Newly Diagnosed, morning reading of 61 on Lantus

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charliecat

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Good morning,

My cat Charlie was dx about 3 weeks ago and we've had some trouble getting him regulated. He was started on Humulin N, didn't take to that and ended up DKA. After 4 days in the emergency room we took him home and for the past week I've been giving him 4 units of Lantus 2x a day. We had a blood glucose curve done yesterday at the vet and his numbers ranged from low 400s down to high 300s and back up to low 400s. The vet raised his dose to 4.5 units but last night I think I accidently gave him 5 units. This morning, 12 hours after his last shot and before feeding or his morning shot his blood glucose level was 61. I didn't check him twice but I tested myself and I think this number is pretty accurate. I skipped his morning shot (should have been at 7:30), and fed him his normal 3/4 can of Purina DM with a little bit of dry food thrown in (he's been on an all canned food diet). I'm going to test his blood suger levels every 2 hours throughout the day but I'm a bit confused as to whether I need to give him the shot I skipped and, if so, when. Traditionally his levels run high - we've not been able to get him regulated yet. I apologize for the long explanation but his new vet doesn't know much about Lantus and I'm hoping the expertise of the forum can help me figure this one out. Right now he's acting completely normal with a good appetite, normal thirst, and standard energy level. Thank you for your help!!!


UPDATE: I just checked his blood sugar level again and he's at 167. This is 14.5 hours after his last shot and 2.5 hours after eating.
 
Fantastic that you skipped the shot. A number like that so late in the cycle certainly calls for skipping and then for a dose reduction at the next shot. He could have gone very low mid cycle.

Many cats are so stressed at the vet with strange sounds, smells and other animals that they test much higher there than at home. Then doses determined at the vet are too high once they get home and relax. One of the many reasons we want you to home test!

Have you read the stickies on the Lantus support group forum? They have great info on how Lantus works and how to dose.

viewforum.php?f=9
 
Thank you for your quick response! I have read the stickies on the forum and I'm trying to take in and fully understand all of the great info. I'm just not super-familar with his curves yet since they've been all over the place so I appreciate the one-on-one guidence. I took another reading - 167 at 14.5 hours after his last shot and 2.5 hours after eating and will continue to do so throughout the day. Thanks again for the support!
 
A morning preshot of 61 may mean a serious reduction in dose - there is no knowing how low he went overnight and you are very lucky he is still here. Thats a number you want to see in the middle of the cycle, roughly 6 hours after insulin, unless the cat is off insulin completely.

It is possible you started too high on the Lantus and won't find the right dose unless you start over at 1 unit, with urine ketone monitoring. Pop over to the Lantus forum and ask them what they think. I suspect they may suggest a major dose reduction, too.

He is going to start coming up through the day, so expect that. He's also likely to bounce, ie go really high as a result of the low. Get some urine ketone testing strips to monitor for ketones.
 
WHOA! That's sort of a ugly number for a morning reading....

There's a HUGE difference between Humulin N and Lantus. If your vet isn't truly familiar with how Lantus works then I understand their thinking BUT PLEASE don't go back to that dose.

Humulin works thru it's single cycle and when it's cycle is run, it's gone. It will not act again - you must give another injection to begin another cycle.

Lantus, on the other hand, works from a 'reserve' or like a 'timed release' pill - it slowly adds insulin into the system but for a longer time. With Lantus and hypo numbers, (this 61 ISN'T a hypo #) you'll need to test and watch over a 24 hour period. With this being your first-ish dose, you won't have that buildup that some of us with longer time periods have.

I don't feel like I have enough experience to give dosage advice so I'll let someone else walk you thru that.

HUGS AND WELCOME! You've found the best place you never wanted to be...
 
Welcome to FDMB.

I'm going to take a very different position on some of the information others have been providing. Charlie has recently been through an episode of DKA. Ketones are very scarey stuff. They are expensive emotionally and financially for you and physically for your cat. One of the best ways to keep ketones in check is insulin. That said, you're going to need to make sure that Charlie is getting enough insulin to keep the ketones at a trace or lower level and not so much insulin to drop his numbers too low. You can manage the insulin levels with food if you need to. If you are not checking for ketones at home already, you can pick up Ketostix at any pharmacy and do a urine test. Home ketone testing is an inexpensive form of prevention and a great way to keep your cat safe. (My cat was through an episode of DKA and I never want to do that again.)

