predose BG and levemir dosage

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Meya14

Meya14

Member Since 2015
I'm new posting to to board, but have read many threads. So I'll start with a little background.

Max is 8, male, and diagnosed in July 2014 with DM and Ketoacidosis. Blood testing at this time and recently (2 weeks ago) showed no other disease process (however he did have peridontal disease). Lantus was started, and doses increased slowly until he was to 7u twice a day. Curves were high and flat (lowest bg 390's, highest 590's on this dose). Vet switched us to levemir and started increasing again. 3 weeks ago he was up to 6 units twice a day with little response (lowest about 290's, highest 550's).

I noticed a month ago, Max had bleeding teeth, and appeared to have an oral infection. Antibiotics started. Teeth were cleaned and several extracted 2 weeks ago. Due to continued high BS readings, vet increased us to 7 units levemir twice a day. Since this time, Max's sugars have been lower (highest 350's, lowest 37). I haven't taken a curve, but rather spot check usually daily, sometimes several times during the day. I don't keep a spreadsheet as we had almost no curve (always high) in the past, but will probably start. He's had several episodes of blood sugars below 50 mg/dl since starting on 7U twice a day. These occur very late after his dose, about +8h to +9h. At times, the predose BS is 120ish, at other times it is up to 300.

Called the vet today to report sugars, and vet recommended, "If he's low dose 6U next dose, and give 7U if not low". However, I'd like to keep a stable regimen for his insulin, so I'm wondering what parameters and what time I should take BS to adjust dose, especially considering his late nadirs. Also, is this late of a nadir possibly a reason that we are fluctuating so much? Other advice also very welcome.

Thanks.
 
Welcome to the Lantus and Lev forum. Are you Meya?

First, getting a spreadsheet started will be very helpful. It'll give us history of increases/decreases and is an essential tool in suggesting what to do about the dose. We dose Lantus and Levemir based on how low it takes the kitty. Any number below 50 means the dose is too high and he needs a reduction. 7 units twice a day is a rather high dose. I expect Max is being overdosed. How much does he weigh? What is his ideal weight. Getting rid of any infection he had with the dental will also lower his insulin needs.

What are you feeding Max? It's best to feed a low carb wet food or raw food.

The typical levemir curve has it's lowest values around +8 or +9, my Neko sometimes is a late as shot time. We dose the same amount AM and PM. Typically we'll take a blood test just before each shot, and one sometime in the middle of the cycle, ideally around the low point or nadir, to see how effective the dose is.
 
Note: if you are feeding high carb dry food and/or high carb canned food, switching to low carb canned food may reduce the glucose levels from 100-300 mg/dL.
Go to Cat Info for more info, along with a downloadable PDF on protein/fat/carbohydrate values for many US foods.
 
I feed chicken soup for the soul kitten wet food (has lower carbs) at night and dry food (grain free - higher protein) during the day. I have another cat that cannot tolerate the wet food only due to kidney issues so it's a compromise. We we did try to go back to 6 units twice a day, his BS shot up again from high 200-low 300 with no dip, however this was only for a couple days we reduced due to low BS.

Max weighs 16lbs, but this was after a significant weight loss (1-2 lbs) from when he was diagnosed. He likely should weigh much less, but the vet said he's probably going to gain a little in the sort term. I'm unsure of a target weight. He is a large cat, and muscular. Also, Max is a manx and has partial seizures since the time I got him (age 2), former owner says "he always did that". Not on medication for seizures, as they are related to his spine deformity. These are stable. Vet said she sees this in Manx with no tail like him.

I'm trying to figure out which numbers I should target for the nadir, and predose, although I'm sure all cats are different. It's good to hear that levemir nadir is later for you too, that helps me understand a little better how to monitor.

I'm watching him closely for a sudden decreased need for insulin due to having his teeth fixed. Still crossing my fingers that it was the magic bullet :)

Thanks,
Ann
 
Welcome to L & L Land!

My best guess, short of a kitty with a high dose condition, is that the dental problems were fueling the high numbers. In fact, at the time of diagnosis, the oral infection/inflammation, coupled with not yet starting insulin, are what caused or contributed to the ketoacidosis.

