3/8 I am Bagheera and I Need Help With My Dosing

[bagheerathediabeticcat]

Hello, everyone. Dale 'n' Chip was nice enough to direct me here. I am looking for some help because my blood sugar levels, while nowhere what they were like back when I first started getting treated with insulin, are not where my human wants them to be.

I was diagnosed with diabetes in last summer, and initially the vet started me on Prozinc. We started with two units, then went up to three, and then to five. It did not get my blood sugar levels under control, so the vet referred me to a specialist.

That vet taught my human how to do blood sugar testing better and she also moved me off of Prozinc to Levemir. I have endured two ear sticks a day since then, and my human sends them reports of my blood sugar on a weekly basis. At first, they were using the AlphaTrak software to track things, but since they they have moved me to a Google Docs spreadsheet.

For the past month or so, even though my human has wanted the vet to change my dosing because my blood sugar isn't where we want it, they have kept the dosing consistent. So I am turning to you wonderful humans to see if I can get some help.

I have already learned that I will have to endure an extra ear stick or two when my human can get that in. He's only able to do this a couple of times a week. I've also learned that we need to track my blood sugar readings over the course of several days to determine what to do with dosing, because Levemir accumulates and when he tests, he's not just seeing the effect of the last dose, but also of the past four or five.

So with all that in mind, here is a screenshot of the Google docs spreadsheet for the past few weeks. You can add in a reading of 301 at 6:54 AM, 282 at 2:41 PM and 320 at 6:04 PM today.

To explain what the columns mean, the date, time and reading should be self explanatory. The next column is the amount of food that I got. Then you've got the amount of the food served that I ate, and my dosing per the chart the vet gave to my human. Do not worry, though, that's not all the food I get. I also have some Nutro weight management dry food that I nibble on. My human has to have that out because my girlfriend Jacey likes dry food so he can't have just wet food out. I would say that I get about half of my calories from the wet food and half from the dry.

Also, my human mixes lingzhi tea in to the wet food because it's linked to lower blood sugar. My human figures it can't hurt!

Also, you will see that I get tested in the evening once my human gets home. But he doesn't dose me until 12 hours after the morning dose.

Head bonks and paw taps to all of you for being so kind!

 

[Blue]

Hello, everyone. Dale 'n' Chip was nice enough to direct me here. I am looking for some help because my blood sugar levels, while nowhere what they were like back when I first started getting treated with insulin, are not where my human wants them to be.

I was diagnosed with diabetes in last summer, and initially the vet started me on Prozinc. We started with two units, then went up to three, and then to five. It did not get my blood sugar levels under control, so the vet referred me to a specialist.

That vet taught my human how to do blood sugar testing better and she also moved me off of Prozinc to Levemir. I have endured two ear sticks a day since then, and my human sends them reports of my blood sugar on a weekly basis. At first, they were using the AlphaTrak software to track things, but since they they have moved me to a Google Docs spreadsheet.

For the past month or so, even though my human has wanted the vet to change my dosing because my blood sugar isn't where we want it, they have kept the dosing consistent. So I am turning to you wonderful humans to see if I can get some help.

I have already learned that I will have to endure an extra ear stick or two when my human can get that in. He's only able to do this a couple of times a week. I've also learned that we need to track my blood sugar readings over the course of several days to determine what to do with dosing, because Levemir accumulates and when he tests, he's not just seeing the effect of the last dose, but also of the past four or five.

So with all that in mind, here is a screenshot of the Google docs spreadsheet for the past few weeks. You can add in a reading of 301 at 6:54 AM, 282 at 2:41 PM and 320 at 6:04 PM today.

To explain what the columns mean, the date, time and reading should be self explanatory. The next column is the amount of food that I got. Then you've got the amount of the food served that I ate, and my dosing per the chart the vet gave to my human. Do not worry, though, that's not all the food I get. I also have some Nutro weight management dry food that I nibble on. My human has to have that out because my girlfriend Jacey likes dry food so he can't have just wet food out. I would say that I get about half of my calories from the wet food and half from the dry.

Also, my human mixes lingzhi tea in to the wet food because it's linked to lower blood sugar. My human figures it can't hurt!

Also, you will see that I get tested in the evening once my human gets home. But he doesn't dose me until 12 hours after the morning dose.

Head bonks and paw taps to all of you for being so kind!

Hi Tony,
You posted the above identical info in the Levemir forum and I did reply.

Please see the reply in the Levemir forum
viewtopic.php?f=10&t=90547

For the other posting on Tony's cat, please see the thread from the Health forum
viewtopic.php?f=28&t=90291

 

[Dale 'n' Chip]

Hi Tony,
You posted the above identical info in the Levemir forum and I did reply.

Thanks Gayle that was great info.

I actually told him to post over here for more eyeballs.

 

[Blue]

Tony posted in 3 forums, and it will be hard for everyone to keep track of what's been said.... If Tony is using Levemir, then it was good to post in that forum. I replied in the Lev forum, but then saw that Tony has posted again in the Lantus forum.

That's why I gathered up all the 3 postings into here so that others on the Lantus board know that there is already a Lev thread and a sizable thread in Health, just in case they want more info like feeding dry food, etc.

 

[Dale 'n' Chip]

...So with all that in mind, here is a screenshot of the Google docs spreadsheet for the past few weeks. You can add in a reading of 301 at 6:54 AM, 282 at 2:41 PM and 320 at 6:04 PM today.

Welcome bagheerathediabeticcat!


Now would be a good time to start also putting the numbers in your own spreadsheet.

I'd suggest you use the spreadsheet that we all use to keep track of your data.

If you have any trouble with that, Marje is pretty good and setting those up and might be able to help.

But the directions are pretty straightforward. By using this format you will be "on the same page" so to speak with those needing to look at your numbers.