I agree with Sue's observation that Charlie's levels may have been elevated while at the vet's office due to stress. Do you have any additional test data other than the two tests that you posted today? That will help us to better understand where Charlie's numbers are when he's home and not under a great deal of stress. If you can post the data you have or put it into a spreadsheet like you see attached to our signatures, that will help us to see how Charlie is doing on this dose of insulin. The spreadsheet is a great way for you to keep track of Charlie's progress.

Just to be clear, a BG level of 60 is not indicative of hypoglycemia. Unless you observe symptoms of hypoglycemia, all this may be is lower numbers than you're used to seeing. Numbers below 40 can be worrisome. Most of our cats have dipped a paw in numbers that are below 40 but because we test, they are not in that range for long and we bring the numbers up with high carb food. As long as you test and have high carb food to intervene, you are in control of Charlie's numbers.

As Lyresa (KT) noted, Lantus is a long acting insulin. Fundamentally what this means is that there is overlap between doses. So, unlike Humulin N which clears a cat's system in well less than 12 hours, Lantus peters out more slowly. By the time one cycle is fully ending, the onset from your next dose is kicking in. One of the other fundamental differences between N and Lantus is that Lantus dosing is based on the nadir or lowest point in the cycle. Thus, it's important for safety reasons to get pre-shot tests but it's just as important to get at least one test per cycle (i.e., AM and PM) in addition to the pre-shot. The spot checks will help you to figure out whether you need to adjust Charlie's dose.

Please let us know how we can help.
 
I just checked him again and he's up to 261, 20 hours after his last dose and 8 hours since he ate breakfast. He's still acting fine - energetic, hungry, and drinking. I'm going to call the emergency vet as they are the ones who put him on Lantus in the first place. I'd like to get their professional opinion on a dosage for tonight.

Thanks again for all the postings. THe information and support is very welcome as I work my way through this!
 
My concern is that the pattern of glucose tests that are available so far do a "checkmark" pattern - highs followed by an all of a sudden drop. That usually indicates the insulin dose is too high, though not by how much.

In addition, you indicated a possible increase of the Lantus another 0.5 units the previous night, and it usually takes Lantus a while to build up in the body, resulting in a gradual, delayed effect. So to suddenly have a value in the 60s at pre-shot was alarming to me after your reporting of pre-shot values in the 300s - 400s from the vet curve.

I understand the need to avoid ketones, which is why I encouraged getting urine ketone testing. If you can spring for a meter which tests ketones, you'll get the ability to check ketones as they happen, not delayed by filtration into urine. There are a few over the counter meters which can test ketones; here are 3: Precision Extra (we have a few folks using this), Nova Max, and now a 3rd one CardioChek Home Blood Testing Device info. Note: ketone strips are pricey, so try online vendors first where you may get a bit of a break on cost.
 
I'm working to get the spreadsheet posted and I'll be updating it from now on. Unfortunately I don't have much in the way of historic numbers for Charlie. He went DKA before I was able to get a glucometer and then we started him on Lantus. I started taking his numbers but the vet said not to bother for the first week because the numbers would be erratic due to his body adjusting to the Lantus. His first glucose curve since we started him on lantus was yesterday and he definitely does not like being at the vet which could have skewed his numbers into those high 300s/low 400s. Then I gave him too much insulin resulting in the 60 this morning. Phew! Luckily he's continuing to eat, drink, and act normal. I think I'm going to have to pick up some ketone strips.

My main concern was with skipping the shot this morning. Sounds like I made the correct decision in doing so and the levels have been slowly rising throughout the day. I'm going to call the vet this evening but I'm so glad I found this forum - I've received so much more information here than from the vet.
 
Great job on the spreadsheet. It looks perfect.

When you have a minute, you might edit your signature to include Lantus as your insulin and what food you are feeding. Saves your answering those questions each time you post.
 
