#We don't have to wait any more Closed-loop systems: transforming the landscape


  • Charlotte Boughton Wellcome-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge UK
  • Roman Hovorka Wellcome-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge UK




hybrid closed-loop, type 1 diabetes, quality of life, glycemic control


Hybrid closed-loop systems are transforming the clinical management of T1DM. Large randomised controlled trials of hybrid closed-loop systems have demonstrated safety and efficacy, with significant improvements in glycaemic control compared to control therapy, and there are now several commercially approved hybrid closed-loop systems available in the UK. There is also a growing body of evidence demonstrating the quality of life benefits associated with hybrid closed-loop systems, both for users and also for parents/caregivers and other family members.

We review the clinical evidence supporting currently available hybrid closed-loop systems in the UK and also new systems on the horizon. We discuss the emerging evidence for associated psychosocial benefits of hybrid closed-loop therapy. We also address future challenges around healthcare professional readiness to deliver closed-loop technology and ensuring equitable access across the UK.


tients with type 1 diabetes: systematic review and meta-analysis. BMJ 2018; 361. https://doi.org/10.1136/bmj.k1310

Pease A, Lo C, Earnest A, et al. Time in range for multiple technologies in type 1 diabetes: a systematic review and network meta-analysis. Diabetes Care 2020;43(8):1967-75. https://doi.org/10.2337/dc19-1785

Summary of effectiveness and safety data. MiniMed 670G System. FDA. September 28, 2016 available at https://www.accessdata.fda.gov/ cdrh_docs/pdf16/P160017S031B.pdf

Leelarathna L, Choudhary P, Wilmot EG, et al. Hybrid closed-loop therapy: Where are we in 2021? Diabetes, Obesity Metabolism 2021;23(3):655-60. https://doi.org/10.1111/dom.14273

Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the inter- national consensus on time in range. Diabetes Care 2019;42:1593-603. https://doi.org/10.2337/dc19-0028

Chen NS, Boughton CK, Hartnell S, et al. User engagement with the CamAPS FX hybrid closed-loop app according to age and user character- istics. Diabetes Care 2021;44(7):e148-e50. https://doi.org/10.2337/dc20- 2762

Lal RA, Basina M, Maahs DM, et al. One year clinical experience of the first commercial hybrid closed-loop system. Diabetes Care 2019;42(12):2190-6. https://doi.org/10.2337/dc19-0855

Bergenstal RM, Nimri R, Beck RW, et al. A comparison of two hybrid closed- loop systems in adolescents and young adults with type 1 diabetes (FLAIR): a multicentre, randomised, crossover trial. Lancet 2021;397(10270):208-


Brown SA, Kovatchev BP, Raghinaru D, et al. Six-month randomized, mul- ticenter trial of closed-loop control in type 1 diabetes. New Engl J Med 2019;381(18):1707-17. https://dooi.org/10.1056/NEJMoa1907-863

Breton MD, Kanapka LG, Beck RW, et al. A randomized trial of closed-loop control in children with type 1 diabetes. New Engl J Med 2020;383(9):836-45. https://doi.org/10.1056/NEJMoa2004736

Ware J, Allen JM, Boughton CK, et al. Randomized trial of closed-loop con- trol in very young children with type 1 diabetes. New Engl J Med 2022; 386(3):209-19. https://doi.org/10.1056/NEJMoa2111673

Ware J, Boughton CK, Allen JM, et al. Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial. Lancet Digital Health 2022; 4(4):e245-e55. https://doi.org/10.1016/S2589-7500(22)0005-8

Boughton CK, Hartnell S, Thabit H, et al. Hybrid closed-loop glucose control compared with sensor augmented pump therapy in older adults with type 1 diabetes: an open-label multicentre, multinational, randomised, crossover study. Lancet Healthy Longevity 2022;3(3):e135-e42. https://doi.org/ 10.1016/S2666-7568(22)0005-8

Messer LH, Buckingham BA, Cogen F, et al. Positive impact of the bionic pancreas on diabetes control in youth 6-17 years old with type 1 diabetes: a multicenter randomized trial. Diabetes Technol Ther 2022;24(10):712-25. https://doi.org/10.1089/dia.2022.0201.pnb

Brown SA, Forlenza GP, Bode BW, et al. Multicenter trial of a tubeless, on- body automated insulin delivery system with customizable glycemic targets in pediatric and adult participants with type 1 diabetes. Diabetes Care 2021;44(7):1630-40. https://doi.org/10.2337/dc21-0172

