increasing dose but can't lower BG

I've been trying to get Milo onto the tight Lantus regime, i.e. keep his BG below 100/5.75 all the time. But as I increase the dose he just seems to go higher. I am up to 7 IU twice a day and am about to start reducing the dose as we don't seem to be getting anywhere and 7 seems a lot. Have I been giving him too much?

Here are his last 6 days starting at 3.5 rising to 7 IU every 12 hours. The left vertical scale is mg/dL, the right is mmo/L, the dark blue dots are readings and the light blue are injections and readings at the same time. The bottom scale is time with marks every 12 hours.

I know the increases are large/over a short period but I was hoping to see him drop and he hasn't. His twin sister who doesn't have diabeties is always between 3 and 5 mmo/L.

Milo is a 9 year old domestic short hair and weighs 6.4kg (above his target weight of 6kg). He lives on dry diabetic cat food (low carb high protein).

 

What insulin?
Are you increasing by 1/2 unit every shot?
Every day?
What you are getting typically indicate you are giving too much insulin. Also, increasing so fast makes it hard to see the effects. That is especially if using Lantus or Levemir.

 

Thanks I am coming to that conclusion. Its now two hours since that graph and his last 7 shot (7 IU) and he has gone up not down, to 180/10.

Dose increase was 3.5 to 7 over 11 shots so just under 1/3 unit increase per shot, I know that is fast. I am puzzled why too much doesn't push his BG way down though. When I was injecting him with caninsulin that amount would have put him way down below 5.

What's the best way to go about reducing his shot? Gradual I presume, not cold turkey.

The insulin is Lantus/glargine.

 

One thing to remember is that each cat is different. My Tonis first responded to Lantus well then I got BG similar to yours. When I got up to 5 units I changed to Levemir with no real improvement up to 8 units. I had some R insulin and that dropped his BG. I ended up with 8 unit levemir and 5 units of N twice daily. I could maintain his BG between about 70 and 120 with that.

 

well maybe the high dose is starting to work:

 

You're below 200 mg/dL much of the time, so that is doing OK. Vets may get nervous with numbers much lower than that in inexperienced clients.

At +6 hours give or take an hour, is when Lantus is likely to hit its nadir.

All dose adjustments should be made based on the nadir, not the pre-shot values.

Roughly 2 hours after eating, food is starting to offset the insulin and the glucose level may be near the pre-shot level.

It generally takes about 3 full days before you can evaluate the effectiveness of a dose because of the overlap effect, aka depot.

Reductions in dose are advised when a new diabetic drops below 50 mg/dL (2.7 mmol/L).

A reduction in dose may be advised if the pre-shot test value is often too low to shoot safely. When starting out, we ask folks to not shoot below 200 mg/dL (11 mmol/L). That number is gradually lowered as you get nadir data to show it is safe.

 

I forgot to ask, what in particular indicates that? Thanks.

 

Because that is sometimes a symptom when the BG goes up with increasing insulin dose..

 

Too much insulin as well as too little insulin can cause the BG numbers to be high.

Lantus insulin dosing changes are based on the nadirs, not the pre-shot tests. Please list the nadirs for the last 7 days.

 

You can get the nadir (or close to it from the graph). The dark blue dots are BG readings. The light blue dots are the BG at the shot time.

 

Larry,

Yes, I could 'guess' at the nadirs. And the doses because that dot size does not tell me how much insulin. It only tells me with a bigger blue dot that the dose has gone up.

Our standard format spreadsheet is used for a reason. Without that, few people are going to take the extra time to look at this guys graph and 'guesstimate' if he should hold, increase or decrease the dose. We standardize all sorts of things in our lives. Like rules of the road. For good reasons.

I can't tell if the times are +1 or +2 or +6 hours or something in between. I can only guess. With our standard spreadsheet, I could see the times without having to guess. I could see the numbers without having to guess. I could see the doses without having to guess or search back through all his multiple posts and various topics. I could see if he gave a late shot or an early shot.

He isn't holding the dose long enough. He's not following the Roomp and Rand protocol or even our modified version from what I can see. I haven't a clue what he bases the dosing changes on. He's not giving enough time for the depot to fill or drain before he changes the dose again.

