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June 7, 2005

Insulin Analogs

Question from Israel:

My nine year daughter was diagnosed with type 1 diabetes three and a half years ago and has been taking NPH with Humalog. She is doing well, A1cs of 6 to 6.5. My wife would like to try Lantus in order to reduce number of low blood sugars and to avoid the need to give her a night meal. The main reason for that is that she feels that it will allow us to better control her weight. My wife also showed me polls from your site (Children with Diabetes) that, in the last two years, more and more kids are switching from NPH to Lantus. Our daughter is an independent girl and knows how to use Humalog pen, however when she does, we are always around. She has no issue with injecting a few times a day, if needed. Our diabetic team is not excited at all about switching to Lantus. They say that Lantus is not predictable for kids and that we will have to continue and test at night, like we do with NPH. In any case, they say that, for her age, they recommend Lantus in the morning and not prior to bedtime. I am pretty nervous about this change since our daughter will have to inject Humalog whenever she eats, even if we are not around. What is your experience with nine years old kids that use Lantus?

Answer:

Many pediatricians, myself included, have switched our entire practice to Lantus instead of NPH and use this as part of a basal/bolus program. Usually, bedtime Lantus and a smaller amount of Lantus in the morning since Lantus often does not last a full 24 hours in true type 1 diabetes patients. This is very dependent on activity and eating schedules/patterns and must be individually adjusted for each person based upon frequent pre- and post-prandial blood sugar readings and using either NovoLog or Humalog as the prandial insulin. This includes snack coverage with the analogs. The price you pay for more flexibility with meal coverage and fewer overnight hypoglycemic events using Lantus in this fashion is more injections each day, unfortunately. Please go back and review with your diabetes team. There is a good article on using Lantus in this fashion in my own textbook, Pediatric and Adolescent Diabetes also in Insulin-Dependent Diabetes in Children, Adolescents and Adults by Ragnar Hanas, M.D.

SB