(Almost) new member, confused about BG values referenced in FDMB

[SRB]

Hi all,

Boots was diagnosed about a month ago by his internist, and we have him on 1 unit of Lantus 2x/day. I haven't been home testing, but I just got my first good poke the other day, before his 9pm dinner, which read 119 on the AlphaTrak. After reading too much from too many different people, I'm confused about whether that value would be considered too low for insulin. (He was fine.)

For context, here are Boots's curve numbers from the internist after his first almost 3 weeks on Lantus. This is after a small 9am meal and insulin with no snacks, and being freaked out at the vet place:

• 9:40am - 326mg/dL
• 11:40am - 287mg/dL
• 1:40pm - 118mg/dL
• 3:40pm - 161mg/dL

The doctor was not concerned about Boots's dose and just told me to come back in a month. I have been watching the facebook group and reading some of the sticky posts and articles here. Now I am VERY CONFUSED about the numbers considered regulated, remission, high, etc because it seems like everyone is using human meters not calibrated for cats, and then there are metric people vs imperial... I don't want to overdose my cat if his numbers are coming down from gradual changes in diet and meds.

I'm using an AlphaTrak2 so that I can get accurate numbers (for a cat) and work together with my internist. Can someone help me understand the range of low/normal/high in ALPHA TRAK NUMBERS please? And perhaps specific advice for when to hold off or reduce a dose of Lantus? I'd need a phD in posting a subject line in the Lantus forum, and I just can't deal with any more right now. Thank you for understanding.

Sabrina

 

[Sienne and Gabby (GA)]

Welcome Sabrina!!

You are correct -- it's confusing. I'll do my best to clarify.

The first bit of confusion is likely because there are a lot of people here who do not use an AlphaTrack meter due to the cost of the strips. Rather, many opt for using a human meter -- the strips are MUCH less expensive. There isn't a number for number way to convert the numbers between a human meter and an AT. For example, if you follow the Tight Regulation Protocol for Lantus dosing, a cat's dose gets reduced if numbers drop below 50 on a human meter and below 68 on an AT. And that's where the equivalence between the meters stops. The spread between the two meters gets larger as numbers increase. We've had a couple of members attempt to do a correlation between the meters and they gave up. The meters are calibrated differently and maybe if we had a mathematician and a cooperative group of cats we might be able to figure it out. But, so far, no luck and a lot of aggravation for those who tried.

If you use our spreadsheet, a lot of the frustration will be made less so. We have the spreadsheet color coded. Numbers that are green are below 100 (or a little higher on an AT). These are normal range. (Normal on a human meter is 50 - 120). Numbers in the 200s aren't bad. You want to try to get your cat in numbers that are below renal threshold (under about 220 although this varies for each cat). High numbers would be over 300. Again, these are numbers on a human meter. You bump up the numbers a bit for an AT.

The Lantus forum can be a bit daunting. The difference in the subject lines is because it's a big and busy forum. For those of. us who look at a lot of posts, being able to scan the board and see the test results for a cat is a way to identify if someone needs help (especially if they don't recognize they need help). Having been on both sides and being one of those people who looks at everyone's spreadsheet, I like being able to scan to look for trouble spots. People will gladly help you get situated if you want to post there. That said, you'll want to get a spreadsheet set up no matter where you post This link has information on helping us to help you has information on setting up your spreadsheet and signature.

 

[Critter Mom]

Hi Sabrina,

After 03:30 in the UK so please excuse the brevity of this post. I just want to give you some basic info:

For Alphatrak:

Normal Feline BG Reference Range: 3.9-8.3 mmol/L | 70-150 mg/dL (Range provided to me by my vet for use with my Alphatrak. Note that FDMB uses 3.8 | 68 as the lower bound of this range.)

Renal Threshold: 14-16 mmol/L | c. 250-290 mg/dL (Range from online Merck Veterinary Manual - actual renal threshold varies from cat to cat but is statistically most likely to fall within this range.)

A cat is considered regulated if it spends the vast majority of the time below the renal threshold and high enough above the lower bound of the normal BG range to avoid hypoglycaemia.

