When can an insulin drip be restarted in a patient with Hyperosmolar Hyperglycemic State (HHS) after correcting hypoglycemia with intravenous (IV) dextrose?

Restarting Insulin Drip After Hypoglycemia

Restart the insulin infusion immediately once blood glucose is confirmed above 70 mg/dL (or above 100 mg/dL in neurologic injury patients) following dextrose administration, without any waiting period. 1

Immediate Management of Hypoglycemia on Insulin Drip

When glucose drops below 70 mg/dL during insulin infusion:

• Stop the insulin infusion immediately and administer 10-20 g of hypertonic (50%) dextrose IV, with the dose titrated based on the initial hypoglycemic value to avoid overcorrection 1
• Recheck blood glucose in 15 minutes and give additional dextrose as needed until glucose exceeds 70 mg/dL 1
• The goal is to avoid iatrogenic hyperglycemia while correcting the hypoglycemia 1

Specific Dextrose Dosing Strategy

A patient-specific formula can guide dextrose administration:

• Calculate dextrose dose: 50% dextrose dose in grams = (100 − current BG) × 0.2 g 1
• This typically results in 10-20 g of IV dextrose, which is lower than traditional dosing and corrects glucose into target range in 98% of patients within 30 minutes 1
• Avoid rapid boluses of 25 g or more, as this produces excessive glucose elevation (median 169 mg/dL vs 112 mg/dL with titrated dosing) 1

Restarting the Insulin Infusion

There is no waiting period required before restarting insulin once hypoglycemia is corrected:

• Resume insulin infusion as soon as glucose is confirmed >70 mg/dL (>100 mg/dL for neurologic injury patients) 1
• Do not interrupt insulin therapy for prolonged periods, as this is a common cause of persistent or worsening hyperglycemia and ketoacidosis in DKA/HHS patients 2
• Continue monitoring glucose every 1-2 hours after restarting insulin to detect recurrent hypoglycemia 1

Critical Context for HHS Patients

In Hyperosmolar Hyperglycemic State specifically:

• Never discontinue insulin infusion simply because glucose is falling - the goal is gradual glucose reduction to 10-15 mmol/L (180-270 mg/dL) in the first 24 hours 3
• Add 5% or 10% dextrose to IV fluids when glucose falls below 14 mmol/L (252 mg/dL) while continuing insulin infusion 3, 4, 5
• The insulin infusion must continue until HHS resolves (osmolality <300 mOsm/kg, glucose <15 mmol/L, patient clinically improved), even if dextrose supplementation is required 3

Common Pitfalls to Avoid

• Do not wait hours before restarting insulin - hypoglycemia is associated with increased mortality (OR 3.233), but prolonged insulin interruption causes rebound hyperglycemia and worsening metabolic decompensation 1
• Do not overcorrect hypoglycemia with excessive dextrose - this creates glycemic variability which independently increases mortality risk 1
• Do not reduce insulin infusion rate preemptively when glucose is falling appropriately - instead, add dextrose to maintain glucose in target range while continuing insulin 2, 3

Monitoring After Restart

• Check glucose every 1-2 hours initially after restarting insulin to ensure stability and detect early recurrence of hypoglycemia 1
• Identify and address the cause of hypoglycemia (interruption of nutrition, renal failure, sepsis, excessive insulin rate) to prevent recurrence 1
• Monitor for severe hypoglycemia risk factors: diabetes mellitus, sepsis, shock, renal replacement therapy with bicarbonate, and nutrition interruption all increase risk 1