# Situation: A 22-year-old woman with type 1 diabetes mellitus is brought to the emergency department after two days of vomiting, during which she stopped taking her insulin. She weighs 58 kg. Diabetic ketoacidosis (DKA) is diagnosed, and she is admitted to the intensive care unit. Later her DKA has resolved and she is eating. Subcutaneous insulin glargine is ordered to replace the intravenous (IV) insulin infusion. When should the nurse stop the insulin infusion?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 22-year-old woman with type 1 diabetes mellitus is brought to the emergency department after two days of vomiting, during which she stopped taking her insulin. She weighs 58 kg. Diabetic ketoacidosis (DKA) is diagnosed, and she is admitted to the intensive care unit.

Later her DKA has resolved and she is eating. Subcutaneous insulin glargine is ordered to replace the intravenous (IV) insulin infusion. When should the nurse stop the insulin infusion?

## 보기

1. Thirty minutes before the glargine is injected
2. At the same time the glargine is injected
3. One to two hours after the glargine is injected **✔ 정답**
4. Once her glucose is below 180 mg/dL (10.0 mmol/L)

**정답: 3**

## 해설

IV regular insulin stops acting within minutes, while subcutaneous basal insulin takes time to be absorbed. Giving the basal dose 1–2 hours before stopping the infusion prevents a gap in insulin that could cause rebound hyperglycemia and recurrent DKA.

## 심화 해설

Core mechanism

When DKA is treated with an intravenous regular insulin infusion, the insulin effect disappears within minutes after the infusion is stopped because regular insulin has a very short half-life. In contrast, subcutaneous insulin glargine is a basal insulin that must be absorbed from the subcutaneous depot before it produces a clinically meaningful glucose-lowering effect. If the IV infusion is stopped before the glargine has begun to work, a gap in insulin coverage occurs, allowing rebound hyperglycemia, ketogenesis, and recurrent DKA. The correct strategy is to overlap the two routes so that the basal insulin reaches effective plasma levels before the continuous IV insulin is discontinued.

Why the overlap timing matters

Subcutaneous glargine has a slow onset because it forms microprecipitates in the subcutaneous tissue after injection, from which insulin is gradually released. Clinically meaningful absorption and onset generally require 1–2 hours. Therefore, the nurse should inject the glargine and continue the IV insulin infusion for an additional 1–2 hours, then stop the infusion. This creates a seamless transition from intravenous to subcutaneous basal coverage.

Key point! The transition is not based solely on the current glucose value. Even if the glucose is below 180 mg/dL (10.0 mmol/L), stopping IV insulin without overlapping basal insulin can still cause rebound hyperglycemia and recurrent ketosis. The glucose threshold reflects DKA resolution, but it does not guarantee that the subcutaneous basal insulin is already effective.

Comparison of transition timing options

| Timing of stopping IV insulin | Expected effect | Risk |
| --- | --- | --- |
| Thirty minutes before glargine injection | IV insulin effect fades before glargine is even given | Insulin gap, rebound hyperglycemia, recurrent DKA |
| At the same time as glargine injection | IV insulin stops while glargine is still being absorbed | Partial insulin gap during the first 1–2 hours |
| One to two hours after glargine injection | Glargine reaches effective levels while IV insulin continues | Seamless transition, lowest risk of rebound DKA |
| Once glucose is below 180 mg/dL | Stopping based on glucose alone ignores insulin pharmacokinetics | May stop IV insulin before basal coverage is established |

Evidence from the literature

The rationale for early basal insulin administration during DKA management is supported by systematic reviews and randomized trials. A meta-analysis of RCTs evaluating early versus late initiation of long-acting insulin in pediatric and adult DKA found that early subcutaneous basal insulin during IV insulin infusion can improve the transition to subcutaneous therapy without increasing hypoglycemia [1]. Another systematic review and meta-analysis reported that early basal insulin administration during IV insulin therapy may improve glycemic outcomes in adults with DKA [2]. A randomized controlled trial using early insulin degludec with continuous IV insulin infusion also demonstrated that overlapping basal insulin with IV insulin is feasible and safe in DKA management [3]. In pediatric type 1 diabetes, early insulin glargine administration has been studied specifically to prevent rebound hyperglycemia and recurrent ketosis after DKA resolution [4]. These findings reinforce the principle that basal insulin should be given early enough to overlap with the IV infusion, rather than waiting until the infusion is stopped.

Clinical application for the nurse

When the patient is eating and the order is written to transition from IV insulin to subcutaneous glargine, the nurse should coordinate the timing so that the glargine is injected while the IV infusion is still running. The infusion is then stopped 1–2 hours after the glargine injection. During this overlap period, the nurse continues to monitor capillary glucose and ketones because the patient is still receiving both intravenous and subcutaneous insulin. Watch out! Stopping the IV insulin at the same time as the glargine injection, or earlier, creates a period without adequate insulin action even if the patient is euglycemic at that moment. The risk is not immediate hypoglycemia but delayed rebound hyperglycemia and recurrent DKA.References (research sources)

- [1]Early versus late initiation of long-acting insulin in paediatric and adult diabetic ketoacidosis: A systematic review and meta-analysis of randomised control trials.Meta-analysis/systematic reviewNguyen B, Quon S, Dhaliwal B, Warwas M, Stafford S. (2026) · DOI: 10.1111/dom.70542

- [2]Impact of Early Subcutaneous Basal Insulin With Intravenous Insulin Infusion for Diabetic Ketoacidosis and Glycaemic Outcomes: A Systematic Review and Meta-Analysis.Meta-analysis/systematic reviewAbuJlambo A, AbuZarifa M, Sawh RRR, Narayana Reddy N SR, Salman MB, Rampurawala IM, Ashour Y, Ayesh H. (2026) · DOI: 10.1002/edm2.70277

- [3]Early insulin degludec with continuous intravenous insulin infusion in the management of diabetic ketoacidosis: A randomized controlled trial.RCT/clinical trialThammakosol K, Jantarapootirat M, Traiwanatham S, Sriphrapradang C. (2025) · DOI: 10.1111/dom.70101

- [4]Management of diabetic ketoacidosis in children: Does early insulin glargine help improve outcomes?Research articleOhman-Hanson R, Alonso GT, Pyle L, McDonough R, Clements M. (2024) · DOI: 10.1111/1753-0407.13597

## 임상 시나리오

DKA IV to Subcutaneous Insulin TransitionOverlap glargine with IV insulin for 1-2 hours
IV regular insulin loses effect within minutes of stopping, while subcutaneous glargine requires 1-2 hours for absorption and onset. Inject glargine, then continue the IV infusion for 1-2 hours before discontinuing.

Transition timing is based on insulin pharmacokinetics, not solely on glucose value. Even if glucose is below 180 mg/dL, stopping IV insulin without overlap risks rebound hyperglycemia and recurrent ketosis.

CautionDo not stop the IV insulin before or at the same time as glargine injection. A coverage gap of even 30-60 minutes can trigger recurrent DKA.

## 핵심 개념

- **Insulin glargine** — Long-acting basal insulin that forms microprecipitates after subcutaneous injection, with onset of 1-2 hours and no pronounced peak.
- **IV regular insulin** — Short-acting insulin given intravenously during DKA; its glucose-lowering effect disappears within minutes after stopping the infusion.
- **Overlap transition** — Strategy of continuing IV insulin for 1-2 hours after giving subcutaneous basal insulin to prevent a coverage gap.
- **Rebound hyperglycemia** — Rapid rise in blood glucose due to insufficient insulin coverage, which can lead to recurrent ketogenesis and DKA.

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