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Date: May 20, 2026

Guest Skeptic: Dr. Matt McArthur is an ED Physician working primarily in Guelph and Kitchener with occasional rural locums in the small town of Walkerton, where he grew up. His clinical interests include POCUS, emergency cardiology, QI, knowledge translation, motivational interviewing, and vertigo. He is very active in medical education, including as a clinical skills and POCUS instructor, a Contributing Editor with the EMCases Podcast, and Regional Education Lead for Undergraduate Family Medicine at the Waterloo Regional Campus of McMaster University.

Reference: Qiang et al. Safety and Effectiveness of Subcutaneous Insulin for Management of Mild to Moderate Diabetic Ketoacidosis in Non-Pregnant Patients: A retrospective cohort study at a tertiary care centre. Canadian Journal of Diabetes. Oct 2025

Case: A 56-year-old woman with insulin-treated type 2 diabetes presents to the emergency department (ED) with 24 hours of nausea, vomiting, polyuria, and weakness after missing insulin doses during a viral illness. She is alert, mildly tachycardic, normotensive, breathing slightly fast, and appears dry but not toxic. Her labs show glucose 23 mmol/L, pH 7.26, bicarbonate 14 mmol/L, an anion gap of 22, and positive serum ketones. You diagnose her with diabetic ketoacidosis (DKA). After initial IV fluids, she has clinically improved and does not require any vasopressors or airway support. The practical question is whether she really needs an intravenous (IV) insulin drip and intensive care unit (ICU)-level care, or whether a structured subcutaneous (SC) insulin pathway would be safe and effective.

Background: DKA is one of the classic endocrine emergencies that lands squarely in the wheelhouse of emergency medicine. It is a state of insulin deficiency that leads to progressive dehydration, electrolyte deficits, and acidemia, which together can be fatal if untreated. Clinically, these patients show up with some combination of polyuria, polydipsia, nausea, vomiting, abdominal pain, tachypnea or Kussmaul respirations, dehydration, and sometimes altered mental status.

Since the discovery of insulin by Fredrick Banting in Toronto in 1921, the treatment of DKA has changed dramatically in the last 100 years. Prior to insulin, the mortality from DKA was thought to exceed 95%. In modern times, the mortality is less than 1%.

As a reminder, Sir Frederick Banting, Charles Best and James Collip, sold the patent for insulin to the University of Toronto for just $1 in January 1923. Banting famously stated, “Insulin does not belong to me, it belongs to the world”.

DKA treatment involves protocol-based care, including IV rehydration to address hypovolemia; insulin therapy to stop ketoacidosis and restore normal metabolism; electrolyte and dextrose replacement to correct deficits, with regular monitoring of glucose and electrolytes (especially potassium) during treatment.

Most hospitals have labour-intensive DKA protocols involving IV insulin infusion, which often require patients to be admitted to the ICU due to high nursing demands. However, with the introduction of rapid-acting subcutaneous (SC) insulin analogues in the late 1990s, such as insulin lispro and aspart, some clinicians have evaluated the use of rapid-acting SC insulin boluses as an alternative to IV infusion.

SGEM has already dipped a toe into these waters in SGEM#414, which covered the SQuID protocol. That episode asked whether adults with mild-to-moderate DKA could be treated with fast-acting subcutaneous insulin on a non-ICU floor, resulting in shorter ED length of stay. That study by Griffey et al in AEM highlighted the operational appeal of avoiding an insulin drip and an ICU bed for every uncomplicated DKA patient.

Between 2004 and 2016, six small randomized controlled trials found no difference in safety between SC insulin boluses and IV infusions in adults. Given the safety evidence and out of a desire to provide more efficient DKA care and avoid unnecessary ICU admissions, some hospitals have designed and implemented SC insulin-based treatment protocols as a first-line option for uncomplicated DKA patients and have published their outcomes in the medical literature.

In the last five years, several observational studies have been published reporting patient and operational outcomes after implementation of a hospital-wide SC DKA protocol. That includes SQuID I by Griffey et al (SGEM#414), as well as SQuID II, which provided a further report on outcomes in the same hospital in St Louis.

