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Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review
  1. Soulmaz Fazeli Farsani1,
  2. Kimberly Brodovicz2,
  3. Nima Soleymanlou3,
  4. Jan Marquard4,
  5. Erika Wissinger5,
  6. Brett A Maiese5
  1. 1 Corporate Department GlobalEpidemiology, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
  2. 2 Global Epidemiology, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, USA
  3. 3 Boehringer Ingelheim Canada, Burlington, Canada
  4. 4 Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany
  5. 5 Xcenda L L C, Palm Harbor, Florida, USA
  1. Correspondence to Dr Soulmaz Fazeli Farsani; soulmaz.fazeli_farsani{at}


Objectives To summarise incidence and prevalence of diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D) for the overall patient population and different subgroups (age, sex, geographical region, ethnicity and type of insulin administration).

Design Systematic literature review (SLR).

Data sources Medline (via PubMed) and Embase (1 January 2000 to 23 June 2016).

Study selection Peer-reviewed observational studies with reported data on the incidence or prevalence of DKA in T1D adults were included. A single reviewer completed the study screening and selection process and a second reviewer performed an additional screening of approximately 20% of the publications; two reviewers independently conducted the quality assessment; the results were narratively synthesised.

Results Out of 1082 articles, 19 met the inclusion and exclusion criteria, with two additional studies identified that did not specify the patient age range and are therefore not included in the SLR. Overall, eight studies reported incidence with a range of 0–56 per 1000 person-years (PYs), with one outlying study reporting an incidence of 263 per 1000 PYs. Eleven studies reported prevalence with a range of 0–128 per 1000 people. Prevalence of DKA decreased with increasing age. Subgroup analyses were performed using data from no more than two studies per subgroup. There was a higher prevalence of DKA reported in women, non-whites and patients treated with insulin injections compared with men, whites and patients using continuous subcutaneous insulin infusion pumps, respectively.

Conclusions To our knowledge, this is the first SLR on the epidemiology of DKA in T1D adults. Despite an increasing prevalence of T1D in recent years, DKA in adults has been poorly characterised. In an era when the benefit–risk profiles of new antidiabetic therapies are being evaluated, including the potential risk of DKA, there is a clear need to better elucidate the expected rate of DKA among T1D adults.

  • diabetic ketoacidosis
  • type 1 diabetes mellitus
  • systematic literature review
  • incidence
  • prevalence
  • epidemiology

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  • Contributors BAM, EW, SFF conceived and designed the study. EW and BAM undertook the literature search, assessed studies for eligibility and extracted data. In case of disagreement, SFF checked the study. BAM, EW, SFF, KB, NS and JM discussed the data, interpreted the results, reviewed the manuscript and revised it critically. NS and JM provided clinical input. All authors approved the final version and take full responsibility for the integrity of the data and the accuracy of the data summarisation and interpretation.

  • Funding This study was sponsored by Boehringer Ingelheim International GmbH.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at and declare: SFF, KB, NS, and JM are employees of Boehringer Ingelheim. EW and BAM are employees of Xcenda, LLC.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Additional data are available in the appendices.

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