Sticky Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR)

*** IMPORTANT DOCUMENTS ***

Symptoms of & how to treat HYPOGLYCEMIA - what to do if your kitty experiences hypoglycemia
Jojo's Hypo Tool box - be prepared, what to have on hand in case of an emergency
Don't Panic! or How to Handle Low Numbers

THE USE OF PET-SPECIFIC METERS IS DISCOURAGED BECAUSE THE DOSING METHODS USED ON THE FDMB WERE CREATED WITH METERS CALIBRATED FOR HUMANS. ALL REFERENCED NUMBERS CORRESPOND WITH METERS FOR HUMANS, NOT PET METERS.
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~ The best insulin is the one that works for YOUR cat! ~
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DOSING METHODS

There are several dosing methods found on the Internet which have proven to be successful for treating feline diabetes with Lantus, Basaglar, or Levemir. However, we've been very successful with the 'Start Low, Go Slow (SLGS) Method with Lantus, Levemir, or Biosimilars for Diabetic Cats' and the 'Tight Regulation Protocol with Lantus or Levemir for Diabetic Cats'.

We chose to focus on these two dosing methods because given the nature of these insulins, the methods made sense for both cats and caregivers. The guidelines found in each of these methods are not intended to portray the only way one can dose glargine or detemir. Instead, they suggest how to best use Lantus, Levemir, or their Biosimilars when practicing either of these two methods.

In most cases, Lantus, Levemir, and Biosimilars are best given on a 12/12 schedule when following these methods. However, sometimes life doesn't afford the luxury of adhering to a strict 12/12 schedule every day of the week... every week of the year. Don't let fluctuations in your schedule deter you from using these wonderful insulins.

Shooting every 12 hours is best with these methods, but many caregivers have been able to work around their schedules successfully once they're able to get an idea of how their cat responds. Don't be afraid to ask for help. There's a good chance someone else has "been there, done that".
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TIGHT REGULATION (TR)

Tight Regulation with Lantus or Levemir for Diabetic Cats
Management of Diabetic Cats with Long-acting Insulin - summary published in 2013

The Tight Regulation Protocol with Lantus or Levemir for Diabetic Cats was developed by laypersons from the German Diabetes-Katzen Forum. The protocol was eventually published in the Journal of Feline Medicine and Surgery. Note: Basaglar is a new brand of insulin glargine developed and made available since the TR protocol was written.

The tight regulation protocol was tested in 55 diabetic cats for Lantus/glargine and in 18 diabetic cats for Levemir/detemir from the German Diabetes-Katzen Forum. Owners measured blood glucose an average of 5 times daily and adjusted insulin dose based on the protocol. An overall remission rate of 64% was achieved in the cohort. Significantly higher remission rates were observed if good glycaemic control was achieved soon after diagnosis: 84% for cats started on the protocol within 6 months of diagnosis went into remission, and only 35% for cats that began more than 6 months after diagnosis.

Highlights from the Tight Regulation Protocol with Lantus or Levemir (full list found on website):​

• Kitty should be monitored closely the first three days when starting Lantus or Levemir. Initially, blood glucose levels should at least be checked at pre-shot, +3, +6, and +9. More monitoring may be needed.
• It will be necessary to test kitty's blood glucose levels multiple times per day.
• Learn the signs of and how to treat HYPOGLYCEMIA and prepare a HYPO TOOLBOX.
• Test regularly for ketones and know about DIABETIC KETOACIDOSIS (DKA).
• You will need a glucometer made for human diabetics.
• Use U-100 3/10cc syringes with half units marked on the barrel for fine dosing.
• Feed a high quality low carb canned or raw food diet.
• Feed small meals throughout the day. Although, some kitties will adapt well to free feeding.

Many glargine and detemir users in this forum have been successful following a slightly modified version of this Tight Regulation Protocol. These "general" guidelines are based on anecdotal evidence and personal experiences of laypersons frequenting the forum.

