Double nadirs?

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monty_dweezil (GA)

monty_dweezil (GA)

Member Since 2014
Is this a thing? I often notice during the day, Dweezil will go down to the blues and even greens at times, and then for several hours go back up to the yellows, before going back down again at around 11 hours to the blues for several hours past his normal 12 hour next dose.

Does anyone else experience this?
 
It's known as the Lantus 'double dip'.
For some kitties numbers dip around +10 or +11... (not to be confused with nadir). This applies to kitties who are being dosed consistently every 12 hours.

What is your dosing strategy?
 
Well, it is SUPPOSED to be somewhere between 1.3 and 1.8 units every 12 hours with food, but...he dips low for hours at 11 hours. Like right now again, he's still too low to dose even 3 hours after his 12 hour dose was due. If we dose him at 12 hours even though he's low, he goes TOO low so we can't do that.

Looking at his spreadsheet these last few days, his numbers are all blue and yellow with a little green, which is fantastic BUT...it's a constant juggling act and there's no consistency.
 
Please add the dose of 0.4 given at +7 in the +7 cell of your spreadsheet, if that's when you gave it.

Lantus works best with the same dose given every 12 hours. After that LO you saw a couple days ago, the regular (consistent) dose should have been reduced. How about trying 1.25 as his regular dose? With the changing doses that I currently see on his spreadsheet the depot keeps changing and thus you get wonky numbers. The depot takes time (about 3 days) to adjust to a certain level. Once the depot is steady at a certain level, hopefully his numbers will be more predictable. He is a cat, though. They hate to be predictable.
 
Sandy and Black Kitty said:
It's known as the Lantus 'double dip'.
For some kitties numbers dip around +10 or +11... (not to be confused with nadir). This applies to kitties who are being dosed consistently every 12 hours.

What is your dosing strategy?
Click to expand...
So if +10 or +11 is the lowest number of the day you wouldn't count that as a nadir but a double dip? Or this only applies if the kitty has already had a lower number but then gone back up?
 
monty_dweezil said:
Looking at his spreadsheet these last few days, his numbers are all blue and yellow with a little green, which is fantastic BUT...it's a constant juggling act and there's no consistency.
Click to expand...

To achieve consistency in numbers you must first establish consistency in dosing. With the frequent dose changes you are creating an endless loop of wonky numbers.

Please read the TR Protocol. It will give you an idea of how increasing and decreasing are determined for Lantus.

Lantus is slow acting. Finding a dose you can shoot consistently every 12 hours is key.

Shooting additional amounts of Lantus before 12 hours have passed since the previous shot is not recommended as it could result in unexpected lows.
 
Cherish Gallagher said:
So if +10 or +11 is the lowest number of the day you wouldn't count that as a nadir but a double dip? Or this only applies if the kitty has already had a lower number but then gone back up?
Click to expand...
The lowest number of a cycle is nadir. It can come early or late in a cycle. Nadir is not static and can change over time. The double dip (sometimes experienced by some kitties ) at +10 or +11 is a dip back down following the rise after nadir but not down to a level lower than nadir.
 
You can get 1/2 unit syringes from Hyperdrug in the UK; that's where I get mine. They arrive in about a week or so. These are the ones I order for my cat who is on Lantus (Glargine): https://www.hyperdrug.co.uk/BD-Micr...03ml-pack-of-100/Productinfo/BDMICROFINE03ML/

Just curious: I see that you've give 1.2, 1.3, 1.7 and 1.8 doses. I'm not familiar with those numbers. How do you measure that on a 1 Unit syringe? I've been trying to figure it out but haven't been able to so far!
 
So say you give 1.5 units at 5am and the BG is yellow. It goes down to blue for a few hours soon after and stays there for say 5 hours before going back up to yellows for another 4-5 hours. Then it goes down to blues and then maybe even a brief green and stays blue for 3-4 hours past the 12 hour due dose time, even after being given food. By the time the BG is back up to high blues or yellows, it is 4+ hours after the 12 hour dose time.

Surely that 12+ low is the true nadir.

And how do you possibly dose every 12 hours with this daily pattern?
 
Oh YES! I am SO ordering those syringes!!!! We eyeball with a magnifying glass!

