? 2/23 Kokkinoulis AMPS 97.+1 116, +5 109, +7 94, +8.30 98 libre , +10.45 89 Dose advising

[Kokkinoulis]

Dear all,

Previous post: https://www.felinediabetes.com/FDMB...40-mindose-advice-please.286948/#post-3155135

@Wendy&Neko, @Bandit's Mom , @Marje and Gracie , @tiffmaxee , @Chris & China (GA), @Ale & Bobo & Minnie (GA), @Sienne and Gabby (GA)

Kokkinoulis is finally at green colors in the last cycles. Could you please check his ss and advise me about his dose?
As he has a pattern for low (nadir) pre-shots should I stay at 7.5 unit or is it better for safety reason to decrease to 7.0 unit?
Then what are our next steps? How many days/ cycles should I stay in this dose?

Moreover I would like to ask you again about how to deal with Low Preshot Numbers. I read many times the yellow sticky https://felinediabetes.com/FDMB/threads/dealing-with-low-preshots.46005/
In case that the BG increases after stalling and without food I will shoot his normal dose.
In case that after stalling without food the BG decreases instead of increases what should I do? Sometimes it seems that the BGs do not rise slowly at the end of the cycle as the insulin action should be decreasing, but instead the BGs are still decreasing in the first hours of the next cycle. Kokkinoulis having a nadir around +13, which is why numbers continued to drop after +12 when I stalled without food. Plus, my cat gets stressed and angry when he's hungry before shots and it's difficult to test him multiple times every 15 -20 min.
In that case what do you thing about the other alternatives described below from the Tight Regulation Protocol with Lantus or Levemir for Diabetic Cats that was developed by laypersons from the German Diabetes-Katzen Forum. https://pubmed.ncbi.nlm.nih.gov/19592286/ as well from Roomp K, Rand JS. Management of diabetic cats with long-acting insulin. Vet Clin North Am Small Anim Pract 2013;43(2):251–66? https://pubmed.ncbi.nlm.nih.gov/23522171/

If blood glucose at the time of the next insulin injection is 2.8–5.5 mmol/L (50–100 mg/dL)
Initially test which of the alternate methods is best suited to the individual cat:
1. Feed cat and reduce the dose by 0.25–0.5 IU depending on if cat is on low or high dose of insulin
2. Feed the cat, wait 1–2 h; when the glucose concentration increases to >5.5 mmol/L (>100 mg/dL), give the normal dose. If the glucose concentration does not increase within 1–2 h, reduce
the dose by 0.25 IU or 0.5 IU (as above).
3. Split the dose: feed cat and give most of dose immediately and then give the remainder 1–2 h later, when the glucose concentration has increased to >5.5 mmol/L (>100 mg/dL).
If all of these methods lead to increased blood glucose concentrations, give the full dose if preinsulin blood glucose concentration is 2.8–5.5 mmol/L (50–100 mg/dL) and observe closely for signs of hypoglycemia. In general for most cats, the best results in phase 2 occur when insulin is dosed as consistent as possible, giving the full normal dose at the regular injection time.

 

[Bandit's Mom]

As he has a pattern for low (nadir) pre-shots should I stay at 7.5 unit or is it better for safety reason to decrease to 7.0 unit?
Then what are our next steps? How many days/ cycles should I stay in this dose?

Hopefully Wendy will stop by before your PS and advice on dose. You don't want to change doses based on preshots. Dosing is based on nadirs. He hasn't earned a reduction to 7U yet. You want to verify any lower readings you get on the Libre with a regular meter since the Libre reads much lower in the normal range of numbers. If you feel more comfortable going down to 7U, you want to stay with 7U and see how he does on it.

Moreover I would like to ask you again about how to deal with Low Preshot Numbers. I read many times the yellow sticky https://felinediabetes.com/FDMB/threads/dealing-with-low-preshots.46005/
In case that the BG increases after stalling and without food I will shoot his normal dose.
In case that after stalling without food the BG decreases instead of increase what should I do? Sometimes it seems that the BGs do not rise slowly at the end of the cycle as the insulin action should be decreasing, but instead the BGs are still decreasing in the first hours of the next cycle. Kokkinoulis having a nadir around +13, which is why numbers continued to drop after +12 when I stalled without food. Plus, my cat gets stressed and angry when he's hungry before shots and it's difficult to test him multiple times every 15 -20 min.

