Midnight's spread sheet 5/8/13

[TMR]

Just updated the spreadsheet with the curve from today.

 

[Deb & Wink]

I can only hypothesize what the numbers were last night after PMPS. In my imagination, I see a slide down to the blues, then a dip farther down into the greens, possibly a deep dip into hypo territory. I see that because of the low 169 number this morning and then the rise into the sunny yellows after no shot this morning.


The numbers didn't really start to go up again until +20, which is a long time and indicative of a low green number overnight.

You're having to skip shots every 2 to 2.5 cycles. That is because the dose is too high.

It's not the higher pre-shot numbers you should be worried about. It's those unknown "how low is she really going - into hypo territory?" low dips that should concern you. They would me.

"Better too high for a day, than too low for a moment."

I would recommend a reduction to 0.75 or maybe even down to 0.5. If you do that, I do not think you will need to keep skipping shots because Midnight is under 200.

In hindsight, I think you should have shot at least a 0.5u this morning to keep the depot from draining too much. But you know the saying, "Hindsight is great, ain't it?"

 

[TMR]

I have been told repeatedly not to give insulin if the blood sugar is less than 200. So I thought I was doing the right thing by not giving any this morning.

Also, isn't it a good thing to not have to give any insulin? If her dose is one unit, and sometimes her blood sugar is less than 200, isn't that a good thing? Doesn't it seem like her blood sugar is 250 and up often enough that 1 unit is either the right amount or even too small a dose?

You said to decrease her dose down to 0.75 units so I don't have to skip any shots. But that makes it sound like you want me to give her less insulin to make her blood sugar to be above 200. I thought the whole idea was to adjust the dose so her blood sugar is lower (but not too low) so she doesn't need the insulin. Or are you saying she is doing well and therefore needs a smaller dose of insulin? I am getting even more confused!!! Help!!

 

[morrieb1]

OK - I know this is is all very confusing - in part because since you've been here there have been lots of folks weighing in and I'm not sure they were all saying the same thing. I'm pretty sure that I have read everything associated with you and Midnight since you started posting in Relaxed Lantus - and so I'm going to try to help you sort it out by telling you what was said and why....bear with me for a minute - OK?

I have been told repeatedly not to give insulin if the blood sugar is less than 200. So I thought I was doing the right thing by not giving any this morning.

You were doing the right thing. At this point, when you don't have a lot of data (no curve yet, and very few midcycles and those really low numbers you are absolutely right not to shoot below 200 and I recall Mel (MommaofMuse) among others stressing that.

Also, isn't it a good thing to not have to give any insulin? If her dose is one unit, and sometimes her blood sugar is less than 200, isn't that a good thing? Doesn't it seem like her blood sugar is 250 and up often enough that 1 unit is either the right amount or even too small a dose?

OK- the idea is to have your cat spend as much time as possible between 200 and 50 - what some here call the healing numbers. The key is that "as much time as possible" phrase. When you have to skip shots, then your cat probably spends a lot of that cycle above 200. When you are able to shoot every time, the likelihood is greater that your cat will spend most of all of its cycles below 200 and that helps the pancreas to heal - it doesn't have to work so hard to try to bring the blood glucose down - it has help from the insulin. The more even you can keep your cats BG levels, the more comfortable they are, and the more likely they will heal.

And if I'm not explaining that part well, hopefully someone else with a better way with words will jump in.
You said to decrease her dose down to 0.75 units so I don't have to skip any shots. But that makes it sound like you want me to give her less insulin to make her blood sugar to be above 200. I thought the whole idea was to adjust the dose so her blood sugar is lower (but not too low) so she doesn't need the insulin. Or are you saying she is doing well and therefore needs a smaller dose of insulin? I am getting even more confused!!! Help!!

Mel actually said that to you a few days ago as well - and again, the intent isn't to raise her blood sugar - but to keep it more level....which gives you a better chance of healing than having it jump up every time you can't give a shot.

You can see from the curve that if your cat goes for 12 hours without insulin her blood sugar spends a lot of the time in numbers higher than 250. I'm pretty sure that even if your cats BG is 250 before a shot - when you shoot her she spends most of her time in numbers below 200.....I can't say that for sure because you weren't able to do a curve with insulin in it.
But I can absolutely say that if you skip a shot then your cat spends a lot fo time in numbers above 250 - you can see it from the skipped shots before as well as what happened today.

And that is why you are getting the suggestions to reduce the dose - so that you can shoot every time and hopefully not have those 250 and above numbers. Because really, you can't know whether or not .75 is too low until you try it and see what numbers you get....and you need to try it for three days to give it a fair shot (pun not intended).

Hope I helped a little and didn't make it all worse....There's no wrong decision - there's just the one thats right for you.

 

[morrieb1]

Just updated the spreadsheet with the curve from today.

That's really interesting - it looks like she's definitely making some insulin on her own.....and just out of curiousity - does she eat whenever she likes or do you do the meal thing? Generally BG levels are assumed to rise after a meal - so I'm wondering if she was munching out when you got that +4 279 number....cause it seems she came down on her own after that, which is awesome.

Em

 

[TMR]

I will try 0.75 units. I know you all know more than I do about this. It just takes a while to get it through my thick skull sometimes. I have a couple weeks and then I will be gone for a week, and the cat sitter will only be here twice a day to give Midnight her insulin and food. The cat sitter won't be here more than that, so I need to be sure the dose is comfortable and we won't have to worry about hypoglycemia. Also, I don't know who the cat sitter will be yet, and I don't know if he or she will test Midnight's blood sugar.

