How do you calculate the glargine (insulin glargine) dose to transition a patient with Diabetic Ketoacidosis (DKA) off an insulin drip while on a D5 (5% dextrose) infusion?

From the Guidelines

To transition a patient with Diabetic Ketoacidosis (DKA) off an insulin drip while on D5 infusion, administer insulin glargine 0.3 units/kg as a subcutaneous injection 2 hours before discontinuing the insulin infusion, as recommended by the most recent guidelines 1. This approach is supported by emerging data showing that the administration of 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 and prevent rebound hyperglycemia without increased risk of hypoglycemia 1. For example, a 70 kg patient would receive 21 units of glargine. Some key points to consider when transitioning include:

• Continue the insulin drip and D5 infusion during this overlap period to maintain glycemic control and prevent rebound hyperglycemia.
• After stopping the insulin drip, initiate a basal-bolus insulin regimen with glargine once daily and rapid-acting insulin (like lispro, aspart, or glulisine) before meals.
• Monitor blood glucose every 1-2 hours during transition, aiming for levels between 140-180 mg/dL. The total daily dose of subcutaneous insulin can be calculated based on the insulin infusion rate during the prior 6–8 h when stable glycemic goals were achieved, based on prior home insulin dose, or following a weight-based approach 1. Adjust subsequent glargine doses based on the patient's response, typically to 0.2-0.25 units/kg once DKA has resolved. It is essential to ensure correct dosing by using a separate pen or vial for each person and by meticulous pharmacy and nursing supervision of the dose administered 1.

From the Research

Calculating Glargine Dose for Transitioning Off Insulin Drip

To calculate the glargine dose for transitioning a patient with Diabetic Ketoacidosis (DKA) off an insulin drip while on a D5 infusion, consider the following steps:

• Determine the total daily insulin requirement based on the patient's current insulin drip rate 2.
• Calculate 80% of the total daily insulin requirement, as this has been shown to result in the highest percentage of blood glucose values within the target range after conversion to subcutaneous insulin glargine 2.
• Administer the calculated dose of insulin glargine at the time of conversion from the insulin drip to subcutaneous insulin therapy.

Considerations for Patients with DKA

• Co-administration of glargine with intravenous insulin in patients with DKA has been shown to be safe and effective in facilitating transition to a subcutaneous regimen 3.
• However, this approach may be associated with an increased risk of hypokalemia, and patients should be closely monitored for this complication 3.
• The use of insulin glargine in patients with DKA has been shown to reduce the average time of recovery from DKA and the amount of required insulin, without incurring episodes of hypoglycemia and hypokalemia 4.

Key Findings

• A study published in 2017 found that co-administration of glargine with intravenous insulin in pediatric patients with DKA was safe and facilitated transition to a subcutaneous regimen 3.
• A 2006 study found that conversion from continuous insulin infusion to subcutaneously administered insulin glargine at a dose equal to 80% of the total daily insulin requirements resulted in the highest percentage of blood glucose values within the target range 2.
• A 2015 study found that adding glargine to the standard treatment of DKA reduced the average time of recovery from DKA, without incurring episodes of hypoglycemia and hypokalemia 4.