From the Guidelines
To transition a DKA patient from insulin infusion to subcutaneous insulin, subcutaneous basal insulin should be given 2 hours before intravenous infusion is discontinued, with the aim of minimizing rebound hyperglycemia while the subcutaneous insulin action rises. This approach is supported by the most recent and highest quality study, which emphasizes the importance of a transition protocol to reduce morbidity and costs of care 1. When transitioning, the total daily dose of subcutaneous insulin may be calculated based on the insulin infusion rate during the prior 6–8 hours when stable glycemic goals were achieved.
Key considerations for the transition include:
- Ensuring the patient is clinically stable with resolved acidosis (pH >7.3), anion gap normalized, glucose <200-250 mg/dL, and is able to eat.
- Calculating the total daily insulin dose based on the insulin infusion rate or using weight-based dosing (0.5-0.7 units/kg/day).
- Distributing the total dose as basal-bolus insulin, with approximately 50% as basal insulin and 50% as prandial insulin divided before meals.
- Continuing the insulin infusion for 1-2 hours after the first subcutaneous dose to prevent rebound hyperglycemia, as recommended by previous studies 1.
However, the most recent study 1 provides the most up-to-date guidance on transitioning from intravenous to subcutaneous insulin, emphasizing the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion to reduce the duration of insulin infusion and length of hospital stay without increased risk of hypoglycemia.
From the Research
Transitioning from Insulin Infusion to Subcutaneous Insulin
To transition a DKA patient from insulin infusion to subcutaneous insulin, several factors should be considered:
- The patient's anion gap (AG) should be evaluated, although the optimal threshold for transition is not well established 2
- The use of basal insulin analogues, such as long-acting insulin analogues, may facilitate the transition and prevent rebound hyperglycemia 3
- Concomitant administration of basal insulin analogues with regular insulin infusion may accelerate ketoacidosis resolution and prevent rebound hyperglycemia 3
Key Considerations
- The choice of subcutaneous insulin regimen, including the type and dose of insulin, should be individualized based on the patient's needs and response to treatment 4, 5
- The risk of hypoglycemia and hypokalemia should be monitored closely during the transition period 3, 6
- The patient's clinical status, including their level of consciousness, vital signs, and laboratory results, should be closely monitored during the transition period 2, 6
Available Evidence
- Several studies have investigated the use of subcutaneous insulin in the management of DKA, including randomized controlled trials and observational studies 6
- The evidence suggests that subcutaneous insulin may be a safe and effective alternative to intravenous insulin in selected patients with DKA 6
- However, the optimal dosing, patient selection criteria, and long-term outcomes of subcutaneous insulin therapy in DKA patients require further study 6