Sherr JL, Bode BW, Forlenza GP, et al. Safety and glycemic outcomes with a tubeless automated insulin delivery system in very young children with type 1 diabetes: a single-arm multicenter clinical trial. Diabetes Care 2022; 45(8):1907-10. https://doi.org/10.2337/dc21-2359

Burnside MJ, Lewis DM, Crocket HR, et al. Open-source automated insulin delivery in type 1 diabetes. New Engl J Med 2022;387(10):869-81. https://doi.org/10.1056/NEJMoa2203913

Rankin D, Kimbell B, Hovorka R, Lawton J. Adolescents' and their parents' experiences of using a closed-loop system to manage type 1 diabetes in everyday life: qualitative study. Chronic Illness 2021:1742395320985924. https://doi.org/10.1177/1742395320985924

Farrington C, Stewart Z, Hovorka R, Murphy H. Women's experiences of day-and-night closed-loop insulin delivery during type 1 diabetes preg- nancy. J Diabetes Science Technology 2018;12(6):1125-31. https://doi.org/ 10.1177/1932296818800065

Speight J, Choudhary P, Wilmot EG, et al. Impact of glycaemic technologies on quality of life and related outcomes in adults with type 1 diabetes: a narrative review. Diabetic Medicine 2022:e14944. https://doi.org/10.1111/ dme.14944

McAuley SA, Lee MH, Paldus B, et al. Six months of hybrid closed-loop ver- sus manual insulin delivery with fingerprick blood glucose monitoring in adults with type 1 diabetes: a randomized, controlled trial. Diabetes Care 2020;43(12):3024-33. https://doi.org/10.2337/dc20-1447

Abraham MB, de Bock M, Smith GJ, et al. Effect of a hybrid closed-loop system on glycemic and psychosocial outcomes in children and adolescents with type 1 diabetes: a randomized clinical trial. JAMA Pediatrics 2021; 175(12):1227-35. https://doi.org/10.1001/jamapediatrics.2021.3965

Polonsky WH, Hood KK, Levy CJ, et al. How introduction of automated in- sulin delivery systems may influence psychosocial outcomes in adults with type 1 diabetes: Findings from the first investigation with the Omnipod® 5 System. Diabetes Res Clinical Practice 2022;190:109998. https://doi.org/ 10.1016/j.diabres..2022.109998

Benhamou PY, Franc S, Reznik Y, et al. Closed-loop insulin delivery in adults with type 1 diabetes in real-life conditions: a 12-week multicentre, open- label randomised controlled crossover trial. Lancet Digital Health 2019; 1(1):E17-E25. https://doi.org/10.1016/S2589-7500(19)30003-2

Hood KK, Garcia-Willingham N, Hanes S, et al. Lived experience of CamAPS FX closed loop system in youth with type 1 diabetes and their parents. Diabetes, Obes Metabolism 2022. https://doi.org/10.1111/dom.14815

Kimbell B, Rankin D, Hart RI, et al. Parents' experiences of using a hybrid closed-loop system (CamAPS FX) to care for a very young child with type 1 diabetes: Qualitative study. Diabetes Research Clinical Practice 2022; 187:109877. https://doi.org/10.1016/j.diabres.2022.109877

Dovc K, Boughton C, Tauschmann M, et al. Young children have higher variability of insulin requirements: observations during hybrid closed-loop insulin delivery. Diabetes Care 2019;42(7):1344-7. https://doi.org/10.2337/dc18-2625

Lawton J, Kimbell B, Rankin D, et al. Health professionals' views about who would benefit from using a closed-loop system: a qualitative study. Diabetic Medicine 2020;37(6):1030-37. https://doi.org/10.1111/dme.14252

Farrington C, Hovorka R, Murphy HR. Who should access closed-loop technology? a qualitative study of clinician attitudes in England. Diabetes Technology Therapeutics 2020;22(5):404-10. https://doi.org/1089/dia.2019.0380

NHS England News. Patients with type 1 diabetes to get artificial pancreas on the NHS 2021 [Available from: https://www.england.nhs.uk/2021/06/patients-with-type-1-diabetes-to-get-artificial-pancreas-on-the-nhs/ ].

ABCD DTN-UK nationwide closed loop audit (see: http://www.diabetologists-abcd.org.uk/APS/Closed_Loop_Audit.htm