Additionally, we have seen Rao’s 2022 report on their protocol introduced at Kaiser Permanente San Jose, Stuhr et al. in 2023 from Utah, and Ibarra et al. in Fresno in 2026. There were also Diabetes Consensus Guidelines published in 2024 that endorse the use of SC insulin in DKA.

Clinical Question: In nonpregnant adults with mild to moderate DKA, is SC insulin a safe and effective alternative to IV insulin for DKA management?

Reference: Qiang et al. Safety and Effectiveness of Subcutaneous Insulin for Management of Mild to Moderate Diabetic Ketoacidosis in Non-Pregnant Patients: A retrospective cohort study at a tertiary care centre. Canadian Journal of Diabetes. Oct 2025

  • Population: Nonpregnant adults aged 18 years or older admitted with mild or moderate DKA defined as an elevated urinary or serum ketones plus at least two of: pH <7.3, bicarbonate below the local lower limit of normal, anion gap >12 mmol/L, or glucose >14 mmol/L; euglycemic DKA could have relatively normal glucose. 
    • Excluded: Severe DKA or unknown DKA severity, insufficient data, incomplete treatment, patients treated with both IV and SC insulin, insulin pump cases, pregnancy, reduced consciousness (GCS <8), vasopressor use, or body weight >160 kg. Patients not eligible for the SC protocol also included those with these higher-acuity features. 
  • Intervention/Exposure: SC insulin protocol: glargine 0.3 U/kg (or home dose) plus aspart 0.2 U/kg every 4 hours unless glucose fell below 14 mmol/L, with glucose checks every 2–4 hours and electrolytes/blood gas every 4 hours; fluids and replacement per treating physician. 
  • Comparison: Standard IV insulin treatment. 
  • Outcome:
    • Primary Outcome: Co-primary outcomes were time to anion-gap closure and hospital length of stay (LOS).
    • Secondary Outcomes: Hypoglycemia, hypokalemia, and anion-gap acidosis requiring intervention within 24 hours. 
  • Type of Study: Retrospective cohort study.

Authors’ Conclusions: “These results suggest SC insulin is safe. Although it may take 8.4 hours longer to close the AG with SC insulin, there is less hypoglycemia and hypokalemia and no difference in LOS in hospital.” 

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Unsure
  6. Have the authors identified all-important confounding factors? No
  7. Was the follow-up of subjects complete enough? Yes
  8. How precise are the results? Unsure
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study? It was supported by a Quality Improvement Grant from Banting and Best Diabetes Centre Innovative Diabetes.
  13. Did the authors declare any conflicts of interest? None were declared.

Results: The final cohort included 153 unique admissions: 92 treated with IV insulin and 61 with SC insulin. The mean age was about 57 years in both groups. Women made up 53% of the IV group and 54% of the SC group. Type 2 diabetes predominated (65% IV, 69% SC), with type 1 diabetes making up about one-third (33% IV, 31% SC). Euglycemic DKA was present in 24% of IV-treated patients and 16% of SC-treated patients. The IV group appeared sicker at baseline, with more moderate DKA (37% vs 11%), more renal dysfunction (33% vs 13%), and more neurologic dysfunction (17% vs 3%). About 30% of the cohort was taking an SGLT2 inhibitor. 

Key Result: IV insulin closed the anion gap more quickly, but SC insulin caused less hypoglycemia and hypokalemia, with no meaningful difference in hospital length of stay or in anion-gap reopening requiring intervention.

  • Primary Outcomes:
    • IV insulin was faster to close the anion gap: adjusted median 15.6 hours versus 24.0 hours for SC, with an adjusted hazard ratio of 0.65 (95% CI 0.45 to 0.92; p=0.02)
    • There was no statistically significant difference in hospital LOS: adjusted relative risk 0.83 (95% CI 0.61 to 1.13; p=0.24). 
  • Secondary Outcomes:

1a. Confounding by Indication: Treatment was not randomized; the treating physician chose IV or SC insulin. In a cohort study, the exposed and comparison groups should have the same prognosis if we want a minimally biased estimate of the effect. Here, the IV group was clearly sicker at baseline, with more moderate DKA, more renal dysfunction, and more neurologic dysfunction. Multivariable adjustment helps, but no regression model can fully remove bias from unmeasured or poorly measured prognostic differences in a retrospective cohort study.

