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April 16, 2003

Diagnosis and Symptoms

Question from Wauconda, Illinois, USA:

Our 12 year old son had a blood glucose of 160 mg/dl [8.9 mmol/L] and an A1c of 8.3%. I have diabetes and was confused as to why the doctor wants to put him on a sliding scale of Humalog with Lantus in the morning, and didn't offer any education to him on how to take readings or give injections. Why not try diet and exercise or oral medication? We are setting up an appointment with an endocrinologist for next week because I need a consult.


Your main question raises some subsidiary issues. The first relates to the diagnosis which is most probably type 1A (autoimmune) and requires insulin. However, recently the ability to distinguish this from type 2 on purely clinical grounds has been questioned so that it has become customary to do a confirmatory antibody test. This should not be the simple islet cell antibodies screening test but one that includes insulin antibodies, anti-GAD and ICA 512.

The treatment embarked on is entirely orthodox, except that it is more usual to give Lantus (insulin glargine) at bedtime which is a basal insulin lasting throughout the 24 hours, Giving it at bedtime makes it easier to calibrate the dose against the before breakfast blood sugar level. The Humalog can be given just after the meal and the dose adjusted to the before meal blood sugar and the amount of carbohydrate actually consumed. You should also perhaps talk to the endocrinologist about using NPH insulin with the breakfast Humalog as this may make it possible to avoid giving an injection at school at least initially.

The last issue is in regard to education which is absolutely essential. Ideally, your son should be looked after by a team which includes not only a doctor, but a nurse educator, a dietitian and (very importantly for a teenager) a Medical Social Worker.