Not responding to his dose. Safe way to control very high #s

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Kot

Kot

Member Since 2013
Bailey was on 0.75U of Lantus BID till recently with more or less of a success. Then, this fall, his numbers would plunge into hypo range which, I thought, indicated a reduction in dose. Tried for 0.5U but his pre-shot numbers went consistently up. I've switched back to 0.75U because I knew how to get him out of low numbers quick and did not want to risk having a DKA. Long story short, about ten days ago Bailey went into a "death spiral" with very high numbers. After consulting with vet I increased the dose to 1U and now to 1.5U Lantus BID. After testing BG two hours after shot, Bailey's numbers don't go down. I started supplementing with Novolin 1U three times a day to keep BG in 200's range. I know mixing insulins is not a good idea, just don't know how to proceed. Without Novolin, BG is staying in 500's - 600's range. How can I adjust dosage of Lantus (what if it is a bad batch?) and wait out two-tree days for each dose adjustment while Bailey's numbers are THAT high?

Sorry for not updating my spreadsheet - last several days were a blur of testing and shooting.
 
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I don't see any spreadsheet data past December 23rd - we need to see that to help you.

I think it's time to put the Novolin in the back of the fridge and lower the Lantus dose. Too much insulin can often look like too little. Bailey has given you numbers in the 20's at the 0.75 dose, showing it's WAY too much insulin. Please lower the dose to 0.5 units. On November 8th, he even showed you that 0.5 units was too much. Reductions should be taken if you see below 40 for a long term diabetic. And in future, never shoot a dose if you see below 50 for preshot. That is just too dangerous. Experienced people here never shoot below 50.
 
One of the ways you can tell that 0.75u was too much insulin is Bailey would go into green numbers and then you see really high numbers. On cycles when you don't test, he's probably going low again and bouncing up hard into black numbers.

I agree with Wendy. He needed a dose decrease from 0.75u, not an increase. More tests will show you what he's actually doing.
 
I can't agree more with Wendy and Marje.

FWIW, I managed Gabby's diabetes for 6.5 years and was very comfortable with both shooting and managing low numbers. I would never shoot numbers below 50 and if I saw a number like a 22, I would test every 20 - 30 min. to make sure numbers were coming up. Seeing a 22 and not testing for 6 hours (and then shooting a PMPS of 44) could put your kitty in jeopardy. BG when it's that low gives you no margin for error. Likewise, I would never shoot a 25 nor would I encourage anyone else to do so.

I would encourage you to get a "before bed" test every night. Given the bouncing, routinely getting some tests during the PM cycle may help you to sort out Bailey's numbers.
 
I agree with Wendy and Marje. Too much insulin can have numbers that look like too little. I would put the Novolin away in the frig, and reduce the Lantus dose to 0.5 BID, as from the numbers we can see on his spreadsheet the 0.75 dose was too much. Also, shooting insulin when the pre-tests are below 50 is just not recommended and very dangerous. I think the high numbers you are seeing is from him bouncing from low numbers that you don't see during the cycle. Bouncing can be a vicious circle, especially when a short acting insulin is given as a bolus which brings the numbers down too fast. Been there, done that. Also depending upon how bouncy the cat is, they can last up to 3 days.
I also think that giving 1 unit of Novolin TID is too much, and I can't see your spreadsheet numbers, but you would need to keep track of all the nadirs of the 5 injections of insulin and that would be difficult, like juggling 5 balls 24 hours a day.
 
So, just to clarify a bit: I NEVER gave Bailey insulin while he was anywhere below 120. The spreadsheet would be very cumbersome if I showed all the tests I did after I saw a low number up to the point when the reading was high enough to shoot. When reducing his dose to 0.5U and trying it for a few days I saw his pre-shot numbers consistently above the renal threshold. I judged it to be more unsafe for the cat since he is in the last stages of renal failure, had 2 serious episodes of DKA and I was able to deal with his low numbers.

I will try to post my notes on the testing I did in the last few days.

Putting Novolin away: I shot 1U of Novolin at 6am today with AMPS at 286. Checked at +4 and had 176, at +6 - 194; here I gave Bailey food and gave him his 1U of Lantus (Bailey is very responsive to food spikes). Checked again recentl : at +9 for Novolin shot and +3 for Lantus shot - his number is above 600. So, that tells me that Novolin wore off (from previous experience I know it works for Bailey for about 6-7 hours) and Lantus did not work. I know it is an awesome idea to slowly raise or drop the dosage but how do I proceed if I put away Novolin, try 0.5U of Lantus for two-three days and in the meanwhile Bailey's numbers are above 600 for these days?

