Treating DKA with Sub-Q Insulin?

What are the treatment options for people with type 1 diabetes with a COVID infection hospitalized for Diabetes KetoAcidosis (DKA)?

The typical treatment for DKA is fluids coupled with an IV insulin drip. Given the frequent monitoring and ICU bed required for treatment of DKA with an insulin drip, there has been a renewed interest in treating DKA with subcutaneous or sub-q insulin.

But after doing some research, I discovered an excellent 2004 paper co-authored by Dr. Guillermo Umpierrez et al. on using Sub-Q Insulin to Treat DKA. After completing a study comparing treatment of DKA using sub-q insulin vs. insulin drip, the author’s conclude that sub-Q insulin treatment is a safe and effective alternative treatment to IV insulin in the management of people with mild or moderate DKA.

With a little more digging, I found 2 more recent papers that suggest considering Sub-Q insulin treatment as an option for mild or moderate DKA.

It is important to note that sub-Q insulin treatment for DKA is NOT recommended for patients with arterial hypotension, severe and complicated DKA, or with HHS.

Treating DKA with Sub-Q insulin Steps

Insulins: Use either rapid acting lispro or aspart insulin.

1st Bolus: Starting dose is 0.1 or 0.2 or 0.3 units/kg of insulin (depending on initial blood glucose and clinical presentation)

Example: Pt weighs 100 kg, give 100kg x 0.1 – 0.2 – 0.3 units/kg of insulin = 10 or 20 or 30 units insulin sub-q bolus respectively.

Next Step – Sub-q insulin every 2 hours | Give 0.1 – 0.2 units of insulin /kg every 2 hours until blood glucose is less than 250.

Example: Pt weighs 100 kg, give 100kg x 0.1 – 0.2 units/kg of insulin = 10 or 20 units insulin sub-q bolus respectively every 2 hours.

Blood glucose less than 250 | Now give 1/2 the sub-q insulin dose every 2 hours. Calculate 0.05 to 0.1 units/kg every 2 hours until glucose at target and ketosis is resolved.

Example: Pt weighs 100 kg, give 100kg x 0.05 – 0.1 units/kg of insulin = 5 or 10 units insulin sub-q bolus respectively every 2 hours.

Using scheduled subcutaneous insulin allows for safe and effective treatment in the emergency room and step-down units without the need for ICU care. Umpierrez et al

Please see reference chart and articles below for more detailed information.

Fluids and Electrolytes

Of course, fluid and electrolyte status needs to be assessed before starting insulin.

If the K+ is less than 3.3, hold insulin and start with IV fluids (NS or LR) first with potassium replacement. Once the K is stable, start the insulin injection every 2 hours (see article and flow chart below).

Med Clin North Am. 2017 May; 101(3): 587–606.
doi: 10.1016/j.mcna.2016.12.011
Management of Hyperglycemic Crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state

Thank you for reading this article. Please share any feedback or your experiences using sub-q insulin for DKA. We always love to hear from you. You can email us at info@diabetesed.net

Reference Articles

Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. Saudi J Med Med Sci. 2020;8(3):165-173. doi:10.4103/sjmms.sjmms_478_19

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017;101(3):587-606. doi:10.1016/j.mcna.2016.12.011


Hyperglycemic Crises, DKA & HHS | 1.0 CEs

Join Coach Beverly to learn more about causes and treatment of hyperglycemic crisis. (opens in a new tab)”>Find out more here>>

This course is included in: Level 2 – Standards of Care. Purchase this course individually for $19 or the entire bundle and save 70%. 

This 60-minute course discusses common causes of hyperglycemia crises. Topics include hyperglycemia secondary to medications and insulin deprivation. The difference and similarities between Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome are also covered. Treatment strategies for all situations are included.

Topics include:

  • Common causes of hyperglycemic crises.
  • The difference and similarities between DKA and HHS and treatment strategies
  • Causes and treatment of hyperglycemic crises.

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.* 

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Honoring Martin Luther King Jr. Day

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

This quote, by Martin Luther King Jr., reflects his conviction that justice for all includes access to health care.

People with diabetes are more likely to struggle with food insecurity and lack adequate resources to pay for medications and diabetes supplies.

As Diabetes Specialists, we honor Dr. King’s words by advocating for affordable diabetes care, medications, and access to nutritious foods.

