Shadow's spreadsheet

[Jessica Tavares]

Shadow has been adjusting well to his prozinc. He's not in starvation mode, and always thirsty. he had gained weight and his coat is so much better.

What i struggle with is his dose, if we give him 0.75 he hardly goes down, and if we give him 1 unit he drops drastically. I haven't been able to do a proper curve, because my husband is almost obsessive over Shadow's numbers. i find it hard to calm him and deal with shadow.

So I have recommended to my husband that we go down to 0.75 and after 7 days we do a curve. he worries about Shadow being high, and he worries about him getting too low. My husband panics when Shadow is in the 4's before or arounf the +6 mark and sometimes feeds him gravy food instead of testing. And he fails to tell me all the times so i can add it. I don't think its often, as I try to ease him from thinking that Shadow is hypoglycemic, that we have to be patient, and see if it gets lower.

We haven't ever really done one since we started home checking, as we had the sensor before.

https://docs.google.com/spreadsheets/d/1HkPKVOTCpdg1QmYN9wwiVwFj0dAhmo_6ZLLo8Y_iqqY/edit?usp=sharing

 

[Panic]

Sounds like you need to keep that gravy locked away from your husband! It maybe be helpful to tell him that the gravy shouldn't be given until Shadow drops below 50 (2.8). Would it be helpful for you both to have a "cheat sheet" when handling lower numbers?

• Below 50: This is considered the “take action” number. If the blood sugar is permitted to go lower, the cat is in danger of experiencing a hypoglycemic event.
  • Retest immediately to determine the reading is accurate
  • Rub Karo/maple syrup or honey on gums (this is a TEMPORARY fix)
  • Feed high-carb food if possible and recheck blood glucose in 15 minutes
  • Repeat as necessary, testing every 15-30 minutes for at least two hours. Every time you have to feed mid/high-carb food, the 2 hour clock starts over

* Reduce dose by 0.25 units immediately

• 50 – 70: This is an intervention range. Feed 1-2 tsp of low-carb food and retest in 20-30 minutes.
  • If dropping, offer a little more low-carb food and repeat process
  • If holding, no more food but retest in 30 minutes to be sure they are no longer dropping
  • If rising, no more food and take a break. Retest in an hour to make sure they don’t dip back down again

This is kinda a basic guide I wrote for myself a while back, if it will help ease your husband's fears. Of course you want to divide the numbers by 18 to match your meter conversion.
If you are using the Modified Prozinc Method dosing protocol (reductions below 50) then I think he's doing well on 1 unit. The only time he dropped lower was that 2.5 on the 16th and you appropriately dropped the dose. Other than that he hasn't dropped dangerously low at all. May I ask what the reason was for dropping the dose by half on the evening of the 2nd?

@Deb & Wink thoughts?
(I always like to ask Deb to double-check for dosing advice)

 

[Jessica Tavares]

Yeah I have tried to get him to actually think before he wanted to give gravy. But with an adult with anxiety, having to worry about his cat is not easy. He's constantly worries about Shadow's numbers, and trying to analyze them. and i have to be the moderator...
anyway the reason why Shadow was given a lower dose on the 2nd was when husband went to check his PMPS Shadow was 8.2. So we fed him 1/2 his evening meal, and waited an hour to see if he would go up. He did and my husband being the worry wart he is felt it was safe to give .5 since we would be in bed and his worst fear is Shadow going into hyperglycemia or worse.
hope that makes sense

 

[Panic]

Oh yes, it's easy to become a worry wart with a diabetic kitty. Can't tell you how paranoid I was with mine! You'll have to remind him that that gravy can also hinder Shadow from getting better if overused. Healing doesn't start until they're under 5.5 and then we want them to surf as long as possible.

Okay, gotcha. Next time he gets a lower than normal preshot you want to stall feeding and retest, not feed and retest. That second shot was elevated by food and not a "true" number to shoot by. You're still new so it takes time to be comfortable shooting that number but I think you have enough data shooting full would have been fine if you were monitoring, which you were. Eventually you'll be shooting low to stay low.

Another thing you can do is get a +1 or +2 every cycle. You don't have any readings on that so I'm not sure when Shadow's onset is. Onset usually tells you what the cycle is going to be like so you can prepare. If there's a noticeable drop, you'll know to be on alert to intervene before something happens.

I like what one of the members here told me once when I was freaking out about shooting a lower number: as long as you have high carb food, testing strips, and syrup, you can handle any number. (with guidance of course!) You guys are doing great!

