Nadir occurring 12 hour after injection

[Woody/Cheryl (mom)]

Hello, my cat, Woody, has been on Lantus since 9/26. Started at 1 unit then increased to 2 units after 5 days. Did well on 2 units for 7 days with nicely regulated bgs. Then everything went wacko. Nadirs are very low and occur when next dose is due. Wondering if cat is having Somogyi effect. Have skipped a couple of evening doses because bgs are low (27 on human glucometer yesterday) and 98 tonight. Anyone else have nadirs at 12 hours on Lantus instead of at 5 to 7 hours? Forgot to mention bgs are "HI" in the morning and about 300 at 6 hours after injection and keep declining to nadir at 12 hour mark.

 

[Callie & Patches]

You need to call vet and discuss changing to a non deposit insulin. Prozink is an in and out insulin. It does not buildup in the bloodstream over time.

 

[Jill & Alex (GA)]

Hello and welcome to the FDMB Cheryl and Woody!

Hello, my cat, Woody, has been on Lantus since 9/26. Started at 1 unit then increased to 2 units after 5 days.

That's where the problem lies. Dose adjustments with Lantus (actually most insulins) are best done in increments of 0.25 unit. It's easy to become over dose and/or set up a vicious circle of bounces and drops to lower numbers than kitty's body is used to when increasing the dose by whole units.

Have skipped a couple of evening doses because bgs are low (27 on human glucometer yesterday) and 98 tonight.

Yikes! A BG of 27 is dangerously low! I strongly suggest lowering the dose immediately. You want a dose that will allow you to shoot every 12 hours without dropping kitty below 50 on a meter clibrated for humans. If I were in your shoes, I would drop the dose to 1u bid and go from there unless Woody was diagnosed in diabetic ketoacidosis (DKA) or is currently throwing ketones. If 1u bid turns out to be too low, we can always help you fast-track up the dosing scale safely. If Woody has experienced ketones/DKA in the recent past, please let us know. The information will affect the dosing suggestion to drop to 1u bid.

You might want to read through the two dosing methods we use for Lantus on this board to get an idea of how to use Lantus safely to regulate Woody:

• TIGHT REGULATION PROTOCOL (TR)

• START LOW, GO SLOW METHOD (SLGS)

If you have a chance, take a look at all the "stickied" posts (marked in yellow) at the top of the Lantus & Levemir Insulin Support Group for tons of valuable information.

Anyone else have nadirs at 12 hours on Lantus instead of at 5 to 7 hours?

There is such a thing as a "late nadir" kitty, but I suspect Woody is simply is over dose because of the super low reading of 27.

Forgot to mention bgs are "HI" in the morning and about 300 at 6 hours after injection and keep declining to nadir at 12 hour mark.

These are classic signs of a drop to lower numbers followed by a bounce to higher numbers.

Most of us use a spreadsheet to track kitty's progress. If you're willing to start one, we'll be better able to help:

• FDMB SPREADSHEET INSTRUCTIONS
• UNDERSTANDING THE SPREADSHEET/GRID

Please print this information out and keep it handy in case of an emergency:

• How to treat HYPOS
• jojo and bunny's HYPO TOOL BOX

You need to call vet and discuss changing to a non deposit insulin.

At this point, there's no need to change insulins. Woody's been on Lantus for only 2 weeks! The problem is not that Lantus is a depot insulin. What Cheryl is seeing is pretty common when the dose has been increased by a whole unit in a relatively short period of time... no matter what insulin is used, even Prozinc.

Cheryl, ask any questions you may have. I'm headed to bed, but others will be coming on any time now.

 

[Tuxedo Mom]

Jill has given you some excellent information and I totally agree the dose is too high and was raised too much too quickly.

What you are seeing with those low hypo numbers and then the HI readings later is a "bounce" caused by the very low numbers. The body releases counter-regulatory hormones which cause stored glucose (glucogen) to be released in response to the emergency low. The effects of this released glucogen can keep numbers higher for up to 3 days. By increasing the insulin so much so quickly it causes a viscious circle of low numbers, then bounces to high numbers.

As Jill suggested unless your kitty has a history of DKA (diabetic ketoacidosis) ...(this would have been an emergency situation and would have require 24 hour care for several days at an ER vet)...........then reducing the dose to 1 unit and holding that for at least 3 days to allow the bounce to settle and the body to adjust to the "depot" Lantus forms, you will see whether holding that dose is working or if a SMALL increase may be needed.

