Some Approaches if you Forget your Basal/Background Insulin

This is something most of us diabetics on MDI have gone through once or twice and it sucks. Whether it’s waking up in the morning with really high blood-sugar and thirst and realising you fell asleep before taking your shot, getting mixed up after changing your routine or whatever else- it happens and we feel stupid about it and frustrated, but like so many things with diabetes, it’s a small issue and easy to deal with once we understand how to deal with it properly.

There are three main approaches for when this happens, and none of which are better or worse than the others, nor set in stone. The best solution might depend on how long ago you took your last shot, or simply whichever you prefer.

First, you can choose to simply inject your full regular basal amount as soon as you realise. This is usually the best solution if it’s only an hour or two after you normally take your insulin like if you usually take it at 10pm but you were playing video games and got distracted until midnight. The two hour lapse isn’t going to make a huge difference if you haven’t eaten, but you should typically test your blood sugar anyway just in case you also need to administer a bolus correction.
Extra tip: In all cases you should take note, remember or set a reminder for the following day that you’ve taken insulin later than normal and so your chances of hypoglycemia during the following days overlap (if you go back to 10pm) are slightly riskier.

A Second option is to cover the rest of the day using bolus corrections. This is the most recommended approach if you’ve went more than 2 hours since your last basal shot. There are no hard and fast rules here- Should you inject extra units before meals? Should you take small correction shots throughout the day? And then there’s the added complication of chasing your rising blood sugar- your blood sugars may have already risen significantly and because of the typical 20 minutes to 2 hours to reach peak activation on fast acting insulins you might take too much and overcompensate, or you might never catch up. As a general rule I’ll test my blood sugars throughout the day and take a correction dose with an extra 15% units if I think I’m still rising.

A Third option is to take a reduced basal shot based on how long it’s been since your last one. This might be a better solution if you’re closer to your last shot than your next, so if you normally take your shot around 8pm and you realise you’ve missed it around 1am. If you normally take 30 units per day then divide by 24 and multiple by the number of hours left in the day. So 30 % 24 = 1.25. Divide this by the number of hours left in the day from your last shot- so 24 – 5 = 19, 19 x 1.25 = 23.75, or 24 units.
There are some problems with this approach- namely your background insulin might not be enough to cover your fasted glucose levels causing your blood sugar to rise. To compensate for this you might take a couple of small bolus corrections throughout the day to compensate. The other issue is that you’ll have an overlap the following day when you inject your regular 30 units. This overlap will be smaller than in the first approach, but might still be a concern, particularly if you’re normally sleeping during the overlap period.

None of these approaches consider medium profile insulins or NPH like Humulin and Levemir, and using a combination of an NPH with correction dosages, followed by your standard basal dosage may provide a better solution, but also includes a lot more calculations and numbers to worry about and so I recommend it only to those who are already very knowledgeable and familiar with what they’re doing and not the typical person who might find this page useful.

Remember too that elevated blood sugar coupled with lower levels of insulin in your system mean your ketone levels are likely to rise and that you should take extra care to drink lots of water throughout the day to help compensate.

Whichever approach you decide to take understand the added risks of hypoglycemia and test more than you normally would and you will minimise the problems of missing a basal shot. At the end of the day all it really is is a period of less than 24 hours of slightly elevated blood sugars and something every diabetic will likely have to learn at some point, take it as a learning experience at the price of small inconvenience.

Injecting in public and why I changed my mind about it

When I was first diagnosed I was still a teenager and came with all the traditional symptoms of teenagedom- arrogance, idiocy and a strong helping of insecurity and embarrassment about everything and anything in public places. I knew that things like breast feeding and taking insulin in public weren’t a big deal, I felt positive about it and felt everyone should feel no pressure or consciousness about doing so. Despite the way I thought about it I was still too self-conscious to do so. I even understood I was just being irrational and that nobody would care, but still the stigma of injecting, particularly the mental link to drugs and heroin which is still a big problem in Scotland, kept me unable or unwilling to do so. Whenever I ate out or around new people I’d always try to find a restroom or somewhere where I could be inconspicuous.

Public Space AnxietyIt wasn’t until nearly 3 or 4 years later and purely by chance that I happened to be waiting in a queue at McDonalds for a nice healthy Quarter Pounder with Fries when a lady in front of me mentioned to her friend that she’d need to take some insulin because of the food, reached into her bag and completely surrounded by other patrons and the general bustle of the food court, revved up some insulin and injected into her upper arm. No concern, no care, just doing what she needed to do. Nobody cared. Heck, nobody even noticed. The world didn’t skip a beat. I realised at that moment that I had been an idiot to even worry about what other people thought and ever since then I’ve had no issue or really even thought about taking insulin in public.

Having said that, there are plenty times when I get glanced now and I’ve had diabetic friends and reports online mention times when they’ve been asked by restaurant staff and even loved ones to move to a private space or leave if taking a shot and nothing could be more horrifying and affect your confidence more if you’re a person who gets affected that way. But since that moment I’ve realised that taking shots is part of my life and who I am. I understand that some people may find needles horrifying or disgusting, particularly when eating, but I make an effort to be discreet and I feel that’s compromise enough. Anyone who has a problem outside of that simply has a problem and they can live with it. Anxiety and apprehension are completely understandable and I would never tell someone they should or shouldn’t inject in public, but for me, coming to terms with the fact that almost nobody cares and even when they do I’d rather someone judge me negatively than marginalise my health, and that’s what works for me.