1b. Critical Appraisal of a Hospital Implementation/Quality Improvement (QI) Study: This is an observational study in which the authors retrospectively report on outcomes in their hospital after they introduced a new treatment protocol. So, we must appraise it for what it is, and not read it like an RCT.

Observational studies, particularly QI/implementation studies like this one, generally aim to determine whether a given intervention in a specific healthcare setting was feasible and effective. QI studies are highly specific to the site where they took place.

In this study, a new SC insulin protocol was introduced in the Sunnybrook Hospital in Toronto in 2022, and the authors performed a retrospective chart review to look at patient outcomes after they adopted the new protocol. Obviously, how things rolled out in their hospital in 2022 (COVID Times) might be quite different than your hospital in 2026, or in other hospitals that have also reported their outcomes after DKA protocol implementation. We can learn a lot from observational studies of other hospitals’ treatment protocols, but we should remain skeptical of their external validity to other practice settings.  

However, five small RCTs comparing IV and rapid-acting SC insulin in DKA were published between 2004 and 2015, all showing good safety and efficacy of SC insulin. Despite these being small studies, expert consensus and clinical practice guidelines have broadly endorsed the use of SC insulin in DKA care, so many hospitals have already rolled out SC protocols as standard therapy, not as an experimental therapy. As a result, many new SC vs IV DKA papers published over the last several years are not RCTs but observational studies, like this one, that report outcomes after hospital-wide implementation of a new treatment protocol.

If you were dissatisfied with the small RCTs already out there and were hoping to see a big, high-quality, multicenter RCT comparing SC and IV insulin in DKA treatment, unfortunately, the cat is probably already out of the bag, and we are unlikely to see many more RCTs on this topic, because hospitals and clinical practice guidelines have already started to roll this out as a standard practice.

2a. Co-intervention Imbalance: The groups differed not only in insulin route but also in important aspects of care: the IV group received more dextrose infusion, more normal saline, more potassium supplementation, and was more often kept NPO. In observational studies, these accompanying management differences can act as confounders, especially when the outcomes themselves (hypoglycemia, hypokalemia, and even LOS) are plausibly affected by fluids, dextrose, and electrolyte strategies, not just the insulin route.

2b. Possible False Dichotomy of SC vs IV: Lots of studies comparing IV to other forms of treatment will use language that creates a potential false dichotomy, as though the route of administration is the single determining factor on how the drug works, when the reality is far more nuanced.

In fact, both IV and SC are systemic therapies. Think about it: SC insulin doesn’t work by staying in the skin; it works by going into the bloodstream, much like IV therapy –a rapid-acting SC insulin takes 20 minutes or so to be absorbed and reach therapeutic levels in the bloodstream, but it’s still going the exact same place.

When you realize that both therapies are systemic, the IV/SC false dichotomy falls apart quickly.

Much more important than the route of administration is actually the dosing and frequency, which will dictate the serum insulin levels at any given time.

As a very basic hypothetical example, if a patient receives IV insulin infusion at a rate of 5 units per hour, the patient is receiving half the insulin as a patient receiving SC insulin at 20 units administered every 2 hours, but an equal amount of insulin as a patient receiving SC insulin at 20 units every 4 hours.

And this is important because we have several studies of SC protocols that use different dosing and frequency – there isn’t a single universal way to give SC insulin. The same is true for IV insulin: some protocols give an upfront IV bolus, while others do not, and some use different infusion rates. Rather than dichotomizing SC or IV, we should also consider the number of insulin units per hour a patient is receiving, based on the insulin dosing and frequency used.

3a. Detection Bias:The paper notes that electrolytes and venous blood gas were measured every 4 hours in the SC group, whereas in the IV group, physicians could check them every 2 or 4 hours. If the IV group is checked more often, the time to biochemical resolution can look better simply because there are more chances to catch the first normal anion gap. That is classic detection bias. 