 

[Dale 'n' Chip]

To get everyone here up to speed, I hope Sienne doesn't mind if copy the whole post which summarizes the problem dosing Levemir using a sliding scale.

There are several very basic points that people have been noting if you want to successfully use Lev. To summarize:

• Lev and Prozinc are entirely different types of insulin. You cannot treat Lev like Prozinc and expect good results. Fundamentally, you need to forget everything you learned about insulin and think very differently about using Lev. Lev dosing is based on the nadir, not on your pre-shot BG number.
• Because the dose is based on the nadir, you do not use a sliding scale for dosing. The dose is the dose until either a dose reduction is indicated (i.e., numbers drop below 50 if Bagheera is within a year of diagnosis or below 40 if your cat is a longer term diabetic) or if, after 3 days, a dose increase is warranted.
• Pre-shot tests tell you if it's safe to shoot. You also need to start getting some spot checks during the cycle. Again, dosing decisions are based on the nadir. If you don't know how low the numbers are actually going, you can't keep Bagheera safe nor do you know if the dose needs to be adjusted. I'd suggest you use the spreadsheet that we all use to keep track of your data.
• Lev is a depot-type insulin. Prozinc is not. The effect of Lev is cumulative. By adjusting the dose every cycle, all you are doing is insuring that you are going to get very wonky numbers.
• A canned food diet is preferable. Cats are obligate carnivores -- they do not need anything besides protein and certain supplements. Cats do not eat dry food in the wild. There's no reason to give dried food. All it does is elevate BG numbers.
• If you're still giving Greenies as treats, they are very high in carbs. Most of us use either freeze dried chicken (or other protein), jerky style treats, or cooked chicken (or steak or shrimp or whatever is compatible with your budget) as treats.

So the plan is to switch instead to the Tight Regulation Protocol.

But the question is what should the starting dose be when the cat has usually been getting around 5 units of Levemir for most shots as can be seen in the screenshot in the first post?

 

[Sienne and Gabby (GA)]

I'm not comfortable with the BG information that was posted. It's pre-shot data only and the dosing is very inconsistent. So, at least for me, the data are essentially meaningless. One option is to start with the formula for calculating the initial dose:

initial dose = 0.25 x ideal weight in kilograms​

I suspect that this will result in a dose that's around 1.0u. However, Bagheera has been on Lev for a while. We can fast track the dose. Ordinarily, we would take the dose of the previous insulin into account. At this point, because it does not appear that the dose has been worked up to its current level in a systematic way, we have no means to know if Bagheera is over what would be a good dose. Alternatively, given the lowest dose has been 4.0u, It might not be unreasonable to start at 3.5u. I'm going to ask for some additional, experienced Lantus/Lev users to weigh in, as well.

I also agree with Gayle (aka "Blue"). Overall, it's going to be less confusing if you decide whether you want to post in the Lev forum or here. There are quite a number of Lev users in the Lantus forum and the TR protocol is for both types of insulin. You are more than welcome to post here. The community and posting conventions are a bit different on each board so you'll need to feel comfortable where you're posting. This is a busy forum and there is usually someone around close ot 24/7.

The other point I would add to the summary that Dale copied is that Lev dosing is most effective if it is consistent. By that I mean that the dose at AMPS and PMPS is consistent AND the shot time is consistent. I realize that sometimes it's not possible to shoot exactly on time but to the degree that you are not shooting on a 12/12 cycle, it will effect the insulin depot and subsequently, the impact of the dose.

 

[Jill & Alex (GA)]

welcome to the group tony and bagheera!

most lev users (including myself) who have opted to follow the Tight Regulation Protocol have posted in this group on a regular basis for the last 6 years. for all practical purposes the group should probably be called the Lantus & Levemir Tight Regulation Insulin Support Group.

i would encourage you to read through the STICKY: LANTUS & LEVEMIR - TIGHT REGULATION PROTOCOL to determine if the TR Protocol is the right fit for you and bagheera. there are also several "requisites" designed to keep kitty safe when following the TR Protocol.

an excerpt from the protocol linked above (it's written for users new to levemir/lantus):

REQUISITES WHEN FOLLOWING A TIGHT REGULATION PROTOCOL WITH LANTUS OR LEVEMIR:

• Kitty should be monitored closely the first three days when starting Lantus or Levemir.
  Blood glucose levels should at least be checked at pre-shot, +3, +6, and +9. <------- initially, not every day.
  More monitoring may be needed.

• It will be necessary to test kitty's blood glucose levels multiple times per day. <------- preshot plus at least one mid-cycle spot check daily. before bed spot checks wll often offer a clue as to what kitty will do at night.

• Learn the signs of and how to treat HYPOGLYCEMIA and prepare a HYPO TOOLBOX.

• Test regularly for ketones and know about DIABETIC KETOACIDOSIS (DKA).

• Use U-100 3/10cc syringes with half units marked on the barrel for fine dosing.

• Feed a high quality low carb canned or raw food diet.

• Feed small meals throughout the day. Some kitties adapt well to free feeding.

since lantus/levemir use with felines begs for consistency in dosing and doses are primarily adjusted with respect to nadirs (the lowest point in the cycle) with only some consideration given to preshot numbers, i don't find the preshot data you've collected particularly helpful when it comes to figuring out a dose that can be given consistently. for this reason, should you opt for following the TR Protocol, i'm inclined to recommend starting over using an initial starting dose based on ideal weight.

you wrote: "Before I was diagnosed with diabetes, I weighed around 16 pounds. I dropped down to 12.5 at the time of my diagnosis. Now I am back up to 18 pounds, so I'm too fat now!" am i correct in interpreting your statement as 16 pounds is bagheera's "ideal" weight?

