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June 5, 2003

Honeymoon, Insulin

Question from Reno, Nevada, USA:

My six year old son, diagnosed four weeks ago, is in the honeymoon, and we are having to awaken him a couple times a night to give food/juice due to hypoglycemia. Per his pediatric endocrinologist, we have been decreasing his insulin over the last week to the point that now he takes no Lantus and uses Humalog only for correction (above 200 mg/dl [11.1 mmol/L], and not for carbs. However, he has not been above 200 mg/dl [11.1 mmol/L], and hence has not had a shot for two days now. How many days do we go without a shot before the risk of insulin allergy becomes a concern? Do we force a high blood sugar (e.g. give sugar) in order to create a high to administer insulin and avoid risk of insulin allergy?

Answer:

I would not think at all about considerations of inducing “insulin allergy.” The honeymoon is a terrific but special phenomenon. As you likely know, the honeymoon occurs because the patient’s own pancreas is getting a “second wind”, if you will, and is producing some insulin. During this time, it is often possible to cut way back on insulin. Frankly, I would be uncomfortable with cutting out all the longer-acting insulin and only dosing to “chase” the higher glucose readings. The honeymoon will end (they all do). By giving supplemental Humalog, even during the honeymoon, you can probably prolong the honeymoon phase and thus allow a longer period of time for smoother control.

Perhaps the issues of nocturnal hypoglycemia could be addressed by adding more protein to a bedtime snack or changing the timing of insulin administration. For example, the Lantus (insulin glargine) could be given at breakfast, rather than at bedtime which you may have been doing. alternatively, during the honeymoon, use a different insulin as the longer-acting such as Ultralente or even Lente or NPH. Talk with your son’s own diabetes team about the pros and cons of all options and see what may best work for him. This may be a time for some trial and error.

DS

[Editor’s comment: Lantus has recently been approved in both Europe and the US for administration at any time of day.

Lantus is still officially approved only for dosing once a day; this is based on the clinical trials that Aventis has performed, all of which used once-daily dosing.

WWQ]