1/29/2016 Conan AMPS 454, PMPS 442 - Questions

[Jessica & Conan]

Hi everyone,
I am new to these boards, just introduced myself earlier tonight. At the suggestion of another member, I'm posting this in the Lantus forum because it really is a Lantus dosing question - I don't have questions about diet or how to test or that sort of thing. But if mods or others believe it belongs in general Health, please move it there - I am new and am not quite sure of the protocol, so if I'm doing something wrong please let me know.

Since this is the Lantus forum, I'm not sure how much background to offer, but since I'm new I'll give a bit. My 10-year-old, Conan, has been on daily prednisolone since September 2013 (for both inflammatory bowel disease and nasopharyngeal stenosis, each of which separately is treated with the steroid), and finally succumbed to a diabetes diagnosis in mid January. After much discussion with my vet, who is excellent, we've decided that his conditions are so well managed with the steroid that taking him off it is not a good option at this time.

My vet prescribed a starting dose of 1 unit of Lantus twice a day. (Conan's ideal weight is probably 10 lbs or a bit less; he went from 9.5 to 8.3 from mid Dec. to mid Jan and is now at about 8.7.). I have now been doing this for a little over two weeks. She also set me up with an AlphaTrak 2 (so just to flag, my BG readings will reflect this and not necessarily be the same as a human meter), and since about day 3 of the Lantus, I've been doing BG curves every few days and spot checks on the other days. All these are recorded in my spreadsheet, linked below - it's slightly modified with a few extra columns to allow me to better record his eating and to reflect some of my unique circumstances, but otherwise the same as the appropriate US pet-meter template.

Other possibly important fact to note: Conan is (and has been for years, along with all my other cats) on a homemade raw diet, which includes no grains or vegetables (only a vitamin-mineral supplement). He is (still) eating *much* more than he used to need to maintain his weight and is still voracious, and drinking far more than my other (three) cats.

So with that said, here are a few of my issues/questions. The main one - which is about increasing the dose - is last, because I need to first mention two issues that bear on it:

- My schedule absolutely requires, with no options, that on 3 days of the week (M, W, F), my cats get their breakfast at 5 am, while on the remaining days, they get their breakfast at 7:30-8 am. This means that a firm 12-hour insulin dosing schedule simply is not a possibility for Conan. This is not something that can be changed at all in any way - it's simply the way it is, and I have to find a way to work around it. Conan's spreadsheet reflects this - I added columns for "+12", "+13", etc., and I also inserted a column called "Hrs" which shows the actual hours between AM and PM insulin doses (I didn't bother to put one for hours between PM and AM). You can also see just by looking at the time columns - time for AM dose/meal and time for PM dose/meal.

What I have been attempting to do is: on M, W, F, breakfast at 5 am and dinner at 6:30 pm; then the next morning, breakfast at 7:30-8 am, dinner at around 6:30-7 pm; then the next morning breakfast again at 5:00 am. So the schedule is never more than 1.5-2 hours off of 12 hours. So my dosing interval is ranging from 11 to 13 hours most days; it's almost never 12.

I have not varied the 1 unit dose on these days. So far it doesn't seem to have caused great variation in BG levels when I compare the 14-10 hour days to the 12-12 ones - all of them are all over the map at this point, but there's no pattern to it. But I'd welcome advice for how to deal with this, because I'm going to have to find a way.

- Related to this: on the days that they have early breakfast, my previous habit had been to give all the cats a small lunch. I have continued this. On other days they get two meals, but on 5am breakfast days they get three meals, the middle one a bit smaller (recently, much smaller for Conan, since I want to give him his insulin with his larger meals). This has actually appeared to help Conan's BG levels - they seem to actually go down after the "lunch" meal - but I'd be interested in input as to whether this is an issue, to have different number of meals on different days. Mid-dosing meals are marked on my spreadsheet.

