15Feb2020/Maxi/PMPS208,246/+1(288)+2(310) /Lantus Question + Continued Concern

bambinaki

bambinaki

Member Since 2010
Last post: http://www.felinediabetes.com/FDMB/threads/13feb2020maxiamps272.225593/#post-2525825

Hello-

I've read not to even roll the Lantus pen to mix it. I worry that when I flick the syringe to get the air bubbles out, I'm doing the equivalent of shaking it. It seems I have to flick hard to get the bubbles out. Even then, it seems there are bubbles in the syringe. Are the bubbles dangerous? Do I have to flick them out? Is agitating the Lantus dangerous?

Also, Maxi's glucose has been very high for at least 3 weeks, he's up to 2.5 units, and the insulin still isn't even making a dent. I'm concerned about allowing his high glucose to continue to damage his body -- about not giving enough insulin to lower the glucose. I've asked about this before, but week after week of high glucose worries me. Please advise.

Thanks
 
I'm not experienced enough to give advice on dosing but looks like you are following TR and increasing his dose every 3 days. I'm sure you will get to a good dose for him soon.

On the air bubbles front, flicking them to get to the top does not spoil the insulin. At least that has not been my experience. They are not dangerous but if you have air bubbles in your syringe, you may be injecting less insulin than the measured dose. So please do flick them out. Draw a little more than you need so you have enough insulin left in your syringe after flicking the air bubbles out to meet your dose requirements.

Like everything else it is a matter of practice and gets easy with time.
 
Looks like you are beginning to see nadirs less than 300 so increases henceforth would be in multiple of 0.25 units and not 0.50 units.

"Increasing the dose:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
    • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
    • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
  • Increase by 0.25 unit after 3 days (6 consecutive cycles) if nadirs are greater than 200, but less than 300.
  • Increase by 0.5 unit after 3 days (6 consecutive cycles) if nadirs are greater than 300."
Hoping someone with more experience can look at your SS and guide you wrt dosing.
 
Bandit's Mom said:
Looks like you are beginning to see nadirs less than 300 so increases henceforth would be in multiple of 0.25 units and not 0.50 units.

"Increasing the dose:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
    • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
    • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
  • Increase by 0.25 unit after 3 days (6 consecutive cycles) if nadirs are greater than 200, but less than 300.
  • Increase by 0.5 unit after 3 days (6 consecutive cycles) if nadirs are greater than 300."
Hoping someone with more experience can look at your SS and guide you wrt dosing.
Click to expand...


Thank you, BM.
His last 2 of 3 nadirs were over 300.
 
When you draw up your dose, draw up a bit extra insulin. It's fine to flick the syringe to get the bubbles to the needle end. Turn the plunger to "dial in" your dose and at the same time push the bubbles out.

I'm also quite confused. Your spreadsheet says you are following SLGS whereas your signature says you're following TR. Could you please make this consistent so we know which dosing method you're using?

I'm going to assume you're following TR so please correct me if I'm wrong. At the 1.5u dose, you increased after 3 cycles. At the 1.5u dose, you increased after 7 cycles but you increased by 0.5u. With TR:
  • In general, unless nadirs are below 100 or you are starting to see nadirs under 200, you increase the dose after 3 days/6 cycles.
  • If the majority of nadirs are under 200, you increase by 0.25u. (You only increase by 0.5u if the majority of nadirs are over 300).
For 4 of the 7 cycles where you have data, the nadirs are in the 200s. You should have increased Maxi's dose by 0.25u.

One of the things that Lantus teaches is patience. Please don't try to rush the process, especially with TR. TR is an aggressive approach to dosing. If you increase after less than 6 cycles or increase by a larger amount than indicated, you can easily run into trouble.
 
Sienne and Gabby (GA) said:
When you draw up your dose, draw up a bit extra insulin. It's fine to flick the syringe to get the bubbles to the needle end. Turn the plunger to "dial in" your dose and at the same time push the bubbles out.

I'm also quite confused. Your spreadsheet says you are following SLGS whereas your signature says you're following TR. Could you please make this consistent so we know which dosing method you're using?

