This week, Wil has some advice on what to do if you're heading off on vacation... but happen to forget your insulin. A very timely topic in these hot summer months.
Anonymous, type unknown, writes from the road: I’m on vacation and forgot my Lantus. How long can I go without it?
Wil@Ask D’Mine answers: Not long. If you’re type 1, you’re going to start getting very sick within a day and will likely go into DKA before your vacation is over. If you’re type 2, you’ll survive, but you’ll have a miserable vacation. You’ll be peeing all the time, your vision will get blurry, and you’ll get so grumpy that your traveling companions will likely leave you on the road somewhere and go on without you.
The solution, of course, is to find some insulin before you do anything else.
There are actually a number of options, depending on your exact circumstances and where you are; and it goes without saying that you have to avoid allcarbs while you seek out your replacement insulin.
Now, if you normally pick up your Lantus at a national chain pharmacy, a local outlet will have your prescription on their computer. In a perfect world you’d be able to breeze in and refill your prescription. Of course, if you haven’t noticed, it’s not a perfect world. When you go in you’ll likely be told that it’s “too early” to refill your prescription, and that your insurance won’t cover the medication that you need to survive your trip.
Yes indeedy. This is truly the greatest nation on Earth.
If this happens to you, first try calling the customer service folks at your insurance plan. The toll-free number is on the back of your insurance card. Tell them what’s going on and ask them to arrange for an approval. If need be, remind them how much cheaper it will be for them to pay for an extra refill than for a hospital visit.
Oh, speaking of hospital visits, if you get your insulin at a mom-and-pop pharmacy or via mail order back home, you can always look for a hospital where you’re vacationing. Hospitals always have insulin. You can walk into the ER, even though you are still fine at the moment, and tell them you are about to become an emergency. They can get you set up with at least some insulin, although probably only a day or two’s worth, not enough for your whole trip. Still this gives you some breathing room.
Another option is to call your doctor’s office and see if they can FAX a fresh prescription to a pharmacy where you’re staying. Your doc might also be able to intervene with the insurance if you’re stuck on the “too early to refill” stumbling block.
OK. But let’s say you’re in a small town in the Midwest. There’s no local hospital. There’s no chain pharmacy. It’s Sunday so you can’t get ahold of your doc. The only game in town is Walmart.
You’re gonna be fine.
Because Walmart pharmacies sell vials of older insulins that do not require a prescription in most states, at a price you can afford out of pocket, along with cheap syringes for the same. What you’ll need is the ReliOn “N.” This is an old-school basal insulin. It’s not what you’re used to, but it will keep you alive.
Now, your dosing won’t be the same. You’ll actually need more “N” than Lantus, and because “N” doesn’t last as long as Lantus, you’ll need to divide the dose into two shots — one in the morning and one in the late afternoon or early evening. To figure out how much to take in each shot, increase your Lantus dose by 20%, then divide that number in half. So, if your Lantus dose was, say, 40 units:
40 units of Lantus x 1.2 = 48 units of “N” needed per day. Each shot would be half that, or 24 units.
Two words of warning about “N.” The first is that it needs to be well-mixed before you load up a syringe. If you leave a vial of “N” sitting on a counter top for a while, it will settle into a thick white cloud on the bottom of the vial with a clear layer above it. You need to roll the vial back and forth in your hands until the two fluids are smoothly mixed together. It should look like thin milk. The second thing to know (or remember if you’re a diabetes old-timer) is that “N” has a distinct peak in its action curve. That means it works more strongly midway between shots, and that can trigger lows. Lunch will usually cover your morning peak, but a bedtime snack is a good idea to avoid a nocturnal low while using “N.”
Of course, if you also use fast-acting insulin and only forgot to bring along your Lantus, it’s possible to take injections of fast-acting throughout the day to keep your sugars in check, sorta like a poor man’s insulin pump. But it’s a hell of a lot of work and would require you to get up many times each night. How often would you need to do that?
Are you sitting down?
Realistically, for smooth control, I’d say every hour on the hour would be best. In this case you’d reduce your Lantus dose by 20%, then divide by 24 to know how much fast-acting insulin you should inject every hour to stand in for the Lantus. Using our example from before:
40 units of Lantus x 0.8 = 32 units of fast needed per day, so each shot would be 1/24 of that, or 1.3 units.
I think you can see the problem here. A third of a unit is hard to judge in a syringe, and impossible to take using a pen. Not to mention that getting up every hour all night long to take this piss-ant splat of insulin isn’t going to make for a dream vacation. You could probably get away with a shot every two hours, but I wouldn’t spread them out much more than that.
I’m sure some of you are thinking that as fast-acting insulin lasts four hours, why not just take a shot every four hours? And the answer is: That won’t work because of the peaks and valleys of fast-acting insulin. To try to create a steady state Lantus-like insulin action curve, you need to stack the fast-acting shots closely together so that all the peaks and valleys smooth each other out.
Now, I’m sure a lot of readers will be hard on you for forgetting your insulin. Not me. I know exactly what happened. You were packed the night before. All except for your Lantus, which you needed to take in the morning. In the last minute shuffle to get out the door, the Lantus got left on the bathroom counter top, where it’s still sitting at this very moment. As most folks take Lantus once a day, you didn’t even notice you’d left it behind until the next day.
I can feel the pit in your stomach that grew as you frantically rooted through your toiletry bag, the truth slowly dawning on you as panic set in.
So you need to go easy on yourself. As for the rest of you, unless you never, ever forgot anything in your life, you’ve got no right to cast the first stone. I’ve forgotten my meter, my CGM receiver, my cell phone, and once, years ago, I even forgot the baby (briefly).
Still, going forward, an ounce of prevention can make your life simpler in an emergency. Before your next vacation ask your doc for a paper script for your insulins — and any other meds you can’t live without—and keep them somewhere in your suitcase so the scripts are always with you when you travel.
You’ll probably never forget your insulin again, but if you do, having a prescription can save a lot of steps when it comes to getting a replacement in paradise.
“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.”