What should I advise a patient who stopped taking their insulin because their blood sugar level was normal yesterday?

Never Stop Insulin Based on a Single Normal Blood Sugar Reading

Patients should never discontinue insulin therapy based on a single normal blood glucose reading, as this can lead to dangerous hyperglycemia, diabetic ketoacidosis, and increased morbidity and mortality. 1

Why Continuing Insulin is Critical

• Insulin requirements fluctuate daily based on multiple factors including food intake, physical activity, stress, illness, and hormonal changes, making a single normal reading insufficient to determine ongoing insulin needs 1
• During illness, it is especially important that insulin be continued even if the patient is unable to eat or is vomiting, as insulin needs often increase during illness despite decreased food intake 1
• Discontinuing insulin can rapidly lead to hyperglycemia (>16.5 mmol/L or 3 g/L) and potentially diabetic ketoacidosis in patients with Type 1 diabetes, which is a life-threatening condition 1

Patient Education Points

• Explain that insulin therapy is designed to work continuously to regulate blood glucose levels, not just when readings are high 1
• Emphasize that self-monitoring of blood glucose (SMBG) should be used to adjust insulin dosage, not to determine whether insulin should be taken at all 1
• Clarify that normal blood glucose readings indicate that the insulin therapy is working effectively, not that it's no longer needed 1
• Inform patients that insulin dosing may need adjustment based on patterns of blood glucose readings over multiple days, not single readings 1

Management Algorithm

1. Immediate action: Instruct the patient to resume their prescribed insulin regimen immediately 1, 2
2. Blood glucose monitoring: Increase frequency of blood glucose monitoring to every 4-6 hours while awake until stable 1
3. Assess for complications: Check for ketones if the patient has Type 1 diabetes or uses SGLT2 inhibitors 1
4. Dose adjustment: If blood glucose is currently elevated, consider if a correction dose is needed based on their prescribed regimen 2
5. Education: Provide clear sick-day management instructions to prevent future insulin omission 1

Special Considerations

• For patients with Type 1 diabetes, explain that insulin is absolutely necessary for survival regardless of blood glucose readings 1
• For patients with Type 2 diabetes on insulin, explain that while their body may produce some insulin, their prescribed regimen is needed to maintain adequate control 1
• For elderly patients, while hypoglycemia prevention is important, discontinuing insulin entirely is not the solution - dose adjustment is the appropriate approach 1

Common Pitfalls to Avoid

• Failing to assess the patient's understanding of insulin therapy and its purpose 3
• Not addressing the patient's potential fears about hypoglycemia, which may be driving insulin omission 3
• Overlooking the need for sick-day management education to prevent future insulin discontinuation 1
• Using medical jargon that patients may not understand when explaining the importance of continuous insulin therapy 1

Follow-up Plan

• Schedule a follow-up appointment within 1-2 weeks to review blood glucose patterns and adjust insulin dosing if needed 1
• Consider referral to diabetes education if the patient demonstrates knowledge gaps about insulin management 1
• Document the incident and education provided to ensure continuity of care with other healthcare providers 1

Remember that insulin discontinuation is a common cause of diabetic ketoacidosis and hospital readmissions, making proper education about continuous insulin use essential for patient safety 1.