- Finally, and what is really my main concern: adjusting Conan's dosing to better regulate his BG. The spreadsheet, as well as Conan's still-voracious appetite and drinking, suggest strongly to me that his BG is not controlled right now and that the dose needs to be increased, but I'm not confident that I'm reading it correctly or that I know what I'm doing, because really, the numbers are all over the place.

There was one day on which his BG levels all stayed in the mid-100s, and even dipped down to 90, but that day seems to have been a complete anomaly. I have no idea what happened. I wonder whether it could be attributed to inaccurate markings on my BD syringes that resulted in overdosing (I am switching to BD syringes with half-unit markings, with which I can use calipers or the BD ruler, but I haven't received them yet)? Or does this just sometimes happen? And if it does, how do you deal with it in determining dosing?

I have no other explanation for that single low day, or for the occasional low numbers randomly scattered throughout (by which I mean in the 150 range - which is my goal, isn't it?).

There are also a few very high numbers, and some days that overall seem quite high, and it's possible that there might have been some days in which I didn't get the entire dose into him or did a "fur shot" - he's a good patient, and I'm pretty experienced with sticking needles into animals, but it's too easy to go all the way through, and I don't always use the same location.)

But overall, even setting the anomalies aside, it looks to me like far too many of his numbers are in the 300s and 400s. I understand that Lantus takes a while to "even out," even a month or more, and that it's not abnormal for his numbers to be a bit all over the place during that time - but still it seems to me that this has been a long enough time to suggest that the dose is too low to regulate him sufficiently and that maybe I should consider increasing the dose to 1.25 U?

I should mention that I am not necessarily trying to adhere to any particular protocol. I don't believe remission is an option for him given the necessity for ongoing steroid use. I am not reliably around every day at hours 4-7 (which seem to be the "nadir" when there is one) to be alert for hypo, though I'm prepared to deal with it. I have the means and ability to do the tight regulation protocol, but I don't really want to push that hard.

So - does anyone with experience have any thoughts or advice about any of these things? I've passed the initial stages of getting accustomed to the routine, and now I'm kind of floundering about how to proceed. My vet is excellent, but there's so much specialized knowledge and experience here... Plus of course support.

Thank you..

Jessica & Conan

 

[julie & punkin (ga)]

Let me offer a couple of thoughts, and I'm sure others will also weigh in.

At the moment, he's bouncing. The lower numbers you've seen are driving the show. Bouncing occurs because his body has gotten used to higher numbers, and it now thinks that higher range is normal. When you bring him back into normal range again, his body perceives that as a hypo. Even if it's not in dangerously low numbers. Here's a little more about bouncing.

Dosing with Lantus is based upon how low a dose can cause a cat's blood sugar to go. Right now we can see that it can get him into the 90's AT. When you see 149 and 170 the past couple of mornings, it also raises the possibility that he was lower in the nights before those mornings.

Tight Regulation isn't just for those cats that may go off of insulin and become diet-controlled. It is also helpful for those that want to protect their cat's body from the damage of high blood sugar.

The Start Low Go Slow dosing protocol might be a better fit to your lifestyle, however. Here is what it would suggest for you:

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.
​

One difficulty, however, is that you're using an Alpha Trak and our dosing documents are all in human glucometer numbers. We don't have any conversion chart, and not for lack of trying. People have done comparisons between the 2 types of meters but the numbers vary enough that no conversion standard seems to be possible. We do have reduction points - for SLGS the reduction point is 90 and with Tight Reg the reduction point is 68AT.

I encourage people to use a human glucometer for several reasons:

1) the ease of using the dosing guidelines for either the Tight Reg protocol or SLGS,
2) most people here use human glucometers and they are most familiar with those numbers, so are more confident about helping those with human meters, and
3) the human meter strips cost a fraction of the ATs - often as little as 1/4 the cost.

If you want some AT tests for your vet, you can always do them separately when you need them, but mostly use the human meter.

But if you want to use the AT, go for it. Some people have a preference for them.

