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September 2, 2003

Insulin, Insulin Analogs

Question from Pennsylvania, USA:

My 13 year old son was recently diagnosed with type 1 diabetes, and we would love to try Lantus due to the no-peak thing, but my son does not want to inject in school thus NPH works for this reason. The diabetes nurse says switching to Lantus would mean switching to four shots a day since Humalog needs to be given at every meal (including school time). The Lantus manufacturer told me that it simply replaces NPH and that if my son is doing NPH without dosing in school, it's worth baselining Lantus exactly as we are using NPH, i.e., no shot in school. My pediatrician whom I love is on Maternity Leave! She is my supporting edge when dealing with the diabetes nurse. My son is willing to go to three shots with Lantus but not the Humalog dose in school. Can we try Lantus without dosing in school and simply move from two shots a day to three shots a day (breakfast Humalog and Lantus and dinner Humalog) without dosing Humalog in school. Can we simply replace the NPH with Lantus as the company has suggested?

Answer:

I agree with your son’s diabetes nurse: The principle behind any basal/bolus insulin plan (be it by multiple daily injections — especially with a “peakless” insulin, or by continuous low-dose infusion by an insulin pump) is to better mimic natural physiology. Since you do not have diabetes, you make some insulin “all the time” (your basal insulin), and then you make a “spike” of insulin in appropriate amounts relative to a caloric meal or snack (your bolus insulin). If you eat plain celery (thus no significant calories), you won’t make much of a bolus insulin dose, if at all.

Since Lantus seems “peakless”, then if your son eats lunch (or a snack) at school, I would dose him with Humalog or NovoLog at that time. If he does not eat, he need not take the short-acting shot. If someone eats three meals and three snacks, then I would anticipate six shots of Humalog/NovoLog plus the stand-alone Lantus. This is why this type of plan is often referred to as “multiple daily injections” (MDI). But taking all those shots may be problematic. I have some patients who take Regular as the meal shot(s); it “covers” the meal and generally the snack following in the upcoming couple of hours. The trade-off for fewer injections is that I then expect the child to must eat a snack so as to avoid hypoglycemia.

Multiple shots like this is a good learning experience for an insulin pump. If you do not dose for lunch, then the child while still in the honeymoon might be able to keep the lunch glucose values reasonable, but at the expense of the pancreas’ last insulin reserves. They’ll need a lunch shot (eventually) anyway, so take advantage and learn to do this while prolonging the honeymoon. Alternatively, you could still give a small dose of NPH in the morning, in addition the Lantus plus Regular/Humalog/NovoLog allowing the NPH to cover for the lunch (and PM snack). Another “basal” option might be to use Ultralente as the basal shot. It lasts about 12 hours or so, and I usually give it twice daily. It can, however, be mixed with other insulins in the same syringe (unlike Lantus). It would still necessitate some other insulin as described above to cover the lunch.

Caution: if opting for NPH at breakfast (with Ultralente or Lantus, etc.) mealtime should then be consistent and that defeats part of the purpose of the flexibility of MDI game plan. Do not make any changes without the input of your son’s pediatric endocrinologist, of course.

DS