July 19, 2007
Hyperglycemia and DKA, Insulin
Question from Singapore:
My 12-year-old daughter has had type 1 for the last three years. Her height is 150 cm (4 feet, 9 inches) and she weighs is 48 kg (106 pounds). Her periods have not started yet. She is on Lantus and NovoRapid. She takes 30 units of Lantus at bedtime, with 9.5 units of NovoRapid for breakfast, 9.5 units of NovoRapid for lunch, 4 units of NovoRapid for tea and 7 units of NovoRapid for dinner. In between, she eats about 15 grams of carbohydrates around 10 a.m. and 15 grams of carbohydrates for supper for which she is not taking any insulin. Since her growth spurt was slow, her endocrinologist started giving her growth hormone, which she takes before bedtime. She has been taking growth hormone for the last three months. Suddenly, her insulin requirements have changed drastically, from 23 units to 30 units of Lantus and and more NovoRapid, too. Sometimes she goes to bed with a reading between 6 mmol/L [108 mg/dl] and 7 mmol/L [126 mg/dl], has a snack of 15 grams of carbohydrates then wakes with a blood sugar of 8 mmol/L [144 mg/dl]. However, sometimes, she will wake up at 16.5 mmol/L [299 mg/dl]. What could be going on? Is she having a rebound? I am totally confused.
Although she takes Lantus around 10 p.m., her readings start going up between 4.30 and 5 p.m. even though she has not eaten anything. To overcome this problem, I started giving her 4 units of NovoRapid. If I do not give her NovoRapid at this time, she will go up to 20 mmol/L [363 mg/dl]. She often plays badminton in the evening. But, whether she is active or not, eating or not, her blood sugars start going up. What’s going on?
Answer:
It is extremely rare to have growth hormone deficiency and diabetes. Was the diagnosis of growth hormone deficiency based upon specific stimulation testing abnormalities, low IGF-1 and IGF-BP3 levels, pituitary MRI abnormalities, etc.? There is also some concern about increased retinal problems associated with growth hormone treatment and diabetes so careful eye checks should be ongoing.
Any use of growth hormone would likely be associated with increased insulin need. This happens when pubertal growth hormone increases and would happen with injected growth hormone as well so that what you are reporting is not unusual. It simply requires increased insulin doses.
Also, Lantus often does not last a full 24 hours in my experience and we almost always use twice-a-day Lantus often with more at bedtime and a lower dose at breakfast. Using blood glucose readings, you should be able to figure this out with the late afternoon and evening blood glucose values providing a guide for the morning Lantus dose and the morning and lunchtime values a guide for the bedtime Lantus values. Something like an additional 4 to 6 units of breakfast Lantus should work and may even also need a decreased bedtime Lantus dose as the overlap takes place.
SB
