Mesoporous silica nanoparticles (MSNs) have been proposed as drug delivery devices for approximately 15 years. The history of in vitro studies has been promising, demonstrating that MSNs have the capability for stimulus-responsive controlled release, good cellular uptake, cell specific targeting, and the ability to carry a variety of cargoes from hydrophobic drug molecules to imaging agents. However, the translation of the in vitro findings to in vivo conditions has been slow. Herein, we review the current state-of-the-art in the use of MSN for systemic drug delivery in vivo and provide critical insight into the future of MSNs as systemic drug delivery devices and directions that should be undertaken to improve their practicality.