He's had BG's between 50-100 which means he should have either 1. fed, reduced the dose 2. fed, wait 1-2 hrs, til BG >100 shoot normal dose or 3. split the dose, feed, give rest of dose in 1-2 hours if BG >100. This is per the original Roomp and Rand protocol. http://felinediabetes.com/Roomp_Rand_2008 dosing_testing protocol.pdf

He's shooting really low, keeps increasing and then decreasing the dose on some sort of random basis without waiting for the depot to drain or refill, has a wicked inverse curve which usually means too much insulin, has a super early nadir lots of cycles.

This is the Titanic steering directly for that iceberg. I see this cat headed for a hypo with these randomly increasing insulin doses.

Yes, our spreadsheet is not as robust as it could be. Yes, he prefers his graph, but if he wants more people to look at his data, he needs to be using our spreadsheet which will take a lot of the guesswork out of the equation and be more familiar to a lot of very experienced people here.

Diabetic Cat Care has their own format for presenting the data. So does Your Diabetic Cat. Neither one uses a graph.

I'm glad you are advising this guy. There are simply too many other new people here to take an extra hour out of my day to fiddle with the graph.

 

DRY FOOD.

You are feeding DRY food and it is most likely contributing to the high numbers.
You should consider cutting the dose down to 3u or even less and get rid of that dry food.

There was once a cat who was on 20u twice a day of Caninsulin and eating DRY food. When the owner removed the dry and got the cat on wet low carb food, that cat dropped down to 1u twice a day.

if you have a cat who is very carb sensitive, like one of mine was, the maker can tell you it's ZERO carb and it will not be good for your diabetic cat.

Your dose increases are way too fast for Lantus, and I'd go baci to 3u even if you don't change the food right away....
You need to hold each dose at least 5 shots and then increase only 0.5u at the most.

if you switch to WET low carb food, and get back up to the same dose of 7u or more, then you can start to think of your cat having an insulin resistance condition such as acromegaly, but not until you adjust the diet.

Gayle

 

There is clearly a different mindset amongst some on this forum to the one I have. I am trying to monitor regularly and am driven by the curves I see. Some seem to have a rigid formula based on numbers and want to stick to it. I suspect, from their problem understanding a graph curve or reading numbers off it, that they don't really understand why they are doing what they do, they just do it rigidly as if by rote.

I've been injecting and monitoring my cat for 4 months now. His BG figure has never gone hypo and more importantly his curve has never shown a danger of it.

Please if you can't read a graph do save your time and mine and don't comment, stick with your numbers.

For info I am currently aiming for tight regulation, not just maintenance. A lot of the formulas I see seem to be aimed at cats who are not blood tested at home every two hours, hence they quite rightly are rigid and err greatly on the side of avoiding a hypo. My non diabetic cat doubled her BG just by being put into a car so I can't see any reading being anywhere near accurate taken at the vets. Hence the vet guidelines have to be cautious. I am hoping to do better than that.

 

There is absolutely NO evidence for anyone here interpreting BG curves 'by rote'. Every cat is different and each case needs to be considered on an individual basis. I doubt that even 2 cats have the same BG pattern. That is why forum members here generally value the experience and skill of others here who are particularly adept at interpreting the numbers and the patterns.

When I have a problem and I need help with it, I want those with more experience than me to help out. And I want to make it as easy as possible for them to understand my problem; firstly because the more they can understand my problem the better they can help me; and secondly because these people that are helping me have limited time to do that (there are others who also need help), so I want to help them to make the best use of their precious time; And their time really is 'precious'. This forum has saved the lives of many cats, and has helped a great many into remission too.

 

I've no doubt that this forum has saved the lives of many cats but it is clear to me that a few members cannot read a graph. So I don't understand how they are interpreting their figures. If you cannot at least visualise figures as a graph you would have to sit down with a calculator and calculate rates of change and even then that would just be a figure and give you no proper conception of what is happening.

I think it is generally accepted (outside this forum anyway) that a graph usually presents data in a way which is easier and quicker to understand than a table of figures. In fact that is the point of graphs.

 

What I wrote you (said "rigid formula") was a brief synopsis of part of the Roomp and Rand protocol for tight regulation which has been shown by empirical research may result in remission if followed. Co-author Dr Rand of the University of Queensland is an international researcher and expert in feline diabetes.

