Questions and Answers
Will Lantus Give Me the Same Flexibility the Pump Does?
Q: I have had type 1 diabetes for 20 years. I tried the insulin pump and didn't like it. So now I don't have any flexibility with my food or lifestyle if I want to keep my blood glucose under control.
Will Lantus (insulin glargine) give me flexibility the same way a pump does? For instance, can I take it once a day and then inject rapid insulin when I eat, etc.?
Tel Aviv, Israel
A: With Lantus as your basal insulin, you can live a very flexible lifestyle. The dose would be exactly what the basal requirements were with your pump, and you would take the same pre-meal boluses that you do now. If you switch to Lantus (insulin glargine), I recommend getting a good insulin pen with short ultrafine needles for the bolus rapid-acting insulin injections.
The downside, compared to the pump, is that you will be taking several injections per day and will be unable to have alternate basal rates throughout the day.
The upside is that you don't have to worry about pump occlusions, running empty or having the infusion line come out. When these things happen, the blood glucose rises very quickly because there is no long-acting basal insulin on board when using the pump.
Steven Edelman, MD
Associate Professor of Medicine
Division of Diabetes and Metabolism
University of California, San Diego, School of Medicine
Editor's note: For more information about various insulins and insulin pens, available in handy chart form, see these two articles in Diabetes Health: "Everything You Wanted to Know About Insulin" (March 2002, page 46), and "Your Own Injection: An Overview of Insulin Pens" (April 2002, page 48).
How Can I Better Control My Fasting BGs?
Q: People with diabetes, it would seem, have much more control over after-meal spikes by controlling the amount of food they eat, getting more exercise or adjusting meds/insulin.
However, what about the high morning readings?
Try as I may, mornings end up high (175-215 mg/dl).
What do you recommend?
A: The fasting, or morning, blood-glucose concentration may be a victim of several things:
- The concentration of insulin in the bloodstream at that moment. The blood glucose will rise if there is not enough insulin left from the previous injection—perhaps taken 8 to 10 hours earlier—to compensate for the "wake-up" hormones that have anti-insulin characteristics. These hormones include growth hormone and cortisol. The solution—if this is the case—is to increase the bedtime insulin to compensate for the force of the "wake-up" hormones.
- The leftover food in the bloodstream from a late-night snack or a middle-of-the-night raid on the refrigerator. Here, the treatment should be to cover the food eaten with rapid insulin, not to raise the bedtime long-acting insulin.
- The bedtime blood-glucose level. Highs before bedtime can be from either bedtime snacks or leftover food from dinner. If the bedtime blood glucose is elevated and the bedtime dose of insulin is designed to be just enough to maintain the same blood-glucose level all night long, then the wake-up blood glucose will be high. This is because the overnight insulin is not designed to "conquer" the blood glucose but merely to maintain it. If this is the reason the wake-up blood glucose is high, the way to fix it is to fix the bedtime blood glucose.
In addition, if you have a middle-of-the-night low, the low blood glucose elicits a counter-regulatory response of anti-insulin hormones that produce glucose from the storage of glucose precursors in the liver. The net result is a high blood glucose about three hours after the low. Thus, a low at 3 to 4 a.m. can result in a high blood glucose upon awakening.
Lois Jovanovic, MD
Director and Chief Scientific Officer
Sansum Medical Research Institute
Santa Barbara, California