Can insulin infusion be discontinued without bridging therapy?

From the Guidelines

Stopping an insulin drip without bridging is not recommended due to the risk of rebound hyperglycemia and potential complications such as diabetic ketoacidosis. When discontinuing an intravenous insulin infusion, a transition protocol to subcutaneous insulin administration with appropriate overlap is recommended, as it is associated with less morbidity and lower costs of care 1. The standard approach is to administer subcutaneous basal insulin 2 hours before stopping the insulin drip to ensure continuous insulin coverage.

Key Considerations

• For patients with type 1 diabetes, bridging is absolutely essential to prevent diabetic ketoacidosis.
• For type 2 diabetes patients, bridging may still be necessary depending on their insulin requirements and glycemic control.
• 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, based on prior home insulin dose, or following a weight-based approach 1.
• 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 without increased risk of hypoglycemia 1.

Transitioning 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 1.
• For people being transitioned to concentrated insulin (U-200, U-300, or U-500) in the inpatient setting, it is essential to ensure correct dosing by using a separate insulin pen or vial for each individual and by meticulous pharmacy and nursing supervision of the dose administered 1.

From the Research

Stopping Insulin Drip Without Bridging

• Stopping an insulin drip without bridging can lead to a rapid deterioration of glycemic control, as seen in a study where 41 medical and surgical intensive care patients on infusion insulin experienced deteriorating glycemic control within 48 hours of stopping the infusion 2.
• A transition protocol that identifies appropriate patients for subcutaneous insulin, along with the insulin dose and schedule, can help improve glycemic control when stopping an insulin infusion 2.
• The use of a protocol-driven approach can reduce the risk of hypoglycemia and improve glycemic control, as demonstrated in a study where patients transitioned by protocol had better glycemic control than those transitioned without the protocol 2.
• Frequent monitoring of blood glucose levels via bedside glucose testing is crucial in preventing large fluctuations in blood glucose levels when titrating an insulin drip 3.
• There is no direct evidence to suggest that stopping an insulin drip without bridging is safe or effective, and it is recommended to follow a transition protocol to ensure optimal glycemic control 2, 3.

Key Considerations

• Glycemic control can deteriorate rapidly after stopping an insulin infusion, highlighting the need for a transition protocol 2.
• The use of subcutaneous insulin, along with a transition protocol, can help improve glycemic control when stopping an insulin infusion 2.
• Frequent blood glucose monitoring is essential in preventing hypoglycemia and improving glycemic control when titrating an insulin drip 3.

Insulin Management

• Insulin detemir and insulin glargine have been compared in several studies, with results showing that they have similar efficacy and safety profiles in patients with type 1 and type 2 diabetes 4, 5, 6.
• The choice of insulin analog may depend on individual patient factors, such as the presence of hypoglycemia or weight gain 4, 5, 6.