Thanks!
 
Kot said:
When reducing his dose to 0.5U and trying it for a few days I saw his pre-shot numbers consistently above the renal threshold.
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We determine the Lantus dose based on how LOW it takes the kitty. I see hardly any mid cycle tests when you reduced to 0.5 units in November, but I do see a 32 on 11/8 which should have triggered a further reduction to 0.25 units. I think his dose is too high and the reason you saw some high preshots was because he was bouncing. You can't judge a dose by the preshot values only. Too much insulin can also cause high numbers - as kitty's body works overtime to overcome the extra insulin. Your spreadsheet shows 0.75 units being shot into a PMPS of 25 on 12/2. If your spreadsheet does not reflect what you actually did, please fix it. That's the tool we use when making dosing suggestion. What I do see says Bailey is on way too much insulin.
Kot said:
Checked again recentl : at +9 for Novolin shot and +3 for Lantus shot - his number is above 600. So, that tells me that Novolin wore off (from previous experience I know it works for Bailey for about 6-7 hours) and Lantus did not work.
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Not to me, to me it looks like the Lantus kicked in and his body reacted to too much insulin in his body. But again, that's just me guessing without the spreadsheet data. If you Lantus AMPS was nine hours after the Novolin, how often a day are you giving Lantus?

My girl also had renal failure (amongst other things) and in discussion with her internal medicine vet, short times in high numbers are better than potentially hypo causing lows.
 
OK, tried with crossed fingers not to resort to Novolin to bring high numbers down this morning. Result: 600+, 600+, 600+
I would be all hands to do the "low and slow " approach and it worked for us in the past. The lower numbers you see in Bailey's spreadsheet are all from Novolin, I am pretty sure. Jump from 0.75U to 1U was not good idea as many of you are saying. But at this point he is not responding at all to 1U. There is now drop into low-low numbers to warn a Smogii effect. The cat is just starting to recover from "funny walk and bad muscle control" in his hind legs that dropped on him last week. DKA most probably. I just can not see how I can risk several days of him being consistently in 600's and above, without any drop to lower numbers. Anyone to offer an advice?
 
Your SS is hard to understand which makes it difficult for us to help. There are days with zero tests and nothing in the Unit column and days where you gave a shot without testing first. Pushing the BG's down with N and creating those huge drops during a cycle are causing severe bouncing which is different from Smogii which rarely happens with cats. Bouncing on the other had is very common.

This is the reason it was advised to put N on the shelf and continue with safe Lantus increases until the break-though dose is found. I know you're only worried and trying to take care of your cat but it's dangerous IMO and creating more issues than not.

I see N notes starting 12/21. Were you using it prior to that?
 
sometimes you just have to take a step backwards to see the big picture.....

I highly recommend going with what was suggested and backing off ....

try to move forward with better recordings of data....
get the random test in for missing data.....

and we'll be able to advise and make some progress....
You are in the best of hands, but data is key to good management....
 
I am having a similiar situation with my Spot and Lantus. I just started Novalin N tonight one unit.
 
Think you need a white sheet of paper with only one stuff at the time to know what is doing what.
How clear is your Lantus stick ? If you put something behind you should be able to read through
it, it it's more translucent and everything behind is blurry your Lantus stick might be the issue.
How well has it been treated ? Did you put the needle twice into it ? Push insulin back into it ???
Has it always been on the fridge ??

Also look for infection, UTI, Teeth or any other ogran with infection will push numbers up.
Have Bailey verified by a vet is he stays that high. BW might reveal something you don't know.
At least test for ketone or get some Chemstrip 7. You'll know if there is UTI (little red dot
on the strip), Ketone and if anything else is on the roof.

Cats are living organism, the pancreas and it's glucose management is affected by everything
around.

Hope he'll get down, payers to you in this bad pass.

Sébastien
 
Large drops can also cause bounces. Using Novolin may be contributing to the bounces. Take a look at last night, he went from 600 to 277 in four hours. That was probably a combination of the Novolin and the Lantus onsetting around the same time. As a result you are seeing a huge bounce today.

