Jenks HYPO'd today. Need guidance, esp. on dosing

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AZJenks

AZJenks

Member Since 2014
As an initial matter, I admit that we've been ignorantly and naively and incorrectly dosing Jenks for weeks now under a theory that he needed less during the day than he did at night. In this post for help on the main board, it was pointed out that depot shedding was the most likely culprit of his sky-high nighttime numbers, and that it was essential to proper regulation that both the AM and PM dose be equal.

So we took the plunge, purchased syringes, and settled on 2.5U (which is a little more than the usual AM dose and a little less than the PM dose). The difference of equal dosing made itself readily apparent.

That is, until today. His +6 over the last two days was 91 and 149. Today, it was a 34. I can account for no difference over the last three days. Same insulin. Same doses. Same times. Even the same food and feeding schedule. I'm sure there are people ready with "I told you so's" because we haven't been testing AMPS, and I'm not proud of it, but I accept that this is my fault.

Despite being totally asymptomatic, we were prepared with our hypo toolbox and gave him corn syrup, followed by HC gravy, and his favorite treats. He quickly rebounded to about 60 and then into the 100s and has been monitored ever since.

Questions:

How do I adjust the dosing? His PM test comes up in 2 hours. I'm used to him being in the 300s or above. What do I do if it's in the 100s? The sticky post on handling low numbers deals with pre-shot numbers like 50s, but doesn't seem to contain any info on what to do when they're elevated but still lower than usual. Is there some sort of sliding scale to decrease it according to the pre-shot BG levels?

If I can't get his other human on board with AM blood testing, I'm just going to have to find some way to do it myself, even if it means getting fired.

Do I reduce the dose? By how much? For how long?

What else do I need to be doing?
 
everyone is ignorant at the beginning and nearly all of us shot blind for a period of time. there's no blame - so no worries.

i'm looking at his ss, will read the earlier thread, and will be back in a few minutes to give you a hand.
 
Welcome to LantusLand! You're in the right place to get help with treating feline diabetes and Jenks is a super lucky kitty to have you for his bean. :-D :-D Give yourself a big pat on the back for taking this on, it's really hard but so worth it. Julie will give you some excellent advice on how to proceed but I can tell you that the dose will be reduced tonight, having gotten that 34 today. And great job on handling that! Awesome!
Liz
 
i'm reading your other thread and going to comment on a few things

- he's a big boy - i'm seeing 20lbs on the spreadsheet. unless he's gigantic long and big-framed, that's probably too much. i saw you mention that he'd lost 1/3 of his weight and so you were free-feeding him to help him regain it. while it's very important for cats not to lose weight quickly, it's also important to know that fat is the enemy of diabetes. so i'd stop letting him eat as much as he wants and help his weight flatten out, and VERY SLOWLY reduce.

- yes, dose the same AM/PM.

- getting that morning preshot blood sugar is essential for keeping Jenks safe. There are times when it may be better to reduce his dose or skip in order to keep him safe. Someone suggested on your earlier thread to move the shot time so you can shoot when you're home - that's a great idea. Perhaps you can get your significant other to get involved one step at a time - can they learn just to test and not shoot? the testing is really important, as you saw today.

- regarding chasing the nadir (low point) of a cycle. What we encourage is to get tests at a variety of times. you don't have to try to get the nadir every cycle, but get a +2 sometimes, another cycle get a +4, another one get a +6, for example. I like to use the metaphor of a jigsaw puzzle. when you only have the corner or edge pieces you really can't tell what the picture is. what you have is stripes down the middle. When the tests are all over the place, the picture emerges to us. Then we can help better.

- 34 is a low number, but it's not hypoglycemic unless you saw hypo symptoms. we differentiate between those two. we often see low numbers and we give carbs to bring them up. It's not dangerous unless no one is monitoring.

I don't think your dose is too far off. We adjust doses every 6-10 cycles to try to keep our cats tightly regulated between 50-120, the numbers of a non-diabetic cat, because that gives a cat the best chance to have their pancreas heal and to possibly go off of insulin. Even if a cat doesn't go off, keeping in that range keeps a diabetic cat as healthy as possible and prevents the damage of diabetes.

I would just reduce by 0.25u, to a new dose of 2.25u per shot.

what other questions do you have? we're happy to help - we all remember what it was like to arrive here not knowing how to help our beloved cats. everyone here is a volunteer, but we understand diabetic cats.
 
Here's a great post about Feed Kitty as Much as They Want?

Here's the reference that i'm using in suggesting you reduce the dose by 0.25u:

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. See additional notes in the next paragraph about drops into the 20s and 30s. 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.