During these challenging times, I am comforted by his resonant statement  “The arc of the moral universe is long, but it bends toward justice.”

On this 35th national celebration, we thank Dr. King for being a beacon of light and clarity. 

With Gratitude,
Coach Beverly


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Insulin Cost Savings Toolkit

“I ran out of insulin a week ago. There was a glitch with the insurance company, and when I went to pick up my insulin, they said my co-pay was over $1000. So, I just ate low carbs for the week.”

A version of this story happens all across America, every day, insulin rationing is becoming commonplace.

During the pandemic, many people living with diabetes are facing financial barriers that are forcing them to chose between getting insulin or paying for food and rent.

As Diabetes Specialists, we can help our community access low or no cost insulin, so no one goes without this life-saving hormone.

Dr. Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES collaborated with ADCES team members to create this detailed and immensely helpful Insulin Cost Savings Toolkit.

This toolkit is especially relevant as unemployment increases with our current crisis and people need resources to secure their daily insulin.

Thank you Dr. Isaacs and Team for creating this awesome resource to improve insulin access for anyone in need.


Join Coach Beverly and Alan Parsa, MD virtually in Hawaii for the Best Diabetes Care For The Frail and Elderly Webinar! 

Are you interested in learning about diabetes care for the frail and elderly?  Then consider attending this all-day conference that synthesizes exciting findings and new elements that you can incorporate into your daily practice.  Through dynamic presentations and case studies, we will provide you with creative strategies to take your practice to the next level.  In addition, small group activities allow participants to network and share problem-solving strategies.  The goal of this program is to provide cutting edge information that has real-life application.  We want each participant to leave the seminar feeling more empowered and confident advocating for excellence in diabetes care.

Registration Price:
$20 for ADCES members – $40 for non-ADCES members – 6.5 CEs

Click here to register. – Download flyer here.

  • October 24, 2020
    • 9 am to 10 am – Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS) with Alan Parsa, MD
    • 10 am to 11:15 am – Overview – Aging Population and Diabetes with Beverly Thomassian, RN
  • October 31, 2020
    • 9 am to 11:15 am – Treatment Goals, Type 2 Medications and Safety Concerns for Older Adults with Beverly Thomassian, RN
  • November 7, 2020
    • 9 am to 11:15 am – Pharmacologic Approaches to Manage Diabetes and Co-Conditions and Lifestyle Recommendations for the Older Adult with Beverly Thomassian, RN

Who Should Attend?

This course is designed for all health care professionals including providers, nurses, dietitians, pharmacists, and educators who want to:

  • Get re-energized about diabetes care and education
  • Enjoy a comprehensive review of diabetes care in the frail and elderly
  • Get updates on treatment strategies for diabetes care in the frail and elderly
  • Learn about lifestyle recommendations for the older adult

Requirements for Successful Completion:  Participants should try to be in attendance for all three webinars, complete and submit the program evaluation at the conclusion of each webinar.  Partial CE hours (2.25 CE hours) can be awarded per webinar if participants complete and submit the program evaluation.  The three webinars will be recorded for later viewing but NO CE hours will be awarded for viewing of the recorded webinars.

Registration Price:
$20 for ADCES members – $40 for non-ADCES members – 6.5 CEs

Click here to register. – Download flyer here.


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!


Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

PocketCard Updates | New insulin, dose additions and warning removal

There is so much to keep track of when it comes to diabetes medication updates and additions. That’s why Coach Beverly and Bryanna are scouring articles and announcements to keep our Medication PocketCards relevant and up-to-date for our community.

We work hard to keep our content current!

We update our downloadable electronic PocketCards on our CDCES Coach app and website each time we announce a medication update.

Laminated PocketCards are updated and ready to be delivered to you!

Purchase yours today and take advantage of our quantity discounts! Great holiday gift!

3 PocketCard Updates

Since our last announcement, there have been three changes.

The GLP-1 RA, dulaglutide, (Trulicity), has two new higher doses. Until now, the approved doses for Trulicity were 0.75mg and 1.5 mg. The expanded dosing will include a 3.0 mg and 4.5 mg weekly Trulicity dose. Based on recent research, by increasing the dose to 4.5 mgs participants experienced an average weight loss of 10.4 pounds and a 1.9% drop in A1c. Of course, the increased dose is associated with nausea and GI upset, so a gradual titration up to this higher dose should be considered.

