Dose Advice needed

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Screw it, I'm going to reduce the dose tonight. Everyone here seems to have so much first-hand knowledge and I just can't discount that.

I'll speak to the doctor at the hospital tomorrow who told me to freak out if I saw a number below 80. Worst case, she tells me to go back to 1/2.

Cat went however long without any regulation at all and then managed to come through DKA like a champ... If this is a mistake I'm sure he can handle another few days of being higher than optimal.
 
I put a link to the Lantus dosing protocol we use here at the end of my post. Since you are using the Alphatrak meter, you want to use Table 3B.

Here is what it says about what you should do for how low your cat dropped today:
If the cat drops below 70 mg/dL once (4.5 mmol/L) Reduce dose immediately by 0.25-0.5 IU depending on if cat on low or high dose of insulin
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Here is the full text. I tried to copy the whole document here but it lost it's table formatting and was difficult to read. http://www.felinediabetes.com/Roomp_Rand_2008 dosing_testing protocol.pdf You might want to print this and/or save it to your internet favorites folder.
 
Deb & Wink said:
I put a link to the Lantus dosing protocol we use here at the end of my post. Since you are using the Alphatrak meter, you want to use Table 3B.

Here is what it says about what you should do for how low your cat dropped today:
If the cat drops below 70 mg/dL once (4.5 mmol/L) Reduce dose immediately by 0.25-0.5 IU depending on if cat on low or high dose of insulin
Click to expand...

Here is the full text. I tried to copy the whole document here but it lost it's table formatting and was difficult to read. http://www.felinediabetes.com/Roomp_Rand_2008 dosing_testing protocol.pdf You might want to print this and/or save it to your internet favorites folder.
Click to expand...

Thanks. I'm going to give the reduced dose and then try to get a +3 before I go to sleep to see if there is another drastic drop like today. If that really is when he goes lowest I might be able to get one each night.
 
fyi, one of the favorite tests around here is the +2 ... after the preshot test.
If the number at +2 is significantly lower than the preshot number , it is a very good indicator that the cycle could be an active one and you should
definitely monitor to see where it is going.
You will use that a lot in the future.
I hope he safes surfly for you. Goodnite from me.
 
Let's see how he does for a couple of days. His blood glucose has pretty high the last few days anyway on the higher insulin dose... We are hoping this new dose will stop that.

I hope you have been testing his urine for ketones.. We recommend it when cats are over 340 or twice a weeK. Since he is prone to DKA and has been pretty high anyway the last week I would strongly advise you get some - like tomorrow!!! That way you can catch the issue early... I can give you urine catching tips. Walmart sells relion ketone strips or you can get keto-diastix.

Are you home tomorrow to do a few mid day checks? For Next week you might also want to get a before bed test and then set the alarm for a few middle of the night checks since you can't test during the day but hopefully this new dose will stop him going too low... And too high!

Now because he was low you will likely see high numbers again (more blacks) which may last a day or two.

Wendy
 
Wendy&Tiggy said:
I hope you have been testing his urine for ketones.. We recommend it when cats are over 340 or twice a weeK.

Are you home tomorrow to do a few mid day checks? For Next week you might also want to get a before bed test and then set the alarm for a few middle of the night checks since you can't test during the day but hopefully this new dose will stop him going too low...

Wendy
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I've been testing for ketones every third day or so (particularly when I saw the high 600 numbers). So far, every test has been negative (maybe trace, the colors are so similar).

I will do some mid-day tests today.

In any event, the amps was 240. Fingers crossed that the +2 is a less drastic drop than yesterday.
 
I would check for ketones at least every day for a while, especially after lowering the dose. DKA can come back, especially if the episode was recent. You don't want that. And I don't find the two colors to be that close in color (negative and trace). Maybe try to hold the bottle and strips under a brighter light to compare. Trace ketones means you have to be very careful. Please post if you start to get trace ketones.
 
