Lantus SLGS switch from one a day to 12h doses?

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kotek

Member Since 2011
My cat B had a kidney infection about 6 weeks ago, then a strange (not very high BGs) DKA crisis two weeks ago. Since her DKA recovery, her BGs were spiking oddly (eventually so high it was off both mine and the vet's glucometers, so guessing maybe in the 50s/900s) and her caninsulin couldn't keep up with how rapidly her BG was rising. Tried to get her down with short acting/Toronto insulin, which worked, but she still wouldn't respond to the caninsulin. And so we switched her to Lantus.

(NOTE: had discussed this switch previously, but she was doing pretty well on caninsulin, including gaining weight, and has a lot of other factors -- hyperthyroidism, crf -- so we didn't want to shake what seemed like a successful balance. Balance being gone, Lantus enters the picture.)

So now we are trying to settle into Lantus. Keeping a close eye on her, because of the previous sudden spikes, as well as not sure about dosage. I appreciate that Lantus can take a couple days to "settle", but we've been seeing great results from the beginning. I'm definitely not complaining -- completely relieved that she has stopped spiking! But we are working on how to move forward. See result below...sorry for the format...

Day 1 - at the vet
AMPS - HI so into vet again - no injection at home
BG off the scale (50s or 60s?), given 2 units of Toronto over the course of the day, and 1 unit of Lantus at 8:40am readings from home starting at +10.5, counting from her initial Lantus injection at 8:40am,
+10.5 - 5.6
+11.5 - 4.8
+12.5 - 5.2
+13.5 - 4.7
+14.5 - 4.9
+15.5 - 4.2
+16.5 - 4.2
+18 - 7.9
+19 - 9.3
+20.5 -11.6
+21.5 - 15.8 - gave 1 unit

DAY 2 - at home
from last chart AMPS 15.8 - gave 1 unit
+1 - 15.6
+3 - 9.8
+5 - 8.6
+7 - 6.2
+8 - 5.9
+9 - 6.4
+10 - 6.0
+11 - 5.7
+12 - 5.7
+13 - 6.2
+14 - 7.8
+15 - 6.2
+16 - 5.1
+17 - 4.9"
+18 - 7.4
+20 - 12.7
+21 - 17.2

(NOTE: I wouldn't normally use day 1 given the circumstances, but when I compared the pattern was so close to day 2 that it seems worth considering)

DAY 3 - at home
from last chart AMPS 17.2
+2 - 13.7
+5 - 6.5
+6 - 6.3

I'm puzzling over her quick response and not seeming to have to settle in before things going quite well. I have been doing lots of research, and appreciate she's better on a 12h schedule, but this seems tricky given the length she's already getting. So I thought I'd throw it out there...

- I know it's early days...maybe the "shed" will fill up and she'll actually be able to get 24 hours out of 1 unit?
- should we really be giving her another dose at +12 when she's in the 5-range, and could already drop lower based on the dose she had 12h ago? i'm concerned about this particularly because at that point she isn't moving down, and her new doses seems to take effect pretty immediately, rather than waiting a couple hours
- maybe the initial dose is too high, and we need to try 1/2 unit every 12 hours and see where it gets us? in this case, I would try 1/2 unit around +20 (in the 11-12 range) and try to shift from there to a 12h schedule

I'd be interested in your thoughts. The headspace for Lantus is very different than for caninsulin, and I'm just so relieved to have her down in the normal range again after all that terrifying spiking that it's hard to focus on anything else! FYI, I don't think we're in a Tight Regulation space quite yet, after the crazy past few weeks -- but I saw it was suggested this was a better section to post in than the "relaxed" Lantus one.

Thanks so much!
 
Re: switch to Lantus under duress--starting suggestions??

Hi and Welcome to the forum :-D

Can you change your blood glucose numbers to the US numbers? A lot of us are not familiar with the world numbers, including myself, and you will get more help, if you could do that. Also, I would start to work on getting all B's numbers loaded into a spreadsheet, so you and we can see any patterns and help you with your dosing questions.
Here are the instructions on setting up a spreadsheet http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207 if you need help, just ask.
 
Re: switch to Lantus under duress--starting suggestions??

We don't use mmol/L numbers as our standard here. We us the US (mg/dL) as our convention. Here's a link to converting the numbers. In addition, the World version of our spreadsheet template will make these conversions automatically. Here's the converted data:

BG off the scale (50s or 60s?), given 2 units of Toronto over the course of the day, and 1 unit of Lantus at 8:40am readings from home starting at +10.5, counting from her initial Lantus injection at 8:40am,
+10.5 - 5.6 - 100
+11.5 - 4.8 - 87
+12.5 - 5.2 - 94
+13.5 - 4.7 - 85
+14.5 - 4.9 - 89
+15.5 - 4.2 - 75
+16.5 - 4.2 - 75
+18 - 7.9 - 135
+19 - 9.3 - 167
+20.5 -11.6 - 209
+21.5 - 15.8 - gave 1 unit - 285

DAY 2 - at home
from last chart AMPS 15.8 - gave 1 unit
+1 - 15.6 -280
+3 - 9.8 - 175
+5 - 8.6 - 155
+7 - 6.2 - 110
+8 - 5.9 - 105
+9 - 6.4 - 115
+10 - 6.0 - 108
+11 - 5.7 - 103
+12 - 5.7 - 103
+13 - 6.2 - 110
+14 - 7.8 - 140
+15 - 6.2 - 110
+16 - 5.1 - 92
+17 - 4.9 - 88
+18 - 7.4 - 133
+20 - 12.7 - 228
+21 - 17.2 - 310

(NOTE: I wouldn't normally use day 1 given the circumstances, but when I compared the pattern was so close to day 2 that it seems worth considering)

DAY 3 - at home
from last chart AMPS 17.2
+2 - 13.7 - 247
+5 - 6.5 - 117
+6 - 6.3 - 113
Click to expand...
The first concern I would have is whether your Canninsulin was any good.

