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Question:

From Georgia, USA:

My daughter, type 1 for one and a half years, is struggling to keep herself under control. We are trying to put her on the pump; our problem is with her doctors. One, her endocrinologist, says use the NPH, and keep her sugar levels between 100 and 150. The other, her pediatrician, who has many diabetics, says Ultralente, and don't worry about her levels (they are in the mid-300's); just let her be a kid. The Ultralente does not help her keep her level down. We realize that as soon as she goes on the pump this point will be moot, but our job is to keep her alive in spite of our two doctors who have a professional disagreement. She has had her insulin changed three time in the past three weeks; seven times in the past year and half. We have no other doctors to choose from, and it is hard when you have to decide which course of treatment when your doctors disagree. We would welcome another opinion.

Answer:

You did not mention how old your daughter is nor how often she injects insulin. I will answer this question as though she were a teen, and as she is considering a pump, a teen who will take multiple doses of insulin per day.

First of all, blood glucose control matters. There have been studies, such as the Diabetes Control and Complications Trial, which have proven this point. Follow your child's hemoglobin A1c level to get a sense of her overall control. The blood sugars will fluctuate, even with a pump.

Unfortunately achieving the desired level of blood sugars is difficult. There is no one "best" insulin. It is a matter of trying each program to the fullest, to see which insulin is best for your child. When I help a family decide on an insulin regimen, I take into consideration the child's eating patterns. Have you met with a nutritionist experienced in the care of children with diabetes? For example, a teen who does not wish to snack during the day may be better suited for Ultralente as their long-acting insulin. Using Ultralente with a combination of Humalog and Regular can usually achieve the effect. A lunchtime shot is needed with Ultralente. If a large bedtime snack is eaten, a dose of Humalog or Regular may be needed, as Ultralente usually won't be peaking to cover the bedtime snack.

If your child does like snacks, NPH at breakfast and bedtime may be the best option. If the standard approach with NPH doesn't work, we have had excellent success with dividing the NPH into 3-4 doses per day, along with mixtures of Regular and Humalog. Some centers use mixtures of Humalog, Regular, NPH or Lente with Ultralente. It can get complicated, but whatever helps you to achieve your goal.

In summary, working with a team who will make an individual insulin plan is of utmost importance. If standard twice a day NPH and Regular do not work well enough, then creative combinations of insulin can help to match your child's needs. Also, careful attention to food intake is needed, and adjusting insulin for food is necessary for success, in my opinion.

LM

Additional comments from Dr. Quick:

As Linda points out, there's more than one way to skin a cat. Since you're dealing with only two doctors for your daughter, and since the two of them disagree, I'd suggest you might ask each of them whether they see any objection to the other doctor's proposed therapy, after showing them a printed copy of this reply! Then, base your decision on whose proposal to use on what they say to this new request!

WWQ

Original posting 28 Oct 1998
Posted to Daily Care and Insulin

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