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August 26, 2005

Daily Care, Insulin

Question from Queen Creek, Arizona, USA:

I am a registered nurse. I also happen to have type 1 diabetes myself. As a nurse, I do Disease Case Management and have a question regarding one of my patients. My patient is a 16 year old teenager with type 1 diabetes. Her physician has her on Lantus in the evening, NPH in the morning and Humalog sliding scale in between. I have never heard of this type of insulin therapy. Does this sound correct? I know Lantus is a long acting no peak insulin and NPH does have a 4 to 12 hour peak. This insulin therapy just does not make sense to me and I am questioning whether the parents/patient are correct in her regimen or if she was on the NPH and was supposed to be switched to Lantus, but the patient is taking both in error.

Answer:

I’d start by exposing any myth that there are “right” or “wrong” insulins plans, other than the right regimen is one that allows good glucose control and allows proper balance of activities, meals, lifestyle, etc. Having said that, there certainly are more unusual, creative, and atypical insulin regimens. To my mind, the key is optimal matching of insulin to meals and activity rather than adjusting the meals to fit the insulin.

The latter can be done and it does indeed work well. This is best manifested by the old combination, split-fixed-mixed dosing of intermediate plus short-acting insulins (e.g. NPH and Regular). More intensive plans allow for flexibility and try to mimic natural physiology. These are typified as the basal-bolus insulin plans using Lantus plus Humalog or NovoLog or using rapid-acting insulin via an insulin pump.

So, your patient is on Lantus as the baseline, background insulin. They are on Humalog (I hope it is not so much of a “sliding scale” as it is used based on calorie intake and “carbohydrate counting”. If she eats a lot, then she takes more Humalog; if she eats a little, she takes less insulin.) But, perhaps, she really is on a sliding-scale, a reactionary plan that tries to chase higher glucoses. Or, perhaps she is not a good carbohydrate counter. Or, perhaps, she finds she doesn’t like to take insulin at school and declare to the world that she has diabetes in the middle of every day. In those cases, it is not unreasonable to consider adding some intermediate or long-acting acting insulin in the morning to “cover” her for lunch or an early afternoon snack, without the need to take an extra shot. Is this optimal? I don’t really think so. But, it is not at all unheard of and makes some physiologic sense, if one tries to match insulin to the rest of the day’s schedule.

The child’s pediatric endocrinologist may have other reasons, too. It would be terrific if everyone were on the same page and understanding, so you shouldn’t hesitate to call that physician’s office for clarification.

DS