Help! Worried about potential of overdose

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MelanieP and Ninja

MelanieP and Ninja

Member Since 2012
My cat Ninja’s numbers have been very high for the last month (400’s and 500’s, with just a few high 300’s), despite very gradual increases in her Lantus (starting at 1unit b.i.d. on 6/4 and ending at 2 units on 7/3.

I switched out her Lantus vial yesterday (thinking maybe it was bad) and started immediately getting some odd numbers: 276 (she’s never been that low) at AM +6 but then a HI (over 600) PM pre-shot number just 6 hours later. So I’m thinking, “Well maybe it wasn’t the Lantus after all.” Talked to vet and she recommended we try 3 units b.i.d. which I started last night.

Ninja’s PM +5 reading (after the first increase to 3 units of Lantus was 435). Today, her AM +6 was 344. But after her PM shot, her number fell to 191, despite eating a somewhat high carb dinner (I am still transitioning her from high carb dry).

As noted above, her PM +1 this evening was 191. I was concerned her number would dip much lower because of the 3 units given just one hour earlier – so gave Ninja a little more high carb food. Her +3 number rose a little to 213 and I will check her again at +6 just to be sure the 3 units don’t cause her to go too low.

I KNOW THAT 213 IS NOT A LOW NUMBER, but my concern is for tomorrow morning. At what pre-shot number would it be safe to shoot 3 units – or should I drop her back to 1 or 2 for awhile? I guess what I am asking is… assuming the original Lantus vial may not have been effective (which seems the most likely explanation since her numbers were dangerously high for a month on the old vial, and now are dropping more than 200 points with the new one), my question is…should Ninja even be at 3 units at all?

So if you can tell me, a) at what number do you think it would be safe to shoot 3 units tomorrow morning; or b) would you advise dropping Ninja down to 1 or 2 for awhile… and if so, what number should I be looking for. Example: If AMPS number is between 200-250, ok shoot 1 unit; If AMPS number is between 250-300 ok to shoot 2, etc. Thanks!!! I don't want to overdose Ninja!!!!
 
Hi Melanie,

Well, the thing about Lantus is that you don't adjust the dose based on the numbers at shot time. It works best when you keep the dose the same for 3-5 days, test at shot time and at least once between shots (usually around +6 is helpful since that is when the insulin has pushed her BG down to the low point in the cycle). It's actually that point, the nadir, that the dose is based upon rather than the numbers when you give the shots.

The usual recommended increment for a dose adjustment, up or down, is .25u. Your vet telling you to go up one full unit is not the way it is normally done. I'm going to ask someone with experience with your insulin to take a look and see if they can help, but I'm thinking you should go back to 2u rather than stay at three or drop all the way down to one. When you change dose, the reaction isn't usually immediate. Most cats take a couple of cycles at least to adjust to a new level of insulin.

Hold on, I'll see if I can find someone online to chime in...

Carl
 
Thanks Carl! I will stand by. I thought I read somewhere not to shoot when the preshot number is below xxx (don't remember the number); so wanted to make sure I understood what those guidelines were -- and if I am nearing that thresshold, should I reduce the units given. I appreciate any guidance you can provide. This is scary territory for me.


Carl & Bob in SC said:
Hi Melanie,

Well, the thing about Lantus is that you don't adjust the dose based on the numbers at shot time. It works best when you keep the dose the same for 3-5 days, test at shot time and at least once between shots (usually around +6 is helpful since that is when the insulin has pushed her BG down to the low point in the cycle). It's actually that point, the nadir, that the dose is based upon rather than the numbers when you give the shots.

The usual recommended increment for a dose adjustment, up or down, is .25u. Your vet telling you to go up one full unit is not the way it is normally done. I'm going to ask someone with experience with your insulin to take a look and see if they can help, but I'm thinking you should go back to 2u rather than stay at three or drop all the way down to one. When you change dose, the reaction isn't usually immediate. Most cats take a couple of cycles at least to adjust to a new level of insulin.

