How to transition from intravenous (IV) insulin drip to subcutaneous basal-bolus insulin regimen?

From the Guidelines

To transition from an insulin drip to a basal-bolus regimen, calculate the total daily insulin dose (TDID) based on the patient's insulin requirements over the previous 6-8 hours, and consider administering a low dose of basal insulin analog in addition to intravenous insulin infusion to reduce the duration of insulin infusion and length of hospital stay. This approach is supported by emerging data from several studies, including the 2024 standards of care in diabetes 1.

When calculating the TDID, multiply the hourly insulin rate by 24 to estimate the total daily dose. Divide this total into basal and bolus components: typically 50% for basal insulin (such as glargine or detemir) and 50% for mealtime bolus insulin (such as lispro, aspart, or regular insulin). Administer the first dose of basal insulin 2-4 hours before discontinuing the insulin drip to ensure adequate overlap and prevent hyperglycemia. For the bolus component, divide the allocated amount into three doses to be given before meals.

Key considerations in this transition include:

• Adjusting the insulin doses based on blood glucose monitoring, aiming for target ranges of 140-180 mg/dL for most hospitalized patients 1.
• Reducing the calculated TDID by 20% for patients with renal impairment, liver disease, or those at high risk for hypoglycemia.
• Ensuring correct dosing of concentrated insulin (U-200, U-300, or U-500) in the inpatient setting through meticulous pharmacy and nursing supervision 1.
• Implementing a standardized hospital-wide and nurse-initiated hypoglycemia treatment protocol to immediately address hypoglycemia 1.

This transition approach maintains glycemic control while shifting from continuous to intermittent insulin administration, reflecting the physiologic pattern of basal insulin secretion with mealtime increases, and is supported by the most recent guidelines and evidence 1.

From the FDA Drug Label

For the study, the patients' usual doses of insulin were held and blood glucose concentrations were allowed to reach a stable range of 200 to 260 mg/dL during a one to three hours run-in phase The run-in phase was followed by a 6-hour assessment phase. During the assessment phase, patients received intravenous Insulin Lispro at an initial infusion rate of 0. 5 units/hour. The infusion rate of Insulin Lispro could be adjusted at regular timed intervals to achieve and maintain blood glucose concentrations between 100 to 160 mg/dL.

The FDA drug label does not provide specific guidance on how to transition from an insulin drip to a basal-bolus dose. However, it does provide information on the administration of intravenous Insulin Lispro, including the initial infusion rate and the adjustment of the infusion rate to achieve and maintain target blood glucose concentrations.

• Key points to consider when transitioning from an insulin drip to a basal-bolus dose include:
  • The patient's current insulin requirements and blood glucose levels
  • The patient's usual doses of insulin and their response to insulin therapy
  • The need to adjust the infusion rate at regular timed intervals to achieve and maintain target blood glucose concentrations
  • The importance of monitoring blood glucose levels closely during the transition period
  • Consulting the patient's healthcare provider for specific guidance on transitioning from an insulin drip to a basal-bolus dose 2.

From the Research

Transitioning from Insulin Drip to Basal Bolus Dose

To transition from an insulin drip to a basal bolus dose, several factors need to be considered, including the patient's current insulin regimen, glucose levels, and lifestyle.

• The basal plus strategy, as discussed in 3, involves adding prandial insulin to basal insulin, starting with the meal that has the most significant impact on postprandial glucose values.
• According to 4, basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day and then titrated based on the patient's self-measured fasting plasma glucose to achieve an individualized target.
• The choice of basal insulin depends on various factors, including pharmacological properties, patient preferences, and lifestyle, as well as health insurance plan formularies, as mentioned in 5.
• Studies have shown that basal-bolus therapy using insulin glargine and insulin lispro is effective in managing diabetes mellitus, as discussed in 6.
• When switching basal insulins, a unit-to-unit switching approach is usually recommended, but this may not be appropriate for all patients and types of insulin, and glycemic control and risk of hypoglycemia must be closely monitored, as stated in 5.

Key Considerations

• The patient's current insulin regimen and glucose levels should be carefully evaluated before transitioning to a basal bolus dose.
• The choice of basal insulin and the titration strategy should be individualized based on the patient's needs and lifestyle.
• Close monitoring of glycemic control and risk of hypoglycemia is essential during the transition period, as mentioned in 4 and 5.
• Patient education and self-management are crucial for successful transition to a basal bolus dose, as emphasized in 4 and 7.

Basal Insulin Options

• Insulin glargine, detemir, and NPH are commonly used basal insulins, each with its own pharmacological properties and advantages, as discussed in 3, 4, and 7.
• The choice of basal insulin should be based on the patient's individual needs and lifestyle, as well as health insurance plan formularies, as mentioned in 5.