Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis

Rao, Priya; Jiang, Sheng-Fang; Kipnis, Patricia; Patel, Divyesh M; Katsnelson, Svetlana; Madani, Samineh; Liu, Vincent X

doi:10.1001/jamanetworkopen.2022.6417

Cited by 19 publications

(10 citation statements)

References 34 publications

(62 reference statements)

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“…As reported in previous randomized clinical trials comparing the 2 treatment modalities for children and adults with uncomplicated mild DKA, [12][13][14][15]26 SC insulin is safe and effective. The mean LOS in the SC insulin group was 1.90 days, and the mean duration of DKA treatment was 9.06 hours.…”

Section: Discussionmentioning

confidence: 69%

Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children

et al. 2022

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IMPORTANCE Intravenous (IV) insulin infusion is the standard of care for treating diabetic ketoacidosis (DKA) worldwide. Subcutaneous (SC) insulin aspart could decrease the use of health care resources. OBJECTIVE To compare the cost-effectiveness of mild uncomplicated DKA management with SC insulin aspart vs IV insulin infusion among pediatric patients from the perspective of a public health care payer using clinical data. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation included children aged 2 to 14 years presenting to the emergency department of a single academic medical center with mild DKA

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Section: Discussionmentioning

confidence: 69%

Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children

et al. 2022

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“…Despite this study not being designed to quantify the economic impact of transferring patients to the ICU for glucose control, it is anticipated that our non-critical care IV insulin infusion order set may reduce costs as demonstrated in the studies managing diabetic ketoacidosis outside of the ICU. [16][17][18] Furthermore, our order set may reduce costs associated with managing adverse effects. Prior to the development of the non-critical care IV insulin infusion order set patients who were not transferred to the ICU to receive the critical care IV insulin infusion order set were initiated on a prescriber-specific modified version of one of our disease specific order sets (i.e.…”

Section: Discussionmentioning

confidence: 99%

Safety and Effectiveness of a Standardized Intravenous Insulin Infusion Order Set for Managing Uncontrolled Hyperglycemia Outside the Intensive Care Unit

Ibarra

2023

Ann Pharmacother

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Background: Few studies have evaluated the administration of intravenous (IV) insulin infusions for uncontrolled hyperglycemia in non-intensive care unit (ICU) patients, and there is inadequate data to guide how to appropriately administer IV insulin infusions to this patient population. Objective: Determine the effectiveness and safety of our institution’s non-critical care IV insulin infusion order set. Methods: This retrospective study was conducted at 2 institutions within a health care system. The primary outcome was the number of individuals who achieved a glucose level ≤180 mg/dL. For those meeting this endpoint, the time to achieving this outcome and the percentage of glucose checks within the goal range were determined. The primary safety endpoint was the number of individuals who experienced hypoglycemia (glucose level <70 mg/dL). Patients were included if they were ≥18 years of age and received the non-critical care IV insulin infusion order set outside of the ICU. Results: Twenty-one (84%) patients achieved a glucose level ≤180 mg/dL. The median (inter-quartile range [IQR]) time to achieving the primary outcome was 5.7 h (3.9-8.3). In patients who achieved the primary outcome, 41.8% of the glucose readings obtained after achieving this outcome were within goal range. Two (8%) patients experienced hypoglycemia. Both of these events occurred within 8 hours of therapy initiation and neither patient received prior doses of subcutaneous insulin. Of the 4 patients who did not achieve a glucose level ≤180 mg/dL, 2 received high-dose corticosteroids, and 3 achieved a glucose level between 181 and 200 mg/dL. Conclusion and Relevance: Our findings support the safe administration of IV insulin infusions to non-ICU patients when targeting a glucose range of 140 to 180 mg/dL and limiting the infusion duration.

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“…In a recent large retrospective pre-and post-cohort study (n=7989), combination therapy with subcutaneous insulin lispro and subcutaneous insulin glargine reduced rates of ICU admission and 30-day hospital readmission but with no increase in hypoglycaemic or 30-day mortality rates when compared with intravenous RII. 13 Results from meta-analyses often suffer from overestimation (type 1 errors) or underestimation (type 2 errors) of intervention effects due to inclusion of too few patients and multiple and sequential testing. 14 15 Trial sequential analysis (TSA) has been developed and increasingly used recently to reduce false positive and negative results in meta-analyses.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

“…The benefits of subcutaneous LAI and subcutaneous FAIAs may be similar in DKA. In a recent large retrospective pre- and post- cohort study (n=7989), combination therapy with subcutaneous insulin lispro and subcutaneous insulin glargine reduced rates of ICU admission and 30-day hospital readmission but with no increase in hypoglycaemic or 30-day mortality rates when compared with intravenous RII 13…”

Section: Introductionmentioning

confidence: 99%

Subcutaneous fast-acting insulin analogues, alone or in combination with long-acting insulin, versus intravenous regular insulin infusion in patients with diabetic ketoacidosis: protocol for an updated systematic review and meta-analysis of randomised trials

Lim

Lee

et al. 2023

BMJ Open

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IntroductionDiabetic ketoacidosis (DKA) is traditionally managed using intravenous regular insulin infusion (RII) in intensive care unit (ICU)/high dependency unit (HDU). Subcutaneous fast-acting insulin analogues (FAIAs) may help to manage DKA outside ICU/HDU. Furthermore, combining subcutaneous long-acting insulin (LAI) with subcutaneous FAIAs may accelerate ketoacidosis resolution. The latest (2016) Cochrane review was inconclusive regarding subcutaneous FAIAs versus intravenous RII in DKA. It was limited by small sample sizes, unclear risk of bias (RoB) in primary trials and did not examine subcutaneous FAIAs with subcutaneous LAI versus intravenous RII in DKA. We report the protocol for an updated meta-analysis on the safety and benefits of subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA.Methods and analysisWe will search Medline, Embase, CINAHL and Cochrane Library, from inception until December 2022, without language restrictions, for randomised trials on subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA. We also search ClinicalTrials.gov, ClinicalTrialsRegister.eu and reference lists of included trials. Primary outcomes include all-cause in-hospital mortality, time to DKA resolution, in-hospital DKA recurrence and hospital readmission for DKA post-discharge. Secondary outcomes include resource utilisation and patient satisfaction. Safety outcomes include important complications of DKA and insulin. Reviewers will extract data, assess overall RoB and quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation. We will assess statistical heterogeneity by visually inspecting forest plots and the I2statistic. We will synthesise data using the random-effects model. Predefined subgroup analyses are: mild versus moderate versus severe DKA; age <20 vs ≥20 years; pregnant versus non-pregnant; infective versus non-infective DKA precipitating cause; subcutaneous FAIAs alone versus subcutaneous FAIAs and subcutaneous LAI; and high versus low overall RoB. We will also perform trial sequential analysis for primary outcomes.Ethics and disseminationEthics board approval is not required. Results will be disseminated through publication in a peer-reviewed journal.PROSPERO registration numberCRD42022369518.

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Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis

Cited by 19 publications

References 34 publications

Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children

Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children

Safety and Effectiveness of a Standardized Intravenous Insulin Infusion Order Set for Managing Uncontrolled Hyperglycemia Outside the Intensive Care Unit

Subcutaneous fast-acting insulin analogues, alone or in combination with long-acting insulin, versus intravenous regular insulin infusion in patients with diabetic ketoacidosis: protocol for an updated systematic review and meta-analysis of randomised trials

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