Newbie - Introducing Benjamin

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cindyh

cindyh

Member Since 2012
Hello! I am writing to introduce my foster cat, Benjamin, and ask for help. Benjamin is 12 years old and was diagnosed on 7/2/12 when his labwork showed a BG of 558. He had apparently been diabetic for quite some time. Long story short, I work at the vet clinic where Benjamin was diagnosed. His owner, a lovely young lady, immediately bought all his supplies and he was started on 2 units of Lantus twice daily. A week later she brought him back for a recheck and he looked so much better, but she said she was going to have to euthanize him because she couldn’t take care of him. She has serious health problems and is constantly in the hospital, and her friends had proven unreliable in giving Benjamin his injections. Apparently Benjamin saw the “sucker” sign on my forehead, because he was rubbing on my legs and purring as his owner was signing the euthanasia form. So I offered to care for him until a new owner can be found.

He has been on 3 units of Lantus twice daily and eating 2 cans of Purina DM daily and his numbers finally started coming down. He weighs 12 lbs. I have been testing about every 5 days, but only pre-injection and 2 hours after. His numbers have been between 180-300. Then last night prior to his injection his BG was 27. He had no symptoms at all. I gave him some glucose and some dry food, that I know raises his BG, and then his can of DM. I kept monitoring him every hour until his BG was 68. This morning his BG was 198. I gave him 2 units of Lantus and his can of DM. 3 hours later, BG was 201, 7.5 hours later BG was 187.

So last night was a big fat wakeup call for me. And the big problem is that the vet I work for, who agreed to help me with Benjamin, is out of the country for a month. So I am pretty much on my own at this point and not sure what to do. Any help would be greatly appreciated.
Thank you.
Cindy
 
Hi Cindy,
First off, bless you for fostering Benjamin!
He's on a great insulin, a good low-carb diet (although you shouldn't be surprised if people suggest you ditch the Purina DM and feed less expensive low-carb canned foods like Fancy Feast Classics and Friskees Pates!). Also great that you are testing him. We're really big on home-testing here. :smile:

The first thing we will suggest is that you test before each and every shot from now on. I'm sure the 27 was a shocker, and thank goodness you checked prior to the shot! The other important thing is to try to get tests every day "somewhere in the middle". Ideally, you want to find his "nadir", which in theory should be about 6 hours after the shot, but ECID (every cat is different) so that +6 hours is not etched in stone. Do you know if your vet recommends dose adjustments based on the nadir number (and not on the preshot tests)? The protocols that we follow for Lantus all base the dose amounts on the nadir values.

The other thing that will really help you is to keep all your data on a spreadsheet. It's an amazingly valuable tool in treating FD. You'll see most people have links in their signatures that link to googledocs spreadsheets, all using the same format. If you would like to do so, we can help you to set one up.

I am very happy that you found this place, and I think you'll feel the same way. There's a huge amount of knowledge on this site, and lots and lots of helpful wonderful people who have been doing this "dance" for years that will be happy to help you with helping Benjamin.

Carl
 
Sounds like Benjamin is a pretty smart kitty to pick you as his mom in his forever home.

We have a Lantus forum which has some great stickies about how to use Lantus, how to dose it, etc. Reading the starred topics below the grey line on the top of the page will really help:

http://www.felinediabetes.com/FDMB/viewforum.php?f=9

As Carl said, a spreadsheet is a great tool for you and for advice givers. Here are the directions:

http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207

It is kind of tricky to set up, so if you need help, just ask.
 
Thanks, Carl. I am so glad I found this group. I also have a dog with Addison's Disease, and that support group has been invaluable to me over the years becuase of the amount of knowledge they have. I am sure this group will be just as valuable with Benjamin.

My vet (who is also a diabetic!) seems to be adjusting his dose based on the pre-shot number. But I have read a lot of the info here, mostly during the night last night while I was awake, and now understand the importance of that +6 hour number. I will start getting that number more often, and I would like to start a spreadsheet.

I know the DM is expensive, but his numbers were crazy until I got him off all other diabetic-friendly food and gave him only DM. It's working for him, so I am sticking with it.