Please do not let yourself become complacent or blasé about drops into the 20s or 30s.
If kitty drops into the 20s, a full reduction of 0.25u (or 0.5u if kitty is on a higher dose) is strongly recommended.
If your cat drops into the 30s, a full reduction of 0.25u is recommended. There are very few exceptions given for caregivers who have collected years of data and KNOW their cat's response to the combination of insulin and food backwards, forwards, and inside out.
Click to expand...
 
i want to ask you to clarify - did you see any hypo symptoms? because if so, a cat can become more sensitive to insulin and we might want to reduce more than 0.25u.

eta - i'm rereading your first post and seeing that you didn't have any hypo symptoms. if i've got that right, then i think the 0.25u reduction is ok.
 
I hope it's ok to address all questions in one post. Here we go:

julie & punkin (ga) said:
- he's a big boy - i'm seeing 20lbs on the spreadsheet. unless he's gigantic long and big-framed, that's probably too much. i saw you mention that he'd lost 1/3 of his weight and so you were free-feeding him to help him regain it. while it's very important for cats not to lose weight quickly, it's also important to know that fat is the enemy of diabetes. so i'd stop letting him eat as much as he wants and help his weight flatten out, and VERY SLOWLY reduce.
Click to expand...

He is, in fact, a large built cat. At 20 pounds, his back bone and ribs are easily palpable, and his body has digested his post-neuter pooch. Perhaps I needed to clarify the spreadsheet regarding his feeding. He is not free fed. He has been on an all wet food diet since February. He eats four times daily to maintain weight and minimize begging for treats. He eats at AMPS, +6, PMPS, and +6. Typically he eats 1/3 to 1/2 of a 5.5oz Friskies can.


julie & punkin (ga) said:
- getting that morning preshot blood sugar is essential for keeping Jenks safe. There are times when it may be better to reduce his dose or skip in order to keep him safe. Someone suggested on your earlier thread to move the shot time so you can shoot when you're home - that's a great idea. Perhaps you can get your significant other to get involved one step at a time - can they learn just to test and not shoot? the testing is really important, as you saw today.,
Click to expand...

Other human has just come on board and expressed interest in learning how to test blood.

julie & punkin (ga) said:
- regarding chasing the nadir (low point) of a cycle. What we encourage is to get tests at a variety of times. you don't have to try to get the nadir every cycle, but get a +2 sometimes, another cycle get a +4, another one get a +6, for example. I like to use the metaphor of a jigsaw puzzle. when you only have the corner or edge pieces you really can't tell what the picture is. what you have is stripes down the middle. When the tests are all over the place, the picture emerges to us. Then we can help better.
Click to expand...

Ok, I'll have to start additional testing to fill in those gaps. Will the information still be useful if the dose is changing while attempting to piece together the whole picture?

julie & punkin (ga) said:
- 34 is a low number, but it's not hypoglycemic unless you saw hypo symptoms. we differentiate between those two. we often see low numbers and we give carbs to bring them up. It's not dangerous unless no one is monitoring.
Click to expand...

There were no symptoms as I understand them. He was alert, mobile, coordinated, and not begging for food.

julie & punkin (ga) said:
I would just reduce by 0.25u, to a new dose of 2.25u per shot.
Click to expand...

So noted. I'll most likely be back at around 9PST with his preshot number to confirm.

Anne & Zener said:
I am wondering what you feed him, when and how much?
Click to expand...

Hi Liz! He gets Friskies pate wet food exclusively. Currently, we're only feeding Turkey & Giblets. To maintain his weight and minimize begging for treats, we feed 4x daily - at 9am (AMPS), 3pm, 9pm (PMPS), and 3am. He'll eat anywhere from 1/3 to 1/2 of a 5.5oz can at each feeding.
 
Excellent on all counts! Human testing in the morning, wet food, and no hypo symptoms. :-D I don't think Julie was suggesting more testing (although we are hardly ever against that :lol: :lol: ) except for the AM preshot, but just to test at different times in different cycles, rather than always at +6.
Liz
 
Liz is right, although we never say "stop it!" when someone wants to test more! :lol:

just move the test times around so over time there are fewer large white chunks on the spreadsheet.

it's totally ok to answer everything in one post and you don't have to quote unless you want to.

ok on the weight, just keep him stable. some kitties are big. i had a 24lbs boy, but he was the poster cat for being overweight. poor little guy spent his last couple of years getting 1/8 cup of dry food twice a day and always seeming hungry but barely losing any weight. wish i'd known then about the canned food!

most of our cats do well with a majority of the food before mid-cycle. The Lantus is strongest in the first half of the cycle, and feeding after that time can kinda put the brakes on the lantus, causing higher preshot numbers. i fed punkin 1 can of Fancy Feast at preshot and 1/2 can at +3 in both cycles. after that it was just plain boiled chicken breast treats after poking him. he got used to the schedule before too long and as long as we didn't change the Feed Me Contract, it was ok. You might want to try to move that +6 food a couple of hours earlier.
 
PMPS was 237.

I tried my best to give 2.25U, but with these Relion syringes and their sticky plungers it's entirely likely it could've ended up closer to 2U.

