Charlie very sleepy/ a bit wobbly after hypoglycemia episode

[Macey]

I'm not sure if it will work to link my last post, but:

https://www.felinediabetes.com/FDMB/threads/charlie-first-hypo-episode.285198/

As you can see from Charlie's spreadsheet, after low numbers earlier tonight (he seems to be very sensitive to lower BG), his BG has been rising steadily until his last reading @+4.75 (8.8 mmol/L), which is still a good number obviously, but he slept for the past 2ish hours quite soundly. He finally got up when he heard me making food just now, and his back end wobbled once, which is the symptom he had with his last hypo episode. It could just be that he had just woken up and was a bit clumsy... He seems to be moving a little slower than usual? Or maybe I'm just being paranoid. He seems mostly fine. Is there any complications I need to worry about at this point? Is the sleepiness normal behaviour in this scenario? I will bring him to emergency vet if necessary but as an anxious/ADHD person, my worries are often out of proportion, so I'm hoping to get some outside perspectives.

Thanks,

Macey

 

[Basic's Mom]

Intro post
https://felinediabetes.com/FDMB/threads/macey-and-charlie-new-here-food-advice.284580/#post-3132582

Hi, Macey.

I'm unable to see a 2023 spreadsheet and there are some errors on the 2024 spreadsheet in the cells instead of bgs. Where the errors are showing up, try to make sure you didn't change the format of the info you are entering. Ex: 140, +2.5 is the order the cell is looking for, not +2.5 140. This is just an example.

I'm unable to see any hypo numbers on the bgs I can see foe 2024. That doesn't mean he didn't have any, I just don't see them.

I can't try to help you fix them if you want. Just let me know.

I an not familiar with the units you are measuring the bg with. It doesn't make sense for me to ask you the questions I would normally ask. If his BG is below 50, are you apply honey or corn syrup to the gums? It seems from your message he is in a safe range currently. If that is the case, no need for the sweets on the gums.

I'm going to tag some people for you.
@Wendy&Neko @Sienne and Gabby (GA) @Marje and Gracie @Christie & Maverick @Bandit's Mom
@Chris & China (GA) @Suzanne & Darcy

 

[Macey]

What is his current bg?

I just took now after he ate 1/2 -3/4 of a can of fancy feast about an hour ago and it’s 5.2 mmol (94 mg/dl). It wasI don’t know if my spreadsheet is converting properly. It was 137 mg/dl at the same time i gave him the food… it doesn’t make sense that it’s going down. I’m about to test him again and if still falling im bringing him in.

 

[Basic's Mom]

I see the problem. It is converting just fine. Remove the at symbol or @ and the equal symbol = from the bg cells on the world tab. It is what is causing the error. They are on 1/1 and 2/1 in the PM cycles. They all need removed. Your 1/1 pm bgs read like this:
+1.5 = 4 5.2 @2.5 = 4.8 @+3.5 = 4.8 @+5.25
Remove the pink highlighted symbol from your world tab and it will correct the errors on the US tab. Only have the numbers, a (+) symbol and a decimal point (.) Otherwise you will cause errors on the US tab.

Those numbers aren't dangerous levels. I'm not sure I understand. I can't see the other numbers that caused the previoud 2 events either. If you feel he needs to go to the ER, than by all means go. I wouldn't want to advise you otherwise. I just know with the numbers I can see and the ones you converted above for me aren't hypo numbers. While all cats are different, I've never read of a cat going hypo from these figures either.

 

[Basic's Mom]

Here is a link regarding hypo situations.

https://felinediabetes.com/FDMB/threads/how-to-treat-hypos-they-can-kill-print-this-out.15887/

Is Charlie on any meds that would cause his balance to be off?

I appreciate you be overly concerned too. It is to be expected with all they go through.

His bg is going down most likely because this is the onset of his insulin. You want it going down, just in safe ranges. The bgs you have listed are safe.

