What to do if you think you missed your glargine (also known as Lantus™ and Optisulin™) insulin

Remember, the body must have insulin working 24 hours a day

Glargine is a long acting insulin generally given in the evening, that provides the body with a continues supply of insulin. It lasts about 24 hours. If there is no glargine and you have not given rapid acting insulin (NovoRapid™ / Humalog™) within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life threatening diabetic ketoacidosis (DKA).

What to do if missed dose (assuming dose is usually given in the evening)

Have I given my glargine? – I can’t remember!

If you are unsure if you gave your glargine you’ll need to regularly check your BGLs overnight. Ketones will need to be checked if your BGL is over 15 mmol/L. Without glargine, your BGL will start to rise as your dinner rapid acting insulin runs out (generally 4-5 hours after meal). Ketones of 1.0mmol/L or higher with high BGLs would suggest your glargine is missed. If so, follow the advice below, and work out a plan to stop this happening again.

You might try ticking your record book once you have given your dose of insulin, using a white board or setting a phone reminder.

Missing a dose but remembering before bed time

• give your regular glargine dose and return to normal routine time the next night
• check ketones, and if ketones are 1.0mmol/L or higher, in addition to your glargine, give 10% of total daily dose (TDD) of insulin as rapid acting insulin (dose explanation is in the box below)

Missing a dose and not realising until the morning (dose explanation is in the box below)

1. Check BGL and ketones

2. If ketones are less than 1.0mmol/L give 4 hourly rapid acting insulin (NovoRapid™/Humalog™) throughout the day and eat approximately 2 serves carbohydrate (CHO) with each injection (the total CHO intake will vary depending on age and normal meal size). Continue this until you give the evening dose of glargine

3. If ketones are 1.0 mmol/L or higher and associated with any change to conscious state, severe headache, abdominal pain or vomiting, give 10% of TDD rapid acting insulin immediately (see below) and seek urgent medical attention. You might be in DKA

4. If ketones are 1.0mmol/L or more at breakfast:

• Extra rapid acting (Novorapid™/Humalog™) is needed to clear ketones with breakfast
• Add 10% of the TDD to the breakfast dose
• Check BGL and ketones in 2 hours. Another 10% of TDD (rapid acting insulin) may be needed
• 4 hourly rapid acting dose must be given every 4 hours with approximately 2 serves CHO

5. If ketones are 1.0mmol/L or more and breakfast will not be eaten

• Give 10% of TDD as rapid acting insulin
• As soon as breakfast will be eaten and within at least 2 hours, give usual breakfast dose
• Check BGL and ketones in 2 hours. Another 10% of TDD (rapid acting insulin) may be needed
• 4 hourly rapid acting dose must be given every 4 hours with approximately 2 serves carbohydrate

6. If you are unsure what to do after reading the above advice, contact your treating diabetes team

Example

Missed glargine, realised in morning

Waking at 8am with high BGL and ketones after missing an evening dose of glargine:

• BGL is 21.3 and ketone levels are 2.4
• Extra insulin is needed

Regular doses:

• Pre breakfast: 5 units rapid acting
• Pre lunch: 8 units rapid acting
• Pre dinner: 6 units rapid acting
• glargine 15 units at 8pm

Total Daily Dose (TDD) = 5 + 8 + 6 + 15 = 34 units insulin

Calculations

1. 10% of TDD is given as an additional rapid acting insulin

• 10% of 34 = 3.4
  This is rounded to 3.5 units if using ½ unit pen or 3 units if using whole unit pens

2. 4 hourly rapid acting dose

• To calculate the amount of rapid acting insulin to give 4 hourly - take the TDD and÷ by 6
• TDD = 34
• 34 ÷ 6 = 5.7. This is rounded to 5.5 units if using ½ unit pen or 6 units if using whole unit pens

If well and willing to eat breakfast add 3.5 units to breakfast dose of 5 units = 8.5 units rapid acting insulin

• Check BGL and ketones in 2 hours. If ketones still 1.0 mmol/L or higher, consider anther 10% TDD as rapid acting insulin and contact medical services if concerned
• Continue with 4 hourly rapid acting dose for remainder of day with approximately 2 serves CHO until glargine is given again in the evening, In this example give rapid acting insulin at 12noon, 4pm and 8pm. Give glargine at usual evening time
• Resume usual insulin doses the following day

Please note: this is general advice and each child’s insulin plan will differ. The key points are:

• Without insulin in the body, BGLs and ketones will rise. If glargine is missed, rapid acting insulin must be given 4 hourly until glargine insulin is recommenced
• If there are any signs of DKA you must seek urgent medical care
• Seek medical advice if you don’t know what to do