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December 19, 2003

Insulin

Question from Sacramento, California, USA:

My son takes insulin cocktails: Humalog, Regular, and NPH in the morning; and Humalog and NPH in the evening. He has an A1C of 7.1. Recently we have felt much pressure from "latest treatment protocols for children" and our physician about switching to Lantus and NovoLog, which they say is "more flexible, less fewer risk for lows, " etc. So we finally tried it. Our son spent six days with blood sugars from 300-400 mg/dl [16.7-22.2 mmol/L] during the day and frequently went low at night. We reduced the Lantus and increased the NovoLog without a lot of improvement. It has always been difficult to determine his carb-to-insulin ratio because he is so active. Plus I strongly believe that for some reason he has a slow absorption rate (arm and bottom, as he refuses to take a shot in his stomach). Are we mistreating him by using the old style NPH? Did we not try the Lantus/NovoLog regimen long enough? Do other children not respond well to Lantus?

Answer:

This is a wonderful and I think very pertinent question!

By no means are you mistreating your child by being on “old-fashioned” NPH. I think that the approach to diabetes management should allow a goal of good glucose control but that still allows reasonable options in lifestyle that fits for the patient.

The newer basal-bolus insulin plans with Lantus and NovoLog/Humalog and insulin pumps can be very successful and do indeed allow more flexibility in lifestyle, meal times, food consumption, and activities. They also require a lot of work and responsibility and good carb counting skills.

So when I see HbA1c values at 7.1% in a school-aged child, I would see no pressing need to change insulin regimens just for the sake of changing. In elementary school, the day is usually fairly consistent with lunch and recess at about the same time; certain classes at about the same time, etc. Certainly there will be always be some inconsistencies, but not to the degree that perhaps will come with middle school and high school and the more flexibility that will be required as he gets older. (Imagine that you had to eat at the same time and the same amount every day! Basal-bolus plans allow variability.)

If his HbA1c has been trending upward – and continues to go up, then there indeed may be even more valid medical reasons to change.

So, if you and the patient have been satisfied with lifestyle issues on your “cocktail” of insulins, and the glucose control is satisfactory to you and the health care team, then maybe it is not really time to go to basal-bolus. And if he maintains good control and does well with a regimented schedule, then he may never need to change.

Talk with your Diabetes Team, but I hope this helps.

DS