Opinions Please on Insulin Efficacy

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Buffy-&-Cindee

Buffy-&-Cindee

Member Since 2014
I'm pretty sure that this bottle of Lantus is shot. Got it 11/18/2014. Buffy's numbers started going up 8 days ago so I increased her dosage (after a curve) but they're continuing to go up. She's hungry again too.

Would you guys please take a look at her chart and give me your opinion.

Thanks!

Cindee
 
Cindee:

I hate to ask this but if you want to customized Buffy's spreadsheet, could you please retain the color coding that we use. Most of us who review spreadsheets before making any observations really rely on the color coding. It's much easier to see trends when "reading" the colors vs the actual numbers.

I also think it would be easier to know if your insulin has lost potency if you had some PM tests. There's no way to really know what's going on without having a bit more information. Are you able to get at least a "before bed" test in the evenings?
 
The Lantus should be OK if you've been keeping it refrigerated on a stationary shelf between drawing out insulin. refrigerated so, it may last up to 6 months. You're at just under 4 months.

Look for other causes of increased glucose - dental, respiratory, and urinary infections are somewhat common in diabetics.
Also, are you seeing any signs of reduced appetite or "sick" behavior like meatloafing (hunched up like the Sphinx and looking uncomfortable)? Sometimes, pancreatitis (frequently found in diabetic cats), can present as increasing glucose levels.
 
Sienne and Gabby said:
Cindee:

I hate to ask this but if you want to customized Buffy's spreadsheet, could you please retain the color coding that we use. Most of us who review spreadsheets before making any observations really rely on the color coding. It's much easier to see trends when "reading" the colors vs the actual numbers.

I also think it would be easier to know if your insulin has lost potency if you had some PM tests. There's no way to really know what's going on without having a bit more information. Are you able to get at least a "before bed" test in the evenings?
Click to expand...

Thanks for your reply. The colors are the same as the Alpha Tracker software and I did that so that my vet can tell at a glance how Buffy is doing; she uses only the Alpha Tracker in her practice. Also, everyone here will know at a glance from the colors that I’m not using a human meter. If I change the colors to the human meter colors Buffy’s numbers will easily be confused as much higher than they really are. I did include the range at the top of the chart so that it’s easy to see what her target range should be which was given to me by her internist, not just a regular vet.

If you’ll notice, I test Buffy around 9:00am, 3:00pm, and 9:00pm. The 9:00pm test is the last test of the day. :)
 
One way to check and see if your insulin is good or not is to go ahead and start a new pen/vial, use it for a couple of days and if you see a significant change in the blood sugar tests, then you can think your original insulin isn't full potency. If the BGs don't really change overall, that tells you the insulin wasn't the issue.

It looks like you're following the Start Low Go Slow method, which would have you holding the dose for a week at a time, then doing a curve and based upon those results, deciding if the dose needs to be changed. You would need 3 more shots at this dose to have 14 doses, then you'd do a curve and re-evaluate.

Hold the dose for at least a week
  • Unless your cat won’t eat or you suspect hypoglycemia
  • Unless your kitty falls below 90 mg/dL (5 mmol/L) if kitty falls below 90 mg/dL (5 mmol/L) decrease the dose by 0.25 unit immediately.
After 1 week at a given dose perform a 12 hour curve, testing every 2 hours OR perform an 18 hour curve, testing every 3 hours
Note: Random spot checks are often helpful to "fill in the blanks" on kitty's spreadsheet.

  • If nadirs are more than 150 mg/dl (8.3 mmol/L), increase the dose by 0.25 unit
  • If nadirs are between 90 (5 mmol/L) and 149 mg/dl (8.2 mmol/L), maintain the same dose
  • If nadirs are below 90 mg/dl (5mmol/L), decrease the dose by 0.25 unit
  • As your cat's blood glucose begins to fall mostly in the desired range [lowest point of the curve approaching 100 mg/dl (5.5 mmol/L) and pre-shot value around or below 300 mg/dl (16.6 mmol/L)], do lengthen the waiting time between dose increases. If you decide to change another factor (e.g., diet or other medications), don't increase the insulin dose until the other change is complete (but do decrease the dose if your cat's glucose numbers consistently fall below 90 mg/dl (5.0 mmol/L) as a result of the change). Don't be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat's blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose.
Lather, Rinse, and Repeat!
​
The reason Sienne is asking about pm cycle tests is because it's possible that Buffy is going low in the pm cycle and bouncing, causing the high numbers during the day. The only way to know if that's happening is to do some pm cycle tests.
 
