Need dosing advice - should we give more now?

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Jennifer and Spot (GA)

Jennifer and Spot (GA)

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We lowered Spot's dose of .75 after he went down to 41 (35 was the first number) on May 2, so we are giving him .5. But his numbers are now all in the 300's. This can't be healthy for him. Should we stay with this dose or go back up?
 
You might cross post in one or both of the Lantus forums - relaxed and TR and add Lantus to your subject line here.

Sorry I can't help. No experience with your insulin.
 
Hi Jennifer,

He may need a dose somewhere in between .75u and .5u. Doses below 1U can be tricky because sometimes .75u can be too much, but .5u may not be enough. It is helpful to think of the differences in percentages. Lowering from .75u to .5u is a 33% decrease. Keeping the percentage change more in the 15-20% range may yield better results.

So, you're going to ask how in the world do you measure something like .6u? There are a couple methods.

The drop method explanation: http://felinediabetes.com/FDMB/viewtopic.php?f=10&t=15637#p156967

The drop method pictures: http://felinediabetes.com/FDMB/viewtopic.php?f=10&t=34424#p360982

Another way is to use an external measure. You can do that by making marks on an index card with a fine point pen, line up the card beside the syringe and use the drop method to slowly squeeze out enough insulin to line it up with the marks. Or you can use a device called a micrometer. http://s5.photobucket.com/albums/y161/FindingNeo/Micrometer instructions/
 
Hi Jennifer,

I understand your frustration with seeing higher numbers. As you know, I have no first hand experience with Lantus, so all I can do is read the literature and try to make sense of it. I know you aren't following TR, so I looked at the Start Low, Go Slow protocol.

The SLGS recommends you stay on a dose for a week or two weeks at a time. And then it says you would run a full curve and adjust as follows:
a) If the lowest point of the curve is above 150 mg/dl (8.3 mmol/L), increase the dose by 0.5 unit.
b) If the lowest point of the curve is between 90 and 149 mg/dl (5.0 and 8.2 mmol/L), keep the dose the same.
c) If the lowest point of the curve is below 90 mg/dl (5.0 mmol/L), decrease the dose by 0.5 unit.
Click to expand...

Seeing as how he went so low on .75 a few days ago, I don't think I would recommend increasing to more than that.

So I went and read the TR guidelines as well...
Spot has been running high for four days since you reduced his dose, right? TR states that :

Increasing the dose:
Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose.
After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
Click to expand...

Looking at your SS, I don't see anthing mid-cycle that indicates a nadir below 200. I would say that Spot meets the criteria for an increase to .75u. If you check tonight and don't see a low mid-cycle number, I would be inclined to increase in the morning. If you don't feel comfortable with going back to that dose, then maybe just a few drops skinny from .75?

Hoping that maybe someone with lots of L experience will hop in and correct anything I might have stated incorrectly. Seems sort of quiet here today...

Is Spot eating okay? Is he acting sick in any way?

Carl

Edited to include both TR and SLGS guidelines.
 
hi jennifer. got your pm just now. if you post on the Lantus TR forum many people would be able to help you and there's a lot more traffic there - hopefully you'd get a quicker answer that way.

spot is bouncing. he isn't used to being in the green numbers and it caused him to zing up to the red numbers. a bounce can last up to 3 days. i would guess we're seeing a subsequent bounce today - possibly he got into lower numbers the night of the 5th as well. hard to know. many cats go lower at night - it's very common. just looks like he might be going from one bounce to the next at the moment.

i think i would stick with the .5u for now and let him settle down. this is just part of using insulin - it's how the cat's body gets re-accustomed to the normal, non-diabetic numbers. the bouncing isn't specific to any insulin, just a diabetic cat. he will get over bouncing at some point. there isn't really anything one can do to change this part of the process.

he might need more insulin before long, but i think these high numbers are from bouncing, not that the dose is too low. i'd give it a little bit longer.

you're doing a great job of getting mid-cycle bg checks in, by the way. they really help fill out the picture as to what's happening. just hang in there, jennifer - he'll settle down and it will all get easier!
 
Thanks everyone. Spot always eats fine. He is hungry Hungry. I do get worried because when he runs high he acts quite sick and flops down near the water bowl and laps and laps and laps. It cannot be good for him to remain with such high numbers but you guys know more about this than I do so I will keep him on .5u for another day or so and see what happens.
 
my understanding is that highs from bouncing are not as bad for them (ie, not as much to worry about) as highs from not getting enough insulin. i understand your worry, though. we would normally say give 72 hrs after the bounce-causing "event" - which in spot's case would initially be the 35 and other greens that day - and if it's still high to go ahead and increase.

it is possible for a cat to bounce from yellows or blues, though, if they are used to pinks and red numbers. i can't see another event to cause a bounce, but it just looks bouncy still, and if he's a quick bouncer, ie, hits a lower number and is immediately gone high from it, it could be from the night that you missed. i'm not complaining about your testing, though, so don't take it like that. you've got to sleep. i'm just wondering if that's where it was.

BUT, let's watch him today and if he doesn't come down some we'll re-evaluate the situation. Vicky could be right that he needs something in between .5 and .75. if the .75u dose got him to 35 before, it could do it again, and we'd like to avoid that!
 
I agree with Julie's advice to continue holding the dose. Highs can look scary, but you don't want to let them panic you into raising the dose too quickly. Julie's right that the highs from bouncing aren't as bad as the ones from too low a dose because the hyperglycemia isn't constant. I would let the .5u settle for a little longer and see how he does. It can sometimes take a week or more to get a good picture on whether the dose is effective or not.

If you do end up raising the dose, I would recommend "fattening" up the .5u rather than doing a whole increase to .75u. Basically, that's.5u plus a drop or two. The next dose increase you could do after that can be a "skinny" .75u--that's .75u minus a drop or two. Bandit often needed these finer dose changes. Keep in mind that cats are rather small, so they need to be dosed on a much finer scale. It would be awesome if cat syringes existed with markings to help with this, but unfortunately we have to make do with the smallest human syringes available.
 
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