My Hyperglycaemia Symptoms, or the lack thereof

Something I don’t hear or see discussed very often by diabetics is the symptoms and feeling of hyperglycaemia or high blood sugar. I think this is due to a combination of factors, most notably that they’re more subtle and harder to identify than hypoglycaemia, and for some people they may feel easier to deal with because they don’t have as immediate an affect. As for me, I’m one of the people who’s probably more scared of high blood sugars than low blood sugars because I know the complications and things that affect quality of life for diabetics (particularly vision and the nervous system) are more related to hyperglycaemia over longer periods of time. So I try to spend more time and attention on highs when looking at my blood sugar graphs than I do with hypos, and more time worrying about it overall. It’s frustrating then, that highs are so much more difficult to be aware of and deal with quickly than lows. Fast acting insulin is a huge and valuable part of this but knowing when you should or shouldn’t react to high blood sugar after eating a meal and working out the minutia of how much longer your blood sugar is likely to go up for is particularly difficult, and it’s frankly a long, drawn-out pain in the arse to deal with.

The top results on Google for hyperglycaemia symptoms all list thirst and urination but in my experience this tends to be only when you’ve had elevated blood sugar for at least an hour or two, or you’ve already drank a lot of liquids, and by this time some of the damage has already been done. Fatigue and headache are also common symptoms but I’ve never personally suffered or been aware of either. Finally blurred vision is listed and again, I don’t typically notice this or at least don’t think this describes it accurately enough. Instead I find my vision and mental focus narrowing the higher I get, almost like tunnel vision or narrowing vision with bright blurring around the edges, and brightness or white patches seems to become more noticeable, sort of like applying a saturation filter in Photoshop or having too much exposure in a photograph. Either way, this is still a late symptom for me and I’ll usually only begin to notice it when I’m above the 16mmol/l or 300mg/dl range, at which point other more noticeable symptoms like sweet/pungent breath, dry mouth and light headedness become apparent anyway.

Another late symptom I’ve noticed is listed as cramps, which apparently are quite common for others. This is probably my most recognisable symptom and quite consistent once I reach a certain high blood sugar stage. It feels like my muscles are pulling tighter and together, sort of like how I feel after a really short but hard and intense workout where l feel the effects of lactic acid seizing up my muscles. This makes sense in a correlative way considering lactate is used by the body in times of rapid stress on muscles (particularly lifting heavy weights and sprints) to aid short term in the use of glucose by the muscles, but that’s by the by.

It’s also important to know that the body tends to “acclimatise” in some ways to both high and low blood sugar over extended periods of time and false hypos where the symptoms of hypoglycaemia are felt but blood sugar is above a safe range, have been known about for a while. False hypos are talked about a bit more in depth here and has been studied in medicine briefly in the past. Suffice to say that it’s reasonable to assume that since hypo awareness is known to be increased when you’ve remained at an elevated blood sugar over a longer period of time, it’s reasonable to assume that the same and/or inverse are likely true, i.e. that hyper awareness may also be increased after remaining at a low or well controlled blood glucose level for a period of time. The takeaway is that keeping your blood sugar within the recommended range of 4.0 to 5.9 mmol/L or 70–99 mg/dL is the best thing you can do for awareness of highs, but that even this is unreliable or subtle at best in the early stages. There’s also the caveat that over time most diabetics tend to lose both hypo and hyper awareness to a degree and so this isn’t an option for many diabetics after a certain amount of time or a length of particularly bad control.

So what are some reliable early warning signs of high blood sugars? In short, I haven’t found any and unless you can afford the purported average of $20,000 (~£14,000) for a Diabetic Alert Dog or the current average of around £4,000/year for a CGM system then you’re going to have to rely on a combination of old fashioned regular testing, good control and lots of writing/recording your results. I find it frustrating having to leave something that damages my health over time in part to the whim of the cosmos, but like most things related to diabetes and life in general, the bigger picture is more important, and the better strategy is to plan and review until it becomes easier and takes less effort to manage while becoming less common.

A Little Background & Introduction

My name is Sean.

I woke up in hospital with Type 1 diabetes in 2001, confused and overwhelmed with information for a condition that I didn’t understand. It took me a long time to come to terms with even the basics of diabetes and even longer to control my blood-sugars within a healthy range. I’ve been learning and trying new things related to my disease (and dealing with the problems and frustrations) ever since then and slowly but surely I’ve gotten to the stage where I truly feel like I’m in control of my own health. is a place for me to share what I know, what I don’t (where I still go have trouble), and anything else I think could help others with, or related to someone with a diabetic condition and just my thoughts and feelings on my health.
I aim to create a simplified resource for people to understand and deal with diabetes and to boil down any complications and frustrations to as few components as possible.