3b. DKA treatment is more than just insulin: DKA treatment involves IV fluids to correct hypovolemia, insulin therapy to restore normal metabolism and correct metabolic acidosis, and dextrose and electrolyte replacement to correct deficiency.

As such, many factors are at play. Did the providers use normal saline or a balanced crystalloid, such as Ringer’s, for volume therapy? How much IV fluid did they give in total? Were patients made NPO, and if so, when were they allowed to start eating? Did they start an infusion of D5? If so, when and at what rate? What was their protocol for electrolyte replacement?

All of these factors will play a role in the treatment of DKA, so this should also be considered when evaluating the performance of DKA protocols – not just the insulin.

For instance, in this study, fewer patients in the SC DKA protocol received dextrose- or potassium-containing fluids than those in the IV protocol, which could confound comparisons between the groups.

4a. Precision & POO: The total sample was modest at 153, which can lead to wide 95% confidence intervals around the point estimates. The euglycemic DKA subgroup was small (32 patients), so rare harms and subgroup findings are unstable.

Outcome                              Effect Estimate         95% Confidence Interval

Time to AG closure             aHR 0.65                              0.45–0.92

Hospital LOS                        aRR 0.83                              0.61–1.13

Hypokalemia                        aOR 0.35                              0.15–0.80

In addition, anion-gap closure is a lab-oriented outcome (LOO) or disease-oriented outcome (DOO), and not a patient-oriented outcome (POO). Hospital LOS is patient-important, but it is also heavily influenced by bed availability and system operations. So, the study gives useful operational and safety signals, but not the last word on clinically important effectiveness. 

4b. Definition of Anion Gap Closure: In this protocol, they have defined anion gap closure as an anion gap of <12. In protocols reported in the last few years from other hospitals, including Rao, Griffey, Stuhr, and Ibarra, anion gap closure was defined as an anion gap <16. This is probably one of the many reasons they had much longer times to anion gap closure and treatment times than other hospitals’ SC DKA protocols reported in the literature.

5a. External Validity: This was a single-centre tertiary Canadian study, conducted in EDs and ICUs during a period when ward nursing ratios were felt inadequate for protocolized monitoring, so all patients were treated in higher-acuity environments (ICU) rather than on general wards. In addition, the study excluded pregnant patients, patients with severe DKA, markedly obese patients, people with vasopressor needs, patients with reduced consciousness, patients with insulin pump cases, and incomplete treatments. That makes the results most applicable to selected, stable, uncomplicated adults in a well-resourced centre with robust monitoring.

5b. Why is the DKA Length of Stay So Long at Sunnybrook? In the last 5 years, we have had at least 5 different hospitals report on outcomes in the medical literature after they conducted a hospital-wide implementation of an SC DKA protocol: Rao in San Jose in 2022, Griffey in St Louis in 2023 and 2024, Stuhr in 2023, and Ibarra in 2026.

By and large, we know that patients coming into the hospital with uncomplicated mild-to-moderate DKA will do well. Mild to moderate DKA is a very treatable condition with a low mortality rate. Practically speaking, the reason for implementing SC DKA protocols has been to take a group of patients who we already know are going to do well, and make their care more efficient and streamlined, and less resource-intensive, because traditional IV protocols, though effective, are quite cumbersome.

For all DKA hospitalizations, Rao et al reported a 57% reduction in ICU admissions compared to control sites after implementing their SQ protocol with equivalent LOS and safety, as well as a 50% reduction in hospital readmission after implementing their protocol.

Griffey in 2024 found a 33% absolute reduction in ICU admissions for mild to moderate DKA, with LOS of 47 hours for SC protocol compared to 102 hours for IV protocol and no difference in safety outcomes.

Ibarra in 2026 reported on an SC insulin protocol implemented in an ED Obs unit specifically designed for patients requiring ED-level care for reversible problems, with the goal of treating and discharging them within 24 hours. Using this approach, they achieved a median hospital length of stay of just 19.6 hours for DKA patients admitted under the SC protocol.

