learning tight regulation & question

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Pussina2001

Member Since 2012
I had a question about tight regulation. I was looking at that chart The University of Queensland regarding the dosage increases (one of the links in stickies here). So, the increases or decreases of the regular shot dosage that you hold for several days are based on a nadir value, BUT when to skip a shot is based on the pre-shot value, correct? For example, if one’s getting under 200 preshot – skip… or wait 30 mins and retest etc. But the next time it’s time for the shot, measure and give the same dosage you are supposed to and re-evaluate at the next glucose curve...

PS...some of you might have seen my posts from yesterday, where the vet said to start with 2 units twice daily and Pussina had 21, 37 etc at some points... She's a little 7 pound kitty.
So, now I am starting over and giving her .5 a shot and seeing what pre-shot and nadir values she'll get for the next few days. She's only eating low carb and I've been feeding her more and spaced out. I think she's a bit calmer already.

Also: can anyone recommend a good value ketostix brand and how often to measure urine?

Thank you!!!
 
We test at preshot to see if it is safe to give a shot of insulin. That is usually the highest point in the BG cycle. For those just starting we recommend not shooting a BG under 200 until you have more data collected so you can control the following cycle. You will see many of us shooting much lower but we know how our cats react from lots of testing. Soon you will have more data to understand how Pussina reacts to the Lantus and you can start to shoot lower. For newbies shooting low the first time it can be nerve wracking, but there is usually someone here to walk you through it.

I think you were wise to go w/ a lower dose. 2u is a high starting dose especially for such a small cat! Please try to get a spreadsheet setup so we can help you more.

ETA: I just went to look at your posting from yesterday, you were in the Health Forum and many here may not have seen it. Here is a link to yesterday's post.
 
I hadn't seen your posts but, oh my! I'm very glad you reduced the dose. I suspect your vet wasn't familiar with how to calculate a starting dose of Lantus.

You're correct. Decisions about whether and how much to increase or decrease the dose are based on the nadir value. Pre-shot test numbers are important only from the perspective of whether it's safe to give a shot. We tend to shoot a bit lower than they do on the Health board. For a new member, we suggest using a value of 150 to base whether to shoot, stall, etc. We also suggest if you get a lower number than you're comfortable shooting that you post. There's usually someone here 24/7 that can lend a hand. It's important to have enough data to decide what to do. It sounds like you've been doing some reading. The information on how to handle a low pre-shot number, low mid-cycle numbers, and becoming data ready are in the Shooting & Handling Low Numbers sticky.

If you find it easier, we use a slightly modified version of the Tight Regulation Protocol. Most of us have found this to be a little easier to follow.

I use this brand of Ketostix. How often you get a ketone test depends on a few things. First and foremost is whether your cat has a history of developing ketones. If so, get a test whenever you can stalk your cat to the litter box. If not, weekly would be good until your cat is better regulated.
 
I've read through what you posted yesterday and here are a few thoughts.Cats need between 20 and 30 calories per pound a day to maintain weight depending on how active they are. At 7 lb Pussina would need 140 kcal to 210 kcal just to maintain weigh, let alone add another pound. FF usually only has 70 to 90 kcal per can, so she needs more food! We also try to serve more mini meals during the day, not just at preshot. It is easier for their weakened pancreas to deal w/ a little at a time and that is the way cats normally eat anyway. Catch a mouse, eat it, go looking for another! :roll:

We feed Tess 6 times a day: an ounce at preshot and half an ounce at +3 and +6, but Tess has a very late onset and nadir. She is also a small cat 8.75lbs. and we feed higher calorie food. You will have to experiment to see what works for you and Pussina. You usually don't want to feed after nadir because that will be when the insulin dose is losing effect and make the BG rise faster. A snack before bedtime should let you all sleep.

Lantus is an insulin that likes consistency. It builds up in the body w/ a reserve, we call it the shed. That needs time to develop and every time you change a dose it needs to be rebalanced. I think you were wise to reduce the dose, but now you need to hang tough and wait for 6 to 7 days to see where this takes her. Then it will be the time to consider more or less insulin, but only adjusted by .25u increments. You are so lucky that Pussina did not go hypo w/ the 2u.

Got to go, time for Tess's shot, and yes I am probably going to shoot low, but you aren't ready for that yet! BBL

PS any drugstore should have ketone test strips, usually less than $10 for 100 strips. Store brand is fine to save money, but it won't be much difference.
 
