10/31/14 Oz Low PMPS level last night - Need Help

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Ian & Oz

Ian & Oz

Member Since 2014
Hello,
Last night at Oz's PMPS he was at 71, this was a new PMPS level for him, for both of us!
I got on here, but no one was sure whether to give his usual dose shot because of the big jump in pre shot numbers.
He has been in the mid 200's at pre shot lately, so the 71 was kind of instant.
I really need to know what I should have done & what to do when this happens again.
Any help would be greatly appreciated.
Ian
 
The first time everyone sees a green pre-shot number is always a nail biter.

There are a couple of considerations. First, are you data ready? In a way you are -- you're very good about testing and keeping track of Oz's numbers. You just haven't seen very many low pre-shot numbers yet. What goes along with being data ready is being emotionally ready. Last night gave you a chance to think about shooting low and to prepare for it the next time you see low blues or greens. I'd encourage you to think about what numbers you'd be comfortable shooting since this is going to happen again.

Most of us who are experienced with Lantus will shoot any number above a 50. So for me, a number in the 70s is a no brainer. The reality is you have three options:
  • If you're not comfortable shooting, you can do what you did last night -- skip the shot;
  • You can stall. If you had waited 30 min and re-tested, you would have seen that Oz's numbers were rising (e.g., the 87 at +1, or what was really +13 since you hadn't yet shot). The advantage of stalling (and don't feed if you do stall) is that you can determine whether numbers are continuing to drop or are rising. If you're new to shooting low, you probably don't want to shoot a dropping number. (That said, it's possible to shoot a dropping number you just need to know how your cat will react.)
  • Finally, you can shoot a reduced dose.

Each of these alternatives has its pros and cons. Skipping and shooting a reduced dose both have an impact on the insulin depot. Likewise, stalling acts like a dose reduction.

If you opt to shoot low, you have to be there to monitor and you should have a stockpile of strips and high carb food. These are the basics for being prepared to steer low numbers. In addition, you would want to get tests at +1 and +2 and maybe more frequently and you may need to continue to test.

Most of this information is in the Shooting and Handling Low Numbers sticky. It's a good reference.
 
Hi Sienne,
Is there any concern with how he didn't gradually get to the 71? That was one persons concern on whether to give his shot or not.
When someone on here was concerned about the sudden low PMPS, I had no idea what impact his regular dose would have on him, Was it ok to have given him the regular 2.25 dose in that situation?

Ian
 
For last night, if you had shot, you would have wanted to monitor as it was possible you might have earned a reduction in dose.
No worries....
If that's where Oz is heading, he'll get there again.

The favorite test is the +2 because it is a good indicator as to whether or not it's about to be an active cycle.... ( active meaning
lower numbers)
sometimes when there is a decent drop between the pre-shot number and the +2, it indicates a likely active cycle.

If you had shot last night, you would have wanted to continue testing, keeping Oz safe, ready to interfere with food to manipulate the numbers. If he goes low, you've got to give him the boost with higher carbs, or honey.

Next time, maybe you'll feel ready to shoot.....

You could have done it but that first time is always better to have some company online helping you to remember what to do.
 
Hi Rhiannon,
Thank you for your reply!
Is it concerning how he dropped to a much lower pre shot number than before?
How do you know when they earn a reduction?
I know several have told me when shooting low numbers, they will flatten out instead of dropping as low as you think they might, I do understand that they can still drop to a dangerous level, does it take awhile of shooting the low numbers & giving food before you get to the more even flat numbers?

Ian
 
I'm a wuss and have a sleep disorder, too, so I would have skipped, rather than trying to stay up monitoring.

Look for reasons for the sudden drop - did he not eat? Vomit? Have diarrhea? If those can be ruled out, then maybe .... if you're lucky ... his pancreas may be starting to kick in. If that is true, this could happen more often and you'll need to be vigilent for signs of hypo so you can intervene.

If it is not possible to be home and monitor much, you may want to back off the dose 0.25 units, for safety.

Otherwise, gradually reducing the no shot limit by about 10 mg/dL per week, so long as the nadirs are safely above 50 mg/dL on a human glucometer and 68 mg/dL on an AlphaTrak glucometer, is a way to ease into it gradually.
 
Yes... eventually they get to surfing the low numbers routine. That's what you hope for....

He had only been at his new dose a few cycles , the shed (depot) filled up and the dose was working....
It's bringing him down.
That 's what you want the insulin to do....
but his body reacts by dumping counterregulatory hormones because it's not used to being in low numbers anymore ( normal numbers) and you get that bounce.
the process continues until his body gets used to it, and he starts flattening out.... with lower numbers..... eventually, we hope, having normal numbers all the time.

Every time you see green, that's healing time for his pancreas.