Can you check again and let's see if it is coming up some? If it isn't, maybe give a little more food. The last level you gave me was 94. While safe, I understand it is nerve wracking to see low numbers. I also understand because of 2 previous hypo events if you want to give him higher % carb food than you normally give.

 

[Wendy&Neko]

Sybil, Macey is using the AT3, you don't want him to get below 68 (not 50). And since Charlie is being fed some KD, which is high carb food, that means following SLGS for dosing. That 3.8 (68) tonight means his dose is too high still. His dose tomorrow should be 1.5 units.

On the spreadsheet, did you skip his dose last night? There is no number in the Units column for last night. If you did skip (makes sense given how low he was and how new you are), please put "skip" in the units column so we know it was a deliberate skip instead of just forgetting to enter the value.

This morning, was there a preshot test? All I see is the dose for this morning until the AM+11 test. Preshot tests should be at +12, just before the shot, not an hour before the shot.

Cats do sleep a lot, I wouldn't worry about that. Stumbling is a different story.

 

[Macey]

Intro post
https://felinediabetes.com/FDMB/threads/macey-and-charlie-new-here-food-advice.284580/#post-3132582

Hi, Macey.

I'm unable to see a 2023 spreadsheet and there are some errors on the 2024 spreadsheet in the cells instead of bgs. Where the errors are showing up, try to make sure you didn't change the format of the info you are entering. Ex: 140, +2.5 is the order the cell is looking for, not +2.5 140. This is just an example.

I'm unable to see any hypo numbers on the bgs I can see foe 2024. That doesn't mean he didn't have any, I just don't see them.

I can't try to help you fix them if you want. Just let me know.

I an not familiar with the units you are measuring the bg with. It doesn't make sense for me to ask you the questions I would normally ask. If his BG is below 50, are you apply honey or corn syrup to the gums? It seems from your message he is in a safe range currently. If that is the case, no need for the sweets on the gums.

I'm going to tag some people for you.
@Wendy&Neko @Sienne and Gabby (GA) @Marje and Gracie @Christie & Maverick @Bandit's Mom
@Chris & China (GA) @Suzanne & Darcy

I see the problem. It is converting just fine. Remove the at symbol or @ and the equal symbol = from the bg cells on the world tab. It is what is causing the error. They are on 1/1 and 2/1 in the PM cycles. They all need removed. Your 1/1 pm bgs read like this:
+1.5 = 4 5.2 @2.5 = 4.8 @+3.5 = 4.8 @+5.25
Remove the pink highlighted symbol from your world tab and it will correct the errors on the US tab. Only have the numbers, a (+) symbol and a decimal point (.) Otherwise you will cause errors on the US tab.

Those numbers aren't dangerous levels. I'm not sure I understand. I can't see the other numbers that caused the previoud 2 events either. If you feel he needs to go to the ER, than by all means go. I wouldn't want to advise you otherwise. I just know with the numbers I can see and the ones you converted above for me aren't hypo numbers. While all cats are different, I've never read of a cat going hypo from these figures either.

Does it look right now? I added some more values and I think I fixed the formatting. I know they're not dangerous levels on paper, but on monday, when his bg was 72.07, he was having pretty obvious hypo symptoms; he couldn't walk straight and his back end kept falling over. So when his sugar was even lower than that yesterday, I knew it wasn't good. So I guess he's just extra sensitive. Maybe because of his CKD? This is why I would be more comfortable with numbers closer to the middle/top of the healthy range, in case he just doesn't eat as much one day or something. It's just me and him at home, so there isn't somebody always watching him and I worry myself sick while I'm out. I'll be staying home from school today to keep an eye on him.

