? 12/12 Mr. Pants pmps 181 +4 109 +5 149 amps 222

Christie & Maverick said:
Zach, it’s time for some patience :). Hold the 0.25u and give it a chance, remember we don’t dose based on preshot numbers we dose based on how low the dose is taking the cat.
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You're right....I feel like it may have taken him even lower than 109. I may have just missed it. I feel it is very possible that it was another green night and he earned a reduction that I didn't catch. I think we will be able to tell based on today's numbers. I'm holding the dose and me and Mr. Pants are meditating :D
 
Zach Pool said:
You're right....I feel like it may have taken him even lower than 109. I may have just missed it. I feel it is very possible that it was another green night and he earned a reduction that I didn't catch. I think we will be able to tell based on today's numbers.
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Maybe, but you won't necessarily be able to tell based on just today's numbers. You want to be able to look at how the insulin is working over the course of several cycles, not just focus on one particular cycle. Not all cycles will look the same, and I tend to find it helpful to look at the BG cycles over a period of several days to see what the waves of action are. Hence, to quote one of my mentors on this forum, patience grasshopper :)
 
In addition to the great advice so far, I'd like to add to try to look at this as a good thing:

Zach Pool said:
I feel like it may have taken him even lower than 109. I may have just missed it. I feel it is very possible that it was another green night and he earned a reduction that I didn't catch.
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You may not have "caught" that reduction number but you also may not have "caught" the beginning of a bounce. After much time, I feel that for me, its better not to speculate and just take the data as is.
More importantly, more time in normal BG numbers will usually result in less bouncing. :)
 
Zach Pool said:
You're right....I feel like it may have taken him even lower than 109. I may have just missed it. I feel it is very possible that it was another green night and he earned a reduction that I didn't catch. I think we will be able to tell based on today's numbers. I'm holding the dose and me and Mr. Pants are meditating :D
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As the others said:
  1. Don’t change the dose based on the preshot.
  2. Don’t speculate about what his BGs “might” have been. We dose on what we see, primarily the lowest BG we see.
Patience is hard especially when you’ve been dosing on preshots…..but patience works.
 
Marje and Gracie said:
As the others said:
  1. Don’t change the dose based on the preshot.
  2. Don’t speculate about what his BGs “might” have been. We dose on what we see, primarily the lowest BG we see.
Patience is hard especially when you’ve been dosing on preshots…..but patience works.
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So we are @296 pre shot tonight and our nadir today was 145. I'm pretty sure that meets the requirement to go up with insulin does it not?
 
Zach Pool said:
So we are @296 pre shot tonight and our nadir today was 145. I'm pretty sure that meets the requirement to go up with insulin does it not?
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I don’t usually quote the regulation methods but perhaps it will mean more coming from the actual guidelines for SLGS which state:

Don't be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat's blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose.
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Again, don’t dose on the PS.
 
I did increase the dose. Not to a full .5u. I entered the increase in before I gave him the shot. It was more like .4u I guess. yeah its really difficult to watch his BGs rise and his behavior change and not do anything about it.
 
Christie & Maverick said:
As the others have noted, with SLGS you want to hold the dose when nadirs are under 150, 4 cycles isn’t enough time to see what this dose can do. And I thought we were pausing, reflecting and meditating ;).
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I only meditate for an hour in the mornings lol. I run around like a chicken with my head cut off for the rest of the day :banghead::(:woot:
 
Marje and Gracie said:
I don’t usually quote the regulation methods but perhaps it will mean more coming from the actual guidelines for SLGS which state:



Again, don’t dose on the PS.
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It was more the section talking about the nadir being 150 that pushed the envelope for me. Even though his nadir was 145. Seems like a pretty clear uptrend but maybe someone can explain to me how a 16 hour depot time and rising levels over the course of four cycles doesn't indicate an uptrend? I'm being totally serious too....Sincerely....With all due respect. I'm totally open to an explanation. Outside of "its a depot insulin"....or...."give the depot time to work".From my understanding a singular dose is totally out of your system in 24 hours and glargine has a 14-16 hour depot time. So how is rising nadirs and rising pre shot levels over the course of four cycles going to change in three more days. Because Im not really willing to let him get miserable again when ALL of his numbers are pretty clearly rising.
 
