Missed insulin dose

Diabetes & endocrinology
NHS Lothian

Long–acting insulin/intermediate-acting insulin

For example, lantus, abasaglar, tresiba, toujeo, insulatard, Humulin I, levemir

  • If the missed dose is <4 hours overdue then give the usual dose as a STAT prescription then back to the usual time for the next dose
  • If the missed dose is >4hours overdue then give 50% normal dose as a STAT prescription and then back to the usual time for the next dose (e.g. if they usually have 20units of lantus at 10pm and the missed dose is noticed at 7am then give 10units at 7am and the full 20units again at 10pm)
  • If the missed dose is >4hours overdue, and CBG >14mmol/L then in addition check capillary ketones and if raised give a correction dose as per the hyperglycaemia guideline

 

Adjustments for missed long-acting insulin dose

< 4 hours overdue
give usual evening meal dose
> 4 hours overdue
give 50% normal dose
> 4 hours overdue and CBG > 14mmol/

 

Mixed insulin

For example, Humulin M3, novomix30, humalog mix25, humalog mix50

  • If missed dose at  breakfast and <2hours overdue then give usual breakfast dose
  • If missed dose at breakfast and >2hours overdue then give half of the usual dose at lunchtime
  • If missed dose at evening meal and <2hours overdue then give usual evening meal dose
  • If missed dose at evening meal, >2hours overdue and CBG <14mmol then give 60% of dose as insulatard
  • If missed dose at evening meal, >2hours overdue and CBG >14mmol/L then give 60% of dose as insulatard and consider a correction dose of short-acting insulin as per the hyperglycaemia guideline

 

Adjustments for missed mixed insulin dose

Missed dose: breakfast
< 2 hours overdue
give usual breakfast dose
> 2 hours overdue
give half of the usual dose at lunchtime
Missed dose: evening meal
< 2 hours overdue
give usual evening meal dose
> 2 hours overdue
give 60% of dose as insulatard
> 2 and CBG > 14mmol/l

 

Short-acting insulin

For example, Novorapid, humulin S, apidra, fiasp, humalog

  • Most patients on basal bolus insulin who carbohydrate count will be an expert at their own diabetes. Unless the diabetes team have raised a concern about their ability to manage their diabetes, allow them to decide when and how much short-acting insulin to give.
  • If missed dose is <2hours overdue then give usual missed dose as a STAT and do not correct a high CBG for 4-5hours
  • If missed dose is >2hours overdue at breakfast or lunch, then check ketones, if ketones are <0.6 then withhold the missed dose and consider correcting a high CBG at next meal. If ketones are >0.6 the follow the ketone pathway 
  • If missed dose is > 2hours overdue at evening meal and CBG is <14mmol/L then do not give the dose
  • If missed dose is > 2hours overdue at evening meal, >6 hours pre-breakfast and CBG is >14 then check ketones, if ketones are >0.6 then follow the ketone and hyperglycaemia protocols.

 

Adjustments for missed short-acting insulin dose

Missed dose: any
Time overdue: < 2 hours
give usual missed dose as a STAT and do not correct a high CBG for 4-5 hours
Missed dose: breakfast or lunch
Time overdue: > 2 hours

check ketones:

  • if < 0.6 then withhold the missed dose and consider correcting a high CBG at next meal
  • if > 0.6 then follow the ketone pathway
Missed dose: evening meal
Time overdue: > 2 hours

check ketones:

  • if <0.6 withhold the missed dose. Consider a CAUTIOUS correction dose (half normal) if cbg >16
  • if >0.6 follow the ketone and hyperglycaemia pathway

 

Table of insulin types

Action Patient's usual insulin Ward stock
Rapid Novorapid, Apidra, Fiasp, Humalog, Lyumjev NOVORAPID
Short Actapid, Humulin S, Insuman Rapid ACTRAPID
Intermediate Insulatard, Humulin l, Insuman Basal, Levemir INSULATARD
Long Lantus, Abasaglar, Toujeo, Tresiba LANTUS
Fixed Mixture Humulin M3, Humalog Mix (25, 50), Insuman Comb (15, 25, 50), NovoMix 30 HUMULIN M3