Automated Insulin Delivery (AID) systems have transformed diabetes management, offering more precise control over blood glucose levels by automating insulin administration. This systematic review aims to assess the effectiveness of AID systems on glycemic outcomes in the Gulf region, focusing on glycemic variability, hypoglycemia, patient satisfaction, and long-term health impacts. This systematic review followed PRISMA guidelines to evaluate the impact of Automated Insulin Delivery (AID) systems on glycemic control among diabetic patients in the Gulf region. We searched major databases, including PubMed and Embase, using a tailored strategy focused on relevant geographic and intervention terms. Studies published from 2020 onward were included, with strict eligibility criteria ensuring high-quality, region-specific data. Two reviewers independently screened studies, extracted data, and assessed risk of bias. Meta-analysis was conducted where feasible, supplemented by narrative synthesis for heterogeneous data. Subgroup and sensitivity analyses further examined outcomes by diabetes type, age, and AID system type. This review analyzed 20 studies across Gulf countries, including Saudi Arabia, Kuwait, and the UAE, to assess insulin delivery systems for diabetes management during Ramadan fasting. Advanced technologies like continuous subcutaneous insulin infusion (CSII) and automated insulin delivery (AID) systems consistently outperformed traditional methods in glycemic control, hypoglycemia prevention, fasting adaptation, and patient satisfaction. CSII reduced HbA1c by 1.3% compared to MDI, and AID ensured 89% fasting continuity. Hypoglycemia rates were 7% with CSII versus 15% with MDI. Remote-controlled pumps achieved higher satisfaction (87%) than MDI (63%). The findings underscore integrating advanced technologies into diabetes care for optimal outcomes. Advanced insulin delivery systems, including CSII and AID, demonstrate superior efficacy in glycemic control, hypoglycemia prevention, fasting adaptation, and patient satisfaction during Ramadan. These technologies significantly enhance diabetes management outcomes, emphasizing their integration into routine care. Future research should validate these findings through larger, multicenter trials across diverse populations.
References
[1]
Bliss, M. (1982) The Discovery of Insulin. University of Chicago Press.
[2]
Pickup, J. and Keen, H. (2002) Continuous Subcutaneous Insulin Infusion at 25 Years: Evidence Base for the Expanding Use of Insulin Pump Therapy in Type 1 Diabetes. DiabetesCare, 25, 593-598. https://doi.org/10.2337/diacare.25.3.593
[3]
JDRF CGM Study Group (2008) Continuous Glucose Monitoring and Intensive Treatment of Type 1 Diabetes. New England Journal of Medicine, 359, 1464-1476.
[4]
Kovatchev, B.P., Renard, E., Cobelli, C., Zisser, H.C., Anderson, S.M., Breton, M.D., et al. (2009) Multinational Study of Subcutaneous Model-Predictive Closed-Loop Control in Type 1 Diabetes Mellitus: Summary of the Results. Journal of Diabetes Science and Technology, 3, 1054-1061.
[5]
Kudva, Y.C., Carter, R.E., Cobelli, C., Basu, A. and Basu, R. (2014) Closed-Loop Artificial Pancreas Systems: Physiologic Input-To-Output Modeling. Journal of Diabetes Science and Technology, 8, 308-320.
[6]
Peters, A.L., Ahmann, A.J., Battelino, T., Evert, A., Hirsch, I.B., Murad, M.H., et al. (2016) Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline. TheJournalofClinicalEndocrinology&Metabolism, 101, 3922-3937. https://doi.org/10.1210/jc.2016-2534
[7]
Dovc, K. and Battelino, T. (2020) Closed-Loop Insulin Delivery Systems for Type 1 Diabetes. Endocrinology and Metabolism Clinics of North America, 49, 139-151.
[8]
Hovorka, R. (2011) Continuous Glucose Monitoring and Closed-Loop Systems. Diabetic Medicine, 28, 1372-1382.
[9]
Barnard, K.D., Wysocki, T., Allen, J.M., Elleri, D., Heinemann, L., Hoogma, R., et al. (2015) Closing the Loop in Adults, Children and Adolescents with Type 1 Diabetes. Diabetes, Obesity and Metabolism, 17, 872-880.