Wendy&Tiggy said:
Did you get a +3 last night? I stayed up and kept checking but didnt see an update?
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I did not (and I'm so sorry you stayed up, I didn't realize). I tried, but I was so tired my hands were shaky and after 3 sticks without blood I had to call it quits. I am absolutely going to do a +1, +2 and +3 today, and then go from there depending on what they show.

Seeing the 240 this morning makes me feel muuuuuch better, particularly because I am home to test. If he does go too low I can address it quickly.
 
No worries, I just wanted to be here in case he went low again and you needed help.

How's he doing with the testing generally? Still hiding? And how is his appetite?

Edited to add... What time is the +1 due? So I know when to check back in. Although +1 probably isn't really necessary, +2 will give you more info since the lantus will have started to kick in then.
 
Wendy&Tiggy said:
No worries, I just wanted to be here in case he went low again and you needed help.

How's he doing with the testing generally? Still hiding? And how is his appetite?

Edited to add... What time is the +1 due? So I know when to check back in. Although +1 probably isn't really necessary, +2 will give you more info since the lantus will have started to kick in then.
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+1 will be at about 10:50 (15 minutes or so from now). I figured it would be good because if he was starting to drop I would see it early.

Testing depends on the day. I don't want to jinx it but yesterday was a good day despite so many tests.

His appetite is great and has been consistent since he came home. He eats a full 6oz a day, and for the first few days he was eating a little more than that (I wanted to give him a few extra calories because he lost so much weight in the hospital). But now I keep it to just 6oz so he doesn't get fat again.
 
Yep the insulin hasn't kicked in yet, or he could be bouncing/surfing. Will see what the +2 is like.

That's good on his appetite, I would weigh him every couple of weeks and adjust the food if he starts to lose or gain.
 
+2.5 was 170. I will probably wait until +6 to test again. His ears could use a break (I also can't keep burning through tests strips because I won't be able to look into a new meter until next weekend and don't want to have to buy more of the Alphatrak strips if I am going to switch).

I sent yesterday's numbers to the doctor at the hospital and she was also not concerned about the 53 because of the low dose he was already on. But she thought it would be ok to stay with the 1/4 dose and do another curve next weekend.

So, unless I see numbers consistently rising I will stick with this. I will worry about high pre-shot number if or when they happen.
 
I would get a + 4 or + 5 instead because yesterday his low point was before +6. And definately you need a new meter .. Alphatrak is too expensive!!!

Edited to add.. May bailey had a hypo on 0.25 so just because its a low dose doesn't mean anything.
 
Wendy&Tiggy said:
Nice numbers today. Any chance of a PMPS +2 or 3 just to see what his nighttime trends are?
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Wasn't able to do any more last night. Today's numbers are not making me happy, but I need to get to work so I'm going to have to stick to pre-shot tests through the weekend. Hopefully today is just an anomaly.
 
That's a shame you can't get a nighttime test in, I wonder if he dropped low last night.maybe you could change your shot time so u can get a before bed test?

I just worry that he could be dropping dangerously low at night and you are missing it. My bailey did that and nearly died... He was only getting 1/4unit too!!! I happened to wake up in the middle of the night and xouldnt sleep so I thought I would test him only to discover him in a coma on the stair. I could easily have lost him.


Now I always set the alarm for a middle of the night test twice a week. Humans sleep in four hour cycles so I set it for four hours after I go to bed so that its not too disturbing. I got to think its like waking up to feed a baby.. Except you are back in bed quicker!
 
Ah yes, that pesky thing called work is just one of the many responsibilities pulling you in so many different directions. After all, you do have to work so you can buy your kitty lots of food and special treats. ;-) You do what you can. That is all we have ever expected from any of our members.

Sometimes, people get what we call 'an in the door' test. When you get home from work, take a test. That can give you some more data if you think you are interested. It does not need to be every day either. More of a "when you can" time to test.

Also, since you are still using that Alphatrak with the more expensive test strips, only do the tests if you have enough test strips to get you through until you can buy a different meter with more affordable test strips.
 
