The challenges of achieving postprandial glucose control using closed-loop systems in patients with type 1 diabetes

Diabetes Obes Metab. 2018 Feb;20(2):245-256. doi: 10.1111/dom.13052. Epub 2017 Aug 10.


For patients with type 1 diabetes, closed-loop delivery systems (CLS) combining an insulin pump, a glucose sensor and a dosing algorithm allowing a dynamic hormonal infusion have been shown to improve glucose control when compared with conventional therapy. Yet, reducing glucose excursion and simplification of prandial insulin doses remain a challenge. The objective of this literature review is to examine current meal-time strategies in the context of automated delivery systems in adults and children with type 1 diabetes. Current challenges and considerations for post-meal glucose control will also be discussed. Despite promising results with meal detection, the fully automated CLS has yet failed to provide comparable glucose control to CLS with carbohydrate-matched bolus in the post-meal period. The latter strategy has been efficient in controlling post-meal glucose using different algorithms and in various settings, but at the cost of a meal carbohydrate counting burden for patients. Further improvements in meal detection algorithms or simplified meal-priming boluses may represent interesting avenues. The greatest challenges remain in regards to the pharmacokinetic and dynamic profiles of available rapid insulins as well as sensor accuracy and lag-time. New and upcoming faster acting insulins could provide important benefits. Multi-hormone CLS (eg, dual-hormone combining insulin with glucagon or pramlintide) and adjunctive therapy (eg, GLP-1 and SGLT2 inhibitors) also represent promising options. Meal glucose control with the artificial pancreas remains an important challenge for which the optimal strategy is still to be determined.

Keywords: artificial pancreas; closed-loop; glycaemic control; insulin delivery; insulin therapy; type 1 diabetes.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Adult
  • Algorithms
  • Blood Glucose / analysis*
  • Child
  • Combined Modality Therapy / adverse effects
  • Diabetes Mellitus, Type 1 / blood
  • Diabetes Mellitus, Type 1 / diet therapy
  • Diabetes Mellitus, Type 1 / therapy*
  • Diet, Diabetic
  • Humans
  • Hyperglycemia / prevention & control*
  • Hypoglycemia / etiology
  • Hypoglycemia / prevention & control*
  • Meals*
  • Pancreas, Artificial* / adverse effects
  • Pancreas, Artificial* / trends
  • Postprandial Period


  • Blood Glucose