Charlie 4/28 Questions for experienced levemir users

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charliesmom

charliesmom

Member Since 2012
Hi Friends,

It would be real helpful to get some more experienced eyes on Charlie's spreadsheet, if anyone has the time. She is progressing on the levemir, and still not stabilised. Tonight she took a nose dive real early in the cycle. I gave maple syrup and food at +4.75 and +5. Now she's starting to come up a bit, but I still feel a bit lost in managing her on levemir and would like some advice on the following:

- Where do you think her nadir is likely hitting?

- Are there specific times I should be testing to give a full picture on her SS for all of you (in order to answer the question above)?

- The last time Charlie hit a low number and earned a reduction, we reduced to .25 and it wasn't enough. Would you advise reducing to .25 or just reducing to a skinny .5 (from a fat .5)? Or start with the .25 and if it's not enough, move up again to a skinny .5?

- Why are Charlie's cycles not more even? Mornings she seems higher most of the time. Has anyone ever given slightly more insulin in the morning and less in the evening (split dose) due to weird cycles like charlie's? (IE: Should I experiment with giving a skinny .5 in the morning and a .25 at night for awhile)?

Thanks in advance for your input. We are leaving for a trip on Tuesday and taking charlie with us, so input tonight or tomorrow is very much appreciated.

Thank you in advance,
Jill
 
Hi Jill. A couple of weeks ago I attempted to send a PM to you and Melanie in response to a PM she sent me about Charlie. Now I see that it vanished (no in my sent file or drafts)... sigh.

I can't remember totally what i wrote, but I think I suggested a dose between .25u and .5u. Are you using u100 syringes with half unit markings. Here is a link to photos and instructions for making much smaller dose increments than .25u: http://felinediabetes.com/FDMB/viewtopic.php?f=10&t=34424#p360982

You can dose in .1u increments with practice and in .05u increments with practice and determination! For now, just look really hard at where the top of the stopper in for both .5u and .25u and find a place that is half way between them. Look at my photos for an idea of how to "see" the width of the marked lines on the syringe and the width of the stopper flange to estimate doses. You may need a magnifying glass and a very strong light (I just take off my glasses). Just find a place where you can be consistent about how you are drawing the dose.

It won't work to try and shoot more in the morning and less at night, or any sort of varying dose. Lev like consistency and with the longer duration the numbers you are getting are the result of more than one dose as well as other factors like how much food and exercise she gets day vs. night. Often when you are seeing number variations like that it is a very slight rebound response that is so subtle it would be tough to pin it down as such. Anyway, stick with the same dose day/night.

I think in my PM I mentioned that numbers as low as 40 are perfectly safe - not something to let happen daily but not something to panic about. The 33 is definitely where you want to take some action, but you might try feeding regular food and testing in about 20-30 mins and see if she starts to come up from just the food. If she drops lower them try the syrup. You may find that she will be ok with an occasional 30. I have had two cats drop that low on several occasions and no ill effects. But it does warrant a dose reduction. I would not use syrup above 45 as it can set up for a high bounce in numbers later.

The nadir on lev can be any time in the cycle but +6 to +9 is typical. Charlie looks to be in that range, except when she is getting too high a dose, then she nadirs a few hours earlier.

She actually looks pretty good, number-wise. Pretty stable to me. And it looks like you are doing a great job with her on lev. You are at the fine-tuning point. So, shave a bit off that .5u dose, let it settle 3-5 days and see how she does. I am talking about a skinny .5u that I would call about .4u. If she still drops low on that amount then try a fat .25u - approx .3u. Yes a .05u amount can make a difference. Think of dose changes in percentages not volume. A change from .25u to .5u is a 100% increase and the reverse of that is a 50% decrease. Think more in the 20% change range - so, under .5u, that a dose change of .1u. Make sense?
 
My kitty is an acro kitty which means I really don't feel comfortable giving dosing advice for any kitty under 10u as the concept isn't the same...

HOWEVER- for the difference in PS's at cycles- there was a discussion on that in the relaxed lantus forum last week- it might be in the eating factor, as in WHEN they eat. Momma of muse said Autumn had low/high PS's so she decided to "front load" her. Regular schedule was AMPS, +6, PMPS, evening snack before bed and her food was split in 25% across the day. So MOM was going to try and front load her on the food- APMS, +3, light +9, PMPS, +3, we ours of the morning snack.

I am with Sheila in that Charlie is looking good and you might be looking at the drop method in order to fine-tune her dose to get a more consistent #.
 
