? Lantus Questions

[Melisa]

Pekoe has been on Lantus for 4 years now, since his diagnosis. Just over a year ago we switched him to once daily (in the am) as during his curves his 12 hour post injection reading was low. Most recently he had been on 3 units in the am only. On June 30th around 11pm he started to show signs of hypoglycemia, after feeding and applying syrup to his gums his sugar came back up. We did not give insulin the following day (his BG was 18mmol in the morning) and the day after (July 2nd) decreased his dose to 2 units and did a curve that day. Two hours before his last reading his sugar was going really low again so I stopped the curve and fed him early. Yesterday I started over on 1 unit and curved him again. I'm just not sure what to do next? Any experience/advice/insight would be greatly appreciated! Thank you!

 

[Sybil and Zoe]

Pekoe has been on Lantus for 4 years now, since his diagnosis. Just over a year ago we switched him to once daily (in the am) as during his curves his 12 hour post injection reading was low. Most recently he had been on 3 units in the am only. On June 30th around 11pm he started to show signs of hypoglycemia, after feeding and applying syrup to his gums his sugar came back up. We did not give insulin the following day (his BG was 18mmol in the morning) and the day after (July 2nd) decreased his dose to 2 units and did a curve that day. Two hours before his last reading his sugar was going really low again so I stopped the curve and fed him early. Yesterday I started over on 1 unit and curved him again. All of his curves are in his spreadsheet (I only have as far as a year ago because that's when I started using an app to track his BGC). I'm just not sure what to do next? Any experience/advice/insight would be greatly appreciated! Thank you!

Try adding ? or 911 to your header to get more attention for a question you need answered. It feels weird putting 911 in but it grabs attention if you need something right away, and can be removed from the header after you get some help.I would love to give advice but am far from qualified at this point. I am perplexed by the daily use of Lantus even though that was the way it was designed for humans most cats require 2x day dosing. You can tag some of the more experienced members by adding @before their names. Sienne and Gabby (GA), Wendy&Neko, Marje and Gracie, to name a few are very experienced members and have helped me a lot. You might want to try and flip your spread sheet to the most recent BG at the bottom instead of top as that is how most all of our sheets are easily read. Good luck!

 

[Melisa]

Thank you!

 

[Red & Rover (GA)]

Hi Melisa,
Waving to you from the Kawarthas. Hope you are managing to stay cool. With it being a holiday in the US, the board is fairly quiet today.

More experienced eyes than mine will come along before too long.

 

[Melisa]

Hi Melisa,
Waving to you from the Kawarthas. Hope you are managing to stay cool. With it being a holiday in the US, the board is fairly quiet today.

More experienced eyes than mine will come along before too long.

Hello! It sure is a hot one! Thank you

 

[Sienne and Gabby (GA)]

Hi, Melisa.

Sorry if people aren't responding to your post quickly. I suspect traffic is a bit slow due to the July 4th holiday.

A question -- are you still feeding Pekoe W/D dry? W/D dry is crazy high in carbohydrates.

To be honest, the only number I see that is "low" on Pekoe's spreadsheet is the 49 on 6/24/2018. The other numbers are not especially low if you are familiar with the Tight Regulation Protocol. Even with the Start Low Go Slow approach, dose reductions occur only if numbers are below 90. There are sticky notes at the top of the board that describe these two approaches to dosing.

We tend to be a bit more data driven here. We encourage members to test without fail before giving insulin and to get as many tests as is feasible throughout the AM and PM cycles. If you click on the links to any of our spreadsheets you'll get a better sense of the range in frequency that people test.

What I can tell you is that Lantus does best when dosed twice a day. Even for some humans, it needs to be dosed twice a day and a cat's metabolism is faster than a humans. Part of why you're seeing appreciably higher AM numbers is that with the once a day dosing, you're not getting sufficient duration for the insulin to carry Pekoe through a full 24 hours. Further, once a day dosing defeats the purpose of using a depot type of insulin such as Lantus. You need a "stockpile" of insulin in order to get duration and a flat curve.

A better strategy than once a day dosing would have been to cut the dose in half and give a shot twice a day. However, without more data, there's really no way to have a clear idea what's happening with Pekoe's numbers. You have two days of data from this month and then the last test is from February. There are a lot of unknowns that can happen in 5 months.

I think we would be better able to lend a hand if you could accumulate more test data -- testing daily at AMPS and PMPS and at least one additional test during each cycle. I'd strongly recommend a before bed test every night. Many cats drop into lower numbers during the PM cycle and with no evening tests, you're missing over half of your data. Would this be possible for you?

 

[Melisa]

Hi, Melisa.

Sorry if people aren't responding to your post quickly. I suspect traffic is a bit slow due to the July 4th holiday.

A question -- are you still feeding Pekoe W/D dry? W/D dry is crazy high in carbohydrates.

