Fairly urgent / semi-'911' -- re: dose adjustment

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Vidya & Boo

Vidya & Boo

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Hi,

I'm posting here because I know I won't be able to reach my vet tomorrow if needed.

We started Boo on insulin (Lantus) only 3 days ago, and after considerable up-and-down variation in glucose readings, we got our lowest numbers yet -- pre-dose, post-feeding: 8.4; subsequent six-hour approximate-nadir reading: 6.3. (He had a reading of just over 20 right before the first insulin shot, two days after an almost 'cold turkey' switch to a low-carb diet; his first test, that prompted the immediate diet change, was 23). He was consuming a small quantity of low-carb dry food (Wellness CORE) during the first two days of the insulin, which I eliminated completely yesterday afternoon (after getting surprisingly high BG readings), and this change may have partly prompted the dramatic BG drop. His behaviour has undergone an amazing change today -- energetic, very alert, and playful.

My question is, if Boo's pre-insulin reading tomorrow (Sunday) morning is at the same level or a little lower, is it still safe to give him the full 2-unit Lantus dose? My vet's written protocol calls for the first re-evaluation of the insulin dose 7 to 10 days after starting, with a pre-insulin reading of less than 10, or a nadir reading of less than 3 (or symptoms/signs of hypoglycaemia) then requiring a 0.5-1.0 unit decrease. But, obviously, I don't want to risk a hypoglycaemic episode if Boo's numbers stay low (even if not yet completely ideal), especially given that the effects of the dietary change may still be developing. (The 'target' BG fluctuation range is about 4-to-7, but this usually happens after longer insulin therapy.) If I'm unsure based on the numbers, is it safe to scale back the dose by 0.5-1.0 unit for tomorrow's morning shot, and then monitor the BG and re-evaluate for the evening dose? Skip the shot entirely if the pre-shot BG is even lower? Help, please!
 
To clarify - you said your PS was after feeding. How long after feeding? You shouldn't feed in the two hours prior to shooting to make sure that your PS number is not affected by food and it is safe to shoot.

The lower numbers you have seen today are not dangerously low. They are safe pancreas healing numbers :-D . It is quite likely that Boo will bounce from having these numbers which are lower than he is used to so your worry may be wasted. However it is also possible that the removal of the dry food has immediately decreased Boos insulin requirements. Also the lower numbers will be related to the lantus shed filling - you don't see the full effects of a lantus dose for several days while the shed adjusts - hence you should not make frequently changes as you seem to be suggsting, i.e. reduce for tomorrow AM and then reevaluate for PM (unless the cat has got very low and earned a reduction).

If you haven't done so already you should print a copy of the handling low numbers info and keep it handy in case you need it. I assume you have some syrup and/or HC wet food in the house in case you need it - if not get some. The handling low numbers info is here http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=147

Based on the protocol your vet has you following, if I understand you correctly, you had a PS of less than 10 and therefore a reduction would be called for - am I reading that correctly? We usually only make changes in 0.25 increments because of the sensitive nature of Lantus. Do you have 3/10 syringes? It will be very difficult to measure 1/4 units if you are using larger syringes.

Can I suggest that you get a +10 or +11 test and then repost your query on the Lantus (glargine) Tight Regulation forum (it doesn't matter that you're not following the TR protocol) closer to your shot time to get the eyes of experienced lantus users onto your problem. You are going to need to multiply all your numbers by 18 to put them in a form those users can understand and it is clearer if you can set them out like this:

Date:
XX: PS
XX: +6
XX: +10
etc where the XX represents the number from your meter multiplied by 18, or if you have time you can set up a ss for Boo that does the conversions for you automatically. Here is the link to help you do that http://felinediabetes.com/FDMB/viewtopic.php?f=6&t=50130 You want to use the world version and put your meter readings in on the world page, the US page will populate automatically.
 
Thanks!

His pre-feeding pre-shot +12 BG this morning was 8.5 (=153 American), so I took a chance and shot the full 2 units, given that that's not really that low compared to our ultimate goal (but only compared to his diagnosis-time number of 400+). We've previously been monitoring the +12 numbers post-feeding only, because we were concerned about seeing how high they were still going. Is it usual to take the +12 BG readings (of a regulated/stabilized cat) pre-feeding, then? I'm not even a full four days into this, and still feel confused about some things.

