First BG curve, very low BG

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Laura Nels

Laura Nels

Member Since 2015
Vivian started Lantus .5U twice a day a week ago, and today I'm doing her first curve.
Yesterday I taught myself to use the needle and meter, tested myself, then practiced on Vivian.
Yikes! 3 hours after food and insulin her BG was 36.
I contacted the vet who confirmed this was very low and asked, but is she clinically normal -
Clinically normal? I responded that she sleeps a lot and her appetite is down, but we knew that and had attributed it to also starting chlorambucil (Leukeran) the same day, per the vet.
No response.
So I did not give insulin to Vivian last night, but started the curve this a.m.
Eastern U.S. time:
7:15 a.m. after food before insulin BG 163
9:15 two hours after insulin BG 49
11:15 BG 33 - sleepy and less combative of ear pricking but no other major symptoms.
1:30 p.m. BG 49 - so it's on its way back up
I get the feeling Vivian has been spending several hours of each day and night below 50 BG.
Now that we know this we are really pushing the food today, and Vivian is eating more, but she doesn't
seek out food as much when she is on her own.
I emailed the vet, today the clinic is closed so don't know if she'll respond, asking what I should do tonight and beyond, given this information. I am inclined not to give her insulin again until I hear from the vet, which may not be until business hours Monday. So I know that I should follow the advice of my vet and not people on an online forum, she knew Vivian's BG was 36 and didn't recommend making any changes yesterday - curious what folks think about giving insulin to Vivian tonight and tomorrow morning -
thank you
Laura
 
I would reduce dose to no more than 1/4 unit. I would go for 1/8 unit if BG before shot is >160 and she is eating.
A poor appetite after chlorambucil is not unexpected. What is dose of chlorambucil and how often given?
 
I have to admit, even with some of the advice I've seen given by vets, I'm really very shocked that you weren't told to reduce the dose after getting a reading of 36. That's an automatic reduction of 0.25 units no matter what protocol you're using for Lantus! Lantus is one of the insulins that can cause non-symptomatic hypos...one of the many reasons we test is to catch those when they happen as sometimes the first symptom that shows up can be a seizure or worse. I'm sorry - I'm probably really scaring you at this point, but as I'm sure you can understand there are only so many ways to get the facts across especially in writing and I do feel it's very important that you don't continue to dose Vivian at 0.5U at this point.

Have you given her some high carb food or syrup when she's been low? When a cat drops under 50, we use one of those to bring them back up into safer numbers quickly.

It's very possible that, if her high BG was caused purely by the pred, that as you're switching that out for Chlorambucil, her BG is going to reduce and she might not need insulin in the long term. For now, it's important that you keep testing as you are doing to catch those lows and know when she needs a dose reduction.

When (if?) you do resume insulin, you really need to reduce the dose to 0.25U per shot as readings in the 30s show that she's definitely getting too much insulin at 0.5U.

As far as tonight/tomorrow morning goes, I think you're going to likely need to be guided by the numbers you get at her preshot times at this point. If she's under 200 then you shouldn't give the shot as, with only a week's worth of data, there's no way of knowing whether or not that's safe for her at this point. If she's over 200 then you could give insulin, but at the reduced dose of 0.25U.

I do fully appreciate that you know your vet and you really have no idea who I am apart from the information I've got on this site, but please please don't continue to give that 0.5U dose after Vivian dropped so low on it.
 
Wow. Just wow. At 36, the vet gave no intervention instructions? And on .5 units, she dropped almost 85 points? What did you do in response to the low numbers?
 
After I contacted her about the 36 BG the vet emailed me and asked, but is she clinically normal - from my response, which was that she was sleepy, had decreased appetite as she had been all week, was annoyed with us pestering her to eat and so hiding more than usual, I guess she concluded Vivian was clinically normal and therefore good to go. I didn't hear from her again, so I made my own decision not to give her insulin last night, b/c I was alone and as a beginner not coordinated enough to hold a by now very anxious cat down and do a blood test. Both the cat and I were upset and I had bludgeoned her ears earlier in the day just to get one BG # and a bunch of errors. Today I had help. When I saw the BG go that low yesterday and today I pushed food on her immediately - dry, wet, treats, you name it. Fortunately Vivian ate a fair bit and I have made sure she hasn't been alone. I feel a little better now that she seems to be on the upswing, but I am inclined not to medicate her until I hear from the vet, who told me last week NOT to test her daily because her numbers would be all over the place and I would just make myself nuts, she said just stay in tune with Vivian's behaviors and watch for symptoms of hypoglycemia such as staggering, drooling, confusion - at which point I should give Vivian karo or honey on the gums/inside cheek and contact her - Vivian has shown none of these overt signs, except sleepiness/mild lethargy and some hiding in odd places, and even then because we had started chlorambucil the same day we attributed symptoms to that drug - it's been kind of a stressful week.
 
You absolutely did the right thing in not giving insulin last night - it's much safer to have a cat run high than to risk a hypo (and honestly, she didn't go that high even by her preshot time this morning). For people who are starting out with Lantus, we suggest the no-shot limit should be 200 until you have enough data to know that it's safe to shoot lower and have the experience to deal with low numbers if they happen. And I very much doubt she was over 200 at her shot time last night, so even if you'd asked here we'd very likely have suggested skipping the dose anyway!!

The problem with not monitoring BG levels at home and just looking for hypo symptoms instead is that, as you've found, there aren't always any obvious symptoms even with BG readings in the 30s. Regardless of that, your vet shouldn't have told you to keep giving a dose that had dropped Vivian into hypo-level numbers - it doesn't matter whether the hypo is symptomatic or not, continuing to give a dose of insulin that has dropped her that low is dangerous. Actually, not treating the 36 can be dangerous too but it appears Vivian handled the low number and came back up for you on her own this time.

