How to transition a patient with Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State (HHS) from an insulin infusion to a basal-bolus regimen?

Transitioning from Insulin Infusion to Basal-Bolus Regimen in DKA/HHS Patients

To safely transition a patient from insulin infusion to a subcutaneous basal-bolus regimen after DKA/HHS, administer basal insulin 2-4 hours before stopping the insulin infusion to prevent rebound hyperglycemia and recurrence of ketoacidosis.

Timing and Initial Dosing Strategy

1. Timing of transition:

   • Begin subcutaneous basal insulin 2-4 hours before discontinuing the IV insulin infusion 1
   • Continue IV insulin until the first dose of rapid-acting insulin is administered with a meal 1

2. Calculate Total Daily Dose (TDD):

   • Based on patient's weight: 0.5-0.6 units/kg/day for metabolically stable patients 2
   • For patients previously on high insulin doses (>0.6 units/kg/day): Reduce home TDD by 20% 1
   • For elderly patients, renal failure, or poor oral intake: Use lower starting doses (0.3 units/kg/day) 2

3. Distribution of insulin doses:

   • 50% as basal insulin (glargine, detemir, or degludec)
   • 50% as prandial insulin (divided across meals) 1, 2

Implementation Algorithm

1. Assess patient readiness for transition:

   • Resolution of acidosis (pH >7.3, bicarbonate >15 mEq/L)
   • Resolution of ketosis (anion gap normalized)
   • Patient able to eat and drink
   • Blood glucose <250 mg/dL and stable

2. Calculate insulin doses:

   • Example: For a 70 kg patient with no prior insulin use
   • TDD = 0.5 units/kg/day = 35 units
   • Basal insulin = 17-18 units (50% of TDD)
   • Prandial insulin = 17-18 units (divided as ~6 units per meal)

3. Administration schedule:

   • Give basal insulin (glargine/detemir/degludec) 2-4 hours before stopping IV insulin
   • Give first dose of rapid-acting insulin with the first meal
   • Continue IV insulin until first meal and rapid-acting insulin dose 1

Special Considerations

1. Recent evidence suggests:

   • Co-administration of basal insulin with IV insulin may accelerate ketoacidosis resolution 3
   • Low-dose basal insulin analog given during IV insulin infusion can prevent rebound hyperglycemia 1

2. Choice of insulin regimen:

   • A basal-bolus regimen with glargine and glulisine has shown a lower rate of hypoglycemia compared to NPH and regular insulin after resolution of DKA 4
   • 41% of patients on NPH/regular insulin experienced hypoglycemia vs. only 15% on glargine/glulisine 4

3. Monitoring after transition:

   • Check blood glucose before meals and at bedtime
   • Monitor for hypoglycemia (blood glucose <70 mg/dL)
   • Adjust insulin doses as needed based on blood glucose patterns

Common Pitfalls to Avoid

1. Discontinuing IV insulin too early before subcutaneous insulin has reached therapeutic levels, leading to rebound hyperglycemia and recurrence of ketoacidosis

2. Inappropriate insulin dosing:

   • Starting with too high doses in elderly or renally impaired patients
   • Using sliding scale insulin alone, which is inadequate for most hospitalized patients 2

3. Failing to account for nutritional status:

   • Withhold prandial insulin if poor oral intake 1
   • Adjust insulin doses based on carbohydrate intake

4. Neglecting to monitor potassium levels:

   • Co-administration of basal insulin with IV insulin may increase risk of hypokalemia 3
   • Monitor electrolytes closely during transition

By following this structured approach to transitioning from insulin infusion to a basal-bolus regimen, you can effectively manage patients recovering from DKA/HHS while minimizing the risk of complications such as rebound hyperglycemia, recurrent ketoacidosis, and hypoglycemia.