Could I get some other eyes on Celle's spreadsheet?

[Melissa and Celle]

I've actually switched to Lantus, but I feel more comfortable posting over here where I've been.

I haven't posted since we made the switch. I wanted to just take things super slowly because the problem with Levemir seemed in part to be increasing too quickly (albeit in small increments). Numbers got worse as we increased the dose.

I thought we were making progress, as 2.25 units seemed better than we've had for months the first couple of days (i.e., the longest stretch out of the 400s and a consistent dip into the 200s), but now things don't look so good. I think she's bouncing from a low (for her) last night. Usually we can get her highs to come down pretty quickly, but she's holding it up there today.

I'm also reminded of why I tried Levemir in the first place. She's just all over the map and we can't seem to get any consistency. I keep seeing that 107 on 2.0 units and wondering how much higher we can really go. No one is here to test during the day, so I really would be happiest if she never dropped below 100.

So... Yesterday I was thinking I'd go up to 2.5 units today, assuming that the 400s were too little insulin rather than a bounce. But now I'm pretty sure she's bouncing, so holding steady longer seems best.

Does anyone have any thoughts on what is going on? I've certainly given it lots of time to see how each dose works, but it still isn't so clear to me. (Be sure to look at the Lantus spreadsheet.)

 

[Vicky & Gandalf (GA) & Murrlin]

If you're following Tilly, which seems like you are, increases could probably stand to be .5U instead of .25U.

Most cats need to have their dose increased. Do it in 0.25 IU or 0.5 IU steps (0.25 IU if the cat is getting a low dose and/or relatively low BGs, 0.5 IU if the cat is getting a higher dose and/or relatively high BGs). Hold each dose for 5-7 days. However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU. Alternatively, if the cat is continuously producing moderately elevated BGs (nadir always >=200 mg/dl), increase the dose every 2-3 days by 0.25 IU ( if the cat is getting a low dose) or 0.5 IU (if the cat is getting a higher dose). From this point onward test for ketones once per week, or more often if the nadirs are still >=200 mg/dl.

Almost every +6 I see is in the 300s or 400s, with a smattering of 200s. Given that you previously got up to 5U before a breakthrough says to me she needs more insulin. 500s with as many reds and pinks as she has does not say rebound to me, they speak to just not enough insulin. There could be some insulin resistance going on too, with numbers this high for this long.

Have you made any other changes, in diet or medication? When was her last bloodwork?

I'm not sure that trying to stay above 100 and maintaining otherwise good control over BG is possible. Good regulation on Lantus or Levemir is probably not possible without going below 100 as that's how the insulin is meant to work.

 

[Melissa and Celle]

Have you made any other changes, in diet or medication? When was her last bloodwork?

Thanks Vicky. No, no other changes other than the switch to Lantus. Her last bloodwork was probably 4 months ago.

Almost every +6 I see is in the 300s or 400s, with a smattering of 200s.

It's the smattering of 100s that kind of concerns me. I keep thinking that increased dose will decrease those lows. Since I can't check at nadir very often, I assume that I'm not catching the lowest she goes. How do I manage that without constantly checking to make sure she isn't too low?

If you're following Tilly, which seems like you are, increases could probably stand to be .5U instead of .25U.

I'm kind of confused about that. It seems like the protocol would say that I should go up by 0.25 IU because the nadir is NOT always >300??

 

[Vicky & Gandalf (GA) & Murrlin]

I'm considering the fact that she's already above 2U. I feel that anything above 2U is a higher dose. If you want to stay with .25U increases, then maybe follow the increase every 2-3 days instruction from the protocol.

Yes there are some 100s, but few and far between. I am way more concerned about ketones/DKA at this point than I am with her going too low and having a symptomatic hypo. As long as you are leaving plenty of food out for her, she would be fine even if she went to 50 or lower, which doesn't look like it's going to happen.

I never could get a detailed picture of Gandalf's nadirs unless I was on vacation. I think you're underestimating yourself, her spreadsheet is well populated, you aren't skipping preshot tests, you're shooting a pretty regular schedule, everything you should be doing to get her on the right track. You have to hit that breakthrough dose before you concern yourself with how low she's going. And even 50s are not a red alert. Previously the dose may have been dropped too soon.

 

[Sheila & Beau GA & Jeddie GA]

I agree with all that Vicky posted, except I think I might make .25u changes up to at least 2.5u and hold them for 3-5 days. I have just seen too many "too fast" increases in my time.

Are you feeding any of the DM dry any more? It's a little odd to see 500s and 600s on a low carb diet. Those are usually rebound numbers or HC food numbers. But it does look like she may have some insulin resistance that you need to break through.

I think with most insulins, including even vetsulin, they won't drop the same number of points from different PS numbers - so if there is a drop of 200 points from 350 it won't also be 200 points from 250. At least that has been my experience, but I can't explain why that happens. And, yeah, numbers as low as 40 are safe (also my experience). I just wouldn't "aim" for them. I think you have safely make 75-100 your low point to aim for and it will leave some wiggle room in case she drops lower.

 

[Melissa and Celle]

Are you feeding any of the DM dry any more? It's a little odd to see 500s and 600s on a low carb diet. Those are usually rebound numbers or HC food numbers. But it does look like she may have some insulin resistance that you need to break through.

She free feeds low-carb Fancy Feast (along with lettuce or cabbage). I'd love to understand what the random 500s are all about. Sometimes they follow an unusual low so I think rebound, other times they just look like the insulin suddenly wore off after a long flat period. I think the 600s were the result of virtually no insulin. Since the sitter was using pre-filled syringes, I know she didn't overdose. Either she missed a shot or the insulin went bad in the syringe (which I later read can happen with Lantus depending on the syringe brand and the lubricant that is used in the syringe). After that disasterous out of town trip, I know I missed a shot and she was over 600 again. What bad timing.

Thanks for the help Vicky and Sheila. I hope you're doing OK Vicky. I'm still thinking of Gandalf