As well, since you are already home-testing....GOOD JOB!!!...setting up a spreadsheet and recording your data will give a good picture of how the insulin is working. Next to home-testing, the spreadsheet is one of the more important things you can do when treating your kitty for FD. Instructions for setting up the spreadsheet are here:

http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

If you need help setting it up...just ask. I was totally unable to get it done on my own when I started, but there are some great "spreadsheet gurus" that can get you going in no time!

 

[Woody/Cheryl (mom)]

Thank you all so much! Woody does not have any history of DKA but I will get strips and test today to make sure that is not happening now. Are all ketone strips the same?
Forgot to mention I did lower dose immediately to 1 unit yesterday but still got a low of 98 at the 12 hour mark before next shot so was afraid I may have missed a lower bg. Was going to give dose after rise to 115 but Woody was adamant not to have it which he never did before so I skipped last night's dose. I hated to do it but had to follow my instincts. Woody eats all day long so food probably helped his bg to rise to 119. Just tested this morning and bg is 578. So gave 1 unit dose. (Celebrating bg did not read HI. I know 578 is nothing to brag about but still celebrating.)
One more question. I am using Lantus solostar with the pins so need to get syringes. Do the U100 3/10cc syringes all show markings for .25 units?
Thanks again for all your help. I got tears when I got your replies this morning and felt huge relief. You all are tremendous to share your vast knowledge!! Woody appreciates it also. Cheryl

 

[Tuxedo Mom]

so I skipped last night's dose.

With a preshot that low when you are still early in the treatment "game" that is definitely the best thing to do. Until you have a lot of data...and have it recorded in the spreadsheet so that others can review it and offer advice/opinions it is advised not to shoot under 150 on a human meter.

Ketodiastix are the most common name brand and can be found at most pharmacies.

U100 3/10ml syringes do not come with 1/4 unit markings. The best you can get is ones with 1/2 unit markings and either "eye-ball" in between the full unit and half unit or using calipers. These are the ones I use but I know people in the US get similar from Walmart or order online, so hopefully others can give you more information on that/

 

[Sandi and Toby]

Not all ketone strips are the same, but they all do the same job. I think that the biggest difference is that some show ketones as well as some other types of readings like glucose (probably not reliable), and maybe some other things that I have seen mentioned here. I usually use https://www.walmart.com/ip/33574014...75035&wl11=online&wl12=33574014&wl13=&veh=sem

Just be sure to VERY EXACTLY follow the instructions for your strips as far as timing is concerned, for whichever strips you get, because I've seen that can vary from one to another.

 

[Jill & Alex (GA)]

U100 3/10ml syringes do not come with 1/4 unit markings. The best you can get is ones with 1/2 unit markings and either "eye-ball" in between the full unit and half unit or using calipers. These are the ones I use but I know people in the US get similar from Walmart or order online, so hopefully others can give you more information on that/

From the sticky: LANTUS & LEVEMIR - SYRINGE & INSULIN INFO: HANDLING, DRAWING, & FINE DOSES

Picture of 0.25 unit:

USING SYRINGES WITH A PEN, CARTRIDGE, OR VIAL:

• U-100 3/10cc syringes with half unit markings are the best to use for drawing Lantus or Levemir from vials, cartridges, and pens. BD Ultra-Fine, CarePoint Vet, Monoject, GNP, UltiCare Vet Rx, Sure Comfort, and ReliOn are just some of the brands available with half unit markings. Needle gauge and length is your preference Syringes come in ½ inch or 5/16 inch needle lengths. Needle gauges are 29, 30 or 31 (31 being the thinnest)
• Full and half-unit syringe scales:

How to use a syringe to draw insulin from a Lantus SoloStar pen:

Video: How to draw Lantus from a vial or pen:

You can pick up ReliOn U-100 syringes marked with half units if you have a WalMart near you. Ask for Relion U-100 3/10cc 31 gauge syringes at the pharmacy. They come marked with half units even if the pharmacist doesn't know it. A box of 100 runs around $12 - $13. Many states do not require a prescription for syringes. The state I'm in doesn't require a prescription so I would buy a box or two at a time. You should also be able to pick up a vial of Ketostix there.

Congrats on getting a spreadsheet together and linked in your signature! You're fast!

You can continue to post here on Health or you can mosey on over to the Lantus & Levemir Insulin Support Group any time you're ready.

Hope to see you posting often!

 

[Woody/Cheryl (mom)]

Thanks, so helpful! When looking at my spreadsheet, I can see how blind I was when I started. So glad I found you last night. Was so worried with the vet's advice. If only I knew everything I know now! I feel like I am in Veterinarian school. LOL!! Poor Woody!! Would not want to see what grade Woody would give me right now.

