Early Basal Insulin Use in Moderate-Severe DKA: A Retrospective Review

Introduction: DKA is a life-threatening complication of diabetes, with hospital admissions rising 55% over the past decade. Standard treatment involves continuous IV insulin, followed by subcutaneous long-acting insulin at transition. This approach is time-intensive and requires close monitoring. Recent studies suggests that earlier administration of insulin glargine may expedite DKA resolution and reduce infusion duration. Thammakosol et al. found shorter time to resolution and hospital stay with early glargine, without increased hypoglycemia. The 2024 ADA Consensus Report conditionally recommends early glargine in patients receiving IV insulin, though ideal timing, dose, and patient selection remain unclear. This study aimed to evaluate the impact of glargine given within three hours of starting IV insulin in moderate/severe DKA.


Methods: This single-center, retrospective study included adults with moderate/severe DKA treated with IV insulin and glargine at Piedmont Columbus Regional Midtown from Jan 2023–Jan 2025. Early administration was within three hours of IV insulin initiation; late was at transition. The primary outcome was time to DKA resolution. Secondary outcomes included hospital length of stay, glucose decline rate, DKA reoccurrence, hypoglycemia, and hypokalemia. Exclusion criteria included euglycemic DKA, septic shock, surgery within 48h of insulin discontinuation, IV insulin duration < 6h, and systemic steroid use.


Results: Of 100 patients, 22 received early glargine and 78 received late. Baseline characteristics were similar. Mean time to DKA resolution was 13.18h in the early group vs 14.77h in the late group (p=0.14). Hospital stay averaged 3.86 vs 2.99 days, respectively (p=0.11). Glucose decline rate was faster with early administration (53.42 vs 35.94 mg/dL/h, p=0.005). DKA reoccurrence (4.5% vs 26%, p=0.032) and rebound hyperglycemia (23% vs 71%, p< 0.001) were significantly lower with early administration. Rates of hypoglycemia (14% vs 13%, p=0.92) and hypokalemia (50% vs 56%, p=0.59) were similar.


Conclusions: Early glargine administration may improve glycemic control, reduce DKA reoccurrence, and lower rebound hyperglycemia without increasing adverse events. It may support transitions of care, but further research is needed to define optimal timing and dosing.