[10]
Lewis, D. and Leibrand, S. (2016) Real-world Use of Open Source Artificial Pancreas Systems. JournalofDiabetesScienceandTechnology, 10, 1411-1411. https://doi.org/10.1177/1932296816665635
[11]
Weitzman, E.R., Kaci, L. and Mandl, K.D. (2015) Sharing Medical Data for Health Research: The Early Personal Health Record Experience. Journal of Medical Internet Research, 17, e5.
[12]
Renard, E. (2005) Monitoring Glycemic Control: The Importance of Glucose Sensors. Endocrinology and Metabolism Clinics of North America, 34, 49-57.
[13]
DeVries, J.H. (2013) Glucose Variability: Where It Is Important and How to Measure It. Diabetes, 62, 1405-1408. https://doi.org/10.2337/db12-1610
[14]
Leelarathna, L., Choudhary, P., Wilmot, E.G. and Hovorka, R. (2016) How to Integrate New Diabetes Technologies into Clinical Practice: Challenges and Solutions. Diabetes Management, 6, 263-271.
[15]
Berget, C., Messer, L.H. and Forlenza, G.P. (2019) A Clinical Overview of Insulin Pump Therapy for the Management of Diabetes: Evidence, Policy, and Recommendations for Payers. American Journal of Managed Care, 25, 86-90.
[16]
Hovorka, R., Kumareswaran, K., Harris, J., Allen, J.M., Elleri, D., Xing, D., et al. (2011) Overnight Closed Loop Insulin Delivery (Artificial Pancreas) in Adults with Type 1 Diabetes: Crossover Randomised Controlled Studies. BMJ, 342, d1855. https://doi.org/10.1136/bmj.d1855
[17]
Al-Sofiani, M.E., Alharthi, S., Albunyan, S., Alzaman, N., Klonoff, D.C. and Alguwaihes, A. (2024) A Real-World Prospective Study of the Effectiveness and Safety of Automated Insulin Delivery Compared with Other Modalities of Type 1 Diabetes Treatment during Ramadan Intermittent Fasting. DiabetesCare, 47, 683-691. https://doi.org/10.2337/dc23-1968
[18]
Bruttomesso, D., Farret, A., Costa, S., Marescotti, M.C., Vettore, M., Avogaro, A., et al. (2009) Closed-Loop Artificial Pancreas Using Subcutaneous Glucose Sensing and Insulin Delivery and a Model Predictive Control Algorithm: Preliminary Studies in Padova and Montpellier. JournalofDiabetesScienceandTechnology, 3, 1014-1021. https://doi.org/10.1177/193229680900300504
[19]
Deeb, A., Al Qahtani, N., Akle, M., Singh, H., Assadi, R., Attia, S., et al. (2017) Attitude, Complications, Ability of Fasting and Glycemic Control in Fasting Ramadan by Children and Adolescents with Type 1 Diabetes Mellitus. DiabetesResearchandClinicalPractice, 126, 10-15. https://doi.org/10.1016/j.diabres.2017.01.015
[20]
Alamoudi, R., Alsubaiee, M., Alqarni, A., Saleh, Y., Aljaser, S., Salam, A., et al. (2017) Comparison of Insulin Pump Therapy and Multiple Daily Injections Insulin Regimen in Patients with Type 1 Diabetes during Ramadan Fasting. DiabetesTechnology&Therapeutics, 19, 349-354. https://doi.org/10.1089/dia.2016.0418
[21]
Afandi, B., Kaplan, W., Al Hassani, N., Hadi, S. and Mohamed, A. (2017) Correlation between Pre-Ramadan Glycemic Control and Subsequent Glucose Fluctuation during Fasting in Adolescents with Type 1 Diabetes. JournalofEndocrinologicalInvestigation, 40, 741-744. https://doi.org/10.1007/s40618-017-0633-y
[22]
Klonoff, D.C., Buckingham, B., Christiansen, J.S., Montori, V.M., Tamborlane, W.V., Vigersky, R.A., et al. (2011) Continuous Glucose Monitoring: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 96, 2968-2979.