Any infection can cause high numbers. However, for DKA to occur, the basic "recipe" is infection + not eating + not enough insulin. DKA doesn't have to happen as a result of high numbers.

When a cat switches insulin, there can be an immediate response. We typically suggest a 30% reduction in dose with a switch because some cats do have such a marked response. It certainly looks like your cat is responding well.

- I know it's early days...maybe the "shed" will fill up and she'll actually be able to get 24 hours out of 1 unit?
- should we really be giving her another dose at +12 when she's in the 5-range, and could already drop lower based on the dose she had 12h ago? i'm concerned about this particularly because at that point she isn't moving down, and her new doses seems to take effect pretty immediately, rather than waiting a couple hours
- maybe the initial dose is too high, and we need to try 1/2 unit every 12 hours and see where it gets us? in this case, I would try 1/2 unit around +20 (in the 11-12 range) and try to shift from there to a 12h schedule
Click to expand...

Lantus and Canninsulin are very different. I would strongly encourage you to shoot at 12-hour intervals. Shooting 1.5 hours early is not advised. (An early shot acts like a dose increase.) Lantus likes consistency both in terms of dose and in terms of shot times. If you are inconsistent, you can end up with wonky numbers.

As far as shooting if B is in the 100s (5s on your scale), we generally ask a new member to post if he/she has a pre-shot number that's below 150. We can help to walk you through the options and to make sure your cat is safe.

As far as Lantus onset, not every cat has onset beginning at +2. My cat, for example, can already be dropping at +1 or +2. Some cats have early nadirs, some late nadirs, and others follow the rule book (such as it is). Every cat is different.

I would not reduce your dose. You have a cat that is post DKA. This dose is not dropping numbers below 50 which, based on the Tight Regulation Protocol, is what we use to adjust dose.

I would encourage you to read the starred sticky notes at the top of the Board if you've not done so already. They will help to orient you to using Lantus.
 
Re: switch to Lantus under duress--starting suggestions??

Good morning. I'm sorry but I'm new to this as well and can't offer any advice except to edit your post and put a question mark in the subject line. This will alert everyone that you have a question. To do this click on your post and when it opens click on the edit tab in the upper right. When the new screen opens click on the dot to the left of the question mark above the subject line. The dot you want to click is between the OTJ and ? icons. This should get some results fairly quickly. If not and you have an emergency click on the dot to the left of the 911 icon. This one is used for emergency situations.
I hope this helps some.
 
Re: switch to Lantus under duress--starting suggestions??

Welcome to the LantusLand Board! :)

You'll get all the help you'll need here to help your kitty. Lantus is a very good insulin, and most of us use it.. Some longer than others. My cat started on ProZinc in the beginning and wasn't getting results. Once we started on Lantus, I've been seeing some really nice #s.

Read the stickies at the top (the ones marked with stars)... Ask many questions (even if they sound redundant to you, just ask... That's how you learn). Post a dailing thread (aka condo) on here so that the experts can see how your kitty is doing. And please post on your kitty's spreadsheet on a daily basis, too. The experts do check on how our kitties are doing, and will make a comment, suggestion, or provide advice on what to do next if they see something amiss.

Again, welcome!
 
Re: switch to Lantus under duress--starting suggestions??

Thanks all!

I added a question mark, thank you Frosty! :) And thank you Sienne and Gabby for the US conversions. I wasn't actually aware this was an American-focused board...must have missed that somewhere.

When she was DKA, they didn't find any signs of an infection (WBC normal) (although she did get a course of antibiotics in case). She had also only not been eating for about 12 hours. Fast. We've had a cat with hepatic lipidosis, so we pay very close attention to eating. And the caninsulin was definitely working -- just not fast enough, which isn't the behaviour I would expect based on her history. Not dropping enough, yes; not able to keep up, no. We did switch out the bottle with a new one from a different batch to try. She was also not responding as well as previously to the fast-acting Toronto insulin. Something weird going on no one can figure out.

I've read lots on Lantus, including the stickies -- which were very helpful, thank you! I definitely appreciate it is very different that Caninsulin (and am particularly appreciating the many stable hours in the 5s/100s).

Again, I was wondering about: 1) a possible "storage shed" for a 24 hour cycle, and 2) about the general advice about shooting in the 100s. I know I would appreciate the specific feedback if the circumstance should arise and I am ready to move forward, but I am trying to understand more broadly first. Not rocking the boat any more than necessary here!

Note that if I gave her her injection 1.5 hours "early" that still wouldn't be early according to a 12 hour schedule. What I was suggesting was trying a reduced dose at +20 (instead of a larger dose currently at +21), then moving to every 12 hours from that point...just so we'd be starting the 12 hour cycle from a desirable BG (and hopefully not 3am/3pm, since someone has to go to work to pay the vet bills :) ). If at the beginning we had reduced her "regular" caninsulin dose by 30% to start on Lantus we'd be much lower than 1 unit, but given her spikes "regular" got thrown out the window and we just had to make a guess and watch closely.

FYI, I'm paying close attention to the Queensland protocol at: http://www.uq.edu.au/ccah/docs/diabetesinfo/link4.pdf . But since we're not at Phase 2 yet, I'm not sure what kind of additional "settling in" might still occur.

Also, to reiterate, we're not up for Tight Regulation at this point...have had too much stress, mental and physical, over the past couple months. My understanding of advice to previous posters was to post here about Lantus in any case, because the "relaxed" thread isn't watched very much.

