Abstract: Diabetic ketoacidosis(DKA) is a potentially fatal complication in patients with type 1 diabetes mellitus(T1DM). The mainstay of treatment for DKA is correction of dehydration and correcting hyperglycaemia with insulin. Intravenous(IV) insulin is preferred over subcutaneous(SC) insulin as onset of action is rapid and the dose can be titrated based on blood glucose.
Aims: To compare efficacy and hospitalisation cost of subcutaneous insulin therapy to intravenous insulin infusion in treatment of DKA in children admitted at G. Kuppuswamy Naidu Memorial(GKNM) Hospital, Coimbatore, India.
Methods: Retrospective cohort study undertaken on children admitted with DKA from 2013-2017.
Groups analysed: one cohort treated with IV infusion of regular insulin in ICU and another cohort treated with SC regular insulin in paediatric general wards.
Main outcomes: overall cost of hospitalisation and hours to improvement.
Analysis: by independent samples T-test with SPSS software.
Results: 49 patients admitted with 51 episodes of DKA were analysed. Baseline characteristics of two groups were similar for age(P=0.68) and sex(P=0.62). Glucose(P=0.47) and HbA1c(P=0.91) at arrival were comparable. Proportion of girls:boys in either group was 14:8(IV insulin group) and 20:9(SC insulin group). Lowest pH recorded in children treated with IV insulin infusion was 6.822(range 6.822-7.154) and lowest pH in children treated with SC insulin was 6.831(range 6.831-7.292). Mean pH in SC group was 7.1±0.12 and 7.00±0.10 in IV group(p value=0.02).
29 episodes were treated with SC insulin and 22 episodes were managed with IV insulin infusion. 23% of patients had severe DKA, 52% had moderate DKA, and 25% had mild DKA.
Mean time to improvement in SC insulin group was 17.23±9.85hours and 34.95±14.05hours in the IV insulin infusion group(P=0.001).
Average total cost of hospitalisation was Indian Rupees 53712±18813 for the IV group and 14369±5768 for the SC group(P=0.000). Total daily dose of insulin on Day 1 was 1.2unit/kg/day in IV group and 1 unit/kg/day in SC cohort.
Discussion: Sub-cutaneous administration of insulin is effective and cheap in management of paediatric DKA. Earlier reports used a cut-off of a pH>7 to use SC insulin therapy in DKA. This study has established that pH is not a limiting factor for treatment of DKA in non-ICU setting.
Conclusion: SC insulin can be a cost effective alternative in treatment of DKA in resource-poor countries.
19 - 21 Sep 2019
European Society for Paediatric Endocrinology