I think you're going to see some wonky numbers and cycles that don't make as much sense here and there. The changing length of cycles combined with the steroids may keep things from being real consistent for you. I'd suggest you put some sort of note where you give the steroids so you can see if it raises his blood sugar.

We also know that absorption of insulin can vary by as much as 50% from one shot to another. I saw you're giving fluids - some people have found that fluids can lower blood sugar. Just my own thought is that it may have to do with how dehydrated a cat is. The first time punkin got Subq fluids his BGs dropped, but it never happened after that. We did separate the time and location of the fluids and the insulin. We shot in the scruff and gave fluids several inches away at +3.

 

[Jessica & Conan]

Okay, a lot of helpful stuff there, thank you.

First let me offer a bit more information. He gets his steroid in a split dose - 2.5 mg after his morning meal, and 1.25 mg after his evening meal.

Second, with regard to fluids: very recently, really just after the onset of the diabetes, he has had a few episodes of inappetence - loss of appetite, complete disinterest in food. The first of these episodes resulted in weight loss and caused me to bring him in; this is when he was diagnosed. We suspected lymphoma and he also ended up getting scoped - his biopsies actually revealed that his IBD has improved in the years he's been on the steroid. But he came home from the hospital feeling much better, and the only thing that he'd been treated with was IV fluids. So at the vet's suggestion, when next he lost his appetite (more potential consequences this time since I needed to give him insulin) I tried administering SubQ fluids (which I had leftover from a previous renal kitty, who is gone now) - and indeed this seemed to help. I did it regularly for a few days and am gradually tapering off. I suspect dehydration - possibly the beginnings of renal issues, but if so, they're not evident in blood work. But hopefully he should not need fluids often.

A few things about your suggestions/comments/info. First of all, I would be willing to attempt tight regulation - but a few questions. I don't entirely understand what the benefit is - what is its point/goal, versus going slower? Why would I want to do this. Also, as you note, I'm not sure that my schedule is conducive to it. If I know that dosing is going to vary from 11-13 hours pretty regularly, is it really a viable option for me? Further details about schedule: on the 5am breakfast mornings, I must leave immediately after breakfast and do not return home until +7 or +8 - so on those days there is no way I can take +1 or +3 or +6 readings. Is this something else that really would make tight regulation not viable for me?

Second, I just want to make sure I understand: are you saying that the fact that he reached a low of 90 on the current dose suggests that this dose is probably/possibly sufficient? I'm a little confused. I actually did what amounts to a Start Low/Go Slow curve once already - i.e., a 12-hour curve more than a week after starting this dose - and got a low of 90, suggesting I should maintain the same dose. But if I do it again tomorrow, which I will do, I am almost sure that my low will be nowhere near 90, but will in fact be more than 150, which would lead me to increase by .25. Which of these would I follow? If I suspect bouncing, should I just wait, and if so, how long, before deciding to go ahead and do the increase?

Third, if it would help me in some way, I would be amenable to using a human meter - though I do like the AlphaTrak because it's quite easy to use and requires only a very, very tiny drop of blood. But I'm not averse to trying a different one. Do you have a suggestion for a human meter that is similarly easy, and similarly requires only a tiny drop (or maybe they all do - I have no idea)? I would like some idea of how much it really matters - is it really that different?

Finally, you did not express huge concern about my slightly off dosing schedule - I'm hoping that means it's something I can manage! I'm still confused about what, if anything, I should do right now. Continue as I am and do more curves? Try increasing? Something else?

 

[julie & punkin (ga)]

Your description of his inappetance improving with the fluids makes me think of pancreatitis. Fluids is one of the treatments and pancreatitis is fairly common in diabetic cats. Take a look at the Primer on Pancreatitis and see if that sounds like it might be what's going on. I haven't heard of CKD being connected with inappetance, but it's possible. I don't know that much about it even though punkin had the beginnings of CKD. He certainly never had any appy problems!

Second, I just want to make sure I understand: are you saying that the fact that he reached a low of 90 on the current dose suggests that this dose is probably/possibly sufficient?

