Dr. Bernstein says that the biggest problem with losing Lente and Ultralente is that we are now left with fewer insulin-diluting options for children or adults who require very little insulin.

Bernstein gives an example of this by comparing a 140-pound adult with type 1 to a 30-pound child with type 1. He says one unit of Ultralente will lower the blood glucose of a 140-pound adult with type 1 by 40 mg/dl. But one unit of Lantus will also lower the adult’s blood glucose by about 40 mg/dl.

For a 30-pound child, who is approximately only one-fifth the weight of the adult, however, one unit will lower his blood glucose by 200 mg/dl. If you wanted to lower the child’s levels by only 10 mg/dl, you would have to give him one-twentieth of a unit.

“How are you going to measure one-twentieth of a unit?” asks Bernstein “You have to dilute it.”

Bernstein says that the same diluting fluid was used for Ultralente and Lente.

“But those basals are now gone,” he says. “So these kids are screwed and the manufacturers don’t give a damn.”

Bernstein says that the only options left for children is to dilute NPH and give it every eight hours—or to just give them Lantus.

“But you can’t dilute Lantus,” he says. “I started a type 2 patient on insulin, and it turned out that the small doses we were giving her were having too much of an effect. For her Humalog, we have diluting fluid—which is the same as NPH’s diluting fluid. But for Lantus, we can’t dilute it. So I’m stuck.”

Bernstein adds that as long as we have Regular and Humalog, we can dilute pre-meal doses.

“But you can’t dilute your basal doses anymore,” he says, “unless you go back to NPH and give it—instead of twice a day—three times a day. The smaller the dose, the less peaking you get…but it means more shots and is more of a nuisance for patients and parents.”

At press time, insulin detemir (Levemir) was not available. Like Lantus, Levemir is a long-acting basal insulin.