Severe hypoglycaemia and diabetic ketoacidosis in adults presenting to a hospital emergency department: Adverse prognostic markers for survival in type 2 diabetes and the role of SGLT2 inhibitors

Abstract Aims To determine the prognosis associated with severe hypoglycaemia (SH) and diabetic ketoacidosis (DKA) in adults presenting to a hospital emergency department (ED). Methods Medical records of adults with type 1 (T1D) and type 2 (T2D) diabetes who attended the ED with SH and DKA between 1 January 2019 and 30 June 2023, were reviewed for comorbidities, long‐term survival, mortality and causes of death. Results A total of 429 episodes of DKA occurred in 293 people and 643 episodes of SH in 515 people. DKA predominated in T1D (77.6%) and SH in T2D (54.3%). In T2D, 32.3% of DKA events were associated with sodium‐glucose cotransporter‐2 inhibitor (SGLT2‐i) medication. In both SH and DKA, patients with T2D were older and had more comorbidities than T1D, particularly cardiorenal disease, heart failure, cognitive impairment and cancer (all p < 0.005). Compared with T1D, mortality was higher in T2D after SH (48.4% vs. 19.9%, p < 0.005) and after DKA (30.8% vs. 13.4%, p = 0.001) with shorter median times to fatal outcome (SH: 134 vs. 511 days; DKA: 43 vs. 266 days, both p < 0.005). Long‐term survival was lower ( p < 0.005) and mortality risk was higher in T2D after index presentation with SH (HR 3.43 [95% CI: 2.43–4.84], p < 0.005) and DKA (HR 3.00 [95% CI: 1.77–5.10], p < 0.005). Irrespective of diabetes type, most causes of death in SH and DKA were non‐cardiovascular. Conclusions SH and DKA events requiring hospital treatment herald a poor prognosis with greater mortality in T2D adults with multimorbidity. A significant number of DKA episodes in T2D occurred in people receiving SGLT2‐i medication.