I'll monitor him carefully throughout the next 12 hours and, depending on the results, post on the Lantus board later today. I wasn't really expecting to see him go this low in the first week -- the vet's dosing info pertains to adjustments after the first week, once I've done a full BG curve -- and so I was a bit panicked about what to do. Her original estimate was that we'd probably be increasing him in small increments to 4 or 5 units, but I guess the low-carb food may cause a significant alteration in those plans (I hope!).

BTW, there's a reference to one's "first time shooting green" in the low-numbers info page, and I can't find the phrase in the FDMB glossary -- what does "shooting green" mean?
 
What good numbers you are seeing already.
As for happening quickly.... yes, if you switch right over to the low carb wet food, you could very easily find that your Boo is a diet controlled diabetic, and how great would THAT be!

I am glad that you are monitoring over the next 12 hrs; I don't think I would have given the whole 2u dose when I saw such an improvement, just from my shock!

Shooting green I imagine refers to giving a shot of insulin when your BG test number is under 100.

For the feeding, you want to remove food during the 2hrs before shots because it takes about that long for the food to clear the cat's system. If you fed at +11 and then tested at +12/ps, the BG number you would get would be artificially higher because of the food. You would think OK, good, that's a safe BG and I can give a shot. Then, in an hour or so, that food will wear off, and the BG will drop, and then the insulin will start working and the BG would drop down even more and may end up way too low!
What if you fed Boo at +11, when his BG was maybe 85 but you did not know because you had not tested. An hour later, you go and do your ps BG test and Boo tests at 153, and you think OK that's a pretty safe number, and you give his 2u shot.
An hour later, at +1, that food may wear off and Boo starts to drop. His BG may drop to 120 and then 90, and then the insulin would start working, and he'd drop more.

If you had NOT fed at +11, Boo would not have tested at 153, and maybe you would have thought to delay his shot until he started rising without food, or even give a lesser shot like 1u instead of 2u.

People will talk about food-influenced numbers because it can be very misleading, and you want to give shots to safe numbers.
 
Thanks, that all makes a lot of sense. I know that it's generally best to stick to the same AM/PM times for the shots -- if numbers are lower-than-expected/desired, it is common practice to delay the shot by some time (an hour? more?) and monitor the BG, rather than tinker with the dosage itself at the pre-established time? I imagine this might create some challenges when the next scheduled dose-time comes around? But yet I'm hesitant to start making sporadic adjustments to the dosage itself (unless absolutely necessary for safety) while his body's still adjusting to insulin in the first place. Is it safe, if necessary, to drop a single does by a full unit, and then raise it by that much again for the subsequent shot if BG readings warrant it? Goodness, this sugarcat parenthood is stressful and confusing!

While we've been feeding him right around injection time, we're also leaving out the food (wet, very-low-carb only) throughout the day, as the insulin's pretty long-acting, he's used to a lifetime of free-feeding/nibbling, and we want him to be able to 'self-medicate' if he starts to feel uncomfortable from the dropping BG. (The vet also suggested that, as the numbers get closer to ideal/tight regulation, he always have food available, for the latter reason.)

I hope I can get at least a couple of good readings during the next 12 hours -- now that Boo is feeling better (seriously, I haven't seen him this energetic in . . . years, maybe?) he's much more willing to mobilize "the paw of doom" in response to the lancet prick -- and you can see from my avatar the boxer-like arms that this sweet guy has!
 
Shooting green does refer to numbers under 100/5.5 - the spreadsheets we use are colour coded and the green refers to the colour coding on the ss.

Lantus has a shed effect so there is no point shooting a lower or higher dose based on a pre shot number because the full effect of the change in dose will not be felt in that cycle and this will just result in wonky numbers and delay regulation. It is important to be consistent with lantus to avoid wonky numbers you should not adjust the dose except in accordance with the protocol you are using and not usually by more than 0.25 at a time. I think you would find it helpful to read the stickies at the top of the lantus tight regulation forum there is a lot of valuable info about lantus and the way that it works in those threads.

Sometimes people will stall a shot if they are uncomfortable shooting the number that they see to make sure that it is a rising number and yes this does mess with the schedule because then the next shot is due 12 hours after the stalled shot was given and you can only move back to your regular shot time by 30 mins per day. Once people get more experience and have gathered sufficient data on their cat's specific reactions to lantus through home testing they will usually find that there aren't many numbers that are too low to shoot 12 hours after the last shot, with the exception of numbers under 50/2.7 - even the most experienced care givers do not shoot a number this low.

