Need Help with wide swings in BG

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sulile

Member Since 2012
Facts: Buddy - 16 year old male
Diabetic for 5+ years
Meds: Vetsulin for 2-3 years until discontinued; well controlled
Humulin for 2+ years - well controlled on 5 units 2X a day until a hypo event in November 2012
Lantus since 11-26-2012

Other Medical Conditions: HCE (hypertrophic cardiomyopathy)

Crisis: Hypo event where BG went to 20 on November 11, 2012; vet switched to Lantus

Current dose Lantus: 2.5-3.0 Units twice a day

First, I am totally stressed out as I cannot seem to get any kind of consistent curve for Buddy.
My first attempt at a spread sheet is attached.

I am very concerned since yesterday he had a BG=60 at +10 hours, the lowest it's ever been since switching to Lantus (that is, the lowest I know of). I did the check at +10 and +11 after reading one of the stickies that suggested this is a good idea. I was shocked when I saw the 60.

I've been trying since last November 2012 to get something that works. But as you can see from the spreadsheet, he is all over the place.

We intially started Buddy out with 1, then 1.5, then 2, 2.5 etc. Units of Lantus. He stayed in the mid 300-s to 500's through November and most of December, so we increased it to 3 units.

He had a dental cleaning yesterday as he had some gingivitis and the vet wondered if this could be keeping him high. Plus he has had an upper respiratory infection through all of December. Seems to be improving.

Please help...I am a basket case.

P.S. Not sure whay the first 4 rows do not have color-coding for Blood Glucose values; I added them last.
Susan
 
I have heard that dental issues and other infections can cause BG to increase. Maybe if those have been taken care of, he may have more "normal" numbers.
I'm pretty new at this, so I don't want to say anything wrong...I know that Lantus works best with relatively constant dosing and that any new dose should be kept for at least three days. You've been jumping his doses around quite a bit and that may be contributing some to his numbers jumping around. Here's a link to the Lantus "Tight Regulation Protocol" that a number of people here use to manage their cats. You may find it helpful.

I would keep using the 2.5 dose steady for the next 3-5 days, testing before every shot with another test in-between somewhere. After a few days you may know more about whether he needs to decrease, increase or stay the same. There are people here far more knowledgeable than I and they can give you better information.

Just for asking, what are you feeding him? When in his cycle is he eating?
 
Susan, Dont panic! We are here to help . Plus you are doing the right things - home testing, switch to a better insulin (Lantus) and starting a SS!

However I agree with MB minx and your vet, infection can make a big difference to blood glucose levels since it spikes the cortisol. Infection alone can cause cats to become diabetic so having his dental done was a great idea. After my Bailey had a dental my vet said his blood glucose levels could drop and he would need less insulin within a few days of the operation.

Anyway I am going to ask an expert to pop over and have a look at your SS etc.

Meanwhile please let us know what you are feeding him.

Wendy
 
Lantus likes consistency - dose-wise and well as time-wise. I'm not an expert, but I would say you need to pick a dose that you can shoot every 12 hrs. Great job on the testing, keep that up, and then you can see where Buddy is after a few days of consistent shots, and be able to make a decision on whether he needs more or less insulin. Lantus also requires a depot that has to be filled, so it's not unusual to not see results right away, and that's why you have to hold a dose for several days.
 
Welcome! Glad you found us - I'm sure we can help Buddy get back on track. One thing I noticed is the vet was making changes in .5u increments. We like to make smaller changes in .25u increments except in special cases. You will definitely want to strive for consistency in the time you give insulin and also with the amount. You will want to find the dose you can shoot safely every 12 hours. I hope the health issues get resolved soon - that will definitely make a difference. Also, smaller meals spaced throughout the day will help the pancreas along (as opposed to 1 or 2 big meals). Hang in there! Read as much as you can and keep asking questions!
 
Welcome!

