Hourly Subcutaneous Insulin

Aka: Hourly Subcutaneous Insulin, Hourly Subcutaneous Insulin Aspart, Hourly Subcutaneous Insulin Lispro

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II. Indications

  1. See Diabetic Ketoacidosis Management in Adults
  2. See Diabetic Ketoacidosis Management in Children
  3. Alternative to Insulin Infusion (Insulin Drip) in Diabetic Ketoacidosis

III. Contraindications

  1. Severe Diabetic Ketoacidosis (pH <7.0, serum bicarbonate <10 mmol/L)
  2. Altered Level of Consciousness (e.g. stupor or coma)
  3. Significant Electrolyte abnormalities

IV. Precautions

  1. Correct Hypokalemia prior to Insulin Dosing
  2. Fluid administration is central to DKA treatment

V. Protocol: Adults

  1. See Diabetic Ketoacidosis Management in Adults
  2. General
    1. Use subcutaneous Rapid-Acting Insulin (Lispro, Aspart)
  3. Fluids and Electrolytes
    1. Coadminister fluids as per Diabetic Ketoacidosis
      1. Initial Intravenous Fluid bolus (1-2 L NS or LR)
      2. Maintenance fluids at 150 ml/hour
    2. Do not start Insulin until Serum Potassium is at least >3.5 mEq/L
    3. Monitor serum electolytes, Serum Ketones, and Venous Blood Gas every 4 hours
  4. Dextrose solution is added when Blood Glucose <250 mg/dl
    1. Blood Glucose 200 to 250 mg/dl: Add D5W 100 ml/h
    2. Blood Glucose 150-199 mg/dl: Add D5W 150 ml/h
    3. Blood Glucose 100-149 mg/dl: Add D5W 200 ml/h
    4. Blood Glucose <100 mg/dl: Add D5W 250 ml/h, provider notified and hold Insulin
    5. Treat Hypoglycemia (Glucose <70 mg/dl)
  5. Hourly SQ Insulin Protocol (with hourly bedside Glucose)
    1. Initial SQ bolus dose: 0.2 to 0.3 units/kg (other protocols start with 0.1 unit/kg)
    2. Next: 0.1 units/kg/hour SQ until Hyperglycemia corrects (Blood Glucose <250 mg/dl)
    3. Next: 0.05 units/kg/hour SQ until DKA resolves (Anion Gap closed to <16)
    4. Discontinue hourly dosing when Glucose 150-200
  6. Every 2 hour SQ Insulin Protocol (with every 2 hour bedside Glucose)
    1. Initial SQ bolus dose: 0.2 to 0.3 units/kg
    2. Next: 0.2 units/kg every 2 hours SQ until Hyperglycemia corrects (Blood Glucose <250 mg/dl)
    3. Next: 0.1 units/kg every 2 hours SQ until DKA resolves (Anion Gap closed to <16)

VI. Protocol: Children

  1. See Diabetic Ketoacidosis Management in Children
  2. Precautions
    1. SQ Insulin for DKA Management is less established in children
    2. Blood Glucose every 2 hours
  3. General
    1. Use subcutaneous Rapid-Acting Insulin (Lispro, Aspart)
    2. Coadminister fluids as per Diabetic Ketoacidosis
    3. Monitor serum electolytes, Serum Ketones, and Venous Blood Gas every 4 hours
  4. Every 2 hour SQ Insulin Protocol
    1. Give 0.1 to 0.15 units/kg every 1-2 hours
    2. Decrease dosing as Hyperglycemia corrects (Blood Glucose <250 mg/dl)

VII. Efficacy

  1. As effective and safe as Insulin Infusion
  2. Advantage over Insulin Infusion
    1. May be monitored on regular medical ward (non-ICU)
    2. Reduced cost by 39% compared with infusion

VIII. References

  1. Umpierrez (2004) Am J Med 117:291-6 [PubMed]
  2. Karoli (2011) Indian J Pharmacol 43(4): 398-401 [PubMed]
  3. Andrade-Castellanos (2016) Cochrane Database Syst Rev 2016(1):CD011281 +PMID: 26798030 [PubMed]
  4. Griffey (2023) Acad Emerg Med 30(8):800-8 +PMID: 36775281 [PubMed]

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