16 pounds = 7.3kg
7.3kg x 0.25u = 1.825 units.

since he has been given much higher doses, i would simply round that calculation out to 2 units to be administered every 12 hours. if 2u bid does not appear to be doing much, we can help with suggestions on how to safely fast-track bagheera up the dosing scale.

i'd also suggest reading through the information in the "stickies" (threads marked with star icons at the top of the "Topics" section of this forum). there's a ton of information offered in those posts... so much so that you may feel overwhelmed. it takes some time to digest all of it. we will help. :mrgreen:

please review the stickies. ask any questions you may have. we'll do our best to get the answers to you so you can make an educated decision on whether Tight Regulation will work for you.



hope this helps. let us know what you want to do and how we can help.

 

[Libby and Lucy]

welcome to LL, Tony and Bagheera!

Thanks, Jill, for writing a lot of what I was planning to write. :mrgreen:

I agree that you should pick one place to post on a daily basis. Otherwise you'll get a lot of conflicting advice. Take your time to figure out where you want to be, though. In this forum, we have users of both Lantus and Levemir. I have had one cat on Lantus and one on Levemir. Most of us use the Tight Regulation protocol. Some do not, for various reasons. Either way, we just want to help. Please read the requisites Jill listed and think about whether you want to do tight regulation or not.

Regardless of what dosing protocol you want to use, one thing that is consistent is that you do need to get some tests other than preshot tests. It is possible (and common) for cats to be 300+ at both shots but hit a low number in between. It is important to know if that is happening, right? You don't have to test in every cycle, but at least once a day at a time other than preshot, and more tests when you are home. We all try to get a before bed test at the very least.

I see that others have explained the depot idea to you and that you seem to understand now that every cycle is affected by several previous cycles. It may seem weird, but after being here for five years, my eyes have been "trained" to see patterns on the spreadsheet template that we all use. If you want to really understand how Levemir is working in your cat, you want to look at "waves" of action instead of just one 12-hour cycle at a time. You'll get to the point where you can see the waves too, but in the meantime there are plenty of us here who can help. Using our spreadsheet template REALLY helps, though, because that is how our brains are used to interpreting patterns.

I'm also going to suggest a slight change to your feeding/testing routine, as follows:

--- AMPS - test/feed/shoot
--- when you get home - looks like that is usually +10 or +11 - test and feed a SMALL snack, a tsp. or so to placate him until dinner time
--- PMPS - test/feed the rest of his dinner/shoot
--- bedtime - test

This was long, but to summarize what I think your immediate plan should be:

1. read the requisites and think about what protocol you want to use.
2. pick a consistent dose to give every time. I like Jill's suggestion of 2u, but whatever you like.
3. work on getting some tests during the cycle.
4. adjust your test/feed/shoot routine slightly.
5. set up a spreadsheet using our format. Someone can help, if needed.
6. after a few days of a consistent dose, we can help you adjust the dose if needed, using whatever protocol you choose.

Sound good? I'm signing off for a couple of hours, but will check back in later for your feedback.

 

[bagheerathediabeticcat]

I give you all head bonks and happy paw taps for responding.

I do not think I will be able to do the tight regulation. It is just not possible for my human to test me as much as is needed to do that properly. At best, he will be able to test me four times in a day before I revolt and he ends up testing human instead of feline blood. And since he disappears for 10 hours five days each week, that's more than he can test most of the time.

But today he will test three times. My 7 AM reading was 344. He just took another one at 12:30PM and it was 328. If I will tolerate it, he will get a reading for you at my normal time and them maybe right before bed.

I still think you can help him. My human was unable to attach the PDF of my blood sugar levels from August until now, but you can look at them here. As you can see, there are a lot of scary high numbers in there.

Now my blood sugars are generally in the high 200s to low 300s. Even the one test we did yesterday which came in at about where my nadir should be was just slightly below 300. I need your help getting past this plateau. He can definitely do 2 and 3. I know you are recommending two units, but given that I've had readings consistently above 300 for the past few days even though I'm getting 5.5 units, should we stick with this? And he'll get you additional readings today and tomorrow.

So given the restrictions on what my human can do for me, what do you suggest?

 

[Marje and Gracie]

Tony

I'd just like to emphasize something Libby said:

Regardless of what dosing protocol you want to use, one thing that is consistent is that you do need to get some tests other than preshot tests. It is possible (and common) for cats to be 300+ at both shots but hit a low number in between. It is important to know if that is happening, right? You don't have to test in every cycle, but at least once a day at a time other than preshot, and more tests when you are home. We all try to get a before bed test at the very least.

Right now, you would still have to make some changes in diet, etc. to meet the prerequisites of following a TR protocol. Many of our members, whether they follow the TR protocol or the Start Low Go Slow Approach work long days and do the best they can during the week.

I think the focus here needs to be (a) getting him on a good dose and (b) getting as consistent as you can with dose and time of dosing and (c) getting a spreadsheet up that we use. I am more than happy to do (c) for you if you PM me since I will need some info from you. It will take me no time at all.

Yes, we are still recommending 2u dosed every 12 hours so we can see how he adjusts to a consistent dose. As Jill said, if after a few cycles, we see he needs to be increased, we can work with you on that. What you "could" be seeing with those high numbers is he is dropping down somewhere in the cycle and then bouncing right back up. And the inconsistent dosing can also make numbers really wonky.

I don't remember if anyone has explained "bouncing" to you but when Bagheera was first dx, it's possible he was at high numbers for a while. The body, specifically the liver, adjusts to those high numbers and starts to see them as normal. When insulin is given and numbers come down fast, come down lower (they don't even have to be below 100), OR come down below 100, the liver reacts by releasing counterregulatory hormones and glucagon to raise the BG to the level the liver perceives as normal. That's what we call a "bounce". Bounces can take up to 72 hours to clear...some cats take less, some a little more, and it often varies even in the same cat.

 

[Dale 'n' Chip]

That is why I wanted you to come and talk to the guru's here, since the TR Protocol is designed to be safe with as few as 3 tests a day.

