Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been associated
with increased risk of diabetic ketoacidosis (DKA) in both people with type 1 and type 2 diabetes
mellitus. Few studies using data from high-quality registries exist that attempt to determine the real-
world impact of the increasing use of this drug.
Objective: The aim of this study was to investigate the incidence and risk of DKA in connection
with SGLT2i treatment in Denmark between 2013-2017.
Methods: A nationwide retrospective cohort of people with type 2 diabetes mellitus using SGLT2i
or glucagon-like peptide-1 receptor agonists (GLP1-RA) was established and analysed using both
Cox-proportional hazard regression and Kaplan-Meier survival analysis.
Results: The 37,058 individuals included in the cohort, were made up of SGLT2i (10,923), GLP1-
RA (18,849), SGLT2i+insulin (2,069), and GLP1-RA+insulin (10,178) users. The incidence rate
(IR) of DKA was 0.84 (95% CI 0.49-1.44) and 0.53 (95% CI 0.36-0.77) for the SGLT2i and
GLP1-RA groups, respectively. There was no statistically significant increase in the risk for DKA
with SGLT2i use (HR 1.02, 95% CI, 0.44-2.36). However, for the SGLT2i+insulin and GLP1-
RA+insulin groups, IRs were 3.47 (95% CI 1.92-6.27) and 0.97 (95% CI 0.68-1.37) respectively,
and the risk was statistically significantly higher (HR 5.42, 95% CI 2.16-13.56).
Conclusion: We observed no significant increase in the risk of DKA for SGLT2i users compared
to GLP1-RA. However, a significantly higher IR of DKA was observed with concomitant insulin
use, and the risk of DKA was considerably higher for the SGLT2 group using insulin.