At what insulin requirement can a patient transition from intravenous (IV) Glucommander (insulin) to subcutaneous (subq) administration?

From the Guidelines

The transition from Glucommander IV insulin to subcutaneous insulin should occur when the patient's insulin requirement stabilizes at less than 2 units per hour, with blood glucose levels consistently below 180 mg/dL, as recommended by the most recent guidelines 1. To make this transition safely, calculate the total daily insulin dose based on the insulin infusion rate during the prior 6–8 h when stable glycemic goals were achieved. The total daily dose of subcutaneous insulin may be calculated based on the insulin infusion rate, prior home insulin dose, or following a weight-based approach 1. Some key points to consider when transitioning from IV to subcutaneous insulin include:

• Administering subcutaneous basal insulin 2 h before intravenous infusion is discontinued to minimize rebound hyperglycemia 1
• Calculating the dose of basal insulin based on the insulin infusion rate during the last 6 h when stable glycemic goals were achieved 1
• Dividing the total daily insulin dose into basal and bolus components for subcutaneous administration
• Ensuring correct dosing and meticulous supervision of the dose administered, especially when using concentrated insulin 1
• Adopting and implementing a hypoglycemia prevention and management protocol to prevent episodes of hypoglycemia among inpatients 1. It's also important to note that emerging data suggests 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, and prevent rebound hyperglycemia without increased risk of hypoglycemia 1. Overall, the goal of transitioning from IV to subcutaneous insulin is to establish effective subcutaneous dosing while preventing dangerous gaps in insulin coverage and minimizing the risk of hypoglycemia and rebound hyperglycemia.

From the Research

Insulin Requirement for Transitioning from Glucomander IV to Subq

• The transition from intravenous (IV) to subcutaneous (Subq) insulin therapy is a crucial step in patient care, and several studies have investigated the safest and most effective method for this transition 2, 3, 4.
• A study published in the Journal of Diabetes Science and Technology in 2016 found that critically ill adults may be safely transitioned to 50-59% of their 24-hour IV insulin requirements 2.
• Another study published in the International Journal of Clinical Pharmacy in 2022 observed that patients were converted to Subq therapy using a lower transition percentage, with a median transition percentage of 45% [IQR: 28 - 69] 3.
• A review article published in Current Diabetes Reports in 2015 suggested a stepwise approach to the transition, including evaluating the patient and clinical situation, calculating proper Subq insulin doses, and deciding the appropriate type of Subq insulin 4.
• The total insulin requirement for transitioning from IV to Subq insulin therapy is not explicitly stated in the provided studies, but the studies suggest that the transition percentage is a critical factor in determining the safety and efficacy of the transition 2, 3.

Transition Percentage

• The study published in the Journal of Diabetes Science and Technology in 2016 found that the 50-59% group achieved the highest rate of blood glucose concentrations within the target range (68%) 2.
• The study published in the International Journal of Clinical Pharmacy in 2022 found that the median transition percentage was 45% [IQR: 28 - 69], but the study did not provide a clear recommendation for the optimal transition percentage 3.
• The review article published in Current Diabetes Reports in 2015 suggested that the transition percentage should be individualized based on the patient's clinical situation and insulin requirements 4.

Clinical Implications

• The studies suggest that a careful evaluation of the patient's clinical situation and insulin requirements is necessary to determine the safest and most effective method for transitioning from IV to Subq insulin therapy 2, 3, 4.
• The transition percentage is a critical factor in determining the safety and efficacy of the transition, and individualized approaches may be necessary to optimize patient outcomes 2, 3, 4.