I'm going to assume you're following TR so please correct me if I'm wrong. At the 1.5u dose, you increased after 3 cycles. At the 1.5u dose, you increased after 7 cycles but you increased by 0.5u. With TR:
  • In general, unless nadirs are below 100 or you are starting to see nadirs under 200, you increase the dose after 3 days/6 cycles.
  • If the majority of nadirs are under 200, you increase by 0.25u. (You only increase by 0.5u if the majority of nadirs are over 300).
For 4 of the 7 cycles where you have data, the nadirs are in the 200s. You should have increased Maxi's dose by 0.25u.

One of the things that Lantus teaches is patience. Please don't try to rush the process, especially with TR. TR is an aggressive approach to dosing. If you increase after less than 6 cycles or increase by a larger amount than indicated, you can easily run into trouble.
Click to expand...

Thank you, Sienne.

The spreadsheet has been corrected to TR.

By 'trouble' do you mean hypoglycemia? Maxi has not come close to hypoglycemia, so I felt it was ok to increase as I have outlined below.
The 2 times I have increased dose before 6 cycles, I have increased by only .25 with 20 tests all in the 300s except 5 in the high 200s and one in the 400s.

I have not been able to test at +6 every cycle. Considering +5, +6, and +7 as nadirs, I have tested 18 nadirs. Of those 18 nadirs, all except 4 have been over 300. Of those 4 nadirs below 300, all were in the mid and high 200s (245, 253, 288, 295).

After 6 cycles at the 1 unit dose, with all numbers in the 300s (mostly high 300s) except one 292 and one 436, I increased by .5.
After 4 cycles at the 1.5 unit dose, with 3 of the 4 nadirs over 300, I increased by .25.
After 2 cycles at the 1.75 unit dose, with 3 of the 4 tests over 300 (the one below 300 was 289), I increased by .25.
After 8 cycles at the 2 unit dose, with of 10 of 18 tests over 300, one over 400, and 6 in the high 200s (the remaining one was 245), this morning I increased the dose by .5. Of all cycles at 2 units, the 4 nadirs measured were 295, 300, 245, and 308.
The one cycle (so far today) at the 2.5 unit dose was 305 at pre-shot, 253 at +6, 240 at +8, 215 at +10.

Any explanation as to why the +6, which is supposed to be the nadir (right?), is higher than +8 and +10?

I will hold steady (i.e., remain patient) at 2.5 units for 6 cycles.
 
Last edited:
Well, Maxi's PMPS is 208, his lowest number since diagnosis, and I'm scared to give him 2.5 units, but I also don't know if reducing is right.

Please advise ASAP!
 
bambinaki said:
Thank you, BM.
His last 2 of 3 nadirs were over 300.
Click to expand...


Not seeing Nadirs in the 300s during the day. Dosing is based on the lowest a dose takes a pet's BG. Some cats go lower at night, but they're are a few around who have lower nadirs during the day.
Cat's don't " always" experience their lowest BG at +6...that is just where the usual nadir occurs on a Lantus cycle. There is a sticky under the new to the group post that might be helpful- here- it explains a bit about nadirs, the typical lantus curve, and how some cats will experience higher numbers after an increase. So, a nadir is just the lowest number represented- not the +6 specifically. My cat's is usually +4 . but it has changed several times from +7, to +5 and sometimes after we hold a dose for awhile +8.

The only issue with increasing after 4 doses is that since Lantus is a depot insulin- it can take some time before the previous doses depot is drained and the numbers you are seeing are actually being influenced by the current dose on it's own... I think that is why they recommend 3-5 days before increasing (or 6-10 doses).
 
I would stall- not feed - and retest in 20 minutes. See if he is starting to come up or if he is trending downwards
 
"Not seeing Nadirs in the 300s during the day"

What about Feb 3-8 at +5? Or do you mean more recently?
 
Nice preshot! Do you have enough test strips, some high carb food if necessary? If yes....shoooooot! 2.5u and get a +1 and +2 test and see how we go. This is what you have been waiting for, I know it can be scary, but you can do this!
 
bambinaki said:
Well, Maxi's PMPS is 208, his lowest number since diagnosis, and I'm scared to give him 2.5 units, but I also don't know if reducing is right.

