Hello and can someone look at numbers

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Welcome :-D

We will be able to help you with Jules. Would you be able to put all of that information from your Excel spreadsheet into the type of spreadsheets we use? We would be able to more readily help you, if you could.
14 is not that old for a cat, and Jules may go back into remission.

If that is a BG of 36 I see on January 22nd, then I would definitely lower his dose.
We usually do dose adjustments in 0.25 increments. It looks to me (and I may be missing something) that his dose was changed by 1 unit from 4U to 5U at one time.
 
Hi Bruce & Welcome :-D

My Simon will be 18 in a few months, and we're trying for his 4th OTJ!
Anything's possible, and you are very definitely in the right place to see it happen!
 
Julesx said:
Hi Bruce & Simon,

How did you get him off multiple times once the diet stuff was all taken care of? that's what has me so frustrated.
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The first time he was much younger and got off using Caninsulin. The second time was ALL diet, the switch to wet low-carb food resulted in an immediate hypo, and he was OTJ.
The last two relapses were brought about by his hyperthyroidism (I think & vet concurs) Once it was controlled, he went OTJ.
Unfortunately between bloodworks HT progressed, and BG tested high, so back on insulin. HT is now controlled, so we're hoping for another OTJ.

The last two are on his SS linked below (including some Rainbow-like Caninsulin #s at the beginning before the switch to Lantus :lol: ).
 
I'm having a hard time following what you cut and pasted. If you put "Spreadsheet Help" in your subject line (edit the first post in this thread to change the subject line), one of the members here may be available to give you a hand.
 
Bruce

AMPS is the a.m. Preshot BG that you get before you shoot; PMPS is the p.m. Preshot that you get before you shoot.

The + columns are hours from the shot. There are twelve hours in each cycle, two cycles a day. So let's say you shoot at 7am and 7 pm. You test at 6:50 a.m. and get 200. That goes in the AMPS box. The say you test two hours after the shot and get 180. Put that in the +2 box for that day and that cycle. If you test 4.5 hours from the shot, then go to the +4 column and put ( for example) "175 @ 3.5".

If you get a 40, just put it in the correct column. If you get a number below 40, put it in the right column. Most of us change the color on a number below 40 to get attention to the SS. If you look at Gracies SS in my signature block, you will see how it's done.

We don't usually talk in specific time because we are all on different time zones including members in China and Kuwait. But if we know a specific test is four hours after you shot...the +4... Then we know where he is in the cycle.
 
22-Jan ........ ........ / ........ ........
........ ........ / ........ ........
4:00am ........ +11.25 ........ 243 / 13.5 ........ 4.5U ........
2:45pm ........ +10.75 ........ 36 / 2.0 ........ ........
6:00pm ........ +14.00 ........ 41 / 2.3 ........ ........ pre-meal
8:15pm ........ +16.50 ........ 71 / 3.9 ........ ........ I think long low run is better than short high one.
10:30pm ........ +20.25 ........ 195 / 10.8 ........ 4.5U ........ going with longer runs and lower bg's
........ ........ / ........ ........
23-Jan ........ ........ / ........ ........
........ ........ / ........ ........
10:30am ........ +12.00 ........ 311 / 17.3 ........ 4.5U ........
8:15pm ........ +09.75 ........ 298 / 16.6 ........ 4.5U ........ may have to go back up to 5U, I'll give it another run.
........ ........ / ........ ........
24-Jan ........ ........ / ........ ........
........ ........ / ........ ........
7:00am ........ +10.75 ........ 196 / 10.9 ........ 4.5U ........ Last try to stay at 4.5U, see how this run goes
6:00pm ........ +11.00 ........ 26 / 1.4 ........ ........ Sticking with 4.5U I guess.
11:45pm ........ +16.75 ........ 95 / 5.3 ........ ........
........ ........ / ........ ........
25-Jan ........ ........ / ........ ........
........ ........ / ........ ........
1:30am ........ +18.50 ........ 104 / 5.8 ........ ........
2:45am ........ +19.75 ........ 253 / 14.1 ........ 4.5U ........ should have tested and shot a bit sooner

Hi Bruce.
Thanks for working on getting the Google spreadsheet in order.
We are not used to see a format like you have, sorry. We try to all use the same color coded Google spreadsheet format as that is what we are used to and we can more quickly understand the data to give you help.
If Jules had a 36 on January 22nd (if I am reading this right), you should have reduced his dose by 0.25 at that time.
If that is a 26 at 6:00pm yesterday, then you really really need to reduce his dose.
Please let me know your thoughts and if I am wrong in reading your data.
 
