2 weeks in, the numbers are a mess

[Grey In Ottawa]

Grey was diagnosed as diabetic and prescribed Lantus and a Libre2 CGM on Oct 16.

We are now on day 14 of insulin, but the results are not what we expected, and we would appreciate your guidance.

The main issue is his glucose response after injections. We are seeing two patterns:

1. In some cases, there is little to no change in glucose, or only a very brief lowering. We presume this is due to a technique error on our end of the needle.

2. In other cases, approximately 2.5 to 3 hours after injection, his glucose drops over 8 hours from >400 to around 90-140 and then rises back to >360 within an hour to 90 minutes of bottoming out. Today’s injection he did this twice going from >400 to 180 to 336 to 126 to 350 all in the span of four hours.

The only day the insulin worked as expected was October 24th, when it dropped from HI to 270 about 2.5 hours after injection and then remained between 270-306 throughout the day. I believe that was the day we switched to flank shots, which seem to work better and are more agreeable to him.

We are currently giving him one unit at 8am and one unit at 8pm. Briefly he had moved him to 1.5 units after multiple no-response injections, but we returned to 1 unit as at 1.5 we assumed the rapid rebound was because the dose was too high.

Additionally, we have noticed that the CGM often enters diagnostic mode and does not provide readings for 10–15 minutes, and occasionally for 60–90 minutes. This happens 5+ times per 24-hour period. Is this normal?

We don't think 1 unit is high enough, but would like to understand the implications of going higher: would it make the dose last longer? On 1 unit his nadir is around 8 hours following the dose, and on the days we get the full dose in him he touches 90-140. However he always returns to his HI starting point before the next one; We are terrified of inducing hypoglycemia, and if he can get to the 90-140 goal on 1 unit, is there any benefit to increasing the dose? The potency seems ok, but the longevity less so.

We would greatly appreciate any advice on how to interpret any of this and proceed for Week 3. Our short-term objective is to establish some consistency and for him to spend most of his time below 270 mmol/L, where he seems most content and like his old self. My expectation was that this would be a more gradual and smooth lowering of glucose levels and I am finding the rapid changes alarming.

Current regimen: 1u Lantus 2x per day
Diet: Fancy Feast pate, fresh cooked chicken, and Tiki After Dark
Feeding: offered at shot time and left out for him to nibble on into the day and overnight

 

[Grey In Ottawa]

Basically, I'd just like him to get more out of all the poking and jabbing. I have noticed that in week 2 his HI readings now orbit around the 378 mark, so he has made some metabolic progress on that front. He clearly feels terrible when his glucose is at that level, though, so even if it weren't harmful (it is) I would still be determined to get him into a comfortable range.

In sum, we have a slightly delayed onset of 1 unit of Lantus (2.5 hours or longer), delayed nadir (8 hours), followed by a rapid return to HI. Many jagged lines, reversals, Libre blackouts, etc, along the way: occasionally his numbers slide down, but more often they're a scary cliff-dive: eg., after waiting three hours last night for a response, he suddenly went from 378 to 198 in an hour (!).

I see these graceful glucose curves posted everywhere, and then look at our graph, which looks like a soap box derby car crash landing, and can't help but suspect there's room for improvement.

 

[Kat & Trixie]

Hello and Welcome to FDMB!

Don't despair, Grey is in the very early days of diagnosis, and you have come to the right place. There are so many folks here with lots of experience and who can help. One thing you will notice on the forum is that most folks will use mg/dL to describe blood glucose values and not mmoL.

What type of insulin was Grey prescribed and what is his dose? What is Grey's feeding schedule? Do you have a spreadsheet that shows recent shot data? If not, that's okay, but it is something that will help others help you. I'm going to share a link with you that can help get you started.

It shows how to set up both a spreadsheet and how to complete your signature. Thread 'New? How You Can Help Us Help You!'

Keep posting questions, we are here to help.

 

[Grey In Ottawa]

Good advice, Kat and Trixie -- I edited both posts and converted the values to mg/dL.

 

[Lara & Luciole (Lu)]

Hey Ottawa! Waving back to you from Montreal! You've found the best place for trusted advice.

One thing I'd say is that you're just starting with treating your diabetic cat, and it's really up to your cat to acclimate to insulin on their own time. Marje, I believe, would tell you to put on your patience pants.

