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Smart pharmaceutical systems are emerging as integrated therapeutic platforms that combine physiological sensing, algorithmic interpretation, and automated drug release. They mark a shift from passive delivery technologies toward systems that can respond to changing biological states in near real time. Their promise lies in reducing therapeutic delay, personalising dose adjustment, and extending pharmacotherapy beyond fixed schedules and clinician-mediated titration. The central challenge is that therapeutic intelligence changes the risk profile of pharmaceutical products. A delivery system that senses inaccurately, computes incorrectly, or actuates unpredictably can convert a pharmacological benefit into an autonomous harm pathway. This makes safety assurance inseparable from system architecture, rather than a downstream verification step. The review identifies a recurring sense–control–deliver architecture, but argues that this architecture remains unevenly mature. Glucose-responsive and automated insulin systems provide the strongest clinical evidence, whereas multi-analyte drug monitoring, implantable autonomous platforms, and reinforcement-learning controllers remain closer to proof-of-concept or early translational validation. Four tables organise the system logic, sensor landscape, feedback-control approaches, and safety oversight framework. The review concludes that smart pharmaceutical systems should not be judged solely by pharmacokinetic precision or device performance. Their clinical legitimacy will depend on robust control under uncertainty, interpretable autonomy, resilient human oversight, and regulatory pathways that can evaluate integrated drug–device–software behaviour. Safe therapeutic autonomy will require co-development of engineering validation, clinical governance, and patient-centred design.