Take a look at Bandit's spreadsheet

Julia did use both SLGS and TR.

But scroll down a bit on the spreadsheet and you can see a period when I believe Julia was working 2 jobs with a long commute. There were months where she could only get 3 tests a day. And a curve every other weekend.

Bandit went Off The Juice twice and still is OTJ to this day.

 

[Blue]

Tony,
You were using PZI before and that insulin may be OK to keep changing the dose to match the test number at shot time, but you can't dose Lantus or Levemir in the same style.... it just won't work. Sorry.

You are feeding food that's going to likely make good numbers very difficult to get, and while you are at higher numbers, let's say above 240, you are opening the door to organ damage in your cat. You need to get those numbers down, or you will be causing harm to your cat's health.

Now, about the testing.... put aside any mention of 'prerequisites' because that sort of talk muddies the picture and scares people away from this forum. If you decide to post in the Lantus forum, and use Levemir, and feed dry food, and test less frequently, you can post here. There are some who will be able to help you a bit, but most will not be able to help because they are following the protocol set out and don't know how to deal with the out of the ordinary ways of dosing.

Testing can EASILY be done 3 times a day. Logically, you are home to give the am shot and the pm shot, and you most likely sleep in your own home, so when you get up, you can test and shoot, then when you are home for the pm shot, you can test and shoot, and finally, just before you turn out the lights to go to bed, you get one before-bed test. Just 3 tests a day.
Then, when you have a day off, you can do a curve, testing every 2 or 3 hours between the am and pm shots. That way you can get an idea of your cat's nadir location.

I lived alone and worked long hours, sometimes almost 12hrs on days and often 6 days a week. I know that it can be difficult at times to get a curve done, but those 3 tests a day.... they can be done. Two of my cats needed testing much more often than a normal diabetic, so I did my curves when I was able. Any test that you can get in, counts.

Some may say you have to test all sorts of times, and set your alarm and get up in the middle of the night, well, you don't. Unless you have a cat whose numbers do weird things and you KNOW that you have to watch, then OK, but the normal diabetic cat is fine overnight.... that's why you get a before-bed test - to be sure the cat has not gone too low .... some cats tend to drop lower overnight, so you need to know if YOUR cat is one of THOSE cats.

It can get like breathing, like waking up and going to sleep; you can do it.

Gayle

 

[Libby and Lucy]

I do not think I will be able to do the tight regulation. It is just not possible for my human to test me as much as is needed to do that properly. At best, he will be able to test me four times in a day before I revolt and he ends up testing human instead of feline blood. And since he disappears for 10 hours five days each week, that's more than he can test most of the time.

Four tests a day is plenty for tight regulation, at least until he starts to drop a lot. In my view, the main thing holding you back from being able to do tight regulation is diet, not testing. The Tight Regulation Protocol is not appropriate for cats that are not on a strictly low carb wet or raw diet. But that's ok, you can still work within the parameters of the Start Low Go Slow approach. With SLGS, essentially you are holding the dose for at least a week, then you do a curve and adjust the dose based on that curve. You are aiming for nadirs a little higher than we do with Tight Regulation, over about 90, mainly because you need to be more conservative to account for the unpredictability of dry food, a bit less testing, etc. Even if you are using SLGS, we still strongly suggest testing at least 3-4 times a day. The approach says to hold doses for at least a week, but of course if he starts hitting low numbers mid-cycle then you need to know about them. You may need to reduce the dose sooner than a week if he is low, but you don't want to increase the dose too quickly.

I still think you can help him. My human was unable to attach the PDF of my blood sugar levels from August until now, but you can look at them here. As you can see, there are a lot of scary high numbers in there.

I'll try to find someone to help with a spreadsheet (edit - Marje and Gracie has offered to help with a spreadsheet. Just send her a PM and she'll get you set up ASAP). Scary highs can mean too much insulin or too little insulin. You need the mid-cycle numbers to be able to know for sure which it is.

Let's look at my cat Lucy's spreadsheet for an example:

6/15/08
AMPS - 302
PMPS - 416
AMPS on 6/19 - 459

Pretty high, right? Makes you want to increase the dose, right?

But look what really happened between those shots:

6/15/08
AMPS - 302
+4 - 52
She didn't start to climb out of the 50s until two hours later, and that was with a good amount of high carb food to help.
PMPS - 416
Then down to the 90s before heading back to 459 by morning.

I'm glad I knew about those lows so I didn't increase her dose! Lots of cats' spreadsheets look like this when they first start hitting low numbers. Eventually she flattened out, and finally went off insulin.

I tested a lot with Lucy, for one because I liked learning her patterns, and second because she was a drama kitty and I kind of had to. If you look at the spreadsheet for my second diabetic cat, Jazzy, I didn't test as much. By then I understood the action of Lantus and Levemir much better so I didn't have to test as much to understand what she was doing between the shots. I tested more whenever things seemed to be changing with her, just so I could be sure I understood what was going on. Jazzy had acromegaly, which makes diabetes behave somewhat differently than it does in most cats, so I had to be careful with her.

I know you are recommending two units, but given that I've had readings consistently above 300 for the past few days even though I'm getting 5.5 units, should we stick with this?

I wouldn't, based on the numbers you provided.

Let's look at 3/5 as an example:
AMPS - 350 - gave 5.5 units
PMPS - 140 - gave 2.5 units

From this we can see that 5.5 units is capable of bringing Bagheera down to at least 140. What we don't know is what he did in the middle.

Here are two examples of very typical Levemir curves:

One could look something like this:
AMPS - 350
+6 - 80 (or lower)
PMPS - 140
- then what would typically come after a cycle like this would be either a "normal" Levemir curve, dipping lower than 140 then rising again, or a bounce back to a high number. How much lower? There's only one way to know! That would be where you need a bedtime test.