Your cat's body will get used to insulin, but while it does you'll see some bounces, for sure. It takes time

 

[Grey In Ottawa]

Hello! You're right -- I'm happy to meet him where he's at, I'm just concerned that we're going through the motions but not getting the best outcomes for him. Yet I don't want to make any sudden moves, either.

I've been lurking this board for a few days already, and thanks to you guys I have honey, Whiskas (Sheba) with gravy, a spare glucometer, all ready to go.

We sleep in shifts to monitor his nighttime dose. When did you all start sleeping through the night?

 

[Wendy&Neko]

Hello, and waving from the west coast. We have many sayings here, on is "feline diabetes is a marathon, not a sprint". Two weeks is very early in the journey. Insulin is a hormone, not a drug, it takes a while for their body to get used to it and for you to find a fitting dose.

One of the behaviours that you are seeing is something that we call bouncing:

Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

Sounds like Grey is both dropping fast and seeing numbers his body is no longer used to. The more time he spends in normal blood sugar values, his body will get used to those numbers and reduce the amount of bouncing.

How often are you feeding Grey? And what food are you giving him? Many diabetics do well with several small meals and those meals at the beginning just before onset can help slow down those fast drops - which cause bounces.

We sleep in shifts to monitor his nighttime dose. When did you all start sleeping through the night?

Right away. Back in the day, the Libre was not a thing. The Libre is both good and bad. You have lots of data so you can see what he's doing, and you have lots of data so you can obsess over his numbers. The other thing to keep in mind, in lower numbers under 100, the Libre can registers numbers a lot lower than a blood glucose meter would. Our dosing methods go by the blood sugar values.

You should be able to start seeing patterns in the data, if you use the spreadsheet. Those patterns are over several cycles. Also, a tip that can help Lantus users - is to compare his preshot number to his +2 (maybe 2.5 for you). If the +2 is the same as the preshot, it'll be a normal Lantus cycle with some downward movement. If the +2 is quite a bit lower than preshot, it'll be quite an active cycle needing more monitoring. If the +2 is higher than the preshot value, time for sleep! Note, where I say +2 above, you have to see what works for Grey. For my girl, who had a later onset and nadir, the +2 wasn't useful, but +3 or +4 was useful as a cycle predictor. So I could potentially go to sleep after that +3 or +4 test. That is one thing good about bounces, great cycles for sleeping.

 

[Lara & Luciole (Lu)]

Folks can't really help you until we see how Grey is using his insulin. Right now we have no idea, so please get your spreadsheet set up and linked in your signature as soon as you can. Looking forward to getting Grey regulated!

 

[Grey In Ottawa]

I now wonder if some of our difficulty is due to the syringes we're using. The vet's office started us with a handful of 29 gauge 13mm syringes, and then when those ran out they topped us up with 31 gauge 8mm syringes. Smaller seemed better but ever since, it's been more partially or un-successful doses than successful ones.

in lower numbers under 100, the Libre can registers numbers a lot lower than a blood glucose meter would. Our dosing methods go by the blood sugar values.

Interesting. To clarify, do you mean the Libre could show 80-100 (4-5) when in reality he's a little higher than that?

If the +2 is the same as the preshot, it'll be a normal Lantus cycle with some downward movement. If the +2 is quite a bit lower than preshot, it'll be quite an active cycle needing more monitoring.

This is a very helpful rule of thumb. I think we might be in for an active cycle this morning.

 

[Lauren & Esse]

To clarify, do you mean the Libre could show 80-100 (4-5) when in reality he's a little higher than that?

In my experience, 80-100 is typically pretty accurate, but the low-lows (LO to 60) can be anywhere from actually low (30s) to 80s. It's also important to understand that since the Libre is reading interstitial fluid, not blood, there is a delay between them. This video is helpful for explaining that.

If you're able to, learning to use a handheld glucometer is extremely helpful in being able to verify lower numbers. If you look in my spreadsheet in my signature and scroll down to about July, you can compare some of the values I've checked--I have the Libre numbers in the main grid and the handheld glucometer numbers color-coded in the "Remarks" on the right side.

Edit: Sorry if I missed someone else linking it, but this is our page for getting started with CGMs.