So my baby really IS nadiring after 12 hours. Hmm. So if his dose was right for him, would he not anymore?

Update - just ordered! AU$42. More than our normal vet ones but WHO CARES!
 
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Please read about the basics of Lantus here for a better understanding of the following.

In brief, along with nadir, you need to identify when the insulin action begins (Onset) as well as how long the insulin continues to lower BG (duration). Duration lasting past 12 hours is Carryover which can lead to a period of Overlap (when the effects of one shot are fading and the next shot is taking effect).

Finding a dose you can shoot consistently every 12 hours is key to discovering these important landmarks of how Lantus works for your kitty.
 
It seems the dose begins to work from +2 hours and then continues working until +16 hours before the numbers start to rise again.

During those hours though, the BG will go up slightly for a few hours before going down and eventually after 12 hours reaching the final nadir.
 
I have a few concerns....

Lantus is meant to be dosed every 12 hrs. There are exceptions. However, using a sliding scale dose is really not an exception. By changing your dose amount based on the pre-shot numbers, you are defeating the way in which Lantus works best. Lantus dosing is based on the nadir -- regardless of when in the cycle the nadir falls. Nadirs are typically somewhere in the middle of the cycle but this varies depending on the cat (my kitty's nadir was usually at around +3, except when it wasn't). However, nadirs can and do change. As Sandy noted, many cat's experience an occasional "double dip" but this is not to be confused with a late nadir. Whenever the lowest number in the cycle occurs, that is the nadir.

If you are actually shooting at some time other than your usual pre-shot time, the next shot is due 12 hours later. If you shoot late and the next shot is at your usual time, this has an effect on the cycle. Early shots function like a dose increase whereas a late shot acts like a dose reduction. Regardless of how the shot functions, there is a resultant effect on the insulin depot which, in turn, effects the duration and action of the insulin. More succinctly put, lack of consistency in the dose amount and in the shot time can cause wonky numbers.

I would encourage you, as Sandy suggested, to read the sticky notes on both the tight regulation protocol (you certainly are testing enough to follow TR) and the start low go slow method for dosing. What you're doing now is not going to yield good results when using Lantus to treat your cat's diabetes.
 
Cherish Gallagher said:
So if +10 or +11 is the lowest number of the day you wouldn't count that as a nadir but a double dip? Or this only applies if the kitty has already had a lower number but then gone back up?
Click to expand...
Your question got overlooked but is important.

If the +10 or +11 is the lowest number of the day, it is the nadir. A lower number at the end of the cycle is considered a double dip only if there was already a nadir. The double dip number is typically not lower than the nadir.

While there are many patterns you might see in a cycle, in this instance, let's talk about just two, most often seen in Lantus, to help you distinguish.

One is where the kitty comes down to a nadir, goes back up, and then comes down again around the end of the cycle, but not as low as the nadir....this is a cycle with a double dip.

The other is usually when kitty is clearing a bounce and the BG drops all day long so the lowest BG of the cycle (the nadir) is at the end of the cycle. We call this a dropping number.

It's important to know the difference between a second dip and a dropping number when deciding whether to shoot. With a second dip, you can safely shoot above 50 knowing the numbers will go back up before the next shot onsets. With a dropping number, it takes time and data, experience, knowing your cat, etc, to shoot a lower number (above 50) that is the lowest of the cycle. The numbers can continue to drop after the shot and then when the next shot onsets, numbers can drop again. You can see why it's really important to know your cat, have data, etc to shoot a lower dropping number. But it also can give great carryover and overlap for nice long, green cycles as long as the CG knows what they are doing, how the BG might fall, and how the kitty responds to food.

With Levemir, many of these kitties, including mine, have a nadir at the end of the cycle. It's the beauty of Levemir as it can allow for great carryover and overlap. Levemir users have to learn to shoot low (above 50). There are some Lantus cats who quite often nadir late in the cycle (not as part of clearing a bounce but they just have a late nadir) and those CGs also have to learn to shoot lower numbers (above 50).
 
Marje and Gracie said:
Your question got overlooked but is important.

If the +10 or +11 is the lowest number of the day, it is the nadir. A lower number at the end of the cycle is considered a double dip only if there was already a nadir. The double dip number is typically not lower than the nadir.