I did end up bringing him to the ER because he just wasn't acting like himself; was hard to rouse whereas he usually wakes up immediately if you touch him lightly. Plus, I didn't understand how his numbers were continuing to decline when the food should have had plenty of time to get into his system. The vet wasn't particularly concerned, and said we *could* put him on an IV and monitor him for the next 4-6 hours, but he said it with that underlying tone of "...but it's unnecessy". He said he's confident in my attentiveness and monitoring that he should be fine at home, and I can come back if necessary. The vet stresses him out so much, especially this one, for whatever reason, so I wasn't going to put him through that. Poor babe just buried his face in me as hard as he could.

Anyway, he ate a little right when we got home and more just now, and is acting much more like himself. I'm skipping his next dose to be extra safe; I'd rather his sugar be too high than too low, and then I'll increase VERY slowly. Would starting at 1 unit be overkill?

Macey

 

[Macey]

Here is a link regarding hypo situations.

https://felinediabetes.com/FDMB/threads/how-to-treat-hypos-they-can-kill-print-this-out.15887/

Is Charlie on any meds that would cause his balance to be off?

I appreciate you be overly concerned too. It is to be expected with all they go through.

His bg is going down most likely because this is the onset of his insulin. You want it going down, just in safe ranges. The bgs you have listed are safe.

Can you check again and let's see if it is coming up some? If it isn't, maybe give a little more food. The last level you gave me was 94. While safe, I understand it is nerve wracking to see low numbers. I also understand because of 2 previous hypo events if you want to give him higher % carb food than you normally give.

He is on a small daily dose of gabapentin for nerve pain, but shouldn't be a sedative dose. It his harder to metabolize with CKD, but I've already accounted for that. I can't find anything online, but I feel like it might accumulate regardless due to the CKD and eventually get to a slightly sedative level. I think I will skip his dose of gaba as well as his next insulin dose, to let it fully clear his system. I don't want him to be in pain, but I don't want it disguising any symptoms, plus if he's just eating wet food, his mouth should be ok I would imagine.

Since Lantus is an extended release insulin, does it still have a peak? Should it start clearing his body when the next dose is skipped? He's due in about 1.5 hours, so it would help me sleep if I knew that was the case. How often do you think I should wake up to check?

 

[Macey]

Sybil, Macey is using the AT3, you don't want him to get below 68 (not 50). And since Charlie is being fed some KD, which is high carb food, that means following SLGS for dosing. That 3.8 (68) tonight means his dose is too high still. His dose tomorrow should be 1.5 units.

On the spreadsheet, did you skip his dose last night? There is no number in the Units column for last night. If you did skip (makes sense given how low he was and how new you are), please put "skip" in the units column so we know it was a deliberate skip instead of just forgetting to enter the value.

This morning, was there a preshot test? All I see is the dose for this morning until the AM+11 test. Preshot tests should be at +12, just before the shot, not an hour before the shot.

Cats do sleep a lot, I wouldn't worry about that. Stumbling is a different story.

No, I didn't skip his shot last night. Just an oversight - it's fixed now. I am skipping this coming shot though. There wasn't a preshot test because I thought with him going back to his regular dose that he's been on for weeks, he'd be totally fine. I will definitely be testing before every shot now though.

 

[Basic's Mom]

No, the world spreadsheet still isn't liking the way you are entering the numbers. All numbers you have that include the (+) symbol are not converting. I'll tag someone that may know the proper way to enter your +1.5 (example) into the world tab. @Bandit's Mom can you please explain how the + numbers should be entered into the spreadsheet so they don't cause an value error on the US sheet? Thank you. *updated to add. I did look at a couple other world spreadsheets and anytime anything else was entered other than numbers, it populated the error on the US spreadsheet. Maybe hold off on using any symbols in the world ss cells. Add your + times in your notes maybe.

I am sorry that I didn't realize you were using a pet meter. Your low in 68, no matter what. It is NOT 50 as I originally stated.

I'm sorry you went to the ER, but thankful Charlie is okay. We all worry sick when we have to leave. It is fine that you are stating home with him today. It is better to be safe. If you get a chance, next time let us know you're heading to the ER so the person helping you will not you won't be back for awhile. It isn't any big deal if you don't have time, it just helps the person that was assisting you.

