4 days on Lantus and already earned a *mandatory* reduction?

[Dale 'n' Chip]

Perhaps someday soon I will be ready for tight regulation but for now just trying to navigate the minefield of the 16 hour supercharged Lantus hypo. ;-) Of course on the long holiday weekend no less. Humulin N has nothing on that... it's gone almost before it started. :smile:

Chip's Lantus Record

Food is FF classics. Meter is relion confirm. Chip is 6yo 15 lb Main Coon, ideal weight more like 16 lbs. Been hometesting for 8 months. On (and off) Humulin N for just over a year since diagnosis. After a nasty 10 week long Humulin N *rebound* this spring which saw the return of neuropathy I finally decided it was time for *real* insulin. Thus on Lantus 1.0 U bid for the last 4 days. And I'm quite happy with the response so far but need to hit the correct dose and be ready when the pancreas comes back to life, which past experience suggests might be as soon as in a week or two.

Looks like the AAHA guidelines say to reduce to half a unit if at any time the level falls below 150. Other dosing schedules seem to reduce by a quarter unit.

So should I start over with a half unit now, or instead carefully ride the next (likely) 36 hour rebound at the current 0.75 U dose and then go 0.5U just before the bounce clears? Seems to be plenty of warning when the rebound is fading. That's the only reason I reduced to 0.75 U even though he was still over 200 AMPS. With what happened next that seemed like the correct move rather than skipping the shot altogether. Perhaps I over reacted to that dip this morning but the greens were too early in the cycle, and I had to work harder than expected to get him up to safer levels considering our lack of experience with Lantus. Will I ever survive tight regulation? :smile:

So a few more cycles @ 0.75U or should I drop now to 0.50U and just endure the bounce?

Thanks,
Dale 'n' Chip

 

[Sienne and Gabby (GA)]

Re: 4 days on Lantus and already earned a *mandatory* reduct

Welcome to Lantus Land!!

I'm not entirely sure what the AAHA guidelines are based on. The protocol we use is based on research that has been published in a leading veterinary journal and has an excellent track record to getting cats into remission. Falling below 150 is not the cut off we use with the Tight Regulation protocol nor is it the cut off if you are using the Start Low Go Slow (SLGS) protocol. (Please note that if you use SLGS, the dose reductions for Lantus are 0.25u, not 0.5.) With SLGS, the drop is below 90 for a reduction.

Since you are already home testing, feeding low carb, and able to test at pre-shot and at least one additional time during each cycle, there's no reason that you can't use the Tight Regulation Protocol.

You need to remember that Lantus is lower in potency but longer in duration than most of the other types of insulin -- certainly compared to Humulin N. I'm concerned that if you reduce by 0.5u, your reduction is going to fail and you will have a difficult time finding a good dose. With Lantus, in most cases, you want to change the dose by 0.25u.

While this may be semantics, unless Chip was demonstrating symptoms of hypoglycemia, what you saw was a lovely cycle with Chip dipping his toes in dose reduction territory. These are low numbers -- not hypoglycemia. Only when he's symptomatic is it considered a hypoglycemic episode. You did a great job with monitoring. I'd strongly encourage you to take a look at the sticky on Handling & Shooting Low Numbers -- especially the section on handling low numbers. We recommend testing a bit more frequently if numbers are dropping so you don't get caught by surprise by an unexpectedly low number.

As I indicted, I would hold the dose. Reducing the dose, especially when a dose reduction isn't warranted, will not help with a bounce.

Please let us know how we can help. The people here are incredibly generous with their time and their knowledge. We're happy to answer questions and lend a hand in whatever way we can. I hope you'll continue to post regularly, visit our "condos" (aka our threads), and look at our spreadsheets.

 

[arozeboom]

Re: 4 days on Lantus and already earned a *mandatory* reduct

Welcome to Lantus Land!
I never thought we'd survive "tight regulation" either, but after 8 weeks of it, Ruby decided she'd had enough. Its been 5 weeks and 2 days since her last dose of insulin!

We couldn't have done it without the help of every one here. You've found the right place!

 

[Marje and Gracie]

Re: 4 days on Lantus and already earned a *mandatory* reduct

Welcome Dale and Chip!!!

I agree 100% with Sienne....I wouldn't decrease his dose; those were very nice mid cycle numbers.

Please read the stickys and let us know what questions you have. We are always happy to help.