We've got some reading for you to do that should help you understand more about using Lantus. Most importantly - no dose hopping! You do not decide your dose based on the pre-shot number; you decide it based on the nadir - the lowest point in the 12 hour cycle, usually around 6 hours after the shot. That is part of the reason your numbers jump around so much - the full effect of changing from 2 to 3 units may show up the next day.

Here's a starter bit to read and maybe print out:
STICKY: LANTUS & LEVEMIR - TIGHT REGULATION PROTOCOL

What are you feeding right now? How much does your cat weigh and what is his ideal weight?
 
I have had the same problem with my diabetic kitty. She had two teeth pulled and then vet put her on antibiotic. The antibiotic killed all her normal flora allowing her eye herpes to flare up causing severe conjunctivitis. All the stress of the teeth and the herpes caused a cat well controlled on lantus to have glucose values of 400. No matter what I do the values are up too high. I have increased the lantus dose from 2 units to 2.5 units twice a day. No carbs in diet. It must take the body a long time to get over the stress and settle back down.
 
My Maggie was well controlled on Levemir (which acts very similar to Lantus). Then she was diagnosed with HCM (Hypertrophic cardiomyopathy). At first, it didn't effect her glucose. Later her bg varied greatly, I think depending on how she was feeling.

Infection and pain does cause the blood glucose to go up. So if the dental doesn't help, check his other health conditions. In Buddy's case, how is the heart disease being treated? Could he need an adjustment in his heart meds? I wouldn't be surprised if, due to his heart condition, he might have problems with fluid retention and that might be enough to cause Buddy's bg to go up.
 
Thanks everyone for the great comments.

Buddy is eating EVO Ancestral Diet Dry - Turkey & Chicken Formula (the one lowest in carbs ~ 7%).
He is a normal weight: 11 lbs. He's never been overweight in fact.
He is a grazer; eats little bits throughout the day.

I've taken 3 more readings since I got home today and his BG numbers are trending down. So here are his numbers today:

Jan 10, 2013
7:30 A 547 - 2.5 Units Lantus
12:30 P 424
4:30 P 414
5:30 P 355
6:30 P 328
7:30 P 298

I updated spreadsheet. This is so different from yesterday.

Should I give him 2.5 Units at 7:30 tonight? I aim for 7:30 AM and 7:30 PM as times for shots.
But when the pre-shot number is 60, as it was yesterday, it's hard to make myself give a shot. I'm so afraid he will crash again. I know it's better to dose at the same time everyday. But I just couldn't make myself do it yesterday and several other times when his numbers were much lower than normal. Normal for Buddy is pretty high.

Susan
 
Ok so you have chosen a dose.. great! Now lets see where that gets him. As well as the link provided by BJM, this one on shooting and handling low numbers may help: http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=147

Can I suggest you come over to the tight regulation forum and start posting regularly there? That way we can help as experts will constantly be looking at your sheet and will help with dosing, when to increase/decrease etc... You will get more eyes on your cat in that forum.
 
As others have said, you need to shoot consistently but I also see the dose being increased in large increments. We typically increase by only .25u unless the nadir is over 300 and then we would increase by .5u max.

However, in your early days of this, you ewe rent getting enough tests to tell where his nadir was. I've seen cats be at 300 at AMPS, 40 at +6, and 300 at PMPS. If you don't catch the low number, your tendency is to want to continue to increase which can result in an overdose.

I'd suggest you leave him on 2u for at least six cycles and try to get some mid cycle tests as you have been doing lately. Lantus can be compared to a cruise ship. You can turn the wheel but it takes time to change the course.

I will also say tht he needs to be on low carb canned or raw food and off the dry food. We've seen dramatic changes in the amount of insulin needed when the kitty was switched to wet food.
 
Thanks everyone. I know the wet food is better and I've gone through trying all kinds of the recommended Fancy Feast varieties. I have bought so much food he just will not eat. Will keep trying.

I'll stay at 2 Units for 6 cycles (that's 3 days, right?).
I like the analogy of the cruise ship....I've been struggling to understand exactly how Lantus works.
So when I inject, that injection is not immediately being used by the body? It's stored in reserve for later?

