Happy Saturday, and welcome back to our weekly advice column, Ask D'Mine, hosted by veteran type 1, diabetes author and educator Wil Dubois.

This week, Wil looks at a fascinating topic: the functionality of long-acting insulin taken multiple times a day versus that of an insulin pump. Once again, you may be surprised by what you read!

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Thomas, type 1 from Texas, writes: I recently met a T1D who takes a small shot of Lantus before every meal, as well as at bedtime. She says it mimics a pump in some ways, and is an important reason why she has excellent control. Indeed, her BG control readings are enviable, with few peaks and valleys. She also mixes Humolog and Humulin, is on a fairly strict low-carb diet, and does a few other things that clearly contribute to her ability to keep her BG very close to normal. But have you ever heard of anyone else doing this with Lantus? She believes, and I concur, that despite what the manufacturer says, Lantus peaks in 9-10 hours. I told her that even if that were true, I take it twice a day and believe it still mimics the steady drip-drip of a normal pancreas. Her premise seems to be that just taking it throughout the day is even better. I would be interested in your opinion on this. Thanks.

Wil@Ask D'Mine answers: Wow, I've heard of some crazy therapy plans, but this takes the cake -- which your new buddy wouldn't eat, as she's low-carb and all. But, no, I've never heard of anyone doing this, and I actually have a hard time conjuring up a theory as to why her approach might have an advantage over one or two larger Lantus shots per day.

First off, I don't really agree with the two of you that Lantus has a peak. And to be clear, Lantus isn't instant. It still has an onset time, and it tapers off at the end of its action curve, so I guess you could define anything in between as a "peak," but it's one hell of a long flat one. I'd be OK with saying that Lantus has a mesa. But a peak? I don't think so. I've looked at literally hundreds of meter downloads of Lantus users, and I think that it runs flat enough to be legitimately called "peakless" after 2-3 days of starting therapy.

But there's more to the story. A fact that doesn't get enough press is that there's a correlation between duration of action and dose volume. When it comes to basal insulins such as Lantus, less is shorter. The less you take, the shorter the duration of action is. People who shoot relatively small volumes won't get the full 24-hour effect from a single shot. This is also true of our other long-actingLantus SoloStar insulin, Levemir. In both cases, simply taking a shot in the morning and a shot in the evening usually does the trick to restore a fairly flat 24-hour action curve in small-dose users because, as the first dose is winding down, the second one is ramping up.

Oh, and as an interesting factoid for your next game of Diabetes Trivial Pursuit: for an altogether different reason, people who take very large doses of Lantus need two shots per day for sure, as there's only so much liquid your fat can absorb at one time in any given injection site.

Now you said that your friend mixes Humolog and Humulin, but we don't know how and when she's taking those shots, so for now I'll focus on her contention that multiple shots of Lantus mimic a pump. Hmmm... not so much. I don't think multi-Lantus shots could mimic a pump's basal delivery supremacy. That would require variable doses every couple of hours, which is surely a recipe for a nervous breakdown. But, but, but... and here's an interesting thought that just occurred to me... as small doses of Lantus run for short periods of time, taking a small Lantus shot at each meal MIGHT be like taking a dual wave (a.k.a. combo bolus) on a pump.

A pump will let you take a portion of the insulin needed to cover the meal at once and deliver the rest over a period of time that you can select. It's a great tool for mixed meals that have some fast-acting carbs and lots of fat, like, say, pizza. In reality a pump accomplishes this by delivering some insulin at once, then running a higher temporary basal rate for a time. So, as small doses of Lantus last a shorter period of time than larger ones, taking a wee shot with a meal might be like running a dual wave. You could probably do the same thing with NPH insulin, too.

So I could see that small doses of Lantus taken with a meal might help down-stream excursions beyond the two-hour peak of fast-acting insulin, if you were having that problem. But I think it's moot in her case, as your pal eats low-carb. There's no need for a dual wave bolus on a low-carb meal. In fact, I think her low-carbness is likely the key to her success and I'd bet if she dropped the baby Lantus doses nothing would change for her.

If you eat low-carb religiously, and I do mean religiously, your insulin needs can drop to scary-low volumes. I'm pretty low-carb myself, being both hyper-sensitive to carbs and gluten intolerant. But then again I cheat a lot, having weaknesses for all kinds of higher-carb delights. I'm six-foot tall and 170 pounds. Based on my weight, you'd expect my total daily dose of insulin (combined basal and fast) to be between around 40 units, as the "typical" total daily dose for an adult type 1 is a half-unit per kilo, more or less. But checking the stats on my RapidCalc app, it shows I'm using 28 units a day on average.

And like I said, I cheat a lot. When I keep my nose to the grindstone for a week or two, my insulin needs drop off sharply. When I avoid the gluten-free pasta and gluten-free brownies, I can keep my sugar pretty well flat-lined on less than five units of fast-acting insulin a day, and I've seen other type 1s who take low-carb seriously survive on mere insulin fumes.

All of that is a long-winded way of saying that I think your friend's diet is the key to her success, not her injLow Carbection mania. If she eats extremely low-carb, her total insulin needs could be scant, and it may not matter what combo of insulins she uses to get her body's needs.

But I could be wrong. Figuring out what's happening is complicated enough when there are two types of insulin taken conventionally. But three types of insulin? Mixed and matched in unusual patterns? She's creating a blizzard of peaks and valleys of various sizes which makes it impossible to really know what insulin is accomplishing which job. I doubt Sherlock Holmes, a flock of endos, and a Cray Supercomputer could sort this out!

But hey, if it works, it works. I'd still bet her diet is the largest factor in her success, but if she doesn't mind taking her crazy mix of shots, and gets "enviable" results, then more power to her. That said, would I recommend this approach to anyone else?

No way.



This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.


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