title: Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis.
abstract: OBJECTIVE
  To compare the efficacy and safety of subcutaneous insulin lispro with that of a standard low-dose intravenous infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis.
  
  
  METHODS
  In this prospective, randomized open trial, 20 patients treated with subcutaneous insulin lispro were managed in regular medicine wards (n=10) or an intermediate care unit (n=10), while 20 patients treated with the intravenous protocol were managed in the intensive care unit. Patients treated with subcutaneous lispro received an initial injection of 0.3 unit/kg followed by 0.1 unit/kg/h until correction of hyperglycemia (blood glucose levels <250 mg/dL), followed by 0.05 to 0.1 unit/kg/h until resolution of diabetic ketoacidosis (pH > or =7.3, bicarbonate > or =18 mEq/L). Patients treated with intravenous regular insulin received an initial bolus of 0.1 unit/kg, followed by an infusion of 0.1 unit/kg/h until correction of hyperglycemia, then 0.05 to 0.1 unit/kg/h until resolution of diabetic ketoacidosis.
  
  
  RESULTS
  Mean (+/- SD) admission biochemical parameters in patients treated with subcutaneous lispro (glucose: 674 +/- 154 mg/dL; bicarbonate: 9.2 +/- 4 mEq/L; pH: 7.17 +/- 0.10) were similar to values in patients treated with intravenous insulin (glucose: 611 +/- 264 mg/dL; bicarbonate: 10.6 +/- 4 mEq/L; pH: 7.19 +/- 0.08). The duration of treatment until correction of hyperglycemia (7 +/- 3 hours vs. 7 +/- 2 hours) and resolution of ketoacidosis (10 +/- 3 hours vs. 11 +/- 4 hours) in patients treated with subcutaneous lispro was not different than in patients treated with intravenous regular insulin. There were no deaths in either group, and there were no differences in the length of hospital stay, amount of insulin until resolution of diabetic ketoacidosis, or in the rate of hypoglycemia between treatment groups. Treatment of diabetic ketoacidosis in the intensive care unit was associated with 39% higher hospitalization charges than was treatment with subcutaneous lispro in a non-intensive care setting ($14,429 +/- $5243 vs. $8801 +/- $5549, P <0.01).
  
  
  CONCLUSIONS
  Treatment of adult patients who have uncomplicated diabetic ketoacidosis with subcutaneous lispro every hour in a non-intensive care setting may be safe and more cost-effective than treatment with intravenous regular insulin in the intensive care unit.
authors.affiliation: Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA. geumpie@emory.edu
authors.forename: Guillermo E
authors.initials: GE
authors.lastname: Umpierrez
authors.forename: Kashif
authors.initials: K
authors.lastname: Latif
authors.forename: James
authors.initials: J
authors.lastname: Stoever
authors.forename: Ruben
authors.initials: R
authors.lastname: Cuervo
authors.forename: Linda
authors.initials: L
authors.lastname: Park
authors.forename: Amado X
authors.initials: AX
authors.lastname: Freire
authors.forename: Abbas
authors.initials: A
authors.lastname: E  Kitabchi
mesh_terms: D020155:3-Hydroxybutyric Acid / Q000097:blood; D000328:Adult; D001639:Bicarbonates / Q000097:blood; D001786:Blood Glucose / Q000187:drug effects / Q000378:metabolism; D003422:Critical Care / Q000191:economics / Q000379:methods; D016883:Diabetic Ketoacidosis / Q000188:drug therapy* / Q000191:economics / Q000378:metabolism; D004334:Drug Administration Schedule; D005260:Female; D017722:Hospital Charges / Q000706:statistics & numerical data; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000191:economics / Q000494:pharmacology; D007262:Infusions, Intravenous; D007279:Injections, Subcutaneous; D007328:Insulin / Q000008:administration & dosage* / Q000031:analogs & derivatives* / Q000191:economics / Q000494:pharmacology; D061268:Insulin Lispro; D007659:Ketones / Q000097:blood; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D001639:Bicarbonates; D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin; D061268:Insulin Lispro; D007659:Ketones; D020155:3-Hydroxybutyric Acid