5/24 Boo Radley

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Jessica & Boo Radley

Jessica & Boo Radley

Member Since 2011
I'm hoping someone can take a peak at my spreadsheet. I increased the dose from 3.0 to 3.5 3 cycles ago. Yesterday we had a great day of greens followed by a bounce and then today, greens again....down to 39 at +8.

It looks like a decrease is in order, just wondering if you think 3.25 or back to 3.0 would be the answer. Last time we decreased it didn't hold at we ended up climbing a few more rungs on the ladder....

Thanks!

Jessica
 
BooBoo!!! DER u iz!! I ben missin' u!

Hey Jessica! I can't help with dosing nor spreadsheet but I sure can send you a BIG hug! I do remember a condo a few days ago but didn't have time that day to post.

ANOTHER big hug!
 
Hi (((sweet Lyresa)))) and we sure miss you too! Give KT a big HUG for us as well :YMHUG: :YMHUG:

Boo is feeling right at home over here with Levemir - and I really think he loves, loves, loves it! I was just saying to my husband last night how chubby and playful he was getting. The only change for him has been the insulin.
 
I don't see where you dropped before - and it didn't hold...? He might be getting too much insulin (well, duh, but I mean too much by 1u or more).

He had some nice numbers on 2.5u. Oh, is the drop to 2.25u where you are saying it didn't hold?

I think that 2.5u or 2.25 - or in between might be a better dose that won't cause lows and then bounces into the 400s. Don't forget to allow for settle time when decreasing as well as increasing. He might need more than 3 days to settle.

My theory on rebound is that a little bit too much insulin cause high flat number, but add a bit more insulin and you start to get greens, but you also have highs.

Read her on Somogyi rebound:
http://petdiabetes.wikia.com/wiki/Somogyi_rebound
A typical rebound pattern, most often seen with long-acting insulins, is a high, flat, unresponsive blood sugar over a period of days. Sometimes, often when raising dosage, this high flat curve will be punctuated by sudden drops to very low values, (with possible hypoglycemic events) followed by a fast return to high unresponsive numbers. (It's the sudden dip that distinguishes this pattern from inadequate insulin, but it doesn't always happen.)
Click to expand...
 
I think you should definitely reduce the dose. If it was me, I would go to 2.5 and see if he can stabilize the numbers after several days. Expect a few days of higher numbers right after a reduction like that.

You could also "step down" in .5u increments and let each one settle, going down when there is no longer settling of the numbers.

I think that if you look at his SS from where he was on 2.5u and you reduced, you can see the "pinks and reds" that prompted an increase each time after that just generated more pinks and reds. When you get several days of lower numbers with nice greens and then a sudden 300 or 400, it is best to hold the dose - or even reduce if a bounce looks possible.

This reminds me of "pilot-induced turbulence". When turbulence upsets the airplane the pilot makes small control inputs to stabilize it, but constant small control inputs upset the airplane. It's a "which came first" situation, right?

Same with dose increases: which came first the high numbers or the dose increase? A bounce to a higher number, even a slightly higher number, that leads to a dose increase starts the ball rolling - or, I should say, bouncing.
 
Worked yesterday so was out of pocket!

So Sheila, I took your advice and dropped back down to 2.5. You were right about the next few days of highs! I'm going to put my patient pants on here and give it about a week to see how he settles. I'll make sure I ask for some input before making any major changes.

Thank you for your help - I know you have your hands full right now.
 
I might be wrong, but I don't see how he can have nice blues and greens on 2.5u less than a month ago and now need a whole unit more.

One of my theories on overdosed insulin is that the rebound response is so set in, when you reduce the dose suddenly that response (the pumping out of cortisol and stored glucose) causes the pendulum to swing too far in the other direction (high BGs).

He should drop today or tomorrow, but if he doesn't you can either increase quickly in steps of .25u with 2-3 days to settle between them or return to a higher dose in one step (I'd suggest 3u) and see how he does.

Paws crossed that today he comes back down.
 
You are so good at this Sheila....take a look at how he settled out today. I'm guessing you'll still want me to hold to see how things settle, but things are falling EXACTLY as you said they would.

