Finding the correct dose... Glucose higher on 3-units vs 1-unit

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Jason Capriotti

Member Since 2016
Hi everyone... I'm new here and committing an internet faux pas (or paw?), as I haven't done a thorough search for an answer to my question.

My cat Atari started urinating inappropriately about 2 months ago. A few weeks later he was diagnosed with diabetes. Vet recommended 1 to 2 units of Lantus twice a day. I found a local person who has several diabetic cats who gave me some tremendously helpful tips about diet, dosing, and recommended this site and a few others.

I started Atari with 1 unit of Lantus and started home testing and made a glucose curve. The glucose levels never got below 250, so started increasing the dose by 0.5 units and continued doing curves. Every single curve since then has had higher glucose readings. He's currently at 3 units, and the glucose is still higher (see image below)
He hasn't had any diet changes as far as food amount or type goes. I tried feeding him 4x daily, but that proved to be difficult from a consistency standpoint so have been doing 2x daily.

I'm trying to figure out why his glucose is higher now than it was at 1-unit, and how to get his glucose to a good level. I'm know the dose shouldn't be increased too fast, although I might have jumped from 1 to 2 units too quickly.

I'm not quite sure what to do here. Any advice?

Thanks,
Jason

image.png
 
Hi Jason,


Welcome on board!!!

First, congratulation for testing your cat!!!! You are very lucky to have in your relationships a person familiar to feline diabetes.

We need more information about your current situation:
- What meter are you using?
- What are you feeding your cat (brand and flavor)?

As @Sharon14 mentioned just above, it would be easier for us to give you advice if you use our spreadsheet (if you need help to do so, just ask).

Regarding the difficulty to feed several times per day, a lot of us use an autofeeder, that you can find on Amazon (US link : https://www.amazon.com/PetSafe-5-Meal-Automatic-Pet-Feeder/dp/B000GEWHNS/?tag=felinediabetesfdmb-20. I have assumed that you were living in the US, but if you live elsewhere, no problem, this auto-feeder can be found on Amazon all over the world).
 
Jason Capriotti said:
I'm new here and committing an internet faux pas (or paw?)
Click to expand...
'faux paw' - haha! :smuggrin:

Hi Jason,

I'm not saying this is the situation in your case (we don't have enough data to be able to tell at this point), but a common reason for blood glucose levels to rise when the insulin dose goes up is that the dose is actually too high.
This may sound strange, but the reason that it happens is this: If the blood glucose drops too low (or too fast) the liver can respond to that 'threat' by releasing stored glucose in order to raise the blood glucose level.

Can I ask...
Are you testing your kitty's blood glucose prior to each insulin shot?
And are you also getting some mid-cycle tests in addition to the 'curves' that you're doing?

Eliz
 
Welcome, Jason and Atari.

I echo other members' comments on the great job you're doing with the testing and also how fortunate you are to have a friend with knowledge of feline diabetes.

Following on from Eliz's questions, can you let us know the following (it will help us give you better comments and suggestions):

1. Atari's weight at time of diagnosis and whether he was underweight/overweight/at ideal weight.

2. Atari's current weight/body condition.

3. How fast and how soon did you step up from 1.0 to 2.0 IU Lantus?

Do you still have a record of all the dosages and BG test results for the period you've been giving treatment thus far? If you could plug those values into a spreadsheet and link it into your forum signature it would be helpful.

If you're not doing so already, it would help enormously if you could do BG tests prior to giving insulin in morning and evening (AMPS and PMPS on spreadsheet) plus a mid-cycle test in the AM cycle as best your schedule will allow plus a 'before bed' mid-cycle test every PM cycle. The spreadsheet uses "+<hour>" convention for data input. Simply fill in the cell corresponding to the number of hours after the dose when the test was performed. Lantus is dosed on the nadir BG (sometimes with a nod to the preshot BG) so the daily mid-cycle tests really make a difference in determining dose suitability and safety.


Mogs
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Hello,
Thanks for the replies! To answer the questions...