With TR you can shoot any number over 50 (on a human meter) without stalling, if you can monitor. Sometimes the BG will keep falling when you stall - especially with late nadir cats like Kokki. Since you know that Kokki often nadirs at the end of the cycle or even at +13, you want to get comfortable shooting lower preshots without stalling. Food will help slow the drop and you needn't worry about an angry Kokki!

Does he get food later in the cycle when you test and find that his numbers are dropping? Like today? Feeding will ensure that he doesn't drop too low at PS to shoot.

 

[Kokkinoulis]

Hopefully Wendy will stop by before your PS and advice on dose. You don't want to change doses based on preshots. Dosing is based on nadirs. He hasn't earned a reduction to 7U yet. You want to verify any lower readings you get on the Libre with a regular meter since the Libre reads much lower in the normal range of numbers. If you feel more comfortable going down to 7U, you want to stay with 7U and see how he does on it.



With TR you can shoot any number over 50 (on a human meter) without stalling, if you can monitor. Sometimes the BG will keep falling when you stall - especially with late nadir cats like Kokki. Since you know that Kokki often nadirs at the end of the cycle or even at +13, you want to get comfortable shooting lower preshots without stalling. Food will help slow the drop and you needn't worry about an angry Kokki!

Does he get food later in the cycle when you test and find that his numbers are dropping? Like today? Feeding will ensure that he doesn't drop too low at PS to shoot.

Does he get food later in the cycle when you test and find that his numbers are dropping? Like today? Feeding will ensure that he doesn't drop too low at PS to shoot

Hi Bhooma,

I can feed him later in the cycle when his numbers are dropping. This is the main reason I put again libre (although I trust more glucometer) to alert me especially during the night when BG drops low. I will closely monitor him during weekend as he is new at greens. My main concern will be for the next days as many days of the week I will be at office or at several Hospitals and Kokki will be alone at home. I bought a feeder and also put a camera to watch him when i will be out of home but unfortunatelly I cant monitor his BGs remotely with libre 2 ( libre 3 is not available in Greece). So, it is crucial to have the knowledge how he deals with green numbers and 7.5 units. If the BG drops down close to 70-60 mg/dl with accu-check I am afraid to give him 7.5 units when he will be alone. Let's hope that he will give us the opportunity this weekend to observe him at low numbers.

 

[tiffmaxee]

With the skip he’s still in green. That’s great! Maybe he will earn a reduction over the weekend.

 

[Kokkinoulis]

With the skip he’s still in green. That’s great! Maybe he will earn a reduction over the weekend.

Yes althought after the skip it was increaced to high numbers after 2 cycles. I am trying now to understand the differences in low numberbetween n Libre 2 and accu-check. Although accu-check is more accurate I think I am trying to see below which low numbers in libre I should double check by ear for hypo. Do you know someone more experienced in libre 2 and glucometer?

 

[Bandit's Mom]

Yes althought after the skip it was increaced to high numbers after 2 cycles. I am trying now to understand the differences in low numbers betwwen Libre 2 and accu-check. Although accu-check is more accurate for me I am trying to see below which low numbers in libre I should double check by ear for hypo. Do you know someone more experienced in libre 2 and glucometer?

Going to tag @Staci & Ivy who has experience with the difference between Libre and meter readings.

 

[Staci & Ivy]

Yes althought after the skip it was increaced to high numbers after 2 cycles. I am trying now to understand the differences in low numberbetween n Libre 2 and accu-check. Although accu-check is more accurate I think I am trying to see below which low numbers in libre I should double check by ear for hypo. Do you know someone more experienced in libre 2 and glucometer?

Hi Gabriella, I have used a Libre 2 and I now use a Libre 3 with my cat, Ivy.
What I find is that when the Libre drop low, under 100, I start paying attention closely.
I have found numbers in the 40s and below are when she tests in the low 100s to under 100 on a handheld glucometer.
I use a contour next meter.
When Ivy hits LO on the Libre that is most likely when she will be under 100 or in the low 100s on the handheld meter.
I hope that helps guide you.

