The Utility of Continuous Subcutaneous Insulin Infusion for Management of Mild to Moderate Diabetic Ketoacidosis
American Journal of Internal Medicine
Volume 4, Issue 3, May 2016, Pages: 43-48
Received: Apr. 13, 2016;
Accepted: Apr. 22, 2016;
Published: May 11, 2016
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Magui Abdel Moneim Shalash, Internal Medicine Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
Ali Ahmed Abdel Rahim, Internal Medicine Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
Kamel Hemida Rohoma, Internal Medicine Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
Marwa Abdel Maaboud Elnabawy, Internal Medicine Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
Diabetic ketoacidosis (DKA) is the commonest hyperglycemic emergency in people with diabetes. Fluid and insulin, commonly via intravenous route, is the mainstay of treatment; however, other methods of insulin administration have been tried. In this study, we aimed at comparing the efficacy and safety of continuous subcutaneous insulin infusion (CSII) to intravenous (IV) insulin infusion protocol using a short acting insulin analogue, glulisine, in patients with mild to moderate DKA. This is a prospective randomized controlled trial including 30 patients with DKA randomly assigned to receive Glulisine insulin via CSII or IV infusion. Metabolic parameters were observed till resolution of DKA. Primary end point was assessment of the duration till resolution. Secondary end points included total length of hospitalization, amount of insulin used and the number of hypoglycemic events. There were no statistical differences in the mean duration of treatment until correction of DKA being 16.58 ± 3.68 hours for CSII group versus 14.60 ± 3.2 hours in the IV group, p=0.136. There was no mortality and no differences in the length of hospital stay, or the number of hypoglycemic events among treatment groups. However, the total amount of insulin administration until resolution of ketoacidosis was significantly higher, 61.50 ± 13.89 units, in CSII group compared to 46.60 ± 13.53 units in the IV group, p=0.009. We concluded that the use of CSII of glulisine insulin represented a safe and effective alternative to the use of IV glulisine in the management of patients with mild to moderate DKA.
Magui Abdel Moneim Shalash,
Ali Ahmed Abdel Rahim,
Kamel Hemida Rohoma,
Marwa Abdel Maaboud Elnabawy,
The Utility of Continuous Subcutaneous Insulin Infusion for Management of Mild to Moderate Diabetic Ketoacidosis, American Journal of Internal Medicine.
Vol. 4, No. 3,
2016, pp. 43-48.
Umpierrez GE, Murphy MB, Kitabchi AE. Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome. Diabetes Spectrum 2002; 15: 128-36.
Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care 2003; 26: 109–17.
Lebovitz HE: Diabetic ketoacidosis. Lancet 2001; 345: 767–72.
Wallace TM, Matthews DR. Recent advances in the monitoring and management of diabetic ketoacidosis. QJM 2004; 97: 773-80.
Marshall RD, Rand JS, Gunew MN, Menrath VH. Intramuscular glargine with or without concurrent subcutaneous administration for treatment of feline diabetic ketoacidosis. Journal of Veterinary Emergency and Critical Care. 2013; 23 (3): 286-90.
Kitabchi AE. Low-dose insulin therapy in diabetic ketoacidosis. Fact or fiction? Diabetes Metab Rev1989; 5: 337–363.
Sacks HS, Shahshahani M, Kitabchi AE, et al. Similar responsiveness of diabetic ketoacidosis to low-dose insulin by intramuscular injection and albumin-free infusion. Ann Intern Med 1999; 90: 36–42.
Vincent M, Nobécourt E. Treatment of diabetic ketoacidosis with subcutaneous insulin lispro: A review of the current evidence from clinical studies. Diabetes & metabolism. 2013; 39 (4): 299-305.
Fisher JN, Shahshahani MN, Kitabchi AE. Diabetic ketoacidosis: low-dose insulin therapy by various routes. N Engl J Med 1977; 297: 238–241.
Menzel R, Jutzi E. Blood sugar behavior in recompensation of diabetic coma. Dtsch Gesundheitsw 1970; 25: 727–32.
Freire AX, Umpierrez GE, Afessa B, et al. Predictors of intensive care unit and hospital length of stay in diabetic ketoacidosis. J Crit Care 2002; 17: 207–211.
Latif K, Umpierrez GE, Stoever J, et al. Subcutaneous lispro insulin in the treatment of diabetic ketoacidosis. Diabetes 2003; 51 (Suppl. 2): 427.
Vasiliki Valla. Continuous Subcutaneous Insulin Infusion (CSII) Pumps. Advances in Experimental Medicine and Biology 2013; 414-419.
Bohan JS. Chemical measurements in ketoacidosis. Arch Intern Med 1999; 159-89.
Voulgari C, Tentolouris N. The performance of a glucose-ketone meter in the diagnosis of diabetic ketoacidosis in patients with type 2 diabetes in the emergency room. Diabetes Technol Ther 2010; 12 (7): 529-35.
Lassmann-Vague V, Clavel S, Guerci B, at al. When to treat a diabetic patient using an external insulin pump. Expert consensus. Diabetes Metab 2010; 36: 79-85.
Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001; 24: 131-153.
Abramson E, Arky R. Diabetic acidosis with initial hypokalemia. Therapeutic implications. JAMA 1996; 196:401.
Workgroup on Hypoglycemia, American Diabetes Association. Defining and reporting hypoglycemia in diabetes. Diabetes Care 2005; 28: 1245.
Joint British Diabetes Societies Inpatient Care Group. The management of diabetic ketoacidosis in adults, September 2013. http://www.diabetes.org.uk/Documents/About%20Us/What%20we%20say/Management-of-DKA-241013.pdf. Last accessed 17 May 2015.
Barski L, Kezerle L, Zeller L, et al. New approaches to the use of insulin in patients with diabetic ketoacidosis. Eur J Intern Med 2013; 24: 213-16.
Snežana, Bošnjak. "The declaration of Helsinki: The cornerstone of research ethics". Archive of Oncology 2001; 9: 179-84.
Kirkpatrick LA, Feeney BC. A simple guide to IBM SPSS statistics for version 20.0 Student ed. Belmont, Calif.: Wadsworth, Cengage Learning 2013; 115
Ellemann K, Soerensen JN, Pedersen L, et al. Epidemiology and treatment of diabetic ketoacidosis in a community population. Diabetes Care 1996; 7: 528–532
Genuth SM. Constant intravenous insulin infusion in diabetic ketoacidosis. JAMA 1973; 223: 1348-51.
26- Edwards GA, Kohaut EC, Wehring B, et al. Effectiveness of low-dose continuous intravenous insulin infusion in diabetic ketoacidosis: a prospective comparative study. J Pediatr 2000; 91: 701–5.
Ebenezer A, Kitabchi AE. Evidence-based management of hyperglycemic emergencies in diabetes mellitus. Diabetes Research And Clinical Practice 2011; 94: 340–51.
Jeannette G, Jeremy G. Hyperglycemic Emergencies in Adults. Canadian Journal of Diabetes 2012; 73: 72–6.
Karoli R, Fatima J, Salman T, et al. Managing diabetic ketoacidosis in non-intensive care unit setting: Role of insulin analogue 2011; 43: 398-401.
Cohen M, Leibovitz N, Shilo S, et al. Subcutaneous regular insulin for the treatment of diabetic ketoacidosis in children. Pediatric Diabetes. 2016 Mar 1. doi: 10.1111/pedi.12380.