  • I threw all my data in the template... here it is: https://docs.google.com/spreadsheets/d/12qQ0thNgNR3Da9Y1HUR7AXuAFVzASxoWXIfgmGTfFUs/pubhtml
  • Using a Relion Prime meter
  • Weight was 14.5 about 6 weeks ago (at the vet/diagnosis). He had lost about 1.5 lbs in the last two years, and i think he is almost down to ideal weight. Haven't weighed him since (I suppose I should do that).
  • Thinking back, I think I went from 1 unit to 2 units too fast. He was on 1 unit for a week, then I went to 2.
  • He's eating 1/2 can of "9 Lives Tender Morsels Flaked Tuna in Sauce", plus 1/2 can FF "grilled" (ended up with a variety pack, so either beef, turkey, or chicken).
  • I'm not testing prior to each shot every day. I have done it from time-to-time between "curve days" either before his shot or a few hours afterwards. The values have all been in line with his recent curves.

Thank you,
Jason
 
Ack. That's not pretty. (((Atari)))

Starting weight (assumed approximately ideal per info provided above): 14.5lb / 6.6kg

Starting Lantus dose (@ 0.25 IU per kg per Roomp-Rand study): should have been 1.65 IU BID (probably rounded down to 1.5IU BID to be on the safe side).

Lantus is a depot insulin which gradually builds up a "chemical tank" of insulin under the skin which then gradually releases into the bloodstream to lower BG over a longer period. It can take at least 6 cycles (1 cycle = dose + 12 hours thereafter) for the depot to adjust after a dose change before one can get an idea of its effectiveness or lack thereof. (There are a lot of educational resources for Lantus in the forum stickies at the top of the Lantus & Levemir Support Group board.)

At start of treatment the Lantus dose is held for several days to allow the depot to establish and then a curve is run and the dose adjusted as needed. Thereafter the dose should be adjusted as required in 0.25IU increments - might be an increase or a decrease depending on the nadir BG value. Assuming that numbers are in a safe range each new dose is held for for 3-7 days, depending on the dosing protocol or method being followed. Daily home testing (AM & PM preshot tests and at least one mid-cycle test per day) it would allow you to better determine exactly what's happening in response to each dose so the sooner you can start that the better, Jason.

Unfortunately more insulin does not automatically lead to lower BGs. As Eliz mentioned above both too much and too little insulin can result in high, flat BG numbers similar to what you've been seeing in Atari's test data. Too high a dose can lead to the cat's body releasing stored glucose to compensate. Also a cat may sometimes go low (or lower than the cat's body is currently comfortable with) on a given dose and then spend anything up to 3 days at higher numbers - a phenomenon referred to here as 'bouncing' - because again the cat's body, having been used to higher numbers, releases counter-regulatory hormones to protect the cat and again the liver starts releasing too much stored glucose for a period until things settle down again. If BG monitoring is limited to periodic curves alone, in theory it would be possible to end up running said curves only on days when a cat happens to be bouncing and you'd have no visibility of the lower nadirs, hence why we so strongly advocate daily testing.

In addition to the situations discussed above, there are some cats who just need more insulin than others (especially those with certain high-dose conditions).

The best way to get to a 'good dose' is to increase the dose in tiny increments; too fast and one can end up 'skipping over' a good dose which then leads to the cat ending up in a state of chronic overdose mode where subsequent increases may drive numbers higher, not lower (and which may eventually exhaust the body's stored supplies of glucose).

Going forward, diligent daily home BG monitoring will enable you to better understand what's happening in Atari's body in response to his Lantus but right now you need to get some handle on how to address Atari's current needs. I'm tagging some very experienced members ( @Wendy&Neko , @Chris & China ) to come and have a look at Atari's thread when they come online so that they can look at Atari's data and hopefully better advise you on where to go from here.

In the meantime, especially because numbers are so high at the moment if you're not already doing so I strongly recommend you pick up some urine testing strips at a pharmacy (e.g. Keto-diastix) and check Atari daily for ketones. (If you get a positive trace you should let your vet know straight away; anything higher than trace and you should look to get immediate treatment to flush the ketones out of his system in order to prevent development of diabetic ketoacidosis). Also keep monitoring Atari's weight and let your vet know if he's losing weight.


Mogs
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Thank you for the info.

On the testing for ketones, I had thought about that a few weeks ago, but since he was just at the vet I thought it would have shown up in their test (they did a blood and urine test). But it doesn't hurt to check at home. Depending on how this week goes, I am tempted to take him back. But he hates going... and so does my wallet.

For dosing, last night I read somewhere (either here or another popular site) that it might be good to drop back down to his starting dose, if I might be in this situation where maybe I went up too high, too fast.
 