Welcome to Lantus Land! Can you tell us your name please?

The starting dose for lantus if the cat has never been on any other insulin and you are using a tight regulation protocol is .25u/kg of ideal weight unless the cat is underweight and then we typically use the formula of .25u/kg of actual weight.

I'm not sure what her ideal weight is....you say she weighs 7 lbs now and many of our cats have lost weight by the time they are diagnosed. But, for examples sake, let's say her ideal weight is 7 lbs. Her starting dose would be .25u x 3.1 kg = .79u. We would have recommended .75u bid as a starting dose as opposed to the 2u bid your vet recommended.

I agree with Sienne that it was wise to reduce her dose to .5u and see where she settles out. You can always take her up if need be once we see what she does.

As Ann said, it helps us immensely in helping you if you have a Spreadsheet for Pussina.

It also helps us if you can Create a Profile for her. It gives us quick access to important info we need about Pussina.

We'll be happy to help in any way we can! Just ask :-D
 
Thank you so much, everyone! My name is Mel.

So, I talked to my vet today...she is not super happy that I readjusted the dose myself (and there is her name on the prescription; she has her professional reputation to take care of, I totally understand), but she really is trying to work with me. She said that 2 units to start was a good dose according to her training given Pussina's initial high glucose diagnosis (560), and that with DX that high its .50 per kg, not .25 per kg for initial Lantus dosing. And she agrees to the dose probably needed to be dropped.
The issue is that she doesn't quite trust my glucometer (ReliOn). When I told her that I got pretty low readings (21, 37) but Pussina didn't seem to be "comatose", she said that it's strange, "she should have barely been able to lift her head" rather than come begging for food. So she still wants me to bring Pussina in for an in clinic curve and test to glucometer as well just to see comparative numbers and then, she said, she'll work for me and I'd never have to bring her in again and we can do over the phone. So, I am going to do it just in order to keep a working relationship with her...

12/12/12 5:30 pm, we gave her .5 units (food etc.)
at 9:30 pm, she was 309
12/13/12 at 5:30 am, she was 320, we gave her .5 units (food etc.)
at 5:39 pm, she was at 89, so we skipped a shot and fed her
at 9:10 pm, she was 114 - so I'll give her a night snack and go to bed!

I'll work on google charts at some point. Thank you so much for support everyone!
 
Consider it this way, doctors give Rx for insulin all the time and they don't expect their patients to keep coming back every time they or their child need the dose adjusted. I know that it can be stepping on professional toes, but most vets get very little training in FD or even feline nutrition. Usually about a day in their entire vet school training. I for one am much more impressed w/ a vet who is willing to learn more to give my cat the best care. Your vet may just not be used to being questioned, but don't you want explanations for treatment for yourself or you family? Why not with your vet? Perhaps if you brought her a copy of the Roomp/Rand Study Protocol so she could see "official" provenance for what you are wanting to do.Some vets want to know it isn't coming from some internet crackpots.

As for the meter, human meters tend to run about 30 points lower than the animal calibrated meters that vets like. As long as the vet knows the difference in the meter calibration there should be no problem. If she was thinking in terms of an AlphaTrack meter that 20 would have bee really unbelievable for the cat to show no effect. We have seen a few cats dip that low here and if they are brought back up quickly have had no visible symptoms. On the other hand those numbers can be seen in full hypo situations too.

Unfortunately the strips for the animal meters are only available from a vet or online. so if you run out on a weekend or at night when the cat's BG goes suddenly low you are out of luck. And they are so expensive that few people can afford to test often, and testing cats is even more important than people. Cats can't tell you if they are feeling bad or go get food for themselves. The only way we know is by testing. No parent would give their child insulin without testing, so why should it be fine to do so for cats.
 
Hello Mel. Welcome to LL. I know you will soon discover that finding this forum is the best tool you will have to safely treat your diabetic cat. Hopefully your vet will come around and be more receptive to learning something from her patient's care taker.

You'll find that there are some people on this forum that are very well informed, and I would call experts, on treating diabetic cats. I can tell you from experience that if you have a problem they will stay with you until it is over. The first time you have to give a shot at a low number will be terrifying. My DW (darling wife) and I were nervous wrecks but did it under the direction of the awesome folks on this forum.

As you visit different post, called condos here, you'll see links to "yesterday's condo" or "PurrFace's Condo, etc. You start a new condo each day with your PMPS BG# and paste a link to your previous days condo in the new condo. Whenever you need advice, whomever is assisting you will review your spreadsheet, profile and previous condos so it is important. Here are the instructions to insert the link to your previous day's post.

