequently also feature insulin resistance. This review discusses the mechanisms, clinical features, and therapeutic relevance of insulin resistance by focusing mainly on human studies using gold-standard techniques (euglycemic–hyperinsulinemic clamp). In T1D, tissue-specific insulin resistance can develop early and sustain throughout disease progression. The underlying pathophysiology is complex, involving both metabolic- and autoimmune-related factors operating synergistically. Insulin treatment may play an important pathogenic role in predisposing individuals with T1D to insulin resistance. However, the established lifestyle-related risk factors and peripheral insulin administration inducing glucolipotoxicity, hyperinsulinemia, hyperglucagonemia, inflammation, mitochondrial abnormalities, and oxidative stress cannot always fully explain insulin resistance in T1D, suggesting a phenotype distinct from type 2 diabetes. The mutual interaction between insulin resistance and impaired endothelial function further contributes to diabetes-related complications. Insulin resistance should therefore be considered a treatment target in T1D. Aside from lifestyle modifications, continuous subcutaneous insulin infusion can ameliorate insulin resistance and hyperinsulinemia, thereby improving glucose toxicity compared with multiple injection insulin treatment. Among other concepts, metformin, pioglitazone, incretin-based drugs such as GLP-1 receptor agonists, sodium-glucose cotransporter inhibitors, and pramlintide can improve insulin resistance, either directly or indirectly. However, considering the current issues of high cost, side effects, limited efficacy, and their off-label status, these agents in people with T1D are not widely used in routine clinical care at present.

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Crossref · 10.1210/endrev/bnae032

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  • Interindividual variability in baseline management, comorbidities, insulin sensitivity, and mode of insulin delivery contributes to the wide range of insulin adjustments reported.

    “Likewise, interindividual variability in baseline management, comorbidities, insulin sensitivity, and mode of insulin delivery (MDI, AID, or HCL/AHCL) contribute to the wide range of adjustments reported.”

    From A systematic review of glucocorticoid use in type 1 diabetes: Glycaemic effects and clinical management strategies (2026) · cites this paper as [64]

    The 'Modes of Insulin Treatment' section (page unavailable) reports that switching from multiple daily injections to continuous subcutaneous insulin infusion reduced daily insulin requirements in insulin-resistant people with type 1 diabetes, supporting a role for delivery mode. It does not attribute a wide range of reported insulin adjustments to the combined effects of baseline management, comorbidities, insulin sensitivity, and MDI versus AID or hybrid closed-loop systems. (LLM, conf=0.78)

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Authors
Apostolopoulou, M., Lambadiari, V., Roden, M., & Dimitriadis, G. D.
Affiliations
  • Düsseldorf University Hospital (DE)
  • National and Kapodistrian University of Athens (GR)
Corresponding author
Roden, Michael
Venue
Endocrine Reviews
Published
2025-02-25
Volume
46
Issue
3
Pages
317-348
ISSN
  • 0163-769X (ISSN-L)
  • 1945-7189
OpenAlex
W4407909469
Cited by
90
References
389
Citations by year
2026: 65 · 2025: 25
FWCI
12.16
Type
journal article
Language
en
Open access
Locations
  • Endocrine Reviews (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Keywords
insulin resistance, type 1 diabetes, glucolipotoxicity, hyperinsulinemia, hyperglucagonemia, oxidative stress, mitochondrial dysfunction, endothelial dysfunction, insulin pump therapy, insulin therapy, metformin, pioglitazone, GLP-1 receptor agonists, SGLT2 inhibitors, pramlintide, incretin-based therapy, autoimmune factors, lifestyle risk factors
MeSH terms
Diabetes Mellitus, Type 1, Humans, Hypoglycemic Agents, Insulin, Insulin Resistance

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