1/22 Terra AMPS 517 +4 355 +6 470 + 9 471

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KarenAmelia

Member Since 2012
I'm attempting now to follow the tight regulation protocol, to the degree that I'm able to understand it. I hope you will entertain my request for advice. Spreadsheet below. Also note that I will be taking readings to try and catch the nadir.

My vet wants to quickly jump to the conclusion that Terra is resistant to Lantus. I'm skeptical: we haven't really given it a fair try. How do I know when it's time to switch insulins? With the kind of sustained high readings she's having, when should I increase the dose (instead of holding it for 6 cycles)? The protocol says it's only a guideline and should be modified in the event of high flat curves, etc. But it doesn't say HOW to modify it. Shorter time before increasing insulin?

Her chart reflects that she was sick several days ago and I stopped testing her. Vet thought she may have a virus, but we didn't test and she pulled out of it. We sort of started over with 1 unit.

Terra refused to eat canned food a couple of days ago, and rather than have her eat nothing, I gave her small amounts of the Iams. That may account for her off the charts high reading yesterday morning (I guess that means >600), as well as her continued high readings. But this morning she ate the Wellness and some bits of chicken liver, so I'll try and keep her on that.

Two problems: I may have to consider her diet a transitional one between dry and canned food, and give her a combo of both. That will require higher doses. Second is the sustained high readings. This is making things complicated to know when to raise the dose. Can I go higher sooner?

She is acting okay - fur looks good, good energy, gaining some weight, staying hydrated, purring and talking, moving around well, playing with the bug. This despite the continued high readings. Maybe because she's getting some fuel into her cells, as her dose is increasing a bit and I'm feeding her lots of small meals.
 
Re: terra sustained high readings

Hi Karen,

I don't think I have seen your condo before, so I want to extend a welcome to you and Terra, from me and Weezer. I'm not experienced enough to answer your questions, but someone will be along later to help. I look forward to following Terra's progress.
 
Re: terra sustained high readings

Welcome to Lantus Land!

I tend to agree with your opinion that you haven't given Lantus a sufficient period to evaluate whether it's doing the job. There are a few things that may help with regard to how you think about using Lantus with Terra.

The first and arguably most important issue is consistency. The reason that doses are held is because Lantus is a depot-type of medication. (We refer to this as the "shed.") This reservoir is what gives Lantus it's duration and overlap between doses as well as it's cumulative effect. As a result, any change is dose means that the shed needs to catch up. What this also means is that if you skip a shot or give a fur shot, your count regarding the number of cycles starts over. It also means that if you tinker with the dose -- even adding or shaving a drop -- has an effect on the shed. Unfortunately, when you make back-to-back changes in dose, numbers can get wonky.

The other consideration with Lantus is that while it has a long duration, it is a less potent type of insulin. What that means is that it is gentle -- it doesn't yank numbers down the way many of the shorter acting types of insulin do. I suspect this is why you're feeling so frustrated with Terra's numbers. You want them to come down now. What we often see with Lantus is that once you hit an effective dose, there is a marked turn around with the numbers. Lantus does teach you patience!

I think it's pretty clear that 1.0u wasn't a good dose. You started seeing some movement at 2.0u. You just increased Terra's dose. I'd stick with the dose for 4 more cycles (2 days).
 
Re: terra sustained high readings

Hi there and welcome to LL ~O)

Sienne has given some great advice.

I too recommend that you hold your current dose for a total 6 cycles, then re-evaluate and adjust the dose if needed.

Try and work her back to 100% wet LC food as soon as possible; you are correct - the dry food has raised the numbers.

During this period of high numbers, it's important that you check Terras urine for ketones using Ketostix test strips.
You can get them at any pharmacy. If you don't have any please get some today.

If you are interested in Tight Regulation you have come to the right place.
Stick around, set up a "condo" (daily thread) and visit other condos. Tons of tribal wisdom here in Lantus Land.
It will get better :-D
 
Re: terra sustained high readings

Thanks Sienne. I tried to learn whether Terra's numbers are way out there or are similar to what others have experienced, and so I looked at several spreadsheets of folks on this forum. I had expected something like the curve that is plotted in one of the Lantus articles, where the BG , on average, falls over time. But some spreadsheets show a cat looking regulated and then going back up into the pinks and reds again. I know that being sick or having an infection can also confuse the readings, and will make them rise. I suppose it's possible that Terra has something else going on that we don't know about , as was the case the other day.

