Glargine versus regular insulin protocol in feline diabetic ketoacidosis

Abstract Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children’s hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.

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Subcutaneous regular insulin for the treatment of diabetic ketoacidosis in children

Pediatric Diabetes ◽

10.1111/pedi.12380 ◽

2016 ◽

Vol 18 (4) ◽

pp. 290-296 ◽

Cited By ~ 8

Author(s):

Michal Cohen ◽

Noa Leibovitz ◽

Smadar Shilo ◽

Nehama Zuckerman-Levin ◽

Itai Shavit ◽

...

Keyword(s):

Diabetic Ketoacidosis ◽

Regular Insulin

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Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis

The American Journal of Medicine ◽

10.1016/j.amjmed.2004.05.010 ◽

2004 ◽

Vol 117 (5) ◽

pp. 291-296 ◽

Cited By ~ 128

Author(s):

Guillermo E. Umpierrez ◽

Kashif Latif ◽

James Stoever ◽

Ruben Cuervo ◽

Linda Park ◽

...

Keyword(s):

Diabetic Ketoacidosis ◽

Insulin Lispro ◽

Regular Insulin ◽

Subcutaneous Insulin

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Effect of Bolus Insulin Administration Followed by a Continuous Insulin Infusion on Diabetic Ketoacidosis Management

Pharmacy ◽

10.3390/pharmacy6040129 ◽

2018 ◽

Vol 6 (4) ◽

pp. 129

Author(s):

Hannah Brown ◽

Richard Tran ◽

John Patka

Keyword(s):

Diabetic Ketoacidosis ◽

Insulin Infusion ◽

Length Of Hospital Stay ◽

Retrospective Chart Review ◽

Regular Insulin ◽

Bolus Administration ◽

Emergency Department Admission ◽

High Incidence ◽

Bolus Insulin ◽

Continuous Insulin Infusion

Despite the high incidence of diabetic ketoacidosis (DKA) there is no consensus on the most appropriate way to manage insulin therapy. This study was conducted to evaluate the effect of an insulin bolus on the resolution of DKA. A retrospective chart review of patients admitted between 1 September 2014 and 30 June 2016 with a diagnosis of DKA was conducted. Patients were assigned to the bolus or no bolus group based on provider preference. All patients were initiated on a 0.1 unit/kilogram (kg)/hour (h) intravenous (IV) regular insulin infusion, and patients in the bolus group were treated with a 0.1 unit/kg IV regular insulin bolus. Of the 145 admissions evaluated, 58 received a bolus and 87 did not. There was no difference in baseline demographics, except baseline blood glucose was higher in the bolus group (653 vs. 591 milligrams (mg)/deciliter (dL), p = 0.04). The time to resolution of DKA from emergency department admission did not differ between the bolus and no bolus group (15 vs. 15.9 h; p = 0.24). There was no difference in total insulin received (1.3 vs. 1.1 units/kg, p = 0.18), incidence of hypoglycemia (2 vs. 7%, p = 0.64), hypokalemia (16 vs. 29%, p = 0.65), or length of hospital stay (3.2 vs. 2.7 days, p = 0.27). The insulin bolus administration was not associated with reduced time to resolution of DKA.

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Role of Insulin Glargine in Early Phase of Treatment of Diabetic Ketoacidosis

QJM ◽

10.1093/qjmed/hcaa039.022 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

S S Wahba ◽

M Elsersi ◽

A M Alansary ◽

M H Elzahaby

Keyword(s):

