Lispro insulin and electrolyte supplementation for treatment of diabetic ketoacidosis in cats

Comparison of insulin infusion protocols for management of canine and feline diabetic ketoacidosis

OBJECTIVE

Describe the use of fixed-rate intravenous insulin infusions (FRIs) in cats and dogs with diabetic ketoacidosis (DKA) and determine if this is associated with faster resolution of ketosis compared to variable-rate intravenous insulin infusions (VRIs). Secondary objectives were to evaluate complication rates, length of hospitalization (LOH), and survival to discharge (STD).

DESIGN

Randomized clinical trial (January 2019 to July 2020).

SETTING

University veterinary teaching hospital and private referral hospital.

ANIMALS

Dogs and cats with DKA and venous pH <7.3, blood glucose concentration >11 mmol/L (198 mg/dL), and β-hydroxybutyrate (BHB) concentration >3 mmol/L were eligible for inclusion. Patients were randomly assigned to receive either FRI or VRI.

INTERVENTIONS

Neutral (regular) insulin was administered IV as an FRI or VRI. For FRI, the rate was maintained at 0.01 IU/kg/h. For VRI, the dose was adjusted according to blood glucose concentration.

MEASUREMENTS AND RESULTS

Sixteen cats and 20 dogs were enrolled. Population characteristics, mean insulin infusion rate, time to resolution of ketosis (BHB <0.6 mmol/L), complications, LOH, and STD were evaluated. In cats, overall resolution of ketosis was low (9/16 [56.3%]), limiting comparison of protocols. In dogs, resolution of ketosis was high (19/20 dogs [95.0%]) but the time to resolution in the FRI group was not different than that in the VRI group (P = 0.89), despite a 25% higher average insulin infusion rate in the FRI group (P = 0.04). The incidence of complications was low and did not differ between protocols. In cats, LOH and STD did not differ between protocols. All cats that died (5/16) did so within 78 hours and none had resolution of ketosis. Dogs receiving FRI had a shorter LOH (P = 0.01) but STD did not differ between protocols. Six dogs (30.0%) did not survive to hospital discharge but all had resolution of ketosis.

CONCLUSIONS

FRIs can be used in veterinary species but may not hasten resolution of ketosis.

Glargine versus regular insulin protocol in feline diabetic ketoacidosis

Objectives

To determine whether basal‐bolus administration of glargine insulin is a safe and effective alternative treatment compared to the standard continuous rate infusion (CRI) protocol.

Design

Prospective randomized clinical trial.

Setting

University teaching hospital.

Animals

Twenty cats diagnosed with diabetic ketoacidosis (DKA).

Interventions

The cats were block‐randomized to either a CRI protocol using regular insulin (CRI‐group; n = 10) or a basal‐bolus SC and IM glargine protocol (glargine‐group, n = 10). Baseline blood gases, electrolytes, glucose, and β‐hydroxybutyrate (β‐OHB) concentrations were measured at the time of admission and later at predefined intervals until reaching the primary endpoint of the study, defined as a β‐hydroxybutyrate concentration < 2.55 mmol/L.

Measurements and main results

The main outcome measure was time (h) to resolution of ketonemia. Secondary outcome measures were time until first improvement of hyperglycemia and ketonemia, decrease of glucose to ≤13.9 mmol/L (250 mg/dL), resolution of acidosis, consumption of first meal, and discharge from hospital. Additionally, occurrence of treatment‐associated adverse events and death were compared. Seventeen cats (85%) survived to discharge, with no difference in survival between groups (P = 1.0). Median times to β‐OHB < 2.55 mmol/L were 42 (CRI‐group) and 30 (glargine‐group) hours, respectively (P = 0.114). Median times to first improvement of hyperglycemia (glargine‐group: 2 h; CRI‐group: 6 h; P = 0.018) and until discharge from hospital (glargine‐group: 140 h; CRI‐group: 174 h; P = 0.033) were significantly shorter in the glargine‐group. No significant differences were observed in any other parameter under investigation (P > 0.05).

