For the past six months, I have been on a regimen consisting of Novolog by day and Lantus by night. I eat well in measured portions and try and make the best assumptions I can about foods that are not always easy to measure. I keep an exact journal and turn this in weekly. However, my A1c has actually been rising the past few months (from 8.4-8.9%), and my doctors were so stunned by this that they have (at least temporarily) “blamed” the Lantus and have decided to switch me to NPH.

I have read three years of Q and A on your site, and I feel I am going in the wrong direction based on your answers. They all seem to be moving towards Lantus while I am moving away. I am little scared as there is an NPH peak, not to mention an additional morning shot. Is NPH past its prime? Are there not newer sources? After all, a lot has happened in the fifty years since they developed NPH. Should I be looking elsewhere? Can you provide a more enlightened and empowering set of questions to proposition my doctors?

Hemoglobin A1c levels in the 8% and above range are simply too high if you are to minimize or avoid long term diabetes related complications. With so much monitoring, I suspect you are not setting correct target blood glucose goals.

It is possible to achieve tight control with overlapping doses of NPH plus Humalog or NovoLog for bolus control. It is also possible to use insulin pumps as well as Lantus (insulin glargine) as basal insulin. Many times, Lantus does not work for a full 24 hours, and, in such cases, one can use a second morning dose of Lantus to complement the bedtime Lantus dose.

All should be decided based upon blood glucose detective work. You should work closely with your diabetes team to try to figure out what is working or not for you and then problem solve together. One can also use bedtime Lantus with lunchtime NPH for the same benefit overnight with the Lantus and then instead of morning Lantus use the lunchtime NPH to compensate for the time the Lantus is wearing out. Still, problem solving needs to be individualized. Go back and find out how your team suggests you improve the A1c and the day to day blood glucose values that creates this too high A1c.

SB