Flat readings - suggestions for dosing?

Ramon's mom

Ramon's mom

Member
Ramon has been having flat readings in the upper 200's (Human meter) for a few weeks. Today's curve was pretty flatish too. I am thinking I should try to bump his dose up a tad (to 1.4 from the 1.2 he's been getting). Am I right in thinking this? I really don't want to trigger a bounce but I'd also rather get his readings down. (check my human meter spreadsheet)
 
It's hard to be sure what's going on. Honestly, it could be that you just need to kick it up to 1.4, but without more mid cycle numbers (not even necessarily nadir just whatever you can get) we can't be sure that today's cycle wasn't just a bounce cycle. High and flat all day usually means a bounce...but could also mean a sudden drop is coming. Is there any way you can get more numbers through the day or night? Not always the same, just anything you can. I can't recall your schedule off the top of my head (my memory is terrible I'm sorry!).
 
So you think I need a few more days of checking mid-cycle numbers before making a change? I had stopped for the last week because his readings were disrupted while I boarded him out so I could go on a trip. I'm certainly glad he is steady instead of swinging all over the place like he had been earlier (including on the Alpha Trak spreadsheet). But I'd like to see him lower.
 
I agree about trying to get a few more BGs in the +4 to +7 range or so. The dose's effectiveness is judged mainly by how low it takes BG. A pattern that's noticed often is that a flat run of yellows often precedes a drop in numbers so keep that in mind. I don't think anyone knows why but it's commented on often.
 
No I'm pretty sure it was not a fur shot. He is shaved and I always rub around the area to see if there is any wetness. He has often gotten flat readings all day with no apparent reaction to the insulin I give him.
 
He's an up and down and flat kitty. It's trickier to find a good dose but you'll get there. The best way to tell if you've had a total or partial fur shot is to smell the area. Lantus has a really strong Bandaid -like smell.
 
Well I am 99% positive he is not getting fur shots. I'm certain I would feel the wetness. And I am using very short needles and can see exactly what I am doing since his hair is shaved off. This has been an ongoing problem with his BG numbers. he tends to have very flat curves most of the time.
 
Sorry I think I looked at the wrong SS and saw a note about a fur shot on that! Sure, you can try bumping to 1.4 and see what happens...but I'd be sure to do that on a cycle you can monitor.
 
Bad news. The 1.4 not only didn't improve the curve much but now he is up past 300 for PMPS and 2+ PM I think I triggered a bounce up. I need to go to sleep and cannot do more testing tonight. I can only hope it doesn't swing way down after this. All I really wanted to do was to get his nadir into the blue. Darn.
 
I think you haven't yet reached the good dose range and have probably been holding ineffective doses too long. That can lead to glucose toxicity which shows as a general unresponsiveness to insulin. What we often suggest here is to hold a dose for only 3 to 4 cycles if it doesn't give a good BG lowering response - ie., BGs dropping to low blues or high dark greens mid cycle. Why not try a 0.2 u increase after 3 to 4 cycles and continue that until you see progress? For a month now you've been dosing in a very narrow range of 1 to 1.4 u and he likely needs more.
 
I agree with Kris - this is more likely insufficient insulin than a bounce. Also, the evening before you had a 295 and the morning of the increase you had a 285, so 310 is right in that same range. Sometimes when it changes colors it makes us feel like the difference is bigger, but in reality those numbers are all essentially the same. So it didn't "go up" so much as just pretty much stay the same.

I think doing some systematic increases as Kris suggested would be a good idea to see if you can't get him moving a little.
 
Thanks for the input! This morning @ +11 he was 237 and at AMPS, after eating, was @ 258, so I think I'll finish out the 1.4 dose for 2 more cycles (to make 4) and see what this really is going to do for him. If the nadir still doesn't go down I'll try your suggestion of bumping it up another 0.2
 
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Any thoughts now on his readings? The 1.4 dose has leveled out again so I'm still getting only yellow readings, though I guess there is a nadir dip within that, so I suppose that's an improvement. Anyway, do I keep at the 1.4 longer or make another move to 1.6? Thanks again for any advice!
 