Deb & Wink said:
Also, since you are still using that Alphatrak with the more expensive test strips, only do the tests if you have enough test strips to get you through until you can buy a different meter with more affordable test strips.
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Just ordered a Relion Micro and lots of strips. I should have few strips left for the Alphatrak when it gets here, so I will save those for backup if I see a really high or low number one day.
 
Another high number today. I'm starting to wonder whether the dose reduction was the right move.
 
I dont like to harp on, but a major issue is that you arent getting any tests in at night. He could be going dangerously low and bouncing high. Many cats do go low at night. If you raise the dose and he is doing that (which I do strongly suspect) he could have a hypo and die. Can you move your shot time to say 8am and 8pm and then do a test at 10pm at night?

A bounce =
When a cat is first diagnosed, the blood glucose has probably been high for a while. As the insulin starts to take effect and numbers start to come down, the liver has to learn to adjust to the lower numbers. We call this "liver training school". But before it relearns that low numbers are ok, when the BG drops to a number lower than the liver is accustomed, or if BGs drop low, or if the BG drops suddenly, the liver”panics” and reacts by releasing counterregulatory hormones and glucagon. This drives the BG back up. This is what we call a "bounce". Bounces can take up to 72 hours to clear so we are generally careful about increasing doses during the bounce. Once the bounce clears, then you can see the "real" numbers and determine if the dose needs to go up or down.
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I will start moving it back gradually. It will take a few days to get to 8 (I'm at 945 now).

Thank you for all the help.
 
A dose change takes time to 'settle in'. Your cats body needs to get used to the new dose. We have a term for it NDW or "new dose wonkiness". :shock:

For that reason, you need to be patient when changing a dose and make sure you can get some more test numbers, especially around the nadir which is usually around +6 give or take an hour. We realize that you have a very full life,work full time, like to go out with friends, hobbies, family etc... But your cat needs some extra help right now.

We ask people to hold a dose change for a minimum of 3 full days or 6 cycles, maybe longer.

Without the test numbers in the middle of the cycle, especially at night, it will be almost impossible to know if your cat is dropping low still and this even lower dose you are giving may be too high. We can't know what to advise next without some data to support our recommendations.

Dose changes for lantus are based on the nadir, not the pre-shot values.

Stay with the course for a few days more, be patient and get those tests if you can. Glad to see you will be shifting your pre-shot times 30 minutes earlier for the next few days. That will allow some other testing to occur.

You are doing great and sending you {{{{hugs}}}. Keep up the good work and let us know if you have any questions.

ETA: Would you please put those ketone tests and results in the comments/remarks column at the right side of the spreadsheet. Thank you.
 
Deb & Wink said:
A dose change takes time to 'settle in'. Your cats body needs to get used to the new dose. We have a term for it NDW or "new dose wonkiness".
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Technically, NDW only applies to dose increases. ;-) Regardless of the technical definition, I've always noticed similar "wonkiness" with Mikey on his dose decreases so maybe someone has some other explanation or name for it. Usually though, it only takes a couple of days after a decrease before his numbers stabilize again.
 
I agree. Please add Ketones are Negative, or whatever the test result is, into the Remarks section of your spreadsheet.

ETA: Please let us know by posting if you see a trest result other than negative, or if he is acting off, or lethargic, or throwing up, or if his appetite wains.

Thanks.
 
Well, because I can't do another curve or be sure I can get mid-cycle tests until Saturday, I would never change a dose during the week anyhow (unless it was an emergency situation). So, I will stick with the 1/4 unit until the weekend at minimum, do another curve, and then go from there.

As for ketones, let's just say that no news is good news. And if I ever do see keytones any post on here will begin with "and I just got off the phone with the hospital and already did x, y, and z." And I mean no offense at all to anyone here when I say that (I would never have gotten this far without everyone's knowledge and advice). But because that is a situation that can go from bad to horrible in a flash, I want the doctor who would be handling the worst-case scenario to be in control the entire time.

Likewise for any behavioral changes... now that I know the things which should have raised flags when I saw them a while ago I will be much quicker to pick up on them and not just write it off as "he's getting older."
 
