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Question:

From Houston, Texas, USA:

My 3 year old son was diagnosed with type 1 diabetes at age 18 months. He currently takes Humalog mixed with NPH insulin three times per day. He wakes up most mornings with elevated blood sugar of 200 or more. Would the use of Ultralente insulin help with control of the A.M. reading, and how would we give it?

Answer:

There are many different regimens to try and give insulin in a manner more similar to the way it is normally produced.

Normally, the pancreas makes a relatively constant amount of insulin 24 hours a day ("basal" insulin requirements), and then makes extra insulin when food is eaten ("bolus insulin")

The "basal" insulin can be provided with a continuous infusion of fast acting insulin (Regular or Humalog) as in the pump, or can be given using intermediate or long acting insulins 2 - 4 times a day (intermediate insulins include NPH and Lente) and long acting is Ultralente.

There is no perfect way to provide the basal insulin to exactly mimic the way the body makes it. In young children, it can be especially difficult as they tend to go to bed early, and have a long time between their bedtime snack and breakfast. If you are not careful and don't check the blood sugars during the middle of the night, you can cause low blood sugars during sleep while trying to lower the blood sugar before bedtime and breakfast.

The trick is to try and figure out when the NPH doses are working and if you add or substitute Ultralente, to figure out when it is working. Even though you will read in books when the insulin is "supposed" to peak, there is wide variation in individuals when the insulin is actually peaking. As you increase a dose of any insulin, it tends to last longer.

Possibilities to consider and discuss with your own child's physician (you should not make any change without discussing this first with your child's own doctor):

  1. Giving part or all of the evening NPH later in the evening so it lasts longer.
  2. Substituting Ultralente for NPH before supper (you may not need exactly the same amount of Ultralente in the evening as NPH - also, you may need to lower one of the daytime insulins if the Ultralente lasts longer into the day and overlaps the daytime insulins. Note: Eli Lilly does not recommend combining NPH and Ultralente in the same syringe. If you need to combine an intermediate and long acting insulin, you may want to consider substituting Lente for the NPH. Lente and Ultralente can be mixed in the same syringe.
  3. Substitute Ultralente 2 or 3 times daily for the NPH 3 times a day.

As I mentioned, make sure to test during the night while you are making any changes to lower the blood sugar at bedtime, during the night, or before breakfast to make sure your child's blood sugar is not going low while he is sleeping.

Unfortunately, only "trial and error" can determine the best regimen for an individual child. Again, do not make any change without first discussing it with your child's own physician.

TGL

Original posting 9 Oct 1998
Posted to Insulin

  
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Last Updated: Tuesday April 06, 2010 15:09:02
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