From the Guidelines
Early initiation of insulin glargine (Lantus) in diabetic ketoacidosis (DKA) management is beneficial and recommended, as it helps prevent rebound hyperglycemia and recurrence of ketoacidosis. According to recent guidelines, successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped 1. Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.
When implementing this approach, it is essential to consider the following key points:
- Start Lantus at a dose of 0.2-0.3 units/kg/day once the patient shows initial improvement with IV insulin therapy, typically when glucose levels fall below 200-250 mg/dL and the anion gap begins to close.
- Administer Lantus 2-4 hours before discontinuing the insulin infusion to ensure adequate basal insulin coverage.
- For patients with known diabetes already on basal insulin, resuming their home dose (or 80% of it if they've been NPO) is appropriate.
- Early basal insulin administration addresses the underlying insulin deficiency that caused DKA while the IV insulin resolves the acute metabolic derangements, creating a more physiologic insulin replacement strategy and potentially shortening hospital stays.
The use of basal insulin analogs like Lantus in DKA management is supported by recent studies, which have shown that this approach can be safer and more cost-effective than treatment with intravenous insulin alone 1. However, it is crucial to provide adequate fluid replacement, frequent POC blood glucose monitoring, treatment of any concurrent infections, and appropriate follow-up to avoid recurrent DKA.
From the FDA Drug Label
Insulin Glargine is not recommended for the treatment of diabetic ketoacidosis. The role of early insulin glargine (Lantus) in the management of diabetic ketoacidosis (DKA) is not supported.
- The FDA label explicitly states that Insulin Glargine is not recommended for the treatment of DKA 2.
- Therefore, it is not advised to use insulin glargine for the management of DKA.
From the Research
Role of Early Insulin Glargine in Diabetic Ketoacidosis Management
- The use of early insulin glargine in the management of diabetic ketoacidosis (DKA) has been investigated in several studies 3, 4, 5, 6, 7.
- A randomized controlled trial found that a basal bolus regimen with glargine and glulisine after resolution of DKA resulted in similar glycemic control but a lower rate of hypoglycemia than with NPH and regular insulin 3.
- Another study suggested that concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycemia 4.
- A randomized controlled trial found that early combination of insulin glargine with intravenous insulin infusion led to a faster DKA resolution and a shorter length of hospital stay, without increasing hypoglycemia and hypokalaemia 5.
- A systematic review with meta-analysis found that subcutaneously administered insulin glargine, in addition to standard treatment, significantly reduces the time to resolution of diabetic ketoacidosis 6.
- A retrospective cohort study found that early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and a shorter duration of insulin infusion 7.
Key Findings
- Early insulin glargine administration may reduce the time to resolution of DKA 5, 6, 7.
- Early insulin glargine administration may be associated with a shorter length of hospital stay 5.
- Early insulin glargine administration may not increase the risk of hypoglycemia or hypokalaemia 5.
- Basal bolus regimen with glargine and glulisine may result in a lower rate of hypoglycemia than with NPH and regular insulin 3.