I do not know how your particular meter reads, but when you do an ear prick, you will get an idea for how it reads compared to the Libre.
I’ve been using the Libre system for about a year now, so I have somewhat of an idea where the numbers fall. They are never exact every time, however so you do need to check with an ear prick if they go low.
I hope this helps and wish you all the best

 

[Kokkinoulis]

I have found numbers in the 40s and below are when she tests in the low 100s to under 100 on a handheld glucometer.

I cannot understand what exactly do you mean!

Thanks a lot for your reply. This is the 2nd time I use libre 2 (libre 2 is not available in Greece). The 1st time I noticed that when the BG is is high numbers with glucometer it is higher with libre more from 20 to 40 md/dl and when the BG is low with libre with glucometer was higher. For example it was 85 with accu-check and 64 with libre 15 min later. Now I noticed the opposite in low numbers: when it was 89 with accu-check it was 102 with libre 15 min later. So, I am very confused what happen. As his number finally are at greens and blew I would like to be aware below which green numbers with libre I should double check for hypo with accu-check.

 

[Sienne and Gabby (GA)]

When following TR, if you skip or adjust a dose, the cycle count starts over. So, when you skipped Kokki's shot on 2/21, the PMPS for today is the 5th cycle at the 7.5u dose. You need to evaluate the dose from tonight and tomorrow morning and then decide what to do regarding the dose.

I think what Staci was saying is that Lo readings on the Libre are considerably lower than what you would get using a handheld glucometer. A 40 on the Libre is likely to be around 100 on the handheld meter. There may be some variability based on your meter so it will be good if you can compare the readings between the two meters.

FYI - I didn't get your tag.

 

[Kokkinoulis]

A 40 on the Libre is likely to be around 100 on the handheld meter.

Hi Sienne, I noticed the same with my glucometer the 1st time that a 40 on the Libre is likely to be around 100 on the handheld meter. But now it is the opposite that 102 with libre is 89 with accu-check so I am very confused

 

[Staci & Ivy]

I think what Staci was saying is that Lo readings on the Libre are considerably lower than what you would get using a handheld glucometer. A 40 on the Libre is likely to be around 100 on the handheld meter. There may be some variability based on your meter so it will be good if you can compare the readings between the two meters.

Yes, this is what I was trying to say, thank you Sienne.

 

[Staci & Ivy]

Hi Sienne, I noticed the same with my glucometer the 1st time that a 40 on the Libre is likely to be around 100 on the handheld meter. But now it is the opposite that 102 with libre is 89 with accu-check so I am very confused

It will never be exactly the same each time. It may be somewhat close.
That’s why I double check on a handheld meter when my Libre reads “Lo” and even a low 40s Libre number is worth checking to be sure.

 

[Wendy&Neko]

For some reason, I didn't get the tag. I'm glad you shot the full dose. And good to see you've been getting those +1. With those lower preshots, looks like he's getting at least 20 points from his food.

In case that after stalling without food the BG decreases instead of increases what should I do?

It may be a trite answer, but don't stall. Or stall no more than 10-15 minutes. Try to prevent that drop. It's not uncommon for cats to drop without food. How late in the AM cycle does he get food? Maybe a little low carb snack around +8 or +9 will help him keep his numbers up. You don't want to feed after nadir, but his nadir is late so you can feed later.

I shot Neko as low as 51 when she was on higher doses. I didn't stall unless she was under 50. But I knew she nadired around +9-+12, though sometimes a bit later. And she got a food bump of around 30 points, plus it was still several hours until onset (when the insulin starts working) so her numbers would keep going up until then.

 

[Kokkinoulis]

For some reason, I didn't get the tag. I'm glad you shot the full dose. And good to see you've been getting those +1. With those lower preshots, looks like he's getting at least 20 points from his food.















It may be a trite answer, but don't stall. Or stall no more than 10-15 minutes. Try to prevent that drop. It's not uncommon for cats to drop without food. How late in the AM cycle does he get food? Maybe a little low carb snack around +8 or +9 will help him keep his numbers up. You don't want to feed after nadir, but his nadir is late so you can feed later.