Thanks so much to all!
 
Re: switch to Lantus under duress--starting suggestions??

We have any number of international members. I wouldn't say we're "American focused" -- the webmaster is from the US and using US conventions has become the norm.

There is no problem using the Start Low Go Slow (SLGS) approach on this Board. As you noted, this is a busy board and help is readily available unlike on the Relaxed board. Just what may be a dumb question... You realize what you're calling the "Queensland" protocol is the Tight Regulation Protocol that we use here? The protocol you linked was actually published by Jacqui Rand from University of Queensland and Kirsten Roomp who is from the counterpart of this board in Germany. The protocol you linked and the English translation of the German board's protocol is linked in the Tight Regulation sticky. Let me know if you want the pdf of the published article.

Again, I was wondering about: 1) a possible "storage shed" for a 24 hour cycle, and 2) about the general advice about shooting in the 100s. I know I would appreciate the specific feedback if the circumstance should arise and I am ready to move forward, but I am trying to understand more broadly first. Not rocking the boat any more than necessary here!
Click to expand...
I'm not sure what your question is regarding the "storage shed" is. (We've converted to using the more generally accepted term, insulin depot, since no one other than those of us who are denizens of Lantus Land know what a "storage shed" is.) The depot is what gives Lantus it's duration and allows for the action of the insulin to be cumulative. It's not a 24-hour thing. It's simply a matter of the pharmacology of the medication.

The mantra here is "Shoot low to stay low." However, you need to be data ready. In other words, you need to have sufficient data to know when Lantus onset and nadir are for your cat. You also need to be available to monitor and have supplies -- low carb and high carb canned food, strips, etc. Most of us who have been here a while shoot substantially lower than the 100s. We have worked our way down the numbers to be comfortable shooting in that range. As I mentioned previously, if you have a pre-shot that's less than 150, please post. There's usually someone around who can lend you a hand. There's also a post on dealing with low pre-shot numbers in the off chance no one is here. With a cat that has been through a recent episode of DKA, I'm very reticent to suggest skipping a shot.

With Lantus, if you need to move your shot time, the safest way to do s is to move your shots by 15 min. twice a day or 30 min. once a day. This would have minimal impact on the effect of the dose. There really isn't a formula for figuring out how to calibrate dose for an early shot. On the other hand, if numbers were running high, shooting an hour early (or sometimes more than an hour early) is quite feasible.
 
Re: switch to Lantus under duress--starting suggestions??

Thanks for pointing out the connection between Tight Regulation and the Queensland protocol -- that is what I thought.

I guess what I'm looking for is some suggestions on Start Low Go Slow using Lantus. There seems to be a lot on Tight Regulation, but I haven't been able to find much on a less assertive approach. While we may get there eventually, we are not in a TR place right now.

For example, the advice on "dealing with low pre-shot numbers" you kindly referred to specifically says it is aimed at those following TR. But I haven't been able to find much on dealing with these if I am *not* following TR.

So, for example, I am approaching my 12 hour mark, when theoretically I would be advised to give her another dose. But I am in the 100-range. I am using a SLGS approach. What would your advice be?

I'm not really "skipping" a shot if I don't give one, because she has never had 12h doses of Lantus. It is only day 3, and we have been following her BG. While I appreciate this is not the generally advised approach for Lantus, the circumstances have been such that we've had to make things up as we go along. It has been working remarkably well, and we want to work from stable and get more stable -- again, no boat rocking.

In regard to my question about the "insulin depot" over 24 hours, it is exactly the pharmacology I am wondering about. If many cats build up a flat curve over time on 12h dosing, due to how the body responds to to a combination of the current insulin injection and the insulin depot, is it possible we may also achieve this over 24 hours once the depot fills, given the results we are getting now when it is theoretically empty? In other words, could the "depot" accumulate and work over 24 hours as it typically does over 12hours?

Question about your advice on moving the shot 15 min twice a day or 30 min once a day. I'm assuming you mean either based on 12h dosing, and not the former if 12h and the latter if 24h?

Thanks again for your thoughts and suggestions!
 
Re: switch to Lantus under duress--starting suggestions??

Question about your advice on moving the shot 15 min twice a day or 30 min once a day. I'm assuming you mean either based on 12h dosing, and not the former if 12h and the latter if 24h?
Click to expand...

Yes, if you are shooting every 12 hours, you can move each shot ahead by 15 minutes, or move just one of them up by 30 minutes.

Carl
 
Re: switch to Lantus under duress--starting suggestions??

So, for example, I am approaching my 12 hour mark, when theoretically I would be advised to give her another dose. But I am in the 100-range. I am using a SLGS approach. What would your advice be?
Click to expand...

Whether you are following the TR protocol, or the SLGS protocol, you would still want to dose every 12 hours, just because that's the way Lantus works on cats. They metabolize it twice as fast as humans do.

I am not sure of what effect dosing every 24 hours would have regarding the depot, but my guess is that it will give you odd numbers and the depot would never be established "correctly".

I guess what I'm looking for is some suggestions on Start Low Go Slow using Lantus. There seems to be a lot on Tight Regulation, but I haven't been able to find much on a less assertive approach. While we may get there eventually, we are not in a TR place right now.
Click to expand...

Link to explanation of SLGS protocol:
http://binkyspage.tripod.com/SLGS.html
The primary difference between SLGS and TR is how long a dose is held. Also, what criteria you use to hold, increase, or decrease the dose. Each protocol calls for a number of days or cycles that is dose is kept the same (with the exception of when you reduce a dose due to low numbers - that calls for an immediate reduction). Each protocol tells you how much to reduce or increase, and when.