Hold on, I'll see if I can find someone online to chime in...

Carl
Click to expand...
 
For newbies - it's usually recommended to not shoot if the BG is under 200 unless you have the data to support that it's OK to do so. Yesterday morning, I gave Zeus a big chicken shot of .50U at 112. It was my first time shooting that low, but I did have a couple of times of data that I was able to test a low number without insulin and with normal feedings. It was really difficult for me to give that shot and then go to work (I actually left work to check on him. Tonight, I gave a shot of 1U at 94, but I'm testing to make sure it doesn't go too low. I increased it from .5 to 1 because based on the data yesterday, it wasn't enough.

With that said, I can't give you any advice with how much to shoot based on whatever numbers you get; but I do wish you luck. Hopefully someone with more experience will be along soon.
 
Welcome, Melanie. Carl asked if those of us experienced with using Lantus would stop by and try to lend a hand.

We generally recommend that for someone who is new to using Lantus, you don't shoot if your pre-shot test falls between 150 and 200. (On the Lantus board, we use 150; here on Health, they suggest 200.)

Carl is correct -- Lantus dose is not based on your pre-shot test. Instead, it's based on the lowest point in the cycle (i.e., the nadir). If numbers drop below 50, the dose is reduced. If numbers stay high for more than 3 - 5 days, the dose is increased if you are using the Tight Regulation Protocol. Dose increases are usually in 0.25u increments (although, if nadirs are above 300, increased can by in 0.5u increments).

It's very hard to give a recommendation regarding dose without seeing more data. From what you're describing, it sounds like Ninja's numbers dropped a bit and then she bounced back into higher numbers. This isn't unusual if your cat is accustomed to being in high numbers. If Ninja was, as you indicated, spending the majority of her time in numbers around 400, when her numbers come down to a closer to normal level, her liver will overreact and dump a stored form of glucose and counterregulatory hormones into her bloodstream and, as a result, blood glucose (BG) levels will spike back up.

Since a great deal can happen in the space of a cycle, it may be best if you get a test at +11 and post so people will have time to respond if you're not sure what to do.

If you are transitioning Ninja to lower carb food, you will need to be testing to make sure her numbers don't drop too fast. I suspect that Ninja's numbers have been high due to what you've been feeding. As you increase insulin and change over to lower carb food, you will need to monitor Ninja's BG carefully.
 
Thank you Sienne. Ninja's numbers started falling really fast when I switched out her Lantus vial on July 3. Prior to that, her BG numbers were consistently in the 400's and 500's - all month long. That led me to wonder if perhaps her original Lantus vial was bad. As an example, Ninja's AM nadir reading on July 1 was 524, on July 2 it was 471, and the day we switched the Lantus on July 3 it dropped to 276 (an approximate 200 point drop) -- even though I was giving her the same dose (2 units) as I had the entire month before.

But it gets confusing because, later that same day, Ninja's preshot PM number jumped back up to 600+ (HI); and due to the fact that Ninja's numbers had been running so dangerously and consistently high all month long, Ninja's vet said to go ahead and try 3 units -- starting that evening (up from 2 units) to see if we could get some movement in her numbers. In retrospect, I wish I had held to 2 units for a few days, just to determine if the change I was seeing in Ninja's numbers may have been related to the potency of the Lantus vial. But I didn't.

The first full day shooting 3.0 units (yesterday, Jully 4), Ninja's +1 number (PM) dipped below 200 and scared me a little. A number of 191 is vastly different than the 400, 500, and 600 numbers I had been seeing all month.

My concern is, if we assume the original Lantus vial was bad (an assumption at this point), should Ninja even be receiving a dose of 3 units in the first place? Should I step back to 2 and see how that goes? I certainly don't feel comfortable shooting 3 units into Ninja if her preshot number is in the 200 range -- and thinking that maybe we got to this high dosage based on bad numbers (if the prior Lantus bottle was indeed bad).