Whenever someone starts using Novolin N or R, we strongly suggest that they start using it with help from someone here who has used it before. I've only used Novolin R, the principals are similar but N lasts longer. The goal of using the bolus insulin (N or R) on top of Lantus is that you don't want to drag down the numbers, you want the Novolin to take the numbers down by no more than 100 points over it's duration. Otherwise you set up a wild drop and bounce sequence, which is Bailey's spreadsheet is looking like now. Using 1 unit of Novolin is a LOT. When we start people using N or R, we usually suggest they start with 0.1 or 0.25 units at the most. And only after having gathered data on the onset, nadir and duration of N or R and how it interacts with the basal insulin (Lantus), then you increase the bolus dose if needed. Some cats end up needing no more than a drop or two of Novolin.

You also need to be consistent with the Lantus dosing by shooting every 12 hours. It looks like you are missing doses, such as the night of the 28th. Any time you miss a dose, you mess with the Lantus depot and you'll get higher numbers.

And Sebastian brings up a good point, I'd strongly recommend daily ketones tests.
 
Photorecon said:
How clear is your Lantus stick ? If you put something behind you should be able to read through
it, it it's more translucent and everything behind is blurry your Lantus stick might be the issue.
How well has it been treated ? Did you put the needle twice into it ? Push insulin back into it ???
Has it always been on the fridge ??
Sébastien
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I've checked the insulin and it is very clear, though does not draw out of the pen into the syringe as easy as it should. Always been in the fridge. I don't put syringe in twice. Bought it from one of the members here...

Bailey just went through a shot of Convenia (an antibiotic that lasts 2 weeks) but it might not have worked for him... I just seem on spending hundreds of dollars on his tests every month for the past half-year. Money are REAL tight right now. Hopefully I can manage another $400 for a blood work :(

Wendy&Neko said:
Whenever someone starts using Novolin N or R, we strongly suggest that they start using it with help from someone here who has used it before. I've only used Novolin R, the principals are similar but N lasts longer. The goal of using the bolus insulin (N or R) on top of Lantus is that you don't want to drag down the numbers, you want the Novolin to take the numbers down by no more than 100 points over it's duration. Otherwise you set up a wild drop and bounce sequence, which is Bailey's spreadsheet is looking like now. Using 1 unit of Novolin is a LOT. When we start people using N or R, we usually suggest they start with 0.1 or 0.25 units at the most. And only after having gathered data on the onset, nadir and duration of N or R and how it interacts with the basal insulin (Lantus), then you increase the bolus dose if needed. Some cats end up needing no more than a drop or two of Novolin.

You also need to be consistent with the Lantus dosing by shooting every 12 hours. It looks like you are missing doses, such as the night of the 28th. Any time you miss a dose, you mess with the Lantus depot and you'll get higher numbers.

And Sebastian brings up a good point, I'd strongly recommend daily ketones tests.
Click to expand...

Testing for ketones, negative for now.
Bailey has been in the black for over two weeks now even with increase in dosage. The mystery is why he responds to the shot one day (and drops pretty far) and then does not respond at all, it seems, on the next day? There were some numbers below 100 (once when I've panicked and gave a shot of Novolin N) but in general if he drops into 200's at nadir it should not warrant a bounce, right?
 
Kot said:
I've checked the insulin and it is very clear, though does not draw out of the pen into the syringe as easy as it should. Always been in the fridge. I don't put syringe in twice. Bought it from one of the members here...

Bailey just went through a shot of Convenia (an antibiotic that lasts 2 weeks) but it might not have worked for him... I just seem on spending hundreds of dollars on his tests every month for the past half-year. Money are REAL tight right now. Hopefully I can manage another $400 for a blood work :(



Testing for ketones, negative for now.
Bailey has been in the black for over two weeks now even with increase in dosage. The mystery is why he responds to the shot one day (and drops pretty far) and then does not respond at all, it seems, on the next day? There were some numbers below 100 (once when I've panicked and gave a shot of Novolin N) but in general if he drops into 200's at nadir it should not warrant a bounce, right?
Click to expand...
They can bounce just from dropping faster or to a number that's still high but lower than previous numbers. You can't rule out a bounce merely on the basis of what the nadir number is. I see in the earlier parts of the thread people were recommending doses in the 0.5 u to 0.75 u range and your SS shows doses well above that, 1.5 u to 2 u. It looks to me that your 2017 data is showing too high a dose and lots of bouncing. You might want to try a lower dose and hold it longer without intervening too soon with a dose increase and/or giving Novolin. Your kitty might need some dosing stability to get settled.
 