[23]
Thabit, H. and Hovorka, R. (2012) Closed-Loop Insulin Delivery in Type 1 Diabetes. EndocrinologyandMetabolismClinicsofNorthAmerica, 41, 105-117. https://doi.org/10.1016/j.ecl.2011.12.003
[24]
Deeb, A., Al Qahtani, N., Attia, S., Al Suwaidi, H. and Nagelkerke, N. (2016) Does Reducing Basal Insulin during Ramadan Fasting by Children and Adolescents with Type 1 Diabetes Decrease the Risk of Symptomatic Hypoglycemia? DiabetesTechnology&Therapeutics, 18, 539-542. https://doi.org/10.1089/dia.2016.0197
[25]
Nevo-Shenker, M., Phillip, M., Nimri, R. and Shalitin, S. (2019) Type 1 Diabetes Mellitus Management in Young Children: Implementation of Current Technologies. PediatricResearch, 87, 624-629. https://doi.org/10.1038/s41390-019-0665-4
[26]
Wilson, L.M., Jacobs, P.G., Ramsey, K.L., Resalat, N., Reddy, R., Branigan, D., et al. (2020) Dual-Hormone Closed-Loop System Using a Liquid Stable Glucagon Formulation versus Insulin-Only Closed-Loop System Compared with a Predictive Low Glucose Suspend System: An Open-Label, Outpatient, Single-Center, Crossover, Randomized Controlled Trial. DiabetesCare, 43, 2721-2729. https://doi.org/10.2337/dc19-2267
[27]
Wilmot, E.G. and Danne, T. (2020) DIY Artificial Pancreas Systems: The Clinician Perspective. TheLancetDiabetes&Endocrinology, 8, 183-185. https://doi.org/10.1016/s2213-8587(19)30416-4
[28]
LeRoith, D. and Smith, D.O. (2005) Monitoring Glycemic Control: The Cornerstone of Diabetes Care. ClinicalTherapeutics, 27, 1489-1499. https://doi.org/10.1016/j.clinthera.2005.10.010
[29]
Alsairafi, Z.K., Smith, F.J., Taylor, K.M.G., Alsaleh, F. and Alattar, A.T. (2018) A Qualitative Study Exploring Patients’ Experiences Regarding Insulin Pump Use. SaudiPharmaceuticalJournal, 26, 487-495. https://doi.org/10.1016/j.jsps.2018.02.010
[30]
Almazrouei, R., Sharma, C., Afandi, B., Aldahmani, K.M., Aburawi, E.H., Beshyah, S.A., et al. (2022) Continuous Subcutaneous Insulin Infusion Is Associated with a Better Glycemic Control than Multiple Daily Insulin Injections without Difference in Diabetic Ketoacidosis and Hypoglycemia Admissions among Emiratis with Type 1 Diabetes. PLOSONE, 17, e0264545. https://doi.org/10.1371/journal.pone.0264545
[31]
Alshahrani, A. (2024) Abstract #1851113 Comparative Study of Glycemic Control and Treatment Satisfaction for Patients with Type 1 Diabetes on Sensor-Augmented Insulin Pump, Insulin Pump, and Multiple Daily Insulin Injection: Cross-Sectional Study. EndocrinePractice, 30, S1. https://doi.org/10.1016/j.eprac.2024.09.019
[32]
Khalil, A.B., Beshyah, S.A., Abu Awad, S.M., Benbarka, M.M., Haddad, M., Al-Hassan, D., et al. (2012) Ramadan Fasting in Diabetes Patients on Insulin Pump Therapy Augmented by Continuous Glucose Monitoring: An Observational Real-Life Study. DiabetesTechnology&Therapeutics, 14, 813-818. https://doi.org/10.1089/dia.2012.0061
[33]
Haidar, A., Legault, L., Dallaire, M., Alkhateeb, A., Coriati, A., Messier, V., et al. (2013) Glucose-responsive Insulin and Glucagon Delivery (Dual-Hormone Artificial Pancreas) in Adults with Type 1 Diabetes: A Randomized Crossover Controlled Trial. CanadianMedicalAssociationJournal, 185, 297-305. https://doi.org/10.1503/cmaj.121265
[34]
Arabi, Y.M., Dabbagh, O.C., Tamim, H.M., Al-Shimemeri, A.A., Memish, Z.A., Haddad, S.H., et al. (2008) Intensive versus Conventional Insulin Therapy: A Randomized Controlled Trial in Medical and Surgical Critically Ill Patients. CriticalCareMedicine, 36, 3190-3197. https://doi.org/10.1097/ccm.0b013e31818f21aa
[35]