I'm echoing Dyana's comment. Just like you're struggling with our shorthand, I'm struggling with yours. For example, you noted:

6:00pm ........ +11.00 ........ 26 / 1.4 ........ ........ Sticking with 4.5U I guess.
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  • Is 6:00 your shot time?
  • Does the +11.0 mean 11:00 or that the 6:00 was your +11 time?
  • Is the 26/1.4 your reading in both mg/dL and mmol/L? (The convention here is to use mg/dL since the majority of people are from the US)

And BG reading below 50 in a newly diagnosed cat warrants a dose reduction of 0.25u.

I want to strongly encourage you to read the sticky notes. We aggressively manage numbers like a 26 since it it low and there is no margin of safety. The sticky notes will give you guidelines for dosing as well as what to do when you encounter low numbers.
 
Jules went OTJ 3.75 years ago, so he's not newly diagnosed.
Any number below 40 in a non-newly diagnosed cat, is an automatic reduction (you will read about that in the stickys).

Let us know all your questions, and we will help you.
 
Just a thought with the data entry, you might want to enter in your recent data and work backwards to catch up. The older data is important but you need to have a record of what's happening now so we can lend a hand if you want us to. You can always insert rows if you need to.
 
Thanks for doing that. To insert rows, go all the way to the left to where the numbers are. If you want to insert a row below row 22, for example, right click on the actual box that has the "22" (or whatever number in it). Then you'll see options for inserting a row above or below it.

Right off the bat.....Jules needs a reduction. Any number below 40 for him, since he is not newly dx, and he earns a reduction. We normally recommend you reduce by .25u. He's already been really low twice at this 4.5u dose. So starting tonight, I'd be shooting 4.25u if it were me.

It looks to me like you've been dosing on the preshots and not the nadirs and that's why you are getting such low nadirs. For instance, on 1/12 you raised his dose to 5.25u when you got that 353 but he had recently been in low green on the 5u dose.

I've been on the other forum you were on and recognize their reporting format. I was just "snooping" around :lol: :lol: but if they were teaching you to dose on the PS, that is not the way to work lantus and levemir. We dose on the nadir, primarily, with some consideration given to the PS.

So...I'd take him down to 4.25u tonight and try to get a few more tests when you can especially around his nadir.
 
Good job on getting all that data entered into the spreadsheet.

I am wondering why the PM units column tonight says 5.00 units.
With the recent 36 and 26 tests, you should be reducing the dose, not increasing it.
Please tell me that was just a typo.
 
Bruce:

I'm going to do a bit of teaching so I am going to apologize up front if you already know this.

Lantus dosing is based on the nadir -- the lowest point in the cycle. This is one of the reasons that with Lantus, you need to not only test at pre-shot times but also get tests around the middle of the cycle. You base your dose adjustments on the nadir. Dose reductions are based on a newly diagnosed cat (i.e., a cat that's less than a year from diagnosis) having a BG test that falls below 50.

You do not raise the dose because you have a higher than expected pre-shot number. There can be any number of reasons pre-shot numbers are elevated. Most of these reasons don't warrant your increasing the dose. In fact, if you do raise the dose, you could put your cat at risk for dropping into dangerously low numbers.

The data you've entered on your SS suggests that Jules is on too high of a dose. I would encourage you to drop the dose tomorrow to 4.25u or even 4.0u given that you've missed a few reductions.

I also want to underscore that it's important to get spot checks. If you're not at home during the day, then it's even more important to get tests at night. The days you have tested, you're seeing the Jules is dropping into low numbers. In addition, please read the sticky note on Shooting & Handling Low Numbers. Jules has been in both situations and the information will guide you through what to do. Usually there is someone here who can walk you through the process but in case there isn't, this information is very useful.
 
