1/20 Dino Baby: 3 day bounce and nadir at +11

[Charlotte + Dino Baby]

Does anyone have the problem of nadir coming verrry late in the cycle? My girl's nadir was pretty reliably coming at +11 or at her PMPS. Any advice on how to bring it earlier in the cycle? It leaves us very confused on how to shoot her PM dose because to stay on schedule could put her in danger. I had tried to incorporate Fancy Feast with gravy at +6 to use up the insulin so she would be ready for her PM dose on time, but it seems that was a failed experiment as her numbers have been insanely high. Going back to extremely low carb only until she's back under 400.

Since we had a near hypo the other night (http://www.felinediabetes.com/FDMB/...7-4-55-and-dropping-help.224409/#post-2510943) she has been almost constantly over 500, often over 600. Can a bounce last for days? I feel it's been impossible to refill her depot on a low dose. I was feeling so optimistic a few days ago but her numbers have been off the charts and she's sooo hungry and thirsty again!

 

[Sue and Luci]

Hello there..looks like you only have 10 days of testing - at least as far as I can see. I'm not sure that I'd say her nadir is indeed at hour 11...since that doesn't seem to be the same case at night.

She had her lowest number at 4+ on 1/17, so if I had to guess I'd say that was more likely a nadir than the other one at PMPS...

The other thing that jumps out at me is that you're switching the dose up frequently - not advisable. If you're following SLGS you should hold the dose for 14 cycles before changing it - unless of course Dino Baby earns a reduction by dropping below 90.

Best to continue to hold the dose. Give the injection at consistent time of day - I see shot times at various times. Test as often as you can to establish a pattern to determine when her nadir is. Lantus usually hits between 2-4 hours after the shot. She needs time to build the depot since Lantus is a hormone, it takes time to build up to a therapeutic dose.

This is not a sprint, it's a marathon...takes a while to get things to stabilize.

 

[Wendy&Neko]

First off, Dino Baby earned a reduction down to 0.75 on the 16th. You held it for a couple days, then increased. I am guessing because of those preshots you saw. Lantus dosing is based on nadirs, or low points, not the preshots, unless of course nadir is at +12.

I would go back to 0.75 units, and hold the dose seven days, unless he goes below 90 before the 7 days are up. At the end of the seven days you do a curve and decide if you need to increase.

And yes, bounces can be ugly and last six cycles or three days. That’s where you have to learn patience. Nadirs can also be later if they are breaking a bounce. My kitty nadired as late as +13. I didn’t do anything different with the feeding schedule as a result. Feeding after nadir, when the insulin effect is waning, can shorten duration and cause even higher number at preshot.

Nadirs can be different times if not bouncing, for example, night of the 16th, the nadir was at +4.

 

[Sienne and Gabby (GA)]

Nadirs can and do move around as Wendy noted. (Why would cats want to be predictable and make our lives easy?) Many of the people who use Lev have cats with a late nadir.. Lev typically has a later onset and nadir. You need to think about it as though the entire cycle is pushed forward. If the nadir is late, then numbers may be rising during the early part of the cycle and then start to drop to the nadir which is then late in the cycle.

Frankly, I was very glad Gabby's nadir was early. It seemed much easier to deal with. Well, except for the fact that she was a diva and she could plummet within the first couple of hours after a shot.

 

[Charlotte + Dino Baby]

Hello there..looks like you only have 10 days of testing - at least as far as I can see. I'm not sure that I'd say her nadir is indeed at hour 11...since that doesn't seem to be the same case at night.

She had her lowest number at 4+ on 1/17, so if I had to guess I'd say that was more likely a nadir than the other one at PMPS...

The other thing that jumps out at me is that you're switching the dose up frequently - not advisable. If you're following SLGS you should hold the dose for 14 cycles before changing it - unless of course Dino Baby earns a reduction by dropping below 90.

Best to continue to hold the dose. Give the injection at consistent time of day - I see shot times at various times. Test as often as you can to establish a pattern to determine when her nadir is. Lantus usually hits between 2-4 hours after the shot. She needs time to build the depot since Lantus is a hormone, it takes time to build up to a therapeutic dose.

This is not a sprint, it's a marathon...takes a while to get things to stabilize.

It’s true, we’ve been struggling to keep her shots fixed at 12 hours with our tricky schedules. That’s something we can definitely improve on going forward!

 

[Charlotte + Dino Baby]

First off, Dino Baby earned a reduction down to 0.75 on the 16th. You held it for a couple days, then increased. I am guessing because of those preshots you saw. Lantus dosing is based on nadirs, or low points, not the preshots, unless of course nadir is at +12.

