Comprehensive Guideline: Transitioning from IV Insulin to Subcutaneous Insulin in Type 1 Diabetes Mellitus (T1DM)

Proper transition from IV insulin infusion to subcutaneous (SC) insulin is crucial to avoid rebound hyperglycemia or hypoglycemia. This guideline covers the transition to:

✅ Basal-Bolus Regimen (Long-Acting + Regular Insulin)
✅ Premixed 70/30 Insulin
✅ Regular Insulin + NPH Combination

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🛑 Step 1: Confirm Readiness for Transition

Before switching, ensure DKA is resolved:
✔ Blood Glucose < 200 mg/dL (11.1 mmol/L)
✔ Bicarbonate (HCO₃⁻) ≥ 15 mEq/L
✔ pH ≥ 7.3
✔ Anion Gap < 12
✔ Patient is eating and stable

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💉 Step 2: Calculate Total Daily Insulin (TDI)

🔹 Formula:
👉 TDI = 0.5–0.7 units/kg/day

📌 Example (for a 60 kg patient, using 0.6 units/kg/day):
🔹 TDI = 60 × 0.6 = 36 units/day

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📌 Step 3: Choose an Insulin Regimen Based on Patient Needs

1️⃣ Basal-Bolus Regimen (Preferred for T1DM) 🏆

💉 Basal Insulin (Long-Acting) – 50% of TDI
✔ Glargine (Lantus) / Detemir (Levemir):
🔹 Example: 18 units at bedtime (or split into two doses if using Detemir)

💉 Prandial (Bolus) Insulin (Regular Insulin – R) – 50% of TDI
✔ Divide into 3 doses before meals
🔹 Breakfast: 6 units Regular (R)
🔹 Lunch: 6 units Regular (R)
🔹 Dinner: 6 units Regular (R)

📌 Administer long-acting insulin 2 hours before stopping IV insulin.

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2️⃣ Premixed 70/30 Insulin Regimen (If Necessary) 💊

🔹 Morning Dose (2/3 of TDI) → Before Breakfast
🔹 Evening Dose (1/3 of TDI) → Before Dinner

📌 Example (for 36 units TDI):
✔ Morning: 24 units (16 units NPH + 8 units Regular)
✔ Evening: 12 units (8 units NPH + 4 units Regular)

✅ Give the first 70/30 dose 2 hours before stopping IV insulin

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3️⃣ Regular + NPH Insulin Regimen (Alternative) 💉

💉 Morning Dose (2/3 of TDI as NPH + Regular in a 2:1 ratio)
✔ Example: 24 units total → 16 units NPH + 8 units Regular (R)

💉 Evening Dose (1/3 of TDI as NPH + Regular in a 1:1 ratio)
✔ Example: 12 units total → 6 units NPH + 6 units Regular (R)

✅ Give first dose of NPH + Regular insulin 2 hours before stopping IV insulin

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⏳ Step 4: Timing & IV Insulin Discontinuation

✅ Administer SC insulin at least 2 hours before stopping IV insulin
✅ Monitor glucose every 2–4 hours initially
✅ Adjust insulin doses based on glucose levels and meal patterns

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🩸 Step 5: Monitor & Adjust Insulin Doses

🔹 Check blood glucose every 2–4 hours initially
🔹 Adjust bolus doses based on carbohydrate intake and blood glucose trends
🔹 If hypoglycemia occurs, consider reducing doses or switching to a basal-bolus regimen

🚨 Caution:
⚠ Regular insulin (R) has a delayed onset (30–60 min) & longer duration (6–8 hrs), increasing hypoglycemia risk
⚠ Prefer rapid-acting insulin (Aspart/Lispro) over Regular insulin for better post-meal control
⚠ 70/30 insulin is NOT ideal for T1DM due to its fixed ratio and hypoglycemia risk

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📌 Summary: Best Practice Recommendation 🏆

✅ Preferred regimen: Basal-bolus using Glargine + Regular Insulin (R)
✅ Avoid 70/30 in T1DM unless no other option is available
✅ Monitor glucose closely to prevent hypoglycemia

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