From the Guidelines
To give overlap insulin in a patient with diabetic ketoacidosis (DKA), start subcutaneous insulin therapy 2 hours before discontinuing the intravenous insulin infusion, as recommended by the most recent guidelines 1. When transitioning from intravenous to subcutaneous insulin, it is essential to minimize rebound hyperglycemia and prevent recurrence of ketoacidosis.
- The administration of 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.
- For long-acting insulin, administer glargine or detemir at 0.25-0.5 units/kg once daily.
- For rapid-acting insulin, give lispro, aspart, or glulisine at 0.1-0.2 units/kg before meals. The total daily dose of subcutaneous insulin may be calculated based on the insulin infusion rate during the prior 6–8 h when stable glycemic goals were achieved, based on prior home insulin dose, or following a weight-based approach 1. It is crucial to monitor blood glucose levels closely during this transition period, typically every 2-4 hours, and adjust insulin doses as needed to prevent hypoglycemia and ensure adequate insulin levels.
- Ensure the patient is eating and drinking adequately before transitioning completely to subcutaneous insulin to prevent hypoglycemia. The use of bicarbonate in patients with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1. Successful transition from intravenous to subcutaneous insulin requires careful planning and monitoring to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
From the Research
Overlap Insulin in DKA Patients
To administer overlap insulin in patients with Diabetic Ketoacidosis (DKA), consider the following points:
- The transition from intravenous (IV) to subcutaneous (SQ) insulin is crucial in DKA management, and the anion gap (AG) is a key factor in determining the success of this transition 2.
- Studies have shown that SQ insulin can be an effective alternative to IV insulin for treating mild to moderate DKA, with fewer hypoglycemic events 3.
- Serum bicarbonate levels can predict the success of insulin transition, with levels ≤16 mEq/L associated with increased odds of transition failure 4.
Key Considerations
- When transitioning from IV to SQ insulin, monitor the patient's anion gap and serum bicarbonate levels closely 2, 4.
- Consider using SQ insulin protocols as an alternative to IV insulin for mild to moderate DKA, as they may reduce hypoglycemic events 3.
- Be aware of the pharmacokinetic and pharmacodynamic profiles of different insulin types, such as insulin degludec and insulin aspart, which can affect glucose-lowering efficacy and hypoglycemia risk 5, 6.
Insulin Types and Protocols
- Insulin degludec is an ultra-long-acting insulin analogue with a flat and stable glucose-lowering profile, which can be co-formulated with prandial insulin aspart for basal and mealtime insulin coverage 5.
- Insulin lispro protamine has been shown to reduce glycaemic variability and improve glycaemic control in people with type 1 diabetes, with fewer hypoglycaemic events compared to other insulin regimens 6.