Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis?

Abstract

OBJECTIVE—The purpose of this study was to assess the efficacy of an insulin priming dose with a continuous insulin infusion versus two continuous infusions without a priming dose. RESEARCH DESIGN AND METHODS—This prospective randomized protocol used three insulin therapy methods: 1) load group using a priming dose of 0.07 units of regular insulin per kg body weight followed by a dose of 0.07 unit · kg−1 · h−1 i.v. in 12 patients with diabetic ketoacidosis (DKA); 2) no load group using an infusion of regular insulin of 0.07 unit · kg body weight−1 · h−1 without a loading dose in 12 patients with DKA, and 3) twice no load group using an infusion of regular insulin of 0.14 · kg−1 · h−1 without a loading dose in 13 patients with DKA. Outcome was based on the effects of insulin therapy on biochemical and hormonal changes during treatment and recovery of DKA. RESULTS—The load group reached a peak in free insulin value (460 μU/ml) within 5 min and plateaued at 88 μU/ml in 60 min. The twice no load group reached a peak (200 μU/ml) at 45 min. The no load group reached a peak (60 μU/ml) in 60–120 min. Five patients in the no load group required supplemental insulin doses to decrease initial glucose levels by 10%; patients in the twice no load and load groups did not. Except for these differences, times to reach glucose ≤250 mg/dl, pH ≥7.3, and HCO3− ≥15 mEq/l did not differ significantly among the three groups. CONCLUSIONS—A priming dose in low-dose insulin therapy in patients with DKA is unnecessary if an adequate dose of regular insulin of 0.14 unit · kg body weight−1 · h−1 (about 10 units/h in a 70-kg patient) is given.

Diagnosis and management of hyperglycemic emergencies

“…Although an initial bolus dose of 10 units regular insulin (0.1-0.15 units/ kg body weight) is recommended by most authors, 32,49 recent data from almost 200 DKA patients suggest this may confer no additional clinical benefit when the infusion dose is adequate (0.1-0.14 units/kg/hour for either DKA or HHS). 50,51 The administration rate should be increased by 50-100% if glucose does not fall ≥10% or 2.78 mmol/L (50 mg/dL) per hour, and decreased to 2-3 units/hour when glucose falls to 11.1 mmol/L (200 mg/dL) in DKA or 13.88 mmol/L (250 mg/dL) in HHS. 3,7 The serum glucose concentration should be maintained between 7.77-9.99 mmol/L (140-180 mg/dL) for ICU patients and between 5.55-9.99 mmol/L (100-180 mg/dL) for patients admitted to general medical wards.…”

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

“…It has been demonstrated that a priming dose of insulin is not necessary, provided that the insulin infusion is started promptly at a dose of 0.14 unit kg )1 h )1 [33]. Although the insulin infusion ª 2011 The Authors.…”

How do I Diagnose and Manage Acute Endocrine Emergencies in the ICU?

“…Recently, a randomized trial has demonstrated that this "priming" bolus is unnecessary and that effective glycemic control can be achieved by starting the insulin drip at 0.14 U/kg per hour. 13 Glucose levels should decrease by 50 to 70 mg/dL per hour. If the serum glucose does not decrease by at least this value within the first hour, the insulin infusion rate should be doubled every hour until a steady decline is achieved.…”