I realize how I may sound right now....Im truly not trying to be rude. But I am aware of "depot insulin" and the fact that the shots overlap etc. I am NOT aware of how a depot time of 16 hours that is totally cleared in 24 hours should be creating the type of environment that is going to magically change 3 days down the road.
 
Zach Pool said:
.From my understanding a singular dose is totally out of your system in 24 hours and glargine has a 14-16 hour depot time. So how is rising nadirs and rising pre shot levels over the course of four cycles going to change in three more days. Because Im not really willing to let him get miserable again when ALL of his numbers are pretty clearly rising.
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Not quite. Depot insulins like Lantus are not totally out of a cat’s system in 24 hours. The characteristics of depot insulins is that they are absorbed slowly which can result in extended action, and can have a cumulative effect. See this for more info on What is the Insulin Depot

Lantus does not have a depot of 14-16 hours, I’m not sure where you’ve seen that. Rising preshot numbers like this evening might actually be an indication of a bounce break. Some cats will go high before they break a bounce, so arguably if Mr. Pants has a better cycle tonight, you might say it was because you increased but I would say it’s because he was breaking the bounce. That’s why you want to evaluate not based on one cycle or one preshot, but how the insulin works over the course of several.

See Mac, here, he shows his highs before a break pretty often. Pm cycle of Dec 10th high then broke to greens. And even this morning https://docs.google.com/spreadsheet...g43M8IypdyD_KjdhV1kawUovjSkvWy6NtldcJ/pubhtml

Does this help?
 
Zach Pool said:
It was more the section talking about the nadir being 150 that pushed the envelope for me. Even though his nadir was 145. Seems like a pretty clear uptrend but maybe someone can explain to me how a 16 hour depot time and rising levels over the course of four cycles doesn't indicate an uptrend? I'm being totally serious too....Sincerely....With all due respect. I'm totally open to an explanation. Outside of "its a depot insulin"....or...."give the depot time to work".From my understanding a singular dose is totally out of your system in 24 hours and glargine has a 14-16 hour depot time. So how is rising nadirs and rising pre shot levels over the course of four cycles going to change in three more days. Because Im not really willing to let him get miserable again when ALL of his numbers are pretty clearly rising.
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The duration of Lantus in cats is generally 12 hours but it can depend on many things including where and how the shot is given, when food is given, etc. Some cats have a shorter duration. The insulin Levemir is known for a little longer duration and my kitty could often have quite a bit of overlap and carryover. But Lantus, less so.

I don’t know where you got the information Lantus has a 16-hour depot time. The depot has to build at a new dose so the doses are cumulative and, once the depot fills, it can affect up to six subsequent cycles but I have seen two cats where it affected ten cycles after a reduction. I also don’t know where you got the information Lantus has “totally cleared” the system in 24 hours. I can attest to that being incorrect as I’ve sat up all night with members whose cats are still hypoglycemic 36 hours after the last shot and after them continually eating high carb food.

I don’t think you are being rude; you have questions and something you’ve read is the antithesis of what we’ve learned and seen here. So, yes, things can change as the depot builds from a new, higher dose or as it depletes from a reduction. Is it always six cycles in the latter? No it isn’t. But it can be and often is.

I know you don’t see a difference between 0.25u and 0.4u but there is one because the dose is so low. If your cat is a high dose cat, say 10u bid and the dose increases and decreases are 1u, then the difference between 0.25u and 0.4u is small. But for a cat on 0.25u, an increase to 0.4u is fairly large.
 
