How to manage diabetic ketoacidosis (DKA) with subcutaneous insulin therapy?

From the Guidelines

Managing diabetic ketoacidosis (DKA) with subcutaneous insulin is generally not the first-line approach, but it can be used in certain settings where IV insulin is unavailable or for mild cases, with the recommended approach involving giving rapid-acting insulin at an initial dose of 0.2-0.3 units/kg body weight, followed by 0.1-0.2 units/kg every 1-2 hours until blood glucose falls below 250 mg/dL, as supported by the most recent study 1.

Key Considerations

• Frequent monitoring of blood glucose (every 1-2 hours), electrolytes, and pH is essential when using subcutaneous insulin to manage DKA, as emphasized in 1.
• Concurrent aggressive fluid resuscitation with normal saline at 15-20 mL/kg in the first hour (typically 1-1.5 L) followed by 250-500 mL/hour is necessary, along with potassium replacement if levels are low, as highlighted in 1 and 1.
• Once blood glucose reaches 250 mg/dL, add dextrose to IV fluids and continue insulin to clear ketones, as recommended in 1.
• Transition to a basal-bolus insulin regimen once the patient is eating, with total daily insulin of approximately 0.5-0.8 units/kg/day, as suggested in 1 and 1.

Important Notes

• The use of bicarbonate in people with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended, as stated in 1, 1, and 1.
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, as emphasized in 1, 1, and 1.
• Individuals with uncomplicated DKA may sometimes be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units, an approach that may be safer and more cost-effective than treatment with intravenous insulin, as mentioned in 1 and 1.

From the Research

Management of Diabetic Ketoacidosis with Subcutaneous Insulin

• Subcutaneous insulin can be used as an alternative to intravenous insulin for managing diabetic ketoacidosis (DKA) in patients with mild-to-moderate cases 2, 3.
• Studies have shown that subcutaneous injections of rapid-acting insulin analogs, such as lispro, every 1-2 hours can be effective in resolving DKA 2.
• Subcutaneous regular insulin administered every 4 hours has also been found to be an effective and safe alternative for the insulin treatment of DKA in children 4.
• The use of subcutaneous insulin can reduce the need for intensive care unit (ICU) admission and decrease healthcare costs 2, 3.
• A retrospective cohort study found that six-hourly subcutaneous regular insulin use was a safe and effective alternative to slow IV insulin infusion for the treatment of DKA in a non-PICU setting 5.

Key Considerations

• Patients with severe complications or those who require close monitoring should be excluded from subcutaneous insulin therapy 2, 3.
• The management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event 6.
• Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA 6.

Treatment Protocols

• Subcutaneous insulin lispro injections every 1-2 hours can be used as an alternative to continuous intravenous infusions of regular insulin 2.
• Subcutaneous regular insulin administered every 4 hours can be used in pediatric patients with DKA 4.
• Six-hourly subcutaneous regular insulin use can be used as an alternative to slow IV insulin infusion for the treatment of DKA in a non-PICU setting 5.