There is a new biosimilar basal insulin called Semglee.
One of our scholarship recipients, Mercy Edziah, alerted us to the addition of yet another biosimilar glargine insulin. Semglee is available in a 10 mL vial or 3mL prefilled pens. This new insulin is competitively priced. Semglee is listed at $98.65 per 10mL vial and $147.98 for a box of five pens.

Thank you to Mercy and our community, for sharing news with us so we can pass it along to others.

Canagliflozin (Invokana) removed the black box warning. Previously, the FDA had announced in 2017 that people on canagliflozin, an SGLT-2 Inhibitor, had an increased risk of lower extremity amputation. In August 2020, the FDA removed that black box warning.

Safety information from recent clinical trials suggests that the risk of amputation, while still increased with canagliflozin, is lower than previously described, particularly when appropriately monitored. Therefore, the FDA concluded that the Boxed Warning should be removed

Canagliflozin and 2 of the other of the SGLT-2 Inhibitors, dapagliflozin and Empagliflozin, have demonstrated additional heart- and kidney-related benefits. They are FDA approved to reduce the risk of major heart-related events such as heart attack, stroke, or death in people with type 2 diabetes who have known heart disease. They are also approved to reduce the risk of end-stage kidney disease, worsening of kidney function, and heart failure in certain people with type 2 diabetes and diabetic kidney disease.

We hope you find these Pocketcards as an easy-to-use resource that is helpful in your clinical practice and exam preparation.


Join Coach Beverly and Alan Parsa, MD virtually in Hawaii for the Best Diabetes Care For The Frail and Elderly Webinar! 

Are you interested in learning about diabetes care for the frail and elderly?  Then consider attending this all-day conference that synthesizes exciting findings and new elements that you can incorporate into your daily practice.  Through dynamic presentations and case studies, we will provide you with creative strategies to take your practice to the next level.  In addition, small group activities allow participants to network and share problem-solving strategies.  The goal of this program is to provide cutting edge information that has real-life application.  We want each participant to leave the seminar feeling more empowered and confident advocating for excellence in diabetes care.

Registration Price:
$20 for ADCES members – $40 for non-ADCES members – 6.5 CEs

Click here to register. – Download flyer here.

  • October 24, 2020
    • 9 am to 10 am – Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS) with Alan Parsa, MD
    • 10 am to 11:15 am – Overview – Aging Population and Diabetes with Beverly Thomassian, RN
  • October 31, 2020
    • 9 am to 11:15 am – Treatment Goals, Type 2 Medications and Safety Concerns for Older Adults with Beverly Thomassian, RN
  • November 7, 2020
    • 9 am to 11:15 am – Pharmacologic Approaches to Manage Diabetes and Co-Conditions and Lifestyle Recommendations for the Older Adult with Beverly Thomassian, RN

Who Should Attend?

This course is designed for all health care professionals including providers, nurses, dietitians, pharmacists, and educators who want to:

  • Get re-energized about diabetes care and education
  • Enjoy a comprehensive review of diabetes care in the frail and elderly
  • Get updates on treatment strategies for diabetes care in the frail and elderly
  • Learn about lifestyle recommendations for the older adult

Requirements for Successful Completion:  Participants should try to be in attendance for all three webinars, complete and submit the program evaluation at the conclusion of each webinar.  Partial CE hours (2.25 CE hours) can be awarded per webinar if participants complete and submit the program evaluation.  The three webinars will be recorded for later viewing but NO CE hours will be awarded for viewing of the recorded webinars.

Registration Price:
$20 for ADCES members – $40 for non-ADCES members – 6.5 CEs

Click here to register. – Download flyer here.


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!


Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Diabetes Meds Management Update for LA LNG Event – Sept 30, 2020

Handouts and Resources

Meds Management PowerPoint Slides 2 per page

Meds Management PowerPoint Slides 1 per page

Please download Medication and Insulin PocketCards

Or Download FREE CDCES Coach App for easy PocketCard access

ADCES Insulin Cost Savings Resources Page.

Insulin Storage Cheat Sheet for all kinds of important details on storage and more!

