Interpretation of SS and dosing advice needed

[KSAkitties]

Hello,

I need some help interpreting Major's SS and dosing advice.

I started slowly reducing Major’s insulin from 0.75u to 0.5u for the past week. I held 0.6u for a week then started 0.5u (fat) last night.
In the last few days (except today), Major’s +4 reading dropped to the 40’s (as low as 40 on 21 Oct) at 0.6u of Levemir. Yesterday, his BG dropped sharply from 134 mmol/dL @ AMPS to 46 @+4 then again from 129 mmol/dL @ PMPS to 48 @+4. However, his pre-shot values seem to be higher than normal. Is this because Major’s BG dropped too fast and too much so we are seeing a bit of rebound on his pre-shot numbers?

I don’t know why his BG dropped so much so fast on Levemir. What does this mean? Dose this sometimes happen to kitties on Levemir? Am I doing the right thing to reduce his insulin to 0.5u now even though his pre-shot BG is actually slightly higher than his pre-shot values in the past?

My current plan is to hold Major’s dose at 0.5u for another week and see how he does. Does this sound right?

Any advice is much appreciated.

 

[Blue]

Hello,

I need some help interpreting Major's SS and dosing advice.

I started slowly reducing Major’s insulin from 0.75u to 0.5u for the past week. I held 0.6u for a week then started 0.5u (fat) last night.
In the last few days (except today), Major’s +4 reading dropped to the 40’s (as low as 40 on 21 Oct) at 0.6u of Levemir. Yesterday, his BG dropped sharply from 134 mmol/dL @ AMPS to 46 @+4 then again from 129 mmol/dL @ PMPS to 48 @+4. However, his pre-shot vales seem to be higher than normal. Is this because Major’s BG dropped too fast and too much so we are seeing a bit of rebound on his pre-shot numbers?

I don’t know why his BG dropped so much so fast on Levemir. What does this mean? Dose this sometimes happen to kitties on Levemir? Am I doing the right thing to reduce his insulin to 0.5u now even though his pre-shot BG is actually slightly higher than his pre-shot values in the past?

My current plan is to hold Major’s dose at 0.5u for another week and see how he does. Does this sound right?

Any advice is much appreciated.

I replied the below in your post on the health forum>.

I think you need to remind yourself that there is that shed in place with Lev.
When you gave .6u at pmps and you got a 40 for the +4, the next morn you gave .6u again and got the 48 for +4.
It's good that you reduced the dose 10/22 at pmps BUT there's still the shed there, so you will not see the effects of your decrease until the following shot..... the shed needs to drain that extra .1 of Lev.
Notice you got a more flat cycle the next morn.

Now, you may find that the decrease was needed just to drain the extra and you may need to go back up, but wait and see how it goes for the next couple cycles. NDW always causes ripples, so you need to give any dose change a cycle or two to settle.... you increase, expect higher numbers as the shed is topped up.... you decrease, expect a delay in the higher numbers as the shed drains.

As for holding the dose for another week, you can't really plan for the same dose for a length of time as the needs may change. If you find that in another 4 cycles, you are getting a lower curve, then you should reduce sooner.
Dosing is based on the lowest BG in a cycle, so get some tests in around nadir and base your dosing on those numbers.
"General" Guidelines:
--- Hold the initial starting dose for 5 - 7 days (10 - 14 cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 cycles).
--- Each subsequent dose is held for a minimum of 3 days (6 cycles) unless kitty earns a reduction (See: Reducing the dose...).
--- Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.

Increasing the dose...
--- Hold the dose for 3 - 5 days (6 - 10 cycles) if nadirs are less than 200 before increasing the dose.
--- After 3 consecutive days (6 cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
--- After 3 consecutive days (6 cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

Reducing the dose...
--- If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further.

--- If an attempted reduction fails, go right back up to the last good dose.
--- Try to go from 0.25u to 0.1u before stopping insulin completely.

Random Notes...
Because of the cumulative nature of Lantus and Levemir:
An early shot = a dose increase.
A late shot = a dose reduction.

A "cycle" refers to the period of time between shots. There are 2 cycles in one day when shooting twice a day.

Sometimes a dose will need to be "fine tuned" by adding some "fat" or "skinny-ing up" the dose.

 

[Vicky & Gandalf (GA) & Murrlin]

I agree with what Gayle said.

It can be a little more difficult at such small doses. Please keep the percentage decrease in mind, which it sounds like you are since you decreased slowly form .75U to .5U. Good job.

 

[KSAkitties]

Gayle & Vicky,

Thank you very much for your replies.

As for holding the dose for another week, you can't really plan for the same dose for a length of time as the needs may change. If you find that in another 4 cycles, you are getting a lower curve, then you should reduce sooner.

OK. Thanks.

Sometimes a dose will need to be "fine tuned" by adding some "fat" or "skinny-ing up" the dose.

