Advice Needed - Am I Dosing Correctly?

[SassyCat04]

Hi All - I'll be as brief as possible. I've got my spreadsheet up and I really need some of you with experience to weigh in with your thoughts.

Makari was diagnosed on October 31st last year and we started Lantus. We did okay but realize now we had some incorrect advice with our vet. He ended up in a hypo crisis on Thanksgiving that was, at the time, considered possible reemission. He was completely off insulin with no symptoms until early January. On Jan. 6th, he was acting strangely and we took a BG and got a number of 560 and obviously restarted insulin.

As you can see from his sheet, we started with 1u twice daily for awhile until we could start with a new veterinarian. His numbers remained high. She had us switch to 1.5u and we did see them come down, which was great. BUT - this is where I need your advice. His drop seems awful fast to me and the low 200 number made me nervous to continue 1.5u. She advised we switch back to 1u for 7 days to see if the 1u would be enough UNLESS we saw him creep back up -- which he did immediately.

Are these swings normal? Should we have just continued with the 1.5u? I'm terrified of sending him into another hypo crisis. The new vet said her goal for a range was 150 - under 300. So that is why we opted NOT to give him 1.5 units with a pmps at 230, fear of going too low.

 

[Diane Tyler's Mom GA]

Previous post about the hypo that happened on Thanksgiving
https://www.felinediabetes.com/FDMB/threads/so-we-had-an-epic-crisis-makari.271369/#post-3021277

 

[Diane Tyler's Mom GA]

Hi All - I'll be as brief as possible. I've got my spreadsheet up and I really need some of you with experience to weigh in with your thoughts.

Makari was diagnosed on October 31st last year and we started Lantus. We did okay but realize now we had some incorrect advice with our vet. He ended up in a hypo crisis on Thanksgiving that was, at the time, considered possible reemission. He was completely off insulin with no symptoms until early January. On Jan. 6th, he was acting strangely and we took a BG and got a number of 560 and obviously restarted insulin.

As you can see from his sheet, we started with 1u twice daily for awhile until we could start with a new veterinarian. His numbers remained high. She had us switch to 1.5u and we did see them come down, which was great. BUT - this is where I need your advice. His drop seems awful fast to me and the low 200 number made me nervous to continue 1.5u. She advised we switch back to 1u for 7 days to see if the 1u would be enough UNLESS we saw him creep back up -- which he did immediately.

Are these swings normal? Should we have just continued with the 1.5u? I'm terrified of sending him into another hypo crisis. The new vet said her goal for a range was 150 - under 300. So that is why we opted NOT to give him 1.5 units with a pmps at 230, fear of going too low.

@tiffmaxee

@Suzanne & Darcy

Edit
@Bandit's Mom

@Sienne and Gabby (GA)

@Wendy&Neko

Looking at her SS there are many times that no AMPS tests and PMPS and not a lot of tests after them

 

[SassyCat04]

@tiffmaxee

@Suzanne & Darcy

Looking at her SS there are many times that no AMPS tests and PMPS and not a lot of tests after them

Correct! Our previous vet had informed us there was "no need' to get BG numbers. We were advised when we first started the Lantus that 1u would be fine and too much testing was unnecessary. She wanted the curve which was at day 7 of insulin and that was it. In hindsight when we did his first curve and got all those numbers in the 100's and the first vet was happy about them, I question that curve was ever normal. It wasn't really a curve at all. Hence why we are seeing a new vet now.

So - We've starting taking a night BG every day. And I really want to know what we need to do as far a testing. The new vet didn't say we shouldn't test, but didn't really advise how much was necessary. And the first vet, honestly, flat out said no need to do it at all and made me feel neurotic for questioning her. I'm trying to find the balance in getting the data we need without doing too much.

