Prospective Randomized Trial of Insulin Glargine in Acute Management of Diabetic Ketoacidosis in the Emergency Department: A Pilot Study

Doshi, Pratik; Potter, Andrew J.; Santos, Daniel De Los; Banuelos, Rosa; Darger, Bryan; Chathampally, Yashwant

doi:10.1111/acem.12673

Cited by 43 publications

(36 citation statements)

References 9 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Conversely, a pilot prospective RCT concluded that this model of treatment was feasible, although it did not find a significant benefit in time to closure of anion gap, or number of hypoglycaemic events (44) (Table 5). …”

Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

View full text Add to dashboard Cite

BackgroundDiabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs).ObjectiveTo review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes.MethodsOvid Medline searches were conducted with limits “all adult” and published between “1973 to current” applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers’ assessment of title, abstract, and availability.ResultsA total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over “sliding scale” insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1–2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes.ConclusionThere are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.

show abstract

Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

View full text Add to dashboard Cite

show abstract

“…This includes patients with euglycemic diabetic ketoacidosis secondary to treatment with an SGLT2 inhibitor and those with ketosis prone diabetes who present with diabetic ketoacidosis. To prevent rebound ketoacidosis or hyperglycemia, administration of a long acting basal insulin (if this has not already been given in the previous 24 hours) with or without a short or rapid acting insulin is needed at least two hours before the intravenous insulin infusion is stopped 677475. This overlap is needed mainly because of the short half life of intravenous insulin (approximately 10 minutes) 7.…”

Section: Transition From Acute Managementmentioning

confidence: 99%

“…This study will provide additional information on use of long acting insulin preparations early in the course of treatment for diabetic ketoacidosis 7475. It is scheduled to be completed in November 2019.…”

Section: Emerging Treatmentsmentioning

confidence: 99%

See 1 more Smart Citation

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

French

Donihi

Korytkowski

2019

BMJ

136

View full text Add to dashboard Cite

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

show abstract

“…Thus, larger trials are needed to test the superiority of the coadministration of long-acting insulin with intravenous regular insulin over standard care in the acute management of DKA. 10,11 Extensive data indicate that uncontrolled hyperglycemia is associated with adverse outcomes in critically ill patients. Recent consensus guidelines recommend a capillary blood glucose goal range of 140 to 180 mg/dL (to convert to millimoles per liter, multiply by 0.055) in acute critical illness-while avoiding severe hypoglycemia.…”

Section: Recommendations For Practicementioning

confidence: 99%