How to transition from Diabetic Ketoacidosis (DKA) insulin drip to basal-bolus insulin regimen?

From the Guidelines

To transition from a DKA insulin drip to basal-bolus insulin, the most effective approach is to initiate subcutaneous basal insulin immediately after stopping the insulin drip, with the dose calculated as half of the total daily insulin dose, and administer ultra-rapid insulin at the first meal, adapting the dose to the quantity of carbohydrates ingested, as recommended by the most recent and highest quality study 1.

Key Considerations

• The basal-bolus scheme is the most suitable in the postoperative period, taking into account variable nutritional supplies and insulin requirements, and it more faithfully replicates the physiology of the normal pancreas 1.
• The initial dose of slow insulin varies between 0.3 and 1.5 IU/kg, and several models have been proposed to assure the transition from IVES insulin to SC insulin, with the most widely used being that of Avanzini et al. 1.
• The change from IVES to SC insulin should be made when blood sugar levels are stable for at least 24 h and at resumption of feeding, and half of the total dose of IV insulin corresponds to the dose of slow insulin, the other half to the doses of an ultra-rapid analogue 1.

Practical Recommendations

• Maintain the electronic syringe until stable blood sugar levels are obtained, and stop the protocol for IVES insulin therapy at the resumption of oral feeding 1.
• Make the injection of slow insulin immediately after stopping the syringe, and make the injection of ultra-rapid analogue at the first meal, adapting it to the quantity of carbohydrates ingested 1.
• Allocate the total daily insulin dose, calculated based on the patient's weight, with 50% as basal insulin and 50% as bolus insulin divided among meals, as supported by another study 1.

Monitoring and Adjustments

• Ensure the patient is eating and drinking adequately, has resolved acidosis, and has a blood glucose <200-250 mg/dL before transitioning, and continue to monitor blood glucose closely after the transition, checking before meals and at bedtime.
• Adjust doses based on blood glucose patterns over the subsequent 24-48 hours, to achieve optimal glycemic control and minimize the risk of postoperative complications.

From the Research

Transitioning from DKA Insulin Drip to Basal Bolus Insulin

• The process of transitioning from a DKA insulin drip to basal bolus insulin involves careful consideration of the patient's insulin requirements and glucose levels 2.
• Studies have shown that co-administration of basal insulin with regular insulin infusion can accelerate ketoacidosis resolution and prevent rebound hyperglycemia 2.
• The use of long-acting insulin analogues, such as insulin glargine, has been suggested as a means of facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA 2, 3.
• Early administration of insulin glargine has been associated with a trend towards faster DKA resolution and a shorter duration of insulin infusion 3.

Key Considerations

• The dose of basal insulin should be initiated at a conservative level, such as 10 units/day or 0.1-0.2 units/kg/day, and titrated thereafter based on the patient's self-measured fasting plasma glucose levels 4.
• The goal of basal insulin therapy is to achieve an individualized target glucose level, usually between 80-130 mg/dL 4.
• It is essential to monitor the patient's glucose levels and adjust the basal insulin dose accordingly to avoid overbasalization, which can lead to hypoglycemia and other complications 4.

Potential Benefits and Risks

• The use of basal insulin in the management of DKA has been associated with several potential benefits, including faster resolution of ketoacidosis and prevention of rebound hyperglycemia 2, 3.
• However, the administration of an initial insulin bolus prior to a continuous infusion has been associated with an increased risk of hypokalemia and other adverse effects 5, 6.
• Therefore, careful consideration should be given to the potential benefits and risks of basal insulin therapy in the management of DKA, and patients should be closely monitored for any adverse effects 2, 5, 6, 3.