Unlike these other hospitals, Qiang et al. at Sunnybrook still admitted their SC DKA patients to the ICU rather than a medical or OBS ward, and their patient population was quite different from those of these other papers.

The biggest patient-level difference that jumps out is that the DKA patients receiving SC insulin in the Sunnybrook study are much older than those in other hospitals that have published SC treatment protocols. The average patient age in the Sunnybrook cohort was 57, compared to the low 30s and 40s in other studies. There was also a higher prevalence of type 2 diabetes of 69%, where the T2DM prevalence ranged in the 30s and 40s in other studies. This suggests that the Sunnybook DKA patients who received this protocol are generally older and likely more complex than those in other hospitals’ SC implementation studies. That might partly explain why the time to anion gap closure and the total hospital LOS were much longer in this study than in other retrospective studies of DKA protocols.

After implementing their protocol, Rao et al at Kaiser Permanente San Jose reported a mean hospital length of stay for all DKA patients (regardless of severity) of 56 hours. Griffey et al. in St. Louis reported a hospital LOS of 47 hours for their SC DKA patients. Using their ED OBS model, Ibarra et al. in Fresno achieved a super quick LOS of just 19.6 hours for SQ DKA patients. For comparison, the Sunnybrook mean LOS was 168 hours for SC DKA patients.

So, older, more complex patients probably played a major role in making the Sunnybrook LOS longer than the other hospitals that have shared their SC DKA outcomes.

In addition to clear differences in patient factors, it’s also quite possible that provider and system factors played a role in the difference in LOS. Most other hospitals deliberately designed their DKA protocols to reduce ICU admissions, whereas at Sunnybrook, all DKA patients still went to the ICU regardless of the protocol. ICU admission can make patient admissions less efficient overall and increase LOS.

Hospital-specific staffing models may also have played a huge role in how efficiently care is delivered; factors such as nursing ratios, physician-to-patient ratios, involvement of learners, and overall culture can all influence care efficiency and patient length of stay.

Lastly, the overall protocol itself could play a role in differences in time to AG closure and LOS. Other hospitals have used different dosing and frequency of SC insulin than Sunnybrook, as well as different protocols for fluids and dextrose that are also part of DKA treatment.

Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We agree with the authors that rapid-acting SC insulin boluses, as an alternative to IV insulin infusion, seem a safe and effective treatment option for adult patients with mild to moderate DKA.

The authors’ other conclusions regarding LOS and time to anion gap closure, as well as the risks of hypoglycemia and hypokalemia, are likely to be very specific to the hospital, patient, protocol, and provider factors in this retrospective implementation study and are not generalizable to other settings. For instance, in this study, the mild-to-moderate DKA patients who received SC insulin had a longer time to AG closure than those who received IV insulin, but in the Squid II Griffey study in 2024, the mild-to-moderate DKA patients who received SC insulin had a shorter time to AG closure than those who received IV insulin.

SGEM Bottom Line: Rapid-acting SC insulin is a reasonable alternative to IV insulin infusion for the treatment of mild-to-moderate adult DKA in hospitals with appropriate resources.

Case Resolution: For the 56-year-old woman in the case, I would not automatically default to an ICU bed and IV insulin just because the diagnosis is DKA. If she remains alert, hemodynamically stable, and clearly has mild-to-moderate hyperglycemic DKA without shock, no concerning comorbidities requiring ICU-level care, and your site has a protocolized SC pathway with frequent glucose/lab monitoring and potassium oversight, an SC insulin strategy would be reasonable. If your department lacks that infrastructure, or if she drifts toward severe DKA, altered mentation, or there is diagnostic uncertainty, I would stick with traditional IV insulin and monitored care.

Dr. Matt McArthur

Clinical Application: Emergency physicians should consider this study as another supportive paper for SC insulin treatment. It makes sense to consider this management for selected adults with mild, uncomplicated DKA who are nonpregnant, awake, hemodynamically stable, and able to receive frequent nursing assessment, point-of-care glucose checks, repeat electrolytes, potassium replacement, and a standardized basal-plus-rapid-acting insulin protocol. This is especially attractive in systems where IV insulin automatically triggers ICU admission or prolonged ED boarding. But IV insulin should remain the default for severe DKA, altered mental status, shock, pregnancy, major comorbidity, need for surgery, unreliable monitoring environments, and probably for many cases of euglycemic DKA until stronger data arrive.

