I manage my mother’s type 1 diabetes because she has had a stroke and can’t do it, but this management is the hardest thing I’ve done. She takes 15 units of NPH with 15u of Ultralente in the morning and Humalog to cover carbs and highs (1 unit to decrease by 50). Lately, her blood sugars run 300-400 mg/dl [16.7-22.2 mmol/L] and giving extra Humalog has not brought her sugars down. Occasionally, when they are down to 180 mg/dl [10 mmol/L] at bedtime, she’ll have a fasting sugar of 300 mg/dl [16.7 mmol/L].. Why can’t I get the highs down with Humalog?

I would suggest your mother’s insulin requirements may have increased. The high fasting blood sugars require more long-acting NPH insulin. The Humalog will not bring the sugars down similar to what worked previously. I would make sure she doesn’t have another infection (urinary tract and pneumonia being most common).

In addition, I would titrate the insulin to keep the values below 200 mg/dl [11.1 mmol/L] without hypoglycemia. You can argue that the control should be even tighter, but prevention of complications is not the goal of treatment. Rather, the glucose levels should not be high enough to cause her to be catabolic or at increased risk of infection.

JTL

[Editor’s comment: This to me is a very unusual insulin regimen. First of all, I hope you are not mixing the NPH with the Ultralente, as they are incompatible.

Secondly, if your mother is indeed getting NPH and Ultralente in the morning, she has very minimal insulin coverage during the night. Most of the effect of the NPH wears off after about eight hours and the Ultralente after about 12 hours.

I think your mother would do much better on a different insulin regimen all together. If she has not been seen by an endocrinologist, please ask for a referral.

SS]