best time to inject?

I'm looking at Lantus taking 6 hours to nadir and food taking 2 hours to create highest BG so it seems best time to inject is four hours before feeding, make it 3 to be safer, is that correct?

 

No, you want to feed when you shoot.

It's fine for the food to "push up the BG" for the first couple of hours. Usually the insulin doesn't start to push it back down until an hour or so after that, like at +3 hours after you give the shot. And usually, the nadir happens around +6, but that varies from cat to cat (ECID) and from day to day. It's isn't "exact" by any means.

Here's a "typical Lantus curve":

When you don't want to feed - the two hours leading up to a shot. That way, the number you get on the preshot test is "free of food".
When you can feed - pretty much at any time other than that two hour window.
Many people find that feeding multiple times per day works best. It seems to spread out the "carb boost" of food more evenly throughout the day or night.
Most people feed at each shot time (these would be the "main meals" for the day) and then feed smaller snack type meals at other times. It will depend on what sort of numbers you see on your spreadsheet as you move forward. Food can be used to slow down a drop in BG if that happens early in the cycle, for instance.

The "normal routine" with Lantus at shot time is "test, feed and shoot". That all can happen over a ten minute or less time span. A lot of people give the shot while kitty has his face in the food bowl and the cats don't seem to even notice it happened.

 

this subject had 5 posts a minute ago, three from three different people seem to have been deleted. If they have been deliberately removed please can I have copy of my one? I did not keep it as I was not expecting it to be removed.

I was about to reply to two of the now missing posts. One was very sensible and said "The problem with shooting before eating is what happens if the cat does not want to eat?". A very good point and the only reason I can think of for shooting at the same time as feeding. In fact slightly after feeding to be sure.

The other post had some stuff saying what if you get a flat curve but it is at 300? This makes no sense to me, given the choice I would prefer a flat curve at 300 to one which went up from 300 and down again, but anyway it is not what I am aiming for. Shooting 3 hours before feeding would make for a flatter curve but I can see no reason for it to be a higher flatter curve.

 

oh crap.... I just posted and it's gone as well!

OK, tonite's not a great nite because this board is in the process of moving from one server to another! There was an announcement and it was mentioned that some posts may well be lost, so that's likely what's happening..... also, I have had to sign in a few times in about 5 minutes, so the activity going on behind the scenes is playing here.

Anyway, I found a link to a discussion about the foods that are available to UK and Sweden and other areas..... try reading here: I hope this post stays!
viewtopic.php?f=28&t=64843

Gayle

 

I should add that one person overseas mentioned that all they could get as the DM canned..... I wonder if you could try the canned version of the dry you are feeding and see if it make a bit of an improvement...

Keep in mind that the food may not be the problem and you may have a high dose cat like two of mine who tested positive for acromegaly.

All we can do it try things and stick with what gives us the best results.

Gayle

 

Thanks, changing to wet food is a last resort, I'll do it if I have to but am hoping Lantus will start working instead. Our feeding system is automated, both cats are very low maintenance (or were until diabeties) and come and go as they please. We are often away too. Someone helpfully suggested freezing patties, we could do that I suppose, though the cat sitter would need to add that to her list.

Sorry if that sounds selfish but we have cats because they are so low maintenance, otherwise we might as well have dogs. It is a similar reason to why we (and I suspect most owners) had both cats neutered, which I always feel slightly guilty about (if I had an owner I wouldn't be happy being 'done'). I draw the line at de-clawing them or never letting them out, do people still do that?

 

My question about the 300_flat curve made one assumption. That the first test was 300 or 350. I had to pick a number to start with.
No, you don't want a flat 300 curve. It causes damage rather that healing, and it's well above the renal threshold. It also leads to glucose toxicity, making an improvement in the condition less likely and more difficult.
You want numbers in the normal BG range for as often as possible and for as long as possible every day, in a perfect world.
Otherwise the condition doesn't improve.

 

Actually, you may well be able to get Milo in good numbers while eating dry food, but it will be alot of insulin. There was a cat who came to this board and was getting 20u of Caninsulin twice a day - and eating dry food. Once that owner switched to wet food, the cat dropped down to 1u of Caninsulin twice a day. So I think that's what people are trying to say in a way. Also, the dry food is not good for the urinary tract of male cats.... you can see Opie's story in the catinfo.org site.

For the spay/neutering, did you know that to spay a female is good because you can eliminate the possibilities of mammary cancer. And females go into heat progressively more often and for longer stretches of time, which is very hard on their bodies. For the males, I do know they would not spray if neutered early enough, and they won't wander is neutered. If you are not breeding your animals, then altering them is best for their health. You are so right about the declawing because later in life, the cats will have health issues as their walking and stance are 'off' if declawed.

