DKA Transition to Subcutaneous Insulin

Continue fixed-rate IV insulin until ketoacidosis has resolved rather than stopping when glucose normalizes. Endotext defines resolution by pH greater than 7.3, bicarbonate at least 18 mmol/L, and plasma ketones below 0.6 mmol/L; anion-gap normalization is also used in transition protocols. WHO+1WHO[PDF] Clinical Practice Guidelines and Standards of Care of Diabetes ...PubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf

Assess oral intake before converting to a standard basal-bolus regimen. Once DKA has resolved and oral intake is adequate, discontinue IV insulin after appropriate subcutaneous coverage and give or resume rapid-acting insulin with meals. If oral intake remains poor, use a variable-rate insulin infusion with glucose-containing solutions rather than an unprotected transition to meal-based subcutaneous insulin. PubMedPubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf

A falling glucose concentration does not establish DKA resolution. When glucose falls below 250 mg/dL, reduce the IV insulin rate to 0.05 units/kg/hour and continue insulin with a glucose target of about 200 mg/dL while ketoacidosis clears; dextrose-containing fluids permit continued anti-ketogenic insulin delivery. PubMed+1PubMedManagement of adult diabetic ketoacidosis - PMC - NIHPubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf

For patients already taking long-acting insulin before admission, continue basal insulin during IV insulin treatment when feasible. This preserves basal coverage and facilitates transition to a basal-bolus regimen once ketoacidosis resolves. PubMedPubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf

For a newly diagnosed patient, initiate basal insulin at 0.15-0.3 units/kg as part of transition planning. Add rapid-acting insulin with meals only after DKA resolution and adequate oral intake. PubMedPubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf

If basal insulin was not administered during the IV insulin course, give the planned subcutaneous insulin dose and continue IV insulin for at least 1-2 additional hours. An electronic transition intervention specifically targeted IV insulin discontinuation without long-acting insulin in the prior 2-6 hours and reinforced a minimum 2-hour overlap. WHO+2WHO[PDF] Clinical Practice Guidelines and Standards of Care of Diabetes ...PubMedImproving Intravenous and Subcutaneous Insulin Overlap During Treatment of Diabetic Ketoacidosis: A Quality Improvement ProjectPubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf

Coadministration of long-acting basal insulin during IV insulin infusion is increasingly used. Trials summarized in a randomized-trial report found that glargine U-100 at 0.15-0.3 units/kg during IV insulin was associated with shorter time to DKA resolution, shorter IV insulin duration, shorter hospital stay, and less rebound hyperglycemia without increased hypoglycemia. Wolters KluwerWolters KluwerEarly insulin degludec with continuous... : Diabetes, Obesity and Metabolism

A systematic review and meta-analysis of randomized trials found no evidence that early basal insulin increased hypoglycemia; pooled hypokalemia rates were not significantly different, although a trend toward more hypokalemia was observed. Continue potassium monitoring because hypokalemia occurs in up to 55% of DKA cases. PubMedPubMedEarly subcutaneous basal insulin with intravenous insulin infusion for diabetic ketoacidosis management: A systematic review and meta‐analysis of randomised controlled trials - PMC

Early basal insulin is most useful when a predictable transition to basal-bolus therapy is expected or when failure to overlap insulin is a recurrent systems problem. It does not permit premature discontinuation of IV insulin: continue the infusion until biochemical DKA resolution. PubMed+2PubMedEarly subcutaneous basal insulin with intravenous insulin infusion for diabetic ketoacidosis management: A systematic review and meta‐analysis of randomised controlled trials - PMCPubMedManagement of adult diabetic ketoacidosis - PMC - NIHPubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf

During IV insulin therapy, check bedside glucose hourly and obtain serial basic metabolic testing to follow bicarbonate, anion gap, potassium, magnesium, and phosphate. These measurements identify persistent ketoacidosis and insulin-associated electrolyte shifts before transition. PubMed+1PubMedSuccess of Insulin Infusion Transitions in Moderate to Severe Diabetic Ketoacidosis With Transition Anion Gap of Less Than or Equal to 12 mEq/L Versus Greater Than 12 mEq/LPubMedManagement of adult diabetic ketoacidosis - PMC - NIH

At conversion, explicitly reconcile three orders: long-acting insulin administration, IV insulin stop time, and dextrose-containing fluid discontinuation. A quality-improvement protocol used a mandatory checklist for at least 2 hours of IV/SC overlap and guidance on stopping IV dextrose-containing fluids to reduce post-transition dysglycemia. PubMedPubMedImproving Intravenous and Subcutaneous Insulin Overlap During Treatment of Diabetic Ketoacidosis: A Quality Improvement Project

Treat post-transition glucose excursions as a possible coverage failure rather than assuming DKA has recurred. Reassess whether basal insulin was administered, whether there was a 1-2-hour overlap, whether prandial insulin matched nutrition, and whether biochemical resolution was documented before the infusion was stopped. WHO+2WHO[PDF] Clinical Practice Guidelines and Standards of Care of Diabetes ...PubMedImproving Intravenous and Subcutaneous Insulin Overlap During Treatment of Diabetic Ketoacidosis: A Quality Improvement ProjectPubMedDiabetic Ketoacidosis - Endotext - NCBI Bookshelf