GLP-1 receptor agonists and acute diabetes complications in adults with type 1 diabetes

GLP-1 receptor agonists (GLP-1 RAs) are increasingly used for weight management in patients with obesity, yet their safety in those with comorbid type 1 diabetes (T1D) remains uncertain due to concerns about diabetic ketoacidosis (DKA). This targets trial emulation using OneFlorida+ EHR data (2014-2024). After 1:1 time-conditional propensity score matching, the cohort included 651 GLP-1 RA initiators and 651 matched non-initiators with T1D meeting anti-obesity medication criteria. DKA incidence rates were 13.5 vs. 21.8 per 1,000 person-years. GLP-1 RA initiation was not significantly associated with DKA (hazard ratio [HR], 0.62; 95% confidence interval [CI]: 0.33-1.17) or severe hypoglycemia (HR, 0.52; 95% CI: 0.17-1.55) but was associated with fewer hospitalizations (HR, 0.74; 95% CI: 0.62-0.90) and emergency department visits (HR, 0.73; 95% CI: 0.57-0.92). These findings suggest that GLP-1 RAs may be safely prescribed in adults with T1D and obesity without increasing acute diabetes complications, while potentially reducing healthcare utilization.