For example, the advice on "dealing with low pre-shot numbers" you kindly referred to specifically says it is aimed at those following TR. But I haven't been able to find much on dealing with these if I am *not* following TR.

So, for example, I am approaching my 12 hour mark, when theoretically I would be advised to give her another dose. But I am in the 100-range. I am using a SLGS approach. What would your advice be?
Click to expand...

You would (if you choose to) follow the "shoot low to stay low" approach with both protocols. And you would react to low numbers after the shot the same way (see the same sticky for instructions on how to bring the numbers up using higher carb food and/or karo syrup or honey) with either protocol. Dealing with low numbers in the middle of a cycle is done the same way no matter what protocol, or which type of insulin you are using.

The "line in the sand" where you choose to shoot or not shoot is completely up to you. Most new members are advised NOT to shoot any BG number below 200 at first. In order to shoot lower numbers, you must have enough data collected to know that shooting is "safe" to do. Until you have that data, you should not shoot a number like you are seeing right now (in the "100-range").

At some point, you will have the data, and you will feel comfortable shooting a number around 100. You should always ask for help if you need it, and when that day comes, people here will walk you through it. They'll stay up all night with you if it comes down to that.

The main thing is that you should never shoot insulin if you are not comfortable doing so.

Carl
 
Re: switch to Lantus under duress--starting suggestions??

I've been thinking, and maybe part of what I am asking is how to make a safe/Start Low Go Slow change from once per day injections to every 12 hour injections.

I am going to change the topic name accordingly, assuming I can figure out how! :)

Again, if there's support for staying at 24h and the possibility of the depot being created and carrying us flat for that long once a build up occurs, I am certainly open to that.

Thanks again to all!
 
Re: switch to Lantus under duress--starting suggestions??

thanks for posting! Sorry I don't know your name or your cat's name. I have a few thoughts:

The depot - Lantus generally lasts about 12 hours in cats. Some cats can get a little more, some cats a little less. What makes Lantus work so well for cats is that some overlap builds up between doses - the first dose may not be completely gone when the next dose is injected, resulting in a nice flat curve. This is based on dosing every 12 hours. If you dose every 24 hours, you will lose the overlap AND you will be constantly emptying and refilling the depot. This almost always results in higher numbers.

Now you are saying "but my cat's numbers aren't high at all, they're great! I don't see the problem here." You're right, they ARE great. But it can be a problem, and here's why: one, her depot hasn't filled, so we are not yet seeing the full impact of this dose. She's hitting 70s on a dose that isn't even fully effective yet. It might be ok if you're just shooting every 24 hours, because the depot might not ever get completely full. But it is likely that at some point soon this dose could cause her to drop even more. When I see a brand new Lantus kitty getting numbers this good, it makes me really pay attention because I expect that they will be needing a dose reduction soon. The second reason her numbers might be so good is that unlike Caninsulin, Lantus "overdoses" often take the form of extended duration rather than low numbers. If she is getting 18 hours on a dose, her dose is probably too high. So now I have two reasons (single digit numbers on an empty depot and long duration) to think that 1 unit might be too much insulin.

You ask about shooting low: with Start Low Go Slow, most new folks don't give insulin lower than 150-200. You'll be able to refine that once you know your cat's patterns. However, because Lantus works SOOOOO much better when given every 12 hours without skipping shots, if you are getting unshootable preshots this often we would usually recommend reducing the dose a bit. That *should* bring her numbers up just enough that she will be shootable at +12. That advice applies whether "shootable" to you means 100, 150, 200, or whatever. Reduce the dose until she starts falling into that range at shot time. I know it seems counterintuitive to try to raise the numbers when you've tried for so long to lower them! But the long, flat curve is the goal and giving shots twice a day is the best way to achieve that safely. I'm not suggesting to reduce by a lot - maybe shave down to 0.75u BID and see what that does, or even go to 0.50u BID so it's like you are splitting your normal 1u dose into two equal doses. You can always increase again if that's not enough.

We will occasionally have a cat that goes to once a day shooting right before they go off insulin, if they are at a point where a drop of insulin is too much but the cat can't seem to get by without any insulin. I honestly can't think of another cat while I have been here (about 4 years) that has done better with Lantus once a day.

Am I making sense?
 
Thanks, Carl! That really helps clarify some of the issues I am facing.

I am definitely following the "don't give it if you're not comfortable" principle, and totalIy agree with the not shooting before 200 before I have more data. The issue I am having is that she is not getting up to 200 until around +20. At her 12h mark we just had 118, and I'm not comfortable giving her another dose. I predict it will be another 8 hours before she is at 200. Great duration, just not quite sure how to deal with it!

Generally speaking, on a 12h dosing schedule with Lantus/SLGS, if you were seeing the results I am, would you then dose her at +20 or wait until +24 to keep on the 12h schedule?

The reason we haven't waited until +24 is due to her recent crazy high spikes, so we are cautious about letting her get even close to too high. That has been priority over getting her on a schedule.

My inclination would be to give her a reduced dose (probably 1/2 unit?) at +20 when she reaches around 200 and try to switch to a 12h cycle that way...so the dose has to do less, because there is more overlap, and then we can give it more often.