 

[Diane Tyler's Mom GA]

I can't tell you what dose you should be giving , I'm not experienced to tell you that
Doing a curve really isn't that helpful, it doesn't tell you what is happening with the BG numbers everyday. Both vets are wrong by telling you to only test at AMPS and PMPS and that's it

You should always be testing at AMPS and PMPS to make sure it's a safe number to shoot . I would get another test at +2 to see if that is lower than the Pre Shots
If it is I would get another test at +4 and +6
Same with the PM cycle , cats usually drop lower at night
Then the next day switch up the test times get a +3, +5 ,same for the PM cycle
If possible get maybe a +7 or 8
You want to try and find Makari's nadir ( the lowest point in the cycle)
That will tell you when you need to reduce
In see you are following SLGS so any drop under 90 you would decrease by 0.25 units If you don't get tests in after the Pre Shots you will never know if a dose adjustment is needed
You hold the same dose ( which I don't know what that would be at this point) for 7 days ,after that you need to do a curve
Hopefully one of the members I tagged will come along and give you some advice on the dose

You might want to read about the SLGS methods again
Here is part of it

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

 

[Diane Tyler's Mom GA]

Can you add SLGS to your signature also please

 

[SassyCat04]

@Diane Tyler's Mom Thanks for the input, I really appreciate it. I absolutely know we need to do more testing and we will be. The thought of letting him hit around 100 scares the crap out of me LOL. Truly the more I learn the more things really make sense and it's not that I think the vets "don't know" but in some ways I think they just don't have the experience in how to deal because they don't treat as many diabetic cats as I thought they did. So I'm finding I'm the one who's going to have to learn and figure this out for myself in a lot of ways and that's scary and overwhelming. I'm so thankful for this group and your experience and knowledge.

Getting comfortable with making judgement calls will come with experience I suppose. I'm just worried about giving him an injection when his number is too low and sending him into dangerous low numbers. It's a hard call to make at first until we can sort of know what to expect. Again, thank you.

 

[Diane Tyler's Mom GA]

Hi All - I'll be as brief as possible. I've got my spreadsheet up and I really need some of you with experience to weigh in with your thoughts.

Makari was diagnosed on October 31st last year and we started Lantus. We did okay but realize now we had some incorrect advice with our vet. He ended up in a hypo crisis on Thanksgiving that was, at the time, considered possible reemission. He was completely off insulin with no symptoms until early January. On Jan. 6th, he was acting strangely and we took a BG and got a number of 560 and obviously restarted insulin.

As you can see from his sheet, we started with 1u twice daily for awhile until we could start with a new veterinarian. His numbers remained high. She had us switch to 1.5u and we did see them come down, which was great. BUT - this is where I need your advice. His drop seems awful fast to me and the low 200 number made me nervous to continue 1.5u. She advised we switch back to 1u for 7 days to see if the 1u would be enough UNLESS we saw him creep back up -- which he did immediately.

Are these swings normal? Should we have just continued with the 1.5u? I'm terrified of sending him into another hypo crisis. The new vet said her goal for a range was 150 - under 300. So that is why we opted NOT to give him 1.5 units with a pmps at 230, fear of going too low.

I'm going to try and tag the members again
@tiffmaxee

@Suzanne & Darcy

Edit
@Bandit's Mom

@Sienne and Gabby (GA)

@Wendy&Neko

Looking at her SS there are many times that no AMPS tests and PMPS and not a lot of tests after them

 

[Diane Tyler's Mom GA]

@Diane Tyler's Mom Thanks for the input, I really appreciate it. I absolutely know we need to do more testing and we will be. The thought of letting him hit around 100 scares the crap out of me LOL. Truly the more I learn the more things really make sense and it's not that I think the vets "don't know" but in some ways I think they just don't have the experience in how to deal because they don't treat as many diabetic cats as I thought they did. So I'm finding I'm the one who's going to have to learn and figure this out for myself in a lot of ways and that's scary and overwhelming. I'm so thankful for this group and your experience and knowledge.

Getting comfortable with making judgement calls will come with experience I suppose. I'm just worried about giving him an injection when his number is too low and sending him into dangerous low numbers. It's a hard call to make at first until we can sort of know what to expect. Again, thank you.

@tiffmaxee

@Suzanne & Darcy

Edit
@Bandit's Mom

@Sienne and Gabby (GA)

@Wendy&Neko

 

[Diane Tyler's Mom GA]

Do you have a hypo kit set up just in case you need to bring Makari's BG up
Such as
med and high carb wet food and some honey?


