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January 17, 2007

Hyperglycemia and DKA, Other

Question from Pakistan:

I am very anxious because of my 18-month-old child. I don't know what type of diabetes he has been suffering, but know that the illness has been present since his birth. Since birth, he has been on insulin, Lilly Regular and NPH. I just mix them according to the doctor's advice and inject to my son twice daily. But, for almost two years, the major problem which I have been facing is very unpredictable blood sugars with the same dose of insulin. Sometimes, he is 40 mg/dl [2.2 mmol/L] and sometimes he is 600 mg/dl [33.3 mmol/L]. Due to this, my child has twice gone into DKA, which, you know, is a life threatening condition. His mental and physical growth has also been compromised. I have recently learned of diluent for insulin and insulin pumps. Although both are unavailable here in Pakistan, I was hoping to get them through my brother who lives in the U.S. What supplies should I ask him to get for me?

Answer:

First, you should have your brother contact Eli Lilly or Novo Nordisk, whichever company’s insulin you are using. The USA main office numbers can easily be reached. They can usually arrange free diluting solutions. Then, this can be sent to you in Pakistan. We usually use a 1:10 dilution so that each line on your syringe will equal 0.1 units and be measurable.

Second, you should be in closer contact with a pediatric endocrinologist in Pakistan. If there is not one where you are living, then in the large cities where there are medical schools, there will be someone with this specialty. They can help you with alternative insulin regimens which should help control the glucose levels better than you are currently describing. Perhaps you can use Lantus instead of NPH. Or, perhaps an overlapping dose of NPH several times each day to prevent some of the large swings The key is doing many blood glucose tests each day so that you are not guessing. This then allows you to make frequent adjustments each day.

Lastly, you should inquire if there is the possibility of genetic testing to see if he has a mutation to explain such a young age of diabetes. This is probably not available in Pakistan or would be very expensive. However, the researchers in England will do this test at no charge as long as you get an appropriate blood sample mailed to them. Dr. Andrew Hattersley is the lead researcher. Your pediatric endocrinologist will know how to contact Professor Hattersley to see if there are congenital sulfonylurea receptor or potassium channel receptor abnormalities. If positive, this would allow discontinuing insulin and switching to a pill and better glucose control at the same time. But, one cannot make such a diagnosis without appropriate genetic testing.

SB

[Editor’s comment: To read more about the use of sulfonylureas to treat type 1 diabetes, see Drug Restores Insulin Secretion for Rare Type 1 Cases.

BH]