 

[TMR]

I feed her 1/4 cup food twice a day. Sometimes she eats it all at once and sometimes she grazes. If she seems especially hungry I might give her a few bites between meals, but not even enough to measure.

 

[Deb & Wink]

I have been told repeatedly not to give insulin if the blood sugar is less than 200. So I thought I was doing the right thing by not giving any this morning.

When you are just starting out, the threshold on the Feline Health forum is 200 for new members. On Lantus Tight Regulation forum, the threshold is 150 for new members. At some point, learning to shoot low numbers is necessary. Since you can't get those PM numbers due to your schedule, I do not know when you might be data ready to shoot low numbers. for now, stick with the 'Do NOT shoot under 200 rule'.

Also, isn't it a good thing to not have to give any insulin?

Yes, but only if the BG numbers had stayed low, under 120. BG numbers for a non-diabetic cat, normal range is 40-120. If your cat always stayed in these low numbers, then no insulin would be required. If the numbers are higher than the 120, you need to be giving some insulin.

Doesn't it seem like her blood sugar is 250 and up often enough that 1 unit is either the right amount or even too small a dose?

Actually, I see the exact opposite. A dose that is too high, can cause higher BG numbers. The pattern I am seeing is bounce, bounce, bounce, dive, dive, skip. Starting 5/5 PM through 5/8 the pattern is low, skip, bounce, bounce, lower, equal, dive, skip. If the dose was the right amount, there would not be the constant bouncing, crash dive and need to skip the dose.

Do you see back on 4/18 when you were giving 2 units? See those low green numbers at +6? That is probably what is happening overnight, a dip to the low green numbers, the liver pumps out counter regulatory hormones and some glycogen to raise the numbers and then you bounce for two and a half days, dive and hit under the 200.

If it was too small a dose, I don't think we would be seeing those drops into the blues, under 200. A dose that was too small would keep you in higher numbers, the yellows, pinks, reds and blacks.

Lantus dosing is not based on the pre-shot number. Not at all. What the pre-shot number tells you is how low the number is and if it is ok to shoot the full dose, shoot a partial dose, wait to feed and retest in 30 minutes (stalling) and then give the full dose, or skip the shot entirely.

The number you base the dose on is the nadir, the low point in the middle of the cycle when insulin is given.

Since there was no insulin given this morning, we can not base a dose on the low point from today. What the curve today told us is that the insulin is lasting about 20 hours for Midnight.

What the pre-shot number told us this morning is that Midnight dropped low enough sometime last night to still be low this morning.

You said to decrease her dose down to 0.75 units so I don't have to skip any shots. But that makes it sound like you want me to give her less insulin to make her blood sugar to be above 200.

I want you to give less insulin, to smooth out the curve. To stop those constant high bounces and even out the pattern. To stop the inferred overnight low drops that are causing the bouncing. To give her body time to adjust to some lower overall numbers. Yes, many of the numbers will be over the 200. But they already are most of the time when you are testing.

Open up your spreadsheet. Put your hand over the middle columns so you are blocking out all the mid-cycle am numbers and can only see the pre-shot numbers. What do you see? I see pinks, dropping to yellows and then blues; pinks, dropping to yellows and then blues; pinks, dropping to yellows and then blues over and over again. Can you see those patterns I am talking about? (If you can't you are normal. It can take months to get to the point where you can see the patterns.)

Or are you saying she is doing well and therefore needs a smaller dose of insulin?

Yes, I do think her pancreas is trying to heal. I also think she is dipping low overnight, almost every night. Many cats do this, go low overnight. Without a few pm tests, it's impossible to teel what is happening overnight.

I am getting even more confused!!! Help!!

Normal state of affairs here in lantus land.

Let me see if Sienne and Gabby can come over to comment. She is so much better at explaining than I seem to be.

 

[morrieb1]

I feed her 1/4 cup food twice a day. Sometimes she eats it all at once and sometimes she grazes. If she seems especially hungry I might give her a few bites between meals, but not even enough to measure.

Ok - then her drop wasn't tied to food - I was just kinda curious. That really is a good sign that she's got a working pancreas and may not need insulin for much longer, honest.

And you do not have a thick head. I'd guess you are a person who wants to know the why behind the advice you are given and I think that's a really smart way to be. This stuff is confusing - even more so because the guidelines themselves aren't even totally consistent.

Em

 

[Sienne and Gabby (GA)]

Deb asked me to stop by.

I don't know the background other than Deb mentioned that your schedule doesn't allow you to get PM spot checks. Is that the case every day? I try to encourage people to get random checks -- when you get home, before you leave the house, in between running errands, before you go to sleep (if that's relevant to the PM cycle), etc. It's very hard to guess what's happening at night.

What I typically suggest is that if you're needing to skip shots because you're uncomfortable with the low numbers, then you want to consider lowering the dose so you can shoot a consistent dose at both AM/PMPS. I don't see that many skipped shots, though. We do use a different approach on the TR board (vs. Health). At the beginning, 150 is the "post and ask for help" number. There are several options when you encounter a lower than comfortable pre-shot number. This is the sticky note we use that describes becoming data ready and shooting and handling low numbers. It's a gradual process of getting comfortable shooting low numbers.

I do want to tweek the info that Deb provided. Normal BG is 50 - 120. For a cat to go into remission, you want numbers to be consistently in that range without insulin. Numbers below 200 are beneath renal threshold. Numbers in this range allows you to minimize the risk for organ damage due to diabetes.

Based on the data on your spreadsheet, I can't conclude if the dose is a good one or not. While a curve is helpful, it's not the full picture. It's what happened today. And even with a curve, on a day when you skipped your AM shot, it's not a typical curve.