Subcutaneous regular insulin for the treatment of diabetic ketoacidosis in children

Cohen M, Leibovitz N, Shilo S, Zuckerman-Levin N, Shavit I, Shehadeh N. Subcutaneous regular insulin for the treatment of diabetic ketoacidosis in children. Pediatric Diabetes 2017: 18: 290-296. Background: Diabetic ketoacidosis (DKA) treatment protocols vary, however low-dose intravenous administration of regular insulin is the standard care for replacing insulin in most centers. Few studies, the majority in adults, demonstrated subcutaneous injection of rapid-acting insulin every 1-2 hours to be a valid alternative. Objective: To evaluate the efficacy and safety of subcutaneous regular insulin administered every 4 hours in pediatric DKA in a clinical setting. Methods: A retrospective chart review was conducted. Charts of all children treated with subcutaneous regular insulin for DKA and pH >= 7.0, between 2007 and 2010, were reviewed. Seventy-six DKA episodes in 52 patients were included. Data regarding clinical characteristics, response to treatment, and the occurrence of complications were analyzed. DKA episodes in patients with new-onset diabetes and in those with established diabetes were compared. Results: Mean age was 11.6 +/- 4.0 yr. Eighteen episodes occurred in children with new-onset diabetes. In all episodes, our protocol resulted in recovery from DKA. Median time to DKA resolution (pH > 7.30, HCO3 > 15) was 10.3 (5.5, 14.2) h. The median total insulin dose was 0.05 (0.04, 0.06) (unit/kg/h). During DKA treatment, hypoglycemia occurred in one episode and hypokalemia, mostly mild, was documented in 14. No cardiac arrhythmias, incidents of cerebral edema, or mortality occurred. Conclusion: Subcutaneous regular insulin administered every 4 hours is an effective and safe alternative for the insulin treatment of DKA with pH > 7.0 in children. Such treatment has the potential to simplify insulin administration when compared to either intravenous regular insulin or q1-2 hour subcutaneous rapid insulin and reduce both patient inconvenience and admission costs.