At this point I'm also wondering how useful it would be to leave her at the vet to make the switch...she will get stress hyperglycemia, I'm sure, so the results will not be super great. But again, to pay the vet bills I also need to go to work! :)

I really appreciate your pointing out the hypo process is the same, regardless. Thankfully we have not had to use our corn syrup yet, but we have everything needed in case. :)
 
HI! Just want to say welcome to Lantus Land! I don't have experience to give dosing advice, still learn something new every day! :-D You are asking great questions as you learn you way into using Lantus for your cat. As you accumulate more data to better understand and anticipate how your cat responds to Lantus, the gurus here will be able to help you fine tune your dosing. As you have already heard from several experts, the 12 hr cycle is key to good regulation. Most folks here find an am/pm time that fits their work, school, etc schedules. We ended up shfiting our time to allow for the testing and shooting and still get critical sleep. You may have to experiment a bit, but I think making the 12 hr cycle work is well worth the effort.
 
Generally speaking, on a 12h dosing schedule with Lantus/SLGS, if you were seeing the results I am, would you then dose her at +20 or wait until +24 to keep on the 12h schedule?

The reason we haven't waited until +24 is due to her recent crazy high spikes, so we are cautious about letting her get even close to too high. That has been priority over getting her on a schedule.

My inclination would be to give her a reduced dose (probably 1/2 unit?) at +20 when she reaches around 200 and try to switch to a 12h cycle that way...so the dose has to do less, because there is more overlap, and then we can give it more often.
Click to expand...

Your instincts are good! If you go back and read what Libby posted just before you posted that, you'll see what she advised goes along with what you said to a degree. Libby is a lot more experienced than I will ever be with Lantus :smile:

You can reduce her current 1u dose to either .75u or .5u, so that you get a number that you feel okay about shooting insulin at every 12 hours. That will help you get to the point where you are seeing flatter cycles, with numbers that gradually come down overall.

Has anyone linked you to the instructions for setting up a spreadsheet? It's one of the most valuable tools in the arsenal for treating feline diabetes!
http://felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207

Carl
 
Libby and Lucy -- I think we crossed posts a bit. In any case, you are making complete sense, and my thinking is along the same lines, as I hope you can tell from my post above.

I am definitely worried about the settling in period and things starting to work "better" in terms of her going lower. I can also already see the benefits of her extended periods in a normal range, and it seems best to use the insulin like it is intended and take advantage of that overlap/achieve that flat curve. Your concerns about things working so well so soon and lasting unusually long are reinforcing what my instincts are telling me.

I'd be very interested in your thoughts about at what point in the current cycle to start the reduced dose: does at +20ish, when she reaches around 200, as I'm considering, make sense to you? At that point she's starting to rise -- she jumps about 5 (100) points in the next hour.

And do you think there is any point trying at the vet's?

Thank you so much for your help!
 
I would shoot at a time that you'll be able to stick with. I'm always a fan of getting insulin into the cat sooner rather than later, so if shooting at +20 today puts you at a shot time you'll be able to maintain most of the time, then go for it.

I wouldn't bother regulating at the vet. You really do need to give each dose at least a few days to work before you change it again, so you would end up paying for a lot of curves when she does nothing just in an effort to try to catch one cycle when she shows some action. It's a whole lot easier and cheaper at home.
 
I apologize. I totally missed that you were shooting once a day. I agree with Libby. You can shoot at any point that's 12-hours after your last shot and that will be convenient for your schedule. I was thinking much along the same lines as Carl with dose, as well -- 0.5u would seem to make sense.
 
Thanks Libby! Ha, I wish she was so cooperative that shooting at +20 tonight would be convenient! She is almost categorically a difficult cat, and no exception here.

+20 tonight would put us at about an 1am/1pm schedule, probably the most inconvenient timing possible. But at 7pm or even 8pm tonight, which would work well for BID dosing, I am guessing she will still be in the 100s.

I could give her one more 24hr dose tonight, which should take us to 8-9pm tomorrow, and then I could start her on a more reasonable 12h timing -- if you don't think the risk of one more 24h dose is too high?

Carl, thanks again for your encouragement, and the spreadsheet advice. I definitely have a spreadsheet, and have plagued the vet repeatedly with my extensive set of caninsulin data. Lantus data, of course, is still new for us. My sheet is a little different than normally used here, I think, so I need to take some time to look at how to best integrate. :)
 
Thanks Sienne and Gabby -- my fault, as I don't think I was very clear in the beginning. :)

Great we're all thinking along the same 0.5 units/BID lines. It really is *such* a different head space from caninsulin...I never would have shot at 200 with caninsulin until I had reams of data to back me up...and even then it was a tiny, tiny dose.

I really appreciate all of your wisdom and help!
 
Hmmm, just got an 11.2/200 reading at +15. Going to wait half an hour and re-test, and if we are going up I am going to give 0.5 units.

Eeee, scary new insulin! Please let me know if you have any cautions!
 
Try not to get hung up on just one number. I would suggest that you figure out what time works best for you that will let you shoot every twelve hours. I would wait until then before shooting, even if the number continues to rise until then. Then choose the dose, like .5u, and go with that dose.
Carl
 
Thanks, Carl! Fortunately, now is about perfect, so could be serendipitous...

Still scary though!
 
I would try to get the SS (spreadsheet) we use up and running as soon as possible. Since the World template will do the conversions automatically (enter on the mmol/L or World tab and it will convert the numbers on the US tab), it will make life easier for you and us. We're so used to seeing the color coding that we talk about the numbers in their color terms.

Since numbers are on the rise and it's at a convenient time that is at least 12 hours from your last shot, it does sound like the stars are aligning in your favor. I'd go for it.

BTW, is your cat's name B? What do we call you?
 
Yes, b the cat (lots of letters in our house), and I am kotek. I have updated my signature. :)

And are you Sienne?

I will try the spreadsheet. Mine is extensive and also tracks other things...last I checked it looked tricky to merge them, but I will see how it goes.

We went up a bit for +1 (15.3/278), but I gather this is not abnormal, and not up too much so hopefully going down again next...