 

[Woody/Cheryl (mom)]

Ketones were negative yesterday (first time I tested with strip). His bgs were more steady yesterday so I gave both the morning and evening 1-unit doses after going 2 days skipping the evening dose. However, I have another HI AMPS reading this morning. Oddly, the AMPS was less than HI yesterday after having skipped the evening shot twice in a row. This perhaps indicates Woody is still recovering from going from a 1 unit to 2 unit dose without phasing it up. I am going to postpone the shot this morning and see what his Bgs do without it. (Woody was very adamantly against having his shot this morning which raised red flags.) He is drinking a lot and urinating a lot (more than ever). Still eating regularly and resting. I am trying to decide if I should go down some more on his dose (below 1 unit), especially since I skipped evening dose twice. Hopefully more readings today may help with that decision. I'm a little concerned how he reacts to getting a shot now. He just doesn't want it anymore. He doesn't mind ear pricks though. I also wish I had collected bg data from day 1. Please let me know if you can't see the spreadsheet. (It looks like it is private on my end.)

 

[Woody/Cheryl (mom)]

I am changing vets. Earliest appointment is on Monday. Will solo until then. Woody ketones are still negative. Bg was 568 at 10:30a. Will try to give his shot soon. I think he needs to get back on 1-unit BID.

 

[Woody/Cheryl (mom)]

Took shot okay. No hassle this go round. I think I will do the PS testings about an hour before shot for now. I think that may help him stay calmer.

 

[Critter Mom]

Hi Cheryl,

I am changing vets. Earliest appointment is on Monday. Will solo until then.

The Lantus and Levemir insulin support group here is very active and there are a lot of very experienced Lantus users in the group who should be able to give you a great deal of help if you post there.

Here is a direct link to the L&L group's board.

http://www.felinediabetes.com/FDMB/forums/lantus-glargine-levemir-detemir.9/

Fingers and paws crossed that your new vet will be good for feline diabetes treatment.




Mogs
.

 

[Woody/Cheryl (mom)]

Thank you Critter Mom! I should reword my statement...I am not alone at all! I have the best support group on the planet!

 

[Critter Mom]

I have the best support group on the planet!

We all do, Cheryl!




Mogs
.

 

[Jill & Alex (GA)]

Ketones were negative yesterday (first time I tested with strip).

Yaaay!

His bgs were more steady yesterday so I gave both the morning and evening 1-unit doses after going 2 days skipping the evening dose. However, I have another HI AMPS reading this morning. Oddly, the AMPS was less than HI yesterday after having skipped the evening shot twice in a row. This perhaps indicates Woody is still recovering from going from a 1 unit to 2 unit dose without phasing it up. I am going to postpone the shot this morning and see what his Bgs do without it. (Woody was very adamantly against having his shot this morning which raised red flags.) He is drinking a lot and urinating a lot (more than ever). Still eating regularly and resting. I am trying to decide if I should go down some more on his dose (below 1 unit), especially since I skipped evening dose twice. Hopefully more readings today may help with that decision.

Actually, skipping shots clouds the issue because the effects of Lantus are cumulative... meaning one dose builds upon the next. It takes at least six cycles/three days to see how low a specific dose can drop kitty.

I wouldn't put too much stock in what happens to kitty's numbers when the cat is bouncing from a low. Let's review what a bounce is:

Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

When kitty is bouncing, we continue with a few spot checks to *see* what's happening because eventually, in most cats, bounces will become shorter and we want to know when the bounce is clearing. If we didn't suspect Woody was over dose at 2u bid and if there hadn't been any skipped shots since the low of 27 on 10/9, I would have expected the bounce to clear yesterday.

Did you dose last night? The cell is blank so I'm not sure if he received a shot. Helpful hint: instead of using clock times on his spreadsheet (we're all in different time zones), make notations of how many hours it's been since the last shot. For example, if I gave a shot that was an hour and a half late I would note the shot was given at +13.5.

Going forward, you'll want to try to shoot 1u every 12 hours consistently for at least 6 cycles/3 days (the cycle count starts over after a skipped shot)... grabbing mid-cycle BG tests whenever you can. Dosing consistently will yield the information needed to determine dose adjustments.

I am trying to decide if I should go down some more on his dose (below 1 unit), especially since I skipped evening dose twice. Hopefully more readings today may help with that decision.

Honestly, it's your decision, but I wouldn't adjust the dose yet for the reasons I've stated above. It's too soon to draw any conclusions.

