Subcutaneous insulin for mild-to-moderate diabetic ketoacidosis: a scoping review and implementation framework

Diabetic ketoacidosis (DKA) is a common emergency department (ED) presentation associated with high morbidity, mortality, and healthcare utilization. While intravenous (IV) insulin remains the most common treatment, emerging data suggest subcutaneous (SUBQ) insulin may be a feasible alternative for patients with mild-to-moderate DKA. This scoping review summarizes current evidence of SUBQ insulin use across a broad range of clinical and operational outcomes in DKA and provides an implementation framework for SUBQ insulin for mild-to-moderate DKA in the ED.

We conducted a scoping review of PubMed from inception through February 2026 for adult studies evaluating SUBQ insulin for DKA. Two investigators independently screened studies, with disagreements resolved by consensus. Data were charted and synthesized across clinical, operational, and implementation outcomes.

A total of 117 articles were identified and 13 included. Available evidence suggests SUBQ insulin may achieve similar time to DKA resolution, compared with IV insulin in select patients with uncomplicated DKA. SUBQ insulin offers potential operational benefits, including reduced intensive care unit (ICU) utilization, shorter ED length of stay, and improved resource optimization. Patient selection criteria, dosing and monitoring strategies, and implementation approaches are summarized. Limitations in the literature include small sample sizes, single-center designs, heterogeneous protocols, and the exclusion of several higher-risk patient populations.

Evidence suggests SUBQ insulin pathways achieve similar clinical outcomes and may reduce ICU utilization and improve operational efficiency in select patients with mild-to-moderate DKA. Because most evidence originates from small, single-center cohorts, future studies should focus on larger, more generalizable populations.