From the Guidelines
In diabetic ketoacidosis (DKA), you should switch from intravenous insulin to subcutaneous basal-bolus insulin when the patient is clinically stable, and administration of basal insulin 2–4 h before the intravenous insulin is stopped is recommended to prevent recurrence of ketoacidosis and rebound hyperglycemia. This approach is supported by recent guidelines, including the 2025 standards of care in diabetes, which emphasize the importance of a personalized approach for perioperative clinical management of individuals taking insulin 1. Key considerations for the transition include:
- Administering basal insulin 2–4 h before stopping intravenous insulin
- Using a low dose of basal insulin analog in addition to intravenous insulin infusion to prevent rebound hyperglycemia without increased risk of hypoglycemia
- Providing adequate fluid replacement, frequent point-of-care blood glucose monitoring, treatment of any concurrent infections, and appropriate follow-up to avoid recurrent DKA
- Considering the use of subcutaneous rapid-acting insulin analogs in the emergency department or step-down units for individuals with uncomplicated DKA, as this approach may be safer and more cost-effective than treatment with intravenous insulin 1. The goal is to ensure a smooth transition and prevent complications, with a focus on morbidity, mortality, and quality of life as the primary outcomes.
From the Research
Transitioning to Subcutaneous Basal Bolus Insulin in DKA
- The decision to switch back to subcutaneous basal bolus insulin in patients with diabetic ketoacidosis (DKA) depends on the resolution of ketoacidosis and the patient's individual needs 2, 3, 4.
- Studies have shown that a basal bolus regimen with glargine and glulisine is safer and more effective than NPH and regular insulin after the resolution of DKA, resulting in similar glycemic control but a lower rate of hypoglycemia 2.
- The use of long-acting insulin analogues, such as glargine, may facilitate the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy, preventing rebound hyperglycemia and ketogenesis 3, 4.
- Subcutaneous rapid-acting insulin analogs, such as aspart insulin, have been shown to be a safe and effective alternative to intravenous regular insulin in the management of patients with mild to moderate, uncomplicated DKA 5.
- A recent study found no difference in the success of insulin transition between patients with an anion gap (AG) ≤12 mEq/L and those with an AG >12 mEq/L, suggesting that the traditional threshold of AG ≤12 mEq/L may not be a reliable indicator of transition success 6.
Key Considerations
- The resolution of ketoacidosis, as indicated by the normalization of blood glucose and ketone levels, is a key factor in determining when to switch back to subcutaneous basal bolus insulin 2, 3, 4.
- The choice of insulin regimen, including the type and dose of insulin, should be individualized based on the patient's needs and response to treatment 2, 5.
- Close monitoring of blood glucose and ketone levels, as well as electrolyte levels, is essential during the transition from intravenous to subcutaneous insulin therapy 3, 6.