From Fayetteville, North Carolina, USA:
I was recently reading the transcript from the forum with Dr. Brink, and was intrigued about his method of the overlapping small doses of NPH. I asked our endo about this method, and not to my surprise, he knew very little about the concept. Could you please explain it, and how I should present it to our endo for further guidance?
We make all our decisions about insulins based upon patterns of blood glucose readings and try to match insulin to food and snack rather than force food and snack to try to match insulin peaks and troughs. With Humalog having such an excellent early peak phase, we cover postprandial glucose values quite nicely. But it also goes away quickly and so does not any longer have the tail effect of the older insulins. This is good since this helps decrease hypoglycemia.
For those who did not like being forced to eat mid-morning or mid-afternoon, we merely get rid of these snacks. However, sometimes for those who are big afternoon eaters and not so active, this means that there is not sufficient insulin by late afternoon. We can give Humalog at the 2-3 P.M. time period to cover this snack, cut back this snack, or use exercise in the late afternoon.
An alternative that we have used nicely is to add a small dose of NPH to lunchtime insulin since this also provides late afternoon and early evening insulin coverage. Thus, we end up with a proactive mixture of Humalog insulin by algorithms according to starting blood glucose level, activity and food planned plus NPH at breakfast, lunch, supper and bedtime. Some need suppertime Humulin NPH for the same reason if they have a very large evening meal but not much activity working by 10 P.M. - 1 A.M. Others use Humalog at bedtime snack especially if the bedtime snack is a very large one.
We make such decisions with a profile of blood glucose: prebreakfast and two hours later, prelunch and two hours later, predinner and two hours later plus two or three times through the night.
Original posting 13 May 1999
Posted to Insulin
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