What Do I Tell the Patient? You have diabetic ketoacidosis, also called DKA. This happens when your body does not have enough insulin. Your blood sugar becomes very high, and your body starts making acids called ketones. This can cause dehydration and lead to an imbalance in your body’s salt levels. DKA can be dangerous if left untreated.

Treatment for DKA includes IV fluids to help with dehydration and insulin to bring your blood sugar and body chemistry back to normal. We will need to check your blood sugar and lab tests often while you are being treated. This means we admit you to the intensive care unit (ICU) for close monitoring. Even with good treatment, DKA can take many hours to get better.

Some hospitals use subcutaneous insulin injections instead of an insulin drip for certain patients with mild-to-moderate DKA. These treatments may work just as well in some people and may help avoid an ICU stay. Our hospital may use this type of treatment in the future, but right now, we use the IV insulin drip and ICU monitoring for patients like you.

Keener Kontest: Last episode’s winner was Dr. Steven Stelts. He knew that the two species of coffee consumed worldwide are Coffee arabica and Coffee canephora.

Listen to the SGEM podcast for this week’s question. If you know the answer, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shout-out.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

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  • Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic ketoacidosis. Nature Reviews Disease Primers. 2020 May 14;6(1):40.
  • Gilchrist HE, Hatton CJ, Roginski MA, Esteves AM. Impact on Diabetic Ketoacidosis Resolution After Implementation of a 2-Bag Fluid Order Set. Ann Pharmacother. 2023 Dec;57(12):1361-1366. doi: 10.1177/10600280231163838. Epub 2023 Apr 5. PMID: 37021360.
  • Griffey RT, Schneider RM, Girardi M, Yeary J, McCammon C, Frawley L, Ancona R, Cruz‐Bravo P. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. Academic Emergency Medicine. 2023 Aug;30(8):800-8.
  • Griffey RT, Schneider RM, Girardi M, et al. SQuID (subcutaneous insulin in diabetic ketoacidosis) II: Clinical and operational effectiveness. Acad Emerg Med. 2025;32:61-71. doi:10.1111/acem.15020
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  • Ibarra F Jr, Cruz M, Chinnock B, Sunde C, Campagne D, Uller M. Evaluation of an Alternative Approach to Managing Diabetic Ketoacidosis: Combination Rapid-Acting and Basal Subcutaneous Insulin (CRABI-DKA). Annals of Pharmacotherapy. 2026;60(1):15-22. doi:10.1177/10600280251331967
  • Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care. 2008 Nov;31(11):2081-5. doi: 10.2337/dc08-0509. Epub 2008 Aug 11. PMID: 18694978; PMCID: PMC2571050.
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  • Qiang JK, Kiss A, Yu W, Amaral AC, Shelton D, Notario L, Halperin I. Safety and Effectiveness of Subcutaneous Insulin for Management of Mild to Moderate Diabetic Ketoacidosis in Non-Pregnant Patients: A retrospective cohort study at a tertiary care centre. Canadian Journal of Diabetes. 2025 Oct 24.
  • Rao P, Jiang SF, Kipnis P, Patel DM, Katsnelson S, Madani S, Liu VX. Evaluation of outcomes following hospital-wide implementation of a subcutaneous insulin protocol for diabetic ketoacidosis. JAMA Network Open. 2022 Apr 1;5(4):e226417-.
  • Stuhr KU, LeeMaster R, Hickman AW, Reachi B, Pace W, Meek C. Subcutaneous insulin versus traditional intravenous insulin infusion in treatment of mild to moderate diabetic ketoacidosis. The Journal of Emergency Medicine. 2023 Sep 1;65(3):e221-8.
  • Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR. Hyperglycemic crises in adults with diabetes: a consensus report. Diabetes care. 2024 Aug 1;47(8):1257-75.