? ? Should I give insulin? BG low - new and unsure

[Girlie's mom]

Hi,
Not sure whether this should be a 911 or not: I'm still new here. I've put Girlie's spreadsheet up. She's been all over the place and really high. I'm in Australia, so it's 11:30 pm Australian time (9:30 am EST in the US). The vet told me not to give insulin if she was under 10 mmol/L (180) and to call the vet; at 9:00 pm (her shot time) she was 9.1 (ca 165), so I didn't give her any insulin. We had a big hypo scare on 4 July and she was in hospital until 12 July: I'd rather not have a repeat!
The emergency vet just rang and said to give her the usual 1.5 U of Glargine. But this means I'll now be on a noon/midnight schedule which won't work for me. She said that I could just give her an injection at 11 AM (if her BG was ok - not sure what she thinks ok is as she was rushed in the emergency room). But that means an injection tonight at midnight and 11 am tomorrow: I've read that you should be really careful about changing times of doses.
The emergency vet also said that I could not give her a shot tonight but that that might throw Girlie off the progress she's made today.
I don't know what to do as her BG has been all over the place and REALLY high; I don't want to mess anything up.
Any advice would be really appreciated!!

 

[Girlie's mom]

If I don't give her insulin tonight, does that mean I can give her insulin earlier in the morning tomorrow? The vet currently has her on a 9 am / 9 pm schedule, but I need to shift that to 6 am / 6 pm as I have to go back to work soon. I don't know what to do... Yikes!

 

[Girlie's mom]

Hope it's ok that I made this 911: if not, I'll put it back to a question mark. I'm new still, so learning how things work at FDMB as I go along. Thanks so much!

 

[Nan & Amber (GA)]

Given your schedule constraints, and the current time, I think it's probably best to skip this shot and then start on your preferred shot time at 6am tomorrow morning. No history of ketones or DKA, correct?

I'm glad girlie is home now after that scary hypo!

 

[Nan & Amber (GA)]

When you go back to work, how much testing do you anticipate being able to do between shots? I'm asking because, with lantus, dosing decisions are made based on the low points (nadirs) rather than pre-shots. You've got tons of good data so far about the 1.5U dose, but given that she hypo'd on 1.0U of Caninsulin, it will be important to keep an eye on what she's doing between shots. It can be tough to do when working full time, but any data you can gather, an "out the door" test at +1 or +2, or any night-time data, will be helpful!

How is she feeling?

 

[Girlie's mom]

Given your schedule constraints, and the current time, I think it's probably best to skip this shot and then start on your preferred shot time at 6am tomorrow morning. No history of ketones or DKA, correct?

I'm glad girlie is home now after that scary hypo!

Thanks so much, Nan. No DKA; no ketones in the urine tests I've done, even with all of those scarily high numbers since she was diagnosed. I think there was something initially when she was diagnosed (I'll have to check), but definitely not DKA.

May I ask another question since you were so kind to reply? I just tried to do a BG, and for the first time she got annoyed (she's slept through all of the previous tests since I started yesterday). I don't want to create a negative association for her, so I just let it go. Question: Can I use the lancet for the next test in an hour? Do I always have to use a fresh lancet straight away even if I have to try the other ear or a different spot if I wasn't successful on the first try?

Also, was it ok to use 911? I don't know if that was okay - I can take that off the prefix if you think that would be better.

Thanks so much!
Darrah (Girlie's mom)

 

[Nan & Amber (GA)]

It's best not to re-use the lancets, especially if she's starting to get cranky-- in addition to infection risk, they get dulled, and the poking gets more painful. Don't worry about the occasional unsuccessful test--just give her her treat anyway, to help build positive associations, and try again later!

You can take down the 911-- we try to reserve it for immediate, life-threatening situations which (thankfully!) this isn't!

 

[Girlie's mom]

When you go back to work, how much testing do you anticipate being able to do between shots? I'm asking because, with lantus, dosing decisions are made based on the low points (nadirs) rather than pre-shots. You've got tons of good data so far about the 1.5U dose, but given that she hypo'd on 1.0U of Caninsulin, it will be important to keep an eye on what she's doing between shots. It can be tough to do when working full time, but any data you can gather, an "out the door" test at +1 or +2, or any night-time data, will be helpful!

How is she feeling?

