Prevalence and outcomes of DKA in type 1 and type 2 DM patients treated and not treated with SGLT-2 inhibitors

To compare the clinical characteristics, biochemical presentation, and short- and long-term outcomes of DKA in hospitalized adults with T1DM and T2DM, including the impact of SGLT2 inhibitor therapy.

A retrospective cohort of 2283 adults (838 with T1DM; 1445 with T2DM) hospitalized with DKA between 2013 and 2023 across Clalit Health Services hospitals was analyzed. Patients were stratified by SGLT2 inhibitor use within 4 months before admission. Outcomes included AKI, 30-day mortality, 1-year mortality, and readmissions. One-year mortality was assessed using Cox proportional hazards regression, 30-day mortality using logistic regression, and recurrent readmissions using a negative binomial model.

2.3% (N = 19) of T1DM and 16% (235) of T2DM patients were treated with SGLT-2 inhibitors. A total of 115 patients from all cohorts presented with eu DKA, characterized by lower glucose and bicarbonate levels. In T2DM, the incidence of AKI was higher among SGLT2 users (26% vs. 17%; p = 0.030) but lower in euDKA cases (9.6% vs. 19%; p = 0.020). In Cox regression analysis, treatment with SGLT2 inhibitors was independently associated with reduced 1-year mortality (HR 0.55, 95% CI 0.36-0.82; p = 0.004). Predictors of increased 1-year mortality included older age, higher HbA1c, cardiovascular disease, CKD and insulin therapy. In the negative binomial model, higher readmission rates were independently associated with T1DM, higher HbA1c, higher BMI, CKD and pre-admission insulin use, while SGLT2 inhibitor use was not linked to increased readmissions.

Pre-hospital SGLT2 inhibitor therapy in patients presenting with DKA was associated with substantially lower long-term mortality and no increase in short-term mortality or readmissions, supporting the safety of these agents when appropriate monitoring is in place. Pre-hospital SGLT2 inhibitor therapy in patients presenting with DKA was associated with improved long-term survival and no increase in short-term mortality, supporting their continued use with appropriate clinical monitoring.