I hear you saying I should hold Terra at 2.5 U for 6 cycles. But what about if she has high readings consistently? Anyway, I hope you'll give continued feedback if I post her readings here.

Her body seems to have gotten accustomed to high blood sugar, as she seems to tolerate it okay. I was worried when I saw the over 500 readings and esp. the over 600 (maxed out the meter so it just read Hi). But she still is adept enough on her feet to jump into and out of the bathtub, which is where the litter box is...
 
Re: terra sustained high readings

There are lots of people here who will offer suggestions and support. LL is a very social community. The best way to get comfortable here is to read other people's condos (aka our daily threads). We "visit" and leave comments, ask questions, look at each other's spreadsheets (SSs), etc. It's the best way to learn about Lantus. When people stop by to say, "welcome," the really mean it!

Her body seems to have gotten accustomed to high blood sugar, as she seems to tolerate it okay.
Click to expand...
This is called "glucose toxicity." The advantage of the Tight Regulation Protocol, IMHO, is that the goal is to get your cat out of high numbers as quickly and safely as possible. The longer a cat spends in high numbers, the harder it can be to break through those numbers and get them into a better range. Like Sandy suggested, it's a good idea to test for ketones, especially if you think there's the possibility of an infection. You can get Ketostix at any pharmacy. There will be plenty of eyes on your condo. We don't let new members flounder.

Please let us know how we can help. Ask questions. People will answer. We do have a couple of conventions which will help us to know if you do have a question or if we see something that raises a red flag. We use a format for the subject line: the date, your cat's name, your AMPS#, and subsequent test results. So for today:

1/22 Terra AMPS-517​
If you have a question, edit your subject line to let people know you have a question and/or use the ? button that will insert the icon into your subject line.
 
Re: terra sustained high readings

Hi Karen and welcome to Lantus!

Everything that's been said above is right on the money!

I just want to stress - consistency, consistency, consistency! That's the biggest lesson I have learned with this disease.

It's perfectly normal to want to react and raise the dose of insulin when you see those high numbers. But you have to keep the dose consistent through the entire 3 to 5 days no matter how high of a reading you see on the meter. Believe me, I went through a couple of BGs where I had to look at the meter with one eye open and grit my teeth at the reading. nailbite_smile

As Sienne said, you are building up a shed and the shed has to fill. Once you get the shed filled after 3 to 5 days on the same dose you will see a change in the numbers.
 
Re: terra sustained high readings

Thank you thank you. I feel like a slow learner, so thanks for your patience. I know some of you are saying the same things you told me a week or more ago :-|

This may sound awful to some, but I do not want to go through (nor put Terra through) the vet ICU process when and if she gets high ketones. I don't believe in going to extreme measures for my pets; if she slides into something bad like DKA I will have her put down. She is an older cat (ca. 15 years); I've been told she has FIV; she could have other complicating health issues but I don't want to go the route of testing and lots of treatment. My priority is to try and get her BG regulated, and my hope is that she can continue to have quality life for some more months or possibly years.

That said, will people on this forum continue to work with me on the Lantus regulation? And also, given what I said above, is there still a value to testing for ketones?
 
Re: terra sustained high readings

Karen, of course we will work with you!

We do what we can for our cats and not everyone has infinite amounts of money, time, or emotional wherewithal to handle every situation that comes at them.

Keeping your cat as comfortable as possible is the key goal.

I would strongly recommend that you buy some ketostix from your local pharmacy. They are not very expensive and easy to use. So, heaven forbid it happens, if Terra did develop DKA wouldn't you want to know as early as possible through home detection rather than waiting until she is in extreme pain?

Your wanting to regulate Terra's insulin is a great step in keeping her comfortable for the time you have been blessed to share with her. You'll notice as Terra's insulin gets regulated that she will begin to feel better too.

For what it's worth, if you read my cat Cini Mini's profile, you'll see he's been through a lot. The last major incident he had in the hospital was probably him borrowing a tenth life from another cat. Heaven only knows he's used up his other nine! But if Cini were to go through another major episode where I had a "decision" to make, I'll probably have to prepare myself for the reality that he's going to have to cross over.
 
