Diabetes, Insulin Basal/Bolus, Multiple Injections & the Pied Piper of Hamelin
"Into the street the Piper stept
As if he knew what magic slept
Then, like a musical adept
Out came the children running-
When, lo, as they reached the mountain side,
A wondrous portal opened wide-
And the piper advanced and the children followed...
The Pied Piper of Hamelin
Robert Browning, 1842
Little do my readers know that I actually enjoy literature other than diabetes journals. I have always loved British literature, as the themes keep intertwining with both my personal and professional life. So, why, today do I quote Robert Browning? The "Pied Piper of Hamelin" has arrived in the 20th and 21st centuries with the latest in diabetes regimens. There has always been a controversy over the correct insulin therapy: the most flexible, most physiologic, most convenient, most portable, least expensive, safest, etc. I am aware that many blogs and chat rooms discuss the best way to treat insulin dependant diabetes. Even at professional conferences (American Diabetes Association, 2008 in San Francisco, California, for example) there was a debate on the benefits of basal/bolus therapy vs. conventional insulin therapy with NPH and Regular or analog insulin. At the February 2009 Post-Graduate Diabetes Update Course in New York City, one of the presenters referred to the "Pied Piper" as we discussed the various insulin regimes.
My own Diabetes team at Children's National Medical Center continues to have multiple discussions about the use of conventional insulin therapy with 2 or 3 injections/day versus basal/bolus therapy via syringe or pen injection or insulin pumps. We are working on a tool to determine what families at diagnosis would do best on conventional insulin therapy or a form of basal/bolus therapy in which we use basal insulin (Lantus once daily, or Levemir twice daily) and fixed doses of rapid acting analog at meals without snacks ("modified" basal/bolus therapy). The best form of insulin therapy depends on multiple factors. Simply deciding which regimen to start should be based on many factors especially in a heterogeneous urban community. What are some of these factors?
The decision to start basal/bolus therapy in a newly diagnosed patient must ensure that important considerations are in place. Firstly, the age of a child is extremely significant. In young children, basal/bolus therapy might be appropriate due to erratic eating patterns (as well as different insulin action profiles) to avoid hypoglycemia. However, a caregiver must be available to give all injections via syringe or insulin pen. Diabetes education is essential. In school-aged children, we have a different dilemma. Who is going to give the insulin at lunch? The child? The nurse? Another trained adult? Will the school allow insulin syringes in the school, or do they require pens only? Will the school enable the child to give insulin in the cafeteria or does he have to report to the nurse? Knowing the answers to these questions are essential before the decision is made to start basal/bolus therapy.
Insurance also is another issue. Some insurance plans will not allow the use of insulin pens. That essentially makes the decision for us (especially if the school will not allow syringes). Additional blood glucose monitoring also is required, thus increasing the number of blood glucose strips necessary. (Obtaining diabetes related supplies for children with type 1 diabetes should not be problematic).
All families do not have equal resources. Financial, psycho-social issues, and physical limitations have major input in the choice of an insulin regimen. Dysfunctional families may not do well with multiple injections for a variety of reasons and may require the simplest regimen possible to ensure that the child receives his insulin. Sometimes simple may be the best way to proceed. I used to think that there was absolutely no place in my insulin tool box for premixed insulins such as 70/30 or 75/25 etc. I do not believe that now. Many families do quite well with these less complicated regimens, especially with an elderly caregiver that has visual difficulties and cannot mix insulin or is not always home. In any case, discussion with the actual caregivers and school or daycare is paramount before a family is sent home on a particular regimen.
It is important to realize that insulin is the key to managing type 1 diabetes. For insulin to be effective, it has to be injected and timed appropriately. Despite excellent intentions, if the diabetes treatment plan includes an insulin regimen that is either too complicated or not practical, there is a real possibility that the child will be underinsulinized or the insulin will not be effective due to timing, or mismatch with carbohydrates etc.
In summary, before we follow the "Pied Piper" into the sea (with the latest insulin regimes), we must ensure that we have the necessary infrastructure and ability to provide the appropriate supplies and education to the townspeople in Hamelin.