Ann Emerg Med

DKA: Does insulin really need to be given intravenously?

February 27, 2025

Subcutaneous (SC) insulin may be safe and as efficacious as IV insulin for adults with mild to moderate diabetic ketoacidosis (DKA), according to this literature review and meta-analysis. However, SC insulin protocols varied in terms of dosage and dosage timing; most studies on SC insulin used hourly dosing.

Study details: Researchers reviewed 6 RCTs and 4 observational studies comparing IV vs. SC insulin for adults with mild to moderate DKA (arterial pH ≤7.3, anion gap >12 mmol/L, serum bicarbonate ≤18 mmol/L, + urine/serum ketones) that included outcomes such as hospital length of stay, DKA resolution time, need for ICU care, hypoglycemia, hypokalemia, and death. Participants totaled 8,689: 712 on SC rapid-acting insulin, 7,962 on IV insulin infusion, 15 on intramuscular (IM) insulin.

Results: Risk of bias was considered “overall low” in the RCTs and “low to moderate” in observational studies. Regarding time to DKA resolution, there wasn’t a statistical difference between IV or SC regimens. Significantly shorter hospital length of stay was seen with SC administration in 2 studies; however, in the pooled analysis, there was no statistical difference noted. No difference was seen in hypoglycemia. No deaths occurred in RCTs, and one death was seen in a retrospective study, attributed to sepsis after DKA resolution. There wasn’t a difference in hypoglycemia episodes. Insufficient evidence was available about hypokalemia.

Source:

Caldwell T, et al. (2025, March). Ann Emerg Med. Is Subcutaneous Insulin Administration Safe and Effective for the Treatment of Mild to Moderate Diabetic Ketoacidosis? https://pubmed.ncbi.nlm.nih.gov/39641681/