In January 1922, the management of type 1 diabetes was forever altered when Leonard Thompson became the first person to receive an injection of insulin extract.1 Although treatment with insulin therapy has been possible for more than a century, providers and persons with type 1 diabetes are faced with the grim reality that the attainment of glycemic targets remains elusive for many, increasing the risk of microvascular and macrovascular complications. To aid with diabetes management, various technologies have been developed. Some are aimed at measuring glucose, with continuous glucose monitors that currently offer a plethora of data on which to make treatment decisions, whereas others work to deliver insulin, with insulin pumps that provide more fine-tuned and precise doses than what is feasible with multiple daily injections. From these foundational components, automated insulin-delivery systems (also known as closed-loop systems) provide a more physiologic approach to diabetes management, tying insulin delivery to sensor glucose values on the basis of algorithms. Insulin delivery with such devices can be interrupted to avert hypoglycemia, and additional insulin can be autonomously delivered to mitigate hyperglycemia. A clear picture has emerged regarding the benefits of automated insulin delivery — evident improvements in glycemia, especially overnight.3 Although the ultimate goal for these systems is full automation, given the limitations of subcutaneously delivered rapid-acting insulin analogues, a hybrid approach has been used, whereby the person with diabetes needs to note (i.e., announce) meals, often by entering discrete amounts of carbohydrates about to be consumed. To date, three such systems have received regulatory approval in the United States, with five systems receiving CE marking.
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