She hypo'd on 1 U of Lantus after having no insulin for three days; prior to that, we were on just 1 U of Lantus 1 x/day. She was only dx on 30 June, so this is all very new to both of us. When she hypo'd on the Lantus, I took her to the vet who then tried the Caninsulin, but that didn't work as her numbers stayed so high. They've been using the Lantus and ActRapid to try to get the numbers down and sent her home on 12 July and asked me to do 1.5 U 2x/day.
She seems fine! She just ate a little bit more (she's a grazer); had some water; and is curled up by the heater and waiting for me to get back into bed so we can go to sleep. (It's winter in Australia, so pretty chilly).

 

[Girlie's mom]

It's best not to re-use the lancets, especially if she's starting to get cranky-- in addition to infection risk, they get dulled, and the poking gets more painful. Don't worry about the occasional unsuccessful test--just give her her treat anyway, to help build positive associations, and try again later!

You can take down the 911-- we try to reserve it for immediate, life-threatening situations which (thankfully!) this isn't!

Thank you so, so much: I've taken down the 911. For me it seemed scary as this is all so new. There's a lot to learn, isn't there? And Girlie is proving to be a big challenge with her BG (according to the vet).
I'll test her at 1 and then 2 am; as long as she's asleep, she doesn't even notice it.

 

[Nan & Amber (GA)]

Ah, OK, I was confused by the spreadsheet.

In any case, I am still a little concerned that the 1.5U might be a bit high for her-- a lot of times, the BG numbers can be elevated due to stress while at the vet's, so she may need less insulin now that she's at home. The other thing that might have led to her recent high numbers was "bouncing"-- the cat's body reacts to an unfamiliar low by raising BG high. A bounce can last up to 3 days (six cycles)! So, looking at her spreadsheet, she had a green on 7/11, then four cycles of high numbers, then she came down a bit to yellow and blue numbers. That looks like a pretty classic bounce! And then this last cycle when she gave you the low pre-shot was the fourth cycle after that blue, so she might have been doing a bit more bouncing.

It's definitely all overwhelming and confusing at first trying to figure out these patterns, but the main point here is just that the high numbers you and the vet have been seeing aren't necessarily a sign that she needs a higher and higher dose of insulin. Especially with the hypo, I'd tend to be a bit more cautious to start.

One thing I'd do if I were you is to be sure to get not just a pre-shot reading tomorrow morning, but get another reading an hour before you want to shoot. Given where she's heading so far tonight, I kind of expect her to be pretty high tomorrow morning, but in case she's lower, having that earlier reading helps tell you if she's heading up or down at shot time (if you hadn't also had the scheduling issues, I probably would have said to shoot tonight, since she was heading up pretty fast by the time I saw this post). It also gives you an opportunity to post earlier for advice on shooting, either here or over in the Lantus boards, which are very active and full of experts. The skipped shot adds a bit of a complication to an already complicated situation, so you'll definitely want expert eyes on any borderline decisions.

Are you going to be able to monitor tomorrow, or will you have to go to work?

 

[Girlie's mom]

When you go back to work, how much testing do you anticipate being able to do between shots? I'm asking because, with lantus, dosing decisions are made based on the low points (nadirs) rather than pre-shots. You've got tons of good data so far about the 1.5U dose, but given that she hypo'd on 1.0U of Caninsulin, it will be important to keep an eye on what she's doing between shots. It can be tough to do when working full time, but any data you can gather, an "out the door" test at +1 or +2, or any night-time data, will be helpful!

How is she feeling?

I live about 20 minutes away from work, so I can pop home during the day if that would be good. Would that be to do a BG to see how low she's gone a certain number of hours after her shot? I don't really understand what you mean by the dosing decisions are made by the nadirs rather than the pre-shots. Is there a post or more information on this I could read? I'm sure it's already here somewhere - I just don't know where to find it. I remember reading something about curves and the bottom of curves - is that what you mean?

 

[Girlie's mom]

Ah, OK, I was confused by the spreadsheet.

In any case, I am still a little concerned that the 1.5U might be a bit high for her-- a lot of times, the BG numbers can be elevated due to stress while at the vet's, so she may need less insulin now that she's at home. The other thing that might have led to her recent high numbers was "bouncing"-- the cat's body reacts to an unfamiliar low by raising BG high. A bounce can last up to 3 days (six cycles)! So, looking at her spreadsheet, she had a green on 7/11, then four cycles of high numbers, then she came down a bit to yellow and blue numbers. That looks like a pretty classic bounce! And then this last cycle when she gave you the low pre-shot was the fourth cycle after that blue, so she might have been doing a bit more bouncing.

