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Lynchburg Journal of Medical Science

Specialty

Emergency Medicine

Advisor

James R. Kilgore, DMSc, PhD, PA-C, DFAAPA

Abstract

The reviewed literature focuses on the clinical application of subcutaneous (SQ) insulin, particularly rapid-acting insulin analogs (RAIAs), in treating selected patients with mild to moderate diabetic ketoacidosis (DKA). The use of SQ insulin offers a viable alternative to traditional intravenous (IV) insulin infusions, enabling DKA management outside intensive care unit (ICU) settings and reducing healthcare resource utilization. Current DKA management protocols emphasize comprehensive fluid resuscitation and correction of electrolyte imbalances, with IV regular insulin administered at 0.1 units/kg/hour. This review synthesizes findings from multicenter cohort studies, meta-analyses, and randomized controlled trials (RCTs) available via PubMed, focusing on adult patients diagnosed with mild to moderate DKA. The primary outcome was time to DKA resolution, while secondary outcomes included hospital and ICU length of stay, rates of hypoglycemia, and operational efficiency.

Findings indicate that SQ insulin regimens using RAIAs demonstrate efficacy similar to IV regular insulin infusions, achieving comparable rates of DKA resolution, total insulin use, and hospital stay lengths. Notably, IV protocols were associated with higher hypoglycemia rates. Meta-analyses corroborate these findings, indicating that SQ RAIAs and IV regular insulin are equally effective and safe for resolving DKA, with no significant differences in hypoglycemia or recurrence rates. SQ insulin protocols also yield operational benefits, such as reduced emergency department length of stay and lowered ICU admission rates, marking a potential shift in DKA management strategies. The American Diabetes Association (ADA) endorses SQ RAIAs as a safe and effective option for treating mild to moderate DKA, stressing the necessity of proper patient selection and monitoring to optimize outcomes. While SQ regular insulin can be an option for select patients, RAIAs are the preferred choice according to most guidelines. Frequent patient monitoring and fluid management remain critical for successful treatment.

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