Bruce

I can't put this strongly enough. You must stop dosing Jules on his preshot. You should have taken his dose down. Here's why:

Lantus works differently than PZI, Prozinc, or short acting insulins like Humulin or Novolin. It's not in and out. It is a depot insulin so each shot you give builds upon the one before it. That is why the TR protocol has caregivers holding a new dose for 3-5 days.

Unlike the faster acting insulins, onset is, generally, +2 or after. Lantus is designed to give long, flat curves. As the depot builds, if the dose is correct, at some point it is like an overflowing bucket and the numbers come down. The dose should be targeted for the nadir because that is the peak action of the insulin. If you give a dose for the highest number you get and then the insulin drops his numbers down as it reaches its peak action, you could end up with a hypo that lasts more than 16 hours. You are seeing high numbers because he is bouncing from the low ones.

Yes, you hold the syringe. But you've asked for our help and we've indicated that the dose needs to be reduced. You might even need to take him down to 4u based on what he does tonight. But at a very minimum, you need to reduce his dose to 4.25u in the morning. You are putting him at risk if you don't.

Please be sure you monitor him carefully tonight. Don't assume because his PMPS is high that he won't clear that bounce this cycle. Bounce clearing cycles can often be extremely active and result in really low numbers.
 
Highs are temporary; lows can kill. My previous diabetic cat was overdosed by his vet on Lantus. His preshots were high, so the vet kept raising his dose. His nadirs dropped out. I almost lost him (if I hadn't found this board, I would have lost him). Please, Bruce, listen to the very knowledgeable people who are trying to help you. The advice you have been given (see above) is sound and based on a great deal of collective experience.

Ella & Rusty
 
I seriously hate to say, "I told you so." but that's exactly what I'm saying. That 36 at +11 is a case in point that Jules' dose should have been reduced. What is even scarier is that you have absolutely no idea if that number was the lowest point of the cycle. Jules could have been seizing in the middle of the night. Losing bladder control is not unusual during a seizure. If this doesn't frighten you, it should because it terrifies me. Hypoglycemia can kill your cat.

What you're seeing with respect to high numbers is a bounce. Jules body has a built in protective mechanism. When numbers drop low or the numbers drop fast, the liver and pancreas react by releasing a stored form of glucose (i.e., glycogen) and counterregulatory hormones. These compounds act to cause BG levels to rise. It can be a lifesaving mechanism. It can take some cats 72 hours to clear a bounce. You do not raise the dose because of the bounce. You wait for it to clear.

What you are doing is overdosing Jules. I'm imploring you to reduce the dose to 4.0u.

It also looks like you stalled this morning which was the right thing to do. I also hope you gave Jules something to eat to bring up the low numbers. (This is the one scenario when it's fine to stall and feed -- you want to "feed the 40s" and below). Given that you shot 4 hours late -- if I'm understanding the note on your SS -- your PMPS will be 12 hours from when you last shot. You can adjust your shot time either by 15 min. at each shot or by 30 min. once a day so it will have minimal effect on the numbers. If Jules' numbers are very high at shot time, there may be other possibilities but there's no safe way to make up a 4 hour delay other than to skip a shot. To be honest, skipping tonight or tomorrow AM may not be a bad idea. It will help to drain the depot and it will help to get Jules out of this dangerous situation.
 
In reality, his highs aren't that high and he is obviously coming right back down. If you backed off the insulin, he might not bounce up quite so high, if at all.

And the peeing could be attributable to something else.
 
I am going to assume that you came here because whatever you were trying before has not been working to your satisfaction, and you are looking for different ideas. If that is not the case, then you can stop reading. ;-)

The protocol that I think you are currently using was designed for PZI insulin. It works very well for that insulin. However, Lantus and Levemir work very differently than PZI, so using the same protocol for both types of insulin does not produce the same kind of results. You've noted that Jules' numbers are all over the place, right? And you're looking to change that?

The main difference between PZI and Lantus is the insulin depot. Read through this link and ask questions - it's not the easiest concept to grasp at first.

The Tight Regulation protocol we use here was developed for Lantus and Levemir, and has been validated by one of the top researchers in feline diabetes. It takes the concept of the insulin depot, as well as the extended duration of Lantus to take advantage of overlap and get the cat into flat numbers quickly and safely.

