As we discussed yesterday, the treatment algorithm for DKA is fairly straightforward with a few subtleties we rarely appreciate, until now. Yesterday we focused on fluids, today we move on to the insulin. Can we offer the patient anything else beside an insulin drip? Obviously the answer is yes, or else this pearl wouldn’t exist.

In 2004, Umpierrez et al conducted an RCT of 20 patients comparing subcutaneous lispro (0.3U/kg bolus followed by 0.1U/kg/h) vs. an IV insulin (0.1 u/kg bolus followed by 0.1 U/kg/h drip). They found that there was no difference in time to correction of hyperglycemia, time to resolution of DKA, length of hospital stay, or rates of hypoglycemia.   Later that year, they conducted a second study of 45 patients comparing doses of 0.1U/kg/h subcutaneous insulin to 0.2U/kg/h subcutaneous insulin to standard therapy. Not surprisingly, they showed that no protocol was more efficacious than another, however they did show a 39% high hospitalization charges in the IV insulin group due to the ICU setting necessary to manage the insulin drip.

Since then the Cochrane collaborative has addressed the same question. They reviewed 5 trials including 201 total patients (some children). They found “low to very low-quality evidence that there are neither advantages nor disadvantages when comparing the effects of subcutaneous rapid-acting insulin analogues vs. IV regular insulin when treating mild to moderate DKA.”

As long as the nurses are comfortable with q1 fingersticks, its something to consider next time you treat DKA.


Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Gonzalez-Padilla DA. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD011281. DOI: 10.1002/14651858.CD011281.pub2.

Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, E Kitabchi A. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med. 2004 Sep 1;117(5):291-6.

Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care. 2004 Aug;27(8):1873-8