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Daughter with Type 1 diabetes on Lantus

Resolved Question:

Good day doctor.

I am writing you on behalf of my daughter age 7, we are in Brazil and have a very basic medical team that is not successful in controlling my childs blood glucose levels.

We have recently changed doctors, our new doctor has changed the medication routine from NPH 2 times a day to Lantus, we were using 14 units of NPH in the morning and 2 at night.
Our child was going too low at snack time at school but was generally under 200 during the day.

In this regime we noticed a 100 point drop per unit of ultra rapid insulin that could increase in the peak times. Now that we are using Lantus we are unable to keep her under 200 and she has gone over 300 multiple times.

We are counting carbohydrates, reduced fat and increased vegetables but the situation is the same.
our doctor refuses to answer our questions and refers us to a nutritionist that is not available for consultation.

Her current background dosage is 11 units of lantus with humalog being next to ineffective.


Category: Endocrinologist

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Category: Diabetologist
Dr. J Muthukrishnan is online now

Expert:  Dr. J Muthukrishnan replied 4 Days.

Hello,
Thank you for choosing DoctorSpring.

First, let me assure you there is no reason to worry. Controlling Sugars needs some patience and perseverance. And it is never impossible. You will need to do is understand it well. At time when there is a chance in medication the bloof sugar values might take some time to be under control. The dose adjust is basically a trial and error method, and there is no 'single' magic dose for each blood sugar value. It varies.

Lantus is a good change from NPH if used well.
You need to target the fasting and premeal sugars with adjusting the dose of Lantus. Humalog before meals is more for controlling the post meal sugars. So I would like you to chart out sugar readings like this....Fasting, pre lunch...pre dinner....post Bfast, post lunch and post dinner (all 2hr post meal) on a day...and let me know...dont change your present dose of Insulin till then.

regards

Col (Dr) J Muthukrishnan, SM
Senior Adviser (Med & Endocrinology)


Patient replied :

Hello Dr. Muthukrishnan
Thank you for your speedy response. I have been using accu-chek compass software to keep records. Counting carbohydrates has been a part of our daily life since my daughter was diagnosed.
her current carbohydrate intake is roughly 10 - 15g per meal/snack.

On average, she is having around 100g of complex carbohydrates a day.

The newest average BG data we have is as follows

AM, (fasting) 109,3
after breakfast 211
Before lunch 93
After lunch 178.6
Before dinner 126
After dinner 202
Evening 180

Her trend graph shows

Above target >140 41.7%
within target 70-140 50%
Below target 8.3%

Highest BG 310
Lowest BG 51
Average BG 158

Ultra rapid dosage was based on this guideline before changing to Lantus

Very low schedule (Insulin-sensitive)
BG 150-199: 0.5 unit bolus Insulin (regular or rapid-acting)
BG 200-249: 1 units bolus Insulin
BG 250-299: 1.5 units bolus Insulin
BG 300-349: 2 units bolus Insulin
BG Over 350: 2.5 units bolus Insulin

Her insulin needs have gone up since the change we now are in between the previous table and the following.

Low schedule
BG 150-199: 1 unit bolus Insulin (regular or rapid-acting)
BG 200-249: 2 units bolus Insulin
BG 250-299: 3 units bolus Insulin
BG 300-349: 4 units bolus Insulin
BG Over 350: 5 units bolus Insulin

Total daily ultra rapid dosages range from 6.5 UI to 8 depending on the day.

Her highest peaks happen at school(15:00), after snack time where she has under 10g of fiber rich carbohydrates.

She is currently 23 kg

Her previous NPH dosage was 15 UI divided in 2 dosages, 12 in the AM and 3 at night.

Our doctor switched to lantus using 11 UI based on the 80% rule changing from NPH.


I am an engineer and the last time I did the math I come up with 12 UI (80% of 15 UI). There might be a very good reason for 11 UI but I throw the question out there.

I hope this is enough data for you to get a picture of the situation. You may contact me david(dot)erikovich(at)gmail(dot)com.

Thank you again for your time and consideration.

Sincerely

David


Expert:  Dr. J Muthukrishnan replied 3 Days.

Dear David,

I have gone through the profile in detail and appreciate your dilligence in maintaining it.

It is generally ok, except the pre-dinner levels. I suggest you make these changes. Lantus 12U at bedtime, Humalog 4U before BF, 6U before Lunch and 4U before dinner. Target premeal sugars at 70-110mg and post meal below 160mg/dl.

You haven't told me about the HbA1c levels.?

You can add the correction bolus as per your chart if the premeal levels are above the intended target.

Check again after 3 days and let me know.
Regards


Dr. J Muthukrishnan
Category: Diabetologist
Experience: 
Fellowships/Training: 
1. 10th Asia-Pacific Pediatric Endocrine Society  Fellows meeting, Seoul, Korea, Oct 2008
2. Eighth ICMR Course on Genetics and Genetic Counseling – Jul 2008 – SGPGI, Lucknow
3. Annual Certificate Course on Endocrinological Laboratory Techniques at National Institute of Nutrition (ICMR) Hyderabad,India, ( Aug-Sep 2006) 
Fellowship: Endocrinology, Diplomate of National Board, National Academy of Medical Sciences, New Delhi, 2008, Medwin Hospital, Hyderabad
Senior Residency: Diplomate of National Board (General Medicine), National Academy of Medical Sciences, New Delhi, 2002
Residency: MD, General Medicine, 1997-2000, Armed Forces Medical College, 2nd position in University
Medical School: MBBS, Armed Forces Medical College, 1992
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