BJM said:
The Lantus should be OK if you've been keeping it refrigerated on a stationary shelf between drawing out insulin. refrigerated so, it may last up to 6 months. You're at just under 4 months.

Look for other causes of increased glucose - dental, respiratory, and urinary infections are somewhat common in diabetics.
Also, are you seeing any signs of reduced appetite or "sick" behavior like meatloafing (hunched up like the Sphinx and looking uncomfortable)? Sometimes, pancreatitis (frequently found in diabetic cats), can present as increasing glucose levels.
Click to expand...

I thought the same thing, but expired insulin is the only thing I can think of that would make her numbers keep going up. I initially thought that I was seeing a bounce because of the dosage increase, but that should have settled down by now.

The insulin has been stored properly. The only thing I might question is that our power was out for 36 hours on February 22nd but our refrigerator never got above 40°. Even our ice didn’t thaw much so I don’t think that was it, but maybe.

She’s completely healthy/normal otherwise. Just hungry again. While I’m not thrilled about having to purchase a new bottle of insulin this soon, at least it’s any easy way to know for sure if it’s the culprit or if something else is going on.
 
julie & punkin (ga) said:
The reason Sienne is asking about pm cycle tests is because it's possible that Buffy is going low in the pm cycle and bouncing, causing the high numbers during the day. The only way to know if that's happening is to do some pm cycle tests.
Click to expand...

We posted at the same time. This part i just quoted is another possibility for her higher numbers. We see cats go low in the pm cycle all the time. All diabetics begin their day by being influenced by Dawn Phenomenon - so the night cycle is critical for spotting low numbers.
 
julie & punkin (ga) said:
One way to check and see if your insulin is good or not is to go ahead and start a new pen/vial, use it for a couple of days and if you see a significant change in the blood sugar tests, then you can think your original insulin isn't full potency. If the BGs don't really change overall, that tells you the insulin wasn't the issue.

It looks like you're following the Start Low Go Slow method, which would have you holding the dose for a week at a time, then doing a curve and based upon those results, deciding if the dose needs to be changed. You would need 3 more shots at this dose to have 14 doses, then you'd do a curve and re-evaluate.

Hold the dose for at least a week
  • Unless your cat won’t eat or you suspect hypoglycemia
  • Unless your kitty falls below 90 mg/dL (5 mmol/L) if kitty falls below 90 mg/dL (5 mmol/L) decrease the dose by 0.25 unit immediately.
After 1 week at a given dose perform a 12 hour curve, testing every 2 hours OR perform an 18 hour curve, testing every 3 hours
Note: Random spot checks are often helpful to "fill in the blanks" on kitty's spreadsheet.

  • If nadirs are more than 150 mg/dl (8.3 mmol/L), increase the dose by 0.25 unit
  • If nadirs are between 90 (5 mmol/L) and 149 mg/dl (8.2 mmol/L), maintain the same dose
  • If nadirs are below 90 mg/dl (5mmol/L), decrease the dose by 0.25 unit
  • As your cat's blood glucose begins to fall mostly in the desired range [lowest point of the curve approaching 100 mg/dl (5.5 mmol/L) and pre-shot value around or below 300 mg/dl (16.6 mmol/L)], do lengthen the waiting time between dose increases. If you decide to change another factor (e.g., diet or other medications), don't increase the insulin dose until the other change is complete (but do decrease the dose if your cat's glucose numbers consistently fall below 90 mg/dl (5.0 mmol/L) as a result of the change). Don't be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat's blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose.
Lather, Rinse, and Repeat!
​
The reason Sienne is asking about pm cycle tests is because it's possible that Buffy is going low in the pm cycle and bouncing, causing the high numbers during the day. The only way to know if that's happening is to do some pm cycle tests.
Click to expand...

Yep...that's what I thought I'd do. I thought I'd check with the experts here though before I did. Thanks everyone. :)
 
Good luck!