It's definitely all overwhelming and confusing at first trying to figure out these patterns, but the main point here is just that the high numbers you and the vet have been seeing aren't necessarily a sign that she needs a higher and higher dose of insulin. Especially with the hypo, I'd tend to be a bit more cautious to start.

One thing I'd do if I were you is to be sure to get not just a pre-shot reading tomorrow morning, but get another reading an hour before you want to shoot. Given where she's heading so far tonight, I kind of expect her to be pretty high tomorrow morning, but in case she's lower, having that earlier reading helps tell you if she's heading up or down at shot time (if you hadn't also had the scheduling issues, I probably would have said to shoot tonight, since she was heading up pretty fast by the time I saw this post). It also gives you an opportunity to post earlier for advice on shooting, either here or over in the Lantus boards, which are very active and full of experts. The skipped shot adds a bit of a complication to an already complicated situation, so you'll definitely want expert eyes on any borderline decisions.

Are you going to be able to monitor tomorrow, or will you have to go to work?

Oh shoot! I should have given her the shot at midnight, I guess. I'm still recovering from surgery, so I'll be home for another two weeks (I hope). But Girlie and I are both early birds, so staying up til 9 pm to give a shot has been rough on us.
I'll do the pre-shot readings in the morning. I'm sure she'll be high again.
She was at the vets from 5 - 12 July; one vet tried her on Caninsulin for a couple of days (no joy there; still high); they put her back on Lantus, but they had to use ActRapid every day and night to try to bring her numbers down. I'm sure that that must have put some stress on her system which was still new to insulin in the first place.
We've also had food issues. She's now on Mirtazapine; she's always been a really fussy eater, but with the enema for the constipation, the pneumonia, and the new drama of insulin, plus new meds, she wasn't eating enough to really handle the insulin. They thought they'd have to put her on an e-tube, but the Mirtazapine is working for the moment. It's been a bit of a roller coaster since 30 June when she was diagnosed, I'm afraid, for both of us.
I think you might be right: she may turn out to do better on a smaller dose.
I'll try posting in the Lantus and Levemir forum as well. The more advice, the better.
Thank you again!

 

[Nan & Amber (GA)]

Is there a post or more information on this I could read? I'm sure it's already here somewhere - I just don't know where to find it.

Best place to start is the yellow "stickies" on the Lantus/Levemir board. There is an overwhelming amount of information in them, but, basically, there are two approaches used by most people on that board when dosing with Lantus: "Start Low, Go Slow" (SLGS), and "Tight Regulation" (TR). They differ by the aggressiveness of the dose increases (TR is more aggressive), and describe how and when to change doses.

In Girlie's case, I'd still also recommend posting over there to get some input on her current dose, given her recent hypo on a lower dose. Was there something else going on during the hypo-- a major food change or something like that? Or maybe the installation of the Freestyle Libre involved a day at the vet and she didn't eat very much while there? Edit: ah, was just about to post when I saw you just answered a lot of these questions. OK, if she wasn't eating much during the hypo episode, then that helps to make sense of things.

 

[Girlie's mom]

Well, the 1;00 am BG shot way up (11 am est): 33.2 (600) immediately tested gain with a fresh strip immediately and got 40.9 (off the chart). Oh boy...now what? Should I post over on the Lantus board, do you think?
Could something be wrong with my AlphaTrak 2? This happened earlier tonight when I tested three strips in a row and got three different readings: 9.1, 10.2, and 9.9 (165 - 180). I'll test it with the control solution, but it was fine when I started a day ago.
It's going to be a long night...
She's happily asleep on my lap, snug and warm: no sign of anything wrong from her.

 

[Yong & Maury GA]

You skipped her shot tonight, correct, Darrah?

 

[Girlie's mom]

You skipped her shot tonight, correct, Darrah?

Yes, I did. She was due to get it 4.5 hours ago now but was initially too low; the vet said no insulin if she was under 10 (180).

 

[Yong & Maury GA]

Yes, that's fine. I just wanted to confirm . One good thing about this is tomorrow morning you can probably start your preferred schedule times . As long as she is not prone to ketones and is happy and content, running a little higher tonight should be OK. It's better than going too low for a second . What part of Oz are you in?

Also, Hi @Nan & Amber . Seems like you've not been around much. Hope everything's well

 

[Girlie's mom]

Phew! She scares the willies out of me too often, especially as this is all so new for us. She's been high for a while now, but still no ketones in her daily urinalysis. The hypo incident on 4 July gave me a few new gray hairs, for sure.
She usually gets her first dose at 9 am. Since I skipped the 9 pm dose, can I just give her the 1.5 units of Lantus at 6 am (3 hours early) as long as she's not low (completely unlikely, of course). And then I give her next dose at 6 pm that same day? I'm a little confused about cycles. I read the great post on getting back on schedule, but anything that involves numbers inevitably confuses me.

