From the Guidelines
Bolusing subcutaneous insulin is not recommended for severe diabetic ketoacidosis (DKA), and instead, intravenous (IV) regular insulin is the standard of care. The most recent and highest quality study, 1, published in 2025, supports this recommendation, stating that continuous intravenous insulin infusion is the most effective method for achieving specific glycemic goals and avoiding hypoglycemia in the critical care setting.
Key Considerations for Severe DKA Management
- Severe DKA requires immediate and precise control of glucose levels, which can only be achieved with intravenous insulin administration.
- Subcutaneous insulin is inadequate in severe DKA due to unpredictable absorption and delayed onset of action, particularly in patients with dehydration and poor peripheral perfusion.
- Intravenous insulin allows for minute-to-minute adjustments based on glucose levels, enabling healthcare providers to respond quickly to changes in the patient's condition.
Transitioning to Subcutaneous Insulin
- Once the patient is stabilized (glucose <200-250 mg/dL, anion gap normalized, pH >7.3), they can be transitioned to subcutaneous insulin, typically with basal-bolus regimens like glargine or detemir for basal coverage and rapid-acting insulin (lispro, aspart, or glulisine) for mealtime coverage.
- The IV insulin should overlap with the first subcutaneous dose by 1-2 hours to ensure continuous insulin coverage during the transition, as recommended by 1 and 1.
Importance of Individualized Care
- Management goals for DKA include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, as outlined in 1.
- Individualization of treatment based on a careful clinical and laboratory assessment is necessary to ensure optimal outcomes, as emphasized in 1 and 1.
From the Research
Bolus Subcutaneous Insulin in Severe DKA
- The use of bolus subcutaneous insulin in severe diabetic ketoacidosis (DKA) is not recommended, as it may not provide the rapid and controlled insulin delivery required to manage the condition effectively 2.
- Intravenous (IV) infusion of regular human insulin is preferred over the subcutaneous route or rapid-acting insulin analogues, as it allows for more precise control of insulin delivery and can help to rapidly correct the metabolic acidosis and hyperglycemia associated with DKA 2, 3.
- Administering an initial IV insulin bolus before low-dose insulin infusions may be necessary to rapidly achieve therapeutic insulin levels and obviate the need for supplemental insulin 2.
- Once the DKA has been resolved, subcutaneous insulin can be recommended, with IV insulin infusions ceased with an overlap of 1-2 hours to ensure a smooth transition to subcutaneous insulin therapy 2, 3.
Key Considerations
- The management of DKA requires careful replacement of fluid and electrolyte deficits, close monitoring of clinical and biochemical parameters, and timely detection of complications, including hypokalemia, hypoglycemia, and cerebral edema 3, 4.
- The use of subcutaneous insulin in the management of DKA is generally reserved for the resolution phase, when the patient's condition has stabilized and IV insulin is no longer required 2, 3.
- The choice of insulin regimen and dosing should be individualized based on the patient's specific needs and clinical status, with careful monitoring of blood glucose levels and adjustment of insulin doses as needed 5, 6.