I've read the sticky notes about what to do with low numbers. So if I get a reading like 60 again, do I:

1) skip that dose altogether, or
2) go ahead and give the 2 Units at the designated time, or
3) give a reduced dose (like 1.5?) at the designated time, or
4) delay giving the shot until I'm sure his BG is coming back up and then give 2 Units?

I'll put this same post on the Lantus tight regulation forum.

Susan
 
Maryrat said:
My vet says never give dose if glucose is is 60 or less. Better too high than low.
Click to expand...

Yikes! I hope you have the data to show that is safe to do for your cat! We suggest new folks start at a no shot level of 200 and as the data accumulate to show it is safe, can gradually reduce that limit.
 
And remember those stickys are for the tight regulation protocol. One of the requisites to use that protocol is that kitty be on low carb canned or raw food. The reason is because the TR protocol is aggressive and we use HC canned food or gravy to bring up low numbers. If Buddy's numbers go low or he drops fast, it takes way too long for the dry food to kick in and stabilize his BG.

And yes...one the depot fills at the 2u dose, then he will start using each injection you give.
 
Marje and Gracie said:
And remember those stickys are for the tight regulation protocol. One of the requisites to use that protocol is that kitty be on low carb canned or raw food. The reason is because the TR protocol is aggressive and we use HC canned food or gravy to bring up low numbers. If Buddy's numbers go low or he drops fast, it takes way too long for the dry food to kick in and stabilize his BG.
Click to expand...

Are there some protocols for the "Relaxed" protocol? Maybe Buddy should be on that since he's eating EVO dry food (7% carbs). I couldn't find a protocol for the Relaxed group.
 
sulile said:
Are there some protocols for the "Relaxed" protocol? Maybe Buddy should be on that since he's eating EVO dry food (7% carbs). I couldn't find a protocol for the Relaxed group.
Click to expand...

There is only one current published protocol for cats on Lantus, which is the one linked. When people refer to a "Relaxed" protocol it means for whatever reason, they are unable or unwilling to follow the guidelines set forth in the protocol (low carb, canned diet only, testing at least 3 times daily [before each shot and a mid-cycle test], and adjusting insulin according to the recommendations in the protocol). There are other things you can use to boost BG if he needs it while you're working on the transition--a small amount of ice cream or plain yogurt (with sugar), honey, karo syrup, etc. I would also see if he will eat a food with gravy just for those purposes--sometimes cats will turn up their nose at pates at first but they'll eat gravy foods readily. Then you can keep a couple cans on hand just for the purpose of boosting BG if it needs it.

Even though you haven't been able to transition Buddy off the dry food yet, I would still try and follow the protocol as closely as possible, and keep working on getting Buddy eating canned food. It's hard with some cats, but don't give up! You just need to keep trying different foods, trying different tricks, and eventually one should work. Have you seen these tips for transitioning? http://catinfo.org/#Transitioning_Dry_Food_Addicts_to_Canned_Food_ There is some great advice there. One of the most common obstacles to transitioning that people continue to free feed the dry food while they are offering the canned. If you're leaving food down for him all the time, that is probably your problem. I would start doing portioned, scheduled feedings of dry food. You want to feed several small meals throughout the day, and not give more food than he'll eat in one sitting (4 times a day is a good number of meals for cats). Getting him on a feeding schedule is really important because you need to work with his natural hunger drive.

I would also work with foods you know he already likes--what's his favorite people food? Chicken? Beef? Fish? Eggs? You can use these with the canned to get him eating it, and shop around for cat foods that resemble these flavors. For example, Merricks makes a food called "Cowboy Cookout" that my picky cat LOVED, but she wouldn't touch Fancy Feast because she wouldn't eat foods with liver or byproducts. I would get a selection of different brands and foods in small cans and keep trying different things. I would also pick up some Fortiflora--it contains the same flavoring they put in dry food to get cats to eat it, and can help a lot.
 
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