The Bottom Line: In patients with mild-to-moderate DKA, subcutaneous injections of insulin lispro every 1-2h offer a feasible alternative to continuous intravenous infusions of regular insulin, and should now be evaluated in larger, more appropriately powered studies.
Summary: The data presented in this review have several limitations. First, all four studies were only exploratory and included small patient numbers of 20–50 patients per study. Also, the studies offered a mean time to resolution of DKA only; median values would have been more representative as the time to event data are almost always skewed. In addition, a wide variety of patients was included in each of the studies, and no information regarding the presence of concomitant complications was provided. Patients with severe complications such as hypovolaemic shock or serious acidosis were excluded from all of these studies, so no data were available for these patient populations. However, patients with severe DKA and those who are critically ill or mentally obtunded, or who have severe complications such as hypotension, anasarca or cerebral oedema, require ICU admission anyway to ensure adequate nursing care and quick turnaround of laboratory test results. Replacing i.v. insulin infusions with s.c. injections would offer no advantages in such cases.