This whole process is certainly nerve-wracking....
 
Yup -- I'm Sienne and Gabby is my kitty. The other 2-legged posters have been Libby, Carl, Angela, and Leslie.

With Lantus, typical onset is at around +2. There's often a food spike at +1. Nadir is ideally at +6, although the nadir is not a fixed point and can move around. Some cats are early nadir (e.g., Gabby) and some are late nadir. The value of getting spot checks or curves is to figure out when onset and nadir are as well as what kind of duration Lantus is giving B.
 
Thanks, and hello and gratitude to all!

Okay, still up a little at +2, 16.8/302. Getting nervous...I will test again at +3.

Spoke to my vet, who agrees with trying this course, but does suggest if she continues to climb to give her another 0.25. This is mostly based on her crazy spikes recently -- we don't want her going that high again.
 
Generally, you want to give the depot a chance to form. Lantus isn't like Caninsulin or the Toronto insulin you were using which are shorter acting types of insulin. You don't want to adjust the dose based on the pre-shot numbers. Dose adjustments are based on nadir.

Just out of curiosity, when you were using Novolin ge Toronto, was it Novolin N or R?
 
I totally appreciate where you're coming from in regard to the depot...but what if she just keeps going up and doesn't have a nadir?? That's what we're worried about.

Again, as recently as Friday morning she was swinging over the 40s (720+)...and was so hard to get down we're guessing she was in the 50s (900s) or higher. We basically want to do whatever it takes from that recurring.

I honestly don't know which Toronto insulin. It was only ever used at the vet's office -- not by me personally. I will ask, though, and get back to you.
 
And at +3, she is still climbing -- now at 18.2 (327). I don't see a risk of a hypo, and do see a risk of a spike.

Unless you see a very serious reason I wouldn't give her another 0.25, I think the spike risk outweighs the depot issue.
 
If you're talking about giving another .25 now or at any time prior to her next scheduled shot at +12..... no, you never give a second shot in between the regularly scheduled shots. There is no immediate crisis from high numbers in the middle of a cycle. This is a marathon, not a sprint. One 12 hour cycle is just that - a 12 hour cycle.
Carl
 
Sorry, the deed is done. And having spoken bit about never shooting when you're not comfortable, this is a case where I would have been uncomfortable *not* giving her more.

I sincerely appreciate what you say about the marathon, and generally agree, but this is an unusual case, and the sprint is the thing until we have a couple occasions where she runs a little high but does *not* leap from 8 (144) to off the scale (600+) in the course of 8-10 hours.

We appreciate your thoughts.
 
Carl is correct. You don't shoot twice. If you do, you end up with overlapping insulin peaks which can end up having a really negative impact on numbers. I've seen this happen once and numbers tanked. It was exceptionally hard to get the cat's numbers back into a safe range.

Better an hour in high numbers than a minute is way too low numbers.

BTW, are you testing for ketones?

Our posts overlapped. It would be far safer if you were to use what we refer to as "regular" insulin or R (Novolin R, Humulin R) rather than shoot a second dose of Lantus. This was the reason I asked if you used Toronto N or R. R is a short acting insulin that can lower numbers quickly. However, it is extremely potent and you need to be able to curve the use of R compared with Lantus. It is not an insulin to be used in a cavalier manner. Libby has experience with using R and can guide you if you want to use this as an option.

Given that B has been in lower numbers, it's possible that this is a bounce. You don't yet know if your cat will be in very high numbers when on Lantus. Many of our cats experience bounces with drops into lower ranges.
 
Yes, definitely testing for ketones, particularly given our recent DKA.

Up only a little this time at +4, 18.9 (340), which is reassuring.

I'm sincerely sorry to diverge from recommendations. Given her increasing BG, I made the decision to go with my vet's recommendation. She's in the same place with me on the spikes, because she had to work crazy hard to get B down to a normal level.

Just out of curiosity, would you normally expect to see an increased BG at +4, even at the beginning of this process? I shot her at 13 (234) and she has since gone up to 18.9 (340). Every other time she has gone down 100-200 by +4-5. I appreciate I am hyper-sensitive due to her recent spiking, so am wondering if this does sometimes happen?

Let me assure you I definitely have an emerg vet nearby and my regular vet is expecting my call first thing in the morning in case I need to bring her in. I think it will be a long, stressful night, but that was how this was going to play out regardless. :(

Again, your thoughts and support are appreciated.

PS - Yes, overlapping posts about overlapping insulin! :) I asked about using the Toronto at home, but they were very hesitant. In addition to the fast-acting, they said it needs to be given intra-muscularly, and, honestly, she is so skinny after her kidney infection in September she has very little muscle on her.
 
FWIW - IM shots are no big deal. Bob got all of his shots except for the first couple of days that way. They were as easy to give as sub-q shots, and I shot into the big muscle in the top of his legs - what we would call the "hamstring" on a human leg.

Your vet needs to look over the dosing protocol for lantus, however, to see that dosing isn't supposed to be done less than 12 hours apart. He may advise a 2nd insulin, a short acting one, if supplementary doses are needed. I have no experience with that.

Carl
 
Just to let you know we're all good and made it through the night with no drama whatsoever, although very little sleep!

