Subcutaneous insulin after DKA

Maintain insulin infusion until resolution of acidosis, which typically takes longer than normalization of blood glucose levels, and is indicated by pH > 7.3, serum bicarbonate > 18 mEq/L (18 mmol/L), and resolution of ketosis (as indicated by blood beta-hydroxybutyrate [BOHB] < 1 mmol/L), and/or closure of the anion gap.

If IV access is not available, an alternative is subcutaneous injection of rapid-acting insulin (insulin lispro or insulin aspart) hourly or every 2 hours.

• This should not be used if peripheral circulation is impaired.
• The suggested dose is 0.15 units/kg every 2 hours starting 1 hour after initiating fluid replacement.
• Consider decreasing the dose to 0.1 units/kg every 2 hours if blood glucose decreases by > 90 mg/dL (5 mmol/L), even if dextrose is added.

The subcutaneous administration of short-acting insulin (insulin human regular) every 4 hours is also a safe and effective alternative to IV insulin infusion or rapid-acting insulin in children with pH ≥ 7.

• The suggested initial dose is 0.13-0.17 units/kg/dose every 4 hours (0.8-1 units/kg/day in divided doses).
• Increase or decrease doses by 10%-20% based on blood glucose levels prior to the insulin injection.
• Consider increasing dosing frequency to every 2-3 hours if acidosis does not improve.

Transition to subcutaneous insulin after DKA has resolved and oral intake is tolerated.

• For convenience, consider transitioning to subcutaneous insulin just before a meal.
• Consider using a dose of basal insulin, while the child is still receiving IV insulin, to assist in the transition from IV insulin to subcutaneous insulin.
• To allow sufficient time for absorption and to prevent rebound hyperglycemia, give the first subcutaneous insulin injection before stopping insulin infusion.
• IV insulin should be gradually tapered and stopped within 15-30 minutes of rapid acting subcutaneous insulin or 1-2 hours with long-acting subcutaneous insulin.
• Children with established diabetes should resume their usual home insulin regimen.
• Frequent blood glucose monitoring is required to avoid marked hyperglycemia and hypoglycemia.

Calculate the Total Daily Dose (TDD)
Determine the baseline 24-hour requirement:

The calculation depends entirely on whether the patient is newly diagnosed or has an established history of Type 1 Diabetes (T1D).

• New Diagnosis: 0.5 to 1.0 units/kg/day (typically starting at 0.5 – 0.75 units/kg/day for prepubertal; up to 1.0 unit/kg/day for pubertal patients).
• Established T1D: Resume home TDD. Adjust upwards by 10-20% only if previous control was poor or non-compliance triggered the DKA.