Any tips on how to achieve such a fine dosing with these syringes? I've incorporated all the tips that I've read, including:

* working the plunger back and forth before filling in order to evenly distribute lubricant
* using a twisting motion rather than a pushing motion to try to eject bubbles and/or insulin to get to your desired dose (that worked on one syringe so far, the rest seem to resist it)
 
some syringes are just stickier than others. there's not really any way to make it move more smoothly - that's just how that brand moves. i really liked the Terumo Thinpro - they have a plunger that really glides easily. some people think they are too easily moved. Just depends on what you like. http://www.americandiabeteswholesale.com/product/terumo-thinpro-insulin-syringe_5891.htm

did you watch the video on how to draw up your insulin? If not, it's worth watching. You want it to last as long as possible. scroll down about 1/2 way. http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=151
 
It's not so important that you're at exactly 2.25, but that whatever YOU decide 2.25 is, that it remains consistent. Many of us use an old syringe and draw up colored water, tea, coffee until we have what we feel is close to the correct dose we're hoping for and then when we draw up the insulin, compare to that one syringe and keep the dose as consistent as possible

If the rubber plunger was just a hair above the 2 unit line, that's probably about 2.25. If it's totally even with the line, it's 2 units. Here are some pictures for you to compare to (they don't go up to 2.25, but they do show what .25 looks like as well as .75....the two doses that are hardest to measure) Fine Dosing Pictures

On testing....One of my favorite tests is the +2 (both AM and PM) I call it my "crystal ball test" since if the +2 is lower than the pre-shot test, it's a good bet that you're going to need to get more tests in if at all possible because they may drop too low. If you just can't get later tests in, leave food down if that +2 is lower than the Pre-shot test. I finally had to change our shooting schedule to 6am/6pm (and I HATE mornings) but that way I could get China tested, fed and shot within 5-10 minutes and sneak back to sleep (if I didn't have to go anywhere). Then at 8am, I'd get that +2 which, if it was lower than the pre-shot, meant I either needed to make arrangements to get more tests in later in the cycle, or I needed to make sure I left food down for China to eat. When our sugarcats BG goes too low, they usually go looking for food, just like when a human diabetic's BG is going to low...they go looking for a Coke and a candybar!!

My 6/6 shot schedule also allows me to get a +6 at night (midnight) since I'm usually up that late anyway, so you just need to discuss with your other and find a schedule that will work best for both you and Jenks! If you decide to change your scheduled shot times, you can adjust in 15 minute per cycle increments. You don't want to just go (for example) from shooting at 9/9 and one day change to 6/6

Keep asking questions! The people here are very generous with their time and WE WANT TO HELP!!

Edited to add...Marje has put together some information on Dosing with Calipers that many of us use
 
That 600 # could be some dried food that perhaps he got into? Some cats are very carb sensitive, and perhaps Jenks may be one of them. If you're still giving him treats, or dried food, it's best to get him off it as the dried food will stay in his system longer, and will turn into sugar, which will make him stay high. Instead of treats, give him brushing, or play with him as a reward. Mine never gets treats because I know how carb sensitive she is. She only gets brushing, and tons of love, and hugs. :-D

Hoping that his #s come down for you today. Hang in there. It WILL happen. :-D
 
The zoom into high numbers is what we call a "bounce." In this case, because Jenks went so low (i.e., into the 30s), his body overreacted. When this happens, the liver and pancreas release a stored form of glucose along with counterregulatory hormones. These cause a spike in BG numbers. It can take up to 72 hours for a bounce to clear. While these bounces are annoying, they are normal and a protective mechanism.
 
When does a bounce typically happen in relation to a low reading? This didn't seem to happen until 9-12 hours after we monitored his low blood sugar event. He was in the 200s at PMSP, and then 586 three hours later.

Curiously, it appeared resolved itself over the course of the next 6 hours and came down into the 200s by AMPS. That's a 700-point swing in a 12-hour period. Weird.
 
If you look at yesterday's 34, you see a straight line progression up - to 58, 133, 237, 586 and then culminating with the HI. As Sienne said, he reacted to the 34. Nearly all cats do this. His body isn't used to being that low. The good news is that he "cleared" the bounce very quickly. We can see it cleared with that nice blue 140 you got this morning. That tells us that he's been spending some time in the lower numbers. If he hadn't, he might have stayed in HI for as many as 3 days.

you've done a super job getting tests since yesterday. can you see why they are so helpful in knowing what happened after the 34? The blood sugar numbers tell us exactly what's going on.

the large swing in blood sugar numbers is typical, but our goal is to get a cat in numbers under 120, where the blood sugar numbers then become more "flat" instead of zig-zag all over the place. cats feel better and that allows their pancreas to heal.

great job!

just stay with this dose for 6 cycles (shots) and then we can re-evaluate. unless he goes below 50, then we'll decrease the dose.
 
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