Given what you're seeing now, post-dental, there's a strong likelihood that Max is getting too much insulin, like Wendy observed. Those high numbers that you're catching are probably what we term a "bounce." Max is used to being in higher numbers. When he drops into lower ranges -- numbers his body is no longer accustomed to -- his liver and pancreas overreact by pumping out a stored form of glucose along with counterregulatory hormones. These cause his numbers to spike back up. However, the only way to know this for sure is to be able to track the numbers.

Like Wendy, I'd encourage you to start a spreadsheet. I've linked the instructions.

Lantus dosing is based on the nadir. It doesn't matter when during the cycle the nadir occurs. My cat is on Lantus which typically has an earlier nadir than Lev. (Lantus nadir is supposed to be at around +6, give or take.) Gabby's nadir is generally at around +3 or +4. Nadirs are particular to your cat -- another reason why having a record of your test data is helpful. Having a spreadsheet will make it easier to identify insulin onset, nadir, and duration -- all of which are important for managing Max's diabetes.

Lev dosing will prove better if your dosing is consistent. The time of the nadir will not cause fluctuations. Giving a different amount of insulin at each shot will, however, contribute to fluctuating numbers.

Please let us know if you have questions. The people here are very generous with their time and knowledge. We're here to help!
 
There are a few low carb over the counter dry foods:
Young Again 0 Carb, 5% calories from carbohydrates, internet order only
Evo Cat and Kitten dry, about 8% calories from carbohydrates
Epigen 90
Stella and Chewey's freeze dried

What kidney issues? Usually, it works better to increase the moisture content when feeding cats with urinary tract issues, be it renal insufficiency, or stone creation. For more, veterinarian-written info on this, see Cat Info page on Urinary Tract Problems
 
My other cat is 17 and has early stage CKD. She's fine, but too much protein is not great for her kidneys. She drinks a lot, and I sometimes put water into the food extra for her. She's also a grazer, and doesn't eat the wet food fast enough, so I'm afraid she'll start to lose weight if I switch to all wet.
 
Actually, for early stages of CKD/CRF, there is new research suggesting that protein restriction leads to muscle loss, and it is more important to use quality animal protein with lower phosphorus. Read the section over from Cat Info, written by veterinarian Dr Lisa Pierson.
There are a number of folks here dealing with both conditions.
 
I have 3 cats now and i have to feed all 3 of them in different rooms - they get the same food, but one would eat all of it and the other 2 would starve. That's one way to be able to feed different foods to each cat. I put one in the laundry room, one in the dining room just outside the laundry room door. The 3rd cat eats in a bedroom. Before I had these 3, I had punkin and anya who ate the same food, but punkin had acromegaly and would've eaten all of Anya's. Before them, Felix and Punkin both ate dry food (pre-diabetes), but felix needed low cal and punkin needed easy-on-the-bladder prescription food.

So that might be one solution so you can get rid of the dry for Max. If you do get rid of the dry, though, his insulin needs might decrease dramatically.

You've already gotten lots of good advice. I'll just add a couple of links - here is one that explains occasions where you might see high numbers but they don't indicate that a cat needs more insulin: New Dose Wonkiness and Bouncing. The spreadsheet is essential for being able to see numbers in context so one can determine if it's bouncing or NDW causing high numbers.

A cat that is overdosed can also have high numbers. Basically the body keeps putting out the hormones/sugars mentioned in bouncing to counter-act the insulin that's being injected. If a cat's insulin was increased by half or whole units, for example, that can easily lead to the cat being overdosed. For a cat newly on Levemir, at 16lbs = 7.5kg, the formula to determine a starting dose is 7.5 x 0.25u = 1.875u per shot. We'd probably have suggested you begin at 1.5u. The Rand Roomp Tight Regulation Protocol suggests that initial doses be held for 5-7 days:

  • 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.

The second link is basically a table of contents to the Lantus/Levemir insulin support group: Where Can I Find___?

Many people start the spreadsheet with as much info as they have - glucometers have a memory so you can go backwards through the test data - and then call the vet to get the initial information if you don't have it. The significant thing with Max would be the size of his dose increases and how they were determined.