While there are many patterns you might see in a cycle, in this instance, let's talk about just two, most often seen in Lantus, to help you distinguish.

One is where the kitty comes down to a nadir, goes back up, and then comes down again around the end of the cycle, but not as low as the nadir....this is a cycle with a double dip.

The other is usually when kitty is clearing a bounce and the BG drops all day long so the lowest BG of the cycle (the nadir) is at the end of the cycle. We call this a dropping number.

It's important to know the difference between a second dip and a dropping number when deciding whether to shoot. With a second dip, you can safely shoot above 50 knowing the numbers will go back up before the next shot onsets. With a dropping number, it takes time and data, experience, knowing your cat, etc, to shoot a lower number (above 50) that is the lowest of the cycle. The numbers can continue to drop after the shot and then when the next shot onsets, numbers can drop again. You can see why it's really important to know your cat, have data, etc to shoot a lower dropping number. But it also can give great carryover and overlap for nice long, green cycles as long as the CG knows what they are doing, how the BG might fall, and how the kitty responds to food.

With Levemir, many of these kitties, including mine, have a nadir at the end of the cycle. It's the beauty of Levemir as it can allow for great carryover and overlap. Levemir users have to learn to shoot low (above 50). There are some Lantus cats who quite often nadir late in the cycle (not as part of clearing a bounce but they just have a late nadir) and those CGs also have to learn to shoot lower numbers (above 50).
Click to expand...
Thanks for all the information! I'm learning so much more :) :)
 
I see that you shot tonight at +5 instead of the usual PMPS time

Tomorrow, you'll need to wait and shoot when it's been 12 hours since tonight's shot....If you have a "preferred" shooting time, you can work your way back to it 15 minutes per cycle or 30 minutes per day

Example...your "preferred" shot time is 6am/6pm......but for whatever reason, you didn't shoot until 11pm tonight.....that means the earliest you should shoot tomorrow is 10:30am (moving 30 minutes ONCE) and then shoot again at 10:30pm...keep going backwards by 30 minutes once per day.....OR you can move 15 minutes per cycle which would be 10:45am tomorrow and 10:30pm tomorrow night...and continue working your way back 15 minutes per cycle

I think if you'll start giving a consistent dose every 12 hours and stop shooting in between because you see higher numbers, Dweezil will start being more "predictable" (although there's no such word as "predictable" in the feline vocabulary...LOL)

If you're concerned about doing 1.25 on your current syringes, how about trying 1.5 and holding that dose for at least 3 days and let's see how he's doing.

If he drops below 50, we'll have to reduce to less, but let's just try it and see how he does!!
 
See, my issue is when his normal PM shot time is (used to be 5pm. Now, who knows) is exactly when he starts to really drop. He drops all day with a few ups and downs but then really goes into his nadir after 5-7pm.

Earlier this week right after he got his monitor back on, I shot at his normal time as his number was 160 and I didn't realise it would keep dropping that late from his morning dose at 5.30am. As you can see from the SS and my LO thread, within 2 hours he had dropped too low for the monitor to read and I spent the next 4 hours feeding and scanning and watching him. If not for the higher carb food and extra feedings, he may have needed emergency care. His numbers during that time LOOK great, but how I got them to stay good and not go too low was NOT what I want to have to do again. AND that dose was only 1.3 units too, less than his previous two. If I'd kept up the previous doses he would have gone even lower.

So THAT is the reason why for the next few nights after, I did not shoot at his normal 5-5.30pm time. I did not delay shooting because I was lazy or forgetful or busy or out swanning around the town. I delayed because his numbers were heading down again and went to their lowest about 2 hours after his 12 hour expected dose time, and they were about 80 then. After this nadir, they stay low for a few more hours before slowly coming up. By then, it is hours late for his regular dose.

So firstly, what should I do at his 12 hour time? The same thing I did that night when I shot a lower amount but he still went too low? I don't think so.

What would you do?

Secondly, I know it's not good to shoot so out of sequence like I did at 12.30am and at 10pm the next night. But I also know that once his nadir completely passes by about 16+ hours, he often goes very high and by the time his morning dose occurs at 5.30am, he's in the red numbers.

Thirdly, if we change his dosing schedule so he gets his dose AFTER his nadir has passed, so say 10pm, then his 10am shot would be done by...who? His brother Monty? Dweezil himself? Often no one is home at that time even if he was able to be dosed then if his numbers weren't still too low after only 12 hours.

