Subcutaneous Insulin Aspart May be Cost-effective Treatment for Mild Diabetic Ketoacidosis in Children


Research suggests that subcutaneous insulin aspart is a cost-effective and accessible treatment option that could allow children with type 1 diabetes to avoid the ICU after a mild episode of diabetic ketoacidosis.

Subcutaneous (SC) insulin aspart was found superior in managing mild uncomplicated diabetes ketoacidosis (DKA) in children compared with intravenous (IV) regular insulin, according to a study published in JAMA Network Open.

Researchers at Kind Saud University Medical City in Saudi Arabia conducted the study with a primary outcome of cost-effectiveness of SC insulin versus IV regular infusion to manage mild DKA, with secondary outcomes that included DKA management—length of hospital stay (LOS), duration of DKA management, and DKA management complications, such as acute kidney injury.

“SC insulin is safe and effective,” the study authors wrote. “The clinical data of this economic analysis provide evidence from the perspective of a public health care payer suggestive of the feasibility and cost-effectiveness of using SC insulin aspart in the treatment of children with uncomplicated mild DKA in a tertiary setting with good health care resources.”

DKA is the primary cause of hospitalization among children with type 1 diabetes worldwide. It traditionally requires treatment at a pediatric intensive care unit (ICU) using regular IV insulin infusion. SC rapid-acting insulin does not require treatment at an ICU, which can often have bed shortages, but it is still uncommon to treat mild DKA with SC insulin, according to the study authors.

To analyze the cost-effectiveness of SC insulin versus regular IV insulin infusion in managing mild DKA in children, the team examined a retrospective cohort of 502 children aged 2 to 14 years who visited the Kind Saud University Medical City emergency department (ED) between January 1, 2015, and March 15, 2020. Among these patients, 129 had a mild DKA episodes, with 70 children treated with SC insulin aspart and 59 treated using an IV regular insulin infusion.

SC insulin aspart was associated with lower hospital costs than IV regular insulin. In US dollars, SC insulin aspart saved patients $34.08 per hour—a 39% reduced cost, excluding the incremental cost-effectiveness ratio.

It was also associated with a DKA treatment that was an average of 2.83 hours shorter, and the LOS was reduced by 16.9 hours. The mean duration of DKA treatment with SC insulin aspart was 9.06 hours, with a mean LOS of 1.9 days.

Mild adverse effects included hypoglycemia and hypokalemia reported among 13.9% of participants. The study was limited because data were not collected to assess health-related quality of life. Further, the cost analysis included pre- and post-hospital visit costs, which are generalized to market-based health care systems, limiting knowledge of DKA treatment in universal health care systems.

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


Bali, Ibrahim Abdulaziz, Al-Jelaify, Muneera Rashid, AlRuthia, Yazed, et al. Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children. September 6, 2022, Accessed on September 8, 2022. JAMA Netw Open. 2022;5(9):e2230043. doi:10.1001/jamanetworkopen.2022.30043

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