Hi Sheila,

Thank you very much for your long reply. Sorry for the bit of delay in replying. When I posted the question, it was 3am Amsterdam time, and I had just fed maple syrup to get Charlie's numbers up. After 2 tests, I accidentally fell asleep, and then later when I woke up to test and check how she was doing, she was heading up, so I fell back asleep.

We will definitely have to learn micro-dosing. Right now we have been avoiding it to some extent, as we haven't been able to hardly even see the difference between .25 and .5 consistently. My .25 is different than my partner's .25

Generally though, both of our .25's don't seem to be enough for Charlie, so i anticipate that she may need slightly more than that for awhile.

If I look at the image you posted, what I was calling a "full .5" was actually a .7, so maybe we should have tried dialling it back just to .5 today and starting there.
As we fly out on vacation tomorrow and will not have as much time to test throughout the next week, we ended up going with a "full .25 this morning". Actually, my partner did the shot this morning while I was still sleeping, and after seeing in our "book" that charlie had gone low, just made a decision to go with .25

I guess we will keep it there for a few days to see how that goes. Likely, while we're traveling, Charlie's numbers may be up due to the stress, so maybe we will move it up to a "skinny .5" over the coming few days if her numbers are extremely high and we feel it's the right thing to do. I updated her sheet so you can see where she's at. Right now she seems to be increasing a bit. I guess that's normal for the morning after going low last night. Time will tell what happens tonight.

We are using the u100 syringes with half unit marks.

We will take your advice and stick with the same dose day and night. That is the advice we got from the levemir board as well (the place we have been posting this past year or so since Charlie was diagnosed).

Thank you again for your input and help. We appreciate it.

Jill and Charlie
 
Currently our feeding schedule is:

7am - 50 grams
1pm - 50 grams
7pm - 50 grams
1am - 50 grams

WIth slightly large amounts of tuna each time we test (1 tablespoon?)

It is difficult to spread the food out to the additional slots you mentioned due to work hours, but I suppose we could do so with the auto feeder if you think it would help. What feed times and amounts would you recommend to front load, if that is what makes sense? Since her numbers are high in the morning, doesn't it seem better to back load (feeding more a bit later)?
 
Yeah, getting 300s after a low like that is pretty standard. The syrup adds to that (not saying you should not have given it on the 33).

I think I have noticed that when there is some rebounding going on, even a very subtle amount, that reducing the dose can cause so "break through" higher numbers until things settle down. You might find that holding .25u over 3-5 days will allow her BG to settle and come down. If it doesn't you can always go back to the .5u as a mid point between the .25u and .7u you think you were shooting.

Good luck with your travels with her. (not sure if you have internet access while away....)
 
So she gets a 1/4 cup (2 ounces) at each meal, plus tuna throughout the day? And they are evenly spaced out... You would think it would give an even keel over the day like that.

I think momma of muse was doing that and then decided to feed more at the AM shot time with 1-2 tablespoons at the normal mid day time (to keep them from attacking her :lol: ) another light snack at +9 then nothing to get the fasting # for the PMPS and mirror that in the evening.

Would Charlie benefit with more? Wait- that is 8 ounces plus tuna treats already.

Can you add more water? Lets say- 3 oz for morning meal (7), +4 slightly less than 1 oz with extra water (11), +8 or +9 (4 or 5) slightly less than 1 oz with extra water. It is difficult. Charlie does have her meals broken down evenly- does she have the chance to free feed during that time? Does she graze on the 50 grams from 7am to 1pm and then you add more food? Or is it picked up directly? A bit of a puzzle when you add being gone for work.

With Sneakers I don't have this much problem- I just leave a dish of half food and half water out while I go to work :lol: .

Give the micro dosing a try first before you have to mess around with her feeding as you are so even.
 
Hi Jill -

I agree with Heather and Sheila. Charlie's numbers look pretty good. Like Heather, I can't offer dosing advice for mini- or micro-dosing; Grayson is a gulper. I think they called it well... fine tuning your dose with those tiny increments... as you're getting some decent numbers.

You're doing well with the food. Grayson usually needs more food at the onset of his insulin. So instead of breaking it up into 4 even servings, I stock his feeder to open at +1, 2, 3 and 4.... or +1.5, 3, 4.5; then offer some as I test later in the cycle. He tends to get a pretty sizeable food spike, so by spreading 1/3 or 1/2 (3 oz) cans throughout the cycle, we don't see nearly as much spike.

I think once you feel like she's leveling off, then you can add those microscopic amounts to gradually bring his numbers ever so slightly lower. Keep up the good work!

Lu-Ann
 
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