Or one would look more like this:
AMPS - 350
+6 - 200
PMPS - 140
- then what would typically come after this type of cycle would be that he will continue dropping for a while, until a bounce sets in. If they are dropping fast at shot time, they can keep dropping fast and kind of out of control if you're not paying attention. This is when extreme low numbers and hypos can happen.

He was 350 again the next morning, which might have been a bounce off of a low number that occurred the previous day. We don't know.

To add insult to injury, remember the insulin depot? Let's say he is having a cycle like the second example, where he keeps dropping. Remember that the cumulative nature of this insulin means that each cycle has influence from several cycles before it. So, even though you only gave 2.5 units at the 140, really that cycle still has a lot of influence from the 5.5 units that morning. So you have a dropping number, lower than usual and still dropping, and you have a lot of long-acting insulin in his body that you can't take back out.

So given the restrictions on what my human can do for me, what do you suggest?

Pretty much the same thing I said before:

I think your immediate plan should be:

1. read the requisites and think about what protocol you want to use. (ok, you have decided on SLGS, we can work with that!)
2. pick a consistent dose to give every time. I like Jill's suggestion of 2u, but whatever you like.
3. work on getting some tests during the cycle. (You're doing this, good!)
4. adjust your test/feed/shoot routine slightly.
--- AMPS - test/feed/shoot
--- when you get home - looks like that is usually +10 or +11 - test and feed a SMALL snack, a tsp. or so to placate him until dinner time
--- PMPS - test/feed the rest of his dinner/shoot
--- bedtime - test
5. set up a spreadsheet using our format. Someone can help, if needed.
6. after a few days of a consistent dose, we can help you adjust the dose if needed, using whatever protocol you choose.

I hope this helps. Questions?

 

[Libby and Lucy]

Now, about the testing.... put aside any mention of 'prerequisites' because that sort of talk muddies the picture and scares people away from this forum. If you decide to post in the Lantus forum, and use Levemir, and feed dry food, and test less frequently, you can post here.

Just to clarify, the requisites are not requirements for posting here, but they ARE requirements for using the TR protocol. We have people posting in this forum who are not following Tight Regulation. The low carb food thing is one of the things that gives us a safety margin for running numbers relatively low. If you think about it, if your cat is typically fed a food that is 20% carb, if you are trying to keep his glucose in the 50-120 range you will probably be giving more insulin than you would be giving if he is on a lower carb food. If one day he decides not to eat or vomits all his food, you could be in trouble. It is less of an issue with SLGS because you are not running his numbers so low, so you have more room for error if the food thing doesn't work out on some days.

Otherwise I completely agree with Gayle. 3 tests a day is easy, even if you work a lot and live alone. You're home to give the shots, and you're home at bedtime. Weekends you want to try to do curves when you can, but you don't have to sit there and test every 2 hours like clockwork. Do the best you can.

OT and kind of a side note, this ISG gets a bad rap for requiring a lot of testing. Yep, there are some people who test a lot. Many, like me, are just dataholics and we can't help ourselves. :lol: I love the "how things work" aspect of feline diabetes. Others I believe may be getting all those tests because they haven't taken the time to sit back and study their own spreadsheets and actually USE the data they have. They feel like they have to see every nadir and every curve because they haven't learned their cat's patterns enough to be able to predict the numbers they can't see. 3-4 tests really IS enough in most cases, as long as you study that data and use it to make decisions. We don't expect new people to be able to do that by themselves! We're happy to help until you start to learn your cat.

 

[Blue]

Exactly.
You can post here but it's tough to make things work with a protocol if you are not following the rules of the protocol..... in order to learn to swim, I think you need water in the pool. You can practice your strokes but you won't get far without the water.

Try it; you'll like it. Hundreds of cats can't be wrong ... the protocol's worked for them and lots never needed insulin, so there's something to it.

I have one cat who, if she became diabetic, would give me tons of trouble. She will NOT eat any wet food and she's fussy with the dry she gets. I don't even know if I'd be able to test her!
So people know that the odd cat may have issues... it'll make TR tough, but maybe you can find a workaround. Sure you can post in this forum as there are always lots of people.

So just do your best to get as close as you can to the TR ways and rules, and you may have some very good luck with your cat and get off insulin. Just don't let anyone here chase you away from posting here, OK? If they can help, they'll post; if they can't, they won't.

Gayle

 

[bagheerathediabeticcat]

Maybe we can make this work.

First, the AM test is set. It will pretty much always take place at around 7 AM because that's when my human gets up. And if he doesn't, I make him. I will sit on the bed or nightstand, patiently wait until the alarm goes off, and then, if my human tries to ignore it, I step in and do things that the black plastic thing cannot. I will tap his face, lick his face, and make him get up.

This afternoon, he was able to get a second test. And then he will test me again at 7PM and make me wait until then to eat. But that will give some data points so we can see where we are going as far as the lows go. If today's reading was any indication, it didn't do much, even with the 5.5 units being given for several days in a row.

My human does not want to get my blood sugar down to the sub 100s. If he can get me to drop another 100-200 points we will both be very happy. We have come a long way since we started, and now we need to get past this plateau. So the higher dose should be okay since I don't think we are targeting that low of a number.

Can you help me if we stick with the 5.5 units, and I get you some more data points? I will endure the torture for a few days if I have to.

 

[Sienne and Gabby (GA)]

So let me make sure I understand. You want to keep Bagheera below renal threshold (approx. 220) and above 100. However, you don't want to reduce the dose like pretty much everyone here is suggesting and would prefer to shoot the higher dose of 5.5u. Are you planning to switch to a canned food only diet?

 

[Dale 'n' Chip]

Sienne, Jill or Libby, et al can correct me if I'm wrong. The answer is yes we can surely make this work. Yes we can help you. No on shifting the status quo to settling a depot on 5.5U Levemir with the data we have now, while keeping Bagheera above 100.

