medwireNews: Implementing a subcutaneous insulin protocol for the treatment of diabetic ketoacidosis (DKA) significantly reduces intensive care admissions and readmission to hospital within 30 days of discharge without increasing hypoglycemia, research shows.
Typically, “diabetic ketoacidosis care in the US includes intravenous [iv] insulin treatment in the intensive care unit,” write Vincent Liu (Kaiser Permanente Division of Research, Oakland, California) and co-authors in JAMA Network Open.
However, this can be expensive, with an estimated annual cost of more than US$ 5 billion (€ 4.7 billion), and interest is therefore growing in options for treating DKA outside the intensive care unit, they say.
In the current study, Liu et al analyzed the outcomes of 7989 DKA hospitalizations that occurred among 5046 patients (mean age 42 years, 52% women) treated at 21 US hospitals, including one site that implemented a subcutaneous insulin protocol in 2016.
The protocol was applied to nonpregnant adults with a Glasgow Coma Scale score above 8 who did not exhibit non-DKA medical conditions requiring intensive care admission.
Upon presentation at the emergency department with DKA, patients were given weight-based subcutaneous insulin glargine and lispro simultaneously, along with iv lactated ringer fluid boluses, dextrose 5% with normal saline infusion, and potassium repletion.
They were then transferred to general medical wards where they continued weight-based lispro every 4 hours until blood glucose was at or below 250 mg/dL (13.9 mmol/L). Volume expansion was also continued as well as dextrose 5% and potassium chloride until patients initiated a sliding scale insulin protocol dependent on capillary blood glucose measurements.
The researchers report that during the pre-implementation period (2010–2015), subcutaneous insulin was the first insulin administered in 13.4% of DKA hospitalizations that occurred at the intervention site and in 14.7% of those that occurred at the 20 standard care sites.
During the postimplementation period (2017–2019) this proportion increased to 80.3% at the intervention site and decreased slightly, to 12.8%, at the standard care sites. The total number of insulin units administered did not differ between the pre- and postintervention periods at the intervention site (122.5 vs 126.2 units) but increased with time at the standard care sites (109.6 vs 121.9 units).
Direct intensive care unit admissions fell substantially at the intervention site, from 67.8% in the pre-implementation period to 27.9% in the postimplementation period, whereas they increased from 75.6% to 79.5% at the standard care sites.
In addition, the 30-day readmission rate at the intervention site fell from 21.1% in the period before the subcutaneous insulin protocol was implemented to 9.8% after implementation, whereas the rates were unchanged at the standard care sites (17.8 vs 17.5%). Of note, all participants at the intervention site were referred for post discharge follow-up with an endocrinologist as part of the subcutaneous protocol.
After adjustment for potential confounders, the investigators calculated that the intervention was associated with a significant 57% reduction in the rate of intensive care unit admissions and a significant 50% reduction in the rate of 30-day hospital readmission when compared with control sites.
There were no significant changes between the two periods in hospital length of stay and mortality rates at either the intervention site or the control sites, and the proportion of patients treated for hypoglycemia also remained stable.
Liu and team conclude: “Our results suggest that [a subcutaneous] insulin-driven protocol including the selection of optimal patients can be used effectively in treating DKA, although these results should be confirmed in future prospective studies.”
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