Landau, Z., Raz, I., Wainstein, J., Bar‐Dayan, Y. and Cahn, A. (2016) The Role of Insulin Pump Therapy for Type 2 Diabetes Mellitus. Diabetes/MetabolismResearchandReviews, 33, e2822. https://doi.org/10.1002/dmrr.2822
[36]
Roze, S., Smith-Palmer, J., Valentine, W.J., Cook, M., Jethwa, M., de Portu, S., et al. (2015) Long-Term Health Economic Benefits of Sensor-Augmented Pump Therapy vs Continuous Subcutaneous Insulin Infusion Alone in Type 1 Diabetes: A UK Perspective. JournalofMedicalEconomics, 19, 236-242. https://doi.org/10.3111/13696998.2015.1113979
[37]
Rodbard, D. (2017) Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes. DiabetesTechnology&Therapeutics, 19, S-25-S-37. https://doi.org/10.1089/dia.2017.0035
[38]
Keyu, G., Jiaqi, L., Liyin, Z., Jianan, Y., Li, F., Zhiyi, D., et al. (2022) Comparing the Effectiveness of Continuous Subcutaneous Insulin Infusion with Multiple Daily Insulin Injection for Patients with Type 1 Diabetes Mellitus Evaluated by Retrospective Continuous Glucose Monitoring: A Real-World Data Analysis. FrontiersinPublicHealth, 10, Article 990281. https://doi.org/10.3389/fpubh.2022.990281
[39]
Köprülü, Ö., Tan, H., Erbaş, İ.M., Şimşek, F.Y., Uyar, N., Karataş, M.Ç., et al. (2025) Risk of Diabetes-Specific Eating Disorders in Children with Type 1 Diabetes Mellitus Using Continuous Subcutaneous Insulin Infusion: A CGM-Based Cross-Sectional Study. Medicina, 61, Article 1585. https://doi.org/10.3390/medicina61091585
[40]
Alarcón, P.P., Álvarez, E.D., Lambert Goitia, C., Rodríguez, M.M., Urbon, L., Maldonado, A., et al. (2025) Does Combining a Mobile Dose Calculation App with a Continuous Insulin Infusion System Improve Glycemic Control and Quality of Life Compared with a Hybrid System in Patients with Type 1 Diabetes? A Descriptive Open-Label Sequential Study. DiabetesTechnology&Therapeutics, 27, 849-857. https://doi.org/10.1177/15209156251363452
[41]
Jalilova, A., Pilan, B.Ş., Demir, G., Özbaran, B., Balkı, H.G., Arslan, E., et al. (2024) The Psychosocial Outcomes of Advanced Hybrid Closed-Loop System in Children and Adolescents with Type 1 Diabetes. EuropeanJournalofPediatrics, 183, 3095-3103. https://doi.org/10.1007/s00431-024-05551-1
[42]
Bassi, M., Spacco, G., Pezzotta, F., Di Jorgi, M., Siri, G., Pintabona, A., et al. (2025) Real-World Efficacy of MiniMed™780G Recommended Settings (Glycemic Target 100 mg/dL, Active Insulin Time 2 Hours) in Youth and Young Adults with Type 1 Diabetes. FrontiersinEndocrinology, 16, Article 1670266. https://doi.org/10.3389/fendo.2025.1670266
[43]
Bombaci, B., Calderone, M., Di Pisa, A., La Rocca, M., Torre, A., Lombardo, F., et al. (2025) Impact of Automated Insulin Delivery Systems in Children and Adolescents with Type 1 Diabetes Previously Treated with Multiple Daily Injections: A Single-Center Real-World Study. Medicina, 61, Article 1602. https://doi.org/10.3390/medicina61091602
[44]
Wolf, R.M., Patel, D., Gera, S., Molano, G., Dolivera, T., Meighan, S., et al. (2025) Does the OP5 Automated Insulin Delivery System Close the Gap in Glycemic Control between White and Black Youth with Type 1 Diabetes? DiabetesTechnology&Therapeutics, 27, 469-478. https://doi.org/10.1089/dia.2024.0612
[45]
Stahl-Pehe, A., Shokri-Mashhadi, N., Wirth, M., Schlesinger, S., Kuss, O., Holl, R.W., et al. (2025) Efficacy of Automated Insulin Delivery Systems in People with Type 1 Diabetes: A Systematic Review and Network Meta-Analysis of Outpatient Randomised Controlled Trials. eClinicalMedicine, 82, Article ID: 103190. https://doi.org/10.1016/j.eclinm.2025.103190
[46]
Wadwa, R.P., et al. (2023) Trial of Hybrid Closed Loop Control in Young Children with Type 1 Diabetes. NewEnglandJournalofMedicine, 388, 991-1001.
