1014-P: Evaluation of Diabetic Ketoacidosis Management with a Subcutaneous Insulin Lispro PowerPlan

Diabetic ketoacidosis (DKA) has traditionally been treated with a continuous intravenous insulin infusion, often requiring management in an intensive care unit (ICU) or step-down unit. There has been growing evidence supporting the use of subcutaneous rapid-acting insulin analogs to treat mild-to-moderate DKA (alert patient able to tolerate oral fluid intake, pH >7.0, bicarbonate ≥10), helping to decrease costs and ICU-bed utilization. We sought to establish the efficacy and safety of a subcutaneous insulin lispro protocol developed at UPMC for the treatment of mild-to-moderate DKA. A retrospective chart review was performed on patients across 15 institutions in the UPMC network from February-October 2022 who had the adult DKA PowerPlan subcutaneous insulin lispro subphase ordered. Of 111 cases analyzed, 47 cases were included that properly used the PowerPlan to treat mild-to-moderate DKA. DKA resolution using the PowerPlan was reached in 45/47 (95.7%) cases. The two unsuccessful cases involved delayed recognition of DKA in the emergency department and premature transition to a prandial insulin regimen before DKA resolution. Hypoglycemia (defined as glucose <70) occurred in 9/47 (19.1%) encounters. Only 1/47 (2.1%) encounters involved hypoglycemia directly attributable to the subcutaneous insulin lispro PowerPlan. The remaining cases of hypoglycemia were attributed to not reducing insulin doses when glucoses were <250, giving insulin doses sooner than 2 hours before the prior dose, not starting dextrose-containing fluids when glucoses were <250, and higher co-administered basal insulin doses (>0.3 units/kg). Overall, these results suggest that a subcutaneous insulin analog can be safely and effectively used to treat mild-to-moderate DKA in non-ICU settings.