Enlarging the graph and adding the axis with mg/dL made it possible to see you have not gotten too low at the times you have measured (especially on my PC - my phone, not so much. On a small display screen the table is marginally easier to see).

Also, all those levels used in the protocols are averages to use as guidelines. There is now a cat on this board who develops hypo symptoms well above 50 mg/dL using a human glucometer - each cat is different and there are always day to day variations in the multifactorial process which is glucose control.

 

Your Sig says the dry food is low carb, high protein. Define "low"? Hill's Prescription m/d is sold as being an appropriate dry food for diabetic cats and low carb. It isn't at all. It's carbage and cats might as well eat sugar cubes. How low is low?

 

its Hills md, they say it is

Carb 12%
fat 12%
protein 76%
see http://www.hillspet.co.uk/en-gb/en-gb/products/pd-feline-prescription-diet-md-dry.html

 

Ick. My chart says 13% but not a big difference. In the case of Hill's it's more likely an issue with "source of carbohyrates" or calories for that matter. This did prompt me to do some reading and research however.

This from the Hill's site:

Chicken by-product meal. Interesting when you look at what that is:

Yummy, but not much "meat" in it. The bolded ingredients are just stuff you don't want to feed a diabetic animal. Sources of carbs. I think the cellulose is non-digestable but it's the "glue" that holds the stuff together. Basically, it's crappy food in terms of quality. Like most if not all dry food (and lots of canned food to be fair).
This is a pretty awesome site that tells you about what all the stuff on the label really means.
http://healthypets.mercola.com/site...e-quality-of-pet-food-ingredients-part-2.aspx

A cat is an obligate carnivore. Therefore, they have no dietary need for ANY carbohydrates from any source. Given that carbs are "anathema" to diabetic cats, it's logical for us to try to feed the lowest amount possible. In the world of dry cat food, 13% would qualify as "low" I suppose, since some of them are 30% or even higher. But the evidence from thousands of sugarcats proves that the lower the carbs, the better off the cat is, and the better chance of achieving regulation or remission.

The trick is convincing the cat that dry food is bad, and canned food is good (assuming the canned food is lower than 10% or even 5% in calories from carbs), and that can be a challenge to everyone with a cat who is a fan of kibble.

 

Regarding your chart...

I have no problem if the chart is what works for you. As others have pointed out, it does have its drawbacks though. I can read it just fine. It just doesn't contain the information that I need in order to give you advice on dosage.
I can't tell where in the cycle the mid-cycle tests were taken in terms of how many hours after the shot. I'm guessing based on the space between your 12 hour marks, but all I can do is guess.
I can't tell what the dose is just by looking. I can tell that the bigger dots mean a bigger dose, but there's no scale to reference. They just get bigger.

I like charts and graphs. I personally don't feel that the way you are doing the recording of your data is as effective as the way people here use spreadsheets, but I guess that's because from a feline diabetes management point of view, my brain is "wired" to the way people here do it. This is the only site I've "used" since my cat got diagnosed so I don't have another way to compare "our way" to. `My cat was only on insulin for 10 weeks, and I used to jot his numbers down in a notebook and fax them to my vet. I never took the time to create a spreadsheet. I look at a spreadsheet, and my brain visualizes a "curve" much like what your chart shows. The only difference, I guess, is that with the times and dose amounts provided in the spreadsheets, the curve makes more sense in my head to me than yours does "on paper".


I don't really think the problem is with the way you are presenting your data. Rather, I think it's the perception you are giving people that "your way" is more "intellligent" and you seem to be insulting their intelligence with comments like these:

I can visualize figures taken off of spreadsheets as a graph, and I don't need a calculator to figure out the rates of change. I can do it in my head. I'm a geek. It isn't that I can't understand your graph. It's that your graph doesn't give me enough information, and the spreadsheets do. Actually, if I wanted to spend the time doing it, I could take someone's spreadsheet, download the data into MS Excel, create a graph, and plot it just like you have. But my graph would include the data I need to make sense of it.