In any case, last night I gave Ninja a high carb snack to make sure her numbers did not fall too low during the night. This morning her AM preshot number was 303, and I reduced her dose back to 2 units. Don't know if that was the right decision, but I just don't feel comfortable shooting 3 units with all the volatility in her numbers the last couple of days and the suspicion about the original Lantus bottle. So I will grab a few more readings today and see how it goes.

My goal is to get back to MARGINAL increases or decreases to Ninja's dosage based on nadirs that are not so volatile -- if that makes sense.

Thanks!
 
Thanks for putting together a spreadsheet!

I think the other confound here is that you are transitioning food. The lower the carbs in the food, the less insulin that's needed. Could you fill us in on how and what you're feeding?

I also want to strongly encourage you to approach how you're testing a bit differently. You want to test before you give a shot. Otherwise, you have no way to know if it's safe to shoot. If you can get spot checks -- at least one during both the AM and PM cycle -- that will give you information about where the nadir is. Since Lantus dosing is based on the nadir rather than the pre-shot numbers, this is very important information.
 
Sienne: I am feeding about 1/2 Hills Science dry (original adult formula) and 1/2 Evo low carb cat and kitten food (I think it is 8% carb) - mixed together. Ninja is a hard core Hills addict and had lost a significant amount of weight at diagnosis. Vet suggested I feed her whatever she would eat for now, and transition her to wet as soon as possible -- while still keeping her eating. I am following Dr. Lisa's suggestion to use Evo low carb as a transition step (from Hills dry to Evo dry to all wet). Initially, Ninja would not go near her bowl if even one piece of Evo kibble was mixed in but is now tolerating about 50/50 mix. I continue to push her one-kibble-at-a-time, one day at a time. It's a balancing act for now. Quite a few folks on this site have recommended cold-turkey approach to switching to wet, and if Ninja doesn't eat for a day or so that that is to be expected. But both the vet and I are seriously concerned with Ninja's weight loss at this point; and her unwillingness to eat any other food her entire life (absolutely no interest in people food, chicken, tuna flakes, parmesan cheese, treats of any kind....NOTHING but Hills Science dry original formula); so for now, we both think it makes sense to transition her gradually, understanding that her BG will be impacted in the meantime. My thought was that, as her weight starts improving, maybe I can be more aggressive in the transition to wet. Does that make sense? I do understand that as we go down on the carbs we have to also watch Ninja's insulin dosage for possible reduction.

I totally agree with you that testing before giving shots is critical. The testing has been the hardest part for me to master and has not been without a lot of tears -- both mine and Ninjas. My vet said to do the best I could and keep working at it; and since Ninja's numbers were running so high (400's and 500's) all month that her danger of going hypo was less (though still a possibility). Initially, Ninja would run away and hide from me when I was trying to test her...then we went to the burrito technique, from which she routinely escaped...and then I would try to sneak up on her while she was sleeping -- which typically worked for me, and why I was more successful getting mid cycle readings than pre-shots. But the good news is... within the last few days, Ninja has (more or less) accepted the testing without putting up too much of a fight. As you can see, I have been getting more numbers from her in recent days. So I think that moving forward, I can do a lot better job of this. Thank goodness...because I am in my late 50's, and chasing Ninja around the house is truly stressful for both her and me. She is a LOT faster than I am. LOL!!

I told a friend earlier today (in jest) that I hope I am not banned from the FDMB site for being so slow. Honestly, this is one reason I have been reluctant to post my spreadsheet (as it illustrates my ineffectiveness with this). So I sincerely thank you all for putting up with me, my questions, frequent "panic mode," and slowness getting up to speed. I truly am trying my hardest -- which my vet says is more than a lot of people with diabetic pets are willing to do -- so that gives me some comfort.

Anyway...sincere thanks your your guidance! Any and all advice is welcomed and appreciated.


Sienne and Gabby said:
Thanks for putting together a spreadsheet!