When I've done that, if the new insulin doesn't change anything then i've gone back to the old bottle and finished it up.
 
julie & punkin (ga) said:
We posted at the same time. This part i just quoted is another possibility for her higher numbers. We see cats go low in the pm cycle all the time. All diabetics begin their day by being influenced by Dawn Phenomenon - so the night cycle is critical for spotting low numbers.
Click to expand...

I did that on March 2nd and 3rd around 1:00am and 3:00am and and they were still high. If you'll notice on her chart, she's never been low after her PM shot usually the opposite. Unfortunately I can't get up throughout the night to test her otherwise I'll be worthless in the morning.
 
oh gosh - you don't have to get up to test her, unless you're a 12 hr sleeper. I wouldn't get up at 1 and 3am (YIKES) unless I had a compelling reason.

Most people just grab one test before they go to bed. Or if you shoot right before you go to bed, test her when you first wake up. Either way will be revealing.

If you do it 3 days in a row, that's enough to point out any low numbers that might be causing bouncing, because a bounce typically only lasts 3 days.
 
LOL…I didn’t relish it that’s for sure but I wanted to see what was going on with her. Her numbers only increase, not decrease which I think is odd.


Just got off the phone with her vet and she says it could be as simple as the Lantus isn’t working for her anymore but to try a new bottle of insulin before we make any other changes. If that’s not the case, the next step she suggested would be a dosage increase. She said if we slowly increase her dosage (to a maximum of 2 units) but her numbers are still high, then we should suspect the Lantus isn’t working. I’m keeping my fingers crossed that it’s just a “gone bad” bottle of insulin.
 
The thing to remember is just because you had one night where her numbers went up in the pm cycle, that doesn't mean it does it every time. As you can see during the day, you can get bounce cycles that are rising when they should be dropping, or you can get a normal Lantus curve that drops to the midcycle and then rises to the next shot.

I've suspected the Lantus went bad a couple of times, but ours never did. Trying the new pen/vial always answers the question. Most of the time the Lantus is still ok - did you watch the video on how to draw up a dose of Lantus? As long as you're doing the right technique the Lantus is likely ok. The video is about 1/2 way down the page here.
 
If cost is an issue (and with the price of Lantus lately, it usually is!) have you read the last post on the Insulin from Canadian Pharmacies thread? A LOT of people are buying from Marks and really pleased with both the price and the customer service.

The bad part is it takes about a week for delivery, so if you want to switch immediately, that won't work
 
Hungry again? Did she have a specific test for hyperthyroidism? That is something which can evolve over time and increase hunger.
 
Chris & China said:
If cost is an issue (and with the price of Lantus lately, it usually is!) have you read the last post on the Insulin from Canadian Pharmacies thread? A LOT of people are buying from Marks and really pleased with both the price and the customer service.

The bad part is it takes about a week for delivery, so if you want to switch immediately, that won't work
Click to expand...

Thanks for the tip. Fortunately, cost is not an issue. In fact I just got back from the pharmacy and it went down $20. It was only $260 this time. If it turns out that the insulin is the problem, I'll probably have it refilled every 3 months to insure that it's fresh. At that price it's only $21.67/week which really doesn't sound all that bad in the big scheme of thing.
 
BJM said:
Hungry again? Did she have a specific test for hyperthyroidism? That is something which can evolve over time and increase hunger.
Click to expand...

Yes she was tested and she is normal. When her BS is up, she acts like she's starving. When it's within the normal range, she doesn't.
 
Sounds like you're using the vial....Have you considered using the Solostar pens?

They're great because each pen is only 3ml (300 units). They come in a 5 pack and the other pens stay good until the expiration date on the box (usually at least 2 years away) so you can usually use each pen down to the last drop and don't have to throw away a lot of insulin like you do with the vials.
 
Chris & China said:
Sounds like you're using the vial....Have you considered using the Solostar pens?

They're great because each pen is only 3ml (300 units). They come in a 5 pack and the other pens stay good until the expiration date on the box (usually at least 2 years away) so you can usually use each pen down to the last drop and don't have to throw away a lot of insulin like you do with the vials.
Click to expand...

Funny you should ask...I just looked into that this morning but found that the Solostar pens only deliver in 1 unit increments. Is that correct?
 