But really, the problem isn't your graph or your data. The problem is the way you are using the Lantus. It's not effective. You need to do more research on how a basal insulin like Lantus acts on a cat vs. how it works on a human. More importantly, to understand what happens "inside the body" once you inject Lantus. It isn't well suited to be adjusted in dose every 12 hours. The "Tight Regulation Protocol" used here, adapted from the protocol used in the U of Q study, calls for holding a dose for a specific number of cycles for logical reasons, not just "because".
The other issue is that you seem to be expecting immediate results from a dose adjustment. Lantus doesn't work that way. Prozinc might, Humulin might, as they are shorter acting, shorter duration insulins, and there's not a "depot" to consider and once the insulin has run its course is less than 12 hours, there isn't a residual effect from prior doses to worry about.

There are only two things you have "control over" with this disease. Food and insulin. You can control how much, and when. What you can't control is "everything else" that has any effect over your cat's blood glucose on a day to day, or an hour-by-hour basis:

That quote is from Dr. Lisa Pierson, a true expert on feline nutrition and feline diabetes management.
Any fluctuations you are currently seeing in BG levels could have something to do with the doses you're shooting. But they could also be due to all of the things Dr. P lists. By changing the dose every cycle or every day, you're removing one of the two "constants" at your disposal from the equation. So there's simply no telling what might be causing the numbers you're seeing.

Lastly (sorry for the novel, but it's "what I do") -
By insisting on doing things "your way" with the graph rather than the spreadsheet, what you're missing out on is the input from the people here who know the most about managing this disease. There are a lot of people here who use the same insulin you are using. And some have more knowledge and experience with this than you or I will ever have. None of them have posted here. It isn't because they don't care. The only thing people care about here is the welfare of your cat. I suspect they haven't chimed in because they simply don't have the time to readjust their way of thinking to accomodate the way that you are presenting your data. There's dozens of cats they help every day and they are only able to do that because their "beans" have no problem conforming to "FDMB standards" in order to get the help they want or need. So they aren't here telling you that it's too hard to wrap their heads around your charts and graphs. It isn't that they can't, it's that they don't have time to do so. They aren't stupid, they're just overworked and underpaid.

So if you really want help, put all your data into a googledocs spreadsheet, drop by the Lantus TR forum, and ask for advice. There's a point where "conformity" makes sense.

Carl

 

http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=59466

 

Before the board "moved", Gayle posted some really good info in this thread. I've tried to go back and retrieve it, but not had the best luck.

All I could do was screenshot captures, and the formatting was terrible. For a while, I was still logged on to the old server, but now I can't get back to it to do a better job of copy/pasting. Anyway, like I said, it was good info, and hopefully you'll be able to click on the jpegs, zoom them and read them. Again, sorry for the crappy formatting.

 

And it's important to remember too that some cats have hypos with no symptoms.

Some cats start to show symptoms when hypoglycemia is mild; some show symptoms when hypo is moderate (as my cat does); and some cats do not show symptoms at all until the hypo is severe. A cat can look absolutely fine one minute and be seizuring the next, with no prior indication at all that this was about to happen.

Absence of symptoms does not mean absence of hypo.

Also it can happen that a cat can hypo (with or without symptoms) and then 'bounce' up from that low number to a much higher BG level, over and over again with apparently no ill effects, leading the care-giver to assume the cat will continue to be OK: But the cat's liver will not be able to do this indefinitely.

 

Wow if you can read those screenshots you will have no trouble reading numbers on a graph!

I did my best to read them and they seem to be about graphs versus the in-house 'spreadsheet'. That is not why I started this thread. In fact my "insulting comments" which Carl has kindly collected together were a way of me trying to say (multiple times) 'we disagree about the value of graphs lets move on' (or rather back to the cat and the subject of this thread).

I won't post Milos latest simplified graph as the gridlines are now quite close together but he is still on 7 IU BID Lantus and bouncing around 6 to 10 (100 to 180). That range is fine but I was aiming for below 6 and tight regulation. 7 IU seems a lot to me so I will now begin slowly reducing it hoping his range will stay the same or even improve. If not I may switch back to Caninsulin, that had much more predictable results and I'm pretty sure I could get Milo into the 2.5-6 range with it.

I'd be interested to receive comments on whether 7IU Lantus is a lot to stay in 6-10 range and whether it might be better to go back to Caninsulin.

 

The amount of insulin a cst needs depends upon the cat. If 7 units works for your cat then it works. As I said before, my Tones was controled below about 120 with 7 or 8 units Levemir and 5 units N twice daily.

 

Regarding the amount of the insulin dosage; the cat needs what the cat needs.