As far as you staying on the middle top range, I'll let someone else discuss that with you. I'm not sure what you mean by that. I understand the need to be safe though. I will let someone else discuss skipping shots with you too. Because I can't see your numbers or know how to convert them, I'm not comfortable.

Gabapentin can cause all the reactions you were describing. Did the vets explain that to you last night? How to tell if his stumble is from the Gabapentin or lows? Did the vet say you should skip a dose of pain meds? Asking because pain can raise the bg.

When you have a chance, please add his meds to his signature, but only when you have a free moment. Signatures and spreadsheets take a back seat when dealing with stresses like low bgs.

Make sure to note Wendy's reduction for your next dose too.

I'm glad he is eating. My boy really stresses at the vet too. Unfortunately for them, they have to go more now.

I'm assuming all insulins have an onset. Lantus is long term so it is grandual. Our cat's nadirs (lowest point of bg throughout cycles) can change per cycle. My cats does sometimes. It would be hard for me to tell you when Charlie's usually is because I can't see his numbers. As you start to notice patterns on Charlie's spreadsheet, as you gather more data, you will be able to answer these questions. With the patterns will also be able to know how often to test. Right now, I would test as much as I can to gather info. If Charlie drops quickly, test more often. I like getting +1, +2, +6, +8 or +10. That gives me most of the numbers I need to figure out what he is doing with his cycle. Usually after eating, I like to get a +1 to see where he is headed. If the +1 is lower than my preshot, I know he is dropping on his own without being inflicted by the insulin because Lantus usually takes longer than an hour to influence the bg. Tells me it is dropping on its own and I need to try and even the drop out with food of it is drastic.

We never give injections without checking the bg first, even if we check it at +11.5, we still check the bg again before the shot. I'm glad you will no longer be doing this. The only way to avoid another hypo event is to know the bg before a shot and to properly monitor the bgs throughout a cycle.

I hope my information makes sense to you and you and Charlie are able to get some rest today.

Let us know his bg at preshot if you need help deciding whether or not to skip, unless you already know you are skipping. If you do decide to skip, just put NS in the cell where his units would have gone for his shot. If NS isn't there, someone will ask you about a missed shot.

 

[Bandit's Mom]

No, the world spreadsheet still isn't liking the way you are entering the numbers. All numbers you have that include the (+) symbol are not converting. I'll tag someone that may know the proper way to enter your +1.5 (example) into the world tab. @Bandit's Mom can you please explain how the + numbers should be entered into the spreadsheet so they don't cause an value error on the US sheet? Thank you.

The US tab has a formula to multiply the value in the World tab by 18 (to convert mmol/L to mg/dl) - which is why, when it encounters anything other than a number, it throws an error. The only way to enter such numbers in the US tab is manually . So you would multiply by 18 and enter that value in the US tab (say 80 @+4.5) and then fill in the colour of that cell also manually. It is a bit of a slog!

I can do this for you for the last few days. You have enough on your plate for now!


Btw @Macey , you might want to start posting on the LBL forum. It's a more active forum of Lantus users and you might get more eyes on your posts there.
https://www.felinediabetes.com/FDMB/forums/lantus-levemir-biosimilars.9/

 

[Basic's Mom]

Lantus builds up a depot, like a reserve, that last a day or so. There won't be a time that he is on Lantus that it fully "clears." As you give him his insulin, his depot is building. If you stop giving insulin, his depot is depleted. Usually close to shot time, bgs start to rise. This usually occurs until you find a good dose. If you look at cat's ss from last year, you will see he rarely had lower PMPS numbers until he hit a dose that agreed with him. Now, his preshot numbers are much closer to his average bg throughout his cycles.