 

[Dale 'n' Chip]

Re: 4 days on Lantus and already earned a *mandatory* reduct

Thanks all for the words of encouragement.

It was a bit much excitement to already be testing the limits of 50 when I was anticipating needing to work though 180 first. But great to see such a response to Lantus. And to help confirm what was likely going on with the lack of control on too much humulin N. Of course I'm not looking forward to seeing all event horizons shift again when the pancreas kicks in.

...I'm not entirely sure what the AAHA guidelines are based on. The protocol we use is based on research that has been published in a leading veterinary journal and has an excellent track record to getting cats into remission. Falling below 150 is not the cut off we use with the Tight Regulation protocol nor is it the cut off if you are using the Start Low Go Slow (SLGS) protocol. (Please note that if you use SLGS, the dose reductions for Lantus are 0.25u, not 0.5.) With SLGS, the drop is below 90 for a reduction...

I think the AAHA example is for vets that may not have close monitoring. And 0.25 Units per kilogram starting dose for Lantus should be around 1.5 units if I'm calculating correctly. But I wonder if I should have started at 0.5U first, to see a nadir with a full shed but without buoyancy from bounce. The problem I had was shooting into steeply falling numbers (simply because the bounce was apparently clearing) yet the nadir was still coming up well after he already reached green, very near the same time we'd likely just filled the shed for the first time.

...Since you are already home testing, feeding low carb, and able to test at pre-shot and at least one additional time during each cycle, there's no reason that you can't use the Tight Regulation Protocol.

You need to remember that Lantus is lower in potency but longer in duration than most of the other types of insulin -- certainly compared to Humulin N. I'm concerned that if you reduce by 0.5u, your reduction is going to fail and you will have a difficult time finding a good dose. With Lantus, in most cases, you want to change the dose by 0.25u.

While this may be semantics, unless Chip was demonstrating symptoms of hypoglycemia, what you saw was a lovely cycle with Chip dipping his toes in dose reduction territory. These are low numbers -- not hypoglycemia. Only when he's symptomatic is it considered a hypoglycemic episode. You did a great job with monitoring. I'd strongly encourage you to take a look at the sticky on Handling & Shooting Low Numbers -- especially the section on handling low numbers. We recommend testing a bit more frequently if numbers are dropping so you don't get caught by surprise by an unexpectedly low number.

As I indicted, I would hold the dose. Reducing the dose, especially when a dose reduction isn't warranted, will not help with a bounce.

Please let us know how we can help. The people here are incredibly generous with their time and their knowledge. We're happy to answer questions and lend a hand in whatever way we can. I hope you'll continue to post regularly, visit our "condos" (aka our threads), and look at our spreadsheets.

They were great numbers in fact the first *documented* greens in months. I wouldn't worry if I knew he could eat or bounce his way out if needed. He had no symptoms and I've tested 34 on the same meter with no effects, symptoms, or intervention other than reducing the next dose of Humulin. But this time it held for longer than he should have been comfortable with in his current state. I tested at least 10 times. Even got out the Contour meter which I believe is more accurate with lower numbers. 85 on the Relion was 98 on the Contour but the Contour takes twice as much blood which of course is more difficult when poking so many times in a row. So not only are the strips twice as expensive, but I used twice as many to get the same number of tests from lack of blood.

I just need to get more data before I can do tight regulation.

And now I'm wondering about the effects of the apparently upcoming sustained 36 hour flat black bounce. :shock: I already (imagined?) increased urination during the 2 sustained flat pink bounces while on Lantus. The prior usual daily trio of humulin curves spent a portion of each day below the renal threshold. It's becoming more clear the problem is likely insulin sensitivity rather than insulin resistance, but that is the much better of the two problems to have. :smile:

 

[Sienne and Gabby (GA)]

Re: 4 days on Lantus and already earned a *mandatory* reduct

FWIW, you haven't seen "flat black" today.

We do urge some caution, especially if you are new to Lantus, when it comes to shooting dropping numbers. The Shooting & Handling Low Numbers that I linked previously outlines options if you have lower than expected numbers. The same options would apply if you have a dropping number.

The information on calculating the initial dose are most applicable to a cat that is new to insulin. If you read what amounts to the fine print, it's also noted that you are encouraged to take the dose on the previous insulin into consideration. Most people start on around 1.0u. If you put this in context with your dose of N, you were previously giving a total of 4.5u per day (1.5u TID). By dropping the dose to 2.0u, you should have been fine. Dropping the dose back was smart! It's your option if you want to drop the dose back further. It looks to me like you do a great job of monitoring and as long as you are around to do so, I think you should be fine with holding this dose.