Letting cats out is still done by some but for a diabetic who relies on insulin, it's not a great idea.

Gayle

 

It's unfortunate that some posts have gone AWOL but basically I have only been able to understand one reason to shoot at the same time as feeding - to make sure the cat has actually eaten before being injected with a load of insulin. That's is a very good reason, especially if the cats appetite is uncertain. Please try and explain again if there are other medical reasons.

I can see it will be more convenient and easier to catch the cat at feeding time.

But looking just at the medicinal side and keeping the BG curve as flat as possible, it seems to me that you would want the peak action of the insulin (lowering BG)to coincide more or less with the peak action of the food (raising BG). Of course you can never be entirely accurate about when either occur, but assuming the food creates a BG peak at 2 hours after eating, and the insulin reaches its most effective at about 6 hours after injection, surely the optimum time to inject is 4 hours before feeding? Unless you are not confident that your cat will actually eat after the injection and/or you are not confident you can push his BG up manually if that does happen.

This is assuming you want the curve to be as flat as you can get it (and at as low a level as possible but that is another issue). Is there any reason not to desire a flat curve? Milo's non diabetic twin sister has a very flat curve - its more of a slightly wobbly straight line in fact.

 

I can't believe I'm even engaging in this conversation when you are clearly looking to prove you know more than we do but here goes.

Dosing of Lantus is based on nadir as noted in the University of Queensland protocol. If you feed with the aim of keeping the curve flat, you run the risk of overdosing, as your cat's nadir will be artificially elevated by food. If this is what you are doing, it is why you need to keep increasing the insulin dose and are not seeing a lower nadir.

edited: d'oh i used the opposite word to what i meant.

 

I think a nice flat curve is exactly what you'd see in any non-diabetic cat, since the internal mechanisms when they are working at 100% efficiency would cause the release of insulin on an as needed basis to help the glucose get from the blood to the cells. It should all be automatic and instantaneous.

If what you are after is stopping the BG from dropping too low at nadir, you can use food (like most people tend to do) to try to hold the BG at a good low but safe level by feeding multiple small meals throughout the day. That's what human diabetics are advised to do. Spread the food load evenly rather than eat just three meals a day.

The key is "good low but safe" BG levels. If you can keep Milo's numbers in the mid-blue to mid-green range 24/7 by feeding him like you want to, then do so.

I guess the frustration that some people are having is "why try to reinvent the wheel"? The Roomp/Rand protocol has been proven to work in thousands of cats and every week, one or more Lantus cats here seem to go OTJ. We know for sure that it works the way it's laid out. It ain't broke.

One thing to consider. It all sounds good in theory. Yes, we "expect" a rise from eating in the first two hours, and then we expect the insulin to onset and push the numbers down for 4 or more hours, reach nadir, and taper off towards the next shot time. That's with food at both shot times, and usually one, two, or more snacks "in the middle". When in the middle depends solely on the day to day data patterns of that specific cat, and lots of experimentation.
But look at any spreadsheet, and you'll see the "oh crap, that isn't supposed to happen now!" numbers. Like when a cat suddenly drops 50% less than two hours after the shot, even with food given at the same time as normal. That's usually due to overlap of doses, which can't be predicted with any certainty. It just happens. And peoplel intervene, give low carb, medium carb, or high carb food to stop or slow the drop. It depends on the severity of the drop, and the level of comfort people have with dealing with low numbers. The more you do it, the easier it is to address.

Waiting to feed until 4 hours after the shot, yes, it might prohibit the nadir from going "too low" on a typical day. But you'll have to figure out a whole new set of contingency plans for things like overlap of dose from one cycle to another. You're going to see, at some point, a big drop in BG when you don't expect it no matter when or how often you feed, no matter when or how much you shoot. By doing things unique to everyone else here, you're basically going to be "flying solo" when that happens, because nobody else will have experience doing it that far "outside the box". But that's your call.

And you still aren't taking into account any of the things I quoted earlier from Dr. Pierson. I think you're assuming things are going to go "just so" because you're going to do things the way you want to do them. But you'll still have no control over any of what happens inside of his system once the insulin and the food are "in". All of those things are going to have a lot more effect on your day-to-day numbers than the insulin and food you're giving him.