I'm a little concerned how he reacts to getting a shot now. He just doesn't want it anymore.

Hmm, I understand your concern. This may sound dumb, but you know what really helped when Alex would give me attitude (and boy, could she ever give me attitude!)? I sat down and a heart to heart conversation with her... calmly explaining what I had to do and why I had to do it. Well, that and I always had a treat ready for her! She loved freeze-dried chicken! After a bit, she seemed to understand I was helping her. Not trying to torture her. Maybe it's worth trying with Woody?

If that doesn't work, what makes Woody tick? What motivates him to do what you want him to do? Whatever it is, use it!!! LOL!

He doesn't mind ear pricks though. I also wish I had collected bg data from day 1.

Not minding ear pricks is a real positive!
And data collection... we all wish we started collecting since day 1!

Please let me know if you can't see the spreadsheet. (It looks like it is private on my end.)

I can see it!

I am changing vets. Earliest appointment is on Monday.

Good luck with the new vet!

Took shot okay. No hassle this go round. I think I will do the PS testings about an hour before shot for now. I think that may help him stay calmer.

Awesome! Happy to hear he took his shot like a big boy.

Just had a thought...
Would he let you test, feed, and then shoot him while he has his head buried in the food bowl? That works for a lot of our caregivers. The reason I'm making the suggestion is a cat's BG numbers can rise or drop considerably between +11 and shot time. I understand the "why" behind taking PS tests about an hour before shooting. Just trying to think of a way around it, but hey... do what you gotta do. Hopefully, he'll come around soon. You're really doing very, very well with him!


I can see the board has been very slow today. Wander over to the Lantus & Levemir Insulin Support Group for help if you'd like. You have more than enough information to start posting over there.


I can't get back here until late tonight, but I will check back in case you have questions. In the meantime others may stop by to comment or offer suggestions.

 

[Woody/Cheryl (mom)]

Jill, thank you so much for your input. I worked today to get some good bg readings from Woody, and he cooperated well. However, I may have screwed up Woody's shot tonight. I am using the SolarStar pen directly because I am giving a whole unit. After I gave injection, I questioned myself whether or not I even dialed the number "1" on the pen. So hopefully I did dial "1" and he got his dose. Woody has been very calm and happy to let me do just about anything I wanted until the bounce threw him for a loop. I think his anger was his way of telling me his body was not ready to accept another injection. The two times he put his claws out and stopped me, I listened and am grateful I did. He let me give a dose last night, this morning, and this evening. I fixed spreadsheet because it was a bit confusing the way I input today's information on two rows for a single day. And thanks also for explaining the bounce. I think Woody is used to high numbers and will benefit by going down slow to avoid another bounce. The bounce was hard on him and me.
Good idea about sneaking shot in during eating; however, Woody is one of those cat's that has the memory of an elephant. He used to love, love, love getting brushed but hated that flea control stuff so I thought I could sneak it in while I brushed him. Well I may have won that battle, but he never, ever allowed me to brush him again. Because of that, I don't want him to associate a shot with his eating. Woody had a recessive gene for blindness and has been blind since age 6. Probably started going blind when he was 2. That may explain some of his ways...survival mode I guess. He knows everything that is going to happen based on his acute hearing. He can hear me heat the rice sock in microwave downstairs and know it is time to get his ear pricked. Time to hide under the bed.
I chose Lantus because Woody's vet suggested it, but does not have experience with it and encouraged me to go to a different vet. Well, instead of going where he initially recommended, I chose a vet close to my house who doesn't have as much experience with Lantus as I would like. So a rough beginning. Woody's lifelong vet is trying to help me select a vet that will follow the right protocol and not wing it based on experience with other types of insulins. I am actually trying to get him (Woody's lifelong vet) to go on this journey with us because I know him well and know how intense he is on getting everything right. He is somewhat connected with a Lantus expert in the area and could call on him if he needed advise or a second opinion. He is thinking about that. When you are using Lantus you need a vet that is open-minded; not set in their ways...since ECID.
Thanks again Jill for all you do!!! You are the best of the best!
Cheryl

 

[Jill & Alex (GA)]

However, I may have screwed up Woody's shot tonight. I am using the SolarStar pen directly because I am giving a whole unit. After I gave injection, I questioned myself whether or not I even dialed the number "1" on the pen. So hopefully I did dial "1" and he got his dose.

You know, stuff happens. There were a few times when I found a filled syringe hours after shot time and realized I did everything except actually give the shot! The world didn't end. Alex received her next shot and all was well. I'm glad you didn't administer another shot. It's tempting when we're not sure, but it's a whole lot safer to not give another shot just in case he did get some insulin. Better safe than sorry!

