Jennifer Cortes, BCCCP, BCPS, PharmD
Clinical Pharmacy Specialist- MICU
Memorial Hermann-Texas Medical Center
Houston, Texas
Disclosure information not submitted.
Annette Augustine, PharmD
Pharmacist
Memorial Hermann-Texas Medical Center, United States
Disclosure information not submitted.
Heather Hartman, PharmD, BCPS, BCCCP
Pharmacist
Memorial Hermann Texas Medical Center, United States
Disclosure information not submitted.
Kasaandra Ibanez, PharmD
Pharmacist
Memorial Hermann-Texas Medical Center, United States
Disclosure information not submitted.
Brittany Pelsue, BCCCP, BCPS, PharmD
Pharmacist
n/a, United States
Disclosure information not submitted.
Title: Continuous Intravenous vs Subcutaneous Insulin Management in Mild to Moderate Diabetic Ketoacidosis
Background: Diabetic ketoacidosis (DKA) is a medical emergency that occurs in patients with diabetes secondary to an inadequate secretion of insulin and is treated with fluid resuscitation, electrolyte repletion and insulin therapy. Historically, insulin was administered as a continuous intravenous (IV) infusion of regular insulin over subcutaneous (SQ) in the management of DKA because of the delayed onset and prolonged half-life of SQ regular insulin. More recently rapid-acting insulin (insulin aspart & lispro) was evaluated for the management of mild to moderate DKA (MMDKA) due to a shorter onset and duration of action compared to regular insulin. In MMDKA, when compared to IV regular insulin, using SQ rapid-acting insulin in these patients results in no difference in the rate of blood glucose decline, time to DKA resolution, amount of insulin used, hospital length of stay or hypoglycemic events.
Methods: IRB approved, single center, retrospective, cohort study evaluating patients with a diagnosis of MMDKA defined as a blood glucose > 250 mg/dL, bicarbonate > 11 mEq/L, anion gap > 12, and pH > 7.2 between 8/2018 - 6/2020 treated with intravenous regular insulin infusion or SQ insulin lispro. Patients were excluded if they were < 18 or ≥ 80 y/o, had altered mental status, acute myocardial infarction, congestive heart failure class III/IV, pregnant, eGFR < 45 mL/min, mean arterial pressure < 65 mm Hg, severe pancreatitis, or anasarca.
Results: 74 patients were included in the study with 37 patients in each group. There were no differences in baseline demographics except greater number of females 59% vs. 35% (p = 0.036) in the IV infusion group and a lower baseline median pH in the SQ group, 7.32 vs. 7.28, p = 0.033). Although not statistically significant, there was greater fluid resuscitation, 25.9 vs. 16.9 mL/kg, and insulin requirements, 51 vs. 30 units, in the IV group. Time to resolution of DKA was 16 hrs in the IV group vs. 10.9 hrs in the SQ group, p = NS, and hospital length of stay was 118 vs. 69.4 hrs, p = 0.037. Incidence of hypokalemia was 21 vs. 8%, p = NS, and hypoglycemia was 19 vs. 19%, p = NS.
Conclusions: Treatment of MMDKA with rapid acting insulin is safe and effective compared to regular insulin intravenous infusions and decreases hospital length of stay.