8/11 Boo Radley Curve and Data

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Jessica & Boo Radley

Jessica & Boo Radley

Member Since 2011
Hello,

Boo Radley and I are 10 days post diagnosis. I am a nurse by trade, so have a good working knowledge of insulin, diabetes, etc. (at least in humans!).

We switched to canned food (from "quality" kibble) about 6 weeks prediagnosis; although admittedly, not with regard to carb content. Since diagnosis, we've been very conscious of carb content and try to stay below 4 per feeding.

Since diagnosis,we have also been testing at home consistently and ran my first curve yesterday. I am strictly following the 12/12 dosing of Lantus (1 unit bid) and regularly testing 3 times per day.

I have been reading this board religiously trying to ensure I am hitting all of the markers. I also have 2 vets I've been working with to ensure I'm getting the best advice. After 10 days, my gut says you guys are so much more advanced in your thinking and experience. My vets are great, I just don't think they're used to working with diabetes in such a controlled manner.

As such, I'd love if someone could take a look at the data I've compiled thus far (link below). We've been in the 200-300's consistently and he's starving all of the time. From everything I've read here, it's justified to increase the dose by 0.5 units bid. My vets are against it and want me to wait another week to "wait and see". We just finished a round of antibiotics for a UTI and I'd really like to give his poor little kidneys a break. I would curve again in 3 days and continue to test 3X a day until then.

Thanks in advance for looking and any advice is much appreciated! Here's the link to the spreadsheet.

https://spreadsheets.google.com/spreads ... E&hl=en_US

Jessica and Boo Radley
 
Morning, Jessica

I think a lot of us have that same problem with our vets, too.

I think the protocol for strict regulation is by increasing the insulin 0.25u, and holding for 6 cycles. Although, someone will be along shortly to help you with this.

A lot of us feed Wellness, and Evo 95% wet foods (mine's on Evo 95% C&T, which is 0% in carbs). Depending upon Boo Radley's weight would depend on the amount that you're feeding him.

I'm hoping that he comes down a bit for you today. Have a great day! :)
 
Welcome Jessica!!

Great job getting your spreadsheet (SS) up and running and it's very clear you're good with testing and shooting. I do have a couple of thoughts on Boo Radley's SS.

First, based on the Tight Regulation protocol we use, his dose would be increased by 0.25u, not a half unit.
"General" Guidelines:

Hold the initial starting dose for 5 - 7 days (10 - 14 consecutive cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 consecutive cycles).

Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction (See: Reducing the dose...).

Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.


Increasing the dose:

Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose.

After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.

After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
Click to expand...

It's also important to get tests in during the PM cycle. Many cats' numbers are lower during the night and since Lantus dosing is based on nadir, you do not want to either miss an opportunity for a dose reduction or have your cat running in very low numbers due to not having that information.

I'd also suggest not testing just at +6. The nadir can be a moving target. Very few cats nadir at +6 precisely and even if that's their usual nadir, it can change. Mixing up your test times also helps to fill out the SS. If you have a chance, look at our SSs. You'll not only get some good information (or have questions), it will also give you a sense of the variation between our kitties.

When you have a chance, if you could complete a Profile on Boo Radley and attach it to your signature. It will help us to get to know your kitty. The Profile contains medical history as well as what your feeding and other information.

We do see a lot of cats with FD -- a lot more than most vets. In their defense, they have to know a great deal about a myriad of illnesses and FD is probably one lecture in vet school. We focus on one illness in one species. There are links to the formal version of the protocol we use and we can provide you with the vet journal article where the protocol was published if you or your vet is interested.

I hope you'll post often and give us a chance to get to know you and Boo Radley. This is an incredible community of people and their cats. Please let us know if you have questions or if we can help in any way.
 
Hi guys and welcome from us! Everyone here on this board is amazing with their kitties and are so knowledgeable .. I'm glad to hear you are already doing the low carb wet cat food .. I also know that when a cat is unregulated, they are often quite hungry so that doesn't surprise me about boo radley .. once he regulates he should slow down on his food consumption .. have a great day guys!
 