A cat is considered tightly regulated if it runs the vast majority of the time in the normal feline reference range. Adequate home BG monitoring is needed to minimise risk of hypoglycaemia.

A cat is considered to be in remission if it's BG levels remain in the normal feline reference range (preferably mostly in the lower part of the range) without needing insulin.

The FDMB 'no shoot' threshold for cats with very little data is 200mg/dL* (11.1mmol/L) on a human meter. You might want to consider setting a slightly higher 'no shoot' threshold for the Alphatrak (they read higher than human meters). I'd suggest discussing this with your vet. After you've gathered enough data on how Boots responds to his Lantus you will be able to gradually lower his 'no shoot' limit (will help him stay in a better range for longer, but must not be attempted until a kitty is 'data ready').


Mogs

(* NB: For kitties with a history of ketosis/DKA, special consideration needs to be given to dosing when preshot BG is lower than normal. It's not desirable to skip doses for ketone-prone cats, so token doses are considered when preshot BG is lower than what would be considered a 'no shoot' situation for a kitty without any history of ketone complications.)

.

 

[SRB]

Thank you.

I will check the spreadsheet, but first, if I can ask a clarification. Would most people consider it dangerous to give a dose of insulin to a cat that tested below, for example, 150 before feeding time? This is the number I'm looking for, as my cat has tested lower than this, and I'm giving him insulin.

What set me off on this is people on the FDMB *facebook group* this morning flipping out about giving a cat insulin who tested 150, and when I asked about it, someone else said they would never give a shot to a cat who tested under 200. As I said, Boots tested 119 last time I tested him before a meal, so now I'm very worried that I shouldn't be giving him his shots.

I've just spent the last hour or more trying to reconcile the conflicting numbers I've seen in articles linked from this site about the bottom of "normal" for a diabetic cat on insulin, but the information is so overwhelming that I can't even retrace my steps to the sources. I swear I just saw this again, which I may be paraphrasing from my personal notes:

"Normal blood glucose levels for the average cat are between 70 - 100 mg/dL before a meal, and remain below 150 mg/dL after eating. An insulin-dependent cat's optimal range would be thirty or so points higher overall, for safety. Goal: 100-130 before food, below 180 after food"

That doesn't seem to match what you're telling me or what's in the FAQ. Should I be concerned?

Welcome Sabrina!!

You are correct -- it's confusing. I'll do my best to clarify.

The first bit of confusion is likely because there are a lot of people here who do not use an AlphaTrack meter due to the cost of the strips. Rather, many opt for using a human meter -- the strips are MUCH less expensive. There isn't a number for number way to convert the numbers between a human meter and an AT. For example, if you follow the Tight Regulation Protocol for Lantus dosing, a cat's dose gets reduced if numbers drop below 50 on a human meter and below 68 on an AT. And that's where the equivalence between the meters stops. The spread between the two meters gets larger as numbers increase. We've had a couple of members attempt to do a correlation between the meters and they gave up. The meters are calibrated differently and maybe if we had a mathematician and a cooperative group of cats we might be able to figure it out. But, so far, no luck and a lot of aggravation for those who tried.

If you use our spreadsheet, a lot of the frustration will be made less so. We have the spreadsheet color coded. Numbers that are green are below 100 (or a little higher on an AT). These are normal range. (Normal on a human meter is 50 - 120). Numbers in the 200s aren't bad. You want to try to get your cat in numbers that are below renal threshold (under about 220 although this varies for each cat). High numbers would be over 300. Again, these are numbers on a human meter. You bump up the numbers a bit for an AT.

The Lantus forum can be a bit daunting. The difference in the subject lines is because it's a big and busy forum. For those of. us who look at a lot of posts, being able to scan the board and see the test results for a cat is a way to identify if someone needs help (especially if they don't recognize they need help). Having been on both sides and being one of those people who looks at everyone's spreadsheet, I like being able to scan to look for trouble spots. People will gladly help you get situated if you want to post there. That said, you'll want to get a spreadsheet set up no matter where you post This link has information on helping us to help you has information on setting up your spreadsheet and signature.

