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August 19, 2002


Question from Michigan, USA:

Regular and NPH is old school stuff. Since my daughter switched to Lantus with Humalog, she has never risen above 200 mg/dl [11.1 mmol/L], and we all know that high blood sugar levels will slowly destroy the cardiovascular system. How can you as a professional allow people to follow these constant guessing games with the peaks and lows of these old insulins?


No arguments here. Rapid acting insulin analogs (Humalog and NovoLog) work better for most people than regular insulin to cover meal time needs. Lantus (insulin glargine) is a wonderful new long-acting insulin which may cause less low blood sugar than NPH.

The good news is that pharmaceutical companies keep coming out with new products that make it easier to live with diabetes and achieve better blood sugar control. A year from now, Humalog and Lantus may be old news and you may be writing to us asking why people with diabetes aren’t all using Inhale Insulin. Isn’t technology grand?

Additional comments from Dr. Tessa Lebinger:

Not everyone is willing or able to take four shots a day. Some people are able to get good blood sugars on two shots a day. Some people can’t get good blood sugars with any regimen. I’m happy for your child and you that you have found a regimen that you like and that works for her.

Additional comments from Dr. Donough O’Brien:

You should be pleased that your daughter has done so well on lispro and glargine. I imagine that she has also learned to carb count and to adjust the after meal lispro to what she actually eats as well as to the premeal blood sugar, all of which is quite an achievement in the teen years.

Nowadays, I think it would be true to claim that almost all new onset children and adolescents in the USA with type 1A (autoimmune) diabetes in are started on some variation of this intensive regimen, certainly if the responsibility for care is with a diabetes team or a pediatric endocrinologist. At the same time, since glargine is still not officially approved for children (even though its use has been extensively tested), a small minority don’t feel comfortable on the new insulin. In some families, the burden of adjusting to a more demanding regimen is too difficult. Sadly too, the expense of this approach may have to be considered.

In addition, professionals don’t ‘allow’ a given approach to care, all they can do is suggest. Besides which, the enormously increased access to medical information on the Internet, that is available to everyone, does place some responsibility on the family to become aware what is new.

Additional comments from Dr. David Schwartz:

I am glad that your daughter is doing better on insulin glargine. There are several reasons why similar basal-bolus basal/bolus therapies are not right for everyone. Ideally, a child’s diabetes team tries to tailor the plan for the child; not all plans work for all children. I’ll give several examples.

Why is your daughter not on an insulin pump? It seems superior to Lantus and it is certainly not classically “old school.” Perhaps because she does not like being attached to a machine. Perhaps you can’t pay $5000 for the device or afford the on-going supplies.

Perhaps a child will not tolerate multiple doses of insulin per day as is typically required in all forms of basal/bolus treatment, including Lantus.

Perhaps a family has very limited technical or cognitive/IQ skills and can’t calculate carb intake or insulin-to-carb ratios.

Perhaps their glucose readings and HbA1c readings are in fact terrific on their current dosages of insulin (NPH, Regular, Ultralente, Lente, NovoLog, Humalog, etc). If doing well, why change “just to change?” So several factors need to be balanced. I hope this helps.

Additional comments from Dr. Linda DiMeglio:

Different insulins, different delivery regimens, and different devices for administering insulin injections are each appropriate for a certain number of patients. Many children and adults with diabetes do very well on NPH and Regular insulin (if other things in their lives stay stable). Some people do not do well with the newer insulins (particularly if the timing of the insulin peak and duration do not match their physiology, absorption, or schedules).