[47]
Pujante, P., García, A.V., Villa-Fernández, E., García-Villarino, M., González-Vidal, T., Díaz-Naya, L., et al. (2025) One-Year Evaluation of Automated Insulin Delivery Systems in Adults with Type 1 Diabetes. FrontiersinDigitalHealth, 7, Article 1596188. https://doi.org/10.3389/fdgth.2025.1596188
[48]
Lee, T. T. M., et al. (2023) Automated Insulin Delivery in Women with Pregnancy Complicated by Type 1 Diabetes. NewEnglandJournalofMedicine, 389, 1566-1578.
[49]
Beunen, K., Van Wilder, N., Ballaux, D., Vanhaverbeke, G., Taes, Y., Aers, X., et al. (2023) Closed-loop Insulin Delivery in Pregnant Women with Type 1 Diabetes (CRISTAL): A Multicentre Randomized Controlled Trial—Study Protocol. BMC PregnancyandChildbirth, 23, Article No. 180. https://doi.org/10.1186/s12884-023-05481-0
[50]
Azahaf, S., Beunen, K., Van Wilder, N., Ballaux, D., Vanhaverbeke, G., Taes, Y., et al. (2025) Cost-effectiveness of Advanced Hybrid Closed Loop Therapy Compared to Standard Insulin Therapy for Type 1 Diabetes in Pregnancy: An Economic Evaluation of the CRISTAL Trial. eClinicalMedicine, 81, Article ID: 103106. https://doi.org/10.1016/j.eclinm.2025.103106
[51]
Doyle, F.J. and Kovatchev, B.P. (2025) Artificial Pancreas: The First 20 Years*. Diabetes Technology & Therapeutics, 27, S1-S8. https://doi.org/10.1089/dia.2025.0134
[52]
Wang, X., et al. (2025) Effectiveness and Safety of AI-Driven Closed-Loop Systems in Diabetes Management: A Systematic Review and Meta-Analysis. Diabetology & Metabolic Syndrome, 17, Article No. 238.
[53]
Kitagawa, H., Munekage, M., Seo, S. and Hanazaki, K. (2025) Artificial Pancreas: The Past and the Future. Journal of Artificial Organs. https://doi.org/10.1007/s10047-025-01510-1
[54]
Kadiyala, N., Hovorka, R. and Boughton, C.K. (2024) Closed Loop Systems: Recent Advancements and Lived Experience. Expert Review of Medical Devices, 21, 927-941.
[55]
Goede, S.L., Snels, V.H., Berghuis, W.W.J.H., Bernards, J.P.C. and Wyder, U. (2024) A Novel Pulse-Modulated Closed-Loop Artificial Pancreas Based on Intravenous Administration of Insulin and Glucagon. ScientificReports, 14, Article No. 16659. https://doi.org/10.1038/s41598-024-77800-0
[56]
Niu, Y. and Lam, S. K. (2025) Securing Automated Insulin Delivery Systems: A Review of Security Threats and Protective Strategies. arXiv: 2503.14006.
[57]
Mameche, O., et al. (2025) Precise Insulin Delivery for Artificial Pancreas: A Reinforcement Learning Optimized Adaptive Fuzzy Control Approach. arXiv: 2503.06701.
[58]
De Carli, S., Licini, N., Previtali, D., Previdi, F. and Ferramosca, A. (2025) Integrating Biological-Informed Recurrent Neural Networks for Glucose-Insulin Dynamics Modeling. IFAC-PapersOnLine, 59, 91-96. https://doi.org/10.1016/j.ifacol.2025.06.016
