Evaluation of an Alternative Approach to Managing Diabetic Ketoacidosis: Combination Rapid-Acting and Basal Subcutaneous Insulin (CRABI-DKA)

Abstract

Background:

Although guidelines recognize the utility of subcutaneous (SQ) insulin regimens in the management of mild to moderate diabetic ketoacidosis (DKA), the need to administer SQ insulin every 1-2 hours may discourage their use due to frequent lab testing and admission to higher level of care units.

Objective:

The purpose of this retrospective cohort study was to compare the proportion of patients whose mild to moderate DKA resolved within 12 hours after receiving the new SQ insulin order set and the institution’s intravenous (IV) insulin infusion order set.

Methods:

The SQ order set included single doses of glargine (0.2 units/kg) and lispro (0.2 units/kg) upon therapy initiation, followed by lispro (0.1-0.2 units/kg) given every 3 hours until DKA resolution. The IV order set included a nurse-managed titratable infusion. Glucose and labs were checked every 3 hours in the SQ group, whereas glucose was checked hourly and labs were checked every 2 hours in the IV group. Patients were managed on units with a RN to patient ratio of 1:4-5 and 1:2-3 in the SQ and IV groups, respectively.

Results:

The percentage of patients whose DKA resolved within 12 hours was 78% in the IV group and 90% in the SQ group (P = 0.1). The time to DKA resolution and rates of hypoglycemia and hypokalemia were comparable between the groups.

Conclusion and Relevance:

Our study highlights the utility of combining rapid-acting and basal SQ insulin in the management of DKA and adds to the limited literature evaluating this approach.