To be honest, the only number I see that is "low" on Pekoe's spreadsheet is the 49 on 6/24/2018. The other numbers are not especially low if you are familiar with the Tight Regulation Protocol. Even with the Start Low Go Slow approach, dose reductions occur only if numbers are below 90. There are sticky notes at the top of the board that describe these two approaches to dosing.

We tend to be a bit more data driven here. We encourage members to test without fail before giving insulin and to get as many tests as is feasible throughout the AM and PM cycles. If you click on the links to any of our spreadsheets you'll get a better sense of the range in frequency that people test.

What I can tell you is that Lantus does best when dosed twice a day. Even for some humans, it needs to be dosed twice a day and a cat's metabolism is faster than a humans. Part of why you're seeing appreciably higher AM numbers is that with the once a day dosing, you're not getting sufficient duration for the insulin to carry Pekoe through a full 24 hours. Further, once a day dosing defeats the purpose of using a depot type of insulin such as Lantus. You need a "stockpile" of insulin in order to get duration and a flat curve.

A better strategy than once a day dosing would have been to cut the dose in half and give a shot twice a day. However, without more data, there's really no way to have a clear idea what's happening with Pekoe's numbers. You have two days of data from this month and then the last test is from February. There are a lot of unknowns that can happen in 5 months.

I think we would be better able to lend a hand if you could accumulate more test data -- testing daily at AMPS and PMPS and at least one additional test during each cycle. I'd strongly recommend a before bed test every night. Many cats drop into lower numbers during the PM cycle and with no evening tests, you're missing over half of your data. Would this be possible for you?

Hello, thank you for your response and all of the information! That is definitely something that I can do! He was living with me until a year ago when he moved two hours away with my sister (we had multiple cats when we lived together and they did not all get along so we split them up when we moved). So now I have him here with me again and am able to do a lot more testing!

I'm almost embarrassed to admit that I am a vet tech, because we really do not learn a lot about insulin or diabetes in school, I feel like I know nothing! so I really appreciate your information!

 

[AliceMeowliss (GA)]

I'm almost embarrassed to admit that I am a vet tech, because we really do not learn a lot about insulin or diabetes in school, I feel like I know nothing! so I really appreciate your information!

From what I’ve seen some people here post, many veterinarians do not grasp how to treat diabetes, so as a tech, I don’t think you need to be embarrassed at all. And the thing is that every case is a little different, so even if you learned one standard approach it still wouldn’t necessarily have applied to all diabetic cats, and I think the vets that learn only one approach and stay rigid to that are at a disadvantage in treating FD, too.
I sent my RN friend a copy of my spreadsheet yesterday. She has done trauma and hospice, caregiver for terminally ill family, etc. Her response to the SS was “that’s really complicated.”
Feline diabetes has a steep learning curve, and then when you learn one thing you’ll find more you want to know.

A good scientist asks questions and does research, so really this just means you’re a good vet tech by learning. Just saying.

I’m glad you will be able to test more! I put off really learning to do it well for longer than I wish I had, now.... And like others, I find dosing once a day strange. I have tried two different kinds of insulin, and the NPH I only achieved regulation of some degree with by dosing TID. You can do really tiny doses of Lantus if you have to, even a drop when you’re weaning off of it, and I personally at least have found I’d rather give not enough insulin in a dose than none at all, if possible, for as long as insulin is needed.

 

[Red & Rover (GA)]

There are no dry foods in Canada that are under the carb allowance for diabetic cats. Even the DM dry is considered too high. Fancy Feast pates and Friskies pates are acceptable and easy on the pocketbook. Freeze dried treats are the only ones that are low carb and are in fact, carb free.

Links to Food Charts can be found here: http://www.felinediabetes.com/FDMB/threads/links-to-food-charts.174182/
We do not have as much choice as the Americans have. Off the top of my head because it's been a few years: Fancy Feast pate only, most of the Tiki line, Friskies only, some of the Wevura.
There is a Canadian chart gives the composition of the PC Extra Meaty canned food.

I see that Pekoe is on Semintra. I tried Rover and another cat on Semintra when it was first approved in Canada. Neither of them could handle it. What stage CKD? And how are the phosphorus levels? There is a chart in the link above listing low carb /low phos foods, last updated 2017. Diabetes and CKD is a balancing act but it can be done. There are a number of people here who do. To keep the carbs low, you can either feed a low bone content raw diet or a low carb/low phos canned diet and when it becomes time to use a phosphorus binder, supplement with aluminum hydroxide powder. (The gel from the vet is manufactured for a dog's liking and is full of sugar.)


And don't be embarrassed. Think about how much more you will be able to help.

 

[Sybil and Zoe]

And don't be embarrassed. Think about how much more you will be able to help.