Re: terra sustained high readings

FWIW, DKA is serious and life threatening. However, it is not a death sentence. There are two current cats here that have been through multiple episodes (Tawny and Garland). Gabby had DKA, along with pancreatitis and hepatic lipidosis at the time of her diagnosis. She spent 3 days on the ICU. She's a happy and healty kitty.
 
Re: terra sustained high readings

I know that cats survive DKA, but I can't go to that expense. It will be a difficult call as to how to respond if Terra does start having elevated ketones. But I WILL go and pick up some ketone testing sticks as soon as the ice melts. I appreciate the suggestion that it would be helpful to know at the outset - perhaps better for Terra's comfort to make better informed decisions.
 
Re: terra sustained high readings

the one thing you can do to help her with those high readings is to mix her food with some water so she is well-hydrated. it keeps everything flowing through her. you don't need to feel badly about your decision and OF COURSE you can still work here! we all do what we think is right. people will give you advice so you are educated about options.

if she starts showing trace ketones the first home remedy is the extra water. so just do that anyway.

the only other bit of advice i would give you is to ask here before you increase her dose. if you're thinking it's time, just post in your subject line and say something like "dose advice?" or "dose increase?" - until you learn all the quirks of lantus that can cause temporary high numbers that you just have to wait through, it's better to have someone take a look at terra's ss and give you advice. we all have done that. i probably did it for 6 months before i felt like i could see trends on the SS on my own.

to edit your subject line, go to the first post in this thread and click "edit" - then change your subject line to reflect current information or questions. once you have an answer you can remove the question. to bump your thread to the top of the pile, add a "reply" box at the end of the thread.

and ask away. yes, we keep our eyes on everyone new to try to help you learn. we've all been there, overwhelmed by so much to learn at the beginning. fortunately, everyone is kind and will teach you what you need to know. until you've learned some, we'll basically just tell you what to do! so don't be offended!!!!

so welcome! i'm glad you're here. :YMHUG:
 
Re: terra sustained high readings

I actually see something different on Terra's spreadsheet than the others (but that's why we like to keep dosing advice public, so all points of view can be considered). :smile:

First, I haven't been following your posts on Health, so I have a very basic question. When was Terra diagnosed? Her spreadsheet starts on 1/2, is that about when she was diagnosed or just when you started testing? Did she start right off on 1.5 units?

Reason I ask is that her numbers at the beginning of the spreadsheet are not really that bad for a newly diagnosed cat. She responded to the 1.5u dose, but then bounced back up. That's very normal for a new diabetic. Then you increased to 2u before that bounce had totally cleared. She responded GREAT on the 4th cycle of the 2u dose, then bounced again (those bounces are annoying, aren't they? But they are normal at first and usually will subside).

Then it looks like you started over at 1u when she was sick. The next several dose increases were done fairly quickly and with no nadir checks. Not your fault, this is the way a lot of vets suggest doing things! But the thing is, you really don't know if those doses would have worked for Terra or not.

The curve on 2u is ugly, for sure, but it honestly looks to me like she was still in a "bounce" cycle then. What I mean is, maybe she went lower at some point during the cycles when you were not testing at all, then shot up high and those high cycles just happened to be the ones you chose to do the curve. Bounces can last up to 72 hours, especially in newly diagnosed cats, so that is a very easy trap to fall into (I've done it myself). Then you increased again, to 2.5u, and the numbers are still bad. Another pattern we usually see with Lantus is that the first couple of days after a dose increase can actually show *higher* numbers, then settle down after 4-6 cycles. Again, it's frustrating but normal.

I'm trying not to be overly technical in my explanations, but I don't think I'm succeeding. :? What I'm saying is that in my opinion, there's a pretty good chance that 2.5 units is too much insulin for Terra. There are two ways to handle this, and either one is fine. One is to reduce to 1 or 1.5 units and gather data and do dose changes according to protocol. The other is to hold the dose at 2.5 and test A LOT so you can catch any lows. That includes at least one spot check every evening because a lot of cats drop at night. You can see that even on 2 units, the cycles where you did spot checks she was ugly/high at preshot time, but hit lows in the middle of the cycle. If you had only gotten the preshot tests, you would have thought she was high all the time, but she wasn't.