I think the other confound here is that you are transitioning food. The lower the carbs in the food, the less insulin that's needed. Could you fill us in on how and what you're feeding?

I also want to strongly encourage you to approach how you're testing a bit differently. You want to test before you give a shot. Otherwise, you have no way to know if it's safe to shoot. If you can get spot checks -- at least one during both the AM and PM cycle -- that will give you information about where the nadir is. Since Lantus dosing is based on the nadir rather than the pre-shot numbers, this is very important information.
Click to expand...
 
Melanie, I think you're doing super trying to get more BG tests in there and updating Ninja's SS and transitioning Ninja to lower carbed food.

Doing a +6 reading would be helpful every day as that could be the lowest reading (nadir) and that is the number you want to base dose increases or reductions on, not the preshot numbers. The nadir isn't always at +6, and isn't necessarily even at the same time every day for a particular kitty. But until you get comfortable testing more frequently throughout the day, a +6 would be a good time to test.

I am in my late 50's, and chasing Ninja around the house is truly stressful for both her and me. She is a LOT faster than I am. LOL!!
Click to expand...

Do I ever understand this! I'm 55, and the lower Pumbaa's numbers go, the more I have to chase him around the house. I try to look at it as getting a cardio/vascular workout without having to join a gym. Hahahahaha!

Suze
 
Thanks for the encouragement Suze! Love the comment about the cardio. LOL! That's a great way to look at it. LOL!!

Pumbaa said:
Melanie, I think you're doing super trying to get more BG tests in there and updating Ninja's SS and transitioning Ninja to lower carbed food.

Doing a +6 reading would be helpful every day as that could be the lowest reading (nadir) and that is the number you want to base dose increases or reductions on, not the preshot numbers. The nadir isn't always at +6, and isn't necessarily even at the same time every day for a particular kitty. But until you get comfortable testing more frequently throughout the day, a +6 would be a good time to test.

I am in my late 50's, and chasing Ninja around the house is truly stressful for both her and me. She is a LOT faster than I am. LOL!!
Click to expand...

Do I ever understand this! I'm 55, and the lower Pumbaa's numbers go, the more I have to chase him around the house. I try to look at it as getting a cardio/vascular workout without having to join a gym. Hahahahaha!

Suze
Click to expand...
 
MelanieP and Ninja said:
Thanks for the encouragement Suze! Love the comment about the cardio. LOL! That's a great way to look at it. LOL!!
Click to expand...

Glad you enjoyed it! When life hands you lemons, you are better off making lemonade out of them, or tucking them in your bra. Either way works! *LOL*

Suze
 
Thanks Suze.....just spit coffee! :lol: :lol: :lol:
Carl
 
You all gave me a huge laugh this morning...guess lots of us 'old people' get to chase our extra sweet kitties at times. KT doesn't run away but he keeps walking...and walking...and walking...about 5 steps ahead of me. I speed up, he speeds up, he just grins over his shoulder while I call him some of his 'pet' names....{{insert innocent look here}}.... :roll:

Don't worry about thinking you 'slow' - everyone has to begin learning this dance, sometimes the steps take a bit longer to learn than others....I'm STILL learning things even tho' we've been doing this dance for over a year!

BIG HUG!!!
 
Thanks everyone for the advice and the laughs. Don't know which I needed more. LOL! Ninja's numbers are moving around quite a bit since I switched out her Lantus vial and increased her dosage. For the last month, her numbers have been stalled in the danger zone - so I am glad to see movement. But I feel a little bit like an inexperienced race car driver --working for over a month to start a Formula 1 Ferrari that was stalled; then suddenly the engine catches and the car lurches forward at 100 miles an hour -- with me trying to hold on and steer, while simultaneously reading the owners manual. LOL!!! But I am far less panic stricken today than Wednesday -- all seems to be going well --so thanks all for the seasoned advice and the smiles. I am sure you will hear from me in the future (unfortunately...LOL!) when Ninja does something slightly abnormal and I panic again. Off to buy some lemons. :)
 
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