Please advise ASAP!
Click to expand...

I wouldn't shoot a 2.5 either way since we try to increase by 0.25- so that we don't drop BG's too quickly and so we don't move past the best dose. Smaller increases give you more information.
He looked like he has been heading downwards since that +8 today...do you have MC and HC food tonight if you need to feed him some carbs and continue to test after giving him insulin?
 
Si am cat mom said:
I wouldn't shoot a 2.5 either way since we try to increase by 0.25- so that we don't drop BG's too quickly and so we don't move past the best dose. Smaller increases give you more information.
He looked like he has been heading downwards since that +8 today...do you have MC and HC food tonight if you need to feed him some carbs and continue to test after giving him insulin?
Click to expand...


I don't know what MC and HC is, but I have high carb food.
 
if you shoot... I would shoot the 2.25 if you can manage that as the 1/2 unit increase might be too much- but that's up to you. If you are nervous to shoot 2.5 on number that are lower than what you are used to- a more appropriate dose might make it so that you can continue to shoot and not have to skip or reduce doses due to Preshot numbers.
 
Si am cat mom said:
if you shoot... I would shoot the 2.25 if you can manage that as the 1/2 unit increase might be too much- but that's up to you. If you are nervous to shoot 2.5 on number that are lower than what you are used to- a more appropriate dose might make it so that you can continue to shoot and not have to skip or reduce doses due to Preshot numbers.
Click to expand...

So, do you think it's ok to shoot 2.25 now, considering his numbers today?
 
Karen, your thread started with this...
bambinaki said:
Last post: http://www.felinediabetes.com/FDMB/threads/13feb2020maxiamps272.225593/#post-2525825

Also, Maxi's glucose has been very high for at least 3 weeks, he's up to 2.5 units, and the insulin still isn't even making a dent. I'm concerned about allowing his high glucose to continue to damage his body -- about not giving enough insulin to lower the glucose. I've asked about this before, but week after week of high glucose worries me. Please advise.

Thanks
Click to expand...
You need to feel comfortable, I don't hold the syringe, you do. But, this is a shootable number. As long as you are prepared to continue to monitor, and intervene if necessary, then I suggest you shoot 2.5u. I will stay with you. I wouldn't suggest you shoot and then abandon you, but it is your decision.
 
Christie & Maverick said:
Nice preshot! Do you have enough test strips, some high carb food if necessary? If yes....shoooooot! 2.5u and get a +1 and +2 test and see how we go. This is what you have been waiting for, I know it can be scary, but you can do this!
Click to expand...

Thanks, Christie. Yes, I have enough test strips and high carb food. But I am scared to give the 2.5. Do you support giving 2.25?
 
Christie & Maverick said:
Karen, your thread started with this...

You need to feel comfortable, I don't hold the syringe, you do. But, this is a shootable number. As long as you are prepared to continue to monitor, and intervene if necessary, then I suggest you shoot 2.5u. I will stay with you. I wouldn't suggest you shoot and then abandon you, but it is your decision.
Click to expand...

OH, just saw this after I wrote the other reply. Could you explain why you think I should shoot 2.5 instead of 2.25? **Thank you!**
 
Christie & Maverick said:
Karen, your thread started with this...

You need to feel comfortable, I don't hold the syringe, you do. But, this is a shootable number. As long as you are prepared to continue to monitor, and intervene if necessary, then I suggest you shoot 2.5u. I will stay with you. I wouldn't suggest you shoot and then abandon you, but it is your decision.
Click to expand...

Hey Christie :)
Maxi was at 2 units- after 1 day of 1.75- and then got in 1/2 unit increase to 2.5- that's why we are wondering if the 2.5 is appropriate or if the 2.25 would be better.
 
bambinaki said:
Thanks, Christie. Yes, I have enough test strips and high carb food. But I am scared to give the 2.5. Do you support giving 2.25?
Click to expand...
You would be disturbing the depot. You shot 2.5u last night and this morning...this is what TR is about...follow the numbers, and reduce only when you need to. Just my 2 cents, if this lower preshot is making you nervous, I have no problem with you shooting 2.25u. Again, you hold the syringe, just trying to explain my thought process...you'll still need to monitor tonight, either way.
 