 

[Bandit's Mom]

Hi Sabrina

We have 2 dosing protocols here - Tight Regulation (TR) and Start Low Go Slow (SLGS).
https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/

With TR, one can shoot any number over 50 and with SLGS any number over 90. The caveat is that the caregiver is monitoring the cat's BG to keep it safe. The confidence to shoot lower numbers comes with experience and after one has enough data on how the kitty responds to the insulin - when is the onset and nadir, how low is the cat going on the dose, etc.

It is dangerous to give a cat insulin without knowing how low the cat goes on the dose and monitoring. I have had instances were Bandit's pre-shot are near 300 and she dips below 50 in that cycle.

If you set up the spreadsheet and start collecting and recording testing data we would be able to help you with dosing and when to shoot or not. If you need any help setting up the SS, please let me know. Won't take me more than a minute to do so.

Welcome to FDMB
Bhooma

 

[Bron and Sheba (GA)]

Here on the main forum, if you are new and have no or little data, we say if you get a BG under 200 (on the human meter) and higher on the alphatrak...... don’t feed, stall and test again in 20 minutes to see if the BG is rising. And post and ask for assistance in what to do. We suggest this because we have no data to see how your kitty reacts to the insulin.

Once you have plenty of data, you can start to reduce your no shoot number safely..

 

[Chris & China (GA)]

when I asked about it, someone else said they would never give a shot to a cat who tested under 200.

There are some people in the group that never grasp the idea of "If you home test, you can safely shoot lower Pre-shot numbers". A lot of it comes from people who trust their vet implicitly. The "no shot under 200" is also repeated so many times that a lot of people think it's a hard and fast rule.

At first, we usually say if you get a PS under 200, stall, don't feed and test again in 20-30 minutes. You want to see the number coming up so you know the last shot is wearing off.
It's all about gathering data at first. Our main concern is keeping your kitty safe. High numbers take a long time to do damage. Low ones can kill quickly.

As you gather more test data and start to understand how the insulin works in YOUR cat, that "stall point" starts to come down and you gradually learn to shoot lower and lower numbers.

I wish I had seen your post this morning in the group and could have explained better....not only for you, but for all those people who are still screaming "No shot under 200"!

 

[SRB]

Thank you, this is starting to make sense now.

I don't have a lot of data, but what I have so far follows a smooth pattern and he seems well regulated. His diabetes is steroid-induced and I'm hoping to get him into remission. I understand now that it's more about how low his numbers might dip during the nadir than a magic number at shot time. His numbers at shot time are probably not as high as some cats.

There are some people in the group that never grasp the idea of "If you home test, you can safely shoot lower Pre-shot numbers". A lot of it comes from people who trust their vet implicitly. The "no shot under 200" is also repeated so many times that a lot of people think it's a hard and fast rule.

At first, we usually say if you get a PS under 200, stall, don't feed and test again in 20-30 minutes. You want to see the number coming up so you know the last shot is wearing off.
It's all about gathering data at first. Our main concern is keeping your kitty safe. High numbers take a long time to do damage. Low ones can kill quickly.

As you gather more test data and start to understand how the insulin works in YOUR cat, that "stall point" starts to come down and you gradually learn to shoot lower and lower numbers.

I wish I had seen your post this morning in the group and could have explained better....not only for you, but for all those people who are still screaming "No shot under 200"!

 

[Sienne and Gabby (GA)]

The FB group has a lot of people who do not use a depot insulin (e.g., Lantus, Basaglar, or Levemir). These types of insulin are very different than Vetsulin/Caninsulin or NPH/Novolin which are faster acting and have a shorter duration. Because those insulins can drop numbers hard and fast, there's more of an issue of where your pre-shot number needs to be and you must have fed your cat at least 30 min prior to shot time. The other issue is that people are not supposed to be giving dosing advice on the FB group since there's no easy access to a spreadsheet and there's no easy way to go back and review any history about your cat.

The depot insulins work differently. They are gentler. The basic "mantra" with them is "shoot low to stay low." For those of us who follow Tight Regulation, you work your way down to shooting numbers that are above 50. If you are new to feline diabetes and planning on following TR, you post and ask for help if the pre-shot number is below 150 (or 200 with Start Low Go Slow). If you look at Gabby's spreadsheet or Chris' China's spreadsheet you'll see what I mean by shooting low. (And don't freak -- I was a testaholic.)