Well, 2 doses now on 1.6 u and nothing is any different. Though he is acting kind of hyper and OCD-ish (could that be caused by the increase in insulin?) I'll keep monitoring him but I am back to being confused and frustrated. Any words of encouragement for me? Also, I poked myself with his insulin needle, after I injected him. Should I worry about that?
 
Don't worry about the poke. We've all done it and no one has turned into a cat yet ;)

As for the dose, some cats will push back against a dose change for the first cycle or two and then react to it on the third or fourth cycle. If you don't see anything before cycle 4, go ahead and increase to 1.8u.

It's a process. It takes some time. And this is Ramon's second round of diabetes which is much more stubborn than the first round. You'll need to be persistent with the increases until he starts to respond. Hang in there, and keep posting. Knowing that you're not alone can really help, especially when improvement is slow to appear.
 
Though sometimes, I wish I WOULD turn into a cat! Sleep in the sun all day, someone else pays the bills and caters to my every need....ahhhhhh!

I agree with Djamila. Continue the increases every 4 cycles or so (most people prefer to increase on cycle 4 as you probably know...so you can always increase during the day). Give it some time and don't get frustrated. The second round is always harder than the first. :bighug::bighug:
 
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As I am now contemplating going to 1.8 units I went back and looked over the charts for the past 2 months. December was still on the Alpha Trak meter chart, but it actually looks better at the 1 unit dose than the last month on the Human meter chart on the raised doses. I was raising the dose to try to stop how erratic his numbers and curves were, but now that all I get are higher numbers even as I raise his dose I am wondering if I really need to go back to 1 unit. I still prefer him having steady numbers but his current ones just seem too high. Any thoughts to help me on this?
 
Ramon's mom said:
As I am now contemplating going to 1.8 units I went back and looked over the charts for the past 2 months. December was still on the Alpha Trak meter chart, but it actually looks better at the 1 unit dose than the last month on the Human meter chart on the raised doses. I was raising the dose to try to stop how erratic his numbers and curves were, but now that all I get are higher numbers even as I raise his dose I am wondering if I really need to go back to 1 unit. I still prefer him having steady numbers but his current ones just seem too high. Any thoughts to help me on this?
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My opinion is still that his dose needs to go up. Glucose toxicity can build quickly and the kitty loses responsiveness to insulin. Let's see what @Djamila thinks.
 
I'd up the dose too. You've done great getting some number throughout the cycle and it shows that he's staying high and flat. You want to see if you can't get some more of a drop during the cycle.
 
I absolutely understand the temptation to read the data that way. We've seen lots of people try lowering the dose based on the same reasoning you shared. What usually happens is that the cat will have a nice cycle on the first lowered dose, raising hopes that this was the right decision. But then start to escalate in the subsequent cycles into higher numbers than they've seen before. And on more than a couple occasions, the cat has ended up in DKA as a result. That last part doesn't always happen, but I can think of four off the top of my head in the past couple of years. Too many to risk it, in my opinion.

I believe Kris and Rachel are right - you're seeing glucose toxicity, and the remedy is to raise the dose in steady and persistent fashion until you break through it. It is super frustrating, but it's a fairly common problem. Sam even went through a round of it recently. I ended up at 4u before we finally broke through.

Adding to the complication, Ramon is on his second diagnosis. It took me a number of months into our second diagnosis before I really started to understand how different it is from the first round. I found that with Sam I had to be much more aggressive with dosing the second time around, and that can be hard to get used to since during a first diagnosis we urge so much caution. Time will tell what Ramon needs, but for now I think we are all in agreement that continuing with the increases every 4 cycles or so is going to be the best thing right now. At some point he's going to start bouncing and when that happens (hopefully sooner than later) you can slow down again.
 