Here are some additional monitoring tools you may find helpful (well .. depending on the number of cats in the household!):

Water Consumption
Measure the amount of water you put down each day.
Measure how much is left at the same time the next day.
The difference is water drunk and some evaporation.
This will gradually decrease as you get better control.

Food Consumption
Measure the amount of food you put down each meal.
Measure how much food is left at the next meal.
The difference is food eaten and some evaporation of moisture from the food.
This will gradually decrease as you get better control.

Urine output
Roughly measure the amount of wet litter produce each day and it’s characteristics
- have you got oceans, lakes, ponds, or cups?
oceans = uncontrolled or possible some other problem such as renal disease or hyperthyroidism
cups = better controlled or lack of water intake

The 5 Ps
Purring - is the cat exhibiting customary signs of contentment or happiness?
Playing - will the cat play and interact with others?
Preening - is the cat maintaining its fur and cleanliness?
Peeing - occurs, and is a normal volume?
Poohing - fecal material is formed and passable? Constipation may happen with a food change; adding a tablespoon or so of water may help, plus ensures the cat is hydrated properly.

Weight
Obtain a reliable, digital baby scale (Craigslist is one resource to check)
Weigh weekly, at about the same time and before a meal.
Pre-shot might work well as the time to do this.
Unplanned changes of more than 0.25 pounds (3-4 ounces) should be noted
Unplanned changes of 0.5 pounds may indicate something is happening.
A consistent, unplanned trend over time may suggest a problem; see the vet.
 
And if I ever do see keytones any post on here will begin with "and I just got off the phone with the hospital and already did x, y, and z."
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Good for you! I agree completely with your plan.

). But because that is a situation that can go from bad to horrible in a flash, I want the doctor who would be handling the worst-case scenario to be in control the entire time.
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Yes, indeed. Excellent plan in place there.
 
Mnyc said:
Likewise for any behavioral changes... now that I know the things which should have raised flags when I saw them a while ago I will be much quicker to pick up on them and not just write it off as "he's getting older."
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Amen Sister! A little knowledge changes everything.
 
Ok, so if I see a "trace" ketones result (without any other suspect behavior), do I need to do anything other than keep testing for ketones in case they increase?

There had been no change in eating, drinking, activity...

Could a "trace" result just be from the fact that he isn't well regulated yet with the insulin?

EDITED TO ADD: the vet told me right from the start not to get nuts about a trace ketone result and to really be on the lookout for the higher levels. So, I don't want to overreact to anything (I'm at max stress level with the insulin and blood tests these days).
 
Because he recently had DKA, I would check at least once a day, and make sure they do not go above trace. Some cats, are more prone to ketones for some reason, and you don't want Mync to have to be hospitlized again.
My cat J.D. is a DKA survivor too, that's why I am concerned. He was hospitalized for 8 and 1/2 days and I'll never forget how scary that was.

If you test yourself with the test strips and compare it to the test result you get from Mync, is it a different color, or is it just the lighting in your house?

If he has trace ketones, make sure he eats plenty and is not dehydrated. Maybe add extra water to his food if he'll eat it. If he goes higher than trace, or shows any of the other symptoms like not eating or lethargy, I would call the vet as you said you would. Higher ketones can happen very fast.
 
He had much better numbers today. Hopefully, that is helping to reduce your stress level.
I am hoping I am not upsetting you more. I just want you to be cautious and diligent, is all.
 
Ok, thanks. I kind of assumed that trace just meant to keep looking. He is eating and drinking as normal and I will make sure to test every night. I can try to test mornings also but I can only stand around and wait for him to pee for so long.

And no, I don't want him to be hospitalized again. Beyond the financial, I saw how much stress he was under while he was there the first time. Doing that to him again is not a decision I would make lightly.


Just tested again and at 15 seconds exactly there was less of a color change than earlier today. So I may have waited a few seconds too many before.
 
Yeah, I ordered the relion the other day. The meter came yesterday and the strips are supposed to arrive today.

