November 25, 2003
Question from Raleigh, North Carolina, USA:
I would certainly like my son to have a little more spontaneity in his life and not live as rigidly as we have done for over a year with the two-shot method. I am under the impression that you can be very flexible with multiple shots. I think it would be heaven for him to be able to sleep in on the weekends and to eat when he felt like it. Since blood sugars are a little challenging to control during adolescence, what is the best approach, in your expert opinion, for keeping tighter control over blood sugars? I plan to speak with my son’s doctor about this when we go back soon, but need as much information as possible to help decide on what is best.
I agree that multiple daily injections using a basal/bolus method [more commonly done with Lantus and a rapid-acting insulin such as Humalog or NovoLog] and insulin pump therapy works on a similar principle (using only rapid-acting insulin) and indeed allow more flexibility in life-style including activities and meals, but with it comes increased responsibilities.
Specifically, the patient needs to be committed to taking a shot with virtually each and every meal and snack; he needs to be able and willing to not only check glucose levels before the meals/snacks, but often will require testing about two hours after the meal to be certain that the “insulin-to-carb ratio” was adequate. This means that the patient must track and “count” the carbohydrates consumed and give a pre-determined amount of insulin for each set quantity of carbohydrates. All of this is not terribly difficult, but it is not always easy. In addition, as with much diabetes management, it is relentless: you get no “days off” from diabetes.
So the standard “two shot” method offers convenience and simplicity at the risk of less flexibility. I think this method (or variants thereof) often work just fine for newly diagnosed patients or younger patients, but adults, teens, and some middle schoolers warrant more flexibility. However, not all are ready to assume such responsibilities or have the proper skills to carb count. By working with your son’s diabetes team, you should be able to find a happy medium.
Having said all that, in response to your question, my opinion is that multiple daily injections can provide tighter control, with less wide fluctuations, if done well and responsibly.