PreShot vs. +6 = Something doesn't seem right...?

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Smokey

Smokey

Member Since 2010
Hi everyone,

Since Smokey has come out of remission 2 weeks ago and has started with Lantus, I have seen no change in his matted fur, his weight loss, his hunger, drinking WAY too much water and his urine output. What is amazing to me is that he seems to have complete opposits BG readings as what is written. His highest BG of the day is always aroung +6 and his lowest of the day seem to be at Pre-Shot! :o

Based upon Smokey's SS, his vet has asked that I decrease his dosage from 2u to 1u (which for 2 days now I've been doing .25 at a time). His findings and diagnosis are based upon the PS BG, not the Nadir BG. He states that the new studies on feline's on Lantus are showing that the PS BG should be in the range of 300-350 at all times and you should use that number to base your dosage changes (with some consideration to behavior and Nadir). I have also seen this information online and see that some of the other users of the FDMB do it this way too. I am fully aware that this isn't the, "Normal" for how the majority of the users here determine dosage changes.

I really do love my vet and I know he has Smokey's best interest at heart...which leaves me torn. I have given my vet all of the information that I have found on this board however, he feels strongly that we should be dosing this way.

Does anyone else know of any or have had any experiences where the BG reads the highest at +6 and the lowest at the PS? I am extremely diligent about his shot times and feeding and had brought him into remission 8 months ago using Vetsulin combined with decreasing his weight from 19lb to 14lb.

He is currently weighing 11.3 and he really is a 14-15lb cat. It is just breaking my heart to see my best friend this way. :cry:
 
Giving you a bump up. It sounds like a reverse curve, which can happen w/ too much insulin but I'm not a dosing expert. If you are only back on insulin for 2 weeks why did you start at 2 units? That's higher than usual for a starting dose, especially when a cat has been OTJ.

I've never heard of that dosing protocol or of any new studies. Where did you see it on the web?
 
One explanation may be that Smokey has a late nadir. What this means is that the cycle is shifted in just the way you describe -- the lowest point is at pre-shot and the highest numbers are mid-cycle. It's like everything is shifted by 6 hours. However, from your spreadsheet, this isn't happening consistently. In some cases, it looks like Smokey dropped into lower numbers and a bounce followed. That's not unexpected.

Is it possible for you to get the reference from your vet regarding basing Lantus dose on the pre-shot numbers? I have access to medical and veterinary library databases and haven't seen anything that supports dosing Lantus based on the pre-shot BG level. In fact, the Journal of the American Animal Hospital Association recently (2010) published guidelines for the treatment of diabetes in dogs and cats. Their recommendations are based on the same protocol we use here -- the Lantus/Levemir protocol that is linked in the Tight Regulation sticky. All of the published research I've seen indicates that dosing is based on the nadir.

The people on this Board that base dosing on pre-shot numbers are not using Lantus or Levemir. These two types of insulin are different than PZI, Humulin N or any of the shorter or intermediate acting types of insulin. Lantus and Levemir are long-acting, depot-type drugs. You can't approach dosing the same way. In fact, it's often a struggle for people who have previously used a different type of insulin and then switch to Lantus. They have to ignore everything they know about dosing and re-learn a new approach.
 
Thank you for your responses. I am going to print out the document you attached and bring that into him also! I have recently had 3 people on this board that their vets have also heard of this new protocol for Lantus and I believe it came from the big vet confrence in Orlando this past January...it is so very frustrating!

Smokey was originally placed on 1unit however, with the clinical signs after a couple of days, I raised him to 2units (at that time, I didn't realize the shed) and the BG numbers seemed to support it, but Smokey just has never stopped the water drinking! Everytime he walks to the bowl I cringe!! nailbite_smile
 
Great article Sienne!

May/June 2010, Vol. 46 AAHA Diabetes Management Guidelines p. 219
If BG is <150 mg/dL, either decrease insulin dose to 0.5 U q 12 hours, consider dosing q 24 hours, or suspend insulin treatment and wait for clinical signs and glycosuria to recur before restarting insulin at 0.5 U q 12 hours.
Click to expand...

I wonder if this is what your vet was thinking of?
 
No, I don't think so. He specifically stated that the BG should be between 300-350 at 12 hour (before the next insulin is given to remain at the current dose). That is why when he saw Smokey's in the 200's, he wanted me to decrease the dosage. But when I see my Smokey drinking so much, my immediate reaction is that he needs more! It's definitely a challenging situation!
 
I just have to throw in here that a BG of 300-350 is not normal; my civvies do not have this high of a BG ever. If you dosed for that, your cat would be getting ALOT more insulin than if you dose for the lowest point (nadir). I think somewhere, there is a miscommunication or misunderstanding. It just does not make any sense at all and IMHO would set a cat up for a big hypo unless their nadirs were the same as their PS.
 
I would be interested in seeing the study that suggests keeping the cat in 300-350. The most recent studies I have seen encourage trying for remission using Lantus or Levemir and a tight regulation protocol.

To me, it doesn't make sense to try to keep the cat well above renal threshhold, especially if he isn't doing very well clinically when he is that high.

IMHO 2 units was looking like a good dose for Smokey. It was starting to flatten him out in blue and yellow with some green.
 
I couldn't imagine what Willie's health would be like today if I had stuck to keeping him in the 300s for preshots. And not in a good way.

I was able to find the schedule for the NAVC Conference in January and there were several FD panels. Libby and Sienne, I've PMed you with what I found. It doesn't appear to be presentations of actual research, which is all the more disturbing. If you guys think it would actually work, I would be happy to contact the presenters and ask for copies of their presentations. Maybe if I bust out the ESQ behind my name??? :lol: :lol: :lol: :lol: :lol:
 
One other point worth considering...

It's not that hard to get a paper or panel discussion accepted at a conference. Some conferences are more selective than others but even with that caveat, it is much easier to have materials accepted at a conference than in a journal. Journals and the accompanying peer review process are far more critical in order for a manuscript to get published. I review conference submissions and journal articles in my field. My standards, and the standards of the academic community, are different for each of these venues. Probably a good 90% of what's presented at a conference will never see the light of day. I'd take it with a large grain of salt.
 
I am going to have a talk with my vet this week, in the meantime I am going to increase Smokey back to 2units tonight. I believe his current readings will support the bump up.

Since I have been unable to find a nadir for him, how do you suggest I base the dosages?
 
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