Generally speaking, Caninsulin is one of the harder insulins to work with. But in some parts of the world, such as the UK, it can be difficult to get a vet to prescribe anything else, and so some people just have to use it; and some lucky cats have even gone into remission with it. The challenges with it are mainly these: Typically, it drops the blood glucose fast (sometimes too fast) and then has a short duration in most cats, perhaps being out of the system in around 8 hours. What that means for cats dosed twice a day is that there could be no insulin in the system for 4 hours out of 12. This can sometimes be remedied (if appropriate for the cat) by giving three shots a day instead of 2.

Having used Caninsulin in my own cat (and having observed the effects of it in quite a number of other cats) I have to say that I would not consider it a suitable insulin for tight regulation. Those steep drops can increase the risk of hypoglycemia. But the risk of hypoglycemia is considered to be much lower with the gentler, longer lasting insulins (Lantus, Levemir or Hypurin Bovine PZI (available in the UK)).

 

I didn't find this a very helpful post. Quite misleading in fact.

1) I don't know about your meter but mine is serum based not whole blood. I suspect your is the same, most seem to be. Therefore we should be using Roop and Rand table 3B not 3A. This means your quote above should be '80 - 130' not '50 -100'. Quite a difference.
2) I have spotted a fairly serious typo in the protocol itself, table 3B under 'change in dose' column it switches back to the '50-100' used in 3A when it should really say '80-130'. I'm surprised that this error has been made and that no one seems to have spotted it.
3) none of my increases were 'random' they were all based on data. I'm a little surprised you concluded they were random without reading the data ( you said "I could 'guess' at the nadirs.")
4) I have tried slowly cutting the dose but BG started rising again and looking carefully at my data and especially the nadir trend I have concluded 7 IU was not enough, so I've upped it again. I think it was my wishful thinking that 7 IU was too much (along with posts like yours). There's no sign of an iceberg in my data but I will keep an eye out and monitor every 2 hours for a while.
5) as I get older and see more evidence of it, I find people often say things with great confidence which are just wrong. My asking for reasoning is my way of trying to wade through that stuff.

 

Can you give more specifics? Maybe an updated chart? I guess what I'm asking for is what doses and what did the numbers do.

I'm thinking (hoping) it might be as simple as that you just haven't given the doses time enough to show results. The two primary protocols most people follow here call for sticking with one dose for "x" number of cycles and adjusting accordingly, with the TR being the more aggressive protocol.

 

That's just the version of the article she linked to. I've personally never bothered reading that version because the font is offensive to my eyes. :lol: The "proper" published version is available here and simply contains this side-note:

Has anyone mentioned to you the increased potential for a high-dose condition once you cross over the 5u BID mark? I wonder if that might be what we're dealing with here....


_____
As for the graph vs. a spreadsheet, I'm a numbers junkie and not a very visual person. So, for me personally, graphs are pretty to look at, but I work better with the data behind the graph: the specific times, the specific dates, the specific doses and BG numbers, etc.... It's just the fastest way my brain works for interpreting data. :lol: ohmygod_smile (I blame it on the Geek in me. pc_work ) You're inputting some sort of data somewhere to create the graph, right? Would you be willing to share with me the "back-end" of the graph instead (i.e. the numbers)?

 

Hi,

I'm just a Newbie on Prozinc, so I can't comment about Lantus or your dose amounts, but I do want to say that Carl & Bob, Deb & Wink, BJM, & KPassa have all helped me through alot of hurdles in this new process. I wouldn't be here without them.

You have a definite perspective on how you want to direct this process for your cat. Aspects of it don't appear to be working, which you acknowledge. Some are. You might want to consider both your graph and a spreadsheet - the two may end up complementing each other, offering different visual patterns among other things. It doesn't make your way wrong to also fill in a spreadsheet, it merely allows members of this forum used to that modality to offer the best advice they can, based on what they know, and how they come to know it.

7 units seems like a lot to me, but every cat is different. I'm struggling with 1.25 units. As another member advised, this is a marathon, not a race.

I wish you & your cat the best and a safe remission.

 

I'm now on top of the timing and I think on the dose, when I have enough data to be sure I'll put it into the standard table. Before that I think I might get confusing responses. Milo just nadir'd at 5.8/104 (plasma/serum meter) six hours after injection which is just within my target range.

 

Congratulations!