Insulin Glargine ◽

Hospital Stay ◽

Diabetic Ketoacidosis ◽

Insulin Infusion ◽

Length Of Hospital Stay ◽

Regular Insulin ◽

Controlled Study ◽

High Morbidity ◽

University Hospitals ◽

Standard Regimen

Abstract Background Diabetic ketoacidosis (DKA) is a common cause of intensive care unit (ICU) admission, with high morbidity and mortality rates. A growing body of evidence has suggested that adding insulin Glargine to the standard regimen may facilitate the transition from an intravenous infusion of insulin to subcutaneous injection in the recovery of patients with DKA. Aim of the Work to investigate the effect of adding Insulin Glargine to the standard regimen of treatment of DKA on the recovery process of patients regarding the amount of intravenous insulin infusion and the duration of the patients’ stay in the ICU. Patient and Methods This randomized controlled study was conducted on 50 Egyptian individuals, in National Institute of Diabetes and Endocrinology & Ain Shams University Hospitals. 50 Patients with Diabetic Ketoacidosis diagnosed according to The American Diabetes Association criteria. All patients were divided into 2 groups according the protocol used for treatment: The first group including 25 patients treated only with the standard regimen of intravenous regular insulin infusion (0.1 unit/kg/hour). The second group including 25 patients treated with intravenous regular insulin (0.1 unit/kg/hour) + Iv infusion of normal saline. Results Added insulin Glargine resulted in a significantly shorter length of hospital stay, compared to SOC alone. The present study showed that insulin Glargine led to statistically significant less amount of insulin infused until resolution of DKA than the SOC alone. Conclusion subcutaneous insulin Glargine coadministration with regular insulin results in a shorter length of hospital stay and less amount of infused insulin in DKA patients admitted to ICU. Larger multi-centric trials are still needed to confirm our findings.

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Efficacy and Safety of Intramuscular Insulin Lispro vs. Continuous Intravenous Regular Insulin for the Treatment of Dogs With Diabetic Ketoacidosis

Frontiers in Veterinary Science ◽

10.3389/fvets.2020.559008 ◽

2020 ◽

Vol 7 ◽

Author(s):

Eleonora Malerba ◽

Federica Alessandrini ◽

Giorgio Grossi ◽

Massimo Giunti ◽

Federico Fracassi

Keyword(s):

Diabetic Ketoacidosis ◽

Insulin Lispro ◽

Regular Insulin ◽

Efficacy And Safety

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Treatment of Diabetic Ketoacidosis With Intravenous U-500 Insulin in a Patient With Rabson-Mendenhall Syndrome: A Case Report

Journal of Pharmacy Practice ◽

10.1177/0897190016645036 ◽

2016 ◽

Vol 30 (4) ◽

pp. 468-475 ◽

Cited By ~ 2

Author(s):

Megan M. Moore ◽

Abby M. Bailey ◽

Alexander H. Flannery ◽

Regan A. Baum

Keyword(s):

Insulin Resistance ◽

Case Report ◽

Blood Glucose ◽

Diabetic Ketoacidosis ◽

Insulin Infusion ◽

Genetic Disorder ◽

Regular Insulin ◽

Control Blood Glucose ◽

Intravenous Insulin ◽

High Doses

Rabson-Mendenhall syndrome is a rare genetic disorder resulting from mutations in the insulin receptor and is associated with high degrees of insulin resistance. These patients are prone to complications secondary to their hyperglycemia including diabetic ketoacidosis (DKA). We report the case of a 19-year-old male with Rabson-Mendenhall syndrome presenting with DKA who required doses of up to 500 U/h (10.6 U/kg/h) of insulin. The patient’s insulin infusion was originally compounded with U-100 regular insulin, although to minimize volume, the product was compounded with U-500 insulin. The DKA eventually resolved requiring infusion rates ranging from 400 to 500 U/h. Although numerous opportunities for medication errors exist with the use of U-500 insulin, this case outlines the safe use of concentrated intravenous insulin when clinically indicated for patients requiring extremely high doses of insulin to control blood glucose.

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RAPID DESENSITIZATION WITH INTRAVENOUS INSULIN IN A PATIENT WITH DIABETIC KETOACIDOSIS AND INSULIN ALLERGY

AACE Clinical Case Reports ◽

10.4158/accr-2019-0562 ◽

2020 ◽

Vol 6 (4) ◽

pp. e147-e150

Author(s):

Shirley Shuster ◽

Rozita Borici-Mazi ◽

Sara Awad ◽

Robyn L. Houlden

Keyword(s):