You need a 49 to earn a dose reduction. anything below 50. But you prefer not to go under 30 at all and if you do, you break out the high carb/honey to get them back up.
 
Thank you Very much Rhiannon & BJM!

BJM, not sure I understand this part.
Otherwise, gradually reducing the no shot limit by about 10 mg/dL per week, so long as the nadirs are safely above 50 mg/dL on a human glucometer and 68 mg/dL on an AlphaTrak glucometer, is a way to ease into it gradually.
Click to expand...

Does "Reducing the no shot limit" mean, you're giving a shot where you might not think you could but it's a reduced dose shot?
Not sure about the 10mg a week amount either.

Ian
 
It's one thing if you know the reason for a low number. Most of the time, we don't. After all, we're dealing with cats and they like to keep us guessing. While BJ claims to be a wuss, I'm on the other end of the continuum and if I'd seen that you had a rising number, I would have yelled, "Shoooooot" providing you could could be up to monitor, had strips and high carb food). Each of us is a bit different. Sandy's point was well taken and you did exactly what she suggested -- you got more data.

At this point and like I said earlier, think about where you would be comfortable shooting. Would you shoot at 150? At 100? You need to start to think about where your comfort zone is and as Oz lands there, where will you be comfortable shooting the next time (i.e., can you shoot lower). All of FD management is a process. The goal is keeping Oz in good numbers.
 
When shooting a low number, can you steer the level using their regular food or does it need to be high carb?
I've been using his regular food to steer the low numbers but his preshot was in the 200's.

Ian
 
Hi Ian!

I'm with Sienne - if i'd been online last night i'd have been yelling "SHOOOTTTT" too.

Here's my reasoning. You are tops at testing. I wouldn't have had any doubts that you would've monitored as much as you needed to. I stayed up with you the other night and you showed up, you tested, you stayed awake even though it was after 1am for you, until we were confident that Oz wasn't going to go into low numbers. If I hadn't known that about you, I might have been more cautious about encouraging you to shoot.

The folks helping you last night were giving you good advice, given that likely they weren't going to be able to stay up with you (i think everyone helping you was on the east coast) and it would've been wrong to encourage you to shoot and then not stay with you. There was nothing wrong with skipping - you had an opportunity to see that he was rising and because Sandy encouraged you and you got a couple of tests in, you could even note how quickly he was rising. In a cat that's got a low preshot number one day there is a great chance that it won't be long, even after a skipped shot, that there will be another low preshot coming again soon.

Now you have a good idea of what he'll do again if you skip a shot. That's part of being data-ready.

However, I'm also more enthusiastic about shooting low than some are because you've got a newly diagnosed cat - that's a HUGE advantage in the diabetes dance. Newly diagnosed cats can have their pancreas heal and go off of insulin. Some cats are only on this board for a couple of weeks even, or maybe a few months, and then the cat goes off of insulin. As cats remain in high numbers their pancreas becomes damaged and the chance for it to heal and turn back on again lessens. So . . . while it would be really cool if everyone had weeks to wrap their heads around shooting low, I encourage anyone who is like you - as I described in the paragraph above - who is "showing up for class," (as Sandy says) asking questions and ready to learn & emotionally ready (ie, not freaked out by the prospect) to go for it as soon as you can monitor.

Why did he give you a lower preshot? I'd guess likely because you've gotten the dose high enough for long enough that he's spending enough time in normal numbers that yes, his pancreas is healing. This is the way it often goes. First you get lower nadirs, then the pmps typically comes down into normal numbers, and last is the amps. Of course there are the cats that don't follow that process, but that's fairly typical.

What BJM is talking about is if you are scared of shooting in the 70's, but you've shot a 150 before, make your next boundary something like 140 - so mentally decide that everything over 140 you're going to shoot. Then when you've found that to be successful, reduce your mental boundary to 130. I have to say, though, that this process is for the human, not for the cat. Some people need to go through it this way. The cat is likely to be fine if shoot everything over 50, as long as he isn't sick and you're available to monitor.

Once you do it, you'll see what happens. Lantus is great at low numbers, however, and typically when people shoot those normal numbers, the cat won't even necessarily go below 50. He might just stay in a 10point range for the next 12 hours til the next shot. It's really amazing to see. Sometimes yes, a cat will go below 50, but all you need to do is give some food and they will come back up over 50.

By the way, when Rhiannon said:
You need a 49 to earn a dose reduction. anything below 50. But you prefer not to go under 30 at all and if you do, you break out the high carb/honey to get them back up.
Click to expand...
I'm sure she meant "not to go under 50 at all" not under 30. We use the 40's to take action and bring the cat up over 50. We'd rather they stay over 50 - 30's and under can become dangerous, although many cats have dropped into the 30's and come up without symptoms or problems. Punkin got a 32 once. For safety, though, we try to keep them in the 40's and then pull them up.