Here's what the night looked like:

PMPS - 13.0 (234) - given 0.5 unit of Lantus
+1 - 15.3 (276)
+2 - 16.8 (303)
+3 - 18.2 (328) *gave another 0.25 of Lantus, as per vet's instructions - at about 22:50, due to rising BG & recent history of uncontrollable high #s (rapid climbs into the 800s and above)
+4 (and +0.5 of shot 2) - 18.9 (341)
+5 (and +1.5 of shot 2) - 17.7 (319)
+6 (and +2.5 of shot 2) - 13.9 (250)
+7 (and +3.5 of shot 2) - 13.7 (247)
+8 (and +4.5 of shot 2) - 12.1 (218)
+9 (and +5.5 of shot 2) - 11.7 (211)
+11 (and +6.5 of shot 2) - 12.3 (222)

Apparently I could have gotten a lot more sleep, but if that's the only side effect of the night I'll gladly take it. :)

Rest assured that I appreciate this double dosing was a very unusual choice, and definitely not something to be done normally. However, I'm not sure you're quite with us on the severity of her BG spikes last week after her DKA. She was basically off the charts for most of the week (even after 5 days in the hospital on constant rate infusion of fast acting insulin), extremely difficult to bring back down even with the fast acting insulin, and with no explanation. In this unusual case, I support my vet's choice to work off-label a bit. She has called me 4 times a day/night to check in and is very aware of how carefully I am monitoring...I don't think she'd advise this to just anyone. She is the categorical opposite of cavalier, and doing her best to support me in working with what we've got, which is not an ideal situation. Having had this one experience where B's rising BG didn't go off the charts will help us both feel a little better about the marathon versus the sprint. :)

Of course, the question now is what to give B next, and when. The 0.5 didn't seem to do a whole lot on it's own...maybe it would have brought things down eventually, maybe not, but I doubt we would have got to the 250s. Meanwhile, the 0.25 is still working through. I'm guessing we could do another 0.5 at the regular time (+12 for the initial shot) then shift to 0.75 overall, but will consult with the vet. Your thoughts are most welcome.

Thanks again for all of your help and support!
 
Hi Kotek, I'm sorry I have not yet read your entire condo. It sounds like you have a good vet on your side. That is great and good ones like that are hard to find. You're fortunate.

Lantus works best with consistancy in both shot times and dose. With other insulins the doses are changed all the time, but Lantus doesn't work that way. We usually have a new person stick to the same dose for 5 to 7 days and test and see how B does as the depot builds up in his system.

I hope you will get a spreadsheet set up today, so that it will be easier to see at a glance how B is doing.
From your recap in your last post, B's numbers don't look that bad from last night.

Please test B for ketones every chance you get.

Hope you have a good day.
 
I'm glad there wasn't any drama overnight.

Here's where I think we diverge from your vet. Lantus is not as potent as some other types of insulin. It is not best used as a bolus insulin (i.e., give a shot to drive numbers down). It is a basal insulin -- it needs to be given as consistently as possible so that you can take advantage of the cumulative action of the medication. Further, dosing is based on nadir, not on the pre-shot values.

Humulin R ("regular" insulin) is given as a sub-q injection. There are members here who can help you with R, if you want to use it. It is effectively used as a bolus insulin and can be given in conjunction with Lantus.
 
I absolutely take your point about basal vs bolus, and I'm sure my vet would agree. I think this was more of a desperate times/desperate measures situation. I will ask about the fast acting as a backup if we get spiky again, although in general I hope I don't need to!

I went in to the vet this morning and we settled on a 0.75 every 12 hours plan. They (2 vets in practice--different one this morning but also great) do seem to lean towards once a day, but were open to twice. You'll be pleased to hear she gave me similar advice to you folks: calm down about the spiking, test for ketones, and let the dose settle before changing. :)

B actually dropped pretty fast today, from low 20s/414 to 6s/115 over about 3 hours. Possibly this is part of the overlap effect you warned about, Sienne...or maybe, if we're supposed to be attending to the nadir versus the pre-shot, this is just where she likes to be on Lantus? Anyway, my partner is watching her while I'm out for a meeting. We'll see if he can manage to get a BG reading. ;)

I'm going to look at some spreadsheets to try and get a sense of how other cats have initially responded to Lantus... that should help.

Meanwhile, I am predicting she will be in the 100s again at 12 hour mark/time for her next shot. If this happens, I will post. But thinking ahead, in that case I should...????
 
kotek said:
B actually dropped pretty fast today, from low 20s/414 to 6s/115 over about 3 hours. Possibly this is part of the overlap effect you warned about, Sienne...or maybe, if we're supposed to be attending to the nadir versus the pre-shot, this is just where she likes to be on Lantus? Anyway, my partner is watching her while I'm out for a meeting. We'll see if he can manage to get a BG reading. ;)
Click to expand...
MUST get a BG reading soon. How long will you be out?

Lantus doesn't usually onset until between +2 and +3 for most cats. That means that this 300 point drop is almost ALL from yesterday's insulin, not this morning's shot. This dose is probably just now starting to kick in. She will probably start dropping faster now.

Was this morning's shot 12 hours after the FIRST shot yesterday, or the second one?

Remember that the bounces/spikes can be caused by fast drops as well as by low numbers.

Let's be sure she is safe today before talking about future dosing.
 
And while you're between tests, here are two things that we need before we can give any further dosing advice:

Profile
Spreadsheet

We are all laypeople here, and cannot offer dosing advice without enough information for us to be able to see the whole picture.
 
Hi Kotek,

I'd like to address the "spiking" (and I agree with your vet that you shouldn't panic over it). First off, the numbers you saw yesterday have little to do directly with the .5u dose followed with the .25u chaser. It could have caused some overlap and screwed up the timing of that cycle, true. But the important thing you need to understand is that the higher numbers you saw that made you feel a 2nd dose was necessary? Those were not caused by the fact that you reduced B's dose to .5u. You would most likely have seen the spike in BG even if you had shot 1u yesterday.

Look back at the numbers you posted at the beginning of this thread. You see the double-digit numbers in the 60s and 70s? Those low (low but perfectly safe normal numbers) were the likely culprit that caused the higher numbers after your shot of .5u.