No. As long as the flat curve is all "good" numbers, in or around the range of normal. But a flat curve of numbers above the renal threshold are not a good thing. There's also no reason to not want a curve that is shaped like a smile, provided the end points are not sky high numbers, the low point is not hypoglycemic, and the majority of the numbers are below the renal threshold and close to "normal". No matter what shape your curve is, flat or smiley, the numbers themselves matter a lot more than the shape.

 

a low flat curve is the desired outcome when using the long-acting insulins (lantus and levemir)... it's what most of us are working towards. lantus and levemir are known for their long flat curves when being used properly!

you can't really tell from looking at alex's current spreadsheet because now i have to work around other problems/illnesses she's developed over the years, but if you open up the link to her spreadsheet (link is in my signature) click on the 2009 levemir tab at the top of the page. she had to go back on insulin after an almost 3 year remission in 2009. i purposely tested her more than usual in that year to develop a spreadsheet i could use for teaching purposes. after about a week and a half back on insulin you can begin to see the long, flat, & low curves you're talking about.

alex happens to experience horrific food spikes after eating (100+ points)... every cat is different. a small piece of freeze-dried chicken is enough to send her numbers upwards by 50 - 60 points (sometimes more). i had to come up with a feeding plan where i could get enough insulin into her to combat the food spikes without dropping her too low while using overlap and carryover to my advantage. plus i wanted to be as aggressive as i possibly could because my personal goal was to get her back into remission as quickly as i could.

the asterisks in the individual cells note when she was fed. this plan worked well for her and yet as carl mentioned there were those "oh crap" moments when she dropped lower than i expected. you can see them on her spreadsheet.

i guess what i'm trying to say is it's up to the individual caregiver to come up with a plan that works best for THEIR cat. and if it makes you feel any better... several years ago there were a lot of nay-sayers when i promoted managing curves with food, but if you look at what's going on in the Lantus Tight Regulation Insulin Support Group today you'll see an awful lot of caregivers successfully managing their kitty's curves with food. it's become a common practice.

my advice... do whatever works for your cat! just stay on top of things. safety should always be the number one priority when experimenting to find what works for an individual cat.


just my thoughts...

 

actually, the opposite is true. when your goal is to use food to keep the curve flat you run the risk of over dosing kitty. when the cat's nadir is artificially elevated with food you have to give more insulin which *could* result in kitty becoming slightly over dose. it's something those of us who use food to manipulate the curve have to keep an eye on.

that's kind of the point to using food to manipulate the curve. in some cases, you want to be able to get more insulin into the cat. you may want to manipulate the curve for various reasons including, but not limited to combating food spikes, increasing duration, and/or preventing early dives.

 

Nothing was removed deliberately. The site is undergoing maintenance. Might be wise to keep copies of posts we write over the next few days in case there are other 'glitches'.

 

I'm not trying to prove I know more than you I'm simply trying to get a reasoned answer to my query. Reasoned rather than 'we all do this we must be right'. There is nothing I can see in the Queensland protocol that says you should shoot at the same time as feeding. Please can you point me at it? Agreed the nadir will be raised just as the zenith would be reduced, that is surely a good thing. I don't see feeding as artificial, it is natural (and rather essential).

 

Thanks to all, it seems it was worth me persisting with this past the first answer. Despite the occasional slightly rude response I got.

Especially thanks to Jill and Alex for a very sensible post with reasoning included. Carl I think you may have softened a bit towards timing food to flatten the curve, (not entirely sure as there is lots of distraction in their about other variables, the impinging of practice over theory, the super eminence of height over shape etc..) but anyway can you point me to anything in the Roomp/Rand protocol that says you must shoot at the same time as feeding?

 

No I can't.
This is the only mention of food I see:

That's from the Tilly site.
I would guess that the main difference you'd experience would be in what your "typical" would be, if you've looked at the info about what a typical lantus curve looks like.
And your results would also vary due to his current diet because of the higher carb content and any difference
In the time it takes to digest/metabolize dry vs. wet food. The thinking is that it takes longer to digest and the carbs hang around longer.

 

After looking at your chart again....
It has six days of data on it. Has Milo only been on Lantus for that long?
If not, regarding the timing of his nadir...
Has it always been "all over the place"? Some days it looks like very early in the cycle, other days late in the cycle. Trying to pick out a "typical" but with a small sample size, I can't.

Does he free feed on the m/d now?

 

Milo has been on Lantus since 3rd May and before that Caninsulin from early Jan. His curve is complicated - he had some remission on caninsulin and we had 10 days away recently when he had to be on 4 units lantus once a day, not ideal but safe. I have been closely monitoring since, allowing me to safely increase the dose and change injection timings, hoping to get a curve that makes sense to me. Not there yet.

