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February 19, 2005

Blood Tests and Insulin Injections, Insulin Analogs

Question from Covington, Washington, USA:

My seven and a half year old daughter is active with basketball and swimming. She has had diabetes for five and a half years and has been on the pump for over four years. With the blessing of our diabetes team, today we began the untethered regime, using 75% Lantus (4.5 units) and 25% (1.25 per 24 hours) pump basal. Have you heard of anything (positive or negative) about using the untethered regime with children that we should be aware of as we proceed? I am hopeful but cautious.


From: DTeam Staff

I have been encouraging patients using the pump to give at least 50% of their basal as an injectable insulin for years now (before someone gave it a fancy name and popularized it). At first I used Ultralente twice a day and then switched to Lantus. I felt it was much safer than giving all the basal through the pump because if there were any catheter problems ketoacidosis could develop quickly when the pump insulin was not infused for over an hour. The injected insulin could provide a safety net making ketoacidosis unlikely even if the blood sugar went high (you need less insulin to prevent the development of ketones than you do to keep the blood sugar normal. The same blood sugar with ketones is much more dangerous than the same blood sugar without ketones). You still could vary the basal insulin during the day giving the rest of the basal using the pump doing away with the main disadvantage of long acting injected basal insulins. For very active individuals, you could often figure out how much injected basal insulin to give so that the individual could disconnect for several hours during sports (instead of setting a lower temporary basal on the pump). It also made pump free days much easier to plan as the main difficulty with pump free days is replacing the basal insulin.

Good luck and I hope this helps your child get the advantages of the pump while at the same time minimizing some of the disadvantages. This is really not such a new, untried concept, so don’t be afraid to try it.

Additional comments from Dr. Larry Deeb:

This seems to be a coming treatment option. I don’t know if it will turn out to be science or a fad. It does seem worthy of a clinical trial. I haven’t seen a paper yet.

The rationale for the approach seems to be that active sports-minded children disconnect to play and they don’t get some of the insulin they need. Historical approaches have included mini boluses at some interval. Some complain that leads to hypoglycemia after high glucoses.

I suppose that’s why we call it practicing medicine; there is always something new to try. Go ahead and “practice” with your team. If it works, great, if not go back to your old plan or try something else.