ENHANCING RECOVERY IN DIABETIC KETOACIDOSIS: THE ROLE OF BASAL INSULIN (GLARGINE) WITH INTRAVENOUS INSULIN INFUSION
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Keywords
Diabetic Ketoacidosis, Insulin Glargine, Metabolic acidosis, Regular Insulin
Abstract
Background: One of the most life threatening metabolic complication of diabetes mellitus (DM) and with a high mortality rate is diabetic ketoacidosis (DKA).
Objectives: To evaluate the use of insulin glargine in addition to intravenous insulin infusion in treatment of DKA.
Methods: This multi-centered prospective cross sectional analytical study was carried out at Department of Emergency of all three different campuses of Ziauddin University, Karachi for six months (January 2023 to June 2023) using non-probability consecutive sampling. The International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines 2018 were used for diagnosing DKA. Through simple random technique, patients were divided into group A (Insulin infusion only) and group B (Insulin + Insulin Glargine infusion). SPSS version 23.0 was used for analyzing data. Independent t-test was applied for the laboratory findings which were compared between group A and group B.
Results: A total of 139 DKA patients (mean age 54.6 years, 61.9% female) were studied. At baseline, they presented with severe hyperglycemia, acidosis, and elevated anion gap. After 6 hours, both groups showed significant glucose reduction, with no difference between insulin infusion alone and insulin plus glargine. However, patients receiving glargine demonstrated faster metabolic recovery, reflected by higher bicarbonate, improved arterial pH, and lower anion gap. Renal function and osmolality improved similarly in both groups.
Conclusion: Adding basal insulin (glargine) to standard intravenous insulin infusion accelerated the resolution of metabolic acidosis and improved biochemical recovery in DKA patients, without affecting glucose reduction or renal function.
References
2. Nasa P, Chaudhary S, Shrivastava PK, Singh A. Euglycemic diabetic ketoacidosis: a missed diagnosis. World journal of diabetes. 2021 May 15;12(5):514. https://doi.org/10.4239 /wjd.v12.i5.514
3. Zeugswetter FK, Luckschander‐Zeller N, Karlovits S, Rand JS. Glargine versus regular insulin protocol in feline diabetic ketoacidosis. Journal of Veterinary Emergency and Critical Care. 2021 Jul;31(4):459-68. https://doi.org/10.1111/vec.13062
4. Barski L, Golbets E, Jotkowitz A, Schwarzfuchs D. Management of diabetic ketoacidosis. European Journal of Internal Medicine. 2023 Nov 1;117:38-44. https://doi.org/10.1016/ j.ejim.2023.07.005
5. Haas NL, Whitmore SP, Cranford JA, Tsuchida RE, Nicholson A, Boyd C, et al. An emergency department–based intensive care unit is associated with decreased hospital and intensive care unit utilization for diabetic ketoacidosis. The Journal of emergency medicine. 2020 Apr 1;58(4):620-6. https://doi.org/10.1016/j.jemermed.2019.10.005
6. Rewers A, Kuppermann N, Stoner MJ, Garro A, Bennett JE, Quayle KS, et al. Effects of fluid rehydration strategy on correction of acidosis and electrolyte abnormalities in children with diabetic ketoacidosis. Diabetes care. 2021 Sep 1;44(9):2061-8. https://doi.org/10.2337/dc20-3113
7. Dhatariya KK, Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults—an updated guideline from the Joint British Diabetes Society for Inpatient Care. Diabetic Medicine. 2022 Jun;39(6):e14788. https://doi.org/10.1111/dme.14788
8. Stuhr KU, LeeMaster R, Hickman AW, Reachi B, Pace W, Meek C. Subcutaneous insulin versus traditional intravenous insulin infusion in treatment of mild to moderate diabetic ketoacidosis. The Journal of Emergency Medicine. 2023 Sep 1;65(3):e221-8. https://doi.org/10.1016/j.jemermed.2023.06.004
9. Thibault E, Loppinet T, Portefaix A, Launay V, Perge K. Impact of early administration of long-acting insulin on ketosis rebound in diabetic ketoacidosis. Archives de Pédiatrie. 2025 Jan 1;32(1):30-5. https://doi.org/10.1016/j.arcped.2024.09.008
