Insulin Regimen After DKA Resolution
When DKA resolves and the patient can eat, start a basal-bolus insulin regimen using long-acting basal insulin (glargine) once daily plus rapid-acting insulin (lispro or aspart) before meals, which is safer and more effective than NPH/regular insulin combinations. 1, 2
Timing of Transition
Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping the IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia. 3, 1, 4, 5 This overlap period is critical—premature discontinuation of IV insulin before subcutaneous basal insulin takes effect will cause ketosis to recur. 4
Recommended Insulin Regimen
Preferred Approach: Basal-Bolus with Analogs
- Basal insulin: Glargine once daily (or detemir once or twice daily) 2
- Prandial insulin: Rapid-acting analog (lispro, aspart, or glulisine) before each meal 1, 2
- Correctional insulin: Same rapid-acting analog for hyperglycemia correction 1
This regimen resulted in significantly lower hypoglycemia rates (15% vs 41%, p=0.03) compared to NPH/regular insulin while achieving equivalent glycemic control. 2
Alternative (Less Preferred): NPH/Regular Insulin
- NPH insulin twice daily plus regular insulin before meals 3, 2
- This older regimen carries a 2.7-fold higher risk of hypoglycemia and should generally be avoided unless cost is prohibitive. 2
Dosing Considerations
While specific starting doses depend on the patient's weight, insulin sensitivity, and prior insulin requirements:
- Typical total daily dose ranges from 0.5-1.0 units/kg/day for most patients
- Split approximately 50% basal and 50% prandial (divided among three meals) 1
- Adjust based on home insulin doses if the patient was previously on insulin therapy
Monitoring Requirements
- Check blood glucose every 2-4 hours while the patient is fasting during the transition period 1, 5
- Once on subcutaneous insulin and eating, monitor pre-meal and bedtime glucose 1
- Continue monitoring electrolytes, particularly potassium, as insulin drives potassium intracellularly 3, 5
Critical Pitfalls to Avoid
Do not stop IV insulin without prior basal insulin administration—this is the most common error leading to DKA recurrence. The 2-4 hour overlap is mandatory because subcutaneous basal insulin requires time to reach therapeutic levels. 3, 1, 4, 5
Do not use only rapid-acting insulin without basal coverage—patients need continuous basal insulin to suppress hepatic glucose production and prevent ketogenesis between meals. 1, 2
Do not discharge patients on IV insulin—ensure complete transition to a sustainable subcutaneous regimen before discharge. 3, 5
Discharge Planning
Structured discharge planning should begin at admission and include: 3, 5
- Medication reconciliation with clear documentation of the new insulin regimen
- Patient education on insulin administration, glucose monitoring, and sick day management
- Follow-up appointment scheduled prior to discharge (increases attendance rates) 5
- Discharge summary transmitted to primary care clinician promptly 5