 

[Girlie's mom]

Yes, that's fine. I just wanted to confirm . One good thing about this is tomorrow morning you can probably start your preferred schedule times . As long as she is not prone to ketones and is happy and content, running a little higher tonight should be OK. It's better than going too low for a second . What part of Oz are you in?

Also, Hi @Nan & Amber . Seems like you've not been around much. Hope everything's well

Sorry - I'm in Sydney. Thank you for the hugs!! Much needed... My vet basically told me to chill out and take a deep breath, but I'm so afraid that I'll do something wrong and hurt her or lose her...she's so incredibly precious to me.

 

[Yong & Maury GA]

Since I skipped the 9 pm dose, can I just give her the 1.5 units of Lantus at 6 am (3 hours early) as long as she's not low (completely unlikely, of course). And then I give her next dose at 6 pm that same day? I'm a little confused about cycles. I read the great post on getting back on schedule, but anything that involves numbers inevitably confuses me.

Yup . Don't worry, you'll get to understanding it more . I had a a couple online friends in Oz, Melbourne so I'm familiar with the time zone. Just wanted to check which area . I'm too new to Lantus to suggest dosings but I am wondering if you should drop back to 1.0U of Lantus since it's gentler and longer lasting than Caninsulin. She might not drop so drastically. Have you made any threads on the Lantus forum yet?

 

[Nan & Amber (GA)]

She usually gets her first dose at 9 am. Since I skipped the 9 pm dose, can I just give her the 1.5 units of Lantus at 6 am (3 hours early) as long as she's not low (completely unlikely, of course). And then I give her next dose at 6 pm that same day? I'm a little confused about cycles. I read the great post on getting back on schedule, but anything that involves numbers inevitably confuses me.

I think so, after the skipped shot. If she were already well-regulated on a particular dose, I'd say it'd be better to move the shot time gradually even after the skip, but since she isn't, I don't think it's that big a deal to make a big shot-time change (after a skip) and have a slightly wonky "depot" for a little while. I'm also less worried about the 1.5U after hearing that the hypo on 1.0U occurred when she wasn't eating well, but it's still a bit high to start for a 7lb cat. I'm not personally comfortable giving specific dose advice except in situations where a cat is pretty obviously being overdosed and needs to come down asap. I don't see Girlie in that category but the Lantus dose experts may have some suggestions-- there are folks over there with a lot more experience with all different situations.

I'm sorry you have to deal with surgery recovery on top of this, but the good news is, two more weeks of being able to keep close track of Girlie is going to be really helpful in trying to get her on track!

P.S. Hi, @Yong!

 

[Bron and Sheba (GA)]

Well, the 1;00 am BG shot way up (11 am est): 33.2 (600) immediately tested gain with a fresh strip immediately and got 40.9 (off the chart). Oh boy...now what? Should I post over on the Lantus board, do you think?

Hi Darrah,
I've just seen your post. Yes, I think it would be a really good idea if you started to post in the Lantus board now as this is just a general health board and the Lantus board is just for cats that have Lantus or levemir so you will have a lot more people who will be able to advise you. If you can link this post and you previous post to the new one it will give everyone your backgrown.

After the skipped dose...yes you could have restarted the Glargine at 6 am. This is because you did not give any insulin last night. Then you will be on your 6:6 schedule.

 

[Bron and Sheba (GA)]

Hi Darrah,
Just looked at Girlies SS. Glad to see you were able to go to the 6:6 option.
I can see she is running In high numbers at the moment. That could be either because you skipped a dose or it could also be that she is bouncing after having what her body thinks is low numbers (around 9 and 10) after being in high numbers for so long. Or it could be a combination of both.
When I was testing Sheba I always offered her a tiny bit of something low carb....often just chicken stock made of bones boiled....no salt at all added. This might be enough to distract Girlie while you test her.

Have sent you a PM ...top right hand corner of page.

 

[JanetNJ]

I just looked at your spreadsheet. Holy cow do you sleep???? No need to test quite that frequently. Lol.

 

[Girlie's mom]

I just looked at your spreadsheet. Holy cow do you sleep???? No need to test quite that frequently. Lol.

Janet, my reply is long overdue - sorry! She was in hospital, so the nurses were doing the testing by swiping her Freestyle Libre implant. Even I can't test that much!