UMEM Educational Pearls

Diabetic ketoacidosis (DKA) is a serious condition that carries the risk of significant morbidity and mortality if not managed appropriately. Typically managed with an infusion of regular insulin, IV fluids, and electrolytes, there is evidence to support treatment of mild to moderate DKA with a subcutaneous (SQ) regimen using a combo of fast-acting and long-acting insulin instead, decreasing the need for ICU admission without increasing adverse events [1].  

What patients? 

• Isolated DKA without other ICU requirements 
• Mild-moderate severity as described below [2].

Adapted from Abbas et al. 

How to manage? 

• These patients still require aggressive fluid replacement, frequent POC & BMP monitoring, aggressive electrolyte repletion and treatment of any underlying precipitating cause for their DKA.   
• Insulin dosing should not be started until adequate electrolyte repletion has occurred. 
• There is no universally-accepted protocol and several exist [1-4].   A reasonable approach:

Initial dose 

• Insulin long-acting (glargine) 0.2 to 0.3 units/kg SQ or patient’s home dose 
• Insulin fast-acting (aspart/lispro) 0.3 units/kg SQ

Subsequent dosing: 

If serum glucose is > 250 mg/dL 

• Insulin short-acting 0.2 units/kg every 2 -4 hours

If serum glucose is < 250 mg/dL 

• Insulin short-acting 0.1 units/kg every 2 – 4 hours OR SSI every 4 hours

Bottom Line 

DKA management with a SQ insulin protocol is a reasonable approach for patients with mild to moderate DKA, is supported by the American Diabetes Association [5], and can be particularly helpful in this era of ED boarding and bed shortages.  Give a long-acting insulin dose every 24 hours (or restart the patient’s home long-acting regimen) and short-acting insulin every 2 to 4 hours.  Aggressive IV fluid resuscitation, electrolyte repletion, and treatment of underlying precipitating cause remain additional cornerstones of DKA management.

References

1. Rao P, Jiang S, Kipnis P, et al. Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis. JAMA Netw Open. 2022;5(4):e226417. doi:10.1001/jamanetworkopen.2022.6417 
2. Abbas E. Kitabchi, Guillermo E. Umpierrez, John M. Miles, Joseph N. Fisher; Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care, 1 July 2009; 32 (7): 1335–1343. https://doi.org/10.2337/dc09-9032 
3. Guillermo E. Umpierrez, Ruben Cuervo, Ana Karabell, Kashif Latif, Amado X. Freire, Abbas E. Kitabchi; Treatment of Diabetic Ketoacidosis With Subcutaneous Insulin Aspart. Diabetes Care 1 August 2004; 27 (8): 1873–1878. https://doi.org/10.2337/diacare.27.8.1873 
4. Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Gonzalez-Padilla DA. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database Syst Rev. 2016;2016(1):CD011281. Published 2016 Jan 21. doi:10.1002/14651858.CD011281.pub2 
5. American Diabetes Association Professional Practice Committee; 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2024. Diabetes Care, 1 January 2024; 47 (Supplement_1): S295–S306. https://doi.org/10.2337/dc24-S016