How to transition off insulin (intravenous glucose tolerance test) therapy in a patient with type 2 diabetes?

Transitioning from Intravenous Insulin to Subcutaneous Insulin in Type 2 Diabetes

When transitioning a patient with type 2 diabetes from intravenous insulin (insulin GTT) to subcutaneous insulin, administer subcutaneous basal insulin 2-4 hours before discontinuing the intravenous insulin infusion to prevent rebound hyperglycemia and maintain glycemic control. 1

Timing and Approach

• Subcutaneous basal insulin should be administered 2 hours before discontinuing the intravenous insulin infusion to prevent rebound hyperglycemia 1
• For patients with diabetic ketoacidosis (DKA), ensure resolution of acidosis and normalization of anion gap before transition 1
• Ensure the patient is hemodynamically stable (not on vasopressors), has a stable nutrition plan, and has stable glucose measurements for at least 4-6 hours before transition 1

Calculating the Subcutaneous Insulin Dose

• Calculate the total daily dose of subcutaneous insulin based on the insulin infusion rate during the prior 6-8 hours when stable glycemic goals were achieved 1
• For example, if the patient received an average of 1.5 units per hour, the estimated daily dose would be approximately 36 units/24 hours 1
• Alternative methods include using the patient's prior home insulin dose or following a weight-based approach 1
• For patients transitioning to concentrated insulin (U-200, U-300, or U-500), ensure correct dosing by using a separate insulin pen or vial for each patient and with meticulous pharmacy and nursing supervision 1

Insulin Regimen Selection

• For most patients, a basal-bolus insulin regimen is preferred over sliding scale insulin alone 1, 2
• For patients with poor oral intake or those taking nothing by mouth (NPO), use basal insulin or a basal plus correction insulin plan 1, 2
• For patients with adequate nutritional intake, use an insulin regimen with basal, prandial, and correction components 1, 2
• Emerging data shows that administration of 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 1

Special Considerations

• For patients with type 1 diabetes, never hold basal insulin, even during care transitions 2
• For patients receiving enteral feedings, consider NPH insulin every 8-12 hours 2
• For patients with steroid-induced hyperglycemia, NPH insulin may be administered concomitantly with steroids to address disproportionate daytime hyperglycemia 1

Monitoring and Follow-up

• Monitor blood glucose levels frequently after transition to detect and prevent hypoglycemia 1
• Implement a hypoglycemia management protocol to identify, treat, and prevent hypoglycemia 1
• Review treatment plans when blood glucose values <70 mg/dL (<3.9 mmol/L) are documented 1
• Schedule an outpatient follow-up visit with the primary care clinician, endocrinologist, or diabetes care and education specialist within 1 month of discharge 1

Common Pitfalls and How to Avoid Them

• Avoid using sliding scale insulin alone (correction insulin without basal insulin), as it is associated with poorer glycemic control 1, 2
• Avoid premixed insulin formulations for in-hospital use due to increased risk of hypoglycemia 2
• For patients with renal insufficiency, consider using lower insulin doses to prevent hypoglycemia 1
• Ensure meal delivery and nutritional insulin coverage are coordinated to prevent hyper/hypoglycemic events 2

Structured Discharge Planning

• Begin discharge planning at admission and update as patient needs change 1
• Include diabetes education prior to discharge, medication reconciliation with attention to access, and scheduled follow-up visits after discharge 1
• For patients discharged to home or assisted living, consider diabetes type and severity, effects of illness on blood glucose levels, and the patient's capabilities and preferences 1