Summary of findings for the main comparison. Subcutaneous insulin lispro versus intravenous regular insulin for diabetic ketoacidosis.

Subcutaneous insulin lispro versus intravenous regular insulin for diabetic ketoacidosis
Patient: participants with diabetic ketoacidosis Settings: emergency department and critical care unit Intervention: subcutaneous insulin lispro versus intravenous regular insulin
Outcomes	Illustrative comparative risks* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Intravenous regular insulin	Subcutaneous insulin lispro
All‐cause mortality (N) Mean hospital stay: 2‐7 days	See comment	See comment	Not estimable	156 (4)	⊕⊕⊕⊝ moderatea	No deaths reported
Hypoglycaemic episodes (N) Mean hospital stay: 2‐7 days	118 per 1000	70 per 1000 (27 to 180)	RR 0.59 (0.23 to 1.52)	156 (4)	⊕⊕⊝⊝ lowb	Comparable risk ratios for adults (4 trials) and children (1 trial)
Morbidity (N) Mean hospital stay: 2‐7 days	See comment	See comment	Not estimable	96 (2)	See comment	No cases of cerebral oedema, venous thrombosis, adult respiratory distress syndrome, hyperchloraemic acidosis
Adverse events other than hypoglycaemic episodes	See comment	See comment	Not estimable	See comment	See comment	Not investigated
Time to resolution of diabetic ketoacidosis (h) Mean hospital stay: 2‐4 days	The mean time to resolution of diabetic ketoacidosis across the intravenous regular insulin groups was 11 h	The mean time to resolution of diabetic ketoacidosis in the subcutaneous insulin lispro groups was 0.2 h higher (1.7 h lower to 2.1 h higher)	‐	90 (2)	⊕⊝⊝⊝ very lowc	Metabolic acidosis and ketosis took longer to resolve in the subcutaneous insulin lispro group in 1 trial (60 children); no exact data published
Patient satisfaction	See comment	See comment	Not estimable	See comment	See comment	Not investigated
Socioeconomic effects: length of hospital stay (days) Mean hospital stay: 4‐7 days	The mean length of hospital stay in the intravenous regular insulin groups ranged between 4 and 6.6 days	The mean length of hospital stay in the subcutaneous insulin lispro groups was 0.4 days shorter (1 day shorter to 0.2 days longer)	‐	90 (2)	⊕⊕⊝⊝ lowd	US setting: treatment of diabetic ketoacidosis in a non–intensive care setting (step‐down unit or general medicine ward) was associated with a 39% lower hospitalisation charge than was treatment with intravenous regular insulin in the intensive care unit (USD 8801 (SD USD 5549) vs USD 14,429 (SD USD 5243); the average hospitalisation charges per day were USD 3981 (SD USD 1067) for participants treated in an intensive care unit compared with USD 2682 (SD USD 636) for those treated in a non–intensive care setting
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; h: hours; RR: risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

*Assumed risk was derived from the event rates in the comparator groups.
 ^aDowngraded by one level because of imprecision (see Appendix 12).
 ^bDowngraded by two levels because of risk of performance bias and serious imprecision (see Appendix 12).
 ^cDowngraded by three levels because of risk of performance bias, serious risk of inconsistency, and serious risk of imprecision (see Appendix 12).
 ^dDowngraded by two levels because of serious risk of imprecision (see Appendix 12).