From the Guidelines
To transition from an insulin drip to subcutaneous insulin in DKA, subcutaneous basal insulin should be given 2 hours before intravenous infusion is discontinued, as recommended by the 2025 standards of care in diabetes 1. When transitioning, it is crucial to ensure the patient is clinically improving with resolved acidosis and the ability to eat. The total daily dose of subcutaneous insulin can be calculated based on the insulin infusion rate during the prior 6–8 hours when stable glycemic goals were achieved, or by using a weight-based approach, as suggested in the 2025 standards of care in diabetes 1.
- Key considerations for transitioning include:
- Calculating the total daily insulin dose based on the insulin infusion rate or weight-based dosing
- Dividing the total dose into basal and bolus components
- Using basal insulin analogs, such as glargine, detemir, or degludec, once or twice daily
- Administering rapid-acting insulin, like lispro, aspart, or glulisine, before meals for bolus insulin
- Monitoring blood glucose closely after transition to adjust insulin requirements as needed Emerging data also suggest that administering a low dose of basal insulin analog in addition to intravenous insulin infusion may reduce the duration of insulin infusion and length of hospital stay without increased risk of hypoglycemia, as noted in the 2025 standards of care in diabetes 1.
- It is essential to prevent rebound hyperglycemia while avoiding hypoglycemia during the transition by carefully planning the timing and dosing of subcutaneous insulin, as the transition protocol is associated with less morbidity and lower costs 1.
From the Research
Transitioning from Insulin Drip to Subcutaneous Insulin in DKA
- The process of transitioning from intravenous (IV) insulin to subcutaneous (SQ) insulin in patients with diabetic ketoacidosis (DKA) is crucial for patient care 2.
- Studies have shown that SQ insulin can be a safe and effective alternative to IV insulin for the treatment of mild to moderate DKA, with fewer hypoglycemic events 3.
- When transitioning from IV to SQ insulin, it is essential to evaluate the patient's clinical situation and calculate the proper SQ insulin dose 2.
- Factors that influence a safe transition include the patient's glucose level, anion gap, and serum bicarbonate level, with a serum bicarbonate level of ≤16 mEq/L being a predictor of transition failure 4.
- The choice of SQ insulin type is also important, with options including basal insulin analogs such as insulin degludec, which has a flat and stable glucose-lowering profile 5.
- In patients with type 2 diabetes, basal-bolus regimens with insulin analogs such as detemir and aspart have been shown to be effective and safe, with equivalent glycemic control and no differences in hypoglycemia compared to split-mixed regimens with human insulins 6.
- A stepwise approach to the transition, including the use of institutional and computerized protocols, can help promote safety and euglycemia 2.