Diabetic ketoacidosis: less hypoglycaemia or hypokalaemia on low-dose insulin regimens.

Clinical bottom line (level 1b)

  1. Patients with diabetic ketoacidosis who had a low dose insulin regimen rather than a high dose one, were less likely to become hypoglycaemic (NNT = 4 at 12 hours) or hypokalaemic (NNT = 4 at 12 hours) .
  2. There was no clear difference in the time taken to return to biochemical normality.
Kitabchi et al: Annals of Internal Medicine 1976; 84: 633-638
Expires October 2003

The study

Unblinded concealed randomised trial with intention-to-treat
Setting: two university hospitals, USA

48 patients (aged range 15 to 70 years; mean 40, ?% male) diabetic ketoacidosis (defined as plasma glucose >16.7 mM, ketonaemia, pH <7.30, bicarbonate <15 m<, glycosuria > +++ with ketonuria)
Control Group: (n = 24, 24 analysed): high dose insulin - stat dose insulin between 40 and 150 units iv and sc based on initial blood glucose (repeated hourly until fall of 10% or more from original value), then 50 units/hour unless initial glucose <22 mmol/l, in which case hourly bolus 15 units
Experimental Group: (n = 24, 24 analysed): low dose insulin : stat dose insulin 0.22 units/kg im (repeated hourly fall of 10% or more), then 5 units per hour im
Both groups received saline and potassium. Sodium bicarbonate use was kept to a minimum. All patients swapped to 5% dextrose once glucose <14 mmol/l and started on an insulin sliding scale subcutaneously.
100% followed for 12 hours

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
hypoglycaemia 12 hours 6
(25.0%)		 0
(0.00%)		 100%
(50% to 100%)		 25.0%
(7.70% to 42.3%)		 4
(2 to 13)
hypokalaemia 12 hours 7
(29.2%)		 1
(4.17%)		 86%
(07% to 98%)		 25.0%
(5.14% to 44.9%)		 4
(2 to 19)

Outcome Control Group
(SD)		 Experimental Group
(SD)		 Mean Difference
(95% CI)
time to glucose <14 mmol/l 6.7
(3.9) 		4.5
(3.9) 		2.2
(-0.07 to 4.5)
time to bicarbonate 15 mmol/l or more 8.3
(4.4) 		6.9
(6.4) 		1.4
(-1.8 to 4.6)
time to arterial pH 7.30 or more 7.5
(7.3) 		11.1
(5.9) 		-3.6
(-7.5 to 0.26)

  • Mean volume of saline was 4 L in the first 6 hours.
  • There were no significant baseline differences between the two groups in terms of initial pH, bicarbonate, glucose, potassium or ketones.

    • Citation

    1. Kitabchi AE, Ayyagari V, Guerra SM, et al: The efficacy of low dose versus conventional therapy of insulin for treatment of diabetic ketoacidosis. Annals of Internal Medicine 1976; 84: 633-638
    Contributor: Richard Hardern and Chris Ball, July 2000
    Reviewer: Jon Levine

    Clinical Question.
    Patient DKA
    Intervention or Exposure lo dose insulin regimen
    Comparison high dose regimen
    Outcome hypoglycaemia and hypokalaemia