From the Guidelines
Omitting insulin in individuals with diabetes can lead to severe and potentially life-threatening complications, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), which can be fatal if not treated promptly. The primary risk of omitting insulin is the development of DKA in type 1 diabetes or HHS in type 2 diabetes, both of which can be fatal if not treated promptly 1. When insulin is skipped, blood glucose levels rise dramatically, causing excessive thirst, frequent urination, nausea, vomiting, abdominal pain, confusion, and fruity-smelling breath. In DKA, the body breaks down fat for energy, producing ketones that make the blood acidic, while HHS involves extreme dehydration and very high blood sugar levels.
Long-term insulin omission can lead to chronic complications including:
- Nerve damage (neuropathy)
- Kidney disease (nephropathy)
- Eye damage (retinopathy)
- Cardiovascular disease
- Poor wound healing
Insulin is a life-sustaining medication for type 1 diabetics and many type 2 diabetics, and its dosage should never be adjusted or stopped without medical supervision 1. Patients experiencing financial difficulties obtaining insulin should immediately contact their healthcare provider, diabetes educator, or pharmaceutical assistance programs rather than rationing or skipping doses, as no alternative can fully replace insulin's glucose-lowering function.
It is essential to note that the management of diabetes, particularly in older adults or those with advanced disease, requires careful consideration of the patient's quality of life, oral intake, and goals of care 1. In some cases, simplifying the insulin regimen or reducing the dose of agents that may cause hypoglycemia may be necessary to prevent hypoglycemia and maintain glucose levels within a target range. However, insulin therapy should always be individualized and guided by a healthcare provider to minimize the risk of complications and optimize glucose control.
From the FDA Drug Label
Hypoglycemia is the most common adverse reaction of all insulins, including NOVOLOG. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death.
The risks of omitting insulin in individuals with diabetes include severe hypoglycemia, which can cause:
- Seizures
- Unconsciousness
- Life-threatening conditions
- Death It is essential to note that hypoglycemia can happen suddenly, and symptoms may differ in each individual and change over time in the same individual. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia. Risk mitigation strategies for hypoglycemia include patient and caregiver education to recognize and manage hypoglycemia, as well as increased frequency of blood glucose monitoring, especially in patients at higher risk for hypoglycemia or with reduced symptomatic awareness of hypoglycemia 2.
From the Research
Risks of Omitting Insulin
The risks of omitting insulin in individuals with diabetes are severe and potentially life-threatening. Some of the key risks include:
- Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS), which are characterized by absolute or relative insulin insufficiency, severe dehydration, and altered metabolism of carbohydrate, protein, and fat 3, 4, 5.
- Hyperglycemia, ketone body formation, and metabolic acidosis, which can lead to serious complications such as cardiovascular instability, inability to protect the airway, and obtundation 4, 5.
- Increased risk of mortality, with DKA mortality rates ranging from 3.4% to 4.6% and HHS mortality rates approximately 15% 5.
- Precipitating causes of DKA and HHS, such as infection, undiagnosed diabetes, and substance abuse, which can be exacerbated by insulin omission 5, 6.
- Severe dehydration, ketosis, and acidosis, which require prompt treatment with intravenous fluids, insulin, and electrolyte replacement 4, 6, 7.
Complications of Insulin Omission
Some of the complications of insulin omission include:
- Cerebral edema, which can occur in patients with mixed features of DKA and HHS, particularly in younger patients 4.
- Vascular occlusion and increased mortality, which can result from undertreatment of DKA and HHS 4.
- Acute abdominal signs or symptoms suggestive of acute gastric dilatation, which require ICU admission and aggressive treatment 4.
- Neurologic changes, such as seizures and coma, which can occur in patients with HHS 7.
Importance of Insulin Therapy
Insulin therapy is the cornerstone of treatment for DKA and HHS, and its omission can lead to severe and potentially life-threatening complications. It is essential to administer insulin promptly and aggressively, along with fluid and electrolyte replacement, to prevent these complications 3, 4, 5, 6.