I also suspect the people who were telling to to not shoot if numbers are under 200 do not appreciate that with a depot insulin, any time you skip a shot or change a dose it has an effect on the depot. With Lantus, you are holding your dose for at least 3 days (that's with TR -- with SLGS it's a week). If you skip, the shot count starts over since any change in dose destabilizes the depot. It takes a few days for the depot to stabilize again. The folks that are yelling about not shooting are likely using insulin that doesn't rely on a depot and skipping or shooting a reduced dose doesn't have the same effect.

(Sorry -- this is probably more information than you wanted. I hope it's helpful and not overwhelming.)

 

[Tomlin]

I wanted to say hello and welcome .....and I really hope to see you over in the Lantus forum !
No PhD required (unless we change it to mean People Helping with Diabetes )...but instead, just a desire to get a cat into remission or if that doesn’t happen, achieve regulation & of course, continued health and happiness for your cat !!

People will be more than happy to help you get set up (spreadsheet) & to continue to explain/answer questions as you continue on the journey. It is really not as overwhelming as it appears upon first glance....promise. Instead, there is really helpful dosing advice specific to Lantus which is very important, especially early on in diagnosis when you are trying for remission. A team approach—which the subject lines help with .

As you may or may not know, cats who are on a steroid and it is discontinued typically have an increased probability of remission .....exciting & promising for you (and everyone here!).

Again...welcome

 

[SRB]

The FB group has a lot of people who do not use a depot insulin (e.g., Lantus, Basaglar, or Levemir). These types of insulin are very different than Vetsulin/Caninsulin or NPH/Novolin which are faster acting and have a shorter duration. Because those insulins can drop numbers hard and fast, there's more of an issue of where your pre-shot number needs to be and you must have fed your cat at least 30 min prior to shot time. The other issue is that people are not supposed to be giving dosing advice on the FB group since there's no easy access to a spreadsheet and there's no easy way to go back and review any history about your cat.

The depot insulins work differently. They are gentler. The basic "mantra" with them is "shoot low to stay low." For those of us who follow Tight Regulation, you work your way down to shooting numbers that are above 50. If you are new to feline diabetes and planning on following TR, you post and ask for help if the pre-shot number is below 150 (or 200 with Start Low Go Slow). If you look at Gabby's spreadsheet or Chris' China's spreadsheet you'll see what I mean by shooting low. (And don't freak -- I was a testaholic.)

I also suspect the people who were telling to to not shoot if numbers are under 200 do not appreciate that with a depot insulin, any time you skip a shot or change a dose it has an effect on the depot. With Lantus, you are holding your dose for at least 3 days (that's with TR -- with SLGS it's a week). If you skip, the shot count starts over since any change in dose destabilizes the depot. It takes a few days for the depot to stabilize again. The folks that are yelling about not shooting are likely using insulin that doesn't rely on a depot and skipping or shooting a reduced dose doesn't have the same effect.

(Sorry -- this is probably more information than you wanted. I hope it's helpful and not overwhelming.)

Thank you, it was helpful, as I'm learning more about how Lantus works. And it's good to know the consequences of skipping a dose. I've unfollowed the fb group and will try to avoid getting worked up about things that don't apply to my situation.

 

[SRB]

I wanted to say hello and welcome .....and I really hope to see you over in the Lantus forum !
No PhD required (unless we change it to mean People Helping with Diabetes )...but instead, just a desire to get a cat into remission or if that doesn’t happen, achieve regulation & of course, continued health and happiness for your cat !!

People will be more than happy to help you get set up (spreadsheet) & to continue to explain/answer questions as you continue on the journey. It is really not as overwhelming as it appears upon first glance....promise. Instead, there is really helpful dosing advice specific to Lantus which is very important, especially early on in diagnosis when you are trying for remission. A team approach—which the subject lines help with .

As you may or may not know, cats who are on a steroid and it is discontinued typically have an increased probability of remission .....exciting & promising for you (and everyone here!).