Thanks again for your precious time :-D :-D
 
Hi Jessica,

Sorry I hadn't dropped by your thread sooner. While I essentially agree with Sheila, I would have gone further and said to drop back to 2U, maybe even 1.5U. The reason is that Levemir simply works best in a step-up approach. Say 2.5U is his optimum dose. Dropping back to that dose can still cause bounces because the shed is at full already and can have spill overs, even on the best dose.

Today is a typical too-much-insulin response where he went from a huge 400 at preshot to this lovely 79. It might be lovely, but that fast of a drop is going to cause another bounce.

You can wait to see how the 2.5U plays out over several days, but since 1U was never held for long enough in the beginning and the wrench of R was being thrown in even dropping back to 1U should not be out of the question.

Levemir is a Gentle Giant, it lumbers along and might take longer than we would like to decide what it's going to do. When we react to those preshot reds on Levemir with more Levemir, it's sometimes counter-productive. The only thing making me scratch my head here is that he was popping 500s on less than 2U but not above 2U. 500s are almost always a reaction to too much insulin, unless the cat has not had insulin or is simply on way too low of dose and in the latter case there will be little to no response to the doses. A month ago he went from 542 to 107 in 24 hours on 1.6U, then remained in 300s for over 48 hours (actually a good thing) after which the dose was raised causing another bounce.

It's very difficult to tell where he got off the dose track because the very beginning is marred with the use of R and a dose increase of 1.5U and even a split dose 2 hours apart, Lev never had a chance to show what even 1U could do.

Sorry to be so critical but the colorful spreadsheet and use of R in the beginning make me want to say START OVER.
 
Thanks, Vicky. All very good points. That was a big drop today - more than I expected, actually.

At this point you can either "start over" at 1u and work back up (if that is needed), or step down each time his numbers flatten out and/or he throws out a low below 50.

I think there is some truth that stepping UP is easier than stepping down - although I did step down with Beau, but he was headed OTJ (as it turned out) and kept throwing me 30s. I'm not sure if that would happen if the dose just needs to be .5u or something, but I think it will.
 
Vicky and Sheila,

Thank you and I hear you both LOUD AND CLEAR.....my apprehensions are with Boo and his history. We were on Lantus to begin with and ended up in DKA 2X by going backwards. We went backwards twice because of advice of too much insulin and both times we ended up in DKA (one time was a bit more complicated with other factors...but DKA none the less). He is a FIV kitty along with diabetes, so things are a bit more complicated.

Boo is a bouncing cat....has been from .5 through 3.5 doses and he has had big drops when he clears it. The difference I've seen with Levemir is that his bounces are much shorter. Today is a perfect example. His 400 this morning was clearly a reaction to glycogen production in response to the numbers he saw early yesterday and the day before. The other thing I notice with Levemir is that he holds "OK" numbers for much longer than he did with Lantus. Just a sight of blues or greens with Lantus made him climb for days.

I am admittingly afraid of much lower a dose without a plan of how to avoid DKA. I'm open for sure for advice on how to do it safely, but at this point, history has shown me he needs more insulin to stay safe.
 
Ah, the DKA history explains a lot then, such as the use of R and the rapid increases.

So it may be best to follow Sheila's advice of keeping at the 2.5U dose unless you get BGs below 50. Then if you lower dose, maybe only in .25U increments.

It's always tricky with the DKA survivors. What type(s) of infection did he have at the time? How is his appetite and weight?
 
His appetite is ferocious...always ferocious......Boo lives to eat.....He's been gaining weight in the last month or so....almost getting a bit chubby on the same amount of food. The insulin is finally unlocking the cells for him. :razz: :razz:

In regards to infection....the first time was a UTI, the second - nothing at all. Healthy as a horse one day, the next day not eating, sky high potassium, ketones, dehydration.....DKA.

Being a nurse; we always use R. Long acting insulin is the background and use R as "coverage". We typically test q6 hours and bolus on a sliding scale. With his DKA history, R has been a way to keep his highs reasonable and always just made sense to me. I found however, he's so sensitive to insulin, that I couldn't find a magic scale that worked.
 
