Justin Delgado is husband to Kacie Doyle-Delgado, diagnosed at age 11. After more than a decade together, he considers himself to be an expert carb counter and Dexcom inserter. He graduated with his Master of Science in Finance from the University of Utah in 2013 and has been working in commercial banking since then. He attended his first Friends for Life conference in 2015 and is looking forward to volunteering with the teens.
July 29, 2005
Daily Care, Insulin Analogs
Question from Lubbock, Texas, USA:
We have just changed my 10 month old daughter's insulin from NPH to Lantus. I have heard great things about better control with Lantus and it took some convincing to get our pediatric endocrinologist to do it. The problem is that he has never put an infant on Lantus and we are having difficulty with dosing. Now, one-fourth of a unit of NovoLog drops her glucose 250 to 300 mg/dl [13.9 to 27.8 mmol/L]. Do you have any suggestions? Should we use less than the one unit of Lantus she's now getting or attempt to dilute her NovoLog?
This problem will be more common, I think.
As far as I still understand, Lantus has NOT been FDA-approved for use in children under age six! So, I understand your physician’s reluctance. As I have commented on this forum several times, “non-FDA approval” is NOT THE SAME as “FDA-disapproval”; rather it means that the FDA has not yet received or reviewed pertinent information on which to make a judgment. Usually, this is because the pharmaceutical company has not done the clinical trials for a particular population or has not provided the information.
Licensed physicians can certainly legally prescribe any appropriate medication, even for “off-label” use. I know many pediatric endocrinologists who indeed prescribe Lantus in young children (although maybe not as young as your child).
An alternative has been the use of another long-lasting insulin called “Ultralente.” This insulin is not quite as peakless as Lantus and, in my experience, more often requires twice daily dosing (some children require twice a day doing with Lantus, too), but, unlike Lantus, it can be mixed in the same syringe with other insulins. The problem is that the manufacturer of Ultralente (and it’s cousin, “Lente,”) has recently announced that they will no longer be producing Ultralente and Lente because of decline of market share: no longer profitable. Ultralente should still be available until near the end of the year.
So, I do not have THE answer for you. I would NOT dilute Lantus and I am not at all a condoner of other insulin dilutions, too much potential for errors (in mixing, converting doses, miscommunications, etc).
So, what can you do? Well maybe YOUR diabetes team is more comfortable with insulin dilutions. Confer seriously with an open mind with them and relay your concerns and frustrations. The use of pre-mixed 70/30 (NPH/Reg), or 75/25 (NPH/Humalog), or 70/30 (NPH/NovoLog) might be worth a try. These prefixed concentrations indicate the proportion of the intermediate to the short acting insulin. If you give 1 unit of 70/30 NPH/Reg, you are really giving 0.7 units of NPH and 0.3 units of Regular, so you can see that you can make tiny adjustments, but always in this fixed ratio. Maybe these types of micro-doses are all the 10 month old will require. I am not a big fan of these premixed insulins, but a clinical situation like yours might be just right.
Finally, you could consider the delicacies of insulin-pump therapy, but that is an issue that you certainly will need to learn more about and get the perspective of your own diabetes team. Insulin pumps are not approved for children under age 6 either, I don’t think.