Pharmacologic Approaches to Glycemic Treatment 2020.  This hyperglycemia road map details strategies to achieve glucose control for both Type 1 and Type 2

Interested in achieving certification? Check out our Getting Started Page

Sign up for our Free DiabetesEd Newsletter here.

Thanks everyone for this opportunity! Beverly Thomassian

Coach Bev’s Diabetes Cheat Sheets

We know that a great resource page full of accurate and helpful cheat sheets can save busy diabetes specialists time and energy.

That’s why we have put together our entire list of cheat sheets so you can access them with ease.

These sheets and cards include information to study for certification exams and to use in your clinical setting. Plus, we have included teaching sheets for people with diabetes.


Our Summer 2020 Boot Camp begins September 16th!

In each webinar, either Coach Beverly, Dr. Isaacs, or Ms. Armstrong, highlight the critical content of each topic area, so you can focus your study time most efficiently. They also launch multiple poll questions to help participants focus on key concepts and assess their knowledge while learning the best test-taking strategies. 

2020 Boot Camp Live Stream Webinar Schedule with Coach Beverly

All courses air at 11:30 a.m. (PST)

  1. Diabetes – Not Just Hyperglycemia | Sept 16
  2. ADA Standards of Care | Sept 23
  3. Insulin Therapy – From Basal/Bolus to Pattern Management | Sept 30
  4. Insulin Intensive – Monitoring, Sick Days, Lower Extremities | Oct 7
  5. Meds for Type 2 | Oct 14
  6. Exercise and Preventing Microvascular Complications | Oct 21
  7. Coping & Behavior Change | Oct 28
  8. “The Big Finish” Test Taking Boot Camp | Nov 4

Can’t make it live?
No worries! All video presentations and podcasts will be available now on-demand.

Enroll Now!

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!


AccreditationDiabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

CGMs Lead to Cost Savings

For people with type 1 diabetes, access to Continuous Glucose Monitoring (CGM) technology, is considered a standard of care by most experts.

There is plenty of research that demonstrates CGM use is associated with not only improved A1c but significantly decreases time in hypoglycemic range and ketoacidosis rates.

Researchers wondered if this translates into cost savings?

YES.
According to a study presented at the Heart in Diabetes virtual meeting.

After three years of follow-up, the savings were substantial.

  • Multiple daily injection plus CGM users saved between $5,777 and $8,549.
  • CGM users with continuous subcutaneous insulin infusion saved between $2,732 and $4,753 per person, compared with non-CGM users.

“In this study, we showed that it didn’t make any difference how you deliver insulin,” Grunberger said. “This difference is in how you monitor glucose.”

George Grunberger, MD, FACP, MACE, Chairman Grunberger Diabetes Institute and more

Glucose Crises are Expensive

According to Grunberger, the cost of diabetes ketoacidosis (DKA) in the U.S. is over 5 billion dollars a year.

Having a CGM reduces DKA rates, hospitalization, and leads to cost savings.

A study in the United Kingdom showed that for 900 people using the Freestyle Libre (Abbott), DKA episodes were reduced by 80% within six months of using this device.

A study in Belgium followed 1,913 people with type 1 diabetes using the Freestyle Libre CGM.

Not only did they see a dramatic reduction in hospitalizations from DKA and hypoglycemia, but the researchers also observed a fifty percent drop in work absenteeism.

The data shows CGM’s are associated with cost savings due to less diabetes emergencies and decreased work absenteeism.

Full Story: Healio (free registration)/Endocrine Today (8/31) 


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!


Register Today

AccreditationDiabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Glucagon Rescue Meds Options

What is Glucagon and How Does it Work?

Glucagon is a counter-regulatory hormone secreted by the pancreas when blood sugars are dipping or during periods of emotional or physical stress. This hormone liberates stored glycogen from the liver, causing an upward surge in circulating glucose.

When people become hypoglycemic, there is not enough circulating glucagon available to drive more glucose release. Glucagon rescue medications increase glucagon levels enough to stimulate further glucose release from glycogen stores in the body.

While administering glucagon is life saving, it also depletes the body of its glycogen reserves and can lead to further hypoglycemia if it is not replaced quickly. It is so important to replace glycogen stores by consuming carbohydrates as soon as it is safe.


3 Different Glucagon Rescue Options

When someone with diabetes is experiencing severe hypoglycemia and needs the assistance of another person, there are now 3 Glucagon options to choose from.