Either protocol TR or SLGS with human depot insulin for felines are actually more complex than dialing in your desired parameters, even as easy as we sometimes make it all sound. ;-) That's why we have the protocols which function off the data in the first place. I'm not aware of any *safe* shortcut like that.

Sienne, what do you see as the testing framework for fast tracking?

A question for Tony, aren't the current numbers all AlphaTrack?

 

[bagheerathediabeticcat]

Yes, my human is worried that because he's been shooting me with 5.5 units, and I'm STILL above 300, if he drops it to two or three units it will cause my blood sugar levels to skyrocket. He just took my pre-shot reading now and it's at 278, which according to the dosing directions he received from the vet means I should get five units. But since you have told him that he needs to be consistent with the dosing he will stick with the 5.5 for now.

I do not know if he can manage to go all wet with me and Jacey. I think he can work on some things, though. So what I think I will have him do is give me half a can of wet food in the morning, half at night and a half cup of dry food in the morning before he goes to work but after I have consumed the wet. There's a spread of about an hour and a half between my dosing in the morning and the time he leaves for work, so I will have consumed all the wet food by then. And the dry will give me and Jacey something to eat while he is away.

He will transfer the data into the spreadsheet that you use. And all the numbers are AlphaTrak 2. If he switches to a human meter, will that mess things up?

Can you work with him this way?

He is very happy right now. My blog just got a comment from someone who is going to help commute sweet diabetic cat Missy's death sentence! That is why he needs to keep posting as me, because he's got to keep the internet persona consistent across properties. I am sure that you will agree that you can tolerate me posting instead of him if he helps keep one kitty alive.

 

[Dale 'n' Chip]

Switching to a human meter will be fine. But you will want to pick one type of meter an stick with it on the spreadsheet. Now may be a good time to switch to a human meter.

100 on an AlphaTrack would be about 70 on a human meter. Just wanted to make sure everyone is talking about the same *numbers* here.

I don't believe anyone here has suggested shooting a consistent dose of 5.5U at this point in time with what we know so far. So I'm not sure that is a good idea? Of course shooting 5.5U instead of 5.0U is not a significant difference. Perhaps what I was attempting to imply in a not so clear way, I would not change anything the specialty vet has you doing as far as the food or insulin dosing until you get a specific recommendation from someone in this thread. Everything we are discussing is still hypothetical and tentative at this point.

In other words don't take up the dry food yet until you reduce the dose of Levemir.

I guess that is another great question for the Gurus: What should Tony be shooting in the mean time while he is sorting everything out, and before he gets started with ketone testing?

 

[Blue]

Maybe we can make this work.

First, the AM test is set. It will pretty much always take place at around 7 AM because that's when my human gets up. And if he doesn't, I make him. I will sit on the bed or nightstand, patiently wait until the alarm goes off, and then, if my human tries to ignore it, I step in and do things that the black plastic thing cannot. I will tap his face, lick his face, and make him get up.

This afternoon, he was able to get a second test. And then he will test me again at 7PM and make me wait until then to eat. But that will give some data points so we can see where we are going as far as the lows go. If today's reading was any indication, it didn't do much, even with the 5.5 units being given for several days in a row.

My human does not want to get my blood sugar down to the sub 100s. If he can get me to drop another 100-200 points we will both be very happy. We have come a long way since we started, and now we need to get past this plateau. So the higher dose should be okay since I don't think we are targeting that low of a number.

Can you help me if we stick with the 5.5 units, and I get you some more data points? I will endure the torture for a few days if I have to.

Tony,
Well, I am afraid that your cat's numbers are quite often going below that 100 mark, but you just don't know because you don't test mid cycle. In case you have not been shown how the most common curve goes for cats on Levemir, here it is...
Example of a typical curve:
+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.
+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 (may dip around +10 or +11).
+12 - PreShot number.

You have numbers on your data ... 3/2/2013 at 6:08pm where your cat was at 128, so yup, you are hitting the low numbers because you are giving irregular doses and way too much insulin...

I think you better have a hypo kit handy because you will need it one day unless you make a few changes. In case you don't have a hypo kit, here's the info on getting one together.

List of Hypo symptoms
How to treat HYPOS-They can kill! Print this out!
Jojo’s HYPO TOOLKIT

Again, I will say that the testing you are doing at or around shot time is useless for deciding on a dose. Take a ping pong ball, go up on your roof, pound that ball into the ground... what happens? The ball bounces high again..... and THAT's what you are seeing when you test at or around shot times... you are seeing the HIGH numbers only.

If your cat needs a dose of 5.5u and has flat high numbers in the 300s all day long, not just at two test times, then you better test your cat for acromegaly - tell your vet to have the IGF-1 test done.
Otherwise, have your hypo kit ready because you cat is likely hitting LOTS of numbers under 100.

Cut the dose to 2u am and pm and leave it at 2u for a minimum of 3 days, feed only wet low carb food, and test at least 3 times a day with a curve done once a week.

ETA:
Sorry, please also have the nearest vet ER phone number handy in case you have to rush your cat into the vet with a severe hypo.

 

[Sienne and Gabby (GA)]

Yes, my human is worried that because he's been shooting me with 5.5 units, and I'm STILL above 300, if he drops it to two or three units it will cause my blood sugar levels to skyrocket. He just took my pre-shot reading now and it's at 278, which according to the dosing directions he received from the vet means I should get five units. But since you have told him that he needs to be consistent with the dosing he will stick with the 5.5 for now.

I'm going to try this again.. The 300 is the PRE-SHOT number. Because you are not getting any checks during the cycle, you haven't a clue how low Bagheera's numbers are dropping. Look at the information Libby posted:

6/15/08
AMPS - 302
PMPS - 416
AMPS on 6/19 - 459

Pretty high, right? Makes you want to increase the dose, right?