Jason Capriotti said:
For dosing, last night I read somewhere (either here or another popular site) that it might be good to drop back down to his starting dose, if I might be in this situation where maybe I went up too high, too fast.
Click to expand...
Whether or not that might be the right approach is beyond my level of experience with Lantus, hence my sending a tag alert to Wendy and Chris to ask them to read through your thread and also look at Atari's data when they're online.

FDMB has a number of highly experienced members with years of experience both using Lantus themselves and helping other Lantus users. (The FDMB support group for Lantus and Levemir users is very active - and busy!) The highly experienced members are likely to have seen similar situations to Atari's and they should be able to give you sound recommendations on what to do first to try to get Atari's BG levels going in the right direction. Thereafter the L&L support group will be able to help you further with improving Atari's regulation.

Re ketone testing, ketones can appear and build up quickly so testing for them should be part of regular home monitoring of a diabetic kitty. It is very important to test regularly for ketones in cats that are unregulated. It is also very important to test for ketones in cats whose appetite is 'off', when there is infection/inflammation present, or if one suspects they might be feeling out of sorts or poorly.

Here are a couple of educational links about ketones and DKA (we're good at vertical learning curves round here ;) ):

The Hows and Whys of Ketones

Forum FAQ sticky on Diabetic Ketoacidosis (DKA)


Mogs
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Hello and welcome Jason. Atari is one lucky kitty having a caregiver willing to home test. :) Thank you for putting your data so far in the spreadsheet. You can also attach it to your signature here, which will make it easy for people to access, and you won't have to keep linking it.

First comment, we recommend low carb wet or raw food here. For us, low carb is anything under 10% carbs. The food chart here on the Catinfo website has a lot of the current products for sale in North America. According to it, all of the Fancy Feast Grilled varieties are all high carb food (15% or above). Try some of the classic or pate ones instead. However, do not change food unless you are monitoring regularly. We've seen cats insulin needs drop a lot when they've switched to low carb food. And don't throw away the grilled version - if Atari's blood sugar is ever low and you want to bring it up, then you can give him some of the Grilled food to do that.

Second, you can take it a little easier with testing on curve days. We suggest a curve as every two hours for a cycle (the time between insulin shots), or every three hours for a cycle and a half - in other words, get a test 3 hours after the night time shot. Since a lot of cats go lower at night, it's very important to get an idea of that night time picture. Of course, if Atari's numbers are going lower (say under 100), then you might want to step up the testing. We do determine how to dose Lantus based on how low a particular dose is taking the cat.
Jason Capriotti said:
For dosing, last night I read somewhere (either here or another popular site) that it might be good to drop back down to his starting dose, if I might be in this situation where maybe I went up too high, too fast.
Click to expand...
That is seldom a good idea. I've seen lots of caregivers try it. The problem is that kitty becomes used to high numbers and it takes even more insulin to get out of the higher numbers. As others have mentioned, once a cat is used to higher numbers, their body will try to react by dumping sugars into the blood stream whenever they see numbers lower than they are used to. And as Mogs mentioned, there are cats whose diabetes was caused by high dose conditions. One of those conditions (that both my Neko and Sharon's Colin have) is called acromegaly. Approximately one in four diabetic cats has this condition. With these kitties, they need even more insulin, and going backwards means it'll take even longer to get regulated.

If you wanted to step back to two units, then gather data to see how that dose is doing, you could do that. Or althernatively, just do a little more testing to see how three units is doing, and let the testing numbers help you decide what to do. If you do decide to switch him to a lower carb food, then I would definitely go back to 2 units. At a minimum, get a test before you give insulin. My Neko has given me numbers in the 40's at shot time before. :cat: I delayed giving insulin - it wasn't safe. And try to get a test some where in the middle of the cycles when you can, and that before bed test. If you can do this testing yourself, and track the data in the spreadsheet, we can help you so that you don't need to take Atari to the vet for blood sugar testing and dose advice. That's one less vet visit for him and your pocketbook.
 
  • Thinking back, I think I went from 1 unit to 2 units too fast. He was on 1 unit for a week, then I went to 2.
You may have missed your optimal dose. One option is to start back over at 1/2 to 1 unit. Wait a week between dose changes before increasing the dose. If an increase is neede, only raise it by 1/2 unit. Wait another week before increasing it again.
 
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