When is it appropriate to transition a patient from Glucommander (glucose management) to subcutaneous (subq) insulin?

From the Guidelines

Patients should be transitioned from Glucommander to subcutaneous insulin when they are clinically stable and their blood glucose levels have been controlled, with the first subcutaneous dose administered 2 hours before discontinuing the intravenous infusion, as recommended by the most recent guidelines 1.

Key Considerations for Transition

• The patient's clinical stability and controlled blood glucose levels are crucial for a successful transition.
• The total daily dose of subcutaneous insulin can be calculated based on the insulin infusion rate during the prior 6–8 hours when stable glycemic goals were achieved, based on prior home insulin dose, or following a weight-based approach 1.
• Emerging data suggest that administering a low dose (0.15–0.3 units/kg) of basal insulin analog in addition to intravenous insulin infusion may reduce the duration of insulin infusion and length of hospital stay and prevent rebound hyperglycemia without increased risk of hypoglycemia 1.

Transition Protocol

• Calculate the patient's total daily insulin dose (TDD) from the previous 6-8 hours of Glucommander use.
• Distribute the TDD into basal, nutritional, and correction components.
• Generally, 50% of the TDD should be given as basal insulin, while the remaining 50% is divided into mealtime insulin.
• Administer the first subcutaneous dose 2 hours before discontinuing the Glucommander to ensure continuous insulin coverage.

Monitoring and Adjustments

• Blood glucose monitoring should continue every 4-6 hours after transition to ensure the new regimen is effective, with adjustments made as needed.
• Meticulous supervision of the dose administered is crucial, especially when using concentrated insulin (U-200, U-300, or U-500) in the inpatient setting 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... See Full Prescribing Information for the recommended starting dosage in patients with type 2 diabetes (2.3) and how to change to Insulin Glargine from other insulins (2.4) Closely monitor glucose when switching to Insulin Glargine and during initial weeks thereafter. (2.4)

• Transitioning from Glucommander to subq insulin: The FDA drug label does not provide specific guidance on when to transition a patient from Glucommander to subq insulin.
• General guidance on switching insulins: The label for Insulin Glargine 2 recommends closely monitoring glucose when switching to Insulin Glargine and during the initial weeks thereafter.
• Clinical decision: It is recommended to individualize the decision to transition a patient from Glucommander to subq insulin based on their metabolic needs, blood glucose monitoring, and glycemic control.
• Key considerations:
  • The patient's current glucose control and insulin regimen
  • The potential need for dose adjustments and close glucose monitoring during the transition
  • The importance of rotating injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.

From the Research

Transitioning from Glucommander to Subq Insulin

• The decision to transition a patient from Glucommander (intravenous insulin) to subcutaneous insulin should be based on the patient's clinical situation and glycemic control 3.
• Studies have shown that transitioning from intravenous to subcutaneous insulin can be done safely and effectively using a stepwise approach, including evaluating the patient, calculating proper subcutaneous insulin doses, and deciding the appropriate type of subcutaneous insulin 3, 4.

Determining the Optimal Transition Percentage

• Research suggests that the optimal transition percentage from intravenous to subcutaneous insulin varies, with some studies recommending 50-59% 4, 60-69% 5, or 80% 6 of the total daily intravenous insulin requirements.
• A study found that transitioning to 50-59% of the 24-hour intravenous insulin requirements resulted in the highest rate of blood glucose concentrations within the target range (68%) 4.
• Another study suggested that an initial subcutaneous dose of 50% of basal intravenous insulin requirements can achieve glycemic targets without hypoglycemia in most patients 5.

Clinical Considerations

• The type of subcutaneous insulin used can also impact the transition, with options including insulin glargine 6, insulin detemir 5, and insulin aspart 6, 5.
• Patients with specific conditions, such as type 1 diabetes or end-stage renal disease, may require special consideration during the transition process 3.
• The use of institutional and computerized protocols can help promote safety and euglycemia during the transition from intravenous to subcutaneous insulin 3, 7.