I have a question that maybe Sienne or BJ or Lyresa can answer?
Noted above that kitty has been on lantus for a little while, long enough for the shed to be built up. He's been on 4? units for a week, and just was increased to 4.5u.
Not exactly sure how the shed "empties"......does just enough get used by kitty to drop the BG, or is there like this reserve that can dump any time? Reason I ask....I've seen dose reduction recommended, which makes sense, but a lot or a little? Is there this reserve that needs to be "lowered" for lack of a better word until kitty stabilizes, or will it empty "as required"? I guess what I am really asking is, does the dose need to be backed down a lot so that this doesn't happen again or several times again?


Carl
 
Vets maybe see 1-2 diabetic cats a year* ... on this board, all of us have, have had, a diabetic cat or two. So in terms of living the experience, as a group, we've got more than most vets. And, we research the 1 topic nearest and dearest to our hearts, while vets have to study a little about a lot and be able to pull it out in a moment.

That being said, many vets are willing to update their knowledge and it can really help to provide them with the most current veterinary articles on feline diabetes. I've linked one of them.

Glargine & BG control-Roomp & Rand_2009-JFMS

*edited to add: depends on the size of the practice, etc., but unless I've gone to a tertiary (specialist) care location, the vets I've seen do not have many diabetic clients.
 
Let's see if I can answer Carl's questions without getting too technical with this right now.

When the shed is really full and you give the next dose, it can drop numbers. Also, if the kitty was in a bounce and the bounce clears, the numbers can also come down quickly but that doesn't necessarily mean the dose is too high. We don't know which scenario applies to Charlie because we don't have the data. When you skip a shot, the shed will drain a bit and you "may" see higher numbers which is why Charlie's BG is going up now. Depending on the cat, it might take a cycle or two to refill the shed. Because every cat is different (ECID), and we don't have alot of data on Charlie, it's unknown how long it will take him to refill his shed.....especially because we don't know his fitting dose.

We typically do not increase the dose by .5u at a time unless the cat has nadirs over 300 so that was a big jump in dose especially considering, as others have said, that the curve was done in the vet's office. However, I agree with Sienne....when you have a DKA kitty, you have to be sure they have enough insulin on board and then you control the numbers with food. I also agree with her that it's very difficult to suggest a dose for Charlie without seeing more data.

I'm going to PM her and ask her to look at Charlie's SS with the additional numbers that are on it now. She's one of our most experienced members and with such a lack of data, I would feel more comfortable if she weighs in further.
 
Go ahead and insert a line or two with the number of days that you've been dosing the 4 and now 4.5 even though you weren't testing at that time, just so folks know how long the doses were held.

If you can get any glucose levels from the vet and and them to your spreadsheet on the dates performed, along with the notation that they were collected at the vet's office, that will help provide more data for review, too.

Besides glucose values, what have you observed in the following behaviors:

How much wet litter are you seeing and has it decreased over time?
How much water drinking are you seeing and has that decreased over time?
How is the appetite - ravenous, hungry, or disinterested?
How is the cat's coat condition and is he grooming?
Will he play at all? More or less than before?

(5 Ps to note in your monitoring: purring, preening, peeing, poohing, playing)
 
Ok -since we got him back from the vet last Sunday night, he's been steadily improving.
*He's always been a hungry cat and his appetite and attitude toward feeding is the same as in his pre-diabetes days. Not ravenous but happy and eager to eat.
*He drinks more and pees more than before he got sick, but this has been improving since the switch to Lantus. He drinks less than when he was on Humulin.
*He poops normally - no diarrhea - but the Purina DM makes for a pretty stinky litterbox.
*He's always had some dandruff but he cleans himself normally. He purrs when petted, sleeps on the bed with me again, follows our dog around to snuggle, hangs out with the family - all behavior characteristics from before his dx.
*He's not really interested in playing but that's really not much of a change from before

I'll certainly get his readdings from the vet and add them to his chart.

Thanks!
 
Once you're confident with the home testing and are getting reasonable control over the glucose, you might consider looking at some different, non-prescription, yet low carb foods.

