20/26 BG but not neuro signs?!

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kphmitten

kphmitten

Member Since 2011
So, funny story is I work at an emergency vet clinic.

But my diabetic cat is the one who is going to make me crazy.

Due to irratic hours and my mom not comfortable home testing him, he gets tested/shot at odd times.

September 24 @ 12:08am - 170 (no insulin)
11:51am - 275 (1.5U Lantus)
10:22pm - 382 (2.5U Lantus)
September 25 @ 2:47pm - 370 (3U at vet rec)
September 26 @ 12:36am - 52!!! (No insulin, Karo syrup - Cat proceeded to hide and/or fidget too much for blood so I kept checking him every few hours and he was perfectly fine. He complained every time I flipped the bed skirt and started talking to him)
12:55pm - 380 (2.5U vet rec)
10:50pm - 20!!!!!! Retested other ear at 26. Karo syrup
11:35pm - 32 - More Karo syrup, treats, and dry food.

The thing is, he's still acting completely...normal. I know cats hide their pain well but shouldn't he with numbers this low be in a coma or seizuring or something? At least then I'd know what to do. But he's arguing with me about testing and hiding under tables and giving me dirty looks as he tries to lick all the syrup off his gums.

Background: He was diagnosed a while ago. Over a year ago? Two years ago now? Times flies. He was on Humulin N and was fairly steady (low 300s). He started dropping weight but otherwise seeming fine. My vet was hesitant about switching insulins saying it's always worked. So, I switched just him to a new vet that specializes in cats and has a fantastic reputation. We switched to Lantus September 5th and are still playing with dosing. I tested at home but not as strictly as the new vet has me doing so I sort of feel like I'm starting all over again. Really, I've been a hot worrying mess for the last three weeks. He's never dropped this low before though.
 
Wow, yes with a 20, you should be seeing some sort of hypo signs. I have to ask what type of meter you are using (only because certain meters have been noted to show "odd" numbers. Are your strips okay (not past the exp. date)? And have you tested the meter on yourself to see what you get?

One thing that's messing you up is the dosing. Unless you dose identical doses AM and PM, you're going to get wonky numbers. Does your vet understand that Lantus doses are determined based on the nadir number and not on the preshot numbers? With Humulin, you can dose based on preshots primarily, but Lantus isn't effective that way.

There's a wealth of Lantus specific information on the Lantus TR forum in all of the "stickied" threads towards the top of the forum that will help you in understanding the way it works. Great info to give to your vet. Also the AAHA guidelines for insulin dosing would be a good thing to share.
http://www.aahanet.org/PublicDocuments/AAHADiabetesGuidelines.pdf

Carl
 
Re: 20/26 BG but no neuro signs?!

Relion Confirm, test strips aren't out of date. I kept trying to poke myself but wasn't getting any blood from me. I tried to go find one of my other cats that is good for a scratch or two to no avail. ;)

I'm not sure if he does? He told me to go via preshot and base on that. Or that's how I understood. Maybe I misunderstood, that's possible. He wanted me to give him 3units BID daily. That seemed high to me so I slowly started increasing his dose from his previous 2units BID Humulin. but then he'd drop to under 150 and I'd skip a dose or was told to reduce if it's under 250 (under vet rec) so that's why he keeps getting different doses. I very well could have misunderstood him and that explains why I can't get him to steady.

He's slowly raising up his numbers to 46 right now. I'm going to go out tomorrow and get the control solution to see if it needs recalibration. I couldn't find the bottle earlier. Grr!
 
Just keep testing every 15-30 mins and feeding HC food until he is well up into the 70s, 80s, 90s. and staying up. With that much insulin you may be in for a long night of keeping his BG up. He may continue to drop after the food raises him up.

You may not see any symptoms, some cats are like that. Is he hungry, spacy? Beau tried eating out of an empty dish when there was one with food in it nearby. I think he ate that last of the food in it and just kept licking at it. He as in the 20s when it finally dawned on me to test. No other symptoms. He maybe moved a little slowly.

I guess I don't need to tell you that the dose increases the vet recommended are way too much. Two increases to 100% more in a few cycles is irresponsible. Increases should be no more than .5u, held at least 3 days and then a curve done before considering another dose change.

I would suggest dropping back to 1.5u and waiting a few days, then getting mid cycle tests to see how low he is going on that dose. But if he is lower than normal at preshot time either do not give insulin or give even less - like .5u.
 
I think your testing supplies are working correctly. These numbers are completely reasonable after the huge dose increase the vet recommended. I do not think this vet knows how to dose lantus. It is NOT based on preshot numbers. Dose changes are based on the nadir (lowest point) - you have to look at the entire cycle, but you can not ignore the nadir. And you would never, ever go from 1.5u to 3u, or start at 3u, if that was what he recommended.

There is very good info on the lantus ISG about how to dose with lantus. You can trust that information it comes from vets and lay people who are experienced with using this insulin.
 
Sheila has given you some great advice. The dose needs to be lowered, and it needs to be low enough to let you give shots twice a day and not have to skip shots.

One other thing your vet said that is odd:
My vet was hesitant about switching insulins saying it's always worked.
Click to expand...
Very odd to see a vet say that Humulin has "always worked". At least from reading here, it's rarely effective with cats. Best suited for dogs but it doesn't last long enough in cats (cats metabolize insulin twice as fast as humans or dogs do). So Humulin is usually only effective for 6 or maybe 8 hours with cats. Lantus, on the other hand, will work for 12 hours at least. Provided the dose is right, it lasts around the clock when you are dosing twice a day, and will lead to more level BG numbers over the course of the day. You'll still see ups and downs initially, but eventually, the cycles will be overall lower, and more "flat".

