What is the best management plan for a patient with type 1 diabetes (T1D) on Lantus (insulin glargine) 11 units, who has recently resolved diabetic ketoacidosis (DKA) but is not eating?

Management of Type 1 Diabetes Patient with Resolved DKA Who Is Not Eating

For a type 1 diabetes patient on Lantus 11 units who has resolved DKA but is not eating, continue the basal insulin (Lantus) at the usual dose while carefully monitoring blood glucose levels and providing glucose as needed to prevent hypoglycemia.

Rationale for Continuing Basal Insulin

Patients with type 1 diabetes require continuous insulin coverage, even when not eating, to prevent recurrence of ketoacidosis. The American Diabetes Association guidelines emphasize that:

• For individuals with type 1 diabetes, insulin administration may be reduced as oral intake decreases but should never be stopped completely 1
• Even during fasting or reduced oral intake, basal insulin is necessary to suppress hepatic glucose production and prevent ketosis

Management Algorithm

1. Continue Lantus at usual dose (11 units)

   • Basal insulin is essential for patients with type 1 diabetes even during fasting periods
   • Abrupt discontinuation of insulin would rapidly lead to insulin deficiency and risk of recurrent DKA within hours 1

2. Monitor blood glucose frequently

   • Check capillary blood glucose every 1-2 hours initially
   • Target blood glucose range: 80-180 mg/dL (4.4-10.0 mmol/L) 1
   • More frequent monitoring may be needed if glucose levels are unstable

3. Provide supplemental glucose as needed

   • If blood glucose falls below 70-80 mg/dL, administer IV dextrose or oral glucose (if able to take oral fluids)
   • Consider D5W or D10W infusion to maintain blood glucose in target range while continuing basal insulin
   • For treatment of hypoglycemia (glucose <70 mg/dL), administer 15-20g of glucose and recheck in 15 minutes 1

4. Fluid management

   • Ensure adequate hydration with IV or oral fluids as appropriate
   • If patient can take oral fluids but not solid food, clear liquids containing glucose may help maintain glycemia

5. Monitor for recurrent ketosis

   • Check urine or blood ketones if blood glucose rises above 250 mg/dL
   • Rising ketones may indicate insufficient insulin coverage

Special Considerations

• Transition back to eating: When the patient resumes eating, continue basal insulin and add mealtime insulin based on carbohydrate intake 1

• Risk of hypoglycemia: The risk of hypoglycemia is increased during fasting periods, requiring vigilant monitoring and prompt intervention

• Avoid insulin discontinuation: For patients with type 1 diabetes, even during fasting, some amount of basal insulin is always required to prevent ketosis 2

Common Pitfalls to Avoid

1. Stopping basal insulin completely - This is dangerous in type 1 diabetes and can rapidly lead to recurrent DKA

2. Inadequate monitoring - Blood glucose should be checked frequently during this transitional period

3. Delayed transition to subcutaneous insulin - When transitioning from IV insulin for DKA treatment, basal insulin should be started 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1

4. Failure to provide glucose supplementation - When a patient is not eating but receiving basal insulin, supplemental glucose may be needed to prevent hypoglycemia

This approach balances the need for continued insulin coverage in type 1 diabetes with the prevention of hypoglycemia during periods of reduced oral intake, prioritizing patient safety while preventing recurrence of DKA.