Conclusions

Basal‐bolus administration of glargine insulin appears to be an effective and safe alternative to the current standard CRI‐protocol for the management of DKA in cats. The positive outcomes and simplicity make it a viable option for the treatment of feline DKA.

Efficacy and Safety of Intramuscular Insulin Lispro vs. Continuous Intravenous Regular Insulin for the Treatment of Dogs With Diabetic Ketoacidosis

The use of rapid-acting insulin analogs as routes of administration other than IV has never been described for the treatment of dogs with diabetic ketoacidosis (DKA). This study aims to compare the efficacy and safety of a new protocol based on IM administration of insulin lispro with that of low-dose IV continuous rate infusion of regular insulin in the treatment of canine DKA. Client-owned dogs with naturally occurring DKA were included. Dogs treated with IM insulin lispro (Group L, n = 11) received 0.25 U/kg. The goal was to achieve a drop of at least 10% in blood glucose between 1 h and the next. If this goal was not achieved, the insulin dose was repeated hourly; otherwise, the insulin dose was not repeated up to a maximum of 3 h, after which the insulin dose was repeated anyway. When blood glucose was ≤250 mg/dL, the insulin dose was reduced to 0.125 U/kg IM every 3 h. Cases receiving IV continuous rate infusion of regular insulin (Group R, n = 13) were treated according to a previously published protocol. The median time to resolution of ketosis was significantly shorter in Group L (12 h; range, 4–27 h) compared to Group R (23 h; 10–46 h; P = 0.04). The median times to resolution of acidemia and ketoacidosis were 13 h (4–35 h) and 17.5 h (4–35 h) in Group L, and 22 h (9–80 h) and 23.5 h (10–80 h) in Group R, respectively. These differences were not significant (P = 0.06 and P = 0.09, respectively). The median length of hospitalization did not differ significantly between groups (P = 0.67). There were no differences in the frequency and severity of adverse events (hypoglycemia, hypokaliemia, and hypophosphatemia) between groups. The new protocol based on IM administration of insulin lispro preliminarily appears effective and safe for treatment of canine DKA.

Lispro insulin and electrolyte supplementation for treatment of diabetic ketoacidosis in cats

Background

Intravenous continuous rate infusion (IVCRI) of lispro at a starting dose of 0.09 U/kg/h and the use of 0.9% sodium chloride (NaCl) for fluid resuscitation in cats with diabetic ketoacidosis (DKA) have not been reported. Protocols for correction of electrolyte deficiencies in cats with DKA are lacking.

Objectives

To characterize the use of IVCRI lispro at an initial dose of 0.09 U/kg/h and the use of NaCl for resuscitation. Explore protocols for electrolyte supplementation in cats with DKA.

Animals

Twelve cats with DKA enrolled from the cat population of a university hospital.

Methods

Randomized, controlled, blinded study. Six cats were randomized into each group, the lispro insulin treatment group (LITG) and regular insulin treatment group (RITG). All cats received IVCRI fluid resuscitation with NaCl. Solutions with higher than previously published electrolyte concentrations were used to treat electrolyte deficiencies.

Results

The median time to blood glucose (BG) concentration <250 mg/dL was significantly shorter in the LITG (median 7 hours, 2‐10 hours) than the RITG (median 12.5 hours, 8‐20 hours; P = .02). Two cats had nonclinical hypoglycemia (BG = 40 mg/dL). The most rapid change in 157 measurements of corrected sodium concentrations was 0.7 mmol/L/h. Low concentrations of serum sodium, potassium, phosphate, and magnesium were over 3 times more common than above normal electrolyte concentrations, despite supplementation with fluids of high electrolyte concentrations.

Conclusions and Clinical Importance

Lispro at a starting dose of 0.09 U/kg/h and NaCl administered for fluid resuscitation are safe and effective for treatment of DKA in cats.