Marje and Gracie said:
The duration of Lantus in cats is generally 12 hours but it can depend on many things including where and how the shot is given, when food is given, etc. Some cats have a shorter duration. The insulin Levemir is known for a little longer duration and my kitty could often have quite a bit of overlap and carryover. But Lantus, less so.

I don’t know where you got the information Lantus has a 16-hour depot time. The depot has to build at a new dose so the doses are cumulative and, once the depot fills, it can affect up to six subsequent cycles but I have seen two cats where it affected ten cycles after a reduction. I also don’t know where you got the information Lantus has “totally cleared” the system in 24 hours. I can attest to that being incorrect as I’ve sat up all night with members whose cats are still hypoglycemic 36 hours after the last shot and after them continually eating high carb food.

I don’t think you are being rude; you have questions and something you’ve read is the antithesis of what we’ve learned and seen here. So, yes, things can change as the depot builds from a new, higher dose or as it depletes from a reduction. Is it always six cycles in the latter? No it isn’t. But it can be and often is.

I know you don’t see a difference between 0.25u and 0.4u but there is one because the dose is so low. If your cat is a high dose cat, say 10u bid and the dose increases and decreases are 1u, then the difference between 0.25u and 0.4u is small. But for a cat on 0.25u, an increase to 0.4u is fairly large.
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It isn't that I think there there is no difference between .4u and .25u, its just that I think he has a sweet spot Im skipping over. Not to mention that I haven't had this type of issue in the last 5 years. Here is my source...or at least one of them.

Insulin glargine is a human insulin analog that has been designed to have low aqueous solubility at neutral pH. At pH 4, as in the LANTUS injection solution, it is completely soluble. After injection into the subcutaneous tissue, the acidic solution is neutralized, leading to formation of microprecipitates from which small amounts of insulin glargine are slowly released, resulting in a relatively constant concentration/time profile over 24 hours with no pronounced peak. This profile allows once-daily dosing as a patient’s basal insulin. In clinical studies, the glucose-lowering effect on a molar basis (i.e., when given at the same doses) of intravenous insulin glargine is approximately the same as human insulin. In euglycemic clamp studies in healthy subjects or in patients with type 1 diabetes, the onset of action of subcutaneous insulin glargine was slower than NPH human insulin. The effect profile of insulin glargine was relatively constant with no pronounced peak and the duration of its effect was prolonged compared to NPH human insulin. Figure 1 shows results from a study in patients with type 1 diabetes conducted for a maximum of 24 hours after the injection. The median time between injection and the end of pharmacological effect was 14.5 hours (range: 9.5 to 19.3 hours) for NPH human insulin, and 24 hours (range: 10.8 to >24.0 hours

https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/021081s024lbl.pdf

This amongst other ncbi articles or Mayo Clinic pieces all refer to the maximum effect of Lantus being 24 hours. Typically ranging from 14-16 hours.

Coupled with my experience of having veterinarians telling me my cat was no longer diabetic and to literally STOP giving him insulin, only to watch his BGs rise to eventual hyperglycemia, I have a hard time believing anyone outside of myself or my experience. If it weren't for my hard headed nature and conviction my cat would have not been nearly as healthy as I have kept him for these last five years. Unfortunately every professional or anyone else that has intervened in his diabetes has only offered information that, had I taken at face value and applied, would have resulted in him being much less healthy and much less efficiently regulated.
 
Zach Pool said:
Coupled with my experience of having veterinarians telling me my cat was no longer diabetic and to literally STOP giving him insulin, only to watch his BGs rise to eventual hyperglycemia, I have a hard time believing anyone outside of myself or my experience. If it weren't for my hard headed nature and conviction my cat would have not been nearly as healthy as I have kept him for these last five years. Unfortunately every professional or anyone else that has intervened in his diabetes has only offered information that, had I taken at face value and applied, would have resulted in him being much less healthy and much less efficiently regulated.
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Well that is a horse of a different colour. I have no doubt that you want to do what’s best for your cat, and so you should advocate for him. It’s unfortunate that your experience with vets has been that way, although I have seen caregivers whose vets are very comfortable with the cat staying in higher numbers, but often in those cases, home testing wasn’t recommended. I can imagine it’s hard to get on board with something you don’t entirely trust.

