Diabetes is a lifelong disease. In the course of long-term treatment, due to various reasons, it is inevitable that diabetic patients will miss their glucose-lowering drugs or forget to take insulin, which, if not handled properly, will inevitably cause significant fluctuations in blood sugar and thus affect the smooth control of the patient’s blood sugar.
Patients may ask how to remedy this situation when they encounter it clinically. The following factors should be taken into consideration when handling the situation: the efficacy characteristics of the missed (or forgotten) glucose-lowering drug, the time of the missed (or forgotten) drug and the blood glucose level at that time, etc. The type of glucose-lowering drug used is the key to determine the different remedies. The following is to discuss the handling of such problems with regard to oral hypoglycemic drugs and insulin respectively.
(A) How to remedy the omission of glucose-lowering drugs
At present, the main oral hypoglycemic drugs commonly used in clinical practice are sulfonylureas, mealtime glucose regulators, alpha-glucosidase inhibitors, biguanides, insulin sensitizers, DPP-4 inhibitors, etc. Here, we will talk about the remedial measures for missed doses of these drugs.
1.Leakage of sulfonylureas
There are many kinds of sulfonylureas, which can be divided into two categories: short-acting sulfonylureas and medium- and long-acting sulfonylureas.
Short-acting drugs (e.g., glucophage, Mepida, etc.) are usually required to be taken half an hour before each meal. If you don’t think about it until it’s time to eat, you can push back your meal time by half an hour. If your blood glucose is mildly elevated, you can increase your activity and not take a refill; if your blood glucose is significantly elevated, you can take a reduced refill at that time. If you remember that you missed the medication until the next meal, take a pre-meal blood glucose test. If the increase of blood glucose before meal is not obvious, you can still take the medication according to the original dose without any change; if the increase of blood glucose before meal is obvious, you can temporarily increase the dose of medication before meal or appropriately reduce the amount of food eaten at the meal to make the blood glucose return to the normal range as soon as possible. Do not add the drugs missed last time to the next time to avoid hypoglycemia.
Medium- and long-acting sulfonylureas include glipizide controlled-release tablets (Rexin), gliclazide extended-release tablets (Damacell extended-release tablets), and glimepiride (Amoxicillin). These drugs are taken once a day, half an hour before breakfast. If you miss a dose before breakfast and don’t remember until lunch, you can take the medication at the original dose, depending on your blood sugar. If you think of it after lunch, you can take half of the original dose as appropriate; if you miss it before or after dinner, you don’t need to take it to avoid nighttime hypoglycemia, then patients can control their blood sugar by reducing the amount of food and exercise at dinner, and wait until breakfast the next day to take the drug normally according to the plan.
2. Missing to take glinine drugs
The representative drugs of this kind are Repaglinide (Novaluron) and Naglinide (Tangli). The treatment of missed doses of these drugs is similar to that of short-acting sulfonylureas. If you remember that you have not taken the medication when you just finished eating, you can take it immediately; if you remember that you forgot to take the medication at the previous meal between meals, you should decide whether to reduce the dosage and take it according to the blood sugar monitoring results; if it is immediately time for the next meal, you should measure the blood sugar before the meal, and if the increase is not obvious, you do not need to change the medication and meal quantity; if the increase is obvious, you can increase the dosage of the medication before the meal or reduce the meal quantity to make the blood sugar return to the normal range as soon as possible and reduce the blood sugar. If the elevation of blood glucose is obvious, the dose of medication before meal can be increased or the amount of food eaten at this meal can be reduced, so that the blood glucose can be restored to the normal range as soon as possible and the effect caused by the missed medication can be reduced.
3.Leakage of α-glucosidase inhibitors
Alpha-glucosidase inhibitors include acarbose (Bactrim, Carboplatin) and voglibose (such as Bexin), etc. These drugs mainly lower blood sugar (mainly postprandial blood sugar) by delaying the absorption of carbohydrates in the intestine, and their correct usage is to chew them at the same time as the first bite of meal. If the missed dose is found during the meal, the original dose should be taken immediately; if the missed dose is found within half an hour after the meal, the original dose should also be taken immediately, but the effect of the drug will be greatly reduced (such patients can take appropriate exercise after taking the drug to make up for the lack of effect); if the missed dose is found half an hour after the end of the meal, there is no need to take the drug because of the lack of substrate. If the blood glucose level is only slightly higher, the blood glucose level can be controlled by increasing the amount of exercise; if the blood glucose level is significantly higher, other short-acting hypoglycemic drugs can be taken to control the blood glucose.