It's a totally different way of thinking. With PZI, if you see a high number you can catch the rise and give more insulin to bring that high number down. With Lantus, that is actually counterproductive because changing the dose and timing very much will disrupt the balance in the insulin depot. Most PZI users (myself included, back in the day) have a hard time grasping the concepts at first, but stick it out, it will work. I know you're not using PZI, but you've been taught to think that way so it's not that different. :smile:

Questions?
 
IMHO, Libby's post is important. You've switched from an insulin that works very differently than Lantus. For those members here who have made the switch from a shorter-acting, non-depot type of insulin to Lantus or Levemir, the biggest challenge they encounter is having to think very differently about how the insulin works and how you approach dosing. It is a very different way of thinking about diabetes management.

With non-depot insulin, you do not have to take the cumulative nature of the insulin into account. The insulin is in and then gone. With Lantus, this isn't the case. Each dose overlaps with the next. This is what gives Lantus its duration. It's also one of the reasons you need to base dosing decisions on the nadir. I really understand that this is an entire shift in the way you think. You've got to leave what you learned about other insulin behind if you want to get the maximum benefit from Lantus and keep your cat safe.
 
hope you're right on the first part...we will see over the next few days :) I think his highs are high…we may disagree on this. Over 200 is unacceptable…and actually over 150 is not good. Over 120 is not good imho. I want him in “normal” range at all times…80-120. That is the goal and I hope we can accomplish this with Lantus.
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The goal with the Tight Regulation Protocol is completely in sync with what you want. Normal BG, at least how we consider it here, is 50 - 120. That's the range we all aim for. Keeping Jules under renal threshold (low 200s) would be a good secondary option. With TR, the dosing is aggressive but because the doses are arrived at in a systematic manner, the approach is safe. What I would point out is that some cats are more prone to bouncing than others and it doesn't matter much how skilled you are with dosing. Just so you're aware, with a longer term diabetic, if Jules' BG drops between 40 - 50 three times or there's a drop below 40, the dose is reduced.

The vet's suggestion to use a needle to get a urine sample is actually the preferred method of testing for a urinary track infection. The procedure is called a cystocentesis and it's the only way to get a sterile sample. If you do a free urine catch, there's a good chance that there will be bacteria from the air, your cat's coat, the container, etc. that will contaminate the sample. Usually the sterile sample is then processed with a culture and sensitivity to determine what bacteria is present so the appropriate antibiotic can be prescribed.
 
Thank you, Bruce, for your detailed post and explaining where you are coming from.

26!!! That's amazing.

It's not that I like your cat or mine above 200 ...in fact, I'd love it if they'd all be in normal numbers all the time. What I did mean is that I've seen many cats in the 400-500 range when they bounce.

Keep in mind that lantus requires patience. Think of it as a cruise ship. You can turn the wheel but it takes a while for the ship to change course. The higher doses you've been shooting can affect up to six subsequent cycles so give him a chance on the lower dose.

God luck and we will be here to answer questions.
 
Hi Bruce.
Thanks for getting all that data in the Google Spreadsheet, I know it was a lot of work, but it will help us to help you.

When you shoot at +10.25, it acts like a dose increase with Lantus, because of the accumluated depot. Please try to get a few tests in this morning, because of that.

I hope you have a good day.
 
Hi again, Bruce,

In re-reading this thread I noticed in one of your posts that you are using the FreeStyleLite meter. You might wish to consider switching to a different meter. Last year many of us were stung by the realization that the FreeStyleLite was reading substantially lower in the upper ranges of the blood-glucose scale than any of the other meters. People using the FreeStyleLite were thinking that their cats had reasonably good numbers, when in reality the cats' numbers were much higher (sometimes over 100 points higher when measured on other brands of meter). The lower range of the blood-glucose scale was not affected to the same extent, but even there the readings on the FreeStyleLite tended to be lower than the readings on other brands.

As a former PZI user, I know that with PZI it is OK to have a leeway of up to 2 hours with regard to shot times. This is not the case with Lantus. Lantus works best when shot times are every 12 hours (there can be a 15-20 minute leeway). If you frequently shoot several hours earlier or later than the 12-hour schedule, you mess with the "shed" and therefore defeat the whole purpose of using this "depot" insulin.

I hope that you will be able to get Jules better regulated. Strict following of the Lantus protocol is the way to do this!