Your choice, what makes you more comfortable? Either way, we're here for you.

And yes, definitely test for ketones. Even if you cannot treat at the vet, if we start to see ketones appearing we can get more aggressive with dose increases and that might help with small levels of ketones before they become a big problem.
 
Re: terra sustained high readings

Hi Karen and Terra:

Just wanted to give you a warm LL welcome and assure you that you have some great eyes on your condo.

As others have said, we post one condo per day and do the subject line as Sienne showed. So if you have questions, just to be sure it's extra clear, you want to leave the data that's in your current day's subject line and then add the questions that Julie referred to so it might look like this:

1/21 Terra AMPS 500 +2 475 +6 320 +10 200 Help Pls?

You can also click on the "?" button above the subject line. We just ask that once your question is answered, please clear the question mark off and take the "Help Pls" or "Dose ??" out of your subject line so we can help others.

By leaving all the numbers, we can quickly scan and see what has been going on that day; of course, we will look closely at Terra's SS before we offer suggestions. The other reason we keep a running line of tests in our subject lines is because there might be a number that catches our eyes that we want to discuss with you. There is so much to learn and we can't expect you to know all of it right off the bat....that's why we are here...to catch trends or numbers we see that you might not think are important.

We are a very active forum with members all over the US, Canada, Australia, Turkey. There's usually someone online most of the time. Quite frequently, we on the West Coast are just going to bed as our East Coast members are getting up...sometimes there are a few hours where it's pretty quiet but you'd be surprised how many people are on all day and most of the night.

We recommend that you print off the "stickys" and keep them in a notebook; especially important are the two that are linked in my signature for Handling Low Numbers and Dealing with Low Preshots. Just in the rare case someone is not around, those posts will help you immensely.

Please ask alot of questions....we are here to help you and Terra. We're all in this together and the combined knowledge is amazing.

And one of our mantras here: FD is a marathon, not a sprint. So take a deep breath and let's work together to help you and Terra! :-D
 
Re: terra sustained high readings

Thanks a lot Marj for the suggestions on protocol for posting. I need to clarify: should I start a new thread each day, and just modify the current day's subject line if new info comes in?

Also, Thanks so much to Sienne for mentioning glucose toxicity. I read a Pet Wikia article on glucose tox. just a while ago and find that it could shed light on what is happening w/Terra. It links to some old discussions on FDMD on same topic, which I'm avidly reading. This new possibility gives me great hope. It makes me feel confident to continue on the tight regulation protocol for Lantus and not get panicked about "rebound" and prematurely lower the dose. I wonder why I have not seen more discussion or even a sticky on this topic - it gives me something to discuss w/my vet, who immediately jumped to the suggestion that Terra may be Lantus-resistant and may need to try another insulin.

I do have a few newer numbers on the spreadsheet - not looking good, but looking not so horrible if it could be glucose toxicity at work. I'm not jumping to conclusions, but rather see that this is another possibility to hold in mind.
 
Re: terra sustained high readings

I think the higher numbers you are seeing today may have more to do with the dry food and the not so low carb canned food you are feeding.

In your spreadsheet you say that you fed dry after Terra's +4 BG reading and now the numbers are higher. That's probably a direct result of the dry food.

Dry food, even low carb dry food, stays in the system longer than canned and will elevate BG readings for a long time.
 
Re: terra sustained high readings

THanks for that last bit of info. But as to "not so low carb" canned food: I read the Binky's lists of low carb canned food and I made good choices from that - selecting for the very few canned foods on the list that are also somewhat low in phosphorus. Hard to find much overlap. Wellness also uses high quality meat, and supposedly ingredients that are okay for human consumption. Don't know if I could be confident about Fancy Feast doing the same.
 
Re: terra sustained high readings

Karen:

Yes...it's one "condo" per day which contains all of the info for that day. You can check some of the others out and see how we do it. Any time you want to add a test result, etc, then just go back to the FIRST post of the day, click on "edit", change just the subject line, click submit. If you want to post something in your condo or just bump it up for others to see, then just open it, click on "post reply" and it will add it just as you have been doing.

You can even start today if you want by changing your subject line to:
1/22 Terra AMPS 517 +4 355 +6 470 + 9 471

Just for info, Sienne has done quite a bit of research on Somogyi Rebound and it is not documented that it exists in cats. I find alot of vets look at our SSs and see the "bouncing" and think it is Somogyi. They are two different things.