Someone just arrived so I gotta go - but hopefully that helps.
 
Hi Ian

I think you did just fine last night; we don't look back and worry about it. We just move forward and learn.

One thing I"m seeing is that he possibly was lower between +7 and +12 and the 71 might have been on the way up; or he could have been surfing since he was at 77 at +7. These are things that could enable you to feel better about shooting a 71.

Remember the other night when I mentioned a dropping number vs a second dip? What's the difference, you might ask.

A dropping number is when the BG comes down from one pre shot to the next and the lowest number is at the second PS. For example, if AMPS is 300 and PMPS is 100 and it was a steady decline all day. That's a dropping number. A second dip (very common to lantus and in some levemir cats), the cat will nadir, come up a bit, and then go back down around PS but the lower number at PS is not as low as the nadir. "Typically" the kitty will then rise until the next lantus dose onsets. "Typically" being the operative word because they don't come with owners' manuals and insulin is a hormone so we can't entirely predict what the BG will do even if a cat has consistent patterns. That's why we do a +1 and +2 when we shoot a lower number until we are really comfortable with our kitty's patterns.

Shooting a dropping number takes a little time and experience to do because numbers will likely keep dropping until the next shot onsets and then they can drop more. The great thing about shooting a dropping number (as long as it is above 50) once you have experience is that it allows you to take advantage of carryover and overlap to get the nice long, flat curves.

Carryover - insulin effects lasting past the insulin's official duration
Overlap - the period of time when the effect of one insulin shot is diminishing and the next insulin shot is taking effect
Click to expand...

Also, the other night, I had you feed the curve as a lesson which I meant to get back and discuss on Wed but work had me busy. Normally we don't need to feed the curve at the numbers you had; however, it gave us a great opportunity to see how he responded to using his regular, LC food to manage the curve when he was still high enough to be safe. Often times, the first time a new member has the chance to feed the curve is when they get a number like you did last night at PMPS. Then things become a lot more anxious for them. But I wanted you to see how Oz responded to food given at specific times to slow the numbers a bit when you didn't have to worry about him being below 100. That lesson could have been applied to last night if I had come back on when I meant to and discussed it with you. I apologize that I wasn't able to get back around. I'll do better next time. :-D

When you are trying to decide whether to shoot a lower number if no one is around to help, look at his SS and decide where he "might have been". Were numbers coming down all day? If so, it's definitely worthwhile to stall a bit and see if he comes up. Is the PS a second dip? If so, you can still stall but really, you'd be ok to shoot on time and get a +1 and +2 provided the number was one you felt comfortable with shooting (above 50 but you might want to ease into that by shooting those 70s first), you had plenty of supplies, you could stay up and test. Refer to the "Shooting Low Numbers" Sienne linked; it's a great help.

When shooting a low number, can you steer the level using their regular food or does it need to be high carb?
Click to expand...
It depends on the number, the situation, and the cat. If Oz is really carb sensitive, you might never need high carb. Even if he is not overly carb sensitive, you might be able to shoot a 70 and manage his curve to keep him above 50 with low carb food. It's usually a good idea to feed a couple good tsps of LC when you get that first green number (above 50), retest, if he is still dropping, give more LC. When he gets to 50 and if he's still dropping, then you might want more carbs on board.

The other thing to look at when using food to manage a curve is where he is in the cycle. The further past +6 you are, usually the less carbs you need because the insulin is normally starting to wane:
Example of an ACTIVE, but NOT necessarily typical Lantus cycle:
+0 - PreShot number.
+1 - Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number. You'll probably see an active cycle if the +2 is the same/similar or lower than the preshot number. Continue testing!
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 - Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (one of the quirks of Lantus/Levemir: some cat's blood glucose numbers dip around +10 or +11... not to be confused with nadir).
+12 - PreShot number.
Click to expand...

Think of feeding after nadir as a car coming up to a stop sign. When you feed, it's like suddenly slamming on the brakes and so you don't make it to the stop sign...you stop right there. If you don't feed or you use less carbs if he's low, then like a car where you just take your foot off the accelerator, he can glide to the next PS (stop sign).

These are all things you will learn with time as he gets into better numbers. You are asking great questions so keep it up. Looks like he is liking nice numbers!!!
 
Typically, we suggest new users not give insulin below 200 mg/dL on a human meter.

As you get mid-cycle test data showing that the nadir is safely above 50 mg/dL on a human meter, you may reduce the 200 by 10-20 mg/dL per week until you hit 150 mg/dL, so long as the nadir remains safe.

Edited to add: once you move into the Tight Regulation forum, and are testing per the TR protocol, you can move faster.

The above is true for the long-acting insulins Lantus, Levemir, ProZinc, and BCP PZI.

