Timing of Basal Insulin Administration in Patients with DKA

Today’s pearl is about the potential benefits of administering basal subcutaneous insulin early for patients with diabetic ketoacidosis (DKA) requiring an insulin infusion

Is earlier better? 

We know that giving basal, long-acting insulin prevents rebound DKA once the drip is shut off. Traditionally, we wait until the anion gap closes, administer the long-acting insulin (glargine, detemir, etc), and then turn the insulin infusion off 1-2 hours later. Timing each of these steps correctly in a busy ED is challenging, and the long-acting insulin sometimes gets missed (or delayed). What if we gave the long-acting insulin much earlier in the DKA course? Dr. Josh Farkas at the University of Vermont recently published an in-depth discussion of the literature on this topic. If you’d like to delve into the weeds, here is the link to the EMCrit post.

Benefits of earlier basal insulin include taking better advantage of the long-acting insulin kinetics and minimizing the risk of rebound DKA when the insulin infusion is discontinued.

Three studies to date investigated this approach (Doshi 2015, Houshyar 2015, Rappaport 2019). It’s also recommended by the British DKA guidelines. The studies suggest this approach is safe, effective, and may facilitate a faster (~3 hours) and smoother discontinuation of the insulin infusion.From Dr. Farkas’  post:“Prompt home-dose basal insulin may be of greatest value in a subset of patients with mild DKA, who could potentially receive an insulin infusion for <12 hours and thereby avoid ICU admission.  This would be most relevant to healthcare systems wherein mild DKA is resolved within an emergency department or ED-ICU context.”

When to consider administering basal insulin: Before the gap closes and as early as when the insulin infusion is starting

What dose of basal insulin to administer: The patient’s full home dose if a known diabetic or the typical starting dose for a newly diagnosed patient

When to turn off the insulin infusion: When the patient meets the traditional criteria (typically resolution of the anion gap and hyperglycemia)


Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

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