A systematic review and meta-analysis comparing outcomes between using subcutaneous insulin and continuous insulin infusion in managing adult patients with diabetic ketoacidosis
Open accessAbstract
The purpose of this systematic review and meta-analysis was to synthesize the current literature to determine the safety and efficacy of using subcutaneous insulin compared to an intravenous (IV) insulin infusion in managing diabetic ketoacidosis (DKA). We searched Ovid-Medline, EMBASE, SCOPUS, BIOSIS and CENTRAL from inception to April 26, 2024. Randomized controlled trials (RCTs) and observational studies that assessed the use of subcutaneous compared to intravenous insulin for the treatment of mild to moderate DKA were included. Data extraction and quality assessment were performed by two independent reviewers and disagreements were resolved through further discussion or by a third reviewer. The Cochrane Risk of Bias tool version 2.0 was used to evaluate the RCTs and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS)-I tool was used to evaluate the observational studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Meta-analyses were conducted using random-effects models. We followed the PRISMA guidelines for reporting our findings. Six RCTs (245 participants) and four observational studies (8444 patients) met our inclusion criteria. Some studies showed a decreased length of stay (Mean Difference [MD] in days: -0.39; 95% CI: -2.83 to 2.08; I 2 : 0%) among individuals treated with subcutaneous insulin compared to intravenous insulin. There was no difference in the risk of all-cause mortality, time to resolution of DKA (MD in hours: 0.17; 95% confidence interval [CI]: -3.45 to 3.79; I 2 : 0%) and hypoglycemia (Risk Ratio [RR]: 1.02; 95% CI: 0.88 to 1.19; I 2 : 0%) between the two groups. Treatment of DKA with subcutaneous insulin may be a safe and effective alternative to IV insulin in selected patients. The limited available evidence underscores the need for further studies to explore optimal dosing, patient selection criteria and long-term outcomes.
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There is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA.
“There is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA (182).”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [182]
The Results report that 712 participants received subcutaneous rapid-acting insulin analogues and 7,962 received intravenous regular insulin; the Conclusion finds no important difference in overall mortality or adverse outcomes for mild-to-moderate DKA. The paper does not establish that this finding depends on aggressive fluid management, and it reports shorter hospital stays in some subcutaneous-insulin studies. Sections cited have no page numbers in our copy. (LLM, conf=0.85)
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- Authors
- Alnuaimi, A., Mach, T., Reynier, P., Filion, K. B., Lipes, J., & Yu, O. H. Y.
- Affiliations
- McGill University (CA)
- Jewish General Hospital (CA)
- Corresponding author
- Yu, Oriana Hoi Yun
- Venue
- BMC Endocrine Disorders
- Published
- 2024-08-01
- Volume
- 24
- Issue
- 1
- Pages
- 133-133
- ISSN
- 1472-6823 (ISSN-L)
- PMC
- PMC11293178
- OpenAlex
- W4401225039
- Cited by
- 9
- References
- 21
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 2
- FWCI
- 0.53
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Endocrine Disorders (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- Fonds de recherche du Québec - santé
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Keywords
- diabetic ketoacidosis, subcutaneous insulin, intravenous insulin infusion, insulin delivery route, length of hospital stay, hypoglycemia, all-cause mortality, treatment efficacy and safety
- MeSH terms
- Adult, Humans, Hypoglycemic Agents, Infusions, Intravenous, Injections, Subcutaneous, Insulin, Insulin Infusion Systems, Randomized Controlled Trials as Topic, Diabetic Ketoacidosis, Treatment Outcome
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