When you're using the pen plus the needles that attach... are you "priming" the pen/performing the safety test (drawing 2u and shooting it into the air/napkin/in the sink prior to drawing the dose for injection, as shown in this video: https://www.lantus.com/using-lantus/using-the-solostar-pen )? If not, Woody may not be receiving a full dose. Many vets aren't aware of that step when using the needles with the pen.

I fixed spreadsheet because it was a bit confusing the way I input today's information on two rows for a single day.

Ah, thank you. Yes, I misunderstood. Now it makes more sense to me!

Good idea about sneaking shot in during eating; however, Woody is one of those cat's that has the memory of an elephant. He used to love, love, love getting brushed but hated that flea control stuff so I thought I could sneak it in while I brushed him. Well I may have won that battle, but he never, ever allowed me to brush him again. Because of that, I don't want him to associate a shot with his eating. Woody had a recessive gene for blindness and has been blind since age 6. Probably started going blind when he was 2. That may explain some of his ways...survival mode I guess. He knows everything that is going to happen based on his acute hearing. He can hear me heat the rice sock in microwave downstairs and know it is time to get his ear pricked. Time to hide under the bed.

I was telling my husband about Woody at dinner... how handsome he is and about him being blind and I had one of those "Duh!" moments. Sneaking anything with a blind cat is probably the last thing one would want to do! Not the best suggestion on my part! I'm glad you're so in tune with him.

I am actually trying to get him (Woody's lifelong vet) to go on this journey with us because I know him well and know how intense he is on getting everything right. He is somewhat connected with a Lantus expert in the area and could call on him if he needed advise or a second opinion. He is thinking about that. When you are using Lantus you need a vet that is open-minded; not set in their ways...since ECID.

That's what I did with Alex's vet. He knew very little of Lantus when we started out and even less of Levemir, the insulin I used with her after she fell out of an almost 3 year remission, but he's very open-minded, he listens, and we share a mutual respect. He often told me he doesn't know who learned more about the newer insulins and feline diabetes over the course of Alex's life... him or me. If you like your vet and think he would make a good partner, it's probably worth your while to see if he's willing to work together.

I'll try to check in on you again tomorrow. My work schedule is crazy this week. I'm trying to fit everything in because I have to report for jury duty next week and the week after that, but I try to log onto the FDMB at some point every day, even if it's just for a few minutes.

 

[Woody/Cheryl (mom)]

Jill, I am glad you brought that up about the solarstar safety check. I have always made sure to get a drop come out of top to make sure needle is not blocked but have only done the 2u test a couple of times. I sort of felt I was wasting insulin but I am thinking now, after your reminder, I should fully follow solarstar instructions to be absolutely accurate. I think Woody got his insulin last night. His urine level dropped a little last night which happens when his bg goes down. Just tested +11 at 158, retest was 141 immediately after. This lower reading was a surprise so will definitely test immediately before shot. Will delay shot if below 150 an hour from now.

 

[Woody/Cheryl (mom)]

okay, AMPS was 207 so staying on track with 1u BID. Did the safety check. Woody is actually doing really well today. Sort of playing with string. Staying near me. He doesn't have to run to potty every minute and drink water constantly. Tested negative for Ketones. So grateful for a good start.

 

[Critter Mom]

Great update, Cheryl!




Mogs
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[Jill & Alex (GA)]

okay, AMPS was 207 so staying on track with 1u BID. Did the safety check. Woody is actually doing really well today. Sort of playing with string. Staying near me. He doesn't have to run to potty every minute and drink water constantly. Tested negative for Ketones. So grateful for a good start.

What a nice start to the day! I also see "no ketones" and a 186 @+4.

Five cycles @ 1u bid and we're seeing some action. If possible, you might want to get another spot check in somewhere between +6 and +9. His nadir *may* be earlier on the lesser dose.

 

[Jill & Alex (GA)]

Woody is actually doing really well today. Sort of playing with string. Staying near me. He doesn't have to run to potty every minute and drink water constantly.

Love hearing this!!!
We call this "the whole cat report". Our kitties are so much more than BG numbers!

 

[Woody/Cheryl (mom)]

That's what I did with Alex's vet. He knew very little of Lantus when we started out and even less of Levemir, the insulin I used with her after she fell out of an almost 3 year remission, but he's very open-minded, he listens, and we share a mutual respect. He often told me he doesn't know who learned more about the newer insulins and feline diabetes over the course of Alex's life... him or me. If you like your vet and think he would make a good partner, it's probably worth your while to see if he's willing to work together.