I shot Neko as low as 51 when she was on higher doses. I didn't stall unless she was under 50. But I knew she nadired around +9-+12, though sometimes a bit later. And she got a food bump of around 30 points, plus it was still several hours until onset (when the insulin starts working) so her numbers would keep going up until then.

I have not have many data yet how he reacts with full dose in low preshot numbers as you had with Neko. So you are suggesting for me to giving him a small snack 3 hours before pre-shot?

 

[Kokkinoulis]

How late in the AM cycle does he get food

I feedteaspoons nly twice a day and 1-2 teaspoon every 2-3 hours (mainly in AM) but never 2 hours before shots. What about his dose? Should I stay in 7.5 unit and for how many days or can I decrease to 7 especially the days that I will be out of home about 9 hours??

 

[Wendy&Neko]

Yes, you could feed a couple tsps food 3 hours before shot time, especially in those cycles where he's low at that point and still going down. That might slow him down and give you a preshot you are more comfortable with. It took a long time before Neko gave me a low preshot. Lots in the 80's and 90's, but ages until a much lower number.

It's up to you if you want to reduce. If you are following TR you would not until Kokki went below 50. If you are nervous and want to raise the nadirs a bit, you could also try 7.25 units. Don't reduce just on days you are away, but stick with that reduction.

I find it quite confusing having readings from two meters. We typically tell people to pick one and use it primarily.

 

[Kokkinoulis]

Thanks a lot Wendy for your advices. For the moment I will stay at 7.5 and I will see how it will be in the next days. I fed him 3 teaspoons LC at +8 and it was raised up a lot at preshot and after that (if this was the only reason and no a bounce)so next time he will be low 3, 4 hours before preshot and it is still dropping I will try 1 teaspoon only.

I will mainly use libre now but I want to verify the lower readings I get on the Libre with my glucometer

According to TR protocol which are the next steps if he did not went below 50?

 

[Bandit's Mom]

I will mainly use libre now but I want to verify the lower readings I get on the Libre with my glucometer

Sounds like a good plan. If you get a lower number at preshot than you are comfortable with or he drop below 50 on the Libre, you can verify it with a meter, so that you know that you are taking decisions based on the "correct" BG value.

According to TR protocol which are the next steps if he did not went below 50?

You would continue to hold the dose unless his numbers start heading up and he needs an increase. Btw, a week in normal numbers also earns him a reduction.
Reminder: *earning* reductions and starting OTJ trials

 

[Kokkinoulis]

Sounds like a good plan. If you get a lower number at preshot than you are comfortable with or he drop below 50 on the Libre, you can verify it with a meter, so that you know that you are taking decisions based on the "correct" BG value.


You would continue to hold the dose unless his numbers start heading up and he needs an increase. Btw, a week in normal numbers also earns him a reduction.
Reminder: *earning* reductions and starting OTJ trials

Good Morning Bhooma,
Now the BG numbers are dropping very fast and he is at 73 ng/ml now with libre. When it will get lower I double check the number wit accu-check. Now I am at home and I can closely monitor him and I could give him some food if it drops more. My fear is when I will be out of home for many hours and he will be alone. With libre 2 I cannot monitor him remotely. He is new at greens. I have now a feeder but I am not yet sure at which exactly interval of time I should feed him 1-2 teaspoons LC wet food in order to avoid numbers below 50.
What do you suggest from your experience?

Moreover, according to the below from sticky:

• reduction *earned* when the cat regularly has its lowest BGs in the normal range of a healthy cat (50 - 80 mg/dL) and stays under 100 mg/dl overall for at least one week and following TR

Kokki now has its lowest BGs in the normal range of a healthy cat (50 - 80 mg/dL) but also numbers at other hours more than 100 mg/dl.
What should I do next ? How long should I stay at 7.5 unit with the numbers that he has now?
What exactly means 'stays under 100 mg/dl overall"?
Should I increase the dose after 5 cycles if he remains with his peaks more than 100?