Carl
 
My old vet made the Humulin comment so I switched. I thought to a good vet because I've heard good things. Maybe I didn't understand his instructions so I'm hesitant to blame him.

*sigh*

I did e-mail him earlier to see what he had to say about Manny's crazy numbers. I'll take the advice here and go back to 1.5u for three days. How do I know when to give him more/less? I've perused the boards a bit but am having trouble, even in the Lantus board, finding something that is like, "OK, do this and this" in plain English. I've read the tight regulation and lose regulation protocol and I suppose I feel like it's a bit over my head if that makes sense? It also might be because it's late and I'm nodding off but keep checking Manny. He went to 44, then down to 42. More syrup and I decided to try some dry food we give the outdoor cats. My mom and I had wiped the house out of all "high carb" wet cans when I read about the wet food diet last year. I guess I missed the "keep a can or two for emergencies" part but at least we had Karo syrup!

He still seems great. He's eating well, no confusion or anything. No dazed attitude. In fact, my other cat is playing fetch and he's keeping an eye on him in his normal look of insult - "That's what the dog does, do you have no standards?"

I will say, I forgot, he coughed up some flem earlier today (~3pm) but no food or anything. Then he pooed outside the litterbox in the dining room. He urinates outside the litterbox but has never pooed - and it was huge! He's a maine coon but this was nearly the size of a small bowel movement from my great dane mix! Slightly runny as well. I'm wondering if this is all playing together.
 
You mentioned in your first post that he gets tested/shot at odd times. Lantus is a depot insulin and works best if given every 12 hours. If you give a shot early, it acts like a dose increase. If you give a shot late, it acts like a dose decrease.

If you can get a spreadsheet set up, and would like to come over to the Lantus TR forum, you will get more eyes experienced with just Lantus over there. Here are the instructions setting up a spreadsheet: http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207 A spreadsheet will help you and others to see in one big picture how the dose is working for your cat.
 
The only way Humulin N seems to work is on an every 8 hour dosing schedule, as it generally lasts only 8 hours at the most.

If your schedule is too crazy to shoot almost exactly every 12 hours, you may need to switch to a non-depot insulin such as ProZinc or BCCP PZI where you can adjust the dose based on the pre-shot glucose test value. Otherwise, you really need to find a time that you can shoot every 12 hours, even if it means waking up in the middle of the night to get one of the pre-shot tests and give the insulin. Anything less substantially risks your cat's health from things like possible hypo events (too low), possible diabetic ketoacidosis (too high), and organ damage (too high for too long).

It sounds like your vet may need a bit of updating on feline diabetes management with Lantus. This is not uncommon - they need to know about many different species and veterinary care is changing daily. Please print out this article and share it with him.
Lantus/Levemir testing & dosing protocol Roomp & Rand
 
Manny is just fine. I got him up, went to sleep for a few hours, then at 8:30am he was at 176. I had to go to work for a few hours and was nervous about giving him his shot so I waited. I got home at 12:30pm and he was up at 348 (I believe...he was in the 300s, I don't have the sheet with me). I dosed him at 1.5u and will stay there for at least three days. I feel awful because his ears are definitely "ouchy" from all the testing last night but he's still happy and doing remarkably well for a kitty that dropped so low.

Thank you, everyone for being there and all the advice/support!
 
See, here's the problem. The vet said not to give him insulin unless he can be tested beforehand. My mom is comfortable giving him insulin but not testing him. She just can't do it. I've explained it to her, been there while she tries, not been there when she tries, and she just can't. Manny is decent for me, and I don't mind if he's fidgety or talkative. My mom freaks out that she's hurting him and he takes advantage of her uncertainty and is extra disobedient. It's just a bad combination. I've tried testing beforehand but that can be hours before his next dose and then the numbers are misleading. If it's okay to stick him on a 12/12 schedule then that won't be a problem since my mom and I can switch off; it's the mandatory testing beforehand that's messing us up.
 
Let me give you an example that just happened to us YESTERDAY. KT has been on insulin for over a year, we test test test. During night before last's cycle, I got up and tested at +6 as I suspected (from spreadsheet history) that he would probably drop. So...at pm+6, I got a 186 - perfectly safe at half way thru the cycle....I returned to bed. When I woke up at pm+10.75 - little over an hour until his NEXT shot. His bg SHOULD have been much higher in the curve than that 186 but I don't ASSUME anything anymore....so I tested...and got a 33!!! Yes that's 33!!!!!! MAJOR HYPO NUMBER!! If I hadn't tested and shot into that number, I would have killed my cat...no other way to say it....he would be dead and I would have to live with knowing it was MY fault for not testing just like anyone taking insulin.

PLEASE PLEASE - don't let you or your mother have to live with something like that - I beg you, PLEASE don't shoot without testing. That would be a MUCH bigger and longer lasting 'problem'....

BIG HUG TOO!!!!
 
Maybe find a friend or pet sitter to teach how to test at the times you cannot?
Perhaps someone who wants to become a vet or vet tech?

Or hire a vet tech, possibly from your vet's office?

Maybe have her practice on an apple until she feels confident with her hand movements and the feel of the needle entering.

And if you apply a dab of neosporin ointment (not cream) with pain relief a few minutes ahead of time, then wipe it off, it helps reduce any annoyance from being pricked, plus aids the blood in beading up. And maybe convinces her the cat is objecting more to restraint and less to being pricked.
 
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