I am having a real hard time doing fat or skinny with such a small quantity. I've got a micrometer as recommended by Vicky, I have practiced the drop mathod, I have looked at the images prepared by Steve & Jock .......but still sometimes I do wonder whether my 0.6u is actually fat 0.5u or my 0.75u is actually 0.8u. What's the best way to do this kind of micro-dosing?

 

[Blue]

All I can say is practice practice practice. Get the drop thing down so you know how many drops you get from a .5u dose... It would be nice to be able to get 5 drops, but when I tried, all I end up with is 4.

I have a magnifier that clamps onto a shelf to help me with measuring doses. We can never be precise, but we can get fairly close, so just do your best with the drops.
There is no way I could measure the diff between .75 and .8...

 

[Lana & Yoyo]

I also bought a caliper but I have never found a helpful way to use it. It is languishing in the closet so if you find an effective way to use it, please let me know.

I bought a lighted SE 5X Magnifier Lamp from HobbyLobby sold through Amazon. It has been truly a life and eye saver. Be aware there are a number of products on Amazon called SE 5X Magnifying Lamps, but many of them are very shoddy. I paid about $23 for the one I bought. It is solidly built and has a glass lens that is about 3.25 inches in diameter. Some of them have plastic lens. The entire lens is 5X magnification -- some of the lens being sold are 2X magnification with a 1" "sweet spot" with a 5X or 10X magnification.

I had some trouble even with the lighted magnifier lamp until Vicky told me I needed a light source behind my syringe as well. So, with 5X magnification and a light in the magnifier lamp, and another lamp behind my syringe, I am quite comfortable measuring routine doses.

For those doses where there is no frame of reference on the syringe, like 0.8 or 0.3, I have never really become comfortable with them. But what I did was get a used syringe and a glass of water. I filled the syringe, twisted the plunger (you have to twist, not push) until I could twist off 5 drop and be down 1/2 unit on the syringe (each drop is 0.1 unit). I did it everyday for two weeks, whether I was shooting fractional doses or not.

Lana

 

[Sheila & Beau GA & Jeddie GA]

One thing about small doses (actual dose as well as small changes) is to be consistent. It doesn't take much to make a .1u change -the drop is the size of the head of a straight pin - very tiny. Just note where the stopper is sitting in relationship to the lines, and draw the same dose each time (or make it more or less if you are changing the dose). It actually doesn't matter that you are drawing a "true" .6u as long as it is more than .5u and less that .75u - or what you think those two doses are. Does any of that make sense?

Also, double check where the stopper is at zero before you draw the dose. Often there is space there above the zero line that you need to be aware of. It can be .1u or even as much as .25u if the syringe is misprinted. It can also be a negative amount where the line actually overlaps the end of barrel and the stopper can't go all the way to zero. I ALWAYS check that before I draw each dose.

 

[KSAkitties]

All I can say is practice practice practice. Get the drop thing down so you know how many drops you get from a .5u dose... It would be nice to be able to get 5 drops, but when I tried, all I end up with is 4.

I have a magnifier that clamps onto a shelf to help me with measuring doses. We can never be precise, but we can get fairly close, so just do your best with the drops.
There is no way I could measure the diff between .75 and .8...

Hi Galye,

Same here. I can't quite CONSISENTLY get 5 drops from a 0.5u dose yet. I will keep practicing and practicing. I am currently using a handheld magnifiying glass with light (for map reading) to help me but the magnification and lighting is not strong enough for what I am diong. I just ordered a handsfree magnifying glass with light (the one you wear it on your head). I hope it will help me.

 

[KSAkitties]

I also bought a caliper but I have never found a helpful way to use it. It is languishing in the closet so if you find an effective way to use it, please let me know.

I have tried the digital micrometer but it hasn't worked out for me either.

I bought a lighted SE 5X Magnifier Lamp from HobbyLobby sold through Amazon. It has been truly a life and eye saver. Be aware there are a number of products on Amazon called SE 5X Magnifying Lamps, but many of them are very shoddy. I paid about $23 for the one I bought.

Is your SE5X Magnifier Lamp like this? I will order one but wanted to make sure I am getting the right one.
http://shop.hobbylobby.com/products/daylight-magnifier-lamp-with-clip-on-318428/

I had some trouble even with the lighted magnifier lamp until Vicky told me I needed a light source behind my syringe as well. So, with 5X magnification and a light in the magnifier lamp, and another lamp behind my syringe, I am quite comfortable measuring routine doses.

Another lamp behind my syringe? What kind? So, we need two light sorces, one with magnifcation from the top and a second one from behind the syringe?

I just ordered a head magnifier with light. I hope this will help. God knows what my neighbours must think I am doing, especially in this part of the world – head magnifier, syringe, vial (insulin)……….

This the head magnifier with light which I just ordered but have no idea how good it is:
http://www.seeitbigger.com/Konus_VueMax_Pro_Head_Magnifier_with_Light_p/kon-3805.htm

I filled the syringe, twisted the plunger (you have to twist, not push) until I could twist off 5 drop and be down 1/2 unit on the syringe (each drop is 0.1 unit). I did it everyday for two weeks, whether I was shooting fractional doses or not.

