When can insulin infusion be discontinued in diabetic ketoacidosis (DKA)?

When to Discontinue Insulin Infusion in DKA

Discontinue the insulin infusion only after DKA has fully resolved (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH ≥7.3, and anion gap ≤12 mEq/L) AND the patient can tolerate oral intake AND subcutaneous basal insulin has been administered 2-4 hours prior to stopping the IV infusion. 1, 2

Resolution Criteria for DKA

Before considering discontinuation of insulin infusion, all of the following must be met:

• 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
• Patient able to eat and drink 1, 3

The 2025 American Diabetes Association guidelines emphasize using clinical judgment and not delaying discharge or level of care if these criteria are not perfectly met, though all should ideally be achieved. 1

Critical Transition Protocol

Timing of Subcutaneous Insulin Administration

The most critical pitfall to avoid is stopping IV insulin without prior basal insulin administration—this is the single most common error leading to DKA recurrence. 2

• Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping the IV insulin infusion 1, 2
• This overlap period prevents rebound hyperglycemia and ketoacidosis recurrence 2
• Continue the IV insulin infusion during this 2-4 hour overlap period 1

Subcutaneous Insulin Regimen

Once DKA resolves and the patient can eat:

• Initiate a multidose subcutaneous insulin regimen combining short/rapid-acting and intermediate/long-acting insulin 1, 2
• For newly diagnosed patients, start with approximately 0.5-1.0 units/kg/day as a multidose regimen 1
• For patients with known diabetes, base the regimen on their previous treatment history 1

Monitoring During Transition

Continue monitoring throughout the transition period:

• Check blood glucose every 2-4 hours until stable 1, 3
• Monitor serum electrolytes, particularly potassium, as insulin drives potassium intracellularly 1, 2, 3
• Measure venous pH, osmolality, and electrolytes every 2-4 hours until clinically stable 1, 3

Special Considerations

Glucose Management During Resolution

• When glucose falls to 150-200 mg/dL (DKA) or 200-250 mg/dL (HHS), add dextrose to IV fluids while continuing insulin infusion 1, 3
• This allows continued correction of ketoacidosis while preventing hypoglycemia 3
• Do not stop insulin infusion just because glucose normalizes—ketoacidosis resolution requires continued insulin 1

Anion Gap Threshold

Recent evidence suggests that transitioning at an anion gap >12 mEq/L may be safe in select patients, with one 2024 study showing no difference in transition success between AG ≤12 versus >12 mEq/L. 4 However, the established guideline threshold of ≤12 mEq/L remains the standard recommendation. 1

Alternative Approaches for Mild DKA

For mild DKA in select patients, subcutaneous rapid-acting insulin analogs every 1-2 hours may be used instead of IV infusion, though this is not standard for moderate-to-severe cases. 1, 5

Common Complications to Avoid

• Hyperglycemia from premature discontinuation of IV insulin without adequate subcutaneous coverage 1
• Hypoglycemia from overzealous insulin treatment—monitor glucose closely 1
• Hypokalemia from insulin administration driving potassium intracellularly—maintain potassium 4-5 mEq/L 1
• Recurrent DKA from stopping IV insulin before administering basal insulin 2