Lantus has never given us the clear nadir timing we used to get with caninsulin. Occasionally there is even a zenith between injections rather than a nadir. This was happening sometimes even when on 1.5 BID. I think I need to settle on the timing of the injections first, hence this post. I will start gently decreasing his dose to see if it goes up as I am uncomfortable with 7 IU BID given the unpredictable results. Still, as mentioned, if he needs it he needs it. On Caninsulin he only needed 1 IU. I do wonder if all the encouraging Tilly stuff on Lantus is correct for my cat. No point asking my vet as he prescribed 4 IU caninsulin BID when Milo was on 50-95!

In fact just a rant on vets while I'm at it, they seem to be a waste of time for two basic reasons:
1) they don't monitor every hour and don't mention home testing (well mine didn't, why would he, he gets paid per visit) and
2) any measurement of BG after putting Milo in a cage and taking him by car a 10 minute drive to the vets will double his BG. I only know that because I have started home testing.
To top that, they charge a huge amount of money.
I now monitor BG and ketones myself, for $20 dollars worth of hardware. A neighbour's cat cost $6,500 for a broken leg and came out with only 3 legs and a permanent electric blanket burn on his back!

So it's great to have these forums (could be a little gentler on newbies asking awkward questions though, and a little more open to new technology, like graphs!).

 

I used compounded bovine-based PZI, so any Lantus thinking I might have to offer is purely 2nd-hand just from observing Lantus/Lev kitties on the TR forum. I'm not really sure if it's highly likely you'd see "clear nadir timing" on Lantus. People who have seen it in their cats will tell you if their cat has (I haven't watched nearly all of them). But a "mobile" nadir seems to be pretty common, at least early on in the process.

I think some of what you might be seeing on the zenith between injections... I see that too, and those are the cycles where the nadir seems to happen early in the cycle (I think I mentioned that yesterday if the post wasn't lost in the transfer). On those particular cycles, maybe what you're seeing is some dose overlap from the previous cycle where that dose and the most current dose are combining to push the BG down in the first couple of hours of the cycle? And then maybe the number goes just low enough to trigger a bounce, which shows up as your "zenith" later in the cycle? Almost like an inverse curve, but with a dip at the beginning of the cycle.

I think it might be too early to call? I like your idea of gradually reducing the dose, settling on a shot timing/food timing routine, and then try to hold a dose for a few cycles to see if you get any fairly predictable numbers that establish a "typical" cycle for Milo?

Just thinking out loud...

 

thanks, my planning is not being helped by the variation of and between meters, see my post http://felinediabetes.com/FDMB/viewtopic.php?f=28&t=97943&p=1047606#p1047606

 

There was a lot of good stuff in all the above, but I wanted to address and (re-)iterate some points for clarification.

For me, this is pretty much it. If I'm worried about Michelangelo's appetite and he's given me a lower pre-shot number than normal, I want to see him physically eating his food before I give him a shot just in case there might be something else going on that I don't know about. The rest of the time, I'm not bothered if he doesn't eat at shot time. I also leave food out for them all day long, so sometimes he might have eaten an hour before shot time. (I've tested enough to know how much food influences his numbers and if it's within two hours of shot time, I'll also grab a pre-food test before I let him eat.)

For the "shape" of a curve, as Carl said:

Basically, the more regulated your cat becomes, the more "flat" the curve becomes. A huge part of that is shooting low numbers. That comes much further down the line once you find the right dose, so for now, having a "smiley" curve is to be expected.

Yes, this is important since dry food takes longer to kick in and also sticks around a lot longer. What we call "typcial" around here for cats on wet, low carb diets will not necessarily be "typical" for what you might see.

On top of that, cats are wont to do their own thing. Mikey sometimes nadirs two hours after a shot. Sometimes he nadirs 14 hours after a shot (and four hours before his next nadir). Sometimes, he doesn't seem to have any nadir. Sometimes, he decides he doesn't want to eat very much one day and overeat the next. This really screws with his numbers and he'll run high for the day of over-eating and lower for the day of under-eating. This all goes back to Carl's point that "the numbers themselves matter a lot more than the shape." Mikey is staying under 200 for most of the time, only spiking past 250 at shot times. I'm okay with that right now because we're going through a dose increase and playing the game of "find the right dose." From past experience, I know that once I find the right dose, he'll start "flattening out" and giving me runs of greens and blues again. In the meantime, I check his urine for ketones once a week (he's never tested positive, but any time over 200, they're at increased risk) and try to make sure he's not spending too much time in higher numbers (he seems to only hit pink when I skip shots or give him fur shots).