My 20 year old son is autistic and has had diabetes since birth, and lately it has become almost impossible to control his blood sugar levels. He has no idea he has diabetes so it’s all the more difficult to handle. He is on twice daily Actrapid (Regular) with Monotard (Lente), and I take him to a diabetes doctor for regular check-ups, but somehow we cannot manage to control his sugar. Please advise.

It is of course difficult at this remove and without knowing a lot more about your son, to have a good idea as to how the conventional approach to this problem would apply. To begin with, of course, I am assuming that he really does get his insulin regularly and that he himself has no responsibility for this. The proportions of Actrapid and Monotard seem within conventional limits although the total dose of 36 Units per day seems small against a usual need of around 0.8 Units per kilogram of body weight per day.

Because of his autism, I would imagine that it would not be acceptable to start to use an insulin pump so that the next stage would be to discuss a change to a different and more flexible insulin regimen with the diabetes doctor. This would include giving Lantus (insulin glargine) at bedtime as a basal insulin. It has the advantage that the dose can be rather easily calibrated against the fasting morning blood sugar. To contain the after meal rise in blood sugar, a very short acting insulin like Humalog or NovoLog should be used, and the dose given just after the meal adjusted for the premeal blood sugar and the amount of carbohydrate that has actually been consumed. The lunch time dose can be omitted and NPH or Monotard used to cover this period. You need to talk to the diabetes doctor about all of this and I realise of course that the autistic problem may make this degree of compliance hard.

In addition to these changes, you may need to offset the need for more blood sugar measurements by using some of the newer almost painless Alternate Site Testing devices. I believe that these devices are available in your part of India.

DOB