Need help navigating life with diabetes? Ask D'Mine! That would be our weekly advice column, hosted by veteran typ e   1, diabetes author and community educator Wil Dubois. This week he's offering some wisdom on what we people with diabetes (PWD) can do if and when we miss a dose of insulin... Yes, it happens. So, read on!

{Got your own questions? Email us at AskDMine@diabetesmine.com}

 

Edwin, type 2 from Maryland, writes: I have been diabetic for approximately 12 years. I take Humalog shots before meals, and one shot of 28 units of Lantus at bedtime. My question is, what do I do if I miss a bedtime Lantus shot, and I realize this the next day?  This is exactly what happened this morning. The previous night, I had stayed home watching movies and I had a few vodka martinis. I got sleepy, and just went to sleep. When I woke up, I realized I forgot my shot!

Wil@Ask D'Mine answers: Gotta watch out for those vodka martinis! But these kind of things can happen to all of us, with or without the martinis, so don't feel badly. Actually, I'm amazed you remembered in the morning. Maybe your blood sugar reminded you?  ;-)

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As to what to do about the missed shot, this is a trickier question than you might think. I'll give you my thoughts, but this probably falls into the "ask your doctor" category, which means that I need to remind everyone that my title of Doctor WilD is a purely honorary one, granted to me by an un-accredited mail-order "university" in the northeastern part of Liechtenstein. And on top of that, my honorary doctorate isn't a medical degree, but a PhD, and it isn't even in diabetes, it's in underwater basket weaving.

So, the medical disclaimer dispensed with, let us proceed...

Some missed meds should be taken as soon as you realize you missed them. With others, you need to wait until the next scheduled dose. The proper action for fixing an oh-shit-I-missed-my-med moment depends on the method of action of the med itself.

Lantus is, for all practical purposes, a time-released medicine. As such, you need to be careful about how much you take, and when. Consider that it's on the job for up to a full 24 hours. If you take your full dose the morning after, and then take your full dose again that night, you'll have twice as much insulin in your system as you need after you go to bed. That's called "stacking," because you're stacking up multiple insulin doses in your body. In your case, you could double your insulin dose for 12 hours in the middle of the night. The last half of the extra morning shot will still be on duty overnight, as well as the first half of the bedtime shot. That could end rather badly. As in you-not-living-to-see-the-dawn badly.

Again, ask your doctor, blah, blah, blah, yada, yada... but my opinion would be that you should take a half-dose of Lantus in the morning when you realize you missed out. Then take about two-thirds your usual dose that night, and then back to your full dose the following night. The alternative is to not take any Lantus the morning after, and use your Humalog to correct for high blood sugar throughout the day, assuming you've been taught how to do that.

Or do nothing at all. As a type 2, one day of bad blood sugar won't kill you; whereas heaps of too much Lantus could.

Now, one more "ask your doctor" note: There's no law that says Lantus needs to be taken at night. It's a 24-hour insulin. It doesn't frickin' matter which hour it's taken, so long as it's taken at more-or-less the same hour every day. Morning, noon, or night. Or any other time, for that matter.

For many people, wake-up time is a more predictable time than bedtime. So you could regularly get out of bed, brush your teeth, take your Lantus, and then make your martini.

 

Mary, type 1 from Wisconsin, writes: I did it again: I forgot to bolus before I ate and went high. When I realized, I took the bolus late, plus the correction my pump recommended, and then dropped to 51 while driving. I spent a half hour in a Road Ranger waiting for my blood sugar to creep back above 70 (they were very nice), so maybe that wasn't the best idea. So what's the best protocol here? I'm not doing this on purpose!

Wil@Ask D'Mine answers: No need to both hang a man first and then shoot him. One or the other will do just fine. You went low because you double-dipped.

Once you realize that you miss a meal bolus you need to either: (1) take the insulin for the meal, and deal with the fact that it's gonna take a while to catch up, or (2) blow off the meal insulin and take a correction for the high that was caused by missing the meal bolus. That'll take a while, too. But you can't do both.

If you take the missing food insulin plus insulin for the high blood sugar caused by missing the meal insulin, you've taken two solutions to the same problem. Make sense?

Hmm... I'm trying to think of a good analogy... It's like dropping two atom bombs on the same city. Sending two posses out after the same bank robber. Lighting a cigarette twice. Putting out a fire with both water and then a fire extinguisher.

OK. None of these analogies really does it for me.

What I'm trying to say, in short, is that it's overkill. Now, sometimes overkill can be a good thing. When one of those nasty eight-inch desert black-and-orange centipedes gets into my house I've been known to jump up and down on it for 15 minutes, spray it with Raid ultra-max nuclear bug killer, and then flush it down the toilet. Then I flush the toilet ten more times. You know. Just to make sure it's dead and gone and won't crawl its creepy little legs into bed with me. But insulin is another matter altogether. Because insulin is a workaholic.

It doesn't matter if there's nothing that it needs to do; insulin will make work for itself, if necessary. And insulin doesn't care if your blood sugar is just fine. Its job is to lower blood sugar, and by God, it's going to do its job. Under any circumstances. That's why we have to be careful not to have too many insulin workers on the jobsite and any given time.

Oh... I have it now.

Let's pretend you're a contractor building a tall gleaming glass skyscraper. You get to the jobsite early one morning and find no one is there. Crap! Where's the work crew?? Frantically, you call Ready Man Labor for temps. They promise to send a crew right away. But you get antsy waiting, so you also call Hard Hats For A Day, and ask them to send a crew, too. Both crews show up. So twice the work gets done. Fine for the skyscraper. Not so great for blood sugar. You don't want two insulin crews working on your blood sugar at the same time.

You wouldn't double your carb count for no reason. You wouldn't double your correction insulin for the hell of it. But that's what you did when you sent two teams of insulin out after the same sugar molecules.

So here's the deal. Moving forward, no more double-dipping. Ya gotta choose. One or the other. Pick a plan that makes sense to you, and stick to it. Of course, if you choose to chase the food with the insulin that should have gone with it (my preferred choice), you may still need a correction down the road. But not for at least three hours! And if you choose to take a correction for the high instead, you may still need another correction later. The digesting food may not have peaked yet.

As I said, it really doesn't matter which you do. The protocol isn't carved in stone. But pick a plan and stick to it!

And I'm glad to hear the Road Ranger folks treated you well. Oh, and do they serve vodka martinis in there, perchance?

 

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

 

 
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