What discharge insulin regimen and management plan is appropriate for a patient with HbA1c 12% who presented with diabetic ketoacidosis, now stable on insulin glargine (Lantus) 8 units daily and maintaining glucose within target?

Discharge Insulin Regimen After DKA Resolution in Severe Uncontrolled Diabetes

This patient with HbA1c 12% who presented with DKA must be discharged on a basal-bolus insulin regimen, not basal insulin alone. 1

Why Basal Insulin Alone Is Insufficient

Your patient's HbA1c of 12% places them in the category requiring intensive insulin therapy at discharge. The current regimen of only Lantus 8 units maintaining glucose "within limits" during hospitalization does not reflect real-world conditions—hospitalized patients often have reduced oral intake, altered activity, and close monitoring that will not continue at home. 1

• Patients with HbA1c >10% should be discharged on a basal-bolus regimen or on a combination of preadmission oral agents plus 80% of hospital basal insulin dose. 1
• The guideline explicitly states this threshold because severe hyperglycemia (HbA1c 12%) indicates profound insulin deficiency that cannot be adequately controlled with basal insulin alone once normal eating resumes. 1

Recommended Discharge Regimen

Basal Insulin Component

• Discharge on insulin glargine (Lantus) at 80% of the hospital basal dose if the patient was previously on oral agents, or continue the current 8 units if glucose control was truly adequate throughout hospitalization with normal meals. 1
• However, given the HbA1c of 12%, the 8-unit dose is likely insufficient and was only "working" due to reduced caloric intake or stress-related factors during acute illness. 1

Prandial (Bolus) Insulin Component

• Add rapid-acting insulin (aspart, lispro, or glulisine) before each meal, starting at approximately 4 units per meal (roughly 10% of total daily insulin requirement per meal). 1, 2
• The total daily insulin requirement for a patient with HbA1c 12% is typically 0.4–0.5 units/kg/day; if the patient weighs 70 kg, this translates to 28–35 units total daily dose (TDD). 2
• Divide the TDD as 50% basal (14–18 units glargine once daily) and 50% prandial (split equally among three meals: 5–6 units rapid-acting insulin before each meal). 3

Correction (Supplemental) Insulin

• Provide a correction-dose scale using the same rapid-acting insulin: add 2 units for glucose 151–200 mg/dL, 4 units for 201–250 mg/dL, 6 units for 251–300 mg/dL, etc. 4
• This correction dose is given in addition to the scheduled prandial dose, not instead of it. 1

Critical Transition Protocol

Timing Before Discharge

• Administer the first dose of subcutaneous basal insulin (glargine) 2–4 hours before stopping any IV insulin infusion if the patient was still on IV insulin. 1, 3
• Continue IV insulin for 1–2 hours after the subcutaneous basal dose to ensure adequate absorption and prevent rebound hyperglycemia or DKA recurrence. 1, 3

Calculation Method (If Transitioning from IV Insulin)

• Use 50% of the total 24-hour IV insulin dose as the once-daily basal insulin dose. 1, 3
• Divide the remaining 50% equally among three meals as rapid-acting prandial insulin. 1, 3

Why Sliding-Scale Insulin Alone Is Dangerous

• Sliding-scale insulin (SSI) as monotherapy is strongly discouraged and is associated with poor glycemic outcomes, higher readmission rates, and increased morbidity. 1, 4, 5, 6, 2
• SSI is reactive (treats hyperglycemia after it occurs) rather than proactive (prevents hyperglycemia), leading to wide glucose fluctuations. 5, 6
• In the RABBIT 2 trial, patients treated with SSI alone had mean daily glucose 23–58 mg/dL higher than those on basal-bolus therapy, and 14% remained with glucose >240 mg/dL despite increasing SSI doses. 2

Oral Agents: Role at Discharge

• If the patient was previously on oral antidiabetic agents (metformin, sulfonylureas, DPP-4 inhibitors, etc.) and had acceptable control (HbA1c 8–10%), you could discharge on oral agents plus basal insulin at 50% of the hospital dose. 1
• However, with HbA1c 12%, oral agents alone or even with basal insulin are insufficient; a full basal-bolus regimen is mandatory. 1
• Consider adding metformin or a DPP-4 inhibitor (e.g., sitagliptin) once glucose stabilizes over 2–4 weeks, as these agents reduce insulin requirements and hypoglycemia risk in combination therapy. 1, 4

Discharge Education & Follow-Up

Patient/Caregiver Teaching

• Teach hypoglycemia recognition and treatment: 15 g fast-acting carbohydrate for glucose <70 mg/dL, recheck in 15 minutes. 4
• Demonstrate proper insulin injection technique, storage, and timing relative to meals (rapid-acting insulin 0–15 minutes before eating). 4, 7
• Provide written instructions distinguishing basal (once daily, same time) from prandial (before each meal) insulin. 4

Supplies & Prescriptions

• Prescribe insulin glargine, rapid-acting insulin analog, appropriate delivery devices (pens or syringes), blood glucose meter, ≥120 test strips (for 4-times-daily testing), lancets, and a glucagon emergency kit. 4
• Do not discharge without confirming the patient has these supplies in hand; lack of supplies is a common cause of readmission. 4

Follow-Up Timing

• Schedule outpatient follow-up within 1 week (not 1 month) after major insulin regimen changes or suboptimal control. 1, 4
• Arrange daily telephone contact during the first week to facilitate rapid insulin titration and prevent both hyper- and hypoglycemia. 4

Monitoring Requirements

• Check blood glucose before each meal and at bedtime (minimum 4 times daily). 4
• Notify provider for glucose <70 mg/dL or >400 mg/dL. 4
• Recheck HbA1c in 3 months to assess adequacy of the discharge regimen. 1

Common Pitfalls to Avoid

• Do not discharge on basal insulin alone when HbA1c is >10%; this predicts readmission for hyperglycemic complications. 1, 4
• Do not continue sliding-scale insulin as the sole regimen; it is ineffective and potentially dangerous. 1, 5, 6, 2
• Do not stop IV insulin (if applicable) without prior basal insulin administration 2–4 hours earlier; this is the most common error leading to DKA recurrence. 1, 3
• Do not abruptly discontinue oral medications when starting insulin; taper or continue them to avoid rebound hyperglycemia. 1, 7

Summary Algorithm

1. Calculate total daily insulin requirement: 0.4–0.5 units/kg for HbA1c 12%. 2
2. Divide as 50% basal (glargine once daily) and 50% prandial (rapid-acting insulin split equally before three meals). 1, 3
3. Add correction-dose scale using the same rapid-acting insulin. 4
4. Provide comprehensive discharge education, supplies, and 1-week follow-up. 1, 4
5. Consider adding metformin or DPP-4 inhibitor once glucose stabilizes. 1, 4