So can you give me an idea of what pre-shot numbers I should be looking for tonight and how to adjust his dose?

Also, I had to go buy more test strips today for the meter that the owner bought and found they are over $60 for 25 strips. I need advice on a reliable meter with more reasonably priced strips.

Thank you!
Cindy
 
Thanks for the spreadsheet info, I will work on that.

Unfortunately, Benjamin is not in his forever home. I am only his foster home. He desperately needs his own forever home.

Cindy
 
What meter are you using, Cindy? Lots of people here use the ReliOn from Walmart. It is the cheapest and has the cheapest strips. If you really like your meter, you can buy strips on Ebay. We got them for our PrecisionXtra for less than half the price of the drug store. Just be sure the seller has a good reputation and the expiration date will work for you.
 
The meter is a OneTouch Ultra2. I got the test strips at Costco, so I was shocked at how much they were. I will check out Walmart.

Cindy
 
This morning his BG was 198. I gave him 2 units of Lantus and his can of DM. 3 hours later, BG was 201, 7.5 hours later BG was 187.
Click to expand...

OK, in "our" lingo, this would be what this cycle looks like:

AMPS 198 (shot 2.0u) 1 can DM
+3 201
+7.5 187

Did he eat since then? How long before his next scheduled shot?

Carl
 
Thanks for the clarification on the lingo!

He ate 1/2 can of DM at 4pm, he is due for his shot and another 1/2 can of DM in about 30 minutes. I will check his reading in a little while.

Cindy
 
Cindy,
Because you don't have much data at your disposal (other than the checks you've gotten on preshot tests on both 3u and 2u), I'm inclined to suggest a lower dose than even 2u, at least short term. But let's see what kind of number he gives you first.

Do you know if he's ever been tested for ketones, or ever shown any ketones from testing?

Carl
 
His PMPS - 211. Suggestions for his dose?

No, he has never been tested for ketones.

Cindy
 
Carl and Sue have provided very good information. With the drop to 27, clearly a dose reduction was in order. I'm leaning toward a "safety first" approach. For a cat at Benjamin's weight, his initial dose of Lantus should have been at around 1.5u. (initial dose = 0.25 x ideal weight in kilograms) It may make sense to lower Benjamin's dose while you're accumulating more test data and we can see how Benjamin is doing on that dose. You can do the same with 2.0u if you are able to monitor to make sure you don't have another visit to low numbers.

On the Lantus board, we recommend getting tests at pre-shot, +3, +6 and +9 which is a "mini-curve." Doing this a few times will give you a better idea of where Benjamin's onset and nadir are as well as what kind of duration you're getting. While I know you're thinking of getting a +6, not all cat's have read the rule book and have their nadir at +6. Once you know when onset and nadir are, you will have more flexibility with your testing. We encourage getting at minimum, one test per cycle in addition to your pre-shot tests.

You might want to take a look at the Tight Regulation Protocol sticky on the Lantus board. This will help you to understand the dosing strategy with Lantus.

Also, just to make sure... You know not to shake or roll Lantus? You may also find that getting U100 syringes that are in half unit increments will make life much easier since Lantus doses are adjusted in 0.25u increments. If you're heading to Walmart, the Relion syringes come in half units.
 
Thanks for all the info. I will give him 2.0u and monitor.

I have read both of the Lantus protocols. I was leaning more towards the low and slow since I can't always do that much testing, but after last night I know I need to do as much testing as possible right now. But I left the rule book in Benjamin's room for him, I was hoping at least he could read it! :-D

I will get some new syringes too.

Cindy
 
Cindy

Sienne has given you terrific advice. All I will add is to your comment about ketones.

Picking up some keto-stix to test his urine for ketones would be a great idea. Not sure if you have seen any diabetic cats at the clinic come in and be diagnosed with "DKA"? Nasty business, and very life threatening. Picking up some sticks (at any pharmacy) and being able to test him, especially when reducing the insulin dose will give you a great "early warning" system so that you can avoid problems in the future.

Carl
 
No, the clinic I work at is a very small holistic vet clinic and we don't handle emergencies. Thankfully I don't have to see any of the really bad stuff.