 

[Jessica Tavares]

So when he is low at a pre-shot time don't feed, and wait? that' hard, since we have 3 other cats (they have't been happy with the wet food only changes) but they are all on the same schedule as Shadow 4 meals a day. that is what works.
And what is considered a no-shot? I've heard anything below 10.
Still learning, still trying to get all the facts and make the best choices for our Shadow.
thanks again there are days i just want to rip out my hair.....

 

[Panic]

Yes, what you do is you stall about 20 minutes, then retest. If the number is rising, it's usually safe to shoot. If it hasn't changed, you could give a token dose (10-25%, so if normal dose is 1u you could just give .25u), or you could skip. And if it's falling, you might prefer to just skip. You can stall another 20 minutes and re-test indefinitely but obviously there comes a point where it's easier to skip so not to go off-schedule. Do what you're comfortable with of course!

For new diabetics the no-shoot number is 200 (so about 10 mmol/L) but you'll gradually lower that no-shoot number down to 150 (8.3 mmol/L), then even lower. It depends on how much data you've collected and whether you'll be available to monitor shooting a lower pre-shot. You've collected a good bit of data so far to start shaving that no-shoot number down a bit but again, do only what you're comfortable with. You can start with stalling the feeding to get the number up above the no-shoot zone.

I would feed the other cats separately if you had to stall, I always fed my girl separately to begin with but that's just what worked for us.

Not sure which dosing method you're using (SLGS has you evaluating dose after 7 days and reductions are given below 5 mmol/L, MPM has you evaluating dose after 3 days and reductions are given below 2.8) so here's instructions on handling low pre-shots for both:

SLGS

How to handle a lower than normal preshot number when following SLGS:

Until you collect enough data to know how your cat will react, we suggest following the guidelines in the FDMB's FAQ Q4.4:
Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.

• Below 150 mg/dl (8.3 mmol/L), don't give insulin.
• Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
  • a.) give nothing
  • b.) give a token dose (10-25% of the usual dose)
  • c.) feed as usual, test in a couple of hours, and make a decision based on that value
• Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
• In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
• Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.

Keep in mind these are general guidelines, and they should be personalized to your own cat's response to insulin once you have data and understand your cat’s cycles. If your experience is that your cat does not became hypoglycemic with a dose which is close to her usual, then personal experience should be your guide.

With experience, you may find that lowering these thresholds may work well for your cat. When you have reached that stage, the following guidelines are suggested for Prozinc users following the Start Low Go Slow approach:

If the preshot number is far below usual preshot numbers:

• Do you need to stay on schedule? Then skip the shot.
• Do you have some flexibility with your schedule? Then stalling to wait for the number to rise might be a good option. Don't feed, retest after 30-60 minutes, and decide if the number is shootable.
• Repeat until the cat either reaches a number at which you are comfortable shooting, or enough time has passed that skipping the shot is necessary.

If the preshot number is near kitty's usual preshot numbers:

Look at your data to see what numbers you have shot in the past and decide what would be a safe, shootable number for your cat. Don't feed. Stall until kitty reaches the preshot number you've decided on and then shoot.

We usually don't suggest or recommend shooting a preshot number less than 90 mg/dL when following the SLGS Method. Remember that with SLGS, generally speaking, your goal is to achieve flat numbers that are greater than 90 mg/dL. However, let experience, data collected, knowledge of your cat, and availability to monitor help in making the best decisions for your cat.

MPM

How to handle a low pre-shot number:

