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Subcutaneous Insulin Linked to Reduced Hospital Costs, LOS in Children With Mild DKA


Treating children with mild diabetic ketoacidosis (DKA) using subcutaneous (SC) insulin aspart was linked to lower hospital costs and better efficacy of DKA management, compared with using intravenous (IV) insulin.

The use of subcutaneous (SC) insulin aspart in treating children with mild diabetic ketoacidosis (DKA) is associated with reduced hospital costs and improved efficacy of DKA management, compared with the use of intravenous (IV) insulin.

IV insulin infusion is the current worldwide standard of care for DKA. However, SC insulin aspart can decrease use of health care resources and, in a study published in JAMA Network Open, researchers found SC insulin aspart was linked to saving of $34.08 per hour for a public health care payer in Saudi Arabia.

The study included 129 children with mild DKA with a mean (SD) age of 9.3 (3.1) years, and most children (55.8%) were female. Of this group, 70 children received SC insulin aspart while 59 received IV regular insulin.

Children in the SC insulin aspart group saw their DKA episodes resolved 2.83 hours earlier than children in the IV insulin group, with a mean DKA treatment duration of 9.06 hours.

Length of stay (LOS) in the hospital was 16.9 hours shorter for children in the SC group compared with the IV group, on average (95% CI, −31.0 to −2.9; P = .005), with a mean LOS in the SC group of 1.90 days.

On top of a shorter LOS, use of SC insulin aspart was also associated with a lower likelihood of prolonged hospital stay (β = −17.22; 95% CI, −32.41 to −2.04; P = .03) compared with IV regular insulin when controlling for age and sex.

Hospitalization costs were also notably lower in the SC group compared with the IV group, with mean (SD) costs of $1071.99 ($523.89) and $1648.90 ($788.03), respectively (P = .001).

The authors cited a study revealing a 39% reduction in hospitalization cost primarily related to intensive care unit (ICU) admission. However, in the cost estimate, that study did not report the incremental cost-effectiveness ratio or the actual included costs.

In the current study, the authors reported an incremental cost-effectiveness ratio of −34.08 (95% CI, −25.97 to −129.82) US dollars per hour.

“The reduced overall cost of hospitalization in the SC group may be associated with the reduced need for ICU admission, shorter LOS, and reduced cost of IV fluids, insulin, and diagnostics,” the authors noted.

With these clear benefits, the authors also noted some setbacks of the SC insulin aspart delivery method as well as recommendation to overcome these issues.

“Although SC insulin does not require preparation and is easier to administer, the recurring injections every 2 hours can be painful and frustrating to the child and add to the discomfort caused by laboratory monitoring every 2 to 4 hours,” the authors noted. “The use of a flexible SC catheter can help to overcome this disadvantage of using SC insulin injection without affecting its efficacy.”

According to the study authors, these findings suggest SC insulin aspart is a cost-effective strategy in the treatment of children with mild DKA.

“Pediatricians, endocrinologists, emergentologists, intensivists, and policy makers may need to reconsider the usual practice of using IV regular insulin for mild DKA,” the authors concluded.


Bali IA, Al-Jelaify MR, AlRuthia Y, et al. Estimated cost-effectiveness of subcutaneous insulin aspart in the management of mild diabetic ketoacidosis among children. JAMA Netw Open. 2022;5(9):e2230043. doi:10.1001/jamanetworkopen.2022.30043

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