Christie & Maverick said:
You would be disturbing the depot. You shot 2.5u last night and this morning...this is what TR is about...follow the numbers, and reduce only when you need to. Just my 2 cents, if this lower preshot is making you nervous, I have no problem with you shooting 2.25u. Again, you hold the syringe, just trying to explain my thought process...you'll still need to monitor tonight, either way.
Click to expand...

"Reduce only when you need to"
Isn't this an appropriate moment to reduce?
 
Christie & Maverick said:
You would be disturbing the depot. You shot 2.5u last night and this morning...this is what TR is about...follow the numbers, and reduce only when you need to. Just my 2 cents, if this lower preshot is making you nervous, I have no problem with you shooting 2.25u. Again, you hold the syringe, just trying to explain my thought process...you'll still need to monitor tonight, either way.
Click to expand...


(How [badly]) Am I disturbing the depot by shooting 2.25 after only 2 times dosing 2.5?
 
Si am cat mom said:
if you shoot... I would shoot the 2.25 if you can manage that as the 1/2 unit increase might be too much- but that's up to you. If you are nervous to shoot 2.5 on number that are lower than what you are used to- a more appropriate dose might make it so that you can continue to shoot and not have to skip or reduce doses due to Preshot numbers.
Click to expand...


"If you shoot..." Are you thinking I shouldn't shoot at all?
 
Si am cat mom said:
Hey Christie :)
Maxi was at 2 units- after 1 day of 1.75- and then got in 1/2 unit increase to 2.5- that's why we are wondering if the 2.5 is appropriate or if the 2.25 would be better.
Click to expand...
Sorry, just back in the SS....Oh I see. Thanks Ari...I'm not sure how I missed that jump. Arguably most nadirs weren't above 300 to warrant a jump to 2.5u. And the previous doses weren't held long enough...Hmm.. well at the moment, I guess it's a bit of a toss up. I suppose try 2.25u and keep monitoring with +1 and +2.
 
I just re-tested. It's 246. It was 208 at PMPS. He ate immediately after that. That was 45 minutes ago.
 
Well, I guess I will shoot 2.25 now. It's 30 minutes after his normal shot time. He ate 45 minutes ago.
OK?
 
You are safe to shoot this number (I know you have fed).
208 is also a shootable number.
Whether you shoot 2.25 or 2.5 you are going to have to monitor closely because of the depot influence.
I would stick with 2.5 as you have given 2 doses of that already. But you must feel comfortable with the decision. You hold the syringe and Maxi is your cat.
If you reduce to 2.25 you will need to stick to that for at least 6 cycles unless Maxi drops under 50.
Either way you need to get a +1 and +2 and go from there with testing as needed
 
Bron and Sheba (GA) said:
You are safe to shoot this number (I know you have fed).
208 is also a shootable number.
Whether you shoot 2.25 or 2.5 you are going to have to monitor closely because of the depot influence.
I would stick with 2.5 as you have given 2 doses of that already. But you must feel comfortable with the decision. You hold the syringe and Maxi is your cat.
If you reduce to 2.25 you will need to stick to that for at least 6 cycles unless Maxi drops under 50.
Either way you need to get a +1 and +2 and go from there with testing as needed
Click to expand...

Oh crap, I already shot before I got your suggestion, Bron.
 
So, I will stick with 2.25 units for 6 more cycles (so he'll be at 2.25 for a total of 7 cycles before I see about increasing to 2.5).
 
bambinaki said:
Oh crap, I already shot before I got your suggestion, Bron.
Click to expand...
That’s ok.
You will need to stick with that dose now though for at least 6 cycles as Lantus likes consistency.
Yes get a +1 and +2 every time you shoot a lower than normal number as it will give you a heads up if the numbers are going to drop.
As you increase the dose, you will need to drop your ‘no shoot number’ and this will get easier as you get more confidence and get used to lower numbers. Blue and green numbers are your friend and Maxi’s too.
 