Cats metabolize insulin so much faster than humans. Some factor needs to be considered like half as much working twice as fast - or something :roll:

I have seen minute amounts of R used here, with lantus, for high numbers on DKA recovering kitties. But the bouncing that you mention seems to be common with some cats on lantus. Lev always gives "softer" curves so maybe those bounces can become a thing of the past, along with the use of R for Boo Radley. But if you did need to use R, maybe only .1u or something like that.

You don't want high numbers because of too much insulin any more than you do from too little, but I am unclear as to the possibility that rebound highs, along with an infection and/or low appetite, can cause DKA. I have been told here that it can't happen. I wonder if you know from your work with humans if that is possible? But I also wonder if we see a lot more rebound with cats than humans because we are monitoring someone that can't tell us how they feel and that they are sensing when they are dropping low, etc.
 
In humans, DKA can happen without an infection but it's not common at all. It's just my theory, but I lean more to the fact that Boo's FIV status lends to a weaker immune system, so no true clinical infections signs don't necessarily mean he's immune system is 100% and that he isn't always teetering on infectious status. I am almost not convinced in anyway about too much insulin, just as I'm not convinced he's at times getting too little.

That probably doesn't make much sense, but he has been a very brittle diabetic for me; this too could be due in large part by his FIV status. We have historically seen very similar numbers at both high and low amounts of insulin. Days of flats followed by drops then bounces and it begins again. At one point last year, we kept reducing the dose without much change to the pattern, just the length of flat time changed....it ended in DKA. I guess the long and short of it is, I don't believe it's the rebounds that are causing him DKA problems....I think it's a lack of enough insulin during the flats.

Boo has always been an eater....I sometimes wonder if that isn't what got us here. If I left out a sandwich, he would eat it. He'd eat pickles, tomatoes, chips, ice cream, lettuce, vegetables....I think you get my point. And anytime we've experienced DKA, his appetite only left him the day of diagnosis. He was never showing clinical signs - no warning whatsoever. If he's not hungry even once, I know we have problem.

And the R....I'm just not using it at all anymore and probably wouldn't unless we were in a Ketone situation. It just amplifies the swings for him and seems to just cloud the view of what's happening. R is so predictable in Humans and allows us to maintain such good regulation....it's a shame it doesn't work that way for cats!
 
Well, it all comes back to ECID - and you now him best. I hope that as you get to know lev you can lessen the swings and if he has "flats" they will be lower - a nice flat curve in the greens and blues would be nice!

My sister's FD (GA now) was FIV+. She used PZI with him (the old kind) and she got him down to around a half unit and it stopped the swings with him. I know she felt he did better with even numbers (over swings) so never tried for "normal" numbers, just below renal threshold, I think. But he never had DKA.

You know to reduce the dose slightly to stop the swings, right? Just make sure it is on the low number that you start the reduction. For instance is the dose is 1u and swings start happening, you want to reduce to .9u, but make the reduction on the low PS, not the high PS. When Jeddie swings, he is low in the am and high at night so i always reduce at the morning shot.
 
That makes perfect sense with the lowering. I think sometimes we see the higher number from the swing for something other than it really is (it's not too little insulin, it's too much glucagon in response to too much insulin!)

I think where I have the itchy finger is when to lower or raise in regards to the pattern and number of cycles. I get the 3-5 cycles, settle, etc., but I know it's not a hard fast rule and I know that somewhere in that 5 a pattern can happen that warrants further holding. If you don't mind....I'd still like a nudge as to when to take that reduction. I'm clear with taking on a lower cycle, just how far into the cycle (for example, if you looked at my spreadsheet now, we're 5 cycles into 2.5; some big swings at the beginning, and now it seems to be leveling out a bit; do I hold to see if he settles more, or should I look to be lowering when on the lower cycle?)
 
I found that Jeddie needed a LOT of settle time - up to a couple of weeks, so let the numbers, well, really the patterns, guide you. What you will be looking for is the opposite of what you look for to raise the dose.

The numbers might start to swing again, but there will be lower numbers at nadir. If you get another nadir below 40-50, then reduce again. I always think that swings are from too much insulin. You need a low enough number to start a swing and reducing the dose stops the swing. (Disclaimer: This is all assuming a low carb diet is being fed. Dry food will cause all kinds of swings.)

It's hopeful that he was in the 200 (just barely) this morning. He probably is still settling so see how the next full day or two go.
 
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