OH..how could anyone resist visiting a condo for a kitty named Boo Radley!! :-D

welcome to Lantus Land!!

celi & binks
 
Sandy and Sienne - thank you for the quick replies. I updated our profile per your recommendations.

I will take your advice and test on a less predictable schedule and only make a 0.25 unit change right now. thank you again so much.

From working so long in diabetes with humans, I'm having a hard time grasping the use (or more specifically, how it's done) of Lantus in cats.

My knowledge of insulin regimens is based on the theory of treating to try and duplicate the normal insulin release pattern from the pancreas. That being, that the pancreas produces a constant (basal) amount of insulin that balances liver glucose production with glucose use and maintains normal blood glucose levels between meals. The pancreas also produces additional (prandial) insulin to prevent blood glucose elevation after meals.
Further, Lantus is a long acting insulin with a 1-2 hour onset, no peak and a 24-28 hour duration. In humans, we give this once a day, generally at night. When used with type II diabetics (which I understand that cats are), often an oral hypoglycemic is used for those prandial times or even a short or intermediate acting insulin dosed 30 minutes before meals. This regimen allows for the most natural pattern in humans, mimicking what the pancreas does.

Based on my human knowledge, I can't grasp why we are using Lantus 2X per day and I don't really grasp why it is important to keep feeding times consistent (since there is no peak). It seems like we are asking this insulin to do something is was never designed to do...which is to maintain glucose levels during the prandial periods. I'm following the protocol as you have all been through this and I'm sure there's something that's very different between humans and animals. I'm analytic by nature so am always in search of the why and appreciate your expertise!
 
Jessica & Boo Radley said:
Based on my human knowledge, I can't grasp why we are using Lantus 2X per day and I don't really grasp why it is important to keep feeding times consistent (since there is no peak). It seems like we are asking this insulin to do something is was never designed to do...which is to maintain glucose levels during the prandial periods. I'm following the protocol as you have all been through this and I'm sure there's something that's very different between humans and animals. I'm analytic by nature so am always in search of the why and appreciate your expertise!
Click to expand...

Welcome Jessica!

Human and dogs metabolize insulin at the same rate, but cats metabolize insulin twice as fast. This is why we shoot twice a day instead of once. A dose that will last 24 hours in a human will only last 12 hours in a cat.

Oral hypoglycemic drugs are not recommended treatment for cats unless the owner refused insulin therapy or considering euthanasia (see p. 4 for citation: http://www.aahanet.org/PublicDocuments/AAHADiabetesGuidelines.pdf). These put stress on the cat's pancreas by forcing insulin production and end up worsening the condition by burning it out. Cats are unique in that they are proven to have a very high remission rate when the pancreas has a chance to rest, and the only way to do that is with insulin therapy.

Lantus is slow acting and does not have a large peak like you would see with other insulins, but there is a peak (or nadir) with cats. This is usually around 6 hours into a cycle, but it can vary from cat to cat which is why in the beginning you want to figure out where it lies by doing a few consecutive tests.

The high remission rate in cats is linked to the amount of time they spend in high numbers. The more quickly you can get your cat in a normal blood glucose range for as much as possible, the more likely remission is. Have you read the article on Lantus and tight regulation yet? http://www.ncbi.nlm.nih.gov/pubmed/19592286 (I have a .pdf if you don't have access to the article, but as a nurse I'm guessing you do :-)
 
And a note about feeding. We just make sure that there is food in the tummy before (or at the same time) we give the insulin. As for other set times during the day...personally I free-feed Jesse because I am away all day at work. I do try and pick his food up ~2 hours before AM or PM test times (so I know it's not a food spike).

Oh, and WELCOME!!! :-D
 
One more thing, because I see you raised the dose from 1u to 1.5u, which is a bit too high of an increase--many newly diagnosed cats just starting insulin will react to normal numbers the same way they would to hypoglycemic numbers. I see you had a 71 a couple days ago so you want to be careful about raising the dose too quickly. When the cat's body thinks its blood sugar is too low, the pancreas releases glucagon which causes the liver to convert stored glycogen into glucose, which is then released into the bloodstream. We've nicknamed this "bouncing" here. Sometimes it can take a few days for a "bounce" to clear, which is why you want to be cautious raising the dose too much when you have lower numbers in the mix. Giving too much insulin can keep your cat's blood sugar levels just as high as too little insulin because of this effect.