As I said, Punkin had acromegaly and when we arrived here at FDMB he was getting about 7ish units. There are cases where cats need a high dose, but MOST cats don't. Infection and dry food can both cause high numbers and a need for more insulin, though. The safest thing to do is to get the spreadsheet going so we can help you look at it and see if he might need less insulin than he's getting.

Sliding scales don't work with Lantus or Levemir. That style of dosing belongs with the older insulins, not these long-lasting depot type of insulins.
 
Julie, Thanks for the info. I've tried feeding them separately, but my old cat eats so slow, that I almost have to lock her away for the whole day to make sure she eats enough. When I feed them together, she eats the dry food in the AM, but picks at any wet food. I've gone all wet food in the past before her CKD, and he eats all of it, and she loses weight. I have tried the "fresh pet" wet kibbles, and that seemed to work better for her, but it's expensive.

I'll start keeping the spreadsheet, so I have better collected data. His dose increases were 1 unit (started at 1u), held for 1-2 weeks. He had NO BS response to any of the dose increases (his curves were high and flat with no nadir or peak - consistently above 400). The first response we have had is this most recent increase from 6U to 7U of levemir, but now it seems like he's getting too much. The vet gave me vague instructions to give either 6 or 7 depending on if he's hypoglycemic, but I'm more comfortable with a set dose, as I'm sure changing the dose frequently will make it hard to determine the correct dose for him, so I'm going to reduce to 6.5, and see what happens. The vet was concerned that he had arcomegly, but we were waiting to have him tested until after his teeth were done. He does have epilepsy, not sure if that increases his need.
 
I added what I had written down into the spreadsheet. There were a lot of BS that I did not write down, as the vet only wanted certain readings. I know I should probably take some PM readings, my weekday schedule does not always allow for this, but I will probably be able to on weekends.
 

Attachments

Can we get you started using our grid to record your glucose tests? It will help us give you better feedback. Instructions are here.

Understanding the spreadsheet/grid:

The colored headings at the top are the ranges of glucose values. They are color-coded to clue you in as to meaning.

Each day is 1 row. Each column stores different data for the day.

From left to right, you enter
the Date in the first column
the AMPS (morning pre-shot test) in the 2nd column
the Units given (turquoise column)

Then, there are 11 columns labeled +1 through +11
If you test at +5 (5 hours after the shot), you enter the test number in the +5 column
If you test at +7 (7 hours after the shot), you enter the test number in the +7 column
and so on.

Halfway across the page is the column for PMPS (evening pre-shot)
To the right is another turquoise column for Units given at the evening shot.

There is second set of columns labeled +1 through +11
If you snag a before bed test at +3, you enter the test number in the +3 column.

We separate day and night numbers like that because many cats go lower at night.

It is merely a grid for storing the info; no math required.
 
Hi Ann, sorry for the name mix-up. :oops: The Chicken Soup for the Soul looks like it's got quite a few carbs in it (rice, potatoes, oatmeal, etc.). BJM gave you the link to the catinfo web page that contains the list of the breakdown of carbs/protein for commercial products. Chicken Soup for the Soul is not on there. Or try some of the dry foods that BJM suggested that are lower carb. We try to stick to foods under 10% carbs on that chart. Carbs really do make a difference. We had one member whose kitty was on 5.5U of Levemir, and she didn't think he was getting any of the other cats food. One day after she removed all dry food from the house, she had a very exciting 36 hours as her cat decided he didn't need insulin anymore.

Putting your spreadsheet in your signature makes it a lot easier for the rest of us to read on our other devices. As for the dose, we often change by as little as .25U or .5U at a time, never as much as 1U. It is possible to bypass a good dose if you go up to fast. Having too high a dose can also produce high flat cycles.

Was there any particular reason your vet thought Max might have acromegaly? Neko does, but it's really hard to tell my looking at her.
 
Wendy, I feed chicken soup for the soul WET food. It's < 5% carbs. It's Here's the breakdown:
Crude Protein 11.0% Minimum
Crude Fat 5.5% Minimum
Crude Fiber 1.0% Maximum
Moisture 78.0% Maximum

The dry food I feed is also reduced carbs, but I'd have to look at the breakdown.

