How to start basal bolus insulin therapy after resolution of diabetic ketoacidosis (DKA)?

Transitioning to Basal-Bolus Insulin After DKA Resolution

After resolution of diabetic ketoacidosis (DKA), patients should be transitioned to a basal-bolus insulin regimen with long-acting insulin administered 2-4 hours before discontinuing the intravenous insulin infusion to prevent rebound hyperglycemia. 1, 2

Criteria for DKA Resolution

Before transitioning to subcutaneous insulin, ensure DKA has fully resolved with:

• Blood glucose <200 mg/dL 1, 3
• Serum bicarbonate ≥18 mEq/L 1, 3
• Venous pH >7.3 1, 3
• Anion gap ≤12 mEq/L 1, 3

Transition Protocol

Timing

• Administer basal insulin 2-4 hours before stopping the IV insulin infusion 1, 2
• Continue IV insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 3

Insulin Selection

• Use a combination of long-acting (basal) insulin and rapid-acting (bolus) insulin 1, 3
• A basal-bolus regimen with glargine (basal) and glulisine (bolus) has been shown to be safer with lower rates of hypoglycemia compared to NPH and regular insulin 4

Dosing Guidelines

• For newly diagnosed patients: start with approximately 0.5-0.8 units/kg/day total insulin 5
• Distribute as:
  • 50% as basal insulin (once or twice daily) 1, 2
  • 50% as bolus insulin divided before meals 1, 2

For Patients Previously on Insulin

• Base the regimen on previous insulin requirements before DKA 5
• Consider a 20% reduction from previous doses if the patient had significant insulin resistance during the acute illness 1

Special Considerations

Meal Planning

• When patient is able to eat, start the multiple-dose insulin regimen 3, 2
• If patient remains NPO (nothing by mouth):
  • Continue IV fluids with appropriate glucose concentration
  • Consider supplemental subcutaneous regular insulin every 4 hours as needed 3
  • For adults, give 5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL (up to 20 units for blood glucose of 300 mg/dL) 3

Monitoring During Transition

• Check blood glucose before meals and at bedtime 1
• Monitor for hypoglycemia (blood glucose <70 mg/dL) 4, 6
• Continue monitoring electrolytes, especially potassium 1, 3

Type 2 Diabetes Considerations

• Some type 2 diabetic patients may be discharged on oral agents and dietary therapy instead of insulin 5
• This applies primarily to patients with previously well-controlled type 2 diabetes where a clear precipitating factor for DKA was identified and resolved 1

Common Pitfalls to Avoid

• Premature discontinuation of IV insulin: Stopping IV insulin before subcutaneous insulin has taken effect can lead to rebound hyperglycemia and recurrence of ketosis 1, 3
• Inadequate overlap time: Failing to overlap IV and subcutaneous insulin administration by 1-2 hours 3, 2
• Inappropriate insulin selection: Using NPH and regular insulin instead of basal-bolus analogs increases hypoglycemia risk 4
• Insufficient monitoring: Not checking glucose levels frequently enough during transition 1, 3
• Overlooking potassium management: Insulin therapy can cause hypokalemia 1, 3

Recent evidence suggests that co-administration of basal insulin with IV insulin during DKA treatment may accelerate ketoacidosis resolution and facilitate an easier transition, though this approach requires further study 7, 8.