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June 29, 2002

Insulin

Question from Virginia, USA:

What is the most widely recommended treatment for people with type 1 diabetes? Is it NPH with Humalog, or Lantus with Humalog after each meal? Are five shots a day generally considered normal or excessive for a 13 year old?

Answer:

I think it depends on several factors, including age of patient, other concurrent medical issues, patient’s (or parents’) competence.

For a newly diagnosed toddler, a patient might get by with only NPH or Lente, or even Ultralente twice daily. I am using more Ultralente as the baseline and then using Humalog or Novolog with meals, even in this population.

For a school aged child, split doses of NPH (or Lente) plus Regular as two to three shots per day is an easy way to start while families learn nuances of insulin and the balancing act of meals, activities and insulin.

For a teen, I sometimes will start with that which I described above, but the use of basal/bolus therapy with Lantus (insulin glargine) plus Humalog, Novolog, or Regular, I think is superior for lifestyle and meal flexibility issues.

If your child did not have diabetes, then he/she would make insulin all day long plus extra “pulses” with each meal. So, in essence, that would be equivalent to “a shot” every time he/she eats. So do I think five shots is excessive? No, depending on the insulin regimen. If he/she takes Lantus at bedtime, eats four times a day and takes Novolog, Humalog, or Regular at those times, then five shots is not excessive. If he/she is on NPH and Regular and then must “chase” his sugars to get back down, then five shots is a lot and implies that the usual doses of insulin are inadequate.

A better question is what is his/her and your attitude to the shots? If he/she thinks this is too many shots, and wants a different regimen, then you have to balance out pros and cons with your child’s diabetes team. I do hope that you have an on-going dialogue with them.

DS

[Editor’s comment: If your child indeed does require five shots a day but wants to decrease the number, I would suggest you explore the possibly of switching to an insulin pump.

SS]