The way to make a fancy link is as follows:

1. Pull up the previous day’s condo

2. Copy the address of the link from the top of your browser

3. Then return to the Tight Regulations Page and click on the NEW TOPIC button on the top left above the first posts

4. At the top you will see several icons such as 911, a candle, rainbow, OTJ etc. Below them is the subject line. Put your subject beginning with the date (mm/dd) and your cats name then enter the numbers as you have been doing

5 Below the subject line are some tabs such as Quote, Code & URL etc. Click on URL

6. [url] will appear in white box belo... welcome and don't hesitate to ask questions.
 
Thanks so much, everyone! I feel the love :)
Pussina has actually been doing very well.
12/13/12 5:45 am she was at 290 and we gave her .5 Lantus (food and snack later)
at 5:45 pm she was at 98, so I didn't give her a shot (food)
at 9:10 pm she was at 114 (gave her snack before bed) and seemed to have slept through the night, or at least we did.
12/14/12 at 5:45 am am she was at 120, so again, I didn't give her a shot (food) and she purred next to me happily till I left for work.

I'll work on creating spreadsheets, profile this weekend ~O) .
 
Ann gave you a link to the bare bones of the Lantus protocol. Here's the journal article that you might want to bring to your vet.


In the earliest iteration of the protocol, the starting dose was based on the formula: initial dose = 0.5 x ideal weight in kilograms. However, Rand found that this was reasonable for cats that were in the hospital. For the cats at home, they were being put over dose. The formula was revised to: Initial dose = 0.25u x ideal weight in kilograms. So, your vet may be basing her recommendation on older data. In addition, that value in the 500s may also reflect vet stress. Because cat's numbers can be much higher at the vet's office, getting a curve done there can often result in dosing errors. It's best to get curves at home where your cat is in familiar, safe surroundings.

Also, if you're comparing your meter to the vet's, if the vet is using an AlphaTrack, a serum chemistry analyzer, or any other meter that's calibrated for animals, like others pointed out, the vet's meter will read 30 points higher than a meter calibrated for use with humans.

FWIW, my cat has hit the 20s. She's not barely moving. As long as it is a brief time in low numbers, your cat will be OK. A prolonged time in very low numbers is an entirely different story.
 

Attachments

Is there an article that specifically addresses the difference in readings between for-human glucometers and for pets glucometers that I can show her.

Also: we've been using 30 guage lancet (because that was the only one availablea at the store when we were buying everything). It can be hard to get blood from Pussina unless we get her right in that little ear vein and then a lot of blood pours out. Is that what we are supposed to do, or the spot between the vein and edge of ear? Would smaller guage needle be better?

Thank you. Mel
 
Pussina2001 said:
Thank you so much, everyone! My name is Mel.

So, I talked to my vet today...she is not super happy that I readjusted the dose myself (and there is her name on the prescription; she has her professional reputation to take care of, I totally understand), but she really is trying to work with me. She said that 2 units to start was a good dose according to her training given Pussina's initial high glucose diagnosis (560), and that with DX that high its .50 per kg, not .25 per kg for initial Lantus dosing. And she agrees to the dose probably needed to be dropped.
The issue is that she doesn't quite trust my glucometer (ReliOn). When I told her that I got pretty low readings (21, 37) but Pussina didn't seem to be "comatose", she said that it's strange, "she should have barely been able to lift her head" rather than come begging for food. So she still wants me to bring Pussina in for an in clinic curve and test to glucometer as well just to see comparative numbers and then, she said, she'll work for me and I'd never have to bring her in again and we can do over the phone. So, I am going to do it just in order to keep a working relationship with her...

12/12/12 5:30 pm, we gave her .5 units (food etc.)
at 9:30 pm, she was 309
12/13/12 at 5:30 am, she was 320, we gave her .5 units (food etc.)
at 5:39 pm, she was at 89, so we skipped a shot and fed her
at 9:10 pm, she was 114 - so I'll give her a night snack and go to bed!

I'll work on google charts at some point. Thank you so much for support everyone!
Click to expand...

OK about the curve at the vet office.... totally useless if you are home testing. Stress alone will skew the numbers badly, then your 'vet' bases the dose on numbers that are overly high, and you come home, your cat's BG comes down, you give the vet's recommended dose, and your cat hypos.
You rush your cat to the vet and that's even MORE money in your vet's pocket at the expense of your cat's health.