Just so I also put this out there, a 52 is certainly reason to consider reducing the dose. You could have tested 5 min. before or after and with meter variance factored in, it's possible that Chip does merit a dose reduction. I tend to look at where in the cycle low numbers occur, what the numbers are doing, etc. when making those decisions. It's your call.

When you have a few minutes, could you also complete a Profile on Chip? It's helpful in terms of knowing when he was diagnosed, any medical problems, etc. You can then link the Profile to your signature the same way you linked your spreadsheet.

 

[Dale 'n' Chip]

Re: 4 days on Lantus and already earned a *mandatory* reduct

FWIW, you haven't seen "flat black" today...

Yes I was pleased to see him back in the pinks so fast. The black might have been pink bounce exacerbated by pushing carbs unnecessarily during the green run? He's doing good, all healed from the pokes and ready to go again. Urination seems nearly normal as well. If I can survive this we will both be just fine. And of course I'm liking Lantus so far. If I see a few more rounds of pinks with yellow nadir I may go back to 1 unit. Give his body time to get used to pinks and yellows, then blue. Hit the correct dose from below.

And 1 unit is a lot easier to measure, as long as I have enough data to know what to expect. :smile:

With the consistency/accuracy of the relion syringes it's not easy to tell my 0.75 from a fat half or a skinny one. And I've already apparently burned through 40 Units from the Pen. The thicker liquid does make more consistent droplets (than N) for counting out when microdosing but still hard to be all that accurate with small increments.

When Gabby was on N, was she being tested? Or do you have fructosamine from that period? And what was her dosing if you remember. Her control looks great for the last 2.5 years, surfing green more days than not. So that must be an example of whats possible with tight control. But with testing her hourly through nadir AM and PM when do you ever find time to sleep?

And you must use a lot of test strips! She's sure a dear. And Gizmo is something else entirely.

...When you have a few minutes, could you also complete a Profile on Chip? It's helpful in terms of knowing when he was diagnosed, any medical problems, etc. You can then link the Profile to your signature the same way you linked your spreadsheet.

I'll try to get something done on that but in the meantime here's a pic taken on his first day of Lantus. His only known issue is diabetes and he's never had steroids. Diagnosed with DKA a little more than a year ago. He looks like such a classic diabetic in the picture, however the neuropathy isn't as bad as it looks. He was slinking around stalking birds. And no he never goes outside... only on the deck, attended. :smile:

 

[Ann & Tess GA]

Re: 4 days on Lantus and already earned a *mandatory* reduct

Welcome to LL

(you didn't think you could escape by reversing the name did you? :lol: :lol: :lol: )

That beautiful green "surf" is exactly what we like to see on Lantus. Chip is off to a great start. I agree from the amount of testing you are doing there is no reason you can't do TR. The main difference in practice is the reduction point and the amount of testing we do. We do walk the line, but it is the most effective way to regulate FD.

Chip is such a handsome fellow! Thanks for the pic.

 

[Sienne and Gabby (GA)]

Re: 4 days on Lantus and already earned a *mandatory* reduct

Awwww...... Chip is very handsome!

I don't have fructosamine levels from when Gabby was on N. I also wasn't home testing at that time. The one curve that was done at the internal med vet's office had a nadir of 115. I don't think the initial level (in the 400s) was accurate since Gabby doesn't travel well and likes going to the vet even less.

Gabby was getting 2.0u of N initially. If I'm remembering correctly, we switched Gabby from N to Lantus after 4 - 6 (maybe 8?) weeks. My regular vet found that Gabby's fructosamine wasn't that good and I'd begun reading about Lantus. My vet doesn't like N (she thinks it's a better insulin for dogs than cats) and we switched Gabby over and she's been on Lantus for the past 3 years. It was about 3 mos. before I found FDMB and started home testing and it was probably a couple of weeks after I'd started Lantus. (This is the post from Gabby's 3 year anniversary and gives a bit of history.)

I do use a lot of strips. If you notice, I tend to test early in the cycle. Gabby is one of those kitties who likes to dive early. The only way I've found to keep her safe is to test early. If you go back to the early days on our SS, you'll see that I was testing at +2. After getting caught by surprise a couple of times, I started testing at +1.

