May 9, 2007
Daily Care, Insulin
Question from Alturas, California, USA:
I learned to do tight control during multiple pregnancies using NPH and Regular or Humalog insulin and practiced it successfully that way for a long time after pregnancies (but not quite as tight of control since I wasn’t pregnant and didn’t want to risk the lows of the super tight control of pregnancy). I was not seeing doctors during the time after pregnancies due to limited resources and no medical benefits.
Now, I am seeing a nurse practitioner (NP) and she wants me to switch from NPH to Lantus. I have always had a problem with a really high fasting blood sugar unless I take really high amounts of NPH insulin (40 units currently) at bed time, even when not pregnant. I am positive it is the dawn phenomenon and not rebound because I have done 3 a.m. blood sugar tests. Plus, it even happened when I was taking no insulin during the day when eating a low carbohydrate diet, so I couldn’t have been rebounding then. I also take 1 unit of Humalog insulin per six grams of carbohydrates during the day with an adjustment of an extra 5 units of Humalog with breakfast.
My main worry about switching to Lantus is that I would end up going low during the day in order to have a good fasting blood sugar level or my fasting level would be bad and I would still need to take NPH in addition to Lantus to handle the big dawn phenomenon that I have. I also worry that if I take the Lantus I will have to eat during the day. I like the freedom of carbohydrate counting and taking Humalog as necessary. I can eat when I want and not eat when I don’t want. But, I worry that with the Lantus, it would be there to pull me low and force me to have to eat when I don’t want to or go low. I have lost 80 pounds in the last year and a half and need to lose 60 more, so not being forced to eat is important to me. I have checked my blood sugars on days that I haven’t eaten much and it didn’t go unreasonably high (only to about 135 mg/dl [7.5 mmol/L]) during the times that I wasn’t eating, so I am not sure I really need an insulin that is active all the time. Have you ever seen a really strong dawn phenomenon like that and seen it controlled well with Lantus?
I will add for your full edification of my situation that I was diagnosed with type 2 diabetes at 33 years old and I look typically type 2 with an apple body shape. My grandmother was my only other relative with type 2 diabetes. My diabetes came on very suddenly with very frequent urination, extreme thirst, what felt like gas pains in my upper abdomen and blurred vision. My blood sugar was around 500 mg/dl [27.8 mmol/L] at diagnosis. I have never been able to go without insulin. There were times that I took no insulin during the day while on a low carbohydrate diet, but I still needed my dose of NPH at bedtime. I have taken metformin before with my insulin and it never altered the dose of insulin I needed. I also have Hashimoto’s thyroiditis and have Immune Thrombocytopenia Purpura. I got diabetes, Hashimoto’s, and ITP all at about that same time, in my early 30s. One time I got septicemia, which sent my blood sugars crazy, and I was in DKA because of that. I kind of suspect that I am double diabetic even though I was obese and over 30 when I got diabetes.
Another question I have is about checking blood sugar before or after meals. I check my blood sugars after meals, but the NP wants me to check before meals instead. I worry it will be harder to keep control good enough this way. I am devoted to keeping my A1c at 6.5 or below. The NP said, at that clinic, they are happy if diabetics’ A1cs are at 8 or below. Do you recommend checking before or after meals?
This clinic is the only one in town and the nearest other doctors are 120 miles away. I want to work with this clinic, but I want to make sure I am doing the right things for my health.
Answer:
It is very reasonable to stay on NPH, rather than switching to Lantus. In a minority of patients, there is need for the peak effect to occur in the morning. Lantus may not provide that. I would suggest you go back to your provider and ask what are the reasons they think you should be on Lantus. Both are reasonable medications, but Lantus does not provide the peak effect in the morning. Some patients are treated with Lantus and a dose of NPH at night. However, that might be too many shots in your case.
JTL
[Editor’s comment: The advantage of checking your blood sugar both before and one or two hours after meals is that it will tell you if you are taking enough insulin to cover the carbohydrates you are eating. Perhaps you could do this for all meals for a few weeks or selected meals (such as every dinner) for a few weeks to see what is going on. With respect to A1cs, I could not find any specific guideline for A1cs, but lower A1cs are usually considered better, as long as you are not suffering too many blood sugars trying to maintain tight control.
While your explanation for using NPH in the evening makes sense, if you were to take Lantus in the evening, you could possibly take a much smaller dose of NPH to cover the dawn phenomenon. Lantus is a non-peaking insulin, so it should not cause you to have lows for which you would need additional food. On the contrary, NPH is a peaking insulin. It was not clear if you were taking NPH in the morning as well. With nightly Lantus, you could skip morning NPH and even skip meals if you are not hungry. You may benefit from reading our previous questions about Insulin Analogs and Daily Care. Please be sure to discuss this with your NP or other diabetes team.
BH]