I use open office, so I'm not sure the best way to upload the spreadsheet.

Vet thought he had arcomegaly because he did respond AT ALL to the insulin. Also, he is a very large cat, and he has seizures. We didn't test yet. Per the vet, the treatment is supportive anyway, and consists of normalizing blood sugars. She said somatastatin isn't very effective in cats.
 
The values for the cat food your using are the guaranteed analysis numbers. In order to calculate the carbs, you need the "as fed" values. Generally, the only way you can get that info is to call the manufacturer.You might post a note on the Health board and ask if anyone has the carb count for those foods.

The spreadsheet we use is a Google document.All you need to do is open a Google account if you don't already have one.

We have a number of macro kitties here. Several of these cats have had stereotactic radiation therapy (SRT) -- radiation treatment to target the pituitary tumor.It's not inexpensive but it can be effective.
 
Ok. I got the spreadsheet attached to my sig. I have numbers going back all the way to august written down, but there wasn't much of interest there (everything was just High with no pattern) and it would have taken me forever to enter.

Getting him tested was the next step if he still wasn't responding. But since his infection is now gone, all of a sudden he's having at least some blood sugars in a normal range. Now I just got to get them to quit bouncing all over the place.
 
Hi Ann, you've found the right place. Cobb is also a high dose kitty. We are at 7u of Lev, but reached 31u of Lantus back in August. I looked at your spreadsheet briefly... what was your starting dose of insulin? It looks like 4units, but I could be reading it wrong.
 
I started Levemir sometime in september I think, after a failed trial on lantus. He was up to 7U of lantus with no response. Then vet started over at 1U on levemir, she said some cats metabolize the two differently and he may respond differently to Lev. She had us increase by 1 unit, and there was usually 1-2 weeks in between (although longer when we were watching for the antibiotics to work). He was diagnosed early summer, was ketoacidotic and almost in a coma. We gave him subQ fluids at home and syringe fed him for a week.

Incidently, this all started after he and my other cat had what looked like some sort of respiratory virus. It went away so fast that I never took either to the vet for it. Then 3 weeks later, he was on death's door.

Also, I use alphatrak (So I'm about 20-30% higher than human glucometers). I'm in the process of comparing a new glucometer I bought, cause the alphatrak are too expensive, and don't seem to be consistent. Sometimes there is >100mg/dl difference on the same drop of blood.
 
Good to know you are on the Alphatrak. Maybe while you are still using it you could put "AT" or Alphatrak meter on your signature. The reduction number for the AT is at 68 instead of 50. Good thing you reduced back to 6.5 units. The AT reads about 30-40% higher than human glucometers. We use a protocol that is calibrated to human glucometer number so it's OK to use one of those. Many of us here use the Relion brand ones available at Walmart. The Confirm/Micro use the same size drop of blood as the Alphatrak and the strips are WAY cheaper.

I can see your SS now, although the color coding doesn't seem to be working. One thing I've noticed is that you don't have very many tests at night. Many cats (including mine) go even lower at night, so it's good to try to get a test just before you go to bed, or if you have to get up for any reason in the middle of the night. With Levemir, if you get up early before shot time, that's also a good time to test to see how low the dose is taking Max.

As for responding to insulin, dry food can make a huge difference. In addition to the kitty I mentioned above, we had one member who adopted a cat who was getting shot blind (no tests) with 13 units of Levemir by the previous owner and eating dry food. Which as it turns out, was probably what kept him alive. Once he went onto all wet food, his dose dropped to 1-2 units and he eventually went off insulin.
 
See my signature link Glucometer Notes for reference values using different types of meters.
A very, very rough estimation is
Alpha Trak * 0.65 = human meter estimate
Alpha Trak estimate = human meter / 0.65

+/- 20% allowable error variance
 
So were that 54 on 12/24 and the 37 on 12/26 both from an Alpha trak meter?