Free feeding is great for a cat on lantus with the proviso that the food is removed at +10.

It's great that you are focussed on learning all this stuff for Boo, it is very confusing and overwhelming to start off with but just keep reading everything you can and asking as many questions as you like and it will all start coming together for you.
 
Thanks, that all makes a lot of sense. I know that it's generally best to stick to the same AM/PM times for the shots -- if numbers are lower-than-expected/desired, it is common practice to delay the shot by some time (an hour? more?) and monitor the BG, rather than tinker with the dosage itself at the pre-established time? I imagine this might create some challenges when the next scheduled dose-time comes around? But yet I'm hesitant to start making sporadic adjustments to the dosage itself (unless absolutely necessary for safety) while his body's still adjusting to insulin in the first place. Is it safe, if necessary, to drop a single does by a full unit, and then raise it by that much again for the subsequent shot if BG readings warrant it? Goodness, this sugarcat parenthood is stressful and confusing!
Click to expand...
When you are home testing, lots of people see this sort of curve ...
How to do a Curve
Example of a typical curve:
+0 - PreShot number.
+1 – Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number.
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 – Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (may dip around +10 or +11).
+12 - PreShot number.

For sure, if you feel that the ps number is a bit low, you can wait, maybe 30min and then test again. That next BG may help you decide what to do. Whatever you do, no feeding until you decide if you are going to give a shot, full dose, half dose, or something in between.
And you are correct about the next shot time being changed as well. If your shots are at 7am/pm, and you give a shot at 8am because you delayed and waited for higher BG, your pm shot will be at 8pm.

There are a couple things you should have to help with your decision. it's good to have a NO-SHOOT number... that's a BG where you will not give a shot below that number, and either you will wait till BG rises or you may skip the shot. The NO-SHOOT number I had for my cats was never below 100 and I usually waited for them to rise above 110 for Oliver and maybe 130 for Shadoe. I also had a window for my delay/wait which was 2hrs. If my cats were not at a 'safe BG' 2hrs after ps, then I skipped the shot. .... alot of times, with skipped shots, you are easily able to give the next shot 1hr or so early. My shot times were 6am/pm so I was OK with moving to 8am/pm for a short time, and that's how I determined my wait window.

One thing you don't do is base your dosing changes on ps numbers.... after a few curves, you will have located your nadir, roughly, and that is the number on which to base your dose adjustments.

How often do people need to delay shots? Well, what if Boo starts feeling better, his pancreas is healing, and it needs less insulin help? You will see numbers coming lower and you could see lower numbers that would earn a dose reduction. As well, if yu were to change diet to better food, more low carb, you will see numbers dropping.... there are other reasons for delaying, but the delays are all just for the safety of your cat.

Once you have decided, full shot, partial shot, no shot, you can feed. There is no issue at all to leave the food out during the day. It will help to level off his BG while you are away; cats do a great job of regulating their own BG by searching out food when they feel the need for a bite to level out the numbers. If you wanted and were home, you could test him every time he goes to eat some food and get a feel for where his numbers are when he gets the munchies.
 
Thanks, your experiences and advice are very useful! I've made a note of the 'no shoot' range on our fridge-posted reference sheets. I was also able to get in contact with our vet, who gave us the go-ahead to reduce the Lantus dose sooner if the numbers do continue to drop, but so far things appear to be holding pretty steady today.

I'm trying best I can to keep calm and be thankful that Boo is actually keeping within a 'good' BG range after less than 4 full days on insulin, and hoping that this bodes well for his body's compensatory and regenerative capacity. Kitty, heal thyself! :-)
 
Just a note that Vyktor's Mum, above, was correct -- Boo's numbers did bounce up yesterday and today (nothing dangerously high, just a little higher than the range we're ultimately aiming for), so my worry was, indeed, wasted. I'm hoping for a few days of stability at this level, so that we can very slowly introduce some nutritional and herbal glucose-control supplements and then establish what sort of effect those have on his levels, before considering bumping up the insulin levels at all.

Boo would like to thank everyone for their help with my query! As I've 'explained' to him, better, more-predictable BG control will mean fewer daily 'pokes'!
 
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