Ella
 
Lantus can be shot at +10 but, as Dyana said, an early shot acts like a dose increase so you need to monitor. I am not certain that I would shoot at +10 every cycle. There might be days when you shoot at +10 because he's on the way up and then shoot at +12 a few cycles but then shoot at +14 because he's low (below 50) and you need to stall.
 
Julesx said:
thanks Ella (great name btw :)),
I appreciate your input, as I do everyone's here :) I know a lot about meters and have tired many. I love my FreeStyle Lite and will never switch, unless it is for financial reasons. There is no meter that can even come close to it's performance in terms of only needing the tiniest amount of blood and a full minute between the time you put the strip to take a reading. We've all been frustrated by a wasted strip when a meter beeps off before you get your sample.
The research I have discovered, with other people, it that yes there is perhaps some slightly lower numbers, but the are mostly at the higher ranges of 300-400's.
We concluded that as long as you use the same meter...it's relative to your cats (hope that makes sense).
On the other hand, perhaps this is a possibility why he is fine at a number like 26 or 36 it doesn't scare us.
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When I first saw you getting numbers like 26 and 36, that did worry me until I saw you were using the FreeStyle, so I think you might be right about why those numbers aren't scary for you guys. I once got a 28 on my Accu-Chek Nano once with no signs of hypo so I tested him on a different meter and he read in a more normal range (48). Even still 48 was low enough to earn him a dose decrease.

Not sure how much the FreeStyle test strips cost, but a comparable meter is the ReliOn Micro from Walmart. It only requires .3 µL of blood (most require .6 µL) and it gives a ~30 second warning beep before giving the final time-out beep. You can get a box of 100 test strips for $36 at Walmart (and probably even cheaper online). It's also much more accurate in comparison to other glucometers vs. the FreeStyle and the "True" meters (another brand that has gotten a few complaints around here for its lack of accuracy).

ITA about making sure you consistently use the same glucometer throughout the day since all glucometers have ~20% variance. I have quite a few glucometers that I've used and I will switch glucometers during the day for only two reasons: either I ran out of strips or I want to double-check that his numbers are accurate (this is usually when he's reading super low/high). Even still, it might be advisable to put in your signature that you're using the FreeStyle as it will help people better understand some of the low numbers you've been getting.
 
Yes, stalling means waiting (without feeding) after the normal PS time, for the BGs to come up, so that the shot can be given.
 
Hi Bruce :smile:

First of all, I'm no expert, but I've been following with this thread with interest, and after seeing that 20!! I thought I'd add my 2 cents worth ;-)
I've never seen him drop down to 20 before ! 26 was the lowest. but he's fine.
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20.. Good grief ohmygod_smile I was fine too, I'd never had a heart attack, until I had one... :-|
as the goal is to get him to level out more
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Why not try the same dose (maybe 3.75u?), 12 hours apart for 3 days or so?
But I would never dose him, regardless of time, unless he was over 130-150 ps
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With a consistent dose and schedule, and the data to back it up, you can (and we do) routinely shoot green numbers on the way to regulation (and hopefully OTJ) "Shoot Low to Stay Low".

And as one of the few still using the Freestyle Lite, for the reasons you stated, I thought I'd chime in ;-)

When I first saw you getting numbers like 26 and 36, that did worry me until I saw you were using the FreeStyle
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You should still worry... 20s are dangerous, symptomatic or not. Every same-drop test I've done on my civvie (his bg usually 50-60) the FS was with a point or two of my One Touch (which requires about a cup of blood)
I'm not convinced that FSL is that far off at low to normal range numbers...
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Exactly, it's not.
 
Morning Bruce ~O)

Ahh, the irony. The two FSL holdouts are both named Bruce ;-)

I'd probably be using the Relion by now, but Walmart don't sell it in Canada :evil:

As for my saying 3.75u, as I'm not qualified to give any advanced dosing advice (others?) I simply refer to
the protocol, which has worked with many hundreds (maybe thousands) of cats. Jules had a 20! That calls for
a mandatory dose reduction. "If the cat drops below 40 mg/dl once, reduce the dose immediately!"
I used 3.75, as that's .25 less than his last dose. I'm not sure, but at 4u the reduction could even be .5u, new dose down to 3.5u.