With Lantus, the cycle following a shot many times is not directly affected by that specific shot. It's the whole concept behind the "depot". There is carryover from the depot that can have an effect after a reduction and can influence the numbers for several cycles after the reduction.

What you are seeing is most likely "bouncing". When a cat has lower BGs than its body has become to see as "normal" - and diabetic cats can live in the 200s, 300s and higher for weeks before diagnosis - their system can react to those lower numbers by releasing glucagon and hormones into the blood, and the numbers go right back to being high. Especially at the beginning of insulin treatment, this can and does happen to most cats. It's just a part of the treatment process that they need to get past. The more time, and the more often, the numbers go down into "normal" ranges, the more used to it the cat becomes, and eventually the bouncing stops.

Throwing more insulin at the problem actually can make the problem worse. The real danger in doing that - and this danger is compounded when a cat is also being treated for an infection with anti-biotics, and being changed to a low carb diet - is that at some point, the bouncing stops, the infection clears and the diet change takes effect. And suddenly the insulin becomes "too much" and the bottom drops out and you see "hypo" numbers that you weren't expecting to see all of a sudden. Once the insulin is in, you can't get it back out. Which is where what Sienne said is really important...."Better an hour in high numbers than a minute in way too low numbers."

I completely understand your fear in seeing high numbers. My cat, Bob, was also DKA, and came within a day or two of dying. He spent 3 days hooked up to a sugar drip and got short acting insulin IM injections while he was fighting for his life. High numbers scared the hell out of me too. His ketones never reappeared, thankfully, but he continued to see 400s at shot time for two or three weeks, and his dose kept going up and up and up before things got under control.

I think settling on .75u is a good idea for now. You'll get an idea of how that works after sticking with it for a few days. During that time, continue to test mid-cycle. Look for a significant drop in numbers by +2 or +3, because that doesn't typically happen. If it does, then that means B might go a lot lower by nadir, and it's something you need to look out for and react to. If you see high numbers at some point in the cycle, look for a "reason", like lower than normal numbers in the cycle or two before that cycle. Those high numbers might be due to a "bounce", and not due to "not enough insulin". And test daily for ketones.

And here is a link that your vet might be familiar with, but if not, make them familiar with it - it is the AAHA guidelines for dosing cats with insulin, and it clearly recommends twice a day shots rather than once a day shots, for any insulin. If I remember correctly, the dosing info is on page 218.

http://www.aahanet.org/PublicDocuments/AAHADiabetesGuidelines.pdf

Carl
 
I'm in transit so will be brief, but so you amazing folks don't worry wanted to let you know that my partner did manage to get a BG reading at 4pm (he is very proud!), and it was 175. So, all good!

More later...thanks again to all!
 
Awesome, when you get home, tell him how proud you are for him! Us too!

Just to make everyone's lives more simple, try to not use actual clock times. Not sure which time zone you are in, but we probably have members in every time zone around the globe. So what we "do" is call the AM and PM shot time AMPS and PMPS , and everything else is "+ the number of hours since shot time", like +6 would be six hours after the last shot. SO, in relation to when you gave B a shot today:
How many hours was that after B's .25u dose?
And 4 PM today where you are was how many hours after this morning's shot?

Drive safe!
Carl
 
Hi Kotek, glad all is well for now. You are already getting sound dosing advice from the experts here and sounds like your vets are on the same page which is wonderful :-D . As mentioned earlier, will be very helpful if you can start posting your bg data in the spreadsheet template used here. The familiar layout helps the gurus quickly review and compare when neede, and makes it easy for the rest of us to learn from each others experience. You mentioned you arleady have your onw spreadsheet. I did too, and still do, engineer what can I say? One suggestion if you are not famialir with Google gsheets, start with the online template as is, put in your recent data to get used to how gsheets do (and dont) work. I tried consolidation of my workbook with the gsheet and soon learned folks here who dont use Excel themselves could not see what was I seeing :o , Google and Microsoft do not play well together :YMSIGH: . For me its been faster and easier to just keep separate online LL spreadsheet and local detailed workbook. Once you set up your LL template, its just a couple clicks to add a number. If you need any help, just ask.
 
Okay, spreadsheet and profile are up!

Thanks to all for the nudging, and to Leslie in particular for the extra motivation I needed to do this...given my own spreadsheet I was kind of exhausted at the thought, but you're right it wasn't that hard. I especially appreciated the advice not to try and merge with my Excel doc...of *course* Google and Microsoft don't work well together... Also glad not to be the only multiple spreadsheet nerd. :smile:

Carl, thanks for the reminder about the nebulousness of time on the internet! The 9.7 (175) was at +7 from this morning's shot, and +16 from yesterday's 0.25 unit "chaser".

Some crazy bouncing today, so I'm pretty convinced of that theory. Yikes! But the more I have numbers like 21 (378) that in 3 hours only go to 23.9 (430) and not 33+ (700+) , I feel better about this settling in process.

I will get up and test her during the night (I think every 3 hours should do it?). However, there really isn't anyone to check on her during the day -- my partner and I work far away (and I have taken a lot of cat time off work already). Given that, any thoughts on how to be as safe as possible during this transition?

It's odd to think of when she was first diagnosed I was giving her 2 units of caninsulin BID blind. When I learned to home test the first result I got was 0.9! :shock:
 
Okay, at +9 she is at 4.8 (86)...if she is under 11 (200) at +12, then...?

Again, there is no one here to monitor and I work far away... I could maybe manage to come back and check in mid-day, but it is a 2-hour return trip, and this isn't a viable solution...for more than a day or two...
 
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