How to determine an initial starting dose for glargine or detemir when following the Tight Regulation Protocol:​

• the formula is 0.25 unit per kg of the cat's ideal weight​
• if kitty is underweight, the formula frequently used is 0.25 unit per kg of kitty's actual weight
• if the cat was previously on another insulin, the starting dose should be determined by taking prior data into consideration as indicated below:
  • If the current insulin is another depot insulin (e.g., switching from glargine to Levemir or vice versa), drop the dose by 30% since some cats can have a marked response to a change in insulin.
  • If the current insulin is ProZinc or a shorter acting, non-depot insulin, the same dose can be used (i.e. if the cat’s BG was stable and above 90 mg/l at 2.0u with the current insulin, the starting dose of the new insulin could be 2.0u). It is important to take into consideration how low the dose of the current insulin is dropping.
  • The BG and the caregiver’s comfort level with the nadir of the current insulin when determining the dose of the new insulin.
  • It is not recommended the starting dose of the new depot insulin be dropped back to the weight-based formula when switching from one insulin to another.
  • It is important to remember that while Lantus (and its biosimilars) and Levemir have a longer duration than other insulins, they have a lower potency.

Tool: Online Calculator for Converting Pounds to Kilograms
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General Guidelines:

• Hold the initial starting dose for 5 - 7 days (10 - 14 consecutive cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 consecutive cycles).
• Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction (See: Reducing the dose...).
• Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.​

Increasing the dose:​

• Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.​
  • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.​
  • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.​
• Increase by 0.25 unit after 3 days (6 consecutive cycles) if nadirs are greater than 200, but less than 300.
• Increase by 0.5 unit after 3 days (6 consecutive cycles) if nadirs are greater than 300.

Reducing the dose:

The TR Protocol is an aggressive method in itself. The modified version of the protocol is slightly more aggressive. Let's keep all our kitties in the Lantus, Levemir, & Biosimilars ISG safe by taking reductions when appropriate.​

• If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit.
• Alternatively, attempt a reduction when the cat regularly has its lowest BGs in the normal range of a non-diabetic healthy cat (50 - 80 mg/dL) while staying under 100 mg/dl overall for at least one week.
• Please do not let yourself become complacent or blasé about drops into the 20s or 30s. Please ask for advice immediately.
• If your cat drops into the 30s, a full reduction of 0.25u is recommended. There are few exceptions given to caregivers who have collected years of data and KNOW their cat's response to the combination of insulin and food backwards, forwards, and inside out.
• Caregivers whose kitties have "High Dose" conditions may find the need to reduce in whole units or more.
• If an attempted reduction fails, go right back up to the last good dose as soon as you see kitty's numbers trending upwards. You don't have to hold the reduced dose for a certain number of cycles before taking the dose right back up. The guidelines listed under the topic "Increasing the dose" do not apply to a failed reduction. Please use common sense in this situation. The "last good dose" is not the dose that just dropped kitty into the 20s or 30s. You want to resume momentum by finding an in-between the dose.
• We've found many kitties benefit from reducing the dose from 0.25u to 0.1u before stopping insulin completely. During a two week OTJ trial, you want to see mostly green numbers (under 100) with only a few random blue numbers between 100 - 120 to help ensure a strong remission. Most kitties will be in the range of a healthy cat (50 - 80 mg/dL) overall.

Remission:
From Tilly's Diabetes Homepage - Phase 5: Remission

"14 days without insulin and normal blood glucose values. Most remission cats are able to stay in the normal range all of the time (50 to 80 mg/dl), although there are a few cases of sporadic higher and lower BGs. Don't stop feeding low-carb and try to avoid cortisone if possible.

Test the cat's BGs once per month. Approximately 25% cats that achieved remission using this protocol relapsed and required insulin again (frequent causes are hyperthyroidism or bouts of pancreatitis). Therefore, it is important to keep your diabetes kit up-to-date. Then you can react immediately by giving insulin and home testing. Importantly, the sooner you react to a relapse (i.e. preventing hyperglycemia and initiating other necessary veterinary treatment), the more likely a second remission will become.

