August 29, 2006
Honeymoon, Insulin
Question from Stoneham, Massachusetts, USA:
My three year old son, 33 pounds, was diagnosed with type 1 diabetes about a month ago. Over the past four days, he has entered into the honeymoon period. He had been taking between 0.5 and 1.5 units of Humalog per a sliding scale before breakfast and dinner, and 4.5 units of NPH before breakfast, plus 1.5 units of NPH before bed. His meal plan is breakfast 30 g of carbohydrates; snack 30 g carbohydrates; lunch 45 g carbohydrates; snack 30 g carbohydrates; dinner 45 g carbohydrates; and bedtime snack 15 g carbohydrates, 7 g protein. He was having quite a few lows, ranging between 39 and 79 mg dl [2.2 and 4.4 mmol/L] mostly just before lunch. The levels of H and NPH were reduced, but he still had lows. We have been advised to discontinue Humalog unless he is over 200 mg/dl [11.1 mmol/L] and to reduce NPH to three units before breakfast and one unit before bed. I would like a second opinion about this.
Since NPH has a peak, is this really the best way? Would it be better to have tiny doses of Humalog with meals? What about something like Lantus with no peak? I read in your prior posts that the best way to prolong the honeymoon is to follow a strict carbohydrate to insulin ratio to preserve the beta cells. What is the best way to preserve these? It seems that if you are calling upon them to cover meals due to no Humalog they might not last as long. I would appreciate your input
Answer:
It is impossible to answer your excellent questions without a lot more detailed information about blood sugar readings, insulin doses and meal planning. There is also no set way to start with insulin. My personal preference is to start with Lantus since it avoids the peaks of insulins like NPH and goes right to a basal-bolus intensified insulin approach from the point of diagnosis onwards. In my experience, this is far superior to NPH and decreases hypoglycemia, improves A1c levels and, therefore, helps rest the damaged pancreas even in the earliest phases of diabetes management. I have just completed a thorough evidence-based medical review of pre-school age diabetes management for a new pediatric diabetes textbook and am more convinced than ever that this is the best approach. You should discuss this in some detail with your diabetes team and specifically ask these excellent questions so that you and they can figure out the most optimal approach for your child. All should be based upon frequent blood glucose, pre and postprandial, readings to allow the best decisions.
SB
