we have a nine year-old son who has had T1 for almost two years now and has been on the pump for about a year. In general he's doing quite well, with pretty good A1Cs (7.5-7.7), but I've been increasingly wondering whether we might try putting him on lantus as well as the pump. Every time I bring this up with a doc or DNE they look at me like I'm crazy. I'm wondering whether anyone here has ever tried such a thing? Here are the possible benefits:
1. He really doesn't like wearing the pump at night, and sometimes gets pretty upset and says he wants to go back to shots just so he can spend some time disconnected. It's a pretty big thing for him to carry around all the time (he's on the minimed). His nighttime basal is by far the lowest of the day (half what it is in the daytime), so if we could calibrate the lantus properly he could get enough to cover his overnight dosage but still take use the pump to have his basals change at other times of day when he needs higher ones.
2. He is a crazy-active soccer (and other sports) player who uses every once of energy in his being when he plays. We disconnect him to play games and have to try to guess how much of a bolus to give him to cover his missed basal for the 30 minute halves. Having a baseline of lantus in him should mean that we can disconnect him for stretches of activity without worrying so much about him spiking, or giving him too much of a bolus to cover his missed basal and having him go low. The same thing would go for swimming and showering and bathing, etc....
3. We find that as we get close to 48 hours the pump will at some point stop being effective, presumably because the site has absorbed as much insulin as it's going to and he will start skyrocketing. We try to head this off by changing his infusion set before the full two days are up, but we don't always make it in time (e.g. when it's in the middle of the school day). We could change him every day, but I don't think that's fair to him. With the lantus in him his end-of-set highs would not be so dramatic.
It would of course mean an extra shot a day, but before we were on the pump we used to give him lantus when he was asleep, so I kind of think the upsides outweigh the downsides (although our doc and DNE don't agree). Anyway, it doesn't seem like *that* crazy an idea, so I'm wondering if someone else has tried it or considered it.
Hi Bruce, There is a very good reason the Dr.s look at you the way they do. Lantus is dosed and lasts 24 hours, the effective times during the day are almost graphed flat across the whole range of hours. Except for the first 30 minutes and the last hour or so, Lantus provides constant coverage. Using the pump and keeping his glucose levels down would become the devil and keeping his overall health would become almost impossible. Lantus is not setup to be the background medicine, while the regular that is used in the pump can be used in that roll. I would think the professional that helped set up the pump for you would be able to better manage adjusting the output of the pump, rather than put his life at risk by trying the time released Lantus along with the pump. That is dangerous and even seasoned diabetics would not do that to themselves. Sometimes the impossible is impossible to do safely.
thanks for your reply, but I'm not sure I understand. Basically I want to use the lantus for the common part of his basal, then use the pump for any variations above that plus boluses. Imagine that his night time basal is .3 u/hr and his daytime is around .6units/hr (which is about right). If I could give him lantus that is equivalent to .3u/hr of humalog then I wouldn't need to give him any humalog over night (since the lantus provides the whole basal he needs, and he could therefore go to sleep without the pump) and I could set his pump basal to .3u/hr during the day to give him the total of .6u/hr he needs. Is that clear? I don't see why it wouldn't work, although it would need careful calibration (like everything in Type I).
Here is the effective dosing for Lantus; Note section 12.2 figure 1.
Considering what you need to know, there is a good chance that during this time in your sons life, the pump may not be the best answer for him. Having those swings are damaging and not something he needs to try and handle with some weird combination of insulins and schedules you are considering to use. I would recommend you become good friends with statistics and functional in the different types and uses of insulins in general. Going into diabetic coma from either highs or lows is very destabilizing, I know from experience this to be true. I understand you want the best for him, and I want you to be successful in your quest to find the best solution for him, however, what you suggest using long term acting insulin to boost the short term acting is just not viable because of the nature of those types of insulins. It is generally (either or) and not (if then) in this case, will not work. You will spend more time in (emergency or recovering from) actions than you will maintaining actions. Good Luck, Jeff
I understand your concerns Bruce, but don't think it would turn out like you're hoping. It would be better to switch him to shots completely.
If you stick with the pump, he can disconnect for hours at a time. I've done that and just reconnect every hour or and tested to take a correction bolus. I often do it what at the pool with my son. I'm just standing there most of the time, not swimming laps, so I take a small bolus before disconnecting and then every hour or so take a correction bolus. My guess is your son's basal rate is pretty low so he's probably not missing out on much insulin being disconnected for 30 - 60 minutes.
thanks for the reply. Can you elaborate? Why not? Do the lantus and humalog interact in some way so that there effects are not just additive? The biggest bonus would be letting him sleep without the pump. I can't imagine going back to shots at this point. Too restrictive and too inaccurate.
