Consider SUB-Q insulin to manage DKA

Abdelwahab Ward, BS Pharm, PharmD

As a hospital pharmacist, you will hear renewed debate about the optimal insulin regimen for treating diabetic ketoacidosis (DKA) in adults. A recent retrospective study suggests that subcutaneous insulin, instead of IV, reduces ICU admissions, with no difference in hypoglycemia. This adds to other limited data suggesting subcutaneous insulin is safe and effective for mild to moderate DKA.

     Continue to rely on an IV insulin infusion for ICU or pregnant patients with DKA, or if insulin dosing or subcutaneous absorption is less predictable (severe kidney disease, extreme obesity, etc). But consider subcutaneous insulin for some mild to moderate DKA cases, such as alert and hemodynamically stable patients with serum bicarbonate above 10 mEq/L and potassium above 3.3 mEq/L.

Develop a subcutaneous insulin DKA protocol similar to IV, include initial fluid resuscitation with IV crystalloids (lactated Ringer’s, etc) followed by IV dextrose-containing fluids to prevent hypoglycemia as treatment continues.

Start subcutaneous basal (glargine, etc) AND rapid-acting insulin (lispro, etc) STAT. For example, use 0.3 units/kg for each initial dose. Schedule basal Q24H, and rapid-acting Q4H to start. Monitor blood glucose frequently, such as Q2H, and reduce rapid-acting insulin doses as glucose improves. For instance, transition to sliding scale when blood glucose is below 250 mg/dL.

Also monitor the anion gap and electrolytes Q4H. If possible, use nursing-led protocols to replete electrolytes (potassium, etc). Confirm colleagues are educated about nuances of the protocol before use. If needed, consider limiting use to certain units. And help prevent common errors with insulin for DKA. For example, emphasize that insulin shouldn’t be held based on NPO status or a “normal” blood glucose. Reinforce that insulin is needed to resolve DKA, such as an anion gap 12 mEq/L or less. Use our note, "Management hyperglycemia (DKA/HHS) in ICU". Also read "Treatment of inpatient HYPERglycemia" to get more information.

REFERENCES

  • American Diabetes Association Professional Practice Committee; American Diabetes Association Professional Practice Committee:, Draznin B, Aroda VR, Bakris G, Benson G, Brown FM, Freeman R, Green J, Huang E, Isaacs D, Kahan S, Leon J, Lyons SK, Peters AL, Prahalad P, Reusch JEB, Young-Hyman D, Das S, Kosiborod M. 16. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S244-S253. Available at: https://pubmed.ncbi.nlm.nih.gov/34964884

    Rao P, Jiang SF, Kipnis P, Patel DM, Katsnelson S, Madani S, Liu VX. Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis. JAMA Netw Open. 2022 Apr 1;5(4):e226417. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790794

    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 Jan 21;2016(1):CD011281. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011281.pub2/full

    Karajgikar ND, Manroa P, Acharya R, Codario RA, Reider JA, Donihi AC, Salata RA, Korytkowski MT. ADDRESSING PITFALLS IN MANAGEMENT OF DIABETIC KETOACIDOSIS WITH A STANDARDIZED PROTOCOL. Endocr Pract. 2019 May;25(5):407-412. Available at: https://www.endocrinepractice.org/article/S1530-891X(20)35898-5/fulltext

Abdelwahab Ward, BS Pharm, PharmD