Last night his numbers went high even though the night before, with much the same schedule, they did not. This morning his numbers stayed high which is the opposite of the day before. Only now, at his 12 hour time, are they starting to come down.

Basically, I DO understand that a consistent dose and dose time are imperative. But HOW do I do this when the nadir is always 12-16+??

We had him on 1.5 units every 12 hours while he had no monitor on and we had no way to test him besides pee strips, water consumption and occasional ear pricks. His pee was always high. His BG was always in the pink and his water drinkage went up. He was hungry more but did not put on weight, so it would SEEM 1.5 units is not enough.

That's the reason we gave him 1.8 units for the first two doses after his monitor was back on. We were trying to get him down from the reds. It worked, but after those two doses, it was too much. Then even 1.5 would have been too much due to the depot.

So NOW we are all over the place. If I start again on 1.5 tonight, I fear him going too low again as at 5pm he has not yet reached his nadir yet. I don't know how low he can go.
 
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Follow the protocol and the numbers will be your guide.

Always remember-
Better a day too high than an hour too low.

Regulation does not happen instantly. You have to consider that his body is not accustomed to normal numbers and may actually perceive them as dangerous. Counter- regulatory hormones are then released to bring BG back up. When that happens you must sit on your hands, holding the dose and wait it out. At the same time, of a dose takes your kitty below 50, you reduce - even if you know it will result in higher numbers the next cycle and the higher numbers may last up to 6 cycles. Once it's clear his counter regulatory system has simmered down, you evaluate the nadir once again and increase or decrease accordingly.

This is why we call it the 'sugar dance'.
One step forward, two steps back...
Your kitty leads the dance- you must follow.

Healing has its own timetable. Some kitties transition from dry to low carb wet and zoom down the dosing ladder to remission. Others, like my Black Kitty, face a variety of challenges along the way and take longer (in our case 21 months). Some never make it to remission but enjoy a much improved quality of life with BG regulated by continued insulin.

You will hear it said around here-
The road to regulation is a marathon, not a sprint.

 
Your profile indicates you have been a member since December 2014 and your signature states dx was 12/2014 and your kitty has had 2 DKA episodes in 2017.

Do you have any historical data?

Please tell us about the recent episodes of DKA.
 
Yes, he was diagnosed in December 2014 and started on 2 units twice a day. He went crazy when they tried to do a curve and wouldn't let them near him after 2 blood tests. A week later with some testing he was a little low so they lowered the dose to 1 unit. Then he was too high do 2 weeks later up to 2 units again.

This seemed to work for a while before suddenly not anymore and his excess water consumption, weight loss and sweet cider smell pee returned. Up to 3 units. Seemed to make no difference. Tests and symptoms still high.

A month or so later, up to 4 units. For one week he seemed great. No symptoms. Put on weight. Was more playful. Then BAM. Hypo one morning at +4 hours. Needed IV glucose.

The vet wanted him to stay on 4 units. I said no way. Down to 3. Was ok for a few weeks but symptoms returned. Wentback up to 4 (against what I wanted). I said if he goes on 4, he'll be hypo again within a week. It was actually 2 days and he went hypo at +4 hour PM. I said I told you so.

Back down to 3 units. Doing ok. Some symptoms. We suspected 3.5 units might be an idea, but then suddenly BAM. Another hypo again exactly +4 hours AM.

I said 2 units now. 4 is too high and 3 is too high. He seemed good for a while, on and off. For months he'd be good, put on weight, low symptoms, and then he'd seem to go backwards. We were advised to put him back up to 3. I refused.

For a long time (6 months) in 2016 he was good on just under 2 units. Was back up to his pre-diagnosis weight for the first time. Then one night, BAM. Hypo. This time at +2 PM.

We lowered him to 1.5 after that. Symptoms returned, lost some weight.

Anyway, so after that we crept him slowly over a few months back up to 1.7-ish. He improved again but we lived in fear of hypo.

