Early vs. late initiation of long-acting basal insulin during IV insulin in pediatric diabetic ketoacidosis: a GRADE-assessed systematic review and meta-analysis.

The effectiveness of starting long-acting basal insulin during the intravenous (IV) phase of pediatric diabetic ketoacidosis (DKA) is still a topic of debate. We question whether it can improve outcomes without causing additional harm. We performed a systematic review following PRISMA guidelines and a random-effects meta-analysis (PROSPERO: CRD420251155626) of studies involving patients under 18 years with DKA. We defined "early basal" as starting subcutaneous glargine or detemir while IV insulin was still being administered, with a planned overlap of four hours or more. Comparators began basal insulin at or after stopping IV insulin or had less than 4 h of overlap. The main outcome was the time to resolution of DKA/acidosis. Secondary outcomes included the duration of IV insulin, hospital length of stay (LOS), hypoglycemia, and hypokalemia. We assessed the risk of bias using RoB-2 and NOS, and we evaluated the certainty of evidence using GRADE. Eight studies (3 RCTs, 5 cohorts; n = 1325) met our criteria (695 early-basal, 630 comparator). Early basal insulin reduced the time to DKA/acidosis resolution (4 studies; n = 445), showing a mean difference (MD) of - 3.58 h (95% CI - 6.13 to - 1.03; p = 0.006; I

conclusionsIn pediatric DKA, starting long-acting basal insulin during IV insulin administration with an overlap of four hours or more speeds up metabolic resolution by about 3 to 5 h without raising the risk of hypoglycemia or hypokalemia. The effects on the duration of IV insulin and LOS are inconsistent. These findings support the use of early basal insulin as a safe transition strategy. Further multicenter pragmatic RCTs with standardized definitions for overlap are needed. WHAT IS KNOWN: • Diabetic ketoacidosis (DKA) in children is a major medical emergency requiring prompt treatment to avoid severe complications, with the standard treatment involving intravenous (IV) insulin administration. • Long-acting basal insulin has been shown in adult populations to hasten recovery from DKA without increasing the risk of hypoglycemia or hypokalemia. WHAT IS NEW: • This meta-analysis emphasizes the effects on the pediatric population, providing high-certainty evidence that early initiation of long-acting basal insulin during IV insulin infusion in pediatric DKA significantly reduces the time to DKA resolution. • The study confirms that early basal insulin does not increase the risk of hypoglycemia or hypokalemia, supporting its safety as a transition strategy in pediatric DKA management.