How should I initiate an insulin (intravenous regular insulin) drip?

From the Guidelines

To start an insulin drip, begin with an initial infusion rate of 0.05 units/kg/hour, as recommended by the most recent guidelines 1. When initiating insulin therapy, it's crucial to consider the patient's weight, hydration status, and clinical condition.

• For patients with mild DKA, consider starting with 0.1 units/kg subcutaneous insulin or 0.05 units/kg/hour intravenous insulin 1.
• For patients with moderate or severe DKA, or those with cardiac compromise, start with 0.05 units/kg/hour intravenous insulin and adjust according to glucose levels and clinical status 1.
• Monitor blood glucose levels hourly until stable, then every 2-4 hours, and adjust the infusion rate accordingly to target a blood glucose range of 150-200 mg/dL for most hospitalized patients 1.
• Always check your institution's specific protocol as variations exist, and ensure you have dextrose solution available to treat hypoglycemia if needed. Key considerations include:
• Using short-acting insulin as a fixed-rate intravenous infusion or nurse-driven protocol with a variable rate based on glucose values 1.
• Giving potassium in each liter of intravenous fluid as needed to keep serum potassium between 4 and 5 mmol/L 1.
• Checking electrolytes, renal function, venous pH, osmolality, and glucose every 2-4 hours until stable 1. The most recent guidelines from 2025 1 provide the best evidence for initiating insulin drip therapy, superseding previous recommendations 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initiating Insulin Drip

To start an insulin drip, several factors must be considered, including the patient's condition, the type of insulin, and the dosage.

• The initial dose of insulin can vary depending on the patient's needs and the type of insulin being used 2.
• For hyperkalemia, 10 units of short-acting insulin may be given intravenously, or 20 units may be given as a continuous infusion over 60 minutes in severe cases 3.
• When initiating basal insulin, a conservative dose of 10 units/day or 0.1-0.2 units/kg/day is usually recommended, with titration based on fasting plasma glucose levels 2.
• However, the use of an initial insulin bolus in the treatment of diabetic ketoacidosis has been associated with more adverse effects, such as hypokalemia, without a corresponding benefit in time to resolution 4.

Considerations for Insulin Administration

When administering insulin, it is essential to consider the following:

• The risk of hypoglycemia, particularly when using large insulin doses, and the need for sufficient glucose to prevent hypoglycemia 5, 3.
• The importance of monitoring plasma glucose levels frequently, especially when using insulin therapy 5, 3.
• The potential for hypokalemia, especially when using insulin to treat hyperkalemia, and the need for careful monitoring of potassium levels 5, 3.

Dosage and Administration

The dosage and administration of insulin can vary depending on the specific condition being treated and the type of insulin being used.

• For hyperkalemia, insulin can be administered as a bolus or infusion, with or without glucose 5, 3.
• For basal insulin, the dose can be titrated based on fasting plasma glucose levels, with a goal of achieving an individualized target range 2.
• The use of insulin boluses or infusions should be carefully considered, taking into account the potential risks and benefits, as well as the individual patient's needs and condition 4.