Fancy Feast Gravy Lovers Gourmet Beef Feast in Grav
20% High Carbs

Fancy Feast Gravy Lovers Gourmet Chicken Feast in Gravy 15% Med Carbs

Fancy Feast Gravy Lovers Turkey Feast in Gravy 15% Med Carbs

Fancy Feast Gravy Lovers Chicken and Beef in Gravy 15% Med Carbs

Good idea to mark the cans with magic marker how many carbs

Or any on the food chart. Doesn't have to be Fancy Feast just an example about the med and high carb foods
And some honey in the house

https://felinediabetes.com/FDMB/threads/dr-pierson-new-food-

Between 11% and 17% is medium carbs.

18% and over is high carb.

 

[Diane Tyler's Mom GA]

Can you add SLGS to your signature also please

 

[SassyCat04]

Can you add SLGS to your signature also please

I've got it on there now. And yes I have Friskies wet which are about 11% in the house for the other cats and I also have KD wet for my other cat which is med carb? And we have Karo syrup. I can get some hi carb wet just for him next time I'm out, I thought the Friskies would be okay.

 

[Diane Tyler's Mom GA]

I've got it on there now. And yes I have Friskies wet which are about 11% in the house for the other cats and I also have KD wet for my other cat which is med carb? And we have Karo syrup. I can get some hi carb wet just for him next time I'm out, I thought the Friskies would be okay.

It doesn't have to be Fancy Feast just an example about the med and high carb foods
You can look in the food chart and see which Friskies are med and high carb

https://felinediabetes.com/FDMB/threads/dr-pierson-new-food-

Between 11% and 17% is medium carbs.

18% and over is high carb.
@SassyCat04

 

[Diane Tyler's Mom GA]

Getting comfortable with making judgement calls will come with experience I suppose. I'm just worried about giving him an injection when his number is too low and sending him into dangerous low numbers. It's a hard call to make at first until we can sort of know what to expect. Again, thank you.

If you get a pret shot below 200 you would stall for 20 minutes ,don't feed yet and post and ask for help , see if her number is coming up
Something such as HELP STALLING then her BG #

 

[Diane Tyler's Mom GA]

Hi All - I'll be as brief as possible. I've got my spreadsheet up and I really need some of you with experience to weigh in with your thoughts.

Makari was diagnosed on October 31st last year and we started Lantus. We did okay but realize now we had some incorrect advice with our vet. He ended up in a hypo crisis on Thanksgiving that was, at the time, considered possible reemission. He was completely off insulin with no symptoms until early January. On Jan. 6th, he was acting strangely and we took a BG and got a number of 560 and obviously restarted insulin.

As you can see from his sheet, we started with 1u twice daily for awhile until we could start with a new veterinarian. His numbers remained high. She had us switch to 1.5u and we did see them come down, which was great. BUT - this is where I need your advice. His drop seems awful fast to me and the low 200 number made me nervous to continue 1.5u. She advised we switch back to 1u for 7 days to see if the 1u would be enough UNLESS we saw him creep back up -- which he did immediately.

Are these swings normal? Should we have just continued with the 1.5u? I'm terrified of sending him into another hypo crisis. The new vet said her goal for a range was 150 - under 300. So that is why we opted NOT to give him 1.5 units with a pmps at 230, fear of going too low.

Trying to get her some help for awhile now

@Bron and Sheba (GA)

@tiffmaxee

@Suzanne & Darcy

@Sienne and Gabby (GA)

@Wendy&Neko

Previous post about the hypo that happened on Thanksgiving
https://www.felinediabetes.com/FDMB/threads/so-we-had-an-epic-crisis-makari.271369/#post-3021277

 

[Bron and Sheba (GA)]

Hi Lisa,
I think the first thing you need to be doing is to be getting a lot more tests in during the cycles I we can see what is happening.
Makira is most likely bouncing but we need to see evidence of that.
Take no notice of the vet who says no need to test..that is dangerous.
If you are not testing for ketones I would recommend you do. You will need a bottle of ketostix from the pharmacy or Walmart if you live in the US and follow the directions on the bottle. There should be no ketones in the urine.
Testing

• Test before every pre shot.
• If the BG is too low to shoot…stall don’t feed and test again in 20 minutes and pst and ask for help
• Try and get at least one test in during every cycle. More if possible
• Make sure to get a before bed test in every night. If that test is lower than the pre shot test, get up and test again a bit later as the BG is likely to drop further.

