How do we transition from an insulin drip to a modified sliding scale and Lantus (insulin glargine) for a patient with Diabetic Ketoacidosis (DKA)?

From the Guidelines

To transition from an insulin drip to a modified sliding scale and Lantus for a patient with Diabetic Ketoacidosis (DKA), calculate the total daily insulin dose (TDD) based on the patient's insulin drip rate over the past 6-8 hours, then administer long-acting insulin glargine (Lantus) at 50% of the calculated TDD, continuing the insulin drip for 2 hours after giving Lantus, and implement a modified sliding scale with rapid-acting insulin for the remaining 50% of TDD. When transitioning from an insulin drip to subcutaneous insulin for a DKA patient, it is crucial to ensure a smooth transition to maintain glycemic control and prevent recurrence of DKA. According to the standards of care in diabetes-2025 1, the transition should be based on the patient's clinical stability, with normal anion gap, glucose <200 mg/dL, and tolerating oral intake. The total daily insulin dose (TDD) can be estimated by multiplying the hourly insulin drip rate by 24.

• Key considerations during the transition include:
  • Calculating the TDD accurately to determine the appropriate dose of Lantus and modified sliding scale insulin
  • Administering Lantus at 50% of the calculated TDD to provide basal insulin coverage
  • Continuing the insulin drip for 2 hours after giving Lantus to ensure adequate insulin coverage during the transition
  • Implementing a modified sliding scale with rapid-acting insulin for the remaining 50% of TDD to address postprandial glucose excursions
  • Monitoring blood glucose every 4-6 hours during the transition and adjusting the regimen as needed. This approach is supported by the latest guidelines 1, which emphasize the importance of individualizing insulin therapy and transitioning from intravenous to subcutaneous insulin once the patient is clinically stable.

From the Research

Transitioning from Insulin Drip to Modified Sliding Scale and Lantus for DKA

• The process of transitioning from an insulin drip to a modified sliding scale and Lantus (insulin glargine) for a patient with Diabetic Ketoacidosis (DKA) involves careful consideration of the patient's insulin requirements and glucose levels 2, 3, 4.
• Studies have shown that the use of basal insulin analogues, such as Lantus, can facilitate the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA 2.
• The co-administration of basal insulin with regular insulin infusion has been shown to accelerate ketoacidosis resolution and prevent rebound hyperglycemia 2.
• A titratable insulin infusion order set has been associated with shorter hospitalization and reduced hypoglycemic events in adult patients with DKA 3.
• The use of subcutaneous insulin regimens, including rapid/short-acting insulin and basal insulin, has been shown to be as effective and safe as intravenous insulin infusions in the management of DKA 4.

Considerations for Transitioning to Modified Sliding Scale and Lantus

• The anion gap (AG) should be considered when transitioning from an insulin drip to a modified sliding scale and Lantus, although the optimal threshold for AG is not well established 5.
• The patient's insulin requirements and glucose levels should be closely monitored during the transition period to avoid hypoglycemia or hyperglycemia 2, 3, 4.
• The use of sliding scale insulin (SSI) has been discouraged in some guidelines, and factors associated with stopping SSI or transitioning to another short-acting insulin regimen should be considered 6.

Key Findings

• The success of insulin transition from an insulin drip to a modified sliding scale and Lantus is not significantly different between patients with an AG ≤12 mEq/L and those with an AG >12 mEq/L 5.
• The co-administration of basal insulin with regular insulin infusion is well tolerated and associated with faster resolution of acidosis without adverse effects 2.
• A titratable insulin infusion order set is associated with fewer days in the hospital and a significant reduction in hypoglycemic events 3.
• Subcutaneous insulin regimens may be as effective and safe as intravenous insulin infusions in the management of DKA 4.