The longer a cat has had diabetes, the less likely it will go into remission. Many long-term diabetics get stuck in Phase 3 or 4. Yet there is a benefit of using this method for such a cat as well: keeping the cat's BG levels as normal as possible is much healthier for it long term. Insulin requirements will often decrease to very low levels too."


Is Tight Regulation Possible with a Full Time Job? Yes!

Journal of Veterinary Medicine, 2015:
Glycemic Status and Predictors of Relapse for Diabetic Cats in Remission

Random notes:​

• KNOW THY CAT. Shooting early or late is a practice best reserved for those who have a full understanding of the insulin used and it's effects on their kitty. Because of the cumulative nature of glargine and detemir be aware: ​
  • Shooting an hour or two early *could* act like a slight dose increase. ​
  • Shooting an hour or two late *could* act like a slight dose reduction.​
  • How your cat will react has a lot to do with what kitty is doing that day. For instance, if a bounce is breaking shooting early probably isn't the best idea because you'll have a little extra action on the dose from both the early shot and the bounce breaking simultaneously. ​
  • The next shot is due 12 hours after the time of the early or late shot if you're shooting twice a day. Oftentimes the effects of an early or late shot will not be seen until the next cycle. Please monitor carefully when shooting early. Ask for guidance if you're unsure.​
• A "cycle" refers to the period of time between shots. There are 2 cycles in 24 hours when shooting on a 12/12 schedule.​
• Oftentimes the dose will require "fine tuning" by adding some "fat" (more) or "skinny-ing up" (less) insulin to the dose. However, we strongly suggest caregivers do not skinny kitty's dose after a drop into the 20s or 30s. Instead, take the full reduction.

Sometimes there are circumstances such as ketones present, an unusually low preshot number, a caregiver leaving the cat with a sitter, relatively high flat curves, loss of appetite, infection, a schedule change, ability to monitor, etc. which may call for adjustments to these guidelines. Please ask for guidance if any of these or other circumstances present themselves or are of concern.

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TR document written by FDMB members Jill & Alex (GA) and jojo and bunny
Updated 1/2019
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START LOW, GO SLOW (SLGS)

The Start Low, Go Slow Method (SLGS) with Lantus, Levemir, or Biosimilars for Diabetic Cats has been adapted from the FDMB's original 5 Steps to Regulating Your Diabetic Cat. Adaptations were necessary to accommodate the action, nuances, and exceptions of the newer Lantus, Levemir, and their Biosimilars insulins.

Requisites when following the Start Low, Go Slow Method:​

• Learn the signs of and how to treat Hypoglycemia and prepare a Hypo Toolbox.​
• Test regularly for ketones and know about Diabetic Ketoacidosis (DKA).​
• Use a meter calibrated for humans, not a pet-specific meter. Reference numbers given are for measuring blood glucose with a human meter.​
• Use U-100 3/10cc syringes with half units marked on the barrel for fine dosing.​
• Most kitties are easier to regulate when fed small meals throughout each cycle. Others adapt well to free feeding.​

Starting Dose:

• 1u BID if kitty is not on a wet/canned low carb diet
• 0.5u BID if kitty has been switched to a wet/canned low carb diet
• If the cat was previously on another insulin, the starting dose should be increased or decreased by taking prior data into consideration
• Generally, shots are to be given 12 hours apart.

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​

As your cat's blood glucose begins to fall mostly in the desired range [lowest point of the curve approaching 100 mg/dl (5.5 mmol/L) and pre-shot value around or below 300 mg/dl (16.6 mmol/L)], do lengthen the waiting time between dose increases. If you decide to change another factor (e.g., diet or other medications), don't increase the insulin dose until the other change is complete (but decrease the dose if your cat's glucose numbers consistently fall below 90 mg/dl (5.0 mmol/L) as a result of the change).

Don't be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat's blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose.

Lather, Rinse, and Repeat!

How to handle a lower than normal preshot number:

Until you collect enough data to know how your cat will react, we suggest following the guidelines in the FDMB's FAQ Q4.4:
Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?​

A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.