The quarter units are challenging to measure. I'm assuming you have syringes that are marked in half unit increments. If not, they will make it relatively easier.

I doubt that the black was from carbs. The value of using a gravy based food or syrup to steer numbers is that the carbs are metabolized far more quickly than if you gave dry food. Unless you kept feeding HC after your AM +4, that black AMPS was a bounce.

Give his body time to get used to pinks and yellows, then blue.

I would discourage you from allowing Chip to get used to pinks and yellows. If a cat acclimates to higher numbers, you end up fighting glucose toxicity. Julie/Punkin put together several links that explain glucose toxicity. Basically, you cat begins to treat higher than normal numbers as his new "normal." As a result, when insulin brings those numbers down, you end up with more bouncing. The TR protocol is designed to be aggressive about dosing but also to keep your cat safe. This is why testing is hugely important and why doses are changed in small increments.

 

[Dale 'n' Chip]

Re: 4 days on Lantus and already earned a *mandatory* reduct

...Gabby was getting 2.0u of N initially. If I'm remembering correctly, we switched Gabby from N to Lantus after 4 - 6 (maybe 8?) weeks. My regular vet found that Gabby's fructosamine wasn't that good and I'd begun reading about Lantus. My vet doesn't like N (she thinks it's a better insulin for dogs than cats) and we switched Gabby over and she's been on Lantus for the past 3 years. It was about 3 mos. before I found FDMB and started home testing and it was probably a couple of weeks after I'd started Lantus...

2.0 units is not so crazy.

When Chip came out of intensive care he was put on 4 units bid and he wasn't even eating yet. Actually they called me down on day three of his hospitalization to come in and persuade him to eat, since he hadn't eaten at that point. I took several kinds of food. After about an hour alone with him in a life or death moment, he finally ate about 20 kibbles of his prior high carb dry. Since his IV port had failed, and the ketones were down they had me wait around and take him home over night to get him to eat. Before we left he was too low to have insulin. So they skipped the shot and sent us home. That night he didn't eat much, nor the next day back in the clinic. His glucose was high by the end of day 4 so he got 4 units of N and was sent home again to eat. This time we got home (with the prescribed Hills MD dry) and within a few hours he started inhaling the dry food (hypo event as I would later learn) but that was a big turning point.

He stayed on 4 units N bid for two weeks until his next fruct. test and urinalysis. No glucose in urine and fructosamine was below 250 umol/l: periods of hypoglycemia so his dose was cut in half, rinse and repeat. He'd regained two pounds in those first two weeks (fighting off the hypo) eating nothing but MD dry as instructed. Next time fruct. was even lower prolonged periods of hypoglycemia and no spillage in urine. Cut the dose in half and do it all again. Fructosamine was lower yet down to around 200 umol/l. The vet was kind of baffled since she apparently didn't personally believe in remission for diabetic cats, but she had the Hills sales material memorized to push the food... if he would just eat nothing but this special high tech food manufactured with a unique process to remove carbs then he would never need insulin, as long as he ate only this very special food. She must have figured the food was actually working so she took him off insulin with the warning to be sure he eats nothing but Hills MD. You can guess how that went.

Had I switched him to FF classics at the time of his last shot, that likely would have been remission or close to it. Instead, by the next fructosamine test, he was down 2 pounds and up to 500 umol/l: poor control, so back on the NPH 2.0 units bid. At least ketones were negative. After his first few (resumed) shots of 2.0 units he stopped eating altogether. So I rushed out and got some MD wet to tempt him. He ate less than half a can a day, basically just licked off the juice. I went to get some more in a week and he'd dropped 2 more pounds in just 6 days. I was horrified that I was losing him and feared the insulin (original vial) was bad, so I went on a massive quest for some answers which lead me to FDMB.

I could replace the vial or attempt hometesting for about the same price. After a trip to Wal Mart and a long night watching youtube I was hometesting by the next day. You guessed it the insulin was working too well. And I first noticed that the only time he ate well was 3-4 hours after a shot when he went low. Within a few days I tested a 34, so I reduced him to 1.5 units and he abruptly started eating the MD dry again with a vengance. I kept reducing the dose because he was going too low. That same week I got him to eat FF classics. I took up the dry. Since he was staying too low to shoot, we skipped the shots. I documented that eating FF classics would take him from 130 down to below 90, with no insulin. I determined that was his pancreas in action. That was about 3 total weeks on the resumed insulin before he was down to whiffs of humulin once a day to perhaps 1- 3 times a week, to keep him surfing below 130. Often below 100.