Jill, Woody's lifelong vet has agreed to do join us on this journey. He spoke with his contact who basically told him that monitoring the overall health of the cat is the most important indicator, and not to get too worked up about day to day changes in the bg numbers which I certainly agree with. Everything he said was pretty much in line with the articles posted here so I am very excited to be back with this vet.

 

[Jill & Alex (GA)]

Jill, Woody's lifelong vet has agreed to do join us on this journey. He spoke with his contact who basically told him that monitoring the overall health of the cat is the most important indicator, and not to get too worked up about day to day changes in the bg numbers which I certainly agree with. Everything he said was pretty much in line with the articles posted here so I am very excited to be back with this vet.

Oh I'm so happy for you, Cheryl! It's such a great feeling to have a vet who is willing to work with you... be your partner!

Looks like Woody is bouncing from the blues he saw today. If I were you, I'd grab a before bed test and then get some sleep. This is one of those night's to save test strips, kitty's ears, and a perfect night to get some rest.

 

[Woody/Cheryl (mom)]

All is well on this end. Cut back today on interval testing to just enjoy Woody being on unit 1. Wanted to share something, and I wish I had taken a picture of it as soon as I saw it because it quickly disappeared. When I looked in Woody's bowl this morning to get an idea of how much food he had eaten, I saw a perfectly shaped heart where he had eaten in two spots close together. It was really a special moment for me to see that. I felt that I had received a message directly from Woody expressing his love for me. That heart is forever etched in my memory. Love my precious Woody!

 

[Critter Mom]

(((Woody)))



.

 

[Jill & Alex (GA)]

Wanted to share something, and I wish I had taken a picture of it as soon as I saw it because it quickly disappeared. When I looked in Woody's bowl this morning to get an idea of how much food he had eaten, I saw a perfectly shaped heart where he had eaten in two spots close together. It was really a special moment for me to see that. I felt that I had received a message directly from Woody expressing his love for me. That heart is forever etched in my memory. Love my precious Woody!

Aww, how sweet! He's such a special kitty!

 

[Woody/Cheryl (mom)]

I guess it is time to move on over to the Lantus page. Smooth surf right now and enjoying Woody getting back to his ol'self (before he was diagnosed). Grateful to have this bonding time with him. Counting my blessings and savoring each moment. Sorry to all those who have lost their precious ones. Just feeling that God matched us up with our kitties to take this journey because we are capable, caring, loving and willing to take the steps necessary to provide the care needed up to the very moment it is time to let go. I feel all your love throughout this site!! Blessings to all!

 

[Jill & Alex (GA)]

Isn't that the best feeling... seeing them get back to themselves! I remember that happening when Alex first started on Lantus. Once she got used to being back in BG numbers less than 100 she seemed to feel even better!

From my perspective, you're ready to move on over to the Lantus/Levemir ISG, but there's no rush if you're not ready. I know this is all still new, but you're catching on fast. You'll want to talk to your vet, but at this point I think I'd hang onto to that 1u dose for a bit longer since you know it has the ability to take Woody down to at least 119. He might even go a little lower if you give this dose a little more time.

Those mid-cycle spot checks will give you a clue as to when he'll clear this bounce. Watch for it.

The next step in this journey is to learn how Woody responds to insulin. We have a saying around here: ECID (every cat is different). Understanding the following concepts will not only help you regulate Woody, but an understanding will help make sense of the two Lantus/Levemir protocols used on the FDMB, the Start Low, Go Slow Method and the Tight Regulation Protocol.

• Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose
• Peak/Nadir - the lowest point in the cycle
• Duration - the length of time insulin continues to lower blood glucose
  

• Carryover - insulin effects lasting past the insulin's official duration
• Overlap - the period of time when the effect of one insulin shot is diminishing and the next insulin shot is taking effect
• Insulin Depot - a "spare tank" of insulin, which has yet to be used by the body
• LANTUS & LEVEMIR: WHAT IS THE INSULIN DEPOT?
• Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

Try not to be intimidated by all the activity in the Lantus & Levemir ISG. It's a busy place, but it has a great group of caring members who give very generously of their time. Sometimes the language or jargon puts people off. Don't let it! Here's a little help 'til you get used to it:

• The Lantus & Levemir Land Slang Dictionary - Created by lynn and bear (ga) with a little help from her friends, circa 2008; updated & edited numerous times over the years by members of the Lantus & Levemir ISG

• FDMB Glossary - common abbreviations & definitions used throughout the Feline Diabetes Message Board

Trust me, this will all become second nature and make perfect sense in no time at all!

