Hi Daniel, I know this is all very new and how nerve-racking it can be, but constantly changing doses up and down, just keeps messing up the depot.
We can’t actually tell what dose is going to work for Simon when the dose keeps changing and being skipped
I’m not trying to give you a hard time at all I promise. I know how stressful this all is and it’s still very new.
I would put something in your title like “dose review” and use the drop-down menu question mark.
So that we can get some advice for you on how to dose properly.
That will get Simon into a much more stable cycle and better numbers
Please see below for guidance
START LOW, GO SLOW (SLGS)
The Start Low, Go Slow Method (SLGS) with Lantus, Levemir, or Biosimilars for Diabetic Cats has been adapted from the FDMB's original 5 Steps to Regulating Your Diabetic Cat. Adaptations were necessary to accommodate the action, nuances, and exceptions of the newer Lantus, Levemir, and their Biosimilars insulins.
Requisites when following the Start Low, Go Slow Method:
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 a meter calibrated for humans, not a pet-specific meter. Reference numbers given are for measuring blood glucose with a human meter.
Use U-100 3/10cc syringes with half units marked on the barrel for fine dosing.
Most kitties are easier to regulate when fed small meals throughout each cycle. Others adapt well to free feeding.
Starting Dose:
1u BID if kitty is not on a wet/canned low carb diet
0.5u BID if kitty has been switched to a wet/canned low carb diet
If the cat was previously on another insulin, the starting dose should be increased or decreased by taking prior data into consideration
Generally, shots are to be given 12 hours apart.
Hold the dose for at least a week:
Unless your cat won’t eat or you suspect hypoglycemia
Unless your kitty falls below 90 mg/dL (5 mmol/L). If kitty falls below 90 mg/dL (5 mmol/L) decrease the dose by 0.25 unit immediately.
After 1 week at a given dose perform a 12 hour curve, testing every 2 hours OR perform an 18 hour curve, testing every 3 hours. Note: Random spot checks are often helpful to "fill in the blanks" on kitty's spreadsheet. The goal is to learn how low the current dose is dropping kitty prior to making dose adjustments.
If nadirs are more than 150 mg/dl (8.3 mmol/L), increase the dose by 0.25 unit
If nadirs are between 90 (5 mmol/L) and 149 mg/dl (8.2 mmol/L), maintain the same dose
If nadirs are below 90 mg/dl (5mmol/L), decrease the dose by 0.25 unit
As your cat's blood glucose begins to fall mostly in the desired range [lowest point of the curve approaching 100 mg/dl (5.5 mmol/L) and pre-shot value around or below 300 mg/dl (16.6 mmol/L)], do lengthen the waiting time between dose increases. If you decide to change another factor (e.g., diet or other medications), don't increase the insulin dose until the other change is complete (but decrease the dose if your cat's glucose numbers consistently fall below 90 mg/dl (5.0 mmol/L) as a result of the change).
Don't be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat's blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose.
Lather, Rinse, and Repeat!
How to handle a lower than normal preshot number:
Until you collect enough data to know how your cat will react, we suggest following the guidelines in the FDMB's FAQ Q4.4:
Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.
Below 150 mg/dl (8.3 mmol/L), don't give insulin.
Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
a.) give nothing
b.) give a token dose (10-25% of the usual dose)
c.) feed as usual, test in a couple of hours, and make a decision based on that value
Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.
Keep in mind these are general guidelines, and they should be personalized to your own cat's response to insulin. If your experience is that your cat does not became hypoglycemic with a dose which is close to her usual, then personal experience should be your guide.
With experience, you may find that lowering these thresholds may work well for your cat. When you have reached that stage, the following guidelines are suggested for Lantus, Levemir, and Biosimilars users following the Start Low Go Slow approach:
If the preshot number is far below usual preshot numbers:
Do you need to stay on schedule? Then skip the shot.
Do you have some flexibility with your schedule? Then stalling to wait for the number to rise might be a good option. Don't feed, retest after 30-60 minutes, and decide if the number is shootable.
Repeat until the cat either reaches a number at which you are comfortable shooting, or enough time has passed that skipping the shot is necessary.
If the preshot number is near kitty's usual preshot numbers:
Look at your data to see what numbers you have shot in the past and decide what would be a safe, shootable number for your cat. Don't feed. Stall until kitty reaches the preshot number you've decided on and then shoot.
We usually don't suggest or recommend shooting a preshot number less than 90 mg/dL when following the SLGS Method. Remember that with SLGS, generally speaking, your goal is to achieve flat numbers that are greater than 90 mg/dL. However, let experience, data collected, knowledge of your cat, and availability to monitor help in making the best decisions for your cat.
If kitty is dropping faster or lower than you'd like, please see "Don't Panic! or How to Handle Low Numbers" and post for help or suggestions.
