Our five year old son, diagnosed with type 1 diabetes eight months ago, has been on two injections a day of NPH and Humalog, but we are having difficulty with control, and this is all complicated by the fact that our son is a picky eater and his activity level is very variable. We were very interested when we heard about Lantus. Used with Humalog to cover food, with little or no peak, it would seem to be perfect for us (and many other young children). It would not only allow appropriate doses of Humalog to cover current conditions (food intake, activity, etc.), but give greater flexibility and freedom, with better control. However, no one in our area seems to be using it for children under age 11. Is there evidence or even a suspicion that it’s unsafe for younger children? (We’ve heard something about the possibility that it may attach to a growth receptor site.) Is it a matter of being conservative with a new drug? We know it’s only approved for kids older than six years. Why?

You are correct in what you write to describe the potential benefits of Lantus (insulin glargine). Studies have not been done in the very young children so that there is no specific safety information, although I suspect most pediatricians will begin to use it for the very young if it works out well for school-aged children and teenagers.

Lantus/glargine is a basal insulin that would replace the NPH, Lente or Ultralente being used in overlapping doses. We often prescribe small doses of NPH at breakfast, lunch, dinner and bedtime to try to provide such basal insulins without giving an overdose effect that you described so nicely. This is coupled with bolus and flexible algorithm amounts of Humalog at breakfast, lunch, mid-afternoon, and suppertime. Such an intensified multidose insulin treatment regimen provides a great deal of flexibility but requires detailed blood glucose record keeping and analysis, carbohydrate counting, adjustments taught for different foods and glycemic effects, activity changes and fussy eaters. It also requires a responsible adult to make such decisions either at home, day care and/or school, of course.

We have had great success with this approach and achieve hemoglobin A1c levels in our practice as good or slightly better than the DCCT reported. Lantus offers the promise of improving the basal insulin delivery, lowering the overnight potential for hypoglycemia while still achieving improved prebreakfast glucose control. It can be used with any of the multidose proactive insulin algorithms but must be re-learned for each individual. Some of the youngest patients seem to need a small dose of NPH either at breakfast or lunchtime shots based upon their own individual food and activity patterns as documented by their own blood glucose readings.

There will likely be a clinical trial starting in about six months or so using Lantus in younger children in the USA to answer these questions.

I would suggest going back to your diabetes team to ask these types of questions, see if you can fine-tune your son’s current basal insulin regimen with some overlapping doses of NPH, etc. You may also ask some specific questions about using Lantus if you and they are willing to learn how it might work for your child.

SB