When kitty is at high BGs for a while, the body gets used to those numbers. When the BG comes down as Terra's did on 1/8 and 1/13, the liver releases counterregulatory hormones and glucagon to keep kitty safe....then the BG comes back up. This is the bounce that Libby is referring to in her quote below:

The curve on 2u is ugly, for sure, but it honestly looks to me like she was still in a "bounce" cycle then. What I mean is, maybe she went lower at some point during the cycles when you were not testing at all, then shot up high and those high cycles just happened to be the ones you chose to do the curve. Bounces can last up to 72 hours, especially in newly diagnosed cats, so that is a very easy trap to fall into (I've done it myself).
Click to expand...
 
Welcome to Lantus Land!!! You have already gotten a lot of great information and it is a lot to soak in. We just wanted to stop by and say hello. Just ask a lot of questions. Everyone here is more than happy to help and there is always someone here.
 
I have a civvie renal kitty and so I shoot for lower phosphorus foods. The Wellness low carb foods that are "lower" phosphorus (they are not "low" phosphorus as in less than .5% on a DMB) are the chicken and the turkey.

While Terra appears to be bouncing, the numbers could also be additionally elevated by the dry. So it's important that as you switch her totally to canned food (hoping that you are), that you do it slowly and carefully so the
BGs do not tumble down on you once the dry food is completely gone. Looks like you are just feeding a tbsp of dry?
 
Thanks Marje. Two days ago Terra refused to eat the canned and, in desperation, I gave her dry food. She did eat that. But then the next day she was willing to eat some wet food, so I reasoned that I might try giving her a mix, measured out. It's like one day at a time. Maybe this is just a feline's fickleness coming out - seems like I can't predict what she'll want to eat from one day to next. I have wasted a lot of cans of food trying :? So I thought the best approach may be to give her a buffet at each meal: some dry, some canned, and some chopped up chicken liver, which she loves. This seemed to work today, though whenever she will take canned over dry I'm leaning in that direction. The problem with that is that it is going to make her numbers look very confusing. But the general guidance here is that fasting is worse than dry food. Reading the article about glucose toxicity, it appears that any high carb food will enhance the cycle of insulin resistance, so in that sense, the quicker she's off dry food, the better for her recovery, if she is truly having glucose toxicity. I believe that may be the case since she went a long time before being diagnosed and has probably become quite accustomed to high BG.

I could only find a few canned foods which meet the low carb criterion which are below 1% phosphorus: Merrick's Cowboy Cookout, Surf and Turf, Evo 95% Turkey/Chicken and Wellness. They are all on the high side of the low phosphorus range, really just barely making it into that category. But better than nothing. I opened the Merrick's and both she and my dogs, who usually scarf up any unwanted food, turned up their noses. I wondered if it uses a poor quality of meat. I'm impressed with Wellness' standards of quality after reading their website. Please feel free to share anything you've found to be helpful. Terra isn't diagnosed with CKD, but I suspect she may be there or getting there. And the high BGs will have caused a lot of strain on her kidneys.
 
The New to the Group sticky has a link to Tanya's renal disease site and the list of low phos foods. This is a link to an additional SS with nutritional values and contains info on carbs and phos.

What I would suggest is to put a note in the comments section of your SS as to what you're feeding. Since you're feeding a combination, you may want to note that until you're able to get Terra on to a canned only diet. If you've not seen her website, Lisa Pierson, DVM has a great site on feline nutrition and discusses transitioning from dry to canned food.

If Terra doesn't have CKD, you can probably be a bit more lenient on the phos levels especially if she's being finicky about her food.
 
Thanks. that's what I used and cross referenced w/Binky's list of low carb canned. There's very little overlap. I'm being cautious because she's an older cat, and she has been drinking water in volumes for a long time - longer than the other diabetic symptoms appeared. So I suspect kidney problems. The vet alluded to that from her blood workup but we agreed not to do more testing. Precautionary principle at work.
 
I agree it is wise to restrict her phosphorus. She is older, she is diabetic. I think it's ok to shoot for the 1.00% range....I don't think you have to get overrestrictive yet.

Thanks for clarifying!!
 
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