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April 25, 2003


Question from Wilmington, North Carolina, USA:

In an answer you gave me to a previous question, you specified that we may be handling my daughter's diabetes plan the old fashioned way. She is taking Humalog and NPH. Can you explain more in detail?


A lot depends upon your treatment goals and the treatment goals of your daughter’s diabetes team. Some of this reflects philosophy of medical care. In the past, blood glucose goals were not targeted, and the concept of treatment was to interfere as little as possible with daily life. This usually meant one or two injections of insulin a day, perhaps regular and NPH pre-breakfast and pre-dinner, but this didn’t control the large swings in blood glucose on a daily basis and did not control the large glucose rise that occurred after eating. However, once or twice a day insulin injection was certainly less intrusive than current four to five injection programs or insulin pumps. Overall control wasn’t horrible but it also did not come close to those without diabetes.

As targets were developed and studies like the DCCT documented improvement in outcome (less eye disease, kidney problems and nerve disease), the diabetes professional community focused on how improved control may be achieved. When we looked at frequent blood glucose monitoring, we noted problems with middle of the night hypoglycemia and inadequate insulin available the next morning. So, three shot insulin programs then began to be used: Regular and NPH pre-breakfast, Regular alone pre-dinner and bedtime NPH. This was a big improvement but did not provide sufficient post-lunch and afternoon glucose control so a pre-lunch dose of insulin was added. When insulin pumps began to be used more frequently, it became obvious that boluses of fast acting insulin would improve the glucose control after snacks and after food. In more recent years, rapid-acting insulin analogs (Humalog and NovoLog) have replaced Regular insulin as the bolus insulin since both have better immediate postprandial glucose coverage and also have effects which dissipate faster thereby decreasing late hypoglycemia at the same time they improve post-meal hyperglycemia.

As a consequence, the basal/bolus injection multidose insulin (MDI) regimen was promoted to mimic what the insulin pump was able of doing. This is now the top treatment protocol with injections and achieve results very close to those obtained with insulin pumps. All this is based upon frequent blood glucose monitoring, carb counting and meal-time flexibility as well as adjustments for illness, activity changes and close contact with diabetes staff. All of this is based on the model of the DCCT where monthly visits were coupled with targets for glucose levels. None of these systems is perfect, and there is still lots of need for daily adjustments of multiple factors affecting glucose control.

In the hands of skilled and experienced diabetes teams, kids, teens, families and adults with type 1 diabetes can aim for lower hemoglobin A1c values and still avoid serious episodes of hypoglycemia. All this must be individualized so you should go back to your diabetes team and have a discussion about their goals and compare them to your own goals. We routinely aim for A1c values in the high 6 or low 7% range once we get the A1c below 8% but also focus heavily on minimizing or avoiding serious hypoglycemia.