My concern at this point is that, as your vet wasn't worried about that reading of 36 (honestly, my vet freaked out any time she saw a reading below about 80 on Rosa's spreadsheet) and was happy for you to continue giving a dose that had dropped Vivian that low (and that is definitely in the danger level - even a non-diabetic cat will usually read 40 or higher so you're outside of the normal range at that point) that they're going to tell you to continue with the 0.5U even though it dropped her very low both yesterday and today. If they insist on waiting for a symptomatic hypo before the dose is reduced, then I'm concerned that by the time that happens, you're going to have to rush her to the ER vet to be put on a glucose drip at the very least - she's already proved she can drop to dangerous levels without showing any obvious signs.
 
When you say I did not treat Vivian's reading of 36, do you mean by that I didn't give her karo syrup? Because I did push dry food and wet food and treats on her successfully in the hours after that reading, I guess I considered that to be treating the 36. I have given all of today's #s so far in an email to the vet, should she decide to read it today I have also said I feel like these numbers are way too low, that I withheld insulin last night and I am inclined to withhold it tonight as well and until I hear from her. I told her I have been here yesterday and today to push food on Vivian, but during the week and in the night I'm not here or up to push food on her, so those numbers may have been staying low for even longer periods earlier in the week. I said all that before I posted here. The directions she gave me for initial dosing and med type came from a consult she had with an internal medicine specialist familiar with Vivian's case because Vivian was there this winter for intestinal disease diagnostics. That person doesn't work Mondays, so I wonder if my vet will wait until she has a consult with the specialist before giving me further instruction, in which case it will be interesting to know what the internal med specialist thinks of BG #s in the 30's without overt symptoms. As far as continuing on the same dose of lantus, I'm not going to do that with BG #s as low as Vivian's have been, I also think I made that fairly clear to the vet. And to be fair, I've had my own opinions about treatment of Vivian's other (intestinal) issues, and she has always been open minded to what I think and would like to try if she thinks it's reasonable. I read and study the issues a lot and she knows this. Diabetes is kind of new one for me so far.
But yes, the goal is to reduce pred to the point where Vivian's BG comes back to normal range, and discontinue insulin, without further compromising her intestinal situation -
 
Generally with a reading as low as 36, we would give karo or honey to give a quick boost to the numbers while we work on stabilizing them at a higher level. You can also give a high carb food at that point, though we don't usually use dry food as that takes longer to get into a cat's system and longer to get out again. The food that we would normally use for that would be a high carb wet food (the in-gravy types work well as you can give just the gravy, which is the part that has the carbs in it - and that has the added advantage of not filling the cat up too much so you can get more food into them later if they need it).

That being said, you did the very best you could with the information you had at the time...and the important thing is that you got Vivian through those low numbers and back up into better ones. The "how" you get there is less important than the fact that you DO get there. :)

I'm really happy to hear that your vet has been inclined to work with you in the past, so hopefully she will do so again with this and you'll be able to have her support as well on getting to the best dose for Vivian. The more help you have available, the better! :)

And I agree, it would be great if you can reduce the pred enough that Vivian no longer needs insulin - if you can get to that point without aggravating her intestinal problems that would be perfect!
 
When I do that last test of the curve, which will be in about an hour, is it supposed to be after a meal? I've given Vivian food during the day to counteract low #s so I don't know how much of a meal I can get her to eat, but just wondering...
thank you
Laura
 
What we like is for them to NOT eat for the 2 hours prior to test/feed/shoot times...other than those 2 hours, it's fine that they eat, but you have to keep in mind that if they eat after nadir (about +6) that you're adding carbs and the insulin is also starting to wear off, so a lot of us try to get all their food in in the first half of the cycle...but of course if they're too low and need the food, that's an entirely different matter...then you do what you need to do to keep them safe!
 
Ok, well that didn't happen, but thanks... I'll remember that: test/feed/shoot. Is that different from the morning? This a.m. I fed/tested/shot
She hasn't had much, but did have a few bites a few minutes ago. Before that I think it was close to a couple hours
We're going to do one more test shortly and call it done, Vivian has had a long day - me too.
If by some miracle she has gone up toward 200 I'll have to consider whether to give her insulin, probably a half dose at most -
I'm thinking it won't even be close but she's full of surprises...
 
6:45 p.m. 117 BG - that's a little over 11.5 hours from the first injection this morning. Doesn't seem high enough to give her insulin tonight
 
That depends - what dose do you normally give? How much does it normally drop her?
Stall for 60 minutes without feeding and re-test.
You have a couple of options
- skip
- shoot a token dose (aka big chicken dose or BCS); in her case, that would be 0.25 units, if your signature is correct.
- chase the numbers - until she gets safely high to shoot, just test periodically. This might mean shooting every 18 - 24 hours, depending on how the testing goes.
 
Generally, we test first (so we get a non-food influenced number), then feed (so we know that they're eating fairly "normally") and then shoot...all within about 5-10 minutes.

It'll REALLY help if you'll get our spreadsheet set up and start putting the test results you get into it. The spreadsheet is a very valuable tool that we'll all want to look at before giving you dose advice in the future. Here's instructions on Creating the spreadsheet...if you need help, please ask!

For tonight, if she's not at 200 at PMPS, I'd probably "stall", don't feed and retest in about 30 minutes to see if she's still heading up and then decide if you need to skip tonight or give the new reduced dose and be ready and able to test tonight as long as necessary (and have the supplies to do that)

If she's been getting .5, she earned a reduction today down to .25 either way, so the most you'd want to shoot tonight is the .25 if you shoot anything
 
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