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Mesenchymal stem cell\u2010derived exosomes (MSC\u2010Exos) as a potent cell\u2010free alternative can deliver miRNAs, proteins, and mitochondrial regulators to reactivate the IRS1\/PI3K\/Akt\/GLUT4 axis. Beyond restoring insulin signalling, these vesicles can protect \u03b2\u2010cells, alleviate endoplasmic reticulum stress, rescue mitochondrial mitophagy and respiration. The genetic engineering strategies including improving the expression of miR\u201021, miR\u20103075, or Sirtuin\u20103, and silencing miR\u201029b\u20103p amplify the therapeutic efficacy. However, scalable good manufacturing practice production, long\u2010term safety of modified products, and advanced therapy medicinal product regulation are still needed to overcome. 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