Transitioning from DKA Protocol to Subcutaneous Insulin
Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping the IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia. 1
Confirm DKA Resolution Before Transition
Before initiating any transition, verify that DKA has fully resolved by meeting ALL of the following criteria: 2, 1
Critical pitfall: Premature termination of insulin therapy before complete resolution of ketosis is a common cause of DKA recurrence. 1 Continue IV insulin until ALL resolution parameters are met, regardless of glucose levels. 1
Timing and Overlap Strategy
The transition requires a mandatory overlap period between basal subcutaneous insulin and IV insulin: 1
- Give basal insulin (glargine, detemir, or NPH) 2-4 hours before discontinuing IV insulin 1
- Continue IV insulin infusion during this overlap period 2, 1
- This overlap prevents the gap in insulin coverage that leads to rebound hyperglycemia and ketoacidosis recurrence 1
Alternative approach: Recent evidence suggests adding low-dose basal insulin analog during the IV insulin infusion (before DKA resolution) may prevent rebound hyperglycemia without increasing hypoglycemia risk. 1 This co-administration accelerates ketoacidosis resolution and allows for shorter duration of IV insulin. 3
Subcutaneous Insulin Regimen Selection
If Patient Can Eat
When the patient is able to eat, initiate a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin: 2, 1
Preferred regimen (based on superior safety profile):
- Basal-bolus with glargine once daily + rapid-acting analog (lispro, aspart, or glulisine) before meals 4
- This regimen results in significantly lower hypoglycemia rates (15% vs 41%) compared to NPH/regular insulin 4
- Provides similar glycemic control with better safety profile 4
Alternative regimen:
- NPH + regular insulin twice daily 4
- Higher hypoglycemia risk but acceptable if preferred analogs unavailable 4
If Patient Remains NPO
If DKA is resolved but patient cannot eat: 1
- Continue IV insulin and fluid replacement 1
- Supplement with subcutaneous regular insulin as needed 1
- Transition to full subcutaneous regimen once oral intake resumes 1
Monitoring During Transition
Continue close monitoring during and after the transition: 2
- Check glucose every 2-4 hours initially 2
- Monitor electrolytes, particularly potassium, as insulin requirements change 2
- Assess for signs of recurrent ketosis if hyperglycemia develops 1
Dextrose Management
When glucose falls to 200-250 mg/dL during IV insulin therapy: 2, 1
- Add 5% dextrose to IV fluids (with 0.45-0.75% NaCl) 2
- Continue insulin infusion despite lower glucose 2, 1
- Critical pitfall: Interrupting insulin when glucose normalizes is a common cause of persistent or worsening ketoacidosis 1
- Maintain glucose 150-200 mg/dL until complete DKA resolution 2
Common Pitfalls to Avoid
- Stopping IV insulin without prior basal insulin administration - leads to immediate loss of insulin coverage and ketoacidosis recurrence 1
- Insufficient overlap period - minimum 2 hours required for basal insulin to achieve therapeutic levels 1
- Transitioning before complete DKA resolution - all four resolution criteria must be met 1
- Inadequate potassium monitoring during transition - insulin requirements change and can affect potassium levels 2
Discharge Planning Considerations
Schedule follow-up within 1-2 weeks if glycemic management medications were changed or glucose control is not optimal at discharge. 2 Ensure medication reconciliation to verify no chronic medications were inadvertently stopped and confirm safety of new prescriptions. 2