But look what really happened between those shots:

6/15/08
AMPS - 302
+4 - 52
She didn't start to climb out of the 50s until two hours later, and that was with a good amount of high carb food to help.
PMPS - 416
Then down to the 90s before heading back to 459 by morning.

My cat has been even more dramatic -- 400s at AMPS and PMPS and a low of 47 at AM +4.5. Dosing is based on the lowest point in the cycle, NOT on the pre-shot value. The pre-shot numbers are important only to determine whether it's safe to shoot.

Please read the starred, sticky notes at the top of the board. You need to start thinking in terms of Lev, not Prozinc. Your vet is not giving you information that is consistent with the way Lantus is used. Read the Roomp & Rand article that BJ provided in your thread on Health. Share it with your vet. And, if you want us to help you, you will need to start a spreadsheet. Marje/Gracie has generously offered to help you get a spreadsheet set up. Unless we have data, we will not be able to provide you with meaningful input.

 

[Libby and Lucy]

Bagheera is your cat. You hold the syringe and you are the only one who can decide what dose to give.

So..... You need to make a decision. Do you want to maintain the high dose of 5.5 units, or do you want to hold the amount of testing down to just a few tests each day?

You can start over at a lower dose, test 3-4 times a day, and adjust the dose depending on what those numbers show. Or you can keep the high dose and test a LOT more. If you choose#2, then you need to be committed to doing whatever it takes to keep Bagheera safe.

We have had people who choose this route, but I will tell you that it is quite a bit more stressful to start at a high dose and work down than it is to start at a low dose and work up. It is stressful because you don't know for sure that your cat is safe from hypo, so if he is running low then you will have to stay up all night or call in sick to work or whatever until he is safe. I don't mean this might happen, I mean it will happen.

If you start low and work up to a good dose methodically, you know your cat is not over dose and you don't have to worry so much about leaving the house or falling asleep. As I said, though, it is your choice.

Edited to add: I want to add that generally the people who would choose the more aggressive "start high" approach are people who have enough experience to fully understand risks, as well as knowing what they will have to do when they see low numbers that they can't control. It's not something we recommend to people who post for advice.

 

[Libby and Lucy]

I guess that is another great question for the Gurus: What should Tony be shooting in the mean time while he is sorting everything out, and before he gets started with ketone testing?

Good question. :smile:

Since we have no data on how low Bagheera is going, the only suggestion I am comfortable making is to start over. If tony wants to ditch the dry food and follow tight regulation, then 2 units is an appropriate starting dose based on his weight. If he wants to follow SLGS, then he may want to start lower than that.

 

[Jill & Alex (GA)]

dale's right. we can make this work with a few adjustments.

tony, you wouldn't be here if you weren't looking for help. we wouldn't take the time to respond if we didn't want to help you with bagheera. the number one priority around here is safety. comments/responses reflect that passion to help combined with the desire to keep bagheera safe.

one of the most difficult concepts for caregivers to wrap their minds around:
not enough insulin can result in high numbers and giving too much insulin can result in high numbers.

a common fallacy about using lantus/levemir:
it takes higher doses of insulin to pull down higher bg numbers and lower doses of lantus/lev to pull down lower preshot numbers.
an extreme example i just pulled off of someone else's spreadsheet...
PS 437 - shot 0.25u
+10 41
+12 33 - obviously too low to shoot again - no shot.
+13 57
+15 101
+17 206
+24 PS 427 - reduced dose to 0.1u

the point is a measly 0.25u pulled this kitty down from 400s to a known low of 33.

we had another cat come through here who was getting 10 units SID. all 10 units did was keep his numbers high. to the caregiver's knowledge, he never experienced a hypoglycemic event. that caregiver started over with 2u BID, eventually brought kitty back up to around 5u BID, and then after a series of reductions kitty went OTJ.

every cat is different, but the one thing we know how to do is dose safely.

what we don't know:

• is bagheera bouncing from dropping into lower numbers than his body is accustomed... resulting in those higher numbers you're seeing?
  those mid-cycle spot checks will help figure out if bagheera needs more insulin or if those higher numbers are simply a response to dropping lower than his body is accustomed. we call that bouncing.

• what's a "good" dose for you to shoot consistently instead of using a sliding scale?
  this one is tough to answer because for the most part data collected so far has been mostly preshot numbers while using a sliding scale. the sliding scale skews the data. in the interest of safety first and foremost... knowing what i know from having "done this" for almost 7 years, i would drop the dose to 2u BID. personally, i'm not a big believer in a whole lot of "settling time". if 2u BID is not enough insulin, depending on his numbers, you could systematically go back up the dosing scale after as little as every 3 - 4 cycles.

a few comments about other remarks made in this thread...

• if you'll be attempting to transition your kitties off of dry food it's more important than ever to drop the dose. the dry food may be the only thing keeping bagheera from bottoming out.

• using a human meter is fine. get one and stick with it so your data will be consistent.

• disregard the example of a typical levemir curve posted above. you were mistakenly given an example of a typical lantus curve.
  a typical Levemir curve will have an onset at approximately +4 and a nadir around +8 - +10. However, please keep in mind every cat is different (ECID).

as i was typing i noticed libby posted. i agree with her 110% on all points made.
ultimately, all decisions are yours.... let us know how we can help.

 

[bagheerathediabeticcat]

So my human gave me another test, and you can see the spreadsheet. We only have two days worth of data points because you folks said that the previous ones were not very useful.

He would prefer to be aggressive. If you look at the PDF from earlier, you can see where I was and where I am now is tolerable, if not good. So since we have progressed to a place which is tolerable, he does not want to go back to the earlier days.

