Sungho Bea¹, Han Eol Jeong^1,2, Sohee Park¹, Oriana H Y Yu^3,4, Yoosoo Chang^2,5, Juhee Cho^2,6, Dong Hyun Sinn⁷, Young Min Cho⁸, Ju-Young Shin^1,2

¹School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
²Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
³Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
⁴Division of Endocrinology, Jewish General Hospital, Montreal, Quebec, Canada
⁵Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
⁶Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
⁷Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
⁸Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea

Correspondence to Dr Ju-Young Shin

We read with great interest the report on risk of incident diabetes mellitus among patients with non-alcoholic fatty liver disease by Mantovani et al.1 The bidirectional relationship between type 2 diabetes (T2D) and liver disease has been largely evaluated.2–4 However, optimal therapeutic options for T2D in patients with metabolic syndrome remain unclear. Several randomised trials have shown that sodium-glucose cotransporter-2 inhibitors (SGLT2is) may have promising effects on early stages of liver disease, yet its effects on advanced liver disease are unclear and warrant further research.5–7 Although one observational study of patients with T2D and liver cirrhosis reported a 11% lower risk of hepatic decompensation events (HR 0.89, 95% CI 0.62 to 1.26) with SGLT2is versus dipeptidyl peptidase 4 inhibitors (DPP4is), it lacked statistical power by having wide CIs.8 Thus, we investigated the risk of hepatic events with SGLT2is among patients with T2D.