10. Thammakosol K, Sriphrapradang C. Effectiveness and safety of early insulin glargine administration in combination with continuous intravenous insulin infusion in the management of diabetic ketoacidosis: a randomized controlled trial. Diabetes, Obesity and Metabolism. 2023 Mar;25(3):815-22. https://doi.org/10.1111/dom.14929
11. Vidyasagar K, Chandrasekar B, Chhabra M, Bhansali A, Bansal D. Efficacy and safety of commonly used insulin analogues in the treatment of diabetic ketoacidosis: a bayesian indirect treatment comparison. Clinical therapeutics. 2020 Aug 1;42(8):e115-39. https://doi.org/10.10 16/j.clinthera.2020.06.017
12. Eledrisi MS, Elzouki AN. Management of diabetic ketoacidosis in adults: a narrative review. Saudi journal of medicine & medical sciences. 2020 Sep 1;8(3):165-73. DOI: 10.4103/ sjmms.sjmms_478_19
13. Mohamed A, Ploetz J, Hamarshi MS. Evaluation of early administration of insulin glargine in the acute management of diabetic ketoacidosis. Current Diabetes Reviews. 2021 Oct 1;17(8):61-8. https://doi.org/10.2174/1573399817666210303095633
14. Welter KJ, Marquez JL, Marshik PL, Yao MV, Bickel ES. Evaluation of early insulin glargine administration in the treatment of pediatric diabetic ketoacidosis. The Journal of Pediatric Pharmacology and Therapeutics. 2023 Apr 1;28(2):149-55. https://doi.org/10.5863/1551-6776-28.2.149
15. Caldwell T, Walton S, Long B. Is Subcutaneous Insulin Administration Safe and Effective for the Treatment of Mild to Moderate Diabetic Ketoacidosis?. Annals of Emergency Medicine. 2025 Mar 1;85(3):273-5. https://doi.org/10.1016/j.annemergmed.2024.10.020
16. Jabbar A, Farooqui K, Habib A, Islam N, Haque N, Akhter J. Clinical characteristics and outcomes of diabetic ketoacidosis in Pakistani adults with Type 2 diabetes mellitus. Diabetic medicine. 2004 Aug;21(8):920-3. https://doi.org/10.1111/j.1464-5491.2004.01249.x
17. Benoit SR, Hora I, Pasquel FJ, Gregg EW, Albright AL, Imperatore G. Trends in emergency department visits and inpatient admissions for hyperglycemic crises in adults with diabetes in the US, 2006–2015. Diabetes Care. 2020 May 1;43(5):1057-64. https://doi.org/10.2337/dc19-2449
18. Stratigou T, Vallianou N, Vlassopoulou B, Tzanela M, Vassiliadi D, Ioannidis G, et al. DKA cases over the last three years: has anything changed?. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019 Mar 1;13(2):1639-41. https://doi.org/10.1016/ j.dsx.2019.03.022
19. Badran A, Thakkar A, Galetaki D, Miller A, Umpaichitra V, Bargman R, et al. Hyperglycemic Emergencies in Minority Children and Adolescents With Diabetes. Clinical Pediatrics. 2025 Mar 12:00099228251321899. https://doi.org/10.1177/00099228251321899
20. Nishikawa T, Kinoshita H, Ono K, Kodama‐Hashimoto S, Kobayashi Y, Nakamura T, et al. Clinical profiles of hyperglycemic crises: A single‐center retrospective study from Japan. Journal of Diabetes Investigation. 2021 Aug;12(8):1359-66. https://doi.org/10.1111/jdi.13475
21. Rittiphairoj T, Owais M, Ward ZJ, Reddy CL, Yeh JM, Atun R. Incidence and prevalence of type 1 diabetes and diabetic ketoacidosis in children and adolescents (0–19 years) in Thailand (2015–2020): a nationwide population-based study. The Lancet Regional Health–Western Pacific. 2022 Apr 1;21. https://doi.org/10.1016/j.lanwpc.2022.100392
22. Ammar M, Aboubakr E, Abdelmoneim W. The Outcome of Using Long-Acting Insulin Glargine with Regular Insulin Infusion in Diabetic Ketoacidosis Patients with Renal Impairment: A Randomized Clinical Trial. Journal of Cellular & Molecular Anesthesia. 2023 Jan 1;8(3). https://doi.org/10.22037/jcma.v8i2.39294
23. Majumder A, RoyChaudhuri S, Sanyal D. A retrospective observational study of insulin glargine in type 2 diabetic patients with advanced chronic kidney disease. Cureus. 2019 Nov 18;11(11). DOI: 10.7759/cureus.6191
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Muhammad Wajahatullah
Al-Tibri Medical College & Hospital Isra University Karachi Campus
Inayat Ali Khan
Ziauddin University & Hospital Karachi
Zeeshan Ali
Ziauddin University & Hospital Karachi
Atiqa Alvi
Dr Ziauddin University Hospital Clifton Campus
Saiyida Kaunain Fatima
Fatimiyah Hospital Karachi
Mariyam Sikander
Dow International Medical College Karachi