In a patient receiving an insulin infusion for diabetic ketoacidosis, with blood glucose now 529 mg/dL after one hour, what is the next step in the treatment plan?

Continue the Current Insulin Infusion and Monitor Closely

With blood glucose at 529 mg/dL after one hour of insulin infusion for DKA, you should continue the current insulin infusion rate without adjustment, ensure adequate IV fluid resuscitation is ongoing, verify potassium is being appropriately replaced, and recheck glucose and electrolytes in 1-2 hours. 1

Why This Approach

The glucose of 529 mg/dL after one hour represents an appropriate response to insulin therapy in DKA. The 2025 ADA Standards of Care explicitly state that during DKA treatment, you should keep glucose between 150-200 mg/dL until resolution for DKA (or 200-250 mg/dL for HHS) 1. Your patient's glucose is still well above target, which is expected and appropriate at this early stage.

The Insulin Infusion Strategy

For moderate-to-severe DKA, guidelines recommend:

• Fixed-rate IV insulin infusion at 0.1 units/kg/hour (or 0.05 units/kg/hour for moderate-severe cases) 1
• Continue this rate until ketosis resolves, NOT until glucose normalizes
• The goal is resolution of acidosis and ketosis, not rapid glucose correction

Critical point: Do not chase the glucose number alone. Recent research confirms that low-dose insulin (0.05 units/kg/hour) is as effective as standard dose (0.1 units/kg/hour) with fewer complications, particularly less hypoglycemia (3.3% vs 13.3%) and hypokalemia (30% vs 43.3%) 2.

What You Must Do Now

1. Verify Adequate Fluid Resuscitation

• Ensure 0.9% NaCl or crystalloid is infusing at appropriate rate
• Target: replace 50% of estimated fluid deficit in first 8-12 hours 1
• Fluid resuscitation alone will lower glucose initially

2. Check and Manage Potassium Immediately

• If K+ <3.5 mEq/L: Hold insulin and give potassium; recheck every 2 hours 1
• If K+ 3.5-5.0 mEq/L: Add potassium to each liter of IV fluid to maintain K+ 4-5 mEq/L 1
• Hypokalemia occurs in ~50% of DKA cases during treatment and severe hypokalemia (<2.5 mEq/L) increases mortality 3

3. Monitor Appropriately

• Recheck glucose, electrolytes, venous pH, and osmolality every 2-4 hours until stable 1
• Use bedside capillary blood ketones if available (preferred monitoring method) 4
• Track anion gap closure and pH normalization—these matter more than glucose

4. When Glucose Falls Below 250 mg/dL

Add 5% or 10% dextrose to IV fluids while continuing the insulin infusion 1. This is essential—you need insulin to clear ketones even after glucose normalizes. A 2026 case report demonstrated that inadequate glucose supplementation with continued insulin led to persistent ketoacidosis despite euglycemia 5.

Common Pitfalls to Avoid

Do NOT:

• Reduce insulin rate just because glucose is falling—you're treating ketoacidosis, not hyperglycemia
• Stop insulin when glucose normalizes—this causes rebound ketoacidosis
• Give an insulin bolus now—a 2024 study showed boluses increase adverse events (45.8% vs 25%, primarily hypokalemia) without benefit 6
• Use arterial blood gases routinely—venous samples are adequate and less invasive 4

Do NOT add dextrose yet at glucose 529 mg/dL. Wait until glucose drops below 250 mg/dL (some protocols use <200 mg/dL threshold) 1.

Resolution Criteria

Continue current management until DKA resolves, defined as:

• Anion gap <12 mEq/L
• Venous pH >7.3
• Bicarbonate >15-18 mEq/L
• Blood ketones <0.6 mmol/L (if measured) 1

The glucose level of 529 mg/dL at one hour is not concerning—it's the metabolic acidosis that defines DKA severity and guides treatment duration, not the glucose value.