You don't use the pen to shoot, you draw your dose out of the cartridge that's inside the pen with a syringe as you normally would out of a vial - you should be able to just get the cartridges that go in the pen without the pen outside part
 
You use your regular syringes and just pull out of the pen

syringe in pen pic.jpg
 
Update on the insulin. So far no change even with the new bottle of insulin. I spoke with my vet and she suggested that I lower the dose back to 1 unit for a few days and see how Buffy reacts. If the numbers stay the same she want me to do a curve and if needed, increase the dose by .25 weekly until her numbers start to drop. Pretty much what I thought the plan would be.

Oh...I also changed the colors on Buffy's spread sheet for this bulletin board so it won't be confusing for you guys. The numbers are a bit different but pretty close. Anything in blue is good. I'll keep the Alpha Track colors for my vet on another chart. :-)
 
Hi Cindee!

It's almost always not an issue with the insulin. Since you've decreased the dose while you're seeing high numbers, I want to encourage you to get at least one or two ketone check (use urine sticks available at any pharmacy) at least per day during this time.

If you haven't seen the Tilly's Diabetes Page, I'd encourage you to read through it. It's the same protocol as the Rand/Roomp, (Kristin is the Roomp) but she describes things in a bit of a different format. The part that I wanted to post for you is:

Be aware that experimental studies in human diabetics over the last 15-20 have rejected the existence of the Somogyi effect (sometimes also called rebound). In cats, no studies have ever been done which properly demonstrate that such a phenomenon exists. Therefore, adjust the dose as described above, focusing on the nadir: don't do so-called rebound checks, as they only lead to unnecessary (and unhealthy!) hyperglycemia.
​
Sometimes people do what you're doing, decreasing the dose. I'm not sure what your vet is thinking unless it's this (above), but Buffy is on a very low dose of insulin and it's more likely that she needs a dose increase rather than a dose decrease. I hope you'll just give it no more than a couple of days before going ahead and increasing her dose instead. The worry for ketones arises especially when blood sugar gets high and the dose is decreased. Ketones can happen at lower numbers as well, but the "recipe" for ketones is "not enough insulin + infection/inflammation + not enough food." So be very vigilant during this time. If you catch even a trace of ketones it means you've got to take immediate action to prevent them from going to large - they can zoom from trace to large in even just one day.

There could be a couple of reasons for her having higher numbers. My first guess is she has developed some Glucose Toxicity, which simply means that her body is getting used to high numbers and it is going to take increasing her dose even more to overcome it and to get her back down into a better range.
 
Shoot, I hit post reply before I was done.

In any case, I just wanted to pass on that information to you. I'm not sure why your vet thinks 1.25u is some magic dose that you can't go over - cats need what they need. If you check out some other spreadsheets, you'll see cats on 0.1u dose and 42u dose. The important thing is to be methodical about the dose increases, which you have been - that reassures you that you haven't overshot the right dose to move her and that you can continue increasing per the protocol (either SLGS or TRP) until you hit the dose that moves her back into good numbers.

I just wouldn't linger long at a lowered dose because of the risk of ketones and glucose toxicity.
 
Thanks Julie for the valuable info. I'm not sure why my vet wanted me to lower the dose but she said if Buffy's numbers continue to climb today, then I should increase her dose by .25 tomorrow, keep it there for a week, do a curve and increase or decrease the dose depending on her nadir. She did mention that she felt that Buffy likely needs more insulin but she wants me to take it slowly.

It's almost impossible to catch Buffy in the act of peeing. I never see her even go near the box much less pee in it. I have ketostix right on my desk in the lucky event that I catch her going toward the box. When she was first diagnosed that's how we knew something was wrong...she'd pee right in front of the box. Even though her numbers are high now, she's not doing that. Did you notice that they started going back down? Still not good but going in the right direction.

I haven't finished reading your post about Glucose Toxicity but what I've read so far is very interesting. I've bookmarked it so I can read it later tonight. Thanks for posting it.
 
I spoke too soon. She's on the rise again, although she ate at 3:30, it 's now 5:30.

Julie...if her numbers are high at 9:30pm (this is her last meal of the day and her PMPS) would you increase the dose tonight or wait until tomorrow morning? After reading your post, I'm concerned that waiting is not the best thing to do.
 
You're welcome - I know it helped me when people gave me the info that pertained to whatever punkin was going through at the moment. There's so much to know about FD!