• Sometimes your kitty will surprise you with a lower than normal PS number (but above 50). When that happens you have four choices:
  • Skip the dose: If the number is below 200, and your kitty is newly diagnosed (less than three months), your best option is to skip unless your kitty has ketones or is post-DKA (see below) and you should post here or in the Health Forum for help.
  • As you gain more experience and data, your goal is to gradually learn to shoot lower and lower numbers (never below 50). You can use other options below as you are learning to shoot below 200. Ultimately, with data, experience, and knowing your cat, you should be able to shoot PSs above 50 provided you are available and able to monitor.
    • If your cat has been diabetic for awhile and the PS is much lower than normal, you may still need to skip if you have to leave the house for many hours and can’t monitor, but in general we don’t recommend skipping if your cat has a good body of data, so see the other options.
  • Stall: Do not feed your kitty but wait 30 minutes and test again. (Note: we generally stall without feeding because food will falsely cause the BG to rise. It’s important to not shoot a food spike
  • If after stalling the number is rising into safer ranges, you can then give the full-dose shot. You can stall as long as you need to (in 30 minute increments), but keep in mind that the next shot needs to be 12 hours later, so be mindful of your new shot time. If it’s getting too late, try the next option.
  • Reduce the dose: How much to reduce can be a tough decision. Some of it will depend on how well you know your cat, how confident you are in testing, if you’ll be around to monitor, etc. This is a good time to ask for advice. If no one is around and it’s your first time, reduce the dose by 50%. If you have been at this awhile and know your cat’s reactions well, you can do a smaller reduction. If your cat is below 150, do not give a dose at all unless you can get regular BG tests throughout the cycle.
  • Give the regular dose: this is recommended if you are able to monitor closely and/or if your cat is a long-term diabetic (more than a year) and you have a lot of data to know it’s safe. Long-term diabetics with solid data can often safely shoot below 150 (and should if possible to do so safely).

If the BG is in the 40s at PS:

• Stall without feeding for 20 minutes and recheck the BG.
• If they are hanging in the 40s for a while, or if they are still dropping, it is ok to feed a tsp or two of LC and retest. This is very tricky. You want to avoid feeding too much while you’re waiting for them to go over 50, because you don’t want to artificially inflate the number with food.
  • Example: if kitty is 43 and you feed a whole meal, or feed some HC, and the number bumps up to 52, is that the cat’s natural end-of-cycle rise, or is it food spike? What if it is food spike? Then if you shoot the 52, when the food wears off he might drop back to the 40’s (and when insulin kicks in a couple of hours later, you might have a problem). If the 52 is the cat’s natural rise, then he will probably keep rising for the next few hours until insulin kicks in. If you can’t tell whether the number is food spike or natural rise, it’s safest to wait. Your data will help you here. Study the spreadsheet. How much food spike does the cat usually get? How many hours after the shot does the insulin’s onset usually occur in this cat? At what number is the cat likely to be when onset occurs? If the cat does drop, how easy/hard is it to regain control of the numbers? How carb sensitive is he?
• Test often (every 15-20 minutes, or at most every 30 minutes). You want to catch the rise the minute it starts. With most of our cats, once they start to rise they will really zoom. You want to get the insulin in as soon as possible, because it will be another 2-3 hours before the insulin kicks in and you don’t want to let the cycle get too far ahead of you.

If the BG is in the 30s at PS:

• Feed a small amount of HC food/syrup and a drop of syrup/honey and skip the shot, testing 20 mins after the meal to ensure the BG is coming up.
• Be sure, even when you skip, to continue testing regularly until the BG is at a safe number and remains there more than two hours after eating.

Perhaps the most important guideline in shooting low is that any time you shoot your lowest ever number, you should get a +1 and +2 to give you an idea of how the cycle will go. If the +1 is not higher than PS, or if +2 is much lower than PS, that means “pay attention” over the next few hours. Those tests will also help you become even more data ready for the next time you are presented with a low preshot reading.

Sometimes there are circumstances such as ketones present, an unusually low preshot number, a caregiver leaving the cat with a sitter, relatively high flat curves, loss of appetite, infection, a schedule change, ability to monitor, etc. which may call for adjustments to these guidelines. Please ask for guidance if any of these or other circumstances present themselves or are of concern. If ketones are present or your kitty is post-DKA, it is best to not skip shots but please post for assistance.

It can be a lot, baby steps! And don't forget to ask time-sensitive questions about dosing on the Main Health forum to get more help with those pre-shots!

 

[Panic]

And I'll add, while I think shooting that 8.2 may have been fine - looking back at your spreadsheet, I see you actually don't have any history of shooting lower than 11, so it's good that you were cautious at a lower number such as that. So you could start by shooting full dose at 10 or 9.5 to see how he does, then work your way down as you learn how he reacts.

One other thing - are all the +11 tests actually PMPS numbers that you fed and retested in an hour like on the 2nd? That would mean his pre-shots are a lot lower than they appear at first glance on your SS. If so you'll want to edit your SS a bit so people realize that you're stalling.

For example, you could write in the PMPS cell something like this: 9.5 (+12) 10 (+12.20) - which would indicate that you tested twice before feeding and how long the wait time was. You'll have to color in the cell manually when you do it but it will be more helpful for those reading your SS.