Rachel said:
I'd up the dose too. You've done great getting some number throughout the cycle and it shows that he's staying high and flat. You want to see if you can't get some more of a drop during the cycle.
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I didn't mean to exclude you, Rachel, when I said let's see what Djamila thinks. Just a boo boo. :confused:
 
Kris & Teasel said:
I didn't mean to exclude you, Rachel, when I said let's see what Djamila thinks. Just a boo boo. :confused:
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I am now wondering if he has started bouncing. Last night he was at 225 and this morning he is at 314. I gave him the 1.6 again because I was feeling too ill to stay up and monitor. I can monitor today but now that he has swung back up high again I wonder now if this means I should stop increasing. Don't know if I'll hear back from you or anyone before I have to decide his morning dose but I though it was worth posting the question....
 
Ramon's mom said:
I am now wondering if he has started bouncing. Last night he was at 225 and this morning he is at 314. I gave him the 1.6 again because I was feeling too ill to stay up and monitor. I can monitor today but now that he has swung back up high again I wonder now if this means I should stop increasing. Don't know if I'll hear back from you or anyone before I have to decide his morning dose but I though it was worth posting the question....
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I'd try 1.8 u this AM. You don't stop increasing if you see bouncing but you might have to slow the rate of dose increase. The best guide to know when you're approaching a better dose range is the appearance of blues and then dark greens in the middle part of the cycle.

This is what @Djamila said:
At some point he's going to start bouncing and when that happens (hopefully sooner than later) you can slow down again.
 
Haha don’t worry about it Kris! I knew you weren’t excluding me...you didn’t say let’s NOT see what Rachel thinks. I figured you saw Djamila online or you’d both been helping on this thread and that’s why you tagged her. I just happened to be online and figured I’d jump in too!
 
Two doses so far on 1.8 and his levels are swinging high and wide. Plus more concerning is that at 1.8 he goes into a deep sleep quickly after. Almost lethargic. Is this good?
 
His numbers look consistent with the ranges you've been seeing. It takes awhile to break through the insulin resistance. The lethargy isn't uncommon, unfortunately. Staying in higher-than-ideal numbers leaves them feeling a little wonky, and the influx of insulin can take some getting used to. Especially since his body is going to fight it until you reach a breakthrough dose. This part of the dance can be hard. As I mentioned I just went through it with my cat recently and I'll admit I cried a few times as we went up and up the dosing scale. But once we broke through he started playing like a kitten, his energy returned, and he's been a ton of fun the past few weeks. The waxing and waning of this disease can be hard on us as caregivers too. Please make sure that you're taking care of yourself during all of this. :bighug:
 
Djamila said:
His numbers look consistent with the ranges you've been seeing. It takes awhile to break through the insulin resistance. The lethargy isn't uncommon, unfortunately. Staying in higher-than-ideal numbers leaves them feeling a little wonky, and the influx of insulin can take some getting used to. Especially since his body is going to fight it until you reach a breakthrough dose. This part of the dance can be hard. As I mentioned I just went through it with my cat recently and I'll admit I cried a few times as we went up and up the dosing scale. But once we broke through he started playing like a kitten, his energy returned, and he's been a ton of fun the past few weeks. The waxing and waning of this disease can be hard on us as caregivers too. Please make sure that you're taking care of yourself during all of this. :bighug:
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Once you hit the high dose that works will it ever come down again? I guess in the back of my mind I just want him to go back into remission, which seems impossible if I have to keep increasing the dose (I'm also dreading telling his vet, without consulting her, that I went up a whole unit from what she recommended). Thanks, by the way, for all the advice and encouragement.
 
If the high-ish flat numbers are from glucose toxicity the BG range can drop once you break through that but not always. Sometimes you get to a dose level that gives a good response and you stay there. Having said that, there are often minor fluctuations in dose needed to maintain a good BG range.
 
In Sam's case, yes. We got to 4u, and now we're down to around 2u (it does go slightly up and down). However, as Kris said, some cats simply need larger doses to stay in good numbers. Only time and data will tell.