Many of the cats here eat over the counter foods that were researched and found to be low carb (10% or fewer calories from carbohydrate). They are summarized at Binky's Page There is a newer list, but I can't find the link for it!
 
I'm not sure what's up with your spreadsheet, but it won't open. You may need to put the link between brackets. If you look at the link in your signature, only a portion of it is in blue. Try putting the url info around it and see if this helps.

What did the ER vet tell you?

If the spreadsheet isn't working, can you list out any test data that you have prior to today? If you can list it out the way it is on the spreadsheet (i.e., the +hours or hours after you gave a shot) that would be really helpful.

I'm just not comfortable suggesting that you reduce your cat's dose overly much. If ketones were under control at the hospital and the vet was giving 4.0u there, I don't know that it's wise to reduce the dose. Can you pick up some ketostix and test Charlie for ketones?

I don't agree with BJ about vets seeing only 1 - 2 diabetic cats per year. I think a lot depends on the practice, especially if it's a feline only practice. I just don't want to make those assumptions based on insufficient information. I also disagree about what a "checkmark" pattern means. If you look at my cat and Marjorie's cats' spreadsheets, you will see that both of our cats are prone to numbers that drop and then bounce back up. It is not an indication that either of our cats are getting too much insulin.
 
Your spreadsheet worked earlier. Try going back to your personal copy and publishing to the web again. (left hand side under file. Then copy and paste into your signature again)
 
Sienne and Gabby said:
I also disagree about what a "checkmark" pattern means. ....
Click to expand...

Sustained highs followed by a sudden low have been described as a "checkmark" pattern by vets and identified as a possible indicator of too much insulin. In fact, on some earlier data of Spitzer's, you pointed that out to me.

After hearing a description of the vet's curve vs this morning's preshot, it sounded very much like that.

There isn't enough home testing data at this point to know if that is what happened or not.
 
charliecat said:
Ok -since we got him back from the vet last Sunday night, he's been steadily improving.
*He's always been a hungry cat and his appetite and attitude toward feeding is the same as in his pre-diabetes days. Not ravenous but happy and eager to eat.
*He drinks more and pees more than before he got sick, but this has been improving since the switch to Lantus. He drinks less than when he was on Humulin.
*He poops normally - no diarrhea - but the Purina DM makes for a pretty stinky litterbox.
*He's always had some dandruff but he cleans himself normally. He purrs when petted, sleeps on the bed with me again, follows our dog around to snuggle, hangs out with the family - all behavior characteristics from before his dx.
*He's not really interested in playing but that's really not much of a change from before

I'll certainly get his readdings from the vet and add them to his chart.

Thanks!
Click to expand...

Every one of those signs you are observing with regard to the "5Ps" that BJ listed..... they are all very positive signs! A lot of the time, especially at the beginning of this "dance", we can become obsessed over "the numbers" and forget to look and see how the kitty is "doing"... Your eyes can be just as valuable a "tool" as the BG meter and those test strips and the spreadsheet are. When you see the opposite.....changes in mood, behavior, activity, appearance and LB habits, those can tip you off that something's not quite right with kitty too, even if the "data" might suggest otherwise. So always trust what you can see too.

Carl
 
Hi there and welcome!

I'm not able to see the ss either. . .

I too agree with Sienne to be cautious about dropping the dose. It's critical that kitty has enough insulin and enough calories during this post-DKA time.
Ketones can turn right back around, sometimes quickly. I've been there with my Black Kitty - twice.
Please pick up some ketostix so that you can monitor.

One very important feature of treatment with Lantus is that dosing is based on the nadir (lowest) value of the cycle, with only some consideration to pre shot values.
More monitoring and data are required to be able to tell which way, if any, this dose needs to go.
 
I have a suspicion that if you hadn't accidentally added an extra 0.5 to last night (a dose of 5.0), the 4.5 the vet asked you to take him to might've been a good level for him.
 
I think I fixed my spreadsheet so that should be working now - hopefully! The emergency vet suggested I go back to his regular dose - 4.0 - for tonight and at least tomorrow and check his levels every couple of hours to determine how he does. I'll post his numbers as I take them and then give them to my regular vet on Monday to determine the best course going forward. I'm taking him in for a blood test on Monday anyway to check my glucometer vs. the vets's glucometer so this will be a good time to go over the weekend's events and see how much his stress at being in the vet's office could have affected his #s.