What people are trying to figure out with all of the questions is whether or not Max is a high dose kitty perhaps, or if his dose is high because it was gotten to inappropriately. I'm thinking at this point, just sticking with it and moving forward. The 37 on an AT is dangerously low. Even on a human glucometer it is dangerously low, so I'm glad you reduced to 6.5u. If you're testing on the AT, anytime you catch a blood sugar test under 68 you want to reduce his dose by 0.25u. If you're using a human glucometer, that cut-off point is 50 to reduce his dose.

Something is still not quite right with his spreadsheet, although thank you for using the board one. It's infinitely easier for us to help you using the board template. I'm thinking this might be the new template that Marje has just been fixing because it has the tab for Labs on it, which is something she just added. I'll send her a message to take a peek at it, because it ought to be color-coding the spreadsheet. If you look at anyone else's you'll see what I mean. The color-coding is hugely helpful, and once you're a little farther along into this you'll be able to tell a lot just by scanning the colors.

If it's difficult to get pm cycle tests in with your schedule, what some people do is to move their shot time earlier. For example, we shot punkin at 7am/pm, basically right after we got up. That allowed us to always be able to get a pm+3 before going to bed, and even if he had low numbers it didn't mean staying up too late. I routinely go to bed at 11:30pm. The reason that we encourage pm cycle tests so strongly is that it's very typical for cats to have their lowest numbers in the pm cycle. Diabetics often have their highest numbers at amps because of Dawn Phenomenon. Because Lantus and Lev are both dosed according to how LOW the dose takes a cat, catching that number becomes very important. We've had plenty of cats who spend their day cycles fairly high and do all of their low numbers at night. It doesn't mean you have to stay up all night, and it doesn't even necessarily mean you need to do additional tests in the day, but if you have to choose only one, the test before you go to bed is often the most important for helping you make decisions about dosing.

Or, since it's Lev and it looks like his nadirs might be fairly late in the cycle, you could move the shot time later if that works with your work schedule. Just an idea for you to consider.

Oh, and in regard to 2 of your comments - don't worry about the fluctuating numbers. that is typical in diabetic kitties until they get regulated.

Also, meters will measure the same drop of blood differently in 2 different strips. By law, meters are allowed to have 20% variance rate. To avoid making ourselves crazy, most people just take the first measurement and believe it unless it's wildly out of context compared to the tests around it.

which is your new meter brand?
 
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So the vet believes that Max is in fact a high dose kitty (or was prior to tooth infection getting fixed) because through the whole trial on lantus, he barely budged from the upper 400- low 500 through all dose changes. I took spot checks at various times, and never really got a reading much below these numbers, even at nadir and predose, although his ketoacidosis improved, and his weight loss stopped. Starting the Lev showed the same result until recently. This is the first time that we've ever gotten numbers in the 200s or below.

I have a target brand(rebranded Onsync) as my new meter. I bought it mostly because it's a very small drop size. I'm aware of the allowable variance in glucometers, but the alphatrak was beyond that at times I retested (>40% sometimes). Be aware, since alphatrak is not for human use, it is not under FDA regulation, and the manufacturer does not need to show accuracy. This is why I'm switching (and cost). I did a compare of 17 reading on both meters using the same drops, and the average difference is the alphatrak is 30% higher than the human.

I think the spreadsheet got mixed up because I downloaded and edited with another program then uploaded.
 
Hi, Ann and welcome to L & L.

I read some of the post, not all to be honest.

But BJM is right : "Actually, for early stages of CKD/CRF, there is new research suggesting that protein restriction leads to muscle loss, and it is more important to use quality animal protein with lower phosphorus. Read the section over from Cat Info, written by veterinarian Dr Lisa Pierson.
There are a number of folks here dealing with both conditions."

My cat is stage 2 CKD and a diabetic, now OTJ, and I was told that as long as his numbers are Stage 2, is better to keep him on low carb food to avoid muscle loss. What I do, is to add a phosphorus binder to his food. I am also member of a group linked to the website http://www.felinecrf.org/

Then about insulin, I also think you are using a very high dose. You need to look for the nadir, but with Levemir cats usually have more flat numbers than with Lantus, so the curve can be kind of flat. Bruno had his nadir with Levemir at the same time as with lantus, around +6, but I know for many others nadir can come from +8 to shot time.