I agree 100%. If Melissa is still working in the field, just think what an asset to that practice you will be!!!

 

[Melisa]

Thank you all for the kind words! I have been doing a lot of reading today and I'm feeling slightly overwhelmed! (this head cold does not help!)

I've been treating his diabetes for three years (he's lived with my sister for the past year) and it's only this past year that it's gotten more difficult (it doesn't help that they live almost two hours away!) and now it makes sense that it's been about a year since we went to once daily Lantus. I also now feel like I'm completely new to everything!

@AliceMeowliss&Cassandra thank you for the information! I've learned so much today! I agree though, before I thought that "monitoring" his diabetes was doing a glucose curve every once in awhile. I'm learning lots of good things that I can hopefully help other people with!

@Red & Rover (GA) thanks! He is currently getting Friskies (all of my cats are Friskies pate addicts) but I will definitely look into the other diet as well! We started the Semintra a few years ago because he had a higher UPC, but since starting it his UPC, BUN, creatinine and phosphorus have all been normal We do full blood and urine every 6 months just to keep an eye on everything!

@Sybil and Zoe thank you

I'm collecting more data to add to my spreadsheet and he's always so good for his injections and BG checks! When we need to collect blood at the clinic, that's a different story! He's like a different cat! He actually needs to be sedated - the poor guy!

Thank you all again!

 

[Red & Rover (GA)]

Just took a look at your spreadsheet. If you did not give any insulin tonight (the spreadsheet reads 0.0), you can take a break with the testing. Pekoe is going up.

Do ask about what dose to give tomorrow morning. Take a +10 or +11 if you can and post a new thread with a question mark -A.M. dosing advice needed. Do mention if you will be home to test or have to go to work.

To get a proper pre-shot reading, there should be no food given after +10 (i.e., the two hours before shooting). The procedure is:
1. Test (to see if the number is high enough to shoot)
2. Feed (to make sure the cat will eat enough)
3. Shoot

 

[Melisa]

Just took a look at your spreadsheet. If you did not give any insulin tonight (the spreadsheet reads 0.0), you can take a break with the testing. Pekoe is going up.

Do ask about what dose to give tomorrow morning. Take a +10 or +11 if you can and post a new thread with a question mark -A.M. dosing advice needed. Do mention if you will be home to test or have to go to work.

To get a proper pre-shot reading, there should be no food given after +10 (i.e., the two hours before shooting). The procedure is:
1. Test (to see if the number is high enough to shoot)
2. Feed (to make sure the cat will eat enough)
3. Shoot

Thank you! So test one-two hours before he’s due for his next dose, post and then test again when dose is due, feed and then potentially shoot (depending on number)? Sorry, this is all so new to me! Luckily I can take him to work with me anytime so that’s no problem!

 

[Red & Rover (GA)]

Test one to two hours before his shot is due. Then post and ask for dosing advice. Because there is not a lot of data on the spreadsheet yet, most likely the dosage given will be small. Lantus dosing is not based on the preshot number. Dosing is based on how low the cat goes during a cycle and that is not known yet.

Also, it is much better to go up the dosing scale in small increments to find the correct dose than it is to go racing down the dosing scale pulling all-nighters and skipping shots.

(I've never felt comfortable giving dosage advice and leave that to the people that know far more than I do.)

If your vet/boss is feeling a bit uncomfortable about everything, the TR Lantus protocol was actually developed by two renowned vets: http://www.felinediabetes.com/FDMB/threads/tight-regulation-protocol-tr.1581/ (scroll down to the bottom for a pdf if you cannot open the link to the article).
The start low, go slow method has been developed and adapted over a period of years. It is for owners who cannot quite meet the requirements of the protocols due to work and/or cat orneriness.

I have been doing a lot of reading today and I'm feeling slightly overwhelmed!

It's a big learning curve that will soon become second nature.

 

[Melisa]

Test one to two hours before his shot is due. Then post and ask for dosing advice. Because there is not a lot of data on the spreadsheet yet, most likely the dosage given will be small. Lantus dosing is not based on the preshot number. Dosing is based on how low the cat goes during a cycle and that is not known yet.

Also, it is much better to go up the dosing scale in small increments to find the correct dose than it is to go racing down the dosing scale pulling all-nighters and skipping shots.

(I've never felt comfortable giving dosage advice and leave that to the people that know far more than I do.)

If your vet/boss is feeling a bit uncomfortable about everything, the TR Lantus protocol was actually developed by two renowned vets: http://www.felinediabetes.com/FDMB/threads/tight-regulation-protocol-tr.1581/ (scroll down to the bottom for a pdf if you cannot open the link to the article).
The start low, go slow method has been developed and adapted over a period of years. It is for owners who cannot quite meet the requirements of the protocols due to work and/or cat orneriness.


It's a big learning curve that will soon become second nature.

Thank you!!!!