Early subcutaneous basal insulin significantly cuts DKA resolution time by over 4 hours in adults.

Diabetic ketoacidosis (DKA) is a severe, life-threatening metabolic emergency characterized by hyperglycemia, ketosis, and metabolic acidosis, primarily affecting individuals with Type 1 Diabetes but also seen in Type 2 Diabetes. Standard treatment involves intravenous (IV) insulin infusion, fluid resuscitation, and electrolyte management. Despite its efficacy, IV insulin alone can lead to prolonged hospital stays and resource utilization. The clinical gap addressed is whether integrating early subcutaneous (SC) basal insulin during IV therapy can accelerate DKA resolution and improve patient outcomes, potentially by providing more stable insulin levels sooner.

A systematic review and meta-analysis, adhering to PRISMA 2020 guidelines, evaluated 8 randomized controlled trials (RCTs) involving 407 adult participants with DKA. Researchers searched PubMed, Embase, and Cochrane Library for studies comparing early SC basal insulin administered concurrently with IV insulin infusion versus IV insulin alone. Primary endpoints included time to DKA resolution and hospital length of stay. Secondary outcomes assessed total fluid requirements, incidence of hypoglycaemia, rebound hyperglycaemia, recurrent DKA, electrolyte disturbances, and mortality. Meta-regression was used to explore heterogeneity sources.

Early initiation of subcutaneous basal insulin significantly accelerated DKA resolution. The meta-analysis revealed a mean difference (MD) of -4.06 hours (95% CI -5.53 to -2.58; p < 0.0001; I2 = 56.3%) in time to DKA resolution compared to IV insulin alone. This finding remained consistent in sensitivity analysis, showing an MD of -3.44 hours with I2 = 0%.

Total fluid requirements were also modestly reduced by approximately 400 mL in the early basal insulin group. Crucially, the addition of early basal insulin did not increase adverse events. No significant differences were observed in hospital length of stay, episodes of rebound hyperglycaemia, recurrent DKA, hypoglycaemia, hypokalaemia, or overall mortality between the two treatment arms. Meta-regression analysis confirmed that patient characteristics such as age, BMI, sample size, or male proportion did not significantly modify these effects.