Ask your vet if the office curve will be FREE because you cannot afford it. Ask exactly how often the vet would be testing your cat, is it every 2hrs or every 3hrs, what is the frequency?
You are testing at home with your own meter and can test at the same frequency, then send the numbers off your meter and to the vet.

It's scary because MANY cats show no signs of hypo, but when tested, their BG are too low.
I would say that 21 and 37 are very low, and need action to bring the numbers up. Often, cats will go looking for food to bring their own numbers up.... that's a good sign to test your cat. There is nothing wrong with the Relion meter, but if you get a number that seems way off, test again right away.

If your vet wants you to use a pet meter, tell the vet the meter and the expensive strips for it will need to be provided to you, at the same price as your Relion meter and strips, if the vet prefers you use the AlphaTrak; see what the vet replies to that.

There are many people who are using the pet meters and the human meters; the difference is usually around 30points, so big deal.... if the Relion says 37, the AT may say around 67. That single difference does not justify the cost of the AT meter and their strips. Stick with the Relion.

The ears learn to bleed so it will get easier in time. I never aimed for the vein or I would get the gushers like you did.
Just in case you have not been given this hypo info:
List of Hypo symptoms
How to treat HYPOS-They can kill! Print this out!
Jojo’s HYPO TOOLKIT
 
Some people like a larger lancet when starting out, I prefer a smaller lancet. What I think really makes a difference is the sharpness of the lancet. I found that the BD 33g lancets seem to take less pressure to use. I think they are sharper and don't hurt as much. I've found them at Target but not at our local drugstore, you can also get them online. There is a link at the top of the page for AWD, which is a very reasonable priced supplier for all things diabetic.

Do you use a lancet device or freehand poke? We freehand, I can see just where i am poking (yes, between the vein and the edge of the ear). I hold the lancet at a 45º angle and barely touch the ear and twist slightly rather than poke. This makes more of a cut than a hole and seals up better. ALWAYS put pressure on the site immediately and for 20 seconds. Tess has very thin ears and you cannot see a mark from all the pokes she gets. Always give a treat afterwards and soon Pussina will be purring in anticipation throughout the test! :-D

On the meters, that's a good question for Sienne, she has access to journal articles.
 
I just did a quick google search and found this article on meters, it may do the trick.
CONCLUSIONS AND CLINICAL RELEVANCE:
Neither PBGM had exact agreement with the automated analyzer; however, the disagreement detected did not have serious clinical consequences. Our findings stressed the importance of using the same device for monitoring trends in dogs and using instrument-specific reference ranges.
Click to expand...

In the Roomp/Rand article that Sienne gave you, point out to your vet that the study was done w/ human glucometers!

Table 1. Parameters for changing insulin dosage when using insulin glargine together with home monitoring of blood glucose concentrations in a pro- tocol aimed at achieving of intensive blood glucose control. Dose increases are per injection per cat. Blood glucose was measured at least three times daily with a glucometer designed for human diabetic patients that reported glucose concentrations for whole blood (not plasma-equivalent) and used ≤0.6 ml of blood per test. A low insulin dose generally is <3 IU, a high dose is ≥3 IU per injection per cat
Click to expand...
 
I agree wholeheartedly with Gayle (Blue). I would not let my vet talk me into doing a curve at her office. You are getting real time data at home where Pussina is not stressed. Also, calculating a dose based on one BG number....I wouldn't do it. Even my vet, who was not well versed in FD, knew to base it on weight and not numbers.
 
Mel said:
Is there an article that specifically addresses the difference in readings between for-human glucometers and for pets glucometers that I can show her.
Click to expand...
In the article I provided, if you look at the end of Table 1 (under the information labeled, "Phase 5"), the authors state the following:
Roomp & Rand said:
NB: For human-use meters which provide plasma-equivalent values, readings are approximately 11% higher than glucose measurements for whole blood in human patients. For veterinary-use meters calibrated to give plasma-equivalent values for feline blood, add approximately 1.7 mmol/l (30 mg/dl) to target glucose-concentrations, for example, aim for 4.4-7.2 mmol/l (80-130 mg/dl), instead of 2.8-5.5 mmol/l (50-100 mg/dl).
Click to expand...
In other words, on a meter calibrated for human blood, normal blood glucose values for your cat (or a human) would be between 50 - 100. On an AlphaTrack or a veterinary use meter, those values would be 80 - 130.
 
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