 

[Marje and Gracie]

Lantus builds up a depot, like a reserve, that last a day or so. There won't be a time that he is on Lantus that it fully "clears." As you give him his insulin, his depot is building. If you stop giving insulin, his depot is depleted. Usually close to shot time, bgs start to rise. This usually occurs until you find a good dose. If you look at cat's ss from last year, you will see he rarely had lower PMPS numbers until he hit a dose that agreed with him. Now, his preshot numbers are much closer to his average bg throughout his cycles.

I just want to clarify. The depot in Lantus and Levemir can last much longer than a day depending on the dose and the cat. I have seen the depot on a specific dose last over six cycles. This was in an overdosed cat; however, it’s quite typical for a normal dose in a cat to have a depot of up to three to four cycles.

@Macey could you please remove the ?911 from your subject since he’s ok? Just click on “thread tools” in the first post, “edit thread”, delete ?911, “save changes”. Thank you.

 

[Lisa and Angel]

He is on a small daily dose of gabapentin for nerve pain, but shouldn't be a sedative dose. It his harder to metabolize with CKD, but I've already accounted for that. I can't find anything online, but I feel like it might accumulate regardless due to the CKD and eventually get to a slightly sedative level. I think I will skip his dose of gaba as well as his next insulin dose, to let it fully clear his system. I don't want him to be in pain, but I don't want it disguising any symptoms, plus if he's just eating wet food, his mouth should be ok I would imagine.

Since Lantus is an extended release insulin, does it still have a peak? Should it start clearing his body when the next dose is skipped? He's due in about 1.5 hours, so it would help me sleep if I knew that was the case. How often do you think I should wake up to check?

Just wanted to share my experience with this. My early-stage CKD kitty also gets hit super hard by gabapentin. At just 1/4th of a 100mg capsule he'll stumble around like he just woke up from anaesthesia. It also lasts at least 16-20 hours for him, in comparison it wears off in about 8-10 hours in my healthy kitty who gets it for anxiety. When he was on it a couple days in a row (at 1/8th dosing), I too felt it was accumulative for him as he got progressively more sleepy and wobbly the longer he was on it.

https://academic.oup.com/painmedicine/article/10/1/190/1835004

"Its [gabapentin's] sole route of elimination is by the kidney and, therefore, impairment in renal function will result in a higher plasma gabapentin concentration and longer elimination half-life. Signs of toxicity are nonspecific and include sedation, dizziness, and confusion."

 

[Macey]

Just wanted to share my experience with this. My early-stage CKD kitty also gets hit super hard by gabapentin. At just 1/4th of a 100mg capsule he'll stumble around like he just woke up from anaesthesia. It also lasts at least 16-20 hours for him, in comparison it wears off in about 8-10 hours in my healthy kitty who gets it for anxiety. When he was on it a couple days in a row (at 1/8th dosing), I too felt it was accumulative for him as he got progressively more sleepy and wobbly the longer he was on it.

https://academic.oup.com/painmedicine/article/10/1/190/1835004

"Its [gabapentin's] sole route of elimination is by the kidney and, therefore, impairment in renal function will result in a higher plasma gabapentin concentration and longer elimination half-life. Signs of toxicity are nonspecific and include sedation, dizziness, and confusion."

Hi Lisa,

Thank you for sharing that info! I believe this has happened to Charlie before. I just found this info:

"Loading doses usually do not need to be adjusted in patients with chronic kidney disease. Published guidelines suggest methods for maintenance dosing adjustments: dose reduction, lengthening the dosing interval, or both.4 Dose reduction involves reducing each dose while maintaining the normal dosing interval. This approach maintains more constant drug concentrations, but it is associated with a higher risk of toxicities if the dosing interval is inadequate to allow for drug elimination. Normal doses are maintained with the extended interval method, but the dosing interval is lengthened to allow time for drug elimination before redosing. Lengthening the dosing interval has been associated with a lower risk of toxicities but a higher risk of subtherapeutic drug concentrations, especially toward the end of the dosing interval." https://www.aafp.org/pubs/afp/issues/2007/0515/p1487.html

Maybe I do need to extend the interval. Will follow up with vet!