It's hard to say, but typically yes, dose changes are based upon how low the dose can cause him to go. Typically we look at about the past 3 days (with Tight Reg) or 7 days (SLGS) and see how low the kitty is getting, and decide on dose changes from that. For Conan, I think I'd hold the dose for the moment and gather more information. I think there's enough to suggest that he could be getting some lower numbers in the wee morning hours. I'm not criticizing, just saying they may be there. It's not unusual for cats to have their lowest numbers at night. Since you're planning on doing a curve tomorrow, if it were me, I'd hold off increasing and wait for that information to make a decision. Cats can be very unpredictable, so it would be good to see what you got tomorrow.

First of all, I would be willing to attempt tight regulation - but a few questions. I don't entirely understand what the benefit is - what is its point/goal, versus going slower?
High blood sugar is hard on the cat's body, just like it is for people. Many body systems can end up being affected. Tight Reg allows for evaluating & adjusting the dose every 3 days or so; SLGS calls for holding every dose for a week. A week is a very long time to hold a dose that you can see isn't getting your cat into healthy numbers. The other pro for Tight Reg is that it is the only dosing protocol for diabetic cats using Lantus/Levemir that has been published in a professional veterinary journal in 2009. SLGS was developed here before the Tight Reg study was done and is especially good for those who feed dry food to their cats, or who can't test enough to safely follow Tight Reg, or who just prefer it for whatever reason. Here's a post that has some history on Tight Reg. There is a sticky at the top of this group's page on managing Tight Reg when you work full time and it might have some helpful ideas for you.

I didn't comment on the schedule because I'm really not sure if it's a problem or not. Shooting more than 12 hours isn't likely to be a problem, but shooting less than 12 hours might be sometimes. There is some flexibility with shooting with Lantus - as you've seen it's not the end of the world to not shoot exactly at 12 hours, but something you should be aware of is that shooting less than 12 hrs from the last shot can act as a slight dose increase. If a cat is in high numbers, that can be an asset, but if they are in lower numbers, it might not be the best idea. One possibility for your schedule is to use ProZinc. It's not a depot insulin like Lantus and Levemir and with a changing schedule, it might be a good fit for you.

Regarding the meters, there are lots of good meters. Punkin passed away 2.5 years ago so it's not something I've stayed current on, but lots of people will have opinions about it if you ask. I do think it matters because of the reasons I mentioned above, but it's up to you. If you choose to continue with the AT, just always make sure that if people are giving you advice they realize that you're using an AT.

Many buy Relion meters from Walmart because they are cheap and the strips are cheap and available. @Chris & China knows a lot about those glucometers. Many people also buy diabetic supplies from www.americandiabeteswholesale.com . They are reliable and inexpensive. There is an inexpensive generic Arkray glucometer & strips on American Diabetes Wholesale that many people like. I bought all my supplies through ADW and was really happy with them, although if I remember correctly, they won't take things back after 30 days. There is a shopping link on the banner above and if people use that a percentage of the sale goes to support this website. There are some links to glucometer comparisons from 2012 and 2013 in the New to the Group? sticky that might be helpful.

Did I answer everything? Keep asking questions. That's the best thing you can do - there is a ton to learn at the beginning but it gets easier as you learn more. I'm hoping that others will stop in and add their opinions as well so you have other perspectives to help you.

 

[Chris & China (GA)]

The Relion Confirm and Micro meters from WalMart are both very popular around here because they're cheap (about $15) and the strips are affordable ($35.88 per 100)

They take the same tiny sized sample as the AlphaTrak too!

If you're anti-WalMart, the Arkray Glucocard o1 from ADW is the exact same meter as the Relion Confirm....Arkray manufactures the meters and WalMart re-brands them as their "Relion" brand. They used to have a great deal on strips but just in the past week stopped offering it (buy 4 boxes of 50, get 1 free for $69.99) but they still offer lots of other sizes of strips you can buy, as well as "combo deals" that have both the meter and strips