That pattern went on through the winter. Come spring he was up over 200, a few days since the last 110. So I shot a skinny half unit. 5 hours later he was over 500. As it turns out I could never really get that down until switching to Lantus. What I never tried was attempting to clear the bounce using whiffs of humulin, because I was afraid of those high numbers. So that brings us to the present.

...I would discourage you from allowing Chip to get used to pinks and yellows. If a cat acclimates to higher numbers, you end up fighting glucose toxicity. Julie/Punkin put together several links that explain glucose toxicity. Basically, you cat begins to treat higher than normal numbers as his new "normal." As a result, when insulin brings those numbers down, you end up with more bouncing. The TR protocol is designed to be aggressive about dosing but also to keep your cat safe. This is why testing is hugely important and why doses are changed in small increments.

I meant break his acclimation to reds and blacks, so he doesn't bounce at the first blue. But the gentle floating/drifting/surfing nature of lantus might make that unnecessary? Perhaps I should return to 1 unit now? But I don't want to get caught again in the trap of shooting down the bounce. How do we really know all bounces have cleared?

Gabby is very lucky to have a vet that's all on board. Don't get me started on that, but at least they did save Chip's life. His Ketones were 80 +++ when I first took him in for diagnosis. Glucose was 689.

But no diabetic cat should ever be taken off insulin while eating moderate carb dry food. Certainly not without glucose testing. That's just malpractice. And what about the six long weeks of Prolonged periods of Hypoglycemia. :evil:

 

[Dale 'n' Chip]

Re: 4 days on Lantus and already earned a *mandatory* reduct

(you didn't think you could escape by reversing the name did you? :lol: :lol: :lol: )

I might pass for Chip but he's not Dale so had to stick with protocol here. :razz:

According to Disney, Chip is the logical schemer, and Dale is the goofy, dim-witted one. Originally the two were of a very similar appearance, but as a way to tell them apart, some differences were introduced. An easy way to visually tell them apart is that Chip has a small black nose (it looks a bit like a chocolate "Chip" as a way to help people remember who is who) and two centered protruding teeth, whereas Dale has a big red nose and his two prominent buck teeth exposed. Chip is also depicted as having smooth, short fur atop his head while Dale's tends to be ruffled.

 

[Sienne and Gabby (GA)]

Re: 4 days on Lantus and already earned a *mandatory* reduct

The problem with a fructosamine level is that <250, which is "prolonged periods of hypoglycemia" translates to below 120. In other words, if your non-diabetic cat were to be tested, the fructosamine value would be <250, or completely normal. If a cat is in normal numbers, the test tells you nothing.

Given that your experience is with N, you are going to have to do a major shift in thinking. N is a short to intermediate lasting insulin. Lantus is long acting. With N, you can slide your doses based on the pre-shot numbers. With Lantus, the pre-shot is only important with regard to whether it's safe to shoot. Dosing is based on the nadir. As a result, spot checks are important.

I meant break his acclimation to reds and blacks, so he doesn't bounce at the first blue. But the gentle floating/drifting/surfing nature of lantus might make that unnecessary? Perhaps I should return to 1 unit now? But I don't want to get caught again in the trap of shooting down the bounce. How do we really know all bounces have cleared?

Here's where you need to think differently. With Lantus, because it's long acting, you really can't "shoot down" a number. That's an approach with short acting insulin. In addition to being long acting, Lantus is a depot-type medication. We refer to the insulin depot as a "shed" in Lantus-speak. Any time you change a dose with Lantus, you need to let the shed stabilize. Too many rapid changes result in very wonky numbers due to perturbations in the shed and the resulting disruption of the long-acting, cumulative function of the insulin. This is why doses are generally held for 3 - 5 days.

Don't worry about bounces. They are normal response by the liver. They are annoying but normal. There are several cats here who are bouncing pros. Gabby used to among them and I still see glimpses. I've had her go from the 400s at pre-shot to the 40s and back to the 400s all in one cycle. Lantus can produce gentle, flat cycles. However, often you need to get through the bounces (aka complete Liver Training School) in order to see those flat cycles.

The biggest secret to using Lantus is patience. So far, it doesn't look like the dose reduction is holding. I would shoot the 0.75u tonight and if numbers are still pink tomorrow, I'd think about raising the dose back up to 1.0u.