Wouldn't I actually have to see him pee to test for ketones? Because of the way I have to seperate all the animals right now, I normally don't see him pee.

Cindy
 
Yes, you'd have to know it was him, and catch him in the act. There are ways around that problem. Some people will set up another box and isolate the kitty from the others. Even if you can't catch him peeing (I had the same problem with Bob, he tends to be very private at the litter box), you can put plastic wrap under the surface of the litter to catch a puddle, then dip the stick in it. Or you can substitute aquarium gravel for the litter and it won't soak it up. But you have to be able to make sure you're testing the right kitty.

Carl
 
Hi Cindy,
I just wanted to say Welcome! You have some of the best people here who can help you! They recently helped me and I'm forever grateful.
Best wishes.... cat_pet_icon
 
Thanks, Chris! I feel better already having support.

Just checked Benjamin's BG +2 hours =255.

Cindy
 
Hi Cindy,

Why did you shoot 3u this morning? He already hypoed on that dose, why risk it again?

Lantus is not dosed based on preshot numbers anyway. It is dose based on the numbers you get at the nadir, which is usually between 6-8 hrs after a shot. And it should certainly never be increased in 1u increments. TR recommends waiting at least 3 days to do a .25u increase when the nadir numbers are lower than 200

This is from the Lantus TR sticky

"General" Guidelines:

Hold the initial starting dose for 5 - 7 days (10 - 14 consecutive cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 consecutive cycles).

Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction (See: Reducing the dose...).

Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.


Increasing the dose:

Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.

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.


Reducing the dose:

If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further.

If an attempted reduction fails, go right back up to the last good dose.

Try to go from 0.25u to 0.1u before stopping insulin completely.
Click to expand...
 
I can't generally do all the testing required for the tight regulation protocol, but I will have the ability to do more testing this week, but getting the number for the nadir is generally the most difficult time for me to be available to test.

Since I have screwed up now, I need to find the dose that I can stick with for a few days to get good numbers. I've got his spreadsheet updated, so if anyone has any suggestions, I would be very grateful. Thanks so much!

Also, I haven't given him any Lantus this morning becuase I am unsure what to do.
 
Cindy,
You did the right thing not giving a shot this morning. For a new member (and for just about everyone else) that is too low a number for insulin.
Carl
 
Cindy,
Can you start another thread and title it something like "Benjamin AMBG 61 Dose???"
Oh, put "Lantus" in the title as well...

Carl
 
First of all, you are doing a wonderful job with Benjamin! This is a tough disease and you saved his life by agreeing to foster him. I would follow Sienne's advice above (one of the dosing experts on Lantus) to go with 1.5u dose, starting tonight. No shot this morning. You need to let his shed drain a little bit.

You can post on the Lantus ISG forum if you want more help. Create a topic with the subject line
8/19 Benjamin AMBG 61

Create a link to this thread with the URL button above the editing box. Like this but all on one line:
[
url]http://www.felinediabetes.com/FDMB/posting.php?mode=reply&f=28&t=77331[/url]

You need to get a pre-shot test (to make sure you don't give him more insulin when he's already low) and a mid-cycle check, doesn't have to be +6. Lantus dosing is based on the nadir and the mid-cycle check will help with that. You can test him as soon as you get up, and right before you leave for work. Then right when you get home from work and before bed. Those are the 4 required checks each day.

The Tight Regulation Protocol and Start Low Go Slow require the same testing. The TR just moves the dose up after 3 days instead of 5 to 7 with SLGS.

Please ask lots of questions. We are anxious to help.
Liz
 
With Lantus, it doesn't matter if you are following Tight Regulation or Start Low, Go Slow. If a dose reduction is warranted, and a test of 27 gets a dose reduction no matter what dosing strategy you're using, you reduce the dose and it stays at the new, lower dose unless the test numbers dictate otherwise. Dosing is not based on your pre-shot number. The pre-shot in the 300s is expected. You would have wanted to keep Benjamin's dose at 2.0u, not go back to 3.0u. Because you shot the 3.0u and then 2.5u, you are seeing a number today that's too low to shoot.

So, for tonight and for the next 3 days, keep your dose at 2.0u.
 
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