2025 Southeastern Residency Conference

Title: Evaluation of the Safety and Efficacy of Early Long-Acting Insulin in Diabetic Ketoacidosis

Authors: Emily Davis, McKenzie Hodges, Lauren Duty, Aayush Patel

Background: Diabetic ketoacidosis (DKA) is a life-threatening complication of uncontrolled diabetes mellitus. Hospital admissions for DKA have increased significantly, rising by 55% over the past decade. Treatment for lowering blood glucose and resolving acidosis in DKA is to administer short-acting insulin via continuous infusion. Once resolved, subcutaneous long-acting insulin is administered one to two hours prior to discontinuing the continuous infusion. This current standard of care is time-intensive, requires heightened monitoring, and is associated with rebound hyperglycemia as well as transition failure. Insulin glargine, a long-acting subcutaneous insulin, is conditionally recommended by the American Diabetes Association 2024 Consensus Report as an adjunct therapy to continuous IV insulin to reduce the duration of treatment and improve outcomes. Preliminary literature supports earlier administration of insulin glargine with continuous IV insulin for reducing time to DKA resolution and hospital length of stay without increasing hypoglycemia risk. However, there are uncertainties as to which patient population would benefit best from earlier long-acting insulin administration and what dose of insulin glargine to utilize. The purpose of this study was to determine the impact of administering insulin glargine within three hours of initiating continuous IV insulin in moderate to severe DKA patients.

Methods: This was a retrospective chart review conducted at Piedmont Columbus Regional Midtown of adult patients diagnosed with moderate or severe DKA who received continuous IV insulin and early insulin glargine. Early administration was defined as insulin glargine given within three hours of IV insulin initiation, whereas late administration was insulin glargine given at transition. The primary objective of this study was to compare the time to DKA resolution between patients who received early insulin glargine versus those who received late. The secondary objectives were to compare hospital length of stay, the rate of blood glucose decline, incidence of DKA reoccurrence, incidence of hypoglycemia, and incidence of hypokalemia in patients who received early insulin glargine versus those who received late. All outcomes were analyzed using student t-test or descriptive statistics. Patients were excluded if they presented with euglycemic DKA, were diagnosed with septic shock, required surgery within 48 hours of continuous IV insulin discontinuation, received continuous IV insulin for less than six hours, and/or received systemic steroids during admission.

Results: There was a total of 100 patients included in the study, 22 patients that received early insulin glargine and 78 that received late. Baseline characteristics were not significantly different between groups, with most patients having severe DKA and a history of type one diabetes. For the primary outcome of time to DKA resolution, the average time for late administration was 14.77 hours and 13.18 hours for early. The average time to DKA resolution was not significantly different between groups. For the secondary outcomes, average hospital length of stay was 2.99 days for late administration and 3.86 days for early. Average decrease in blood glucose per hour was significantly different with 35.94 for late administration and 53.42 for early. Incidence of DKA reoccurrence was significantly different with 26% of patients who received late administration and 4.5% of patients who received early. Incidence of rebound hyperglycemia was significantly different with 71% of patients who received late administration and 23% of patients who received early. Incidence of hypoglycemia was 13% of patients who received late administration and 14% of patients who received early. Incidence of hypokalemia was 56% of patients who received late administration and 50% of patients who received early.  

Conclusion: Early administration of long-acting insulin has the potential to mitigate DKA reoccurrence. Administering insulin glargine earlier in the treatment course had a similar safety profile to the current standard of care with no significant differences in hypoglycemia or hypokalemia. Further research is needed to fully determine the optimal timing of administration and dose of insulin glargine. 

Contact: Emily.Davis2@piedmont.org