Nothing wrong with continuing to ask questions and perhaps over time, you will become more comfortable trusting how we approach managing feline diabetes.
 
Zach Pool said:
It isn't that I think there there is no difference between .4u and .25u, its just that I think he has a sweet spot Im skipping over. Not to mention that I haven't had this type of issue in the last 5 years. Here is my source...or at least one of them.

Insulin glargine is a human insulin analog that has been designed to have low aqueous solubility at neutral pH. At pH 4, as in the LANTUS injection solution, it is completely soluble. After injection into the subcutaneous tissue, the acidic solution is neutralized, leading to formation of microprecipitates from which small amounts of insulin glargine are slowly released, resulting in a relatively constant concentration/time profile over 24 hours with no pronounced peak. This profile allows once-daily dosing as a patient’s basal insulin. In clinical studies, the glucose-lowering effect on a molar basis (i.e., when given at the same doses) of intravenous insulin glargine is approximately the same as human insulin. In euglycemic clamp studies in healthy subjects or in patients with type 1 diabetes, the onset of action of subcutaneous insulin glargine was slower than NPH human insulin. The effect profile of insulin glargine was relatively constant with no pronounced peak and the duration of its effect was prolonged compared to NPH human insulin. Figure 1 shows results from a study in patients with type 1 diabetes conducted for a maximum of 24 hours after the injection. The median time between injection and the end of pharmacological effect was 14.5 hours (range: 9.5 to 19.3 hours) for NPH human insulin, and 24 hours (range: 10.8 to >24.0 hours

https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/021081s024lbl.pdf

This amongst other ncbi articles or Mayo Clinic pieces all refer to the maximum effect of Lantus being 24 hours. Typically ranging from 14-16 hours.

Coupled with my experience of having veterinarians telling me my cat was no longer diabetic and to literally STOP giving him insulin, only to watch his BGs rise to eventual hyperglycemia, I have a hard time believing anyone outside of myself or my experience. If it weren't for my hard headed nature and conviction my cat would have not been nearly as healthy as I have kept him for these last five years. Unfortunately every professional or anyone else that has intervened in his diabetes has only offered information that, had I taken at face value and applied, would have resulted in him being much less healthy and much less efficiently regulated.
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Christie has given you astute responses. Cats are not furry people so you cannot extrapolate human advice and apply it to cats. For instance, if a cat becomes anorexic even for a few days, they can develop potentially deadly hepatic lipidosis. This doesn’t occur in people. If someone advises a human to fast for a few days, they will just be really hungry. The same advice can kill a cat.

We also understand your hesitancy. I actually had a feline specialist vet tell me the same thing about Gracie as you heard for Mr. Pants but she included the words that I was “killing my cat” who she said did not need insulin. That was early on for us. Thankfully, the wise people on this board, including Sienne, told me why Gracie needed insulin. It was a leap of faith by I followed their advice then and as I was learning and it was always spot on. All I can tell you is this board has been in existence for decades and we’ve helped easily over a thousand cats go in remission and most have stayed. Unlike vets, we live this disease 24/7. We’ve been where you are.

But he’s your cat and it’s your decision on whether to believe we know what we are doing. And even though we generally follow the methods of regulation, it’s not one size fits all and we are good at determining when we need to tailor a method for a specific cat. If you see signature blocks which state “custom dosing”, it’s either because we’ve determined that cat needs a different approach or the CG is so experienced and they’ve done TR or SLGS so long, they’ve tailored it for their cat.
 
Christie & Maverick said:
Well that is a horse of a different colour. I have no doubt that you want to do what’s best for your cat, and so you should advocate for him. It’s unfortunate that your experience with vets has been that way, although I have seen caregivers whose vets are very comfortable with the cat staying in higher numbers, but often in those cases, home testing wasn’t recommended. I can imagine it’s hard to get on board with something you don’t entirely trust.

