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Cited by 43Diabetes Management and ResearchDiabetes Treatment and ManagementDiabetes and associated disorders

Glargine co-administration with intravenous insulin in pediatric diabetic ketoacidosis is safe and facilitates transition to a subcutaneous regimen

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Harrison, V. Sanoe, Rustico, Stacy, Palladino, Andrew A., Ferrara, Christine, Hawkes, Colin Patrick·2017·Pediatric Diabetes
DOI 10.1111/pedi.12462PMC PMC5415439
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Abstract

BACKGROUND: Diabetes ketoacidosis (DKA) is a common presentation and complication of type 1 diabetes (T1D). While intravenous insulin is typically used to treat acute metabolic abnormalities, the transition from intravenous to subcutaneous treatment can present a challenge. We hypothesize that co-administration of glargine, a subcutaneous long-acting insulin analog, during insulin infusion may facilitate a flexible and safe transition from intravenous to subcutaneous therapy. OBJECTIVE: To determine if the practice of administering subcutaneous glargine during intravenous insulin is associated with an increased risk of hypoglycemia, hypokalemia, or other complications in children with DKA. METHODS: Retrospective chart review of patients aged 2 to 21 years, presenting to our center with DKA between April 2012 and June 2014. Patients were divided into two groups: those co-administered subcutaneous glargine with intravenous insulin for over 4 hours (G+); and patients with less than 2 hours of overlap (G-). RESULTS: We reviewed 149 DKA admissions (55 G+, 94 G-) from 129 unique patients. There was a similar incidence of hypoglycemia between groups (25% G+ vs 20% G-, P = 0.46). Hypokalemia (<3.5 mmol/L) occurred more frequently in the G+ group (OR = 3.4, 95% CI 1.7-7.0, P = 0.001). Cerebral edema occurred in 2/55 (3.6%) of the G- group and none of the G+ subjects. CONCLUSION: Co-administration of glargine early in the course of DKA treatment is well tolerated and convenient for discharge planning; however, this approach is associated with an increased risk of hypokalemia.

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  • Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia.

    “Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia while the subcutaneous insulin action rises (63,179).”

    From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [179]

    The Introduction says subcutaneous insulin should overlap with intravenous insulin to prevent rebound hyperglycemia and ketosis. It does not support the claimed requirement to give basal insulin 2–4 hours before stopping the infusion: it cites guidance of 15–120 minutes, depending on the insulin used. Its separate reference to 2–4 hours concerns shifting the daily basal dose after transition. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • Administration of a low dose of basal insulin analog in addition to intravenous insulin infusion early in treatment may prevent rebound hyperglycemia without increased risk of hypoglycemia.

    “Studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion early in the course of treatment may prevent rebound hyperglycemia without increased risk of hypoglycemia (64-66,179).”

    From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [179]

    The Introduction (page unavailable) describes early glargine co-administration and says overlapping subcutaneous insulin with an infusion is needed to prevent rebound hyperglycemia. The Results > Hypoglycemia and Discussion (pages unavailable) report no significant increase in hypoglycemia. However, the paper does not demonstrate that its early glargine regimen prevented rebound hyperglycemia: post-infusion glucose trends were similar between groups. The cited passages also do not establish that the basal dose was low. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

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Research works printed but not linked: 19

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  2. [2]Rewers A Klingensmith G Davis C Petitti DB Pihoker C Rodriguez B Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics 5 2008 121 5 e1258 66 18450868
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  4. [4]Wolfsdorf JI Allgrove J Craig ME Edge J Glaser N Jain V ISPAD Clinical Practice Consensus Guidelines Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes 2014 2014 15 Suppl 20 154 79 John Wiley & Sons A/S 25041509
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  6. [6]Mabrey ME Lien LF IV Insulin Infusions: How to Use an “Insulin Drip.” Glycemic Control in the Hospitalized Patient 2010 17 27 Springer New York New York, NY
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  8. [8]McKeage K Goa KL Spotlight on insulin glargine in type 1 and 2 diabetes mellitus. Treat Endocrinol 2002 1 1 55 8 15765621
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  11. [11]Becker RHA Dahmen R Bergmann K Lehmann A Jax T Heise T New insulin glargine 300 Units · mL-1 provides a more even activity profile and prolonged glycemic control at steady state compared with insulin glargine 100 Units · mL-1. Diabetes Care. American Diabetes Association 4 2015 38 4 637 43 25150159
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  14. [14]Doshi P Potter AJ De Los Santos D Banuelos R Darger BF Chathampally Y Prospective randomized trial of insulin glargine in acute management of diabetic ketoacidosis in the emergency department: a pilot study. Smith S, editor. Acad Emerg Med 6 2015 22 6 657 62 26013711
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Authors
Harrison, V. S., Rustico, S., Palladino, A. A., Ferrara, C., & Hawkes, C. P.
Affiliations
Children's Hospital of Philadelphia (US)
Corresponding author
Hawkes, Colin Patrick
ORCID
Venue
Pediatric Diabetes
Publisher
Wiley
Published
2016-11-03
Volume
18
Issue
8
Pages
742-748
ISSN
1399-543X (ISSN-L)
DOI
10.1111/pedi.12462
PMC
PMC5415439
OpenAlex
W2548584210
Cited by
43
References
0
Citations by year
2026: 1 · 2025: 7 · 2024: 10 · 2023: 3 · 2022: 4 · 2021: 6 · 2020: 3 · 2019: 4 · 2018: 4 · 2017: 1
FWCI
3.02
Type
journal article
Language
en
Open access
Licence
Locations
  • Pediatric Diabetes (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Cork Open Research Archive (University College Cork, Ireland) (submittedVersion)
Funders
  • National Children's Research Centre, Dublin, Ireland
  • NIH T32 (#DK063688)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
Keywords
diabetic ketoacidosis, glargine, intravenous insulin, type 1 diabetes, pediatric patients, hypoglycemia, hypokalemia, cerebral edema
MeSH terms
Insulin Glargine, Adolescent, Child, Child, Preschool, Female, Humans, Hypoglycemia, Hypoglycemic Agents, Hypokalemia, Male, Retrospective Studies, Diabetic Ketoacidosis, Young Adult

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