It is nearly 100 years since the discovery of insulin and insulin is still the only treatment we have for type 1 diabetes (T1D). Using and adjusting insulin therapy is very difficult and demanding for patients and rarely allows perfect blood sugar control. Even with recent advances in insulin delivery, less than 30% of patients achieve levels of HbA1c that prevent long-term complications and many of those that do regularly experience hypoglycaemia. Furthermore, a significant number of patients find it difficult to engage with and fully comply with insulin therapy and monitoring, especially during teenage and young adulthood, putting them at risk of ketoaidosis and accelerated complications. An increasing number of safe and effective immunomodulatory biologic agents have transformed the management of other autoimmune diseases such as rheumatoid arthritis, psoriasis, multiple sclerosis and inflammatory bowel diseases. Five different immunotherapies have been shown to preserve beta cell function if given at diagnosis of T1D, and the persistence of even 5% of beta cell function has been shown to halve the rate of hypoglycaemia and allow 50% or more of patients to reach glycaemic targets. In particular, beta cell preservation is likely to be particularly beneficial for patients who find it difficult to engage with T1D, such as teenagers and young adults. This lecture summarises the most recent clinical trial and safety data, the portfolio of agents currently under study and the likely landscape over the next 5 years.