What is the protocol for discontinuing an insulin (Regular Insulin) drip in a patient with Diabetic Ketoacidosis (DKA)?

From the Guidelines

To discontinue an insulin drip in diabetic ketoacidosis (DKA), administer subcutaneous basal insulin 2 hours before stopping the intravenous infusion, as recommended by the most recent guidelines 1. When discontinuing intravenous insulin, a transition protocol is crucial to minimize rebound hyperglycemia and prevent recurrence of ketoacidosis.

• The patient should have achieved metabolic stability, with a normalized anion gap (typically <12 mEq/L), blood glucose <200-250 mg/dL, and resolved acidosis (pH >7.3, bicarbonate >15 mEq/L) 1.
• Subcutaneous basal insulin should be initiated 2 hours before the intravenous insulin is stopped, with a dose of 0.25-0.5 units/kg/day, to ensure continuous insulin coverage 1.
• Mealtime rapid-acting insulin (like lispro, aspart, or glulisine) may be added if the patient is eating, to maintain adequate insulin levels and prevent hyperglycemia.
• Intravenous fluids should be continued until the patient is able to maintain adequate oral intake, to prevent dehydration and electrolyte imbalances.
• Patients should receive education about diabetes management, including blood glucose monitoring, insulin administration, and recognition of hyperglycemia symptoms, before discharge 1. The administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia, as reported in recent studies 1.
• It is essential to individualize treatment based on a careful clinical and laboratory assessment, and to treat any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke 1.
• The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.

From the Research

Discontinuing Insulin Drip in DKA

To discontinue an insulin drip in patients with diabetic ketoacidosis (DKA), several factors must be considered, including the patient's anion gap, serum bicarbonate levels, and the timing of insulin glargine administration.

• The anion gap is a critical factor in determining when to transition from intravenous insulin to subcutaneous insulin, as treatment guidelines recommend transitioning when the anion gap closes 2.
• However, transition failures due to recrudescent ketoacidosis can occur despite adherence to treatment protocols, and serum bicarbonate levels of ≤16 mEq/L have been associated with significantly increased odds of transition failure 2.
• Early administration of insulin glargine has been shown to be safe and potentially associated with a reduction in time to DKA resolution and a shorter duration of insulin infusion 3.
• The choice of insulin regimen, including the use of insulin glargine, detemir, or lispro protamine, can also impact glycaemic variability and control in patients with diabetes 4, 5, 6.

Key Considerations

• Serum bicarbonate levels should be considered when transitioning from intravenous to subcutaneous insulin, as levels of ≤16 mEq/L may be associated with increased odds of transition failure 2.
• Early administration of insulin glargine may be beneficial in reducing time to DKA resolution and shortening the duration of insulin infusion 3.
• The choice of insulin regimen should be individualized based on patient factors, such as glycaemic control and risk of hypoglycemia 4, 5, 6.