I would go back to 0.75 units, and hold the dose seven days, unless he goes below 90 before the 7 days are up. At the end of the seven days you do a curve and decide if you need to increase.

And yes, bounces can be ugly and last six cycles or three days. That’s where you have to learn patience. Nadirs can also be later if they are breaking a bounce. My kitty nadired as late as +13. I didn’t do anything different with the feeding schedule as a result. Feeding after nadir, when the insulin effect is waning, can shorten duration and cause even higher number at preshot.

Nadirs can be different times if not bouncing, for example, night of the 16th, the nadir was at +4.

First off, Dino Baby earned a reduction down to 0.75 on the 16th. You held it for a couple days, then increased. I am guessing because of those preshots you saw. Lantus dosing is based on nadirs, or low points, not the preshots, unless of course nadir is at +12.

I would go back to 0.75 units, and hold the dose seven days, unless he goes below 90 before the 7 days are up. At the end of the seven days you do a curve and decide if you need to increase.

And yes, bounces can be ugly and last six cycles or three days. That’s where you have to learn patience. Nadirs can also be later if they are breaking a bounce. My kitty nadired as late as +13. I didn’t do anything different with the feeding schedule as a result. Feeding after nadir, when the insulin effect is waning, can shorten duration and cause even higher number at preshot.

Nadirs can be different times if not bouncing, for example, night of the 16th, the nadir was at +4.

Thank you for that info that nadirs can come earlier when not breaking a bounce! That totally makes sense with what happened the night of the 16th when it came at +4. And you’re SO right about the patience. Has never been my strong suit and it’s especially tough when it feels so dire. I will go back to .75 and hold for 7 days as you suggest!

It feels as if she responds so much more to her PM shot. If her PMPS is still pretty low, would it be wise for now to try to not feed her and keep testing till she gets up a little higher than normal (maybe 250 or 300) to be safe? Or in your opinion is it still safe to shoot 0.75 on a 200 at night? Should I give her food with a little more carbs with her PM shot? I just will not always be able to stay up all night testing so maybe conservative is best. Very open to suggestions on our PM routine!

 

[Charlotte + Dino Baby]

Nadirs can and do move around as Wendy noted. (Why would cats want to be predictable and make our lives easy?) Many of the people who use Lev have cats with a late nadir.. Lev typically has a later onset and nadir. You need to think about it as though the entire cycle is pushed forward. If the nadir is late, then numbers may be rising during the early part of the cycle and then start to drop to the nadir which is then late in the cycle.

Frankly, I was very glad Gabby's nadir was early. It seemed much easier to deal with. Well, except for the fact that she was a diva and she could plummet within the first couple of hours after a shot.

I think the moral of the story is I just need much more data to work with. It’s possible nadir is coming at a normal hour and I’ve been missing it these last few days by not getting enough tests in. For now I’ll sit tight at 0.75 this week and grab as many tests as I can when my schedule allows.

Gabby was lucky to have such a smart and thoughtful lady in her corner! I’ll try to be the same for Dino Baby

 

[Charlotte + Dino Baby]

Thank you everyone!!! As usual my anxiety gets the better of me and I start trying to change things instead of taking notes and being a good observer.

On the plus side, I think Dino Baby might have actually gained a couple ounces! The change is barely noticeable, but her bones seem to be protruding a bit less and she has some pep back in her step. So good to hear her happy little chirps again!

 

[Si am cat mom]

It looks like from the notes, there have been a few times where the shot was late because you waited for the BG to come up so that you could give a dose. I think if you look at your data, the BG values for even your +10 are lower than the AMPS numbers, so you can see that she is usually coming up by the time the shot is due. Is there a number that you feel comfortable shooting- where you would be able to shoot consistently so you don't have to reduce or skip doses?
I used to grab a +1 so I could see what he was doing after I gave the insulin and found that it often continued to rise until about +2...ECID but some more data might help you feel better about shooting numbers from 150-200 if you know what happens after you do.

Just for reference with SLGS :
How to handle a lower than normal preshot number:

Until you collect enough data to know how your cat will react, we suggest following the guidelines in the FDMB's FAQ Q4.4:
Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.

• Below 150 mg/dl (8.3 mmol/L), don't give insulin.
• Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
  • a.) give nothing
  • b.) give a token dose (10-25% of the usual dose)
  • c.) feed as usual, test in a couple of hours, and make a decision based on that value
• Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
• In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
• Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.

 

[Sienne and Gabby (GA)]

Dino Baby is gorgeous!! I do love those orange kitties!!