The use of diabetes technology under aviation conditions: A systematic review of human and in-vitro studies and future considerations

BACKGROUND: Despite advancements in diabetes management technologies, restrictions on insulin-treated pilots persist, underscoring the need to evaluate the safety, efficacy and performance of these technologies in aviation settings. This systematic review aims to summarize the available evidence on the performance, safety and effectiveness of diabetes technologies in aviation settings.

MATERIALS: Four bibliographic databases were searched, and eligible studies assessing diabetes technologies in-flight or simulated aviation conditions, focusing on glycaemic control and safety, were included. Due to high heterogeneity among the included studies, a qualitative synthesis of the evidence was performed. This systematic review was registered with PROSPERO (CRD42025634909).

RESULTS: Out of 522 references, six human and in-vitro studies were included for final analysis. Human studies demonstrated the high accuracy of continuous glucose monitors (CGM) and good glycaemic control with insulin pump therapy. Automated insulin delivery (AID) systems demonstrated effective glycaemic control and safety under hypobaric conditions. However, hypoglycaemia during extended fasting was noted. In-vitro studies highlighted risks, such as excess insulin delivery during ascent and reduced delivery during descent, influenced by pressure changes. CGMs exhibited minor signal variability in hypobaric conditions.

CONCLUSION: Diabetes technologies, particularly CGMs and AID systems, show promise in aviation environments. However, challenges such as insulin delivery variability, hypoglycaemia during fasting and the limited generalizability of hypobaric studies to real-flight conditions warrant further investigation. Future research should focus on larger, more diverse cohorts, real-world data, standardized protocols and a broader range of devices to further define the safety of their safety for aviation-specific diabetes management.