• Below 150 mg/dl (8.3 mmol/L), don't give insulin.
• Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
  • a.) give nothing
  • b.) give a token dose (10-25% of the usual dose)
  • c.) feed as usual, test in a couple of hours, and make a decision based on that value
• Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
• In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
• Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.

Keep in mind these are general guidelines, and they should be personalized to your own cat's response to insulin. If your experience is that your cat does not became hypoglycemic with a dose which is close to her usual, then personal experience should be your guide.

With experience, you may find that lowering these thresholds may work well for your cat. When you have reached that stage, the following guidelines are suggested for Lantus, Levemir, and Biosimilars users following the Start Low Go Slow approach:

If the preshot number is far below usual preshot numbers: ​

• Do you need to stay on schedule? Then skip the shot.
• Do you have some flexibility with your schedule? Then stalling to wait for the number to rise might be a good option. Don't feed, retest after 30-60 minutes, and decide if the number is shootable.
• Repeat until the cat either reaches a number at which you are comfortable shooting, or enough time has passed that skipping the shot is necessary.

If the preshot number is near kitty's usual preshot numbers:

Look at your data to see what numbers you have shot in the past and decide what would be a safe, shootable number for your cat. Don't feed. Stall until kitty reaches the preshot number you've decided on and then shoot.

We usually don't suggest or recommend shooting a preshot number less than 90 mg/dL when following the SLGS Method. Remember that with SLGS, generally speaking, your goal is to achieve flat numbers that are greater than 90 mg/dL. However, let experience, data collected, knowledge of your cat, and availability to monitor help in making the best decisions for your cat.

If kitty is dropping faster or lower than you'd like, please see "Don't Panic! or How to Handle Low Numbers" and post for help or suggestions.

Remission:

Remission is reached when kitty can go 14 days without insulin. Most cats will remain in the range of a healthy cat 50 - 80mg/dL (2.7 - 4.4 mmol/L) with only sporadic higher or lower BG numbers.

Occasionally, some will experience infrequent BG numbers higher than the norm. Continue feeding low carb food. Test the cat's BGs once per month. If BG numbers begin to trend upwards, it's time to bring kitty in to see your vet for a check-up. Common reasons for kitty falling out of remission include dental issues, infection, inflammation, pancreatitis, etc. Just about any illness or disease can do it.

Journal of Veterinary Medicine, 2015:
Glycemic Status and Predictors of Relapse for Diabetic Cats in Remission


Sometimes there are circumstances such as ketones present, an unusually low preshot number, a caregiver leaving the cat with a sitter, loss of appetite, infection, a schedule change, ability to monitor, etc. which may call for adjustments to these guidelines and suggestions. Please ask for guidance if any of these or other circumstances present themselves or are of concern.

Random Notes:​

• In the case of a furshot, NEVER give another shot. There's no way of knowing how much of the first shot "got into" the cat.
• NEVER give a second shot because "numbers are too high" in a 12 hour cycle.
• Test often for ketones.
• Be consistent in timing and type of food.
• KNOW THY CAT. Shooting early or late is a practice best reserved for those who have a full understanding of the insulin used and it's effects on their kitty. Because of the cumulative nature of Lantus and Levemir, please be aware:
  • Shooting an hour or two early *could* act like a slight dose increase.
  • Shooting an hour or two late *could* act like a slight dose reduction. Please ask for guidance if you're unsure.
• A "cycle" refers to the period of time between shots. There are 2 cycles in every 24 hours when shooting on a 12/12 schedule.

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Adaptation of the original SLGS Method written from suggestions
provided by members of the FDMB community
(Updated 1/2019)
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These are "general" guidelines which have worked for many cats. However, "Every Cat Is Different". Learn how YOUR cat responds to the combination of food and insulin.

Please be aware: There are not any "dose advisers" or "experts" on the FDMB. The FDMB is an open board subject to peer review where laypersons with varied degrees of knowledge and experience are free to share their own thoughts and opinions through explanations and suggestions.

We are not veterinarians. It is not our intention to take the place of your veterinarian. Please discuss dosing, methods, medications, and care for your cat with your veterinarian.​