You know your son best and you have a good understanding of how his body uses insulin. Using pump and Lantus it seems like you'd get the worst of both and would miss out on the best features of each.
Are his basal rates really steady enough that Lantus would be a good replacement? Lantus is okay for the daytime hours because most of our bodies have pretty steady basal needs, but overnight is where the basal goes from it's lowest level to highest level in just a few hours. So you wouldn't be using the pump at the time that it provides the biggest basal benefit.
Mixing Lantus with the pump would make the pump's insulin on board feature unusable. So insulin stacking and lows would be more likely.
Lantus also causes highs and lows, like any long acting insulins do, because they have peaks and durations that don't match the body's needs.
The pump would basically provide just meal and correction boluses. So he still would have to wake up at a certain time to get his morning bolus. Would it really be worth the site changes and wearing the pump if it wasn't providing better control?
For your son in particular I would worry about absorption. You're already dealing with insulin not absorbing well after the 3rd day with the pump. A disadvantage of shots is insulin absorption. Dr. Bernard Goldberg shares about the law of small numbers, which is based on research that shows only doses of 5u or less of insulin given by injection are absorbed completely. With larger insulin doses up to 40% of insulin may or may not be absorbed on any given day. So if the Lantus is absorbed sporadically and the pump bolus is absorbed sporadically, you'd be you'd be dealing with a lot of different absorption issue.
I'm not sure how the pump works for you, but I think it takes more than just insulin amount to create absorption problems with a pump. I usually only get the 3rd day highs when I've hit muscle or something else that bends the canula. Has your son tried infusion sets for a lean build?
What does he dislike about sleeping with a pump? I know it's slightly disruptive, but most kids sleep hard so I'm surprised it's bothering him so much. Is there anything you can do to fix the issues he dislikes? Is he using the shortest tubing? Are you able to clip it on the side of his underwear or pajamas so it doesn't get in his way?
Again, you know your son best and since you have type 1 you understand insulin and pumps and shots well. Knowing all that, the mix you're considering may be worth trying. Each person's diabetes is different. Just make sure if you go that route you get your son's doctor's recommendation on Lantus dose and know it will be a challenge getting the details worked out. And if he does try it I want to hear all about it... but I'm going to be really cranky if it works well and my doctor wants to me start taking Lantus in addition to using my pump. =)
if our son had a significant dawn effect I could see your point, but we've never seen one. His overnight basal is low all night and he typically wakes up at good #, so I don't see why we couldn't have the best of both worlds. His basal goes from .3 overnight to .6 or so most of the day (a bit less in the afternoon). So I would ideally like to give him the amount of lantus that would be the equivalent of 0.3units of humalog, then subtract .3 from all his basals (which would make them 0 overnight meaning he wouldn't need the pump). Then we would get all the advantages of the pump in terms of variable and temp basals, but with a baseline basal that would prevent him skyrocketing when the pump stops working and also allow him to be off the pump at night (and more easily during the day). This is mostly the same as what people typically do with lantus/humalog regiments except we would be using the lantus to cover only the smallest of his basals. From the data I've seen, lantus is pretty flat for most of 24 hours, which of course is the point of it
Does that make sense? I can't see any reason it wouldn't work, but I keep getting "are you crazy?" reactions.
I too thought of this for a time, but after careful discussion with endo and research I decided against it. Of course none of us are endos so I suggest discussing with yours.
But Lantus is very finicky and can actually peak at different times in different people, I think it would be tricky to do Lantus and basal from pump.
I do know some people who do NO basal via pump, and just use it for boluses, while Lantus is doing the background insulin job.
Another suggestion with bad sites is trying out different ones. My son is very lean and plastic never worked well for him. We use steel sets and when a site has gone"bad" we may see a 270 vs a450 from a bent plastic Canula.
I hope this has helped some what, and hopefully your endo can help you make the best decision for your family!
There is actually a name for what you are requesting. The Un-Tethered Regimen coined by Dr. Steve Edelman of TCOYD (Taking Control of Your Diabetes). While I don't think you are crazy I do think that it could be really hard to do this particular method in a child. But, what do I know? I am just a type 1 lol
Maybe you can contact Dr. Edelman directly and ask questions about it, and whether or not he thinks it would be a good fit for your son? He is a highly respected person in the field of diabetes (he also has type 1) and is located in California. This is his email address: svedelman (AT) vapop (DOT) ucsd (DOT) edu
Bruce and Gina-
You're both winning me over to the idea. It does sound crazy at first but you've obviously thought through it Bruce. And like everything else with diabetes, if it doesn't work, you can do something different.
Thanks Gina for the info on Dr. Edelman.