We went away for my mum's 70th birthday this May for 6 days. The furs went to their regular cattery. Apparently all was well, eating well, taking insulin well (we had lowered it to 1.5 just for that time in case of hypo while not as supervised as he is at home) but then suddenly on the overnight / early morning of day 3, Dweezil threw up at 5am green bile and was lethargic and it was a cold night but he wouldn't go in his bed. He wanted the cold tiles. He drank a lot but would not eat.

The cattery lady didn't know if he was going hypo or not so didn't give his insulin and took him to our vet. Ketoacidosis. Some sort of liver infection. No one knew how or why. He responded quickly and 24 hours later was off the drips and eating well on his own. His BG was stable at 2 units.

He came home 2 days later when we got home and was pretty good considering. Not much weight lost. Eating well. VERY thirsty for 2 days but then ok.

We gave him 2 units for a few weeks before noticing his pee strips were not changing colour and we feared hypo again so back to 1.8-ish units.

He was doing well for weeks. Put on a bit of weight, good appetite, playful, relaxed. His recent tests were all very good. Like in the blues. We feared he would surely go hypo when he went to the cattery again in July while we were overseas. They kept his dose at 2 units despite my fears.

A week later, after eating well and seeming fine, he threw up a heap of breakfast he'd eaten an hour before and was limp. The cattery lady took him to the 24 hour emergency animal hospital as it was a Sunday. They tested his BG. 19 (342). Not hypo the understaffed nurses said. They said he's ok, take him home.

The cattery lady refused and said he was not well, not himself. She waited with him for 2 hours until finally a vet was free to see him. They took him away and yep, ketoacidosis again.

They took half the day to start treatment. Sigh. They are always slow there due to it being an emergency place. He did not respond too well for 48 hours but then came good, thank goodness.

He was moved to another ward where a diabetic specialist was. She was baffled by the DKA. He had not lost weight. He had no infection. His insulin dose had not changed and just a week before, he had been great.

They did heaps of tests, found nothing. So they fitted the monitor to try to get his dose right. He recovered well and was eating and feisty 3 days after being admitted.

The monitor revealed that 2 units worked only some of the time. Back at the cattery, 3 units was mostly needed and even that didn't always work. When it did, it worked too well and he went low but seemed ok.

So...yeah. Over a month and several monitors later we're still trying to figure out the right dose.
 
Sandy and Black Kitty said:
Follow the protocol and the numbers will be your guide.

Always remember-
Better a day too high than an hour too low.

Regulation does not happen instantly. You have to consider that his body is not accustomed to normal numbers and may actually perceive them as dangerous. Counter- regulatory hormones are then released to bring BG back up. When that happens you must sit on your hands, holding the dose and wait it out. At the same time, of a dose takes your kitty below 50, you reduce - even if you know it will result in higher numbers the next cycle and the higher numbers may last up to 6 cycles. Once it's clear his counter regulatory system has simmered down, you evaluate the nadir once again and increase or decrease accordingly.

This is why we call it the 'sugar dance'.
One step forward, two steps back...
Your kitty leads the dance- you must follow.

Healing has its own timetable. Some kitties transition from dry to low carb wet and zoom down the dosing ladder to remission. Others, like my Black Kitty, face a variety of challenges along the way and take longer (in our case 21 months). Some never make it to remission but enjoy a much improved quality of life with BG regulated by continued insulin.

You will hear it said around here-
The road to regulation is a marathon, not a sprint.
Click to expand...

Love it - put in my FDMB "what you need to remember" reference doc! Thanks so much. :)
 
Prior to him being fitted with the monitor, where you home testing?

Those recent DKA episodes require extra vigilance on your part - I know you don't want him to go through another one

I very strongly recommend that you check his urine for the presence of ketones every day, switching up the times when possible
Ketones can quickly develop to life threatening levels.

Keep in mind the recipe for development of ketones:
  • not enough insulin
  • not enough calories
  • infection/inflammation
His 9/15/PM cycle looks real nice so far, with the lowest value of 72 at +7, heading up at 8...
Besides shot times, when does he eat during the course of the rest of a cycle?

Lastly a housekeeping item - Start a fresh thread each day
  • Please use that one thread for all your comments and questions you have that day. This will keep all pertaining to your cat together everyday, making it easier for those willing to help you do so.
  • Start your thread with the date, kitty's name, and AMPS
  • Your thread will be bumped to the top of the list when you or anyone else posts on your thread.
 
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