It's possible that the higher numbers you're seeing is from Boo Radley getting into normal numbers in the pm cycle where you don't have any data, in which case you would want to hold the dose at 1u until his liver stops panicking at those normal numbers (which it will over time). Collecting data from the pm cycle will also help determine if this is what's happening, or if you do need to raise the dose.
 
Hello, Jessica!! You are off to a great start!!

To answer one of your questions, cats metabolize lantus twice as fast as humans do, hence the 12/12 dosing.

From the stickies, a typical curve looks like:

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.

though the nadir may be earlier or later in the cycle and will shift on you from time to time. At first, you will see a very defined curve, but as the lantus works its magic, the curve will flatten dramatically. You can take a look at Willie's spreadsheet for an example.

Also at play is the liver. As the diabetes has progressed, the liver has redefined what it perceives to be a normal BG#. When you first start treatment and the insulin is doing its job and bringing the numbers down, the liver will see the low numbers and panic because it now perceives good numbers as abnormally low. It will release stored glucose and counterregulatory hormones to bring the numbers up to what it perceives to be "normal." We call this a bounce, and it can take up to 72 hrs for the glucose and hormones to leave the cat's system. We refer to this period as LTS, or Liver Training School... you are retraining the liver to have a proper perception of normal BG#s. Ideally, each progressive bounce is less dramatic and shorter in duration, though you'll find cats here at all levels of LTS... some are overachievers who graduate very quickly, and others have spent months in remedial courses.

Because there definitely is a peak for cats based on the way they metabolize Lantus, you'll find that many of us feed small meals in the earlier parts of the cycle. It helps to keep impact on the pancreas to a minimum and by not feeding the back end of the cycle, as the numbers head upward, you aren't fueling that further by adding food. Definitely withhold food for the last 2 hrs of the cycle, especially when you see lower numbers. You are making decisions on whether or not it is safe to give a shot, and you want that pre-shot number to be a true number and not a number inflated by food... because the food could wear off well before onset, leaving you with numbers dropping too quickly. You'll also find that many of us use higher carb foods to steer numbers as opposed to just adding karo. The higher carbs will help us get numbers up safely, but getting food on board will keep the numbers from crashing as quickly.

The other factor to keep in mind in terms of differentiating feline and human (or even canine) experience with lantus is that cats are unique in that their pancreas can heal and the cat can go into remission. The chances for remission are best the closer you are to diagnosis, so an aggressive approach towards regulation in the beginning can be beneficial towards getting a cat towards remission. Humans and dogs don't have that possibility, so the advantages can be lower. However, even without remission, keeping a cat in normal numbers for as much of the day as possible has clear benefits in terms of overall health and reducing pressure on other organs (kidneys in particular).

Hope that info helps... and once again, welcome! please keep asking questions as you have them, and we look forward to learning more about you and Boo Radley both!!!
 
Wow - thanks everyone for the welcomes, your input and for explaining some of the mysteries of this to me. Please know I am reading all that I can, including the vast amounts of information that is posted on these boards - truly an unexpected and welcomed resource.

I am only going to increase his dose right now by 0.25 - go low and slow makes perfect sense. I am (at least for right now) feeding him on a very strict schedule so I know what's happening when I get my numbers and can adjust accordingly. I will test at night to also see if there's any variation, but it would stand to reason that if Lantus truly is metabolized in 12 hours, my night curve should mimic my day if; reasoning: I am in fact dosing at strict 12 hour intervals with a long acting insulin..... so my night curve would just be a mirror imagine from the dose that affects the day. But I won't know until I try!

