9/26 Charlie - AMPS 487, PMPS 238 - Increase dose in AM?

[Karen & Charlie]

Last post 9/24/20

I've been a little frustrated with the transition from Vetsuilin to Lantus. I was expecting better results for Charlie than, I guess, I had a right to.

Today is end of Day 3 of increased dosage. The sticky indicates sticking with a change for 3 days.
Looking for advice on increasing dosage again in the morning (Sun, 9/27).
There is no rhyme or reason [yet] to me for wild swings in BG.

Sporadic testing today -- Mama needed a break! (went apple picking)

Thanks for your observations!

 

[Bron and Sheba (GA)]

Hi Karen,
Lantus is a very good insulin for cats. I just think that you haven't reached a good dose for Charlie yet.
So I would increase the dose to 2 units tomorrow morning.
Always get a before bed test done to make sure that Charlie is safe. If the before bed test is much lower than the preshot, that indicates that it could be an active cycle so I would set the alarm and get up a few hours later to check the BG again.

 

[Sienne and Gabby (GA)]

Karen -

It looks like you switched to Lantus on 9/19. I suspect that some of your frustration is that it takes about a week for the Lantus depot to form. One of the big differences between Lantus and Vetsulin is the depot. This is what gives Lantus its longer duration than Vetsulin and makes it a gentler insulin.

I'm not sure who suggested that you increase the dose after 3 days. We typically don't advise a dose increase when starting Lantus until at least 5 days from the point at which your start. Once the depot has been established, you can then increase every 3 days/6 cycles. I also think Bron is correct -- you're not yet at an effective dose of Lantus. I'm not sure you were at an effective dose of Vetsulin.

You may want to open up the PM side of your spreadsheet. Lantus has its nadir (if Charlie follows the rules) at around +6. With Vetsulin, onset and nadir are earlier than with Lantus. There may also be times when you're up early enough to get a +11. Those infrequently used slots can sometimes give some invaluable information. You may want to take a look at the becoming "data ready" section in this sticky note. This post on the insulin depot may help to explain what the depot is all about, as well.

 

[Karen & Charlie]

I also think Bron is correct -- you're not yet at an effective dose of Lantus.

1. What exactly is meant by "effective dose?"

You may want to open up the PM side of your spreadsheet. Lantus has its nadir (if Charlie follows the rules) at around +6.

2. If Lantus has its nadir at +6, why might I see that at night but not during the day.
3. It would be helpful to understand why, by monitoring him through the night, I will see any different results than during the day when his AMPS is 300 or 400.

Do you agree with Bron on a dose increase to 2.0u?

Thanks for patience. It has been a stressful 6 weeks since starting this FD trip, and the information is still overwhelming.

 

[Karen & Charlie]

Always get a before bed test done to make sure that Charlie is safe. If the before bed test is much lower than the preshot.

PM +2 is bedtime. Not sure what you would consider "much lower." Can you define? Do you see evidence of that on Charlie's SS in the Lantus phase?

Thanks for your time, I really appreciate it.

 

[Sienne and Gabby (GA)]

You would see a nadir (at whatever time) in both the AM and PM cycles. Nadir is "supposed" to be at +6 or thereabout but it can and does move. (Some cats have early or late nadirs, too.) My point was more to observe you don't have space to enter the info during the PM cycle on your spreadsheet. You're getting a great amount of testing otherwise.

I'm not suggesting that you monitor all night. You need to sleep! However, if as an example, you shoot a number like last night (238) and at +2, the test was at 120, you might need to get more tests so you can go to sleep confident that Charlie is in safe numbers. Right now, there's no space on your spreadsheet for any numbers past +4.

An effective dose is a dose that's keeping your cat in the range you're looking to see your cat. Some people have a goal of regulation (i.e., below renal threshold which is around 200 - 220) versus remission (normal numbers without the need for insulin).

I do agree that you should increase by 0.25u to 2.0u. Have you shot?

 

[Karen & Charlie]

You would see a nadir (at whatever time) in both the AM and PM cycles. Nadir is "supposed" to be at +6 or thereabout but it can and does move. (Some cats have early or late nadirs, too.) My point was more to observe you don't have space to enter the info during the PM cycle on your spreadsheet. You're getting a great amount of testing otherwise.

I'm not suggesting that you monitor all night. You need to sleep! However, if as an example, you shoot a number like last night (238) and at +2, the test was at 120, you might need to get more tests so you can go to sleep confident that Charlie is in safe numbers. Right now, there's no space on your spreadsheet for any numbers past +4.

An effective dose is a dose that's keeping your cat in the range you're looking to see your cat. Some people have a goal of regulation (i.e., below renal threshold which is around 200 - 220) versus remission (normal numbers without the need for insulin).

I do agree that you should increase by 0.25u to 2.0u. Have you shot?

1. I shot 2.0u.
2. Is nadir just the lowest number during a 12 hr cycle, or is it a consistently low number?

as an example, you shoot a number like last night (238) and at +2, the test was at 120, you might need to get more tests so you can go to sleep confident that Charlie is in safe numbers. Right now, there's no space on your spreadsheet for any numbers past +4.

2. I've always fully expected to monitor a 200 bed time number into the night. When that happens, I'll unhide the hidden columns for data entry, and leave that data unhidden.
3. So I can further educate myself, would you agree that there hasn't [yet] been a PM need to monitor past PM +3?

Thank you!

 

[Sienne and Gabby (GA)]

The nadir is the lowest number in the cycle. Most of will look at that as a general trend but it's a mistake to think that it's always at around the same time. Gabby's nadir was at around +3 or +4 except when it wasn't!

The problem with #3 is that I have no context to answer the question. Kitties can drop from a pre-shot number in the 400s to a nadir in the 40s and be back in the 400s by the next shot time.

 

[Karen & Charlie]

Kitties can drop from a pre-shot number in the 400s to a nadir in the 40s and be back in the 400s by the next shot time.

Very good to know—
I can see that there are many, many unknowns about this process. Given the scenario you mention, how do you know when you need to be up all night? If you’re not testing you have no way of knowing whether the number is going to drop to a dangerous level at 4:30AM when it started in the red at “bedtime.” I’m not expecting you to have all the answers. I’m just terribly frustrated. To be clear, that frustration isn’t with you, or anyone who devotes time helping people like me in this forum.

Thanks.

 

[Sienne and Gabby (GA)]

The suggestion that you will probably hear repeatedly is to get a test at +2 or +3. Those early tests are often (but not always) able to give you a warning that numbers are on the way down. It's a great rule of thumb. It does help to remember that our kitties do not like to be predictable. The minute you think you know what to expect, they will throw you a curve.

While this may seen obvious, it also helps to remember that insulin is a hormone. Unlike an antibiotic, there are lots of environmental factors that can effect the way it works. If your cat is more active than usual, numbers will be lower. If your cat is more stressed than usual, numbers will be higher. If your cat is addicted to carbs and will steal anything that's not nailed down (we have photos of a kitty who would steal waffles out of the toaster or slash open a bag with bread), it will raise numbers. And sometimes, there will be no effect on numbers. They are mysterious beasts whose goal in life seems to keep us on our toes.