Again...welcome

Thank you, Tomlin. It looks like you also have a pancreatitis kitty. Boots has GI enteropathy and low level chronic pancreatitis; his flares seem to be triggered by food in general, so he's on hydrolyzed protein and almost no pred these days. Thank goodness I found Young Again, we are trying that diet and hopefully will remain flare free and low carb through all this.

"People helping with diabetes"

 

[Tomlin]

Thank you, Tomlin. It looks like you also have a pancreatitis kitty. Boots has GI enteropathy and low level chronic pancreatitis; his flares seem to be triggered by food in general, so he's on hydrolyzed protein and almost no pred these days. Thank goodness I found Young Again, we are trying that diet and hopefully will remain flare free and low carb through all this.

"People helping with diabetes"

I do ! Wishing you continued success & flare free days with the diet change!! Keep the faith. It sounds like you have figured out the issue & there are a lot of cats that do really well when it is low level and you find the dietary issue causing the inflammatory response.

We are now a little over 5.5 years managing Ts chronic pancreatitis...knock on wood...he does really well! It is outstanding that you found the GI to be the underlying issue for the pancreatitis & found a diet that helps. We ended up sticking with an immunosuppressive route after many failed novel protein trials in & the initial year of on & off issues with med discontinuation trials & diagnostics. After multiple consults with pancreatitis specialists out of TAMU & other Us to troubleshoot his case, it was decided that there was a strong immune component with Ts disease unrelated to food/GI alone. They have found some cases of autoimmune pancreatitis in felines like they have found in humans. This is what is highly suspected with T. We are lucky that his DM is actually under better control with the Prednisolone than without it as that is not always the case for some cats & it is the first line immunotherapy drug for his issue . We got lucky.

I still made changes with his diet as per recommendations and added a few probiotics to try to help with his GI health....especially given the added DM diagnosis in 2019 & the knowledge that there are metabolic issues with cats with DM . Other than the Pred, he does not need supportive meds & again, knock on wood....absolutely no flares or symptoms ! Can we knock on wood again please ?!

Come on over to the Lantus forum to the PhDs .....when you are ready of course! In the meantime, welcome and happy to meet you!!—Amy & T

 

[Sienne and Gabby (GA)]

If you're feeding your cat Young Again, for the purposes of dosing, that particular food is considered a dry cat food. The Tight Regulation Protocol stipulates that to use that dosing method, your cat needs to be on a canned food diet exclusively. Both approaches to dosing work. It simply means you don't have to worry over a choice -- you'll want to use the Start Low Go Slow method.

 

[Tomlin]

If you're feeding your cat Young Again, for the purposes of dosing, that particular food is considered a dry cat food.

Good catch! Any chance she is using Young Again Premix for a raw diet vs their dry food? I didn’t think to clarify or confirm that with her.......

 

[JanetNJ]

I'm glad he seems to be doi.g a little better, but I agree, funding a new vet might be a good idea. Try askinhg for recommendations on your town or county's Facebook group.

 

[SRB]

If you're feeding your cat Young Again, for the purposes of dosing, that particular food is considered a dry cat food. The Tight Regulation Protocol stipulates that to use that dosing method, your cat needs to be on a canned food diet exclusively. Both approaches to dosing work. It simply means you don't have to worry over a choice -- you'll want to use the Start Low Go Slow method.

I'm not doing any method, I'm just doing what my internist tells me, and so far letting him handle the curves, while learning to home test. Currently, Boots is on half of his high carb Hills Z/D and half Young Again LID Zero Mature. I'm not going to switch him entirely until his next curve. I'm not going to adjust his insulin dose without input from the internist. He knows how to deal with steroid cats and I trust him for the most part.

 

[SRB]

I'm not doing any method, I'm just doing what my internist tells me, and so far letting him handle the curves, while learning to home test. Currently, Boots is on half of his high carb Hills Z/D and half Young Again LID Zero Mature. I'm not going to switch him entirely until his next curve. I'm not going to adjust his insulin dose without input from the internist. He knows how to deal with steroid cats and I trust him for the most part.

And for context, he put Boots on one unit of Lantus 2x a day, obviously before I knew about any of this stuff! I don't expect to go up in dose at all, but I do hope to go down soon...