In speaking with my Vet, one of the main topics we seems to come back to at each discussion is the lack of funding in researching this disease in animals compared to that of humans. I just have a hunch there's something that we do for people, that could benefit these little guys. People too go into "remission" from Type II with strict controls - almost all of them. In today's world, we're seeing soooo much more of it with such younger people. Our goal with adults with Type II is remission, or if remission can't be achieved, the goal is blood glucose control that is ALWAYS under 120. The effects of high blood sugars cannot be understated in the effects it has on the entire body system. I am eager to do all that I can to see if Boo is controllable, in the safest manner possible. I'm on board and ever curious.

Thanks again for everyone's feedback!
 
Sounds like you've got a good plan!! :-D :-D

I do suggest printing out the stickies and putting them in a binder with Boo Radley's lab reports... I know there is SO much information, and when I first started, there would be times I needed a particular piece, but then couldn't remember what sticky it was in! Having everything printed allowed me to take notes, tab the pages, etc.

Because you already have a great understanding of how lantus works generally and the issues surrounding diabetes, I think one thing that might be helpful for you would be to look at different folks' spreadsheets... we all link to them in our signatures. because ECID (every cat is different), looking at a few will help you see how lantus has worked, as well as its limitations for some cats. I generally don't suggest that right away for all newbies because there is so much to absorb, but for you, I think it would help you find some of the answers you're seeking.
 
Welcome Jessica and Boo Radley! You are doing great.....very on top of it with everything. Keep asking questions, there are tons of knowledgable people around here.
 
You are correct in that the PM cycle should replicate the AM cycle. However, you've forgotten one major factor. We're dealing with cats! It is clearly their job to confound us with their unpredictability. What should happen and what does happen can be vastly different things. No doubt, Boo Radley will keep you on your toes!
 
Welcome to Lantus Land Jessica and Boo Radley. Perfect name for a cat: can't wait to see what he looks like!!!
Everyone here wants you to reach your goal of getting Boo Radley into remission. You have come to the right place. And you ask great questions!!
WELCOME!!

Ella & Rusty
 
Jessica & Boo Radley said:
I will test at night to also see if there's any variation, but it would stand to reason that if Lantus truly is metabolized in 12 hours, my night curve should mimic my day if; reasoning: I am in fact dosing at strict 12 hour intervals with a long acting insulin..... so my night curve would just be a mirror imagine from the dose that affects the day. But I won't know until I try!
Click to expand...


The Textbook of Veterinary Internal Medicine, Sixth Edition, states (pg 1576):

Diabetic cats are notoriously unpredictable in their response to exogenous (outside) insulin. No single type of insulin is routinely effective in maintaining control of glycemia, even with twice a day administration.
Click to expand...

This goes back to the "Every Cat Is Different" mantra. Every cat responds to insulin differently, but the best way to figure out how your cat responds is to collect data. Also, until Boo Radley adjusts to having normal blood glucose numbers, he's going to unpredictably bounce from low to high numbers because his liver will be randomly releasing glucose into his blood. So he may be low at night, and then high during the day and you wouldn't know he was low at night unless you collected that data. Once he's well regulated with a reduced insulin need, you can get by with catching only one cycle as long as you're doing curves at least once a week. Until then, though, you want to collect enough data to get him regulated as quickly as possible, and for that you need numbers from both cycles, if you can manage it. I work about 60 hours a week and go to grad school, so it can be hard for me to test a lot. I set an alarm to get a mid-cycle number during the night, and then go right back to sleep. Sure, it's a minor pain for the time being, but when the payoff is testing once a week because your cat is in remission, it's so worth it!
 
Sure, it's a minor pain for the time being, but when the payoff is testing once a week because your cat is in remission, it's so worth it!
Click to expand...

Julia and Bandit, I think that's great advice and I don't mind getting up at night one bit! The sooner the better for him. Thank you for your suggestions on what works for you - sounds like your plate is full and I admire your effort for Bandit- he's a lucky guy! :razz:
 
jessica, you've gotten so much good information already - i don't have anything to add except welcome. we're glad you're here and encourage you to ask away. zillions of questions come up, although you have a distinct advantage over most of us in that you already understand a lot about diabetes.

looking forward to getting to know you and Boo Radley. and yes, awesome name!
 
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