 

[Woody/Cheryl (mom)]

Thanks Jill, I appreciate all your help. Woody is doing so much better after starting Lantus, even though his numbers don't exactly show it. His coat is much tighter and he may have put on some weight. We are going to see the vet on Monday so will know more then. This vet will want to go slow or maybe very, very slow, so I suspect the SLGS will be more what he will go after. After Woody's 27, I will always at a minimum get a PS twice a day. I do need to get more readings. I know they will help. I have another advantage that is probably unheard of. I can actually measure Woody's urine output because he goes in an "unlitter" box. He has done this for years, bless his heart. He even scratches it like there is litter in it. I figured it may be a good data point to have so I pour his urine in a vessel with a screw on lid that has ml measurements. I record the data every 24 hours. An increase in urine output plus a high AMPS was the warning I heeded to watch out for "the unknown" prior to Woody dropping down to 27. I knew something was up but was not expecting that!

Those mid-cycle spot checks will give you a clue as to when he'll clear this bounce. Watch for it.

I notice Woody's urine output is starting to go back up today, so I suspect his bqs are going up or perhaps a bounce. As CG do you ever get used to bounces? So can Woody clear a bounce and stay on the same dose?

Again, thanks Jill for all your replies.

 

[Jill & Alex (GA)]

Note: References to BG numbers are from meters calibrated for humans.

An increase in urine output plus a high AMPS was the warning I heeded to watch out for "the unknown" prior to Woody dropping down to 27. I knew something was up but was not expecting that!

Hmm, interesting. I never measured Alex's urine output, but I did notice the size of her pee "balls" (clumping litter) were larger when her numbers were high. Urine output and appetite returned to "normal" when I could maintain her BG numbers under 100 mg/dL overall.

As CG do you ever get used to bounces?

Most caregivers have a hard time dealing with bounces. However, if one views them as part of the process they're so much better off emotionally... rather than getting upset every time the meter registers a high number.

When I look at a Lantus or Levemir spreadsheet, I look at what I call "waves of action". Initially those waves last about 3 days... sometimes more... sometimes less. Start with a low and then count forward 3 days. *Usually* the bounce will clear sometime in that 3 days (5th or 6th cycle). That leaves high cycles where you can test minimally, get extra sleep, run errands, play... generally do all the "normal" things that you might miss out on when Woody requires close monitoring... if one learns how their cat responds to insulin. That's why learning about onset, nadir, duration, carryover, and overlap is one of the best things caregivers can do for themselves. Otherwise, caregivers tend to become chained to their cat's ear. Although, I would be remiss if I didn't say that doesn't mean one can stop testing entirely when kitty is bouncing because cats love to surprise us!

Think of every data point as being a piece to a puzzle. The more pieces you have, the clearer the picture becomes.

So can Woody clear a bounce and stay on the same dose?

He certainly can clear a bounce and stay on the same dose.

The question is will he stop bouncing on the same dose? Some cats do, but most don't. The ones that do are usually newly diagnosed cats who are fortunate to go off insulin after a change in diet and a short stint on insulin. In *most* cases Lantus/Levemir kitties will require a dose increase(s) to flatten out the curve.

You can see marked differences if you look at Alex's spreadsheets. She started Lantus in 2006 prior to the acceptance of TR with Lantus/Levemir on the FDMB. Lantus was also relatively new at the time (in the USA) and we stumbled all over the place trying to figure out how to best use Lantus. It took 3 months to get her OTJ and that was with dosing that was considered to be a bit aggressive at the time. We were able to accomplish the same in 8 weeks with TR and an experienced caregiver (me). LOL!

Fast forward to 2009 when she fell out of remission. That time I tried Levemir and the Tight Regulation Protocol. The TR Protocol allows for aggressive dosing to pull numbers down quickly as well as flatten out those curves faster. The action is similar (not exactly the same) as Lantus. You can see how I dosed her aggressively and she was back OTJ within 8 weeks. At that point I was no longer new to feline diabetes, I had a very good feel for Alex's response to insulin, I felt confident in my own abilities, and I understood the action of the insulin so I felt comfortable being aggressive. Don't be put off by all the testing on her 2009 spreadsheet. The only reason I tested her so much was I wanted to use her spreadsheet as a teaching tool to illustrate how Tight Regulation and shooting full doses on low preshot numbers (50 mg/dL or higher) enabled a caregiver to achieve the shallow flat curves both Lantus and Levemir are known for.

