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August 17, 2005

Hyperglycemia and DKA, Insulin

Question from Brooklyn, New York, USA:

My 11 year old niece was diagnosed with type 1 diabetes when she was about four years old. She was doing fine until a little over three months ago. The insulin shots that she had being taking since she was diagnosed no longer worked for her. Therefore, her endocrinologist decided to change to a different insulin, but still her blood sugar levels are too high (over 300 mg/dl [16.7 mmol/L). Her doctor says that we should give the new insulin time to work on her, at least for three months, but it has been a little over three months and her sugar levels are still high. We are afraid that she might go into a coma. Which are the different types of insulin and how it is determine which one is best for the patient? Also, I would like to know if you can provide me with any information about getting on the list of pancreas donors.


There is no running list of “pancreas donors” as far as I am aware. Pancreas and islet cell transplant procedures are not yet standard procedures; certainly not islet cell (insulin producing cell) transplants. The drugs that limit the recipient’s ability to “reject” the new transplant have a host of potential problems, including kidney damage and even potential pancreas injury. Such transplants are not, unfortunately, done routinely in children yet.

It would be unusual for the insulin “not to work” no matter the regimen. Certainly, things that influence the success of any insulin plan must also include activities and meal planning. For a younger child on a relatively “fixed” schedule of meals, snacks, school, activities, then a “fixed” dose of insulin at “fixed” times of the day might work really well. But, as the child gets older, more flexibility in activities, meal times, meal choices, etc. must be factored in. So, different, more flexible insulin plans might be employed.

I think that you should not have to wait three months to see if a new insulin plan works or “kicks in.” It should pretty clear that the doses are getting near target after about two weeks, typically.

The first things I might suggest you do include:

ONLY a reponsible adult should draw up and administer the insulin. The child should get a “diabetes vacation” from any self-treating.
Meal plans should be carefully reviewed, preferably with a registered dietitian. Hopefully, the family accurately tracks the calories or “counts carbohydrates.”
Talk with your own diabetes team members about other potential psychosocial stresses that might be contributing to the lack of success, currently.

Finally, you asked about different insulins. You can certainly review What is Insulin?:

Rapid-acting insulins which begin to work within 5 to 15 minutes, peak in their effect after about 90 minutes and then rapidly wane in their effect. These include insulins with the brand names of NovoLog and Humalog in the U.S.
Short-acting insulin which begins to work about 30 minutes after a dose has a peak, maximal effect in about two to four hours and then a slower decline over the next few hours. This would typically be Regular insulin.
Intermediate-acting insulins begin to work about two hours after dosing and then peak with a maximal effect about 6 to 10 hours after a dose and have a gradual waning effect. In the U.S., these include NPH and Lente insulins, although Lente is no longer manufactured and soon will be unavailable.
Long-acting insulins are commonly thought to have “no” peak effect and with a relatively constant, background amount of insulin. They are usually used in conjunction with a rapid- or short-acting insulin. In the U.S., the available insulin in this category is called Lantus. Ultralente is similar, but also is no longer manufactured. Levemir insulin is another long-acting insulin soon to be available.


[Editor’s comment: For information on donating organs, see the U.S. Department of Health and Human Services web site.