Also looking at Jules' SS - all those AMPS@ +16, PMPS@+10 etc. is bound to cause trouble... You shoot late because he's low,
then shoot early because he's high. A 12-hour shooting schedule works (as per protocol ;-) ) As a late shot is effectively a dose reduction,
and an early one an increase, you never get a real view of a dose's effectiveness if it's never been shot on a schedule IMHO.

One other thing (says the gasbag :lol: ) "Shoot Low to Stay Low" refers to shooting at a low BG, not a low dosage. After seeing what Jules can do
with a 12-hour schedule on a given dose, with enough data you shoot low preshot BGs, because you know he's going up, and it's
perfectly safe to shoot a 90 for example, rather than waiting for it to go over 120, when all your carryover and overlap are gone.

What all my blather can be reduced to is "Try the Protocol". If it doesn't work (unlikely) all other options are still open.

If anyone sees any errors above PLEASE point them out...
 
Sorry, I don't know anything about zeniquin (someone else will have to answer that question), but I think this might be what you're looking for regarding shooting low: Shooting and Handling Low Numbers. One thing about the Lantus depot is that it works best if it can safely be shot twice a day, 12 hours apart. If you find yourself skipping shots due to low numbers, that is generally a sign the dose is too high.

And while I'm at it, let me throw some more links your way. ;-) I think some of these you might have seen before and have already been posted for you. They are all located as "Stickies" at the top of the Topics section on the Lantus Forum page. Here's the link to the Tight Regulation Protocol that works so well on cats. The New to the Group? sticky contains general information on shooting and testing, but also gives a great overview on what a typical Lantus curve looks like and some other good tidbits, so it's definitely worth a read-through.

Feel free to take your time reading through those links and keep asking questions! As I'm sure you've seen, the people here are highly knowledgeable and go out of their way to help. I don't know what I would have done without this board and their assistance!

Finally, I want to see more of Jules!! Here's information on creating a profile page for him.
 
No one here can procure antibiotics for you. They require a prescription that you'll need to get from your vet. Even ordering meds from Canada now requires a prescription. You could try on Craig's List but it's not something I would recommend. There's just no way to know what you could be getting.

The sticky notes are the starred notes at the top of the board that are labeled, "Sticky." Here's the guide to the notes:
  • Tight Regulation Protocol: This sticky contains the dosing protocol that we use here. There are also links to the more formal version -- the “Tilly” Protocol developed by the counterpart of this group in Germany, which was also published by Kirsten Roomp & Jacqui Rand, DVM in one of the top vet journals.
  • New to the Group: Everything you wanted to know about this forum and more. Info on our slang, FAQs, links to sites on feline nutrition and to food charts containing carb counts, how to do a curve and the components to look for, important aspects of diabetes such as ketones, DKA, and neuropathy, and most important, info on hypoglycemia.
  • Handling Lantus: how to get the maximum use from your insulin and what to not do with it!
  • Lantus depot: This is an important concept for understanding how Lantus works.
  • Lantus & Levemir: Shooting & Handling Low Numbers: What data you need in order to be able to work toward remission or tight regulation as well as information if you have a low pre-shot number or a drop into low numbers during the cycle.
 
Hi Bruce

One thing I think is important about letting Jules drop and stay in the 20s/30s is, while he might not seem to have any clinical signs of hypo, you do not know what kind of long term damage you could be doing to his brain. The brain cells require sugar to function. And it is possible that any amount of time where numbers are considered to be hypoglycemic, can affect brain cells. And since we don't have our cats hooked up to any monitoring systems, you really don't know how those low numbers are affecting his brain over time.

Is not a chance Im willing to take with my precious Gracie. If she manages to drop down there, I immediately get her BG up, and then I reduce her dose.
 
Bruce:

Like any other discussion board, there are rules of etiquette here. I would urge you to familiarize yourself with those rules. Here's the link to the Community Rules. Personal attacks such as the one you levied above are frowned upon.

As a medical professional, I would think you would have an appreciation for Marje's concern. There are long reaching effects on any organism for repeatedly low BG levels. Her concern is legitimate. Our focus here is on the health and safety of your cat. When offering suggestions, we follow the guidelines in this post, the overriding concern is to first, do no harm.
 
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