4.Omitting to take biguanide drugs
Commonly used biguanides are mainly metformin, which do not increase insulin secretion and generally do not cause hypoglycemia when applied alone. Patients taking metformin, the missed dose occurs within two hours after the meal, if the blood sugar is only mildly elevated, you can temporarily increase the amount of exercise to reduce blood sugar and do not need to make up the dose; if the blood sugar is significantly elevated, you can make up the dose according to the original dose. If the missed dose is found when it is time for the next dose of metformin, there is no need to take it again.
5. Missing insulin sensitizer
The representatives of this type of drugs are rosiglitazone (Vindia, Tylenol) and pyrrolizone (Riton). These drugs only need to be taken once a day, with a slow onset of action, and alone generally do not cause hypoglycemia, therefore, patients with diabetes who use insulin sensitizers alone can take the original dose at any time on the same day after a missed dose.
6.DPP-4 inhibitors
These drugs include sitagliptin (Genovent), saxagliptin (Enzyme), vildagliptin (Gavril), ligliptin (Ortanin), alogliptin (Nixina), etc. These drugs have glucose-dependent insulin-producing effects, and can inhibit glucagon secretion, slow down gastric emptying, reduce body weight, etc. They are safe and do not cause hypoglycemia when applied alone. It only needs to be taken once a day. Patients who take this drug can take the original dose immediately if they miss a dose.
(2) What should I do if I forget to take insulin?
The pharmacokinetic characteristics (including onset of action and duration of maintenance of action, etc.) of insulin of different sizes are different. Therefore, insulin must be injected regularly and quantitatively as required, otherwise it may cause continued fluctuation or increase of blood glucose. However, due to various reasons, the phenomenon of “forgetting to take insulin” happens in diabetic patients from time to time, for type 2 diabetic patients whose blood sugar is not very high, the problem is not too big, and they can take acarbose or Novocain immediately after meals; but for type 1 diabetes, gestational diabetes, type 2 diabetes with poor pancreatic function resulting in drug failure, and For type 1 diabetes, gestational diabetes, type 2 diabetes with poor islet function and drug failure, and some secondary diabetes patients need to take active remedial measures, and only insulin can be chosen, otherwise serious consequences may occur.
If the insulin used is ultra-short-acting insulin (such as Novalax) or short-acting insulin (such as Novalax R) and forgotten before meal, it can be injected immediately after meal, which has little effect on the efficacy.
For patients who inject premixed insulin (such as Novolin 30R) or premixed insulin analogs (such as Novolac 30) before breakfast and dinner, if they forget to take insulin before breakfast, they can make up for it immediately after meal, during which they should pay attention to monitor blood sugar and add meals in between if necessary; if it is almost noon when they remember, they should check blood sugar before lunch, and when it is more than 10mmol/L, they can temporarily inject once before lunch. Short-acting (or ultra-short-acting) insulin should not be combined into two premixed insulin injections in the morning and evening before dinner.
If the patient uses long-acting insulin once a day and misses one injection, he can make up for it as soon as possible. If the next injection is given at the original time, he should pay attention to the hypoglycemic reaction because the interval between two injections is likely to be less than 24 hours, or he can change the injection time to make up for it (such as making up insulin at 8:00 a.m. and injecting insulin at 8:00 a.m. in the future).
It should be noted that any remedy for missed glucose-lowering medication is an unconventional means and should not be used for a long time, otherwise it will cause damage to the body of diabetic patients. As a patient, it is important to minimize or avoid missed glucose-lowering medications or forgotten insulin injections. Once these situations do occur, it is important to take the correct remedial measures in order to minimize the resulting harm.