Subcutaneous Lispro Cost-Effective for Diabetic Ketoacidosis

DKA treatment with a subcutaneous fast-acting insulin analog represents a cost-effective and technically simplified procedure that precludes intensive care unit admission.

"Continuous low-dosage intravenous infusion of soluble insulin has been the procedure of choice outlined in pediatric management guidelines because it provides direct control and results in a predictable rate of fall in serum glucose levels," write Thais Della Manna, MD, from São Paulo University Medical School in Brazil, and colleagues. "However, admission to an intensive care unit to receive intravenous insulin infusion increases health care costs. To avoid the need for a second intravenous line, simplify treatment of DKA, and provide a more economical solution, we proposed using a subcutaneous fast-acting analog of human insulin instead of intravenous continuous regular insulin."

From June 2001 to June 2003, patients representing 60 episodes of DKA were randomized to treatment either with subcutaneous lispro (0.15 units/kg) given every two hours or with continuous intravenous regular insulin ([CIRI] 0.1 unit/kg per hour). DKA was defined as a blood glucose level greater than or equal to 16.6 mmol/L (300 mg/dL), venous pH less than 7.3 and/or bicarbonate less than 15 mmol/L, or ketonuria greater than ++. Volume deficit was restored with 10-mL/kg aliquots of 0.9% sodium chloride. Bedside capillary glucose, venous blood gas, β-hydroxybutyrate, and electrolytes were measured hourly. Plasma blood glucose levels were measured on admission, two hours after admission, when capillary blood glucose was less than or equal to 13.8 mmol/L (250 mg/dL), and six, 12, and 24 hours later.

Capillary glucose levels decreased by 2.9 mmol/L per hour in the lispro group and by 2.6 mmol/L per hour in the CIRI groups. However, blood glucose fluctuated at different time intervals. Metabolic acidosis and ketosis resolved in the CIRI group during the first six hours after capillary glucose reached 13.8 mmol/L, but in the lispro group, these normalized during the next six-hour period. Both groups met criteria for recovery from DKA without complications.

"DKA treatment with a subcutaneous fast-acting insulin analog represents a cost-effective and technically simplified procedure that precludes intensive care unit admission," the authors write. "We believe that the most important tenets of DKA treatment are frequent monitoring of the patient and a skillful fluid replacement, regardless of the setting in which the patient is treated. The international consensus statement on DKA in children and adolescents indicates that low-dose intravenous insulin administration should be the standard of care."
Diabetes Care. 2005;28:1856-1861

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