Unfortunately, I don't really have much information prior to today. About 3 weeks ago Charlie was diagnosed at around 400 and put on 2.5 u of Humulin. Soon after his diagnosis I spoke with the vet about testing at home and ordered his glucometer. Before it arrived he got sick from his resistance to Humanlin and spent 4 days in the vet ER. He came home on Sunday evening with numbers in the 300s and a 4 U Lantus rx. This Monday morning before his shot I got a reading of 498. I called the vet immediately and was told not to worry, his body is still acclimating to the Lantus. She suggested I wait a week to test and in the meantime schedule a blood glucose curve. I didn't test any more this week and brought him in for his blood glucose curve yesterday. I don't have the exact numbers in front of me but they were taken every 2 hours and ranged between 350ish to low 400s. The vet raised his dose to 4.5 and I accidently gave him closer to 5 last night. Today's numbers are the only real, at-home numbers I have and they don't reflect an insulin shot. I realize this makes it difficult to make a recommendation but I do appreciate the support of everyone. Input from the forum and the emergency vet has eased my mind!

Thanks Carl for mentioning that trusting our cat's behavior is often as valuable as trusting the numbers. Charlie looks and acts great so even though I'm worried about getting everything under control, at least I can see that he's feeling pretty happy and comfortable.
 
Charlie's SS (spreadsheet) is working. Thanks!

I'm going to wax didactic so you have information. Lantus is what is called a "depot" type of medication. (We refer to the insulin depot in Lantus-speak as a "shed" but the correct term is depot.) When Lantus is injected, it forms a precipitate (microcrystals) under the skin. Over the first 5 - 7 days of using Lantus, a small amount of what you're injecting goes to build the depot. (This is why your vet told you to not worry about the high numbers. Not all of the insulin you're giving at this point is available for Charlie to use.) The depot is like a reservoir. Once the shed/depot is formed, you have this reservoir that you are continually keeping filled up. This allows for overlap between your current and next dose of insulin. When you skip a shot or reduce the dose, insulin is "borrowed" from the shed so it can take an extra cycle to see the effect of a lower dose. By the same token, when you increase a dose, you have to fill the shed to the new dose. It can take several cycles for the shed to fill up. What this also means is that if you tinker with the dose too much, you end up with wonky numbers.

I'm providing this info so you'll understand if Charlie's numbers are a bit "off." By skipping a dose, you've depleted the insulin depot. In addition, you've been making a couple of dose adjustments that are close together which may contribute to numbers not being what you'd expect. I think the ER vet gave you good advice -- I would check Charlie's numbers every 2 - 3 hours. I suspect that tonight the numbers will be high due to the skipped shot. If you see that they keep creeping up or if they are above 200 and flat, don't stay up all night testing. Get some sleep!

Tomorrow, or even tonight, I would strongly encourage you to pick up some Ketostix. This is particularly important if Charlie's numbers are high. (FYI - ketones can occur even with low numbers but they are more likely with higher numbers.) Catching ketones at a "trace" level and intervening can save you thousands of dollars vs. another hospital stay for your kitty. Testing every 2 - 3 hours at home will also give you a curve to compare with the one the vet ran. (Most of us do not bring our cat in to the vet for a curve since we can home test with far better results.)

What I would suggest you be attentive to is if Charlie isn't eating, or not eating as usual, and if he seems lethargic. While lethargy can be due to high numbers, it's also a red flag for ketones.
 
Hi Sienne,

Thank you for the detailed explanation - it's great to have. I just checked Charlie again and he's 314 at +2 hours. He ate a normal dinner - a can of Purina DM - and has been drinking and peeing as normal. He seems a little tired right now but nothing crazy and I'm keeping my eye on him. I plan to test again in 2 hours and maybe again after that. I'll run out and get the ketone sticks first thing in the morning - one episode of DKA is all I ever want or need to experience!

Thanks again for the your help!
 
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