I wasn't crazy about the 600 last night but the 224 and 298 (meal and shot in between) made me feel better.

Is there any course of treatment that involves one shot a day instead of two, or is it all (2x day) or nothing?
 
Not as far as I know - I think there are insulins that need more shots but those are really rough on the cat. Why? whats your logic?

The 618 was probably a bounce off the 148 (assuming he didnt go lower than that). He has done that a couple of times after a low blue. He will eventually stop doing that once his body gets used to being in normal blue and green numbers.

Definition of a bounce:
When a cat is first diagnosed, the blood glucose has probably been high for a while. As the insulin starts to take effect and numbers start to come down, the liver has to learn to adjust to the lower numbers. We call this "liver training school". But before it relearns that low numbers are ok, when the BG drops to a number lower than the liver is accustomed, or if BGs drop low, or if the BG drops suddenly, the liver”panics” and reacts by releasing counterregulatory hormones and glucagon. This drives the BG back up. This is what we call a "bounce". Bounces can take up to 72 hours to clear so we are generally careful about increasing doses during the bounce. Once the bounce clears, then you can see the "real" numbers and determine if the dose needs to go up or down.
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Remind me again what brand/type of food you are feeding?
 
Mnyc said:
Is there any course of treatment that involves one shot a day instead of two, or is it all (2x day) or nothing?
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Because Lantus is a depot-style insulin, micro-dosing .25u (or even less) twice a day is preferable to once-daily dosing so the depot isn't lost and the numbers remain more stable. If you dose only once a day, your cat runs out of insulin towards the end of the 24 hours and has no coverage and this also increases the likelihood of bounces and higher numbers.
 
Wendy&Tiggy said:
Why? whats your logic?

Remind me again what brand/type of food you are feeding?
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I was curious about whether there was a once-a-day solution just because the pm shots are problematic for me. Being home in time to give it is really causing me grief and if I move the shot time to later it causes problems in the morning. I didn't think there was a way to do one shot every 24 hours but I figured I would ask.

He is eating the Fancy Feast chunky chicken. He seems to like it, is eating a full 6oz a day, his weight seems stable, and it isn't expensive. So, win-win.

So I just got home and the strips for the relion were here. I tested, and his +9.5 was 79. That's roughly a 109 if I were using the Alphatrak, correct?
 
Just do the best you can with two shots a day. A couple of years ago my cats were on an 8/16 hour schedule on the weekends. That lasted for over a years.
 
Mnyc said:
He is eating the Fancy Feast chunky chicken. He seems to like it, is eating a full 6oz a day, his weight seems stable, and it isn't expensive. So, win-win.

So I just got home and the strips for the relion were here. I tested, and his +9.5 was 79. That's roughly a 109 if I were using the Alphatrak, correct?
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That is roughly, correct. It is a good number :mrgreen:
My cats like the Chunky varieties too. They are a little higher in carbs, but not too far up there.
I would test again at +11, so you can compare the PM dose test to the +11, and will then know whether he is staying the same or rising or dropping at shot time.
 
He only has 4 teeth so I have to mash the chunks out of the food anyhow, but this is the first time he has ever been content with just wet food so I'm fine with it. When he grows tired of this flavor I will try one of the not chunky ones. But for now I will take the victories where I can.
 
1/4 unit. Same as all week.

+11 was 205 vs this morning's +11 of 224 on the Alphatrak. So, pretty much the same.
 
Wow ok then I am so glad you didn't increase like you were considering. You can expect another big bounce btw. At this rate I am thinking he might get another dose reduction soon. Be good if you can get some extra tests this weekend as if he drops below 50 he gets another decrease. Next time it's to 0.1iu and I can send you another syringe pic to show how that looks.

At this rate he might end up coming off entirely or being a micro dose cat. Like my bailey who is getting pretty much a sniff of the

Shooting every twelve hours (give or take 30mins) is ideal but you also have a life so try to get to that as much as possible but if you are late at night then you are doing the best you can.

Has he always been on FF chunky chicken or was he on dry or something else prior to diagnosis?

Wendy
 
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