Subcutaneous Insulin Aspart Every 4 Hours in the Treatment of COVID-19 Patients With Mild-to-Moderate Diabetic Ketoacidosis: A Case Series

This case series evaluates the efficacy and safety of subcutaneous (SC) insulin Aspart administered every 4 h for managing mild-to-moderate diabetic ketoacidosis (DKA) in COVID-19 patients, addressing a current evidence gap. We conducted a retrospective review of confirmed COVID-19 patients over 15 years old who developed mild to moderate DKA between July 2020 and October 2021. Insulin Aspart was administered at 0.4 units/kg SC every 4 h, reduced to 0.2 units/kg when blood glucose (BG) decreased to <250 mg/dL, and SC basal insulin was initiated at 0.15-0.2 units/kg at DKA diagnosis. A total of seven patients, with a mean age of 67.4 ± 13.2 years, predominantly female (71.4 %), and all with pre-existing type 2 diabetes mellitus, were analyzed. Initial biochemical parameters included BG of 449 ± 157.3 mg/dL, HbA1c of 10.6 ± 2.8 %, pH of 7.34 (range, 7.26-7.45), beta-hydroxybutyrate of 4.0 ± 1.5 mmol/L, and bicarbonate of 15.5 ± 2.2 mmol/L. The time to resolution of hyperglycemia (BG < 250 mg/dL) and DKA was 8.0 ± 3.1 and was 12.7 ± 5.8 h, respectively. During DKA resolution, one patient experienced hypoglycemia (47 mg/dL) and later developed recurrent DKA as COVID-19 infection worsened. Three deaths occurred due to COVID-19-related complications following DKA recovery. While SC insulin Aspart administered every 4 h shows promise, careful monitoring for recurrent DKA and septic shock is essential for optimal management.