As for the vet, if you show her the data, it's hard to argue too much. The current dose clearly isn't working, and sitting in unhealthy numbers is dangerous as it causes organ damage and greater risk of DKA. I think most of us either win over our vets pretty quickly, or find a new vet. Hopefully your vet will be willing to learn and trust that you're making careful, data-driven decisions, and you'll be able to keep working together to help Ramon.
 
This morning, just as I was planning to go up to 2 units I gave him a fur shot. Do I monitor? Do I stay at 1.8 for the PM shot? I guess I just hope that the evening BG hasn't zoomed too high.
 
Djamila said:
In Sam's case, yes. We got to 4u, and now we're down to around 2u (it does go slightly up and down). However, as Kris said, some cats simply need larger doses to stay in good numbers. Only time and data will tell.

As for the vet, if you show her the data, it's hard to argue too much. The current dose clearly isn't working, and sitting in unhealthy numbers is dangerous as it causes organ damage and greater risk of DKA. I think most of us either win over our vets pretty quickly, or find a new vet. Hopefully your vet will be willing to learn and trust that you're making careful, data-driven decisions, and you'll be able to keep working together to help Ramon.
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Is it possible that his high flat readings are due to his insulin not working anymore? He is on Prozinc since late November, the same vial. Could it have gone bad in that time? Its been refrigerated since then except for one 8 hour stretch.
 
Ramon’s numbers are high enough that I’d go ahead and increase tonight. The odds of going too low are very slim give his usual range right now.

It’s not impossible that you have a bad vial, or that it’s lost effectiveness, although unlikely. We regularly use prozinc 3-4 or even up to 6 months with no problem as long as it’s stored properly (not in the door of the fridge, not shaken, proper temp). Unless the eight hours was during a heat wave, it’s probably fine.

You can always go ahead and get your next vial and give it a comparison.
 
I agree, I think it's time to go ahead and increase. He might be high tonight but that's okay. It happens...fur shots happen to everyone and we just deal with them.

As for the vial, you could try a new one if you wanted. How much of the old vial have you used up?
 
Its about half used up. It cost $100 so I would love it to last longer. This cat has cost me a ton of money for all his tests and now his ongoing meds and supplies. :-(
 
I used my first vial for six months and it didn't seem to lose effectiveness. After six months I just felt better replacing it.
 
I think you'd be fine to hang on to your current vial then. You could give it some time and then see if things get better before worrying about replacing.
 
Since I started raising the dose every few days things have not only not improved but now we are regularly getting numbers in the 300's. I really feel nervous about this.
 
Ultimately, you hold the syringe. We will always give you our best thoughts, but in the end, since you are the one who has to live with the consequences, the choices are yours to make. I still think the increases are the right thing to do right now, but if you decide to try a lower dose instead, we will still be here to help. No one gets their feelings hurt around here. :bighug:
 
Tonight his PMPS was 351, the highest he has ever been at home. I gave the 2 units again but it just seems to get worse and worse.
 
You could try an experiment and drop the dose to a level you feel might work better. Leave it there for a few days to see if there's an improvement. If there isn't you can increase again. At least you'd have evidence one way or the other.
 
Kris & Teasel said:
You could try an experiment and drop the dose to a level you feel might work better. Leave it there for a few days to see if there's an improvement. If there isn't you can increase again. At least you'd have evidence one way or the other.
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Well the last dose that he got any blues on was 1.2 though they didn't stay there long. Is that too big a drop, to go from 2 units to 1.2?
 
Ramon's mom said:
Well the last dose that he got any blues on was 1.2 though they didn't stay there long. Is that too big a drop, to go from 2 units to 1.2?
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I can't say for sure but I don't see why it should be. Too large an increase in dose is potentially more dangerous. ProZinc isn't a depot insulin although sometimes it can have slightly longer than 12 hour duration. You should see the effect of the dose decrease in a couple of days. We always worry about ketone development when BG runs higher so you might want to do urine ketone testing while you do this experiment.
 
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