Here are some highlights of the currently available Glucagon Rescue Medications. Below, is our new Glucagon PocketCard that helps to compare and contrast the delivery system, dosing, age range, route and storage all in one card.

Nasal Glucagon – Baqsimi (Back-see-me)

Baqsimi is a nasal glucagon powder to treat severe hypoglycemia in people with diabetes ages four and older. This non-injectable form of glucagon is available as one pack or 2 pack.

It is approved for pediatrics over the age of four with type 1 diabetes and adults.

Baqsimi does not need to be inhaled, which means it can be effectively administered to a person who is unconscious due to severe hypoglycemia.

*Eligible commercially insured people with diabetes can pay $25 for up to two BAQSIMI devices (1 two-pack or 2 one-packs) with a savings card. This prescription is generally filled on an annual basis. For more info visit www.BAQSIMI.com or call The Lilly Answers Center at 1-800-LillyRx (1-800-545-5979).


Gvoke Pre-Filled Pen or HypoPen Auto-Injector

Xeris Pharmaceuticals offers a pre-filled liquid stable form of glucagon that is approved for use in people with diabetes, age 2 and older. They also have an HypoPen Auto-Injector.

The Xeris glucagon pen was created to simplify glucagon injections. This new Gvoke pen does not require any mixing since it is filled with liquid stable glucagon.

Gvoke Pre-Filled Syringe and HypoPen 2-PackTM is also available. Health care professionals can request a Gvoke HypoPen demo device by completing this request form or contacting your local sales representative. Read more about the Gvoke Glucagon Pen and auto-injector here.

Eligible commercially insured people with diabetes can pay as little at $0 by completing the Gvoke Copay Card* form. Visit this page to sign-up.


Glucagon Emergency Kit | Powder + diluent

Glucagon Emergency Kit by Lilly
GlucaGen Hypo Kit by NovoNordisk

Both Lilly and NovoNordisk manufacture this injectable glucagon that requires mixing glucagon powder in a vial with a diluent, then injecting either sub-q or IM. It can be administered to all ages, but give a half dose for children weighing less than 45kg.


Emergency Action Steps

Glucagon rescue medications raise blood sugar by at least 20 mg/dl and should start working within 15 minutes.

  • After administration, make sure to seek medical help and roll person on their side since glucagon can cause nausea and vomiting.
  • If no response after 15 minutes, administer a second dose.
  • After the person gains consciousness and can safely swallow, administer food or beverage containing at 15 -30 gms of carbohydrate until blood sugars are back in a safe range. Then follow-up with usual meal.

    15 gms of carbohydrate ideas:
    • 4-8 ounces of juice or sugary beverage;
    • A piece of fruit, a handful of raisins, tablespoons of honey or corn syrup;
    • 4 glucose tabs, glucose gel, or GU energy gel.

Glucagon PocketCard – FREE

When addressing severe hypoglycemia, fast and effective treatment is critical. Diabetes Specialists have a vital role in making sure those at risk of a hypoglycemic crisis have a glucagon rescue medication available.

Our new PocketCard provides a concise review of the 3 Glucagon Emergency treatment options.

This card can serve as a decision tool when discussing the pros and cons of the currently available rescue medications with providers and people living with diabetes.

Our new Glucagon PocketCard compares and contrasts the delivery system, dosing, age range, route, and storage of the currently available rescue meds all in one card.

Request a FREE Glucagon Pocket Card to be mailed to your door later this month.

We are offering a FREE copy of this laminated card to the first 50 requests (one per person please).


View it for FREE anytime our CDCES Coach App by clicking on the PocketCard Image on the home screen.


Download it FREE on our PocketCard Page.

Glucagon Rescue Medications require a prescription. Check expiration dates before using them. This information on the Glucagon PocketCard is for educational purposes only. Please consult package inserts for detailed instructions.

Teaching Resources

Hypoglycemia and Hyperglycemia Education Teaching Sheet » This handout is one of my favorites. Cartoon characters depict the signs and symptoms of low and high blood sugars and then detail steps to take.  

Medication Wallet Card PDF » pocket sized document that includes contact info, list of medications and critical health data.

Medication Wallet Card in WORD » Add your program’s logo and provide your clients with a useful, customized document that includes contact info, list of medications and critical health data.  

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!