I am still working on getting the drop method right. I still can’t quite get 5 drops for a 0.5u dose consistently. I am practicing twisting the plunger everyday now.

 

[KSAkitties]

One thing about small doses (actual dose as well as small changes) is to be consistent. It doesn't take much to make a .1u change -the drop is the size of the head of a straight pin - very tiny. Just note where the stopper is sitting in relationship to the lines, and draw the same dose each time (or make it more or less if you are changing the dose). It actually doesn't matter that you are drawing a "true" .6u as long as it is more than .5u and less that .75u - or what you think those two doses are. Does any of that make sense?

Thanks, Sheila. I think you posted a thread on micro dosing before - the drop method with some images. I posted on my fridge door, and that's what I have been following. My 0.6u is just a hairline below the 0.5u marking. and that was the best I could do.

Also, double check where the stopper is at zero before you draw the dose. Often there is space there above the zero line that you need to be aware of. It can be .1u or even as much as .25u if the syringe is misprinted. It can also be a negative amount where the line actually overlaps the end of barrel and the stopper can't go all the way to zero. I ALWAYS check that before I draw each dose.

Thanks you. That's a very good adivce. I am using BD syringes. I haven't checked the accuracy of the zero line. Will check from now on. My current problem is the air bubble in the syringe. I wasted three syringes this morning because I couldn't get the bubbles out, and I wasn't sure whether I could re-insert the un-used syringe back in the insulin pen to re-draw the dose after I had emptied the syringe after my failed attempt to get the air bubble out.

 

[Sheila & Beau GA & Jeddie GA]

LOL, in Saudi Arabia you might be taken for a mad scientist with all that gear on your head! But probably they would think the same in the middle of Chicago - so draw your curtains before donning your headgear!

The second light, from behind your syringe, just helps to illuminate where the inside edges of the barrel are. I hold my syringe up to the kitchen lights or a window - whatever gives me light through the syringe.

I have heard that BD syringes are bad for bubbles. When I get a bubble on my syringes (not BD) I draw down the stopper a bit and wait for the insulin to pull down, then I slowly twist the barrel back up - this is all with the needle still in the insulin cartridge. If I have bubbles after I withdraw the syringe, I do the same steps, something adding a gentle flick with my finger on the syringe before I twist the barrel back up. I did learn to compensate for the bubbles. I think they are usually about .025u or so. At a .6u dose one bubble might not make too much difference (you would have about .575u) . Maybe note it in the SS so you can track the numbers and see if there is any difference over time.

I don't like to stick the needle back into the vial/cart as a general rule. The most that it risks is causing the insulin to loose potency sooner than it would have.

 

[KSAkitties]

LOL, in Saudi Arabia you might be taken for a mad scientist with all that gear on your head! But probably they would think the same in the middle of Chicago - so draw your curtains before donning your headgear!

Curtains definitely down! I have some very nosy and suspicious neighbours.

I draw down the stopper a bit and wait for the insulin to pull down, then I slowly twist the barrel back up - this is all with the needle still in the insulin cartridge.

Thanks. This is a very useful tip. I followed your suggestion this morning, and it worked.

I did learn to compensate for the bubbles. I think they are usually about .025u or so. At a .6u dose one bubble might not make too much difference (you would have about .575u) . Maybe note it in the SS so you can track the numbers and see if there is any difference over time.

This is good to know. I didn't think of compensating for the bubble. 0.025u is about 4% of 0.6u so it's not too much.

I don't like to stick the needle back into the vial/cart as a general rule. The most that it risks is causing the insulin to loose potency sooner than it would have.

I am glad that I now have learned a new way to avoid having bubbles in the syringes. I have wasted too many syringes :sad:

 

[Sheila & Beau GA & Jeddie GA]

Glad that tip was helpful. I hate wasting syringes (and insulin) as well. The darn things aren't cheap.

What is the time difference between S.A. and central U.S.? I noticed that your posts are "in the middle of the night" for me. Your last post was at 2:49 am my time.

 

[KSAkitties]

Glad that tip was helpful. I hate wasting syringes (and insulin) as well. The darn things aren't cheap.

I know, especially we can't get this type of insulin syringes here (0.3ml with half markings). I get very worried and stressed thinking about what if I can no longer get my supply one of these days. I now get them whenever I travel abroad or when DH goes on business trips to the 'outside world'.

What is the time difference between S.A. and central U.S.? I noticed that your posts are "in the middle of the night" for me. Your last post was at 2:49 am my time.

Hello Sheila,

We are currently 7 hours ahead of EST; therefore, I think we are 8 hours ahead of central US. There is no daylight saving
here so soon it will be 9 hours of difference. You are in IL, right? It's been almost twenty years since I visited Illinois. Going to Chicago was a such special treat for me when I was an undergrad at Purdue, West Lafayette, IN. I have such fond memories of my student years in the midwest.