Diabetic Ketoacidosis ◽

Gradual Increase ◽

Laboratory Data ◽

Regular Insulin ◽

Initial Dilution ◽

Insulin Allergy ◽

Intravenous Insulin ◽

Desensitization Protocol

Objective: We report a case of insulin desensitization in a patient with known allergy to multiple insulin preparations who presented with diabetic ketoacidosis (DKA). Methods: Clinical and laboratory data, and desensitization protocols are presented. Results: A 65-year-old woman with type 2 diabetes and a documented insulin allergy presented with severe DKA. She was managed initially with intravenous (IV) fluids, sodium bicarbonate, and hemodialysis. An intradermal skin test was positive for 0.01 units/mL of human regular insulin. A rapid desensitization protocol for IV human regular insulin was initiated after pretreatment with methylprednisolone, ranitidine, montelukast, and cetirizine. An initial dilution of 1 unit of insulin in 100,000 mL of 0.9% sodium chloride was started at 5 mL/hour IV. The dilution was increased at 60-minute intervals to 1 unit/10,000 mL, 1 unit/1,000 mL, 1 unit/100 mL, 1 unit/10 mL, then 1 unit/1 mL. The dose was then increased from 1 to 7 units/hour (0.1 units/kg body weight/hour). The anion gap closed after 24 hours, and overlapping desensitization was started for subcutaneous (SC) human regular insulin starting with 0.00001 units with a gradual increase to 7 units before meals and 6 units at bedtime over 5 days. There were no anaphylactic reactions to IV or SC insulin. She was discharged with human regular insulin SC 4 times daily, oral montelukast, cetirizine, diphenhydramine as needed, and an epinephrine pen. No allergic reactions were reported at follow-up visits. Conclusion: Rapid insulin desensitization is possible to allow treatment of DKA with human regular insulin IV in patients with known insulin allergy.

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Use of lispro insulin for treatment of diabetic ketoacidosis in cats

Journal of Feline Medicine and Surgery ◽

10.1177/1098612x18761696 ◽

2018 ◽

Vol 21 (2) ◽

pp. 115-123 ◽

Cited By ~ 3

Author(s):

Eleonora Malerba ◽

Michela Mazzarino ◽

Francesca Del Baldo ◽

Sara Corradini ◽

Gaia Carotenuto ◽

...

Keyword(s):

Diabetic Ketoacidosis ◽

Clinical Signs ◽

Regular Insulin ◽

Time Interval ◽

Newly Diagnosed ◽

Insulin Group ◽

Lispro Insulin ◽

Naturally Occurring ◽

Beta Hydroxybutyrate ◽

Rate Infusion

Objectives The aim of this study was to evaluate the efficacy and safety of lispro insulin for the treatment of feline diabetic ketoacidosis (DKA). Times to resolution of hyperglycaemia, ketosis and acidosis were compared between cats treated with continuous rate infusion (CRI) of lispro insulin and cats treated with CRI of regular insulin. Methods Client-owned cats with naturally occurring DKA, newly diagnosed with diabetes mellitus (DM) or already receiving treatment for DM, were included. Diagnosis of DKA involved the presence of at least two clinical signs consistent with DKA (eg, polyuria/polydipsia, anorexia, severe lethargy, vomiting and dehydration), blood glucose (BG) concentration >13.9 mmol/l (>250 mg/dl), blood beta hydroxybutyrate (BHB) concentration >2.5 mmol/l and venous pH <7.3 or bicarbonate <15 mEq/l. Cats were treated with a standard protocol of an intravenous (IV) CRI of regular insulin (group R) or lispro insulin (group L). The time to resolution of DKA was defined as the time interval from when the IV CRI of insulin began until marked hyperglycaemia (BG >13.9 mmol/l [>250 mg/dl]), ketosis (BHB concentration >1 mmol/l) and acidosis (venous pH <7.3 and/or bicarbonate <15 mEq/l) resolved. Results Eighteen DKA cases (nine per group) were enrolled into the study. There were no significant differences in the median time to resolution of three variables (hyperglycaemia, ketosis and acidosis) between the two groups. Two cats in group R developed hypoglycaemia during the CRI of insulin. One cat in group L and three cats in group R developed hypophosphataemia, which required phosphate supplementation. Conclusions and relevance IV CRI of lispro insulin has few side effects and appears to be as effective as IV CRI of regular insulin in the treatment of cats with DKA.

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