However, the point is, she was able to go OTJ twice. The first time using a non-aggressive method and the second time using an aggressive dosing method. To sum it up in a nutshell, the more time spent in normal numbers (50-120 mg/dL) the better chance the beta cells will heal and regenerate allowing kitty to go OTJ sooner than later. Of course, this is providing kitty's pancreas is able to heal. If not, cats can live a long, happy life on insulin so while a kitty being off the juice is a bonus... the goal is to have a healthy and happy kitty!

Sorry for rambling on. I didn't intend for this post to become quite so lengthy!

 

[Woody/Cheryl (mom)]

I am so glad you shared your experience. I think Woody is approaching or in a bounce. He peed about 230ml in the last 8 hours. His reading was 502 at +8 this morning. Somehow I let Woody slip to the noon to midnight schedule...with past delays during that last bounce when he was on 2 units. I should have tested more yesterday but was wanting to give Woody a little break from ear pricks. I notice on 10/13 he went from blue +7 to black +9 in just a couple of hours. So I will learn to watch for a pending bounce and test more. No expert yet on urine output, but +300ml in 24 hours may signal a bounce is close approaching.

I don't worry about the highs because Woody's Fructosamine test came back at 616 when he was diagnosed. I believe he can handle the highs okay while we figure this out. The lows scare me a bit although he did make through the 27 ok.

My goal is to keep Woody happy and prolong his life...hopefully remission is in his future but if not...as long as Woody can stay around and thrive, I am happy with that.

Want to thank you again!!

 

[Jill & Alex (GA)]

I am so glad you shared your experience. I think Woody is approaching or in a bounce. He peed about 230ml in the last 8 hours. His reading was 502 at +8 this morning. Somehow I let Woody slip to the noon to midnight schedule...with past delays during that last bounce when he was on 2 units. I should have tested more yesterday but was wanting to give Woody a little break from ear pricks. I notice on 10/13 he went from blue +7 to black +9 in just a couple of hours. So I will learn to watch for a pending bounce and test more. No expert yet on urine output, but +300ml in 24 hours may signal a bounce is close approaching.

Your instincts are on track. Something is happening. Is it the beginning of a bounce or did Woody throw you "a high before a break"?

Today's AM cycle will be the 6th cycle after the low of 119 on 10/13. In the beginning, it *usually* takes 5 - 6 cycles to clear a bounce. It's certainly possible (anything is possible), but not probable that Woody dropped yesterday and is beginning a bounce. However, it's more likely what you're seeing today is a high before a break. Some cats will throw an unusually high number that appears to come out of nowhere before they clear a bounce (sometimes, not all the time). I'd almost bet on that "HI" at PMPS last night being a high before the break. His numbers dropped to 502 @+8. I suspect they'll be even lower at AMPS time. Time will tell. We'll have a better idea as the day goes on.

Getting back on a desired schedule...
Probably the safest/most commonly used methods to getting back on schedule is to skip a shot and then shoot the next shot on your desired schedule, or move each shot by 15 minutes at each shot time until you reach your desired time, or move shot time by up to an hour if kitty is beginning a bounce and numbers are high. 6am/6 pm seem to be popular picks for shot times. Some shoot on a 5am/5pm schedule so they are able to get a spot check or two in before leaving for work.

Looking forward to seeing what the day brings...
Have a good one!

 

[Jill & Alex (GA)]

Ok, I just saw the AMPS of 521. So much for seeing a ps number lower than 502! You would think I would know better than to put these things in writing when we're talking about a newly diagnosed cat!
Let's see how this plays out...

 

[Woody/Cheryl (mom)]

We did see some numbers lower than 502 and 521 but back to 539 at PMPS. Not to mention record high urine output of 525 ml. Would like to start seeing some more consistent numbers below the red and black zones... After seeing (351@+2) and (347@+5) I was sort of expecting a flatter curve until (478@+7) and a PMPS of 539. I am grateful there was not a HI reading. Will see what tomorrow has in store.

 

[Woody/Cheryl (mom)]

Let's see how this plays out...

64 at +11. Noticing Woody walking around more to places he usually does not circle around...eating. Suspected a low number and got one. Will test again in about 15 minutes. Hate to withhold food at the moment because don't want it to drop further if I can help it at all. Will delay shot due in about 30 minutes...till I reach 150 or so...Not so used to this low on a 1 unit dose.... got a an 85 in about 20 minutes, but could be food. At 100 20 minutes after the 85..closed the food bowl and will test again in 30 minutes to see if reading is near 150 for his next dose. Reached 190 and gave dose..will test again at +1 and +2.