The way I tested punkin for ketones was I made a "spare" litter box by putting a box lid (from a case of photocopy paper) into a garbage bag, then putting in a few cups of lentils. Aquarium gravel would be easier, fyi. Then I shut him in the laundry room with his soupy dinner and the spare box. He peed in no time. The gravel/lentils don't absorb anything, so you just tip the box to one side and you can test the puddle.

Just saw your last post. I would go back up in dose to 1.25u in a heartbeat. Just call it a "failed reduction" - which means that you tried to reduce the dose and it didn't work. In that circumstance you don't have to follow any of the other guidelines about waiting a certain number of cycles to increase the dose. With a failed reduction you just go back to the last good dose.

That's why I gave you that info - waiting isn't really a great idea unless there is a compelling reason to do so - like your cat won't eat or something.
 
Yay I can understand your spreadsheet now :) kitty needs more juice, I'm with Julie I would increase tonight and be prepared to stay on top of those increases until she heads back down. It will happen. Purrdy got stuck in a blue rut after 2.25 units but with methodical increases at 4 units we look like we may finally have broken his weird insulin resistance - they usually get stuck in higher numbers. As Julie said don't be concerned about the amount given as long as you have been methodical in the increases you know you're not giving them too much.

If you can't catch a pee you might want to consider getting a meter that will test for ketones. DKA is not pretty.
 
Another vote for go ahead and go back to 1.25 tonight

I must be crazy though because when I look at the link for your spreadsheet, I'm still seeing the "custom" numbers
 
julie & punkin (ga) said:
You're welcome - I know it helped me when people gave me the info that pertained to whatever punkin was going through at the moment. There's so much to know about FD!

The way I tested punkin for ketones was I made a "spare" litter box by putting a box lid (from a case of photocopy paper) into a garbage bag, then putting in a few cups of lentils. Aquarium gravel would be easier, fyi. Then I shut him in the laundry room with his soupy dinner and the spare box. He peed in no time. The gravel/lentils don't absorb anything, so you just tip the box to one side and you can test the puddle.

Just saw your last post. I would go back up in dose to 1.25u in a heartbeat. Just call it a "failed reduction" - which means that you tried to reduce the dose and it didn't work. In that circumstance you don't have to follow any of the other guidelines about waiting a certain number of cycles to increase the dose. With a failed reduction you just go back to the last good dose.

That's why I gave you that info - waiting isn't really a great idea unless there is a compelling reason to do so - like your cat won't eat or something.
Click to expand...

Thanks Julie. What a great idea on the litter box. I'm going to do the same because we're likely to be in this situation again.

1.25 it is. :-)
 
Vyktors Mum said:
Yay I can understand your spreadsheet now :) kitty needs more juice, I'm with Julie I would increase tonight and be prepared to stay on top of those increases until she heads back down. It will happen. Purrdy got stuck in a blue rut after 2.25 units but with methodical increases at 4 units we look like we may finally have broken his weird insulin resistance - they usually get stuck in higher numbers. As Julie said don't be concerned about the amount given as long as you have been methodical in the increases you know you're not giving them too much.

If you can't catch a pee you might want to consider getting a meter that will test for ketones. DKA is not pretty.
Click to expand...
I thought you'd like that...I aim to please. LOL I did the increase tonight so we'll see how the next 7 days goes. Hopefully downward.

Thanks for the suggestion about the ketones meter. I didn't even know there was such a thing. I've got a lot to learn.
 
Chris & China said:
Another vote for go ahead and go back to 1.25 tonight

I must be crazy though because when I look at the link for your spreadsheet, I'm still seeing the "custom" numbers
Click to expand...
Try this direct link: https://docs.google.com/spreadsheet...KdwdsGwbSPvX_JaG1Ca4/edit?pli=1#gid=948661200
The numbers are not exactly the same the regular spread sheet but not too much different. Her "target" zone is 100-180 and her "acceptable" zone is 181-220. Her internist gave me these numbers, keeping in mind that I'm using the Alpha Tracker.

Speaking of the spread sheet, I wanted the top of the sheet to "freeze" so that the values always remain at the top. However, if I simply save the SS and then publish it, it doesn't work. I had to save it as if I were editing it then it works but, you can see all of the editing options although they are grayed out. Does anyone know how to save a SS so that the value row can be frozen but the editing tools don't show? It's not critical but freezing the top of the sheet makes it a bit difficult to see the numbers if you're on a laptop. It doesn't work either way on any Apple devices.
 
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