With Lantus and Levemir, you can reduce your no shot limit further, as long as your test data show it is safe. Typically, you are following the Tight Regulation Protocol and testing at pre-shots, at least 1 mid-cycle, and often a before bed test.
 
By the way, when Rhiannon said:


You need a 49 to earn a dose reduction. anything below 50. But you prefer not to go under 30 at all and if you do, you break out the high carb/honey to get them back up.
I'm sure she meant "not to go under 50 at all" not under 30. We use the 40's to take action and bring the cat up over 50. We'd rather they stay over 50 - 30's and under can become dangerous, although many cats have dropped into the 30's and come up without symptoms or problems. Punkin got a 32 once. For safety, though, we try to keep them in the 40's and then pull them up.

Someone just arrived so I gotta go - but hopefully that helps.
Click to expand...


yeah, I see I didn't say that clearly.... :oops:
I've had a really difficult day today dealing with my DGM .

49 is as low as you want to go with a newly diagnosed kitty.

Anything lower, you feed higher carbs and something syrupy like honey or maple syrup....
and monitor closely cause you want to be back above 50.
if you have a cat that will surf the 70's.... that's the perfect range....

so if you are seeing anything below 30.... you would pull out ice cream, syrup, maybe even head to the vet depending
on where you are in the cycle.


I'm not sure I'm saying it better this time. I hope I am.
If not, someone will say it better.
 
While the Health Forum suggests you not shoot under 200, we do not have a "no shoot number" in this forum. We recommend that you post and ask for help when you get a 150 or below or get a green number for the first time at preshot.

IMHO, reducing your shot number by 10-20 mg/dL per week until you get to 150 as long as nadir is safe could keep a cat from progressing and that recommendation is not something we follow here. Instead, we suggest you post for help and have an experienced member stay with you as you shot and numbers come down. It won't take long for you to build data so that you can safely shoot numbers above 50 as long as you have supplies and can test.

I agree with Julie.....stalling, shooting s reduced dose, skipping is for the human. Do we all do it.....yes, at first, most of us probably do. But you are a fast learner and as long as someone is with you the next green PS, you'll lesrn quickly how to shoot numbers above 50.

But then...I'm like Sienne and I believe Anne/Liz tagged me the "Borg Queen" (resistance is futile) because I like to help new members learn how to shoot green numbers above 50 just as soon as they have some data and have supplies, etc. but always...safety first.
 
Thank you very much Julie, Marje, BJM & Rhiannon!!

I'm reading over all of your posts.
All of your information is much needed & extremely helpful, I'm sure you all remember being at this stage.
It was hard skipping his shot last night knowing that I was delaying his healing time, what sleep I did get I dreamed
it was time to test him for his next shot, I kept waking up hoping it was time so I could give him that next shot.

Ian
 
yes, Ian, it's unforgettable how overwhelming all of this is when you're new. It gets easier.

Don't worry one moment about setting him back, though. You didn't. He'll be fine from the skipped shot - most everyone skips a shot here and there for various reasons and a cat will get back on track fairly quickly.

I hope you sleep well tonight. :YMHUG:
 
I was thinking about you and Oz early this morning, specifically about this tidbit that Marje mentioned above:

When you are trying to decide whether to shoot a lower number if no one is around to help, look at his SS and decide where he "might have been". Were numbers coming down all day? If so, it's definitely worthwhile to stall a bit and see if he comes up. Is the PS a second dip? If so, you can still stall but really, you'd be ok to shoot on time and get a +1 and +2 provided the number was one you felt comfortable with shooting (above 50 but you might want to ease into that by shooting those 70s first), you had plenty of supplies, you could stay up and test. Refer to the "Shooting Low Numbers" Sienne linked; it's a great help.
Click to expand...

One of the things to pay attention to when you're getting ready to shoot is that question of where he's coming from just prior to shot time. If he started the day with amps at 500 and dropped steadily to pmps at 60, you would want to stall to make sure he wasn't plummeting. A cat clearing a bounce and coming down from a really high number can get some big momentum going, and you want to have that momentum stopped or slowed so it doesn't go straight into low numbers (below 50).

If the cat started the day at 85 amps, and was basically flat all day and 60 at pmps, that's a "go for it" time.

If the cat started the day at 200, went down to 50 and back up to 100 at pmps, that's another "go for it" time.

I just wanted to add those little scenarios - the time to be cautious in shooting low is if you have a plummeting numbers situation prior to the shot, or if he's at a preshot number that is lower than you've shot before and you have to shoot and leave and can't monitor.

And always when you shoot a number lower than you have shot before, get a +1 and a +2 to see what's happening in the time right before the insulin begins to onset.

Looking at Oz's numbers for 10/31, he had a nice blue surf, which says that he's already beginning to recover from the skipped shot. You might be facing the "what to do with the lower preshot" again today or tomorrow.
 
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