Kris & Teasel said:
They can bounce just from dropping faster or to a number that's still high but lower than previous numbers. You can't rule out a bounce merely on the basis of what the nadir number is. I see in the earlier parts of the thread people were recommending doses in the 0.5 u to 0.75 u range and your SS shows doses well above that, 1.5 u to 2 u. It looks to me that your 2017 data is showing too high a dose and lots of bouncing. You might want to try a lower dose and hold it longer without intervening too soon with a dose increase and/or giving Novolin. Your kitty might need some dosing stability to get settled.
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And for how long do you think I should hold that 0.5U dose before deciding it might be too low? Considering that Bailey's numbers were consistently well above threshold for 4 weeks? And it all started from him having a bad diabetic neuropathy episode...
 
Kot said:
And for how long do you think I should hold that 0.5U dose before deciding it might be too low? Considering that Bailey's numbers were consistently well above threshold for 4 weeks? And it all started from him having a bad diabetic neuropathy episode...
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There are many Lantus users here who can give specific advice on that. There are two Lantus protocols: SLGS - Start Low and Go Slow and TR - Tight Regulation. In a nutshell, you hold doses 5 - 7 days with SLGS and you change more frequently with TR. There are info stickies at the top in this forum's page describing each protocol in detail.

I truly understand that feeling of wanting to get your kitty's numbers down ASAP. Unfortunately, this is a marathon and not a sprint as is said so often here. Some cats respond well and quickly and others need much more time.
 
Why did Bailey get an antibiotic shot? Infection can cause higher numbers. Is his appetite OK? I can imagine seeing all that black has you worried.

Wendy&Neko said:
Please lower the dose to 0.5 units.
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Marje and Gracie said:
He needed a dose decrease from 0.75u, not an increase.
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Dyana said:
I would put the Novolin away in the frig, and reduce the Lantus dose to 0.5 BID,
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I don't see much on Bailey's SS that would change my mind. I would start with 6-8 cycles in a row of 0.5 units. Let all the bouncing and higher dose depot clear. Because of all his high numbers lately (probably due to being overdosed), he may have some glucose toxicity and may have to go a little bit higher, evenutally. But only do so safely, which you have not been. And when you lower the dose, please get regular ketones tests. If you see anything above trace, we may change the plan. And if he does have an infection, that might also change my suggestion, especially with DKA in the past.

Issues I see: You increased from 1.0 units to 1.5 units after seening blue on 1.0 units. But you did not have 6 consequtive doses on Lantus before doing so. That meant the depot was not full and you did not see what the 1.0 units dose could do. We only increase after a minimum of 6 cycles in a row on a dose for TR and 7 days on SLGS. And with TR, we'd probably hold for 8 cycles with a blue. Skipping a shot restarts the cycle count. To compound the problem, you increased by 0.5 units at that point. Both SLGS and TR would only suggest a 0.25 unit increase - even if you had done enough cycles on this dose to suggest an increase was warranted. Then you increased to 1.75 units after only two cycles - too soon. Since then, the dose has been all over the place. You increased to 2.0 in spite of seeing a 62 (with no subsequent testing to see if he went lower) on a lower dose. Remember that dosing is primarly based on the nadir or how low it takes the kitty. Too much insulin can look like too little. Picking either SLGS or TR as a dosing method will give you all the guidelines you need to increase or decrease doses. If you have any questions about them, please post here and ask for help.
 
Do you see a difference in attitude between the day and at night ? You got some
nice spot this week at night ? Did you share affection to your kitty, were you less
afraid of the turn of event ? Feeling can be ''transmitted'' to your cat. As soon as
I started to stop freaking when high number (by adopting a scientific minding)
things changed.

Also, check at your drug store if you can find these :
Combur-Test® strips

http://www.cobas.com/home/product/urinalysis-testing/combur-test-strip.html

upload_2017-1-11_16-19-59.png


The last line will shot you if there is UTI. If you have little dots it means
it might be the prob. Small Kitty, in DKA pass had UTI. Some test shown
there are not accurate, PH for example.

When you go for testing take a deep breath, relax and take you cat in your
harms, look at his eyes until he start purring (if he does). Then smoothly
test thinking you not in a life or death situation, relax.

If you freak out you'll transmit that mood to your kitty and it's not going to
help. This is NOT EASY, I know, but give it a try, you might be surprised.

Wish numbers will drop soon :bighug:

Sébastien.
 
Photorecon said:
How well has it been treated ? Did you put the needle twice into it ?
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Why is it bad to put the needle twice into the pen? I have sometimes done that if I push too much out into the air when adjusting dose and then put back into the pen to draw more. Never knew that was bad.
 
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