It will be great if you can start a SS, so people can advise on the dose. To be honest I will trust more the advice here at the board than what my vet will say.

Finally, just in case you decide to switch to wet food, be careful with insulin dose, since the change can lower the BG considerably. And CKD is a serious condition, for me, personally, CKD comes first and then diabetes. I am happy that Bruno is now on remission, and I will do anything possible to keep him there, but if he needs insulin again some day, then he will have it.

Welcome, again!
 
Ann

I was just checking in on your SS since I did the SS post and instructions. It might be helpful to also label the bottom SS, which is your 2015 SS, "Max's 2015 SS" just so we know which one is the correct one. If you downloaded and edited the 2014 SS with another program, it won't work as it is supposed to; it looks like you have correctly followed the SS instructions for the 2015 SS. In order to get the info in the "Remarks" section to fit into the blank, just put your cursor on the right line of the top of the Column where the letters are (I believe it is AB) and you will see an arrow that will let you drag the column to the right and widen it.

If that doesn't work for you, please let me know by private message and I'll help you with that. Thanks and welcome to LL!!
 
looks like you're getting the hang of things! I can see the 2015 ss perfectly, complete with color-coding in the cells. that's great.

I didn't know that about the ATs not being regulated. that's interesting and might explain some of the wild variations in tests people have reported.

when people are new, those of us with experience just tell them what we see, so don't be offended by all the advice! i know when I was new that I didn't even know what to ask - you've got more experience when you got here than most people, so it might not all be new to you.

looks like Max had a great mid-cycle run of green today - he's doing very well. I noticed you reduced his dose tonight after the 55 today. One thing to keep an eye on - if his blood sugar tests trend upward in the next couple of days, that may mean that he wasn't quite ready for a decrease yet. The way a depot insulin works is that the amount you shoot is in equilibrium to the amount that has formed a depot (deposit that slow releases) in the body. That means that when you increase a dose it can take a couple of days before the depot is "filled up" and in equilibrium to the dose.

In the same way, when you decrease a dose, the previously larger dose's depot can influence the blood sugar for as many as 6 cycles after the reduction. You had 4 cycles at 6.5u so that might be long enough to not be very influenced by the 7.0u dose, but there's a chance it might still be at play. Hard to say. That's why I'm mentioning it - you'll know by your tests if he's "holding" the reduction - he'll be continuing to get nadirs in this same range.

There's a good post on The Insulin Depot if you haven't seen it yet. I didn't fully "get it" about the depot for a while, so i try to point it out to new members.

Have a great evening Ann!
 
Just a note: data I received from the folks at AlphaTrak. A couple years ago indicated their tolerance was about +/- 10%, rather than +/-20%. I'll see if I can find the PDF they sent me.
 
Julie, the reduction was pretty close to the last one, but I'm not yet used to the idea of Max being this low, and it scares me a little when I am not home all day. I had also been giving him extra food in the am, so I think that was maintaining the sugars. I'm thrilled he's had a whole day with "normal" blood sugars. We've been 6+ months in the 300-500 (usually closer to 500) range so this is a welcome change. I'm hoping he'll be able to reduce lower. Either the dose change from 6-7 just managed to give his pancreas a break, or it was his teeth. I doubt he'll ever have a remission but at least now I know it's possible to have him regulated.
 
Hi Ann, I get where you're coming from on the remission. I doubt Cobb will ever be in remission either, but I bet Sandy felt the same way about Black Kitty. I figure there's always hope, but best to not get my hopes up! Cobb has had several failed reductions, but seems to be holding them much better than he did originally, so don't be discouraged if you do have to go back up. Max is looking good. It's always nice to see the green on the spreadsheet! :D
 
Hi. My Max likes Stella & Chewy's freeze dried, both the chicken and the turkey. There is a shortage right now but they say it can be found. It is supposed to be in good supply in a few weeks. So it might be worth a try. They say it is less than 1% carb but I sprinkle it on top of his canned food and haven't used it exclusively.
 
Thanks. I might see if the local "pet health store" by my house can order it. I never thought of freeze-dried, my other cat (the 17 year old) might find that more to her liking than the wet food. She barely touches it.
 
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