Nothing wrong with continuing to ask questions and perhaps over time, you will become more comfortable trusting how we approach managing feline diabetes.
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I appreciate the patience. I don't feel like he is having a better evening. I can assume its because of the dose increase. I've seen his numbers climb like this and they don't typically stop. I guess I don't really know what step to take next. If I were going it alone Id probably do another .4 u tomorrow morning and look for him to have a better following cycle because he usually has a funky cycle when I do an increase.
 
Marje and Gracie said:
Christie has given you astute responses. Cats are not furry people so you cannot extrapolate human advice and apply it to cats. For instance, if a cat becomes anorexic even for a few days, they can develop potentially deadly hepatic lipidosis. This doesn’t occur in people. If someone advises a human to fast for a few days, they will just be really hungry. The same advice can kill a cat.

We also understand your hesitancy. I actually had a feline specialist vet tell me the same thing about Gracie as you heard for Mr. Pants but she included the words that I was “killing my cat” who she said did not need insulin. That was early on for us. Thankfully, the wise people on this board, including Sienne, told me why Gracie needed insulin. It was a leap of faith by I followed their advice then and as I was learning and it was always spot on. All I can tell you is this board has been in existence for decades and we’ve helped easily over a thousand cats go in remission and most have stayed. Unlike vets, we live this disease 24/7. We’ve been where you are.

But he’s your cat and it’s your decision on whether to believe we know what we are doing. And even though we generally follow the methods of regulation, it’s not one size fits all and we are good at determining when we need to tailor a method for a specific cat. If you see signature blocks which state “custom dosing”, it’s either because we’ve determined that cat needs a different approach or the CG is so experienced and they’ve done TR or SLGS so long, they’ve tailored it for their cat.
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Sorry you have also experienced that. Its not that I don't believe you know what you're doing its just that I believe that his numbers are trending up. I mean its fairly undeniable. What would your suggestion be at this point? Should I stay with the .4u or go back to .25u tomorrow morning? My guess is that his pre shot will be better tomorrow morning around 170 -180 and his nadir will hit around +5 or +6 tonight about two hours later than it normally does.

I will also add that I base the increases on clinical signs as well as numbers. It isn't that I ONLY see a trend ...his behavior is also notably different.
 
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Zach Pool said:
Sorry you have also experienced that. Its not that I don't believe you know what you're doing its just that I believe that his numbers are trending up. I mean its fairly undeniable. What would your suggestion be at this point? Should I stay with the .4u or go back to .25u tomorrow morning? My guess is that his pre shot will be better tomorrow morning around 170 -180 and his nadir will hit around +5 or +6 tonight about two hours later than it normally does.

I will also add that I base the increases on clinical signs as well as numbers. It isn't that I ONLY see a trend ...his behavior is also notably different.
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Honestly, I’m a bit torn with only seeing the PMPS and no subsequent tests. Following SLGS, you would go back to shooting 0.25u bid. OTOH, I really want you to quit dose-hopping so holding the dose might get you to stop.

I have to go to bed so I’d say if he comes down to mid-blue, shoot 0.25u. If he stays flat, I could see holding the dose even if this is a bounce.
 
Zach Pool said:
Sorry you have also experienced that. Its not that I don't believe you know what you're doing its just that I believe that his numbers are trending up. I mean its fairly undeniable. What would your suggestion be at this point? Should I stay with the .4u or go back to .25u tomorrow morning? My guess is that his pre shot will be better tomorrow morning around 170 -180 and his nadir will hit around +5 or +6 tonight about two hours later than it normally does.

I will also add that I base the increases on clinical signs as well as numbers. It isn't that I ONLY see a trend ...his behavior is also notably different.
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Hey, I’m new to this whole thing and still trying to understand all the different approaches, what are the behavioral changes you see that lead you to change the dose?

Hope Mr. Pants is feeling better today!
 
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