Treatment of Diabetic Ketoacidosis With Subcutaneous Insulin Aspart

Abstract

OBJECTIVE—In this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard low-dose intravenous (IV) infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS—A total of 45 consecutive patients admitted with DKA were randomly assigned to receive subcutaneous (SC) aspart insulin every hour (SC-1h, n = 15) or every 2 h (SC-2h, n = 15) or to receive IV infusion of regular insulin (n = 15). Response to medical therapy was evaluated by assessing the duration of treatment until resolution of hyperglycemia and ketoacidosis. Additional end points included total length of hospitalization, amount of insulin administration until resolution of hyperglycemia and ketoacidosis, and number of hypoglycemic events. RESULTS—Admission biochemical parameters in patients treated with SC-1h (glucose: 44 ± 21 mmol/l [means ± SD], bicarbonate: 7.1 ± 3 mmol/l, pH: 7.14 ± 0.09) were similar to those treated with SC-2h (glucose: 42 ± 21 mmol/l, bicarbonate: 7.6 ± 4 mmol/l, pH: 7.15 ± 0.12) and IV regular insulin (glucose: 40 ± 13 mmol/l, bicarbonate 7.1 ± 4 mmol/l, pH: 7.11 ± 0.17). There were no statistical differences in the mean duration of treatment until correction of hyperglycemia (6.9 ± 4, 6.1 ± 4, and 7.1 ± 5 h) or until resolution of ketoacidosis (10 ± 3, 10.7 ± 3, and 11 ± 3 h) among patients treated with SC-1h and SC-2h or with IV insulin, respectively (NS). There was no mortality and no differences in the length of hospital stay, total amount of insulin administration until resolution of hyperglycemia or ketoacidosis, or the number of hypoglycemic events among treatment groups. CONCLUSIONS—Our results indicate that the use of subcutaneous insulin aspart every 1 or 2 h represents a safe and effective alternative to the use of intravenous regular insulin in the management of patients with uncomplicated DKA.

Evaluation of Ward Management of Diabetic Ketoacidosis

“…Two studies analyzing the use of subcutaneous insulin for DKA on medicine wards found rates of hypoglycemia closer to 5% but used a lower threshold for hypoglycemia (< 60 mg/dl). 9,10 The incidence of hypoglycemia after conversion to subcutaneous insulin was slightly higher than what was found in a study by Umpierrez et al, 11 which documented a range of 15-41% depending on the type of insulin to which patients were converted.…”

“…Previous studies have shown that patients with DKA can be safely and effectively treated with subcutaneous insulin on medicine wards; however, we have not identified any studies of ward treatment of DKA with continuous infusions of insulin. [8][9][10][11][12] The Medical University of South Carolina (MUSC) treats a similar percentage of patients on general medicine wards, as seen in the New York study described above, 7 using an internally developed, Internetbased, nursing-driven insulin infusion protocol. The safety and efficacy of the MUSC protocol was validated in a population of cardiothoracic surgery patients.…”

Diabetic Ketoacidosis

“…[162,163]. There were no differences in length of hospital stay, total amount of insulin needed for resolution of hyperglycemia or ketoacidosis.…”

“…There were no differences in length of hospital stay, total amount of insulin needed for resolution of hyperglycemia or ketoacidosis. Patients treated with insulin analogs were managed in the open medical wards which reduced cost of hospitalization by 30% [162][163][164]. This approach is not widely used for many reasons, including titration difficulties with longer half-life preparations, requirement for hourly nursing interventions and lack of staff experience compared to that with standard insulin infusions.…”

“…Subcutaneous rapid-acting insulin analogs (lispro and aspart) offer an efficacious and costeffective alternative to continuous intravenous infusions in the treatment of DKA [162][163][164]. [162,163].…”