 

[Bandit's Mom]

Now the BG numbers are dropping very fast and he is at 73 ng/ml now with libre. When it will get lower I double check the number wit accu-check. Now I am at home and I can closely monitor him and I could give him some food if it drops more. My fear is when I will be out of home for many hours and he will be alone. With libre 2 I cannot monitor him remotely. He is new at greens. I have now a feeder but I am not yet sure at which exactly interval of time I should feed him 1-2 teaspoons LC wet food in order to avoid numbers below 50.
What do you suggest from your experience?

Will he eat from the auto-feeder when you are not at home? When do you leave for work - how long after the shot? Does he get food at +1 and +2?

What should I do next ? How long should I stay at 7.5 unit with the numbers that he has now?

There is no fixed time for how long you hold the dose once the nadirs are where you want them to be. You would hold the dose till one of these 2 scenarios happen:
(a) He earns a reduction or
(b) His numbers go up and he needs an increase.

What exactly means 'stays under 100 mg/dl overall"?

It means that he should stay in the normal range throughout the day except maybe a preshot here and there which is over 100 but under 110 or so. Here are the spreadsheets of a couple of cats who have earned a reduction by staying for a week in normal numbers:
https://docs.google.com/spreadsheet...SSRbyokFfg555ZdBf4gsVX6IXec8f1OV9AB82/pubhtml
https://docs.google.com/spreadsheet...VzOwc25r7_3byQd6l-Pk8BdP4/edit#gid=1458002283

Should I increase the dose after 5 cycles if he remains with his peaks more than 100?

Dosing is based on nadirs and not peaks or preshots.

 

[Kokkinoulis]

My feeder has 4 containers... now I give him insulin around 7:45 to 8:00 am. I leave for work around 9.30 and I will return earlier due to Kokkinouli around 19:00 (unless I go to a hospital where I may return earlier). So I'm thinking of giving him 1 spoonful before I leave, i.e. at 1.30 am and then from 11:00 to 19:00 1-2 spoons every 2 hours. Of course I will fatten him up like this because I was told that he is a few kilos (6.7 Kg) and to give him 1 and 1/3 can and I will give him more but the hypoglycemia comes first, the regulation and then the weight loss...
What do you think with my plan?

 

[Kokkinoulis]

It means that he should stay in the normal range throughout the day except maybe a preshot here and there which is over 100 but under 110 or so

Althouth dosing is based on nadirs and not peaks or preshots this value 100 will be the peak, so if his number is more than 100 he will not earn a reduction !!! Then what? there is a gap here. I will hold the dose until all numbers are below 100 for 1 week. If this not happen how i will fix it as according to his nadir there is no need for reduction or increase. Ηypothetical questions ... i know . If I don't bother you I will write you every day and we will see it together step by step?

 

[Bandit's Mom]

My feeder has 4 containers... now I give him insulin around 7:45 to 8:00 am. I leave for work around 9.30 and I will return earlier due to Kokkinouli around 19:00 (unless I go to a hospital where I may return earlier). So I'm thinking of giving him 1 spoonful before I leave, i.e. at 1.30 am and then from 11:00 to 19:00 1-2 spoons every 2 hours. Of course I will fatten him up like this because I was told that he is a few kilos (6.7 Kg) and to give him 1 and 1/3 can and I will give him more but the hypoglycemia comes first, the regulation and then the weight loss...
What do you think with my plan?

How about feeding lesser food in each meal so that you can control his overall calorie intake? Feed a smaller amount with the shot so that he hungry enough to eat again at +1/+1.5 and for subsequent snacks, feed him only a spoon each. Your idea of snacks at +1.5, +3 and then every 2 hours after that is good. Last snack should be before at least 2 hours before the shot.

Althouth dosing is based on nadirs and not peaks or preshots this value 100 will be the peak, so if his number is more than 100 he will not earn a reduction !!! Then what? there is a gap here. I will hold the dose until all numbers are below 100 for 1 week. If this not happen how i will fix it as according to his nadir there is no need for reduction or increase. Ηypothetical questions ... i know

He can earn a reduction by dropping below 50. Some cats earn a reduction by staying in normal numbers. If neither happens, you just keep holding the dose as long as the nadirs are where you want them to be. I hope I have understood your question?

If I don't bother you I will write you every day and we will see it together step by step?

Sure. We are here to help, so you can post every day and ask. It's no bother at all !