Hi Karen,
Remember to update your thread title with your test numbers. That will help people who are watching you get a quick look at Maxi's numbers.

Also I noticed in your avatar that you joined on Jan. 22, 2010?? Is that correct?
 
bambinaki said:
So, I will stick with 2.25 units for 6 more cycles (so he'll be at 2.25 for a total of 7 cycles before I see about increasing to 2.5).
Click to expand...

Karen, since you have shot 2.5 tonight and you already shot 2.5 for 2 cycles previously, Bron is suggesting that you continue on 2.5 for another 3 cycles - so a total of 6 cycles on 2.5. If Maxi falls below 50, then you reduce to 2.25 immediately. If not, you complete 6 cycles at 2.5.
 
Don’t forget to keep the spreadsheet updated. Also that you shot late. Your +12 is 208, PMPS is at 12.75 if it's 45 minutes past the regular time. Tomorrow morning’s shot will also be delayed. You can get back on schedule by shooting 15 minutes earlier every cycle, or 1/2 hour once per day.
 
Bandit's Mom said:
Karen, since you have shot 2.5 tonight and you already shot 2.5 for 2 cycles previously, Bron is suggesting that you continue on 2.5 for another 3 cycles - so a total of 6 cycles on 2.5. If Maxi falls below 50, then you reduce to 2.25 immediately. If not, you complete 6 cycles at 2.5.
Click to expand...

I shot 2.25 before I saw Bron's post advising 2.5. And I understand her to mean that now I should stick with 2.25 for at least 6 cycles. No?
 
bambinaki said:
I shot 2.25 before I saw Bron's post advising 2.5. And I understand her to mean that now I should stick with 2.25 for at least 6 cycles. No?
Click to expand...

Yes :)

lots of confusion, sorry. Whatever you shot tonight, so the 2.25- hold for 6 doses/cycles so we can see what this is doing before moving up again. Unless you get a BG below (50) - the you would immediately take the reduction and start counting the cycles again for that dose.
 
Wendy&Neko said:
Don’t forget to keep the spreadsheet updated. Also that you shot late. Your +12 is 208, PMPS is at 12.75 if it's 45 minutes past the regular time. Tomorrow morning’s shot will also be delayed. You can get back on schedule by shooting 15 minutes earlier every cycle, or 1/2 hour once per day.
Click to expand...

His shot was 30 minutes late. I tested him at 9:10pm. He ate from 9:15 to 9:30. 9:30 is his usual shot time. I ended up shooting at 10:00.
I was advised recently that within 30 minutes of normal time is ok/not late. Do you disagree?
 
Si am cat mom said:
Yes :)

lots of confusion, sorry. Whatever you shot tonight, so the 2.25- hold for 6 doses/cycles so we can see what this is doing before moving up again. Unless you get a BG below (50) - the you would immediately take the reduction and start counting the cycles again for that dose.
Click to expand...

OK, thanks Si am!
 
bambinaki said:
His shot was 30 minutes late. I tested him at 9:10pm. He ate from 9:15 to 9:30. 9:30 is his usual shot time. I ended up shooting at 10:00.
I was advised recently that within 30 minutes of normal time is ok/not late. Do you disagree?
Click to expand...
My mistake. I saw you say you fed 45 minutes ago. The routine is test (to make sure it’s safe to shoot), then feed, then shoot. All wishing about 10 minutes, so I assumed 45 minutes for the shot. Shooting at 9:30:tomorrow is fine.
 
Judy and Freckles said:
Hi Karen,
Remember to update your thread title with your test numbers. That will help people who are watching you get a quick look at Maxi's numbers.

Also I noticed in your avatar that you joined on Jan. 22, 2010?? Is that correct?
Click to expand...

I posted a few times in 2010 about my cat Billy. I've since forgotten everything. At that time, I was in close contact with Dr. Lisa Pierson, who guided me until Billy quickly went into remission.
 
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