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February 16, 2005

Hyperglycemia and DKA, Insulin Analogs

Question from Springfield, Massachusetts, USA:

Since her diagnosis with type 1 in January 2004, my daughter has had unpredictable blood sugars. She had an extended honeymoon. Her blood sugars would be fantastic for several months and then things would go out of whack and it would take time to get things under control again. For the past couple of months, we have not been able to get the blood sugars back under control. They go as high as 280 mg/dl [15.6 mmol/L] and as low as 75 mg/dl [4.2 mmol/L]. She takes 11 units of Lantus at night and has variable ratios of NovoLog for meals. 1:10 for breakfast, 1:20 lunch, and 1:15 dinner. The bedtime, morning, and mid-morning blood sugars always run very high and then she evens out for the rest of the day with numbers ranging in the low to mid 100s mg/dl [5.6 to 8.3 mmol/L]. Should we be more aggressive with the insulin? Do you think this is a NovoLog issue? How can we tell? The doctors keep saying that we'll take what we can get and shouldn't be concerned about the high numbers. They say that the A1c is what really matters. Her last one was 7.2. I've heard that damage is happening when the blood sugar number is high. If that's the case and the lows are averaging out the A1c, then I don't see how that's healthy at all. The doctors keep saying it's fine. Is it?

Answer:

No, it’s not all fine, I think. Beyond the actual number of the A1c (the gold standard for diabetics is lower than 6.5%) are the wide fluctuations and trends for blood sugar values that matter in terms of the risk of future diabetic complications. I’d recommend that you increase the dose of Lantus, injected in the thighs at dinner time please, until you get a fasting blood sugar level lower than 120 mg/dl [6.7 mmol/L]. Then, you should fine tune the NovoLog dosages before meals in order to have values after the three meals not greater than 140 to 160 mg/dl [7.8 to 8.9 mmol/L] especially at bedtime otherwise the glargine won’t be able to keep fasting blood sugar the next morning within the ideal numbers I just recommended. Make sure you go back to your own team and discuss these possible changes.

MS