Evaluation of Early Administration of Insulin Glargine in the Acute Management of Diabetic Ketoacidosis

Abstract

Background: Few studies have evaluated the early use of insulin glargine in the management of diabetic ketoacidosis (DKA) patients. Early insulin glargine use in DKA was safe and associated with a trend towards faster DKA resolution. Objectives: To evaluate the efficacy and safety of early insulin glargine administration for acute management of DKA in critically ill patients. Methods: This single-center retrospective cohort study included patients, who were >18 years of age with DKA, admitted to the intensive care unit (ICU) for at least 12 h, and received intravenous insulin infusion for at least 6 h. The primary endpoint was the association between the time to insulin glargine administration and time to DKA resolution. Linear and logistic regression analyses were performed. Results: Of the 913 patients evaluated, 380 were included in the study. The overall mean age was 45±17 years, 196 (51.6%) were female, and 262 (70%) patients had type 1 diabetes mellitus. The mean blood glucose level was 584.9±210 mg/dL, pH was 7.16±0.17, anion gap was 28.17±6.9 mEq/L, and serum bicarbonate level was 11.19±5.72 mEq/L. Every 6-h delay in insulin glargine administration was associated with a 26-min increase in time to DKA resolution (95% confidence interval [CI], 14.76–37.44; p<0.0001), 3.2-h increase in insulin infusion duration (95% CI, 28.8–36; p<0.0001), and 6.5-h increase in ICU LOS (95% CI, 5.04–7.92; p<0.0001). Conclusion: Early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and shorter duration of insulin infusion.

Effectiveness and safety of early insulin glargine administration in combination with continuous intravenous insulin infusion in the management of diabetic ketoacidosis: A randomized controlled trial

“…Because of its pharmacokinetic properties, the addition of SC insulin glargine to IV continuous insulin infusion in the early phase of DKA may accelerate DKA resolution by decreasing the requirement for IV insulin infusion and facilitating the transition from continuous IV insulin infusion to SC maintenance therapy. This treatment strategy is supported by several studies that show early glargine administration is effective and appears to be safe 13‐18,22 …”

“…This treatment strategy is supported by several studies that show early glargine administration is effective and appears to be safe. [13][14][15][16][17][18]22 T A B L E 3 Summary of studies associated with the use of early subcutaneous insulin glargine in DKA management Outcomes were from all patients with known diabetes and receiving IV insulin infusion (including with DKA, after solid organ transplantation, and patients with other surgical and medical diagnoses).…”

“…The Joint British Diabetes Societies (JBDS) guidelines recommend the continuation of pre‐existing prescription of SC long‐acting basal insulin analogues during the initial management of DKA to prevent rebound hyperglycaemia when IV insulin is stopped 11,12 . Several retrospective studies showed that concomitant administration of SC insulin glargine with IV insulin infusion during early DKA management accelerated DKA resolution, 13,14 shortened the length of stay (LOS) 14 and appeared to be safe, without increasing hypoglycaemia 15 . Previous randomized controlled trials (RCTs) showed that SC insulin glargine administration during early DKA management led to a reduction in rebound hyperglycaemic events after stopping IV insulin infusion, and tended to decrease the time to DKA resolution 16‐18 .…”

Hyperglycaemic crises in adults with diabetes: a consensus report

“…The administration of basal insulin while on fixed-rate intravenous insulin infusion is advocated by many clinicians but avoided by others because of the risk of hypoglycaemia [134] or hypokalaemia [135]. Several studies have reported that the coadministration of a low dose (0.15-0.3 U/kg) of basal insulin during insulin infusion reduces time to DKA resolution, duration of insulin infusion [136,137] and length of hospital stay [136] and prevents rebound hyperglycaemia, all without increased risk of hypoglycaemia [136,138,139].…”

Success of Insulin Infusion Transitions in Moderate to Severe Diabetic Ketoacidosis With Transition Anion Gap of Less Than or Equal to 12 mEq/L Versus Greater Than 12 mEq/L

“…Notably, the current literature demonstrates substantial variability defining DKA resolution, with some trials utilizing an AG ≤ 12 mEq/L, whereas others do not reference transition AG and utilize parameters such as BG, pH, and bicarbonate. [4][5][6] Clinicians may consider transitioning to SQ insulin when AG remains above 12 mEq/L as IV insulin infusions carry risks of hypoglycemia and electrolyte derangements, and may require an ICU level of care. However, no trials to date have analyzed the success rates of insulin transition or patient outcomes when patients are transitioned with an AG ≤ 12 mEq/L versus an AG > 12 mEq/L.…”