How to transition a diabetic ketoacidosis (DKA) patient after anion gaps have closed?

From the Guidelines

To transition a DKA patient after anion gaps have closed, basal insulin should be administered 2 hours before discontinuing the intravenous insulin infusion, with the aim of minimizing rebound hyperglycemia while the subcutaneous insulin action rises, as recommended by the most recent guidelines 1. When transitioning a DKA patient, it is crucial to ensure a smooth shift from intravenous to subcutaneous insulin to prevent complications such as rebound hyperglycemia and ketoacidosis.

• The total daily dose of subcutaneous insulin can be calculated based on the insulin infusion rate during the prior 6–8 hours when stable glycemic goals were achieved, or based on prior home insulin dose, or following a weight-based approach 1.
• Emerging data suggest that administering a low dose (0.15–0.3 units/kg) 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.
• It is essential to ensure correct dosing, especially when using concentrated insulin (U-200, U-300, or U-500), by using a separate insulin pen or vial for each individual and by meticulous pharmacy and nursing supervision of the dose administered 1.
• The approach to transitioning should prioritize preventing rebound hyperglycemia by ensuring continuous insulin coverage during the transition, as the insulin drip has a short half-life while subcutaneous insulin takes time to reach therapeutic levels 1.
• Monitoring blood glucose regularly, maintaining potassium and electrolyte replacement as needed, and continuing intravenous fluids until the patient tolerates oral intake adequately are also critical components of the transition process.
• The administration of basal insulin 2–4 hours before stopping the intravenous insulin is a key strategy to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

From the Research

Transitioning a DKA Patient After Anion Gaps Have Closed

• The process of transitioning a diabetic ketoacidosis (DKA) patient after anion gaps have closed involves careful consideration of insulin administration and monitoring of the patient's condition 2, 3, 4, 5, 6.
• Studies have shown that co-administration of subcutaneous long-acting insulin analogs, such as glargine, with intravenous insulin can facilitate a safe and flexible transition to subcutaneous therapy 2.
• Subcutaneous insulin lispro has been shown to be effective in treating patients with uncomplicated DKA, with similar outcomes to intravenous regular insulin 3.
• Early administration of subcutaneous basal insulin has been explored as a potential strategy to improve outcomes in DKA patients, although results have been mixed 4.
• Subcutaneous insulin has been compared to traditional intravenous insulin infusion in the treatment of mild to moderate DKA, with some studies suggesting that subcutaneous insulin may be a safe and effective alternative 5, 6.
• Key considerations in transitioning a DKA patient include:
  • Monitoring of blood glucose and anion gap levels
  • Adjustment of insulin dosing and administration route as needed
  • Management of potential complications, such as hypoglycemia and hypokalemia
  • Coordination of care and communication with the patient's healthcare team 2, 3, 4, 5, 6.