Maybe we have reached a point where drugs alone will no longer work on me and I will get better results from changing the food. My human is willing to try it. If I get two thirds of my calories from wet food, and one third from dry instead of the other way around, maybe that will help.

He doesn't care. He just wants me past the plateau. He is tired of it and wants me to be better.

 

[Sienne and Gabby (GA)]

If you want to be aggressive about the dose, it doesn't matter how much or how little dry food is being fed. The dry food is going to impede your efforts to get Bagheera into a BG range that doesn't have a major impact on his health. (His numbers are still well above renal threshold.) The presence of dry food will also make Bagheera's numbers unpredictable.

If you are concerned about insuring that food is available throughout the day, you have options. Many of us use a timed feeder when out of the house. You can also make "catsickles." You mix LC canned food with enough water so it's got a soupy consistency. You then freeze the mixture in portions. (I used an ice cube tray.) You can then leave a couple of the catsickles out and they will gradually defrost.

 

[Dale 'n' Chip]

Thanks Tony for the spreadsheet. Looking good. Already gives some reference to the task at hand. :thumbup

Big thanks to our amazing Gurus for the wealth of information. Almost an overload in such a short time.

If I haven't missed something, I suspect that brings us back to where we started:

So the plan is to switch instead to the Tight Regulation Protocol.

Still up to Tony if he wants to try this. Not to say it will be easy or overnight.

Or that things might not *look* worse before they get better.

But to me, with all the generous guidance offered, it certainly looks doable.

 

[bagheerathediabeticcat]

My spreadsheet now has more data points in just two and a half days than it normally has over a full work week. I guess that is progress?

My human plans on testing me at 1 PM today, which is plus 6, and then before I get my shot in the evening and then before he goes to bed.

Jacey and I have thrown a monkey wrench into the plan to switch to more wet food. This morning, I ate about a quarter can's worth of food and then left the rest. Jacey hasn't eaten any of it. Our human doesn't want us to go hungry, so he's probably going to have to give us some dry food after he gets back from his yoga class.

Also, should I post to the same thread or should I start a new one each day? What do you humans want me to do?

 

[Sienne and Gabby (GA)]

We start a new thread (aka "condo") each day. One condo per cat per day.

You may need to experiment with different flavors of food. Some cats tire of one type whereas others like the routine. Maybe on the way home from yoga, you can take Dr. Lisa's list with you and get a buffet of flavors to try out.

 

[Libby and Lucy]

I see a blue at +6. Please get a +8 and +10 today, in addition to the PMPS test, so we can try to see what and when Bagheera's nadir is.

 

[Jill & Alex (GA)]

yes, we're seeing progress! :mrgreen:

thank you for putting together a spreadsheet. spreadsheets are great tools for spotting trends. attempting to get some spot checks in-between preshot tests will give us an idea how low bagheera is dropping on any given dose.

speaking of dose...
have you given any more consideration to dropping the dose for the reasons many of us have expressed or have you decided to stick with a "start high" approach (saw the 5.5u shot today as well as the 121 @ +6)? the latter comes with an increased risk as well as a huge commitment to get multiple tests per day.

libby said it best:

"You can start over at a lower dose, test 3-4 times a day, and adjust the dose depending on what those numbers show. Or you can keep the high dose and test a LOT more. If you choose#2, then you need to be committed to doing whatever it takes to keep Bagheera safe.

We have had people who choose this route, but I will tell you that it is quite a bit more stressful to start at a high dose and work down than it is to start at a low dose and work up. It is stressful because you don't know for sure that your cat is safe from hypo, so if he is running low then you will have to stay up all night or call in sick to work or whatever until he is safe. I don't mean this might happen, I mean it will happen.

If you start low and work up to a good dose methodically, you know your cat is not over dose and you don't have to worry so much about leaving the house or falling asleep. As I said, though, it is your choice.

Edited to add: I want to add that generally the people who would choose the more aggressive "start high" approach are people who have enough experience to fully understand risks, as well as knowing what they will have to do when they see low numbers that they can't control. It's not something we recommend to people who post for advice."


transitioning to a wet low carb diet compounds the risk of using a "start high" approach...

from Dr. Lisa's: CatInfo.org:

for these reasons as well as other points brought up in this thread... i strongly urge you to drop the dose unless you want to become attached to bagheera's ears 24/7. BUT, the choice is yours. if you choose to maintain the current 5.5u dose keep your hypo kit stocked, know where the nearest ER is located, and be ready to go there at a moment's notice.


you'll find Dr. Lisa's Tips for Transitioning Dry Food Addicts to Canned Food VERY helpful. three of my four kitties took to canned food easily, but i had one hold out. it took almost 4 looooong months to convince him to eat canned. the best advice i can give you is to remain persistent. i sprinkled grated parmesan cheese, fortiflora, crushed freeze dried chicken, or dry food ground into a fine powder on top of canned food as enticements to get him to eat. not going to lie. that 4 months felt like the longest 4 months of my life! the turning point for him came when i introduced raw food to my crew. he took to raw food like a duck to water! wish i would have known that earlier!




edited to add:
given the current dose of 5.5 units, that 121 @+6 begs for spot checks at +8 and +10 as well as at PMPS.
lev nadirs are often found around +8 to +10. ECID.

 

[Dale 'n' Chip]

And that would be a green 91 on a human meter.

I have to say I'm nervous about the "Start High" approach. :shock:

 

[Blue]

Oliver's nadir was around +10 or later on Levemir.
It may help others to be aware that Tony is using an AlphaTrak meter to test, so the numbers on his sheets would be much lower if using a human meter as many others are using.

 

[Dale 'n' Chip]

Exactly Gayle. 30 points lower.

He should note "AT meter" on the Spreadsheet.

I'd advice switching to a Relion Confirm or Relion Micro human glucometer from Walmart with matching test strips.

Reliable meter, uses little blood = easier to test. Much cheaper test strips.