California: Study on Subcutaneous Insulin for Diabetic Ketoacidosis (DKA)

Treatment with subcutaneous insulin in patients hospitalized with diabetic ketoacidosis (DKA) led to lower rates of ICU admission and 30-day hospital readmission versus those who received continuous IV insulin, a recent study has stated. The findings of the study, published in the JAMA Network Open, were based on real-world data for 8,000 hospitalizations for DKA.

Standard DKA care in the US includes intravenous (IV) insulin treatment in the intensive care unit (ICU). Subcutaneous (SQ) insulin could reduce ICU needs, but data are limited. To fill this knowledge gap, Priya Rao, Kaiser Permanente San Jose Medical Center, San Jose, California, and her colleagues aimed to assess outcomes after the implementation of an SQ insulin protocol for the treatment of diabetic ketoacidosis in a cohort study.

For this purpose, they conducted a retrospective evaluation of a prospectively implemented SQ insulin protocol. The study was performed at an integrated health care system in Northern California. Hospitalized patients with diabetic ketoacidosis at 21 hospitals between January 1, 2010, and December 31, 2019, were included. The pre-implementation phase was from 2010 to 2015, and the post-implementation phase was from 2017 to 2019.

They were exposed to an SQ insulin treatment protocol for diabetic ketoacidosis. Difference-in-differences evaluation of the need for mortality, intensive care, length of stay, and readmission at a single intervention site using an SQ insulin protocol from 2017 onward compared to 20 control hospitals using standard care.

Study Findings

• A total of 7989 hospitalizations for diabetic ketoacidosis occurred, with 59.3% occurring before and 40.7% occurring after implementation.
• The overall mean age was 42.3 years, with 4137 hospitalizations (51.8%) occurring among female patients.
• Before implementation, SQ insulin was the first insulin used in 40 intervention (13.4%) and 651 control (14.7%) hospitalizations. After implementation, 98 hospitalizations (80.3%) received SQ insulin first at the intervention site compared with 402 hospitalizations (12.8%) at control sites.
• The adjusted rate ratio for intensive care unit admission was 0.43 at the intervention sites, a 57% reduction compared with control sites, and was 0.50 for 30-day hospital readmission, a 50% reduction. There were no significant changes in hospital length of stay and rates of death.

"These findings indicate that a subcutaneous insulin protocol for diabetic ketoacidosis treatment was associated with reduced hospital resource utilization but was not associated with increased hypoglycemia," the researchers concluded.

Reference

Rao P, Jiang S, Kipnis P, et al. Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis. JAMA Netw Open. 2022;5(4):e226417. doi:10.1001/jamanetworkopen.2022.6417

Keywords

JAMA, insulin, diabetic ketoacidosis, subcutaneous, intravenous, IV, Priya Rao, hospitalization, intensive care, readmission, Priya Rao