Feeding

• Feed a good meal before all the doses
• Offer 2 or 3 snacks during all cycles. A snack is a teaspoon or 2 of normal low carb food.

Dose

• It is best to stick to the same dose unless a reduction is earned. Testing frequently should tell you if the BG is dropping and you need to test more to stop a low number. Remember you can feed to stop the BG from dropping.
  
• If 1.5 U is too stressful, you could try 1.25 U and see how that goes.

I would start posting over on the Lantus page where you will get a lot more eyes on your thread.

 

[SassyCat04]

@Bron and Sheba (GA) thanks! I've done a TON of research today and I think I have a better understanding of what's going on. Yes, more testing. I do think it was bounce. I did not understand that the somogyi effect could be from a "perceived" low from his body and not an ACTUAL hypo number. Given that this happened at 7 injections of 1.5 I believe this was exactly what we saw. His dip to 230 made me a little nervous but it was really okay. Then his rebound was not a "bad" number that needed more insulin (which we did not give) but it was just a high number from his body trying to adjust.

Our routine right now is BG, Shoot, Meal. Every morning and evening. He is allowed food down all day as he is actually a bit underweight. He's on 80% wet. He gets 1/4 of dry before bed and when it's gone, it's gone, most mornings some is left. He's still not eating great - He's 12.5lbs and he's only eating about a 1/2 5oz can at morning (some left to snack on later) and same at dinner. Whenever he eats all the wet, I make sure to offer him more.

As far as Ketones, fortunately it's not something that's come back in his labs thus far.

So our plan is to work on getting some +4, +6, and +8 numbers on alternating days along with an AMPS and PMPS number so we can get a better idea of what's going on. Stick to the 1.5 for the next several days to let him adjust and see what happens. And we'll just see what his numbers are. Hopefully we don't have to adjust his insulin dose - that's the most maddening call to make for me right now. In your opinion - what's a safe number and what's "too low" to dose pre-injection? Is that suggestion of 200 accurate? Neither vet has given any real indication of this and it's a bit frustrating.

 

[Bron and Sheba (GA)]

adjust.
Our routine right now is BG, Shoot, Meal

Routine should be BG, meal then shoot.

As far as Ketones, fortunately it's not something that's come back in his labs thus far.

It can happen at other times apart from when labs are done. I would strongly recommend you start testing while he is unregulated.

So our plan is to work on getting some +4, +6, and +8 numbers on alternating days along with an AMPS and PMPS number so we can get a better idea of what's going on.

Don’t forget the pm cycle testing as well.

Hopefully we don't have to adjust his insulin dose - that's the most maddening call to make for me right now

It ok if the dose needs adjusting. It’s all about finding the best dose for him.

. In your opinion - what's a safe number and what's "too low" to dose pre-injection? Is that suggestion of 200 accurate? Neither vet has given any real indication of this and it's a bit frustrating.

As you have very little data with preshots, you can start off with a pre shot of 200 and when you get more data, you can start to lower it.

did not understand that the somogyi effect could be from a "perceived" low from his body and not an ACTUAL hypo number

There is actually no such thing as somogyl effect. @Sienne and Gabby (GA) can explain that well to you.
It’s called bouncing. Many vets still use the term somogyi effect.

Don’t forget to start posting over on the Lantus forum…I would post daily to get lots of help.

 

[Sienne and Gabby (GA)]

Somogyi ("chronic Somogyi rebound) was a term coined by Michael Somogyi, MD in 1938 when he published a paper based on a very small human sample. He published this in the Weekly Bulletin of the St. Louis Medical Society (not a high profile medical journal!!). For whatever reason, his interpretation of blood glucose variability became popularized and has remained over the years despite no research to replicate his findings. In fact, people will note something as Somogyi rebound despite the fact that newer generations of insulin are being used that bear no pharmacological similarity to what was available in in 1938. Further, the study was done on humans, not cats and even in humans, the results are controversial.

In 2016, Roomp and Rand looked at Lantus data to see if there was any evidence of Somogyi rebound in cats. They could not find any evidence of Somogyi rebound in cats.

We refer to the phenomenon as "bouncing." If you call it that with your vet, s/he won't know what you're talking about!