Timing of glucose curves and increases in dose

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Voula

Voula

Member Since 2014
Hi everyone. We have been on 2.5 units Lantus for a week and a half now. There was one day I only gave 2 units due to my being in hospital and being anxious to give the full dose. I think it might be time for another glucose curve and another increase in dose. I wonder if anyone has any thoughts on our spreadsheet and whether you agree that it looks like we need to increase the dose. The vet said to stay on 2.5 units for at least ten days and though I gave 2 units one day for AM and PM doses I truly don't think it would have made much difference if I had given 2.5 units for those doses. I think we might be waiting too long between curves and increases in dose. The vet suggests to stay on the same dose for at least ten days to two weeks but I can see that there is not much change in the readings we are getting after the first week. Thank you.
 
Looking at her spreadsheet I'm with you I think she needs to go up again in dose. Now granted that with the Start Low Go Slow protocol you hold the dose for up to 2 weeks before changing, but I tend to only hold mine on the same dose for about 10 cycles or 5 days before deciding if I need to reassess the dose, unless of course something has happened in those 10 cycles that indicate that the cat is bouncing, if I have one that is just a bouncy kitty I don't count the 3 days of a bounce clearing in the time of how long I've held a dose.

Mel and The Fur Gang
 
hope she hits that break thru dose soon Voula.
so where do u live Voula. are you in US or another part of the world?
 
Thank you Mel and Nadine too. We are in Australia. Yes I think waiting two weeks might be too long as Lucy doesn't seem to have unpredictable blood glucose levels so I think adjusting the dose sooner than two weeks even at one week should be fine.
 
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We saw the vet who recommended increasing the dose to 3 units so I said I would increase to 2.75 units for a few days and monitor and then increase to 3 units. I think the vet is right we are going to need to go to 3 units but I want to be cautious. We also discussed Lucy's teeth and we are going to have to do a dental soon. The vet wants us to get Lucy's diabetes regulated first and then we can do that but because of Lucy's vestibular syndrome the vet will give us a referral to get the dental done at the university teaching hospital by a dental specialist vet because at the teaching hospital they have full anesthetic monitoring in place with a full anesthetic team. We are so lucky to have this wonderful woman as our vet as she is so open to everything and she said she is most happy to give us a referral to a specialist vet so that Lucy can have the best anesthetic monitoring that there is.
 
Hi Voula,
I'm sure that having a great team of specialists working on Lucy will really help put your mind at ease. You are very lucky to have something like that available and accessible. As you know, I just about had a nervous breakdown worrying about Noodle's dental. :? I live in a small town, remote from anything like a major teaching hospital and while I have a lot of confidence in my vet, it's nothing like having the team you're going to have. And with Lucy's vestibular syndrome, having the best is really going to be reassuring. Please keep us posted on your sweet girl. :smile:

Christi
 
Hi, Voula.

It looks like you've been posting on the Relaxed Lantus board. I'm not sure with the migration to the new board if you wanted to be posting in Tight Regulation.

I have a thought or two regarding Lucy's SS. Is it possible for you to get at least one test during your PM cycle? Regardless of whether you are following TR or Start Low Go Slow (SLGS), getting at minimum one additional test each cycle will allow you to know just where Lucy's numbers are heading. By not testing during the PM cycle, you're missing half of your data. It could also go a long way to let you know if Lucy is dropping into lower ranges and bouncing. Many cats tend to drop into lower numbers during the PM cycle so those PM tests can be important. Looking at Lucy's SS from the past several cycles, it does look like she's visiting green numbers at night.

My understanding of SLGS is that a dose is held for a week and then increase by 0.25u if numbers don't drop below 80. Based on that approach, Lucy's dose should be reduced. With TR, we use a lower number (50 on a human meter) as the value signaling a dose reduction. For my comfort level, I don't know that I would encourage a dose increase for two reasons. First, you're seeing numbers in the 50s at this dose. There's not much room for numbers to drop lower, And, second, without any PM tests to tell you just how low Lucy's numbers have gone, I would be very conservative with a dose increase. When members are unable to test at night, in most cases we urge them to allow their kitty to run in higher numbers than if they were following the TR Protocol. It's the only way to insure their cat is safe.
 
Hi Voula

I'm in Australia too - did you realise that the fancy feast we get here is not the same as they get in the US. Their version is low carb ours isn't, it's full of cereal :( Low carb foods available on our supermarket shelves are Natures Gift, Dine (not all varieties but there are plenty - check the ingredients for cereals), Whiskas tins in loaf varieties only and some of the new pouches that Whiskas are doing (again check the ingredients for cereals), Fancy Feast kitten varieties don't contain cereals and Ultimates - except the one with the rice.

Cheers from Perth - Serryn
 
I think with your tests the past 2 days, it shows pretty clearly that you shouldn't increase the dose. Did you stay with the 2.5u this morning? If I were you, I'd stay with that or if you're following SLGS, reduce by 0.25u. I agree with Sienne about getting at least one test in the pm cycle. From what you have there, it looks like Lucy is very likely one of those kitties that goes low at night. The 115 and the 128 two nights in a row suggest that her lower numbers are at night.

You asked in the subject line about timing of curves . . . what we typically suggest to people is to always get the preshot test in both am/pm, and then get at least one other test in per cycle. It can be as you run out the door to work or as you come in. In the evening, the before-bed test is really important. Because cats so often go low in the pm cycle, it's a critical time to get a test in to help you figure out dosing. As you probably know, Lantus dosing is based upon how LOW the dose causes a cat to go. To some extent, we ignore the high numbers and focus on the lows to determine dosing. Your 70 and 58 the past 2 mornings, at a time when a cat is usually the highest they get to, suggest that Lucy was lower than those numbers in the wee hours of the morning and ROSE to the 70/58 at amps.

It also is helpful if you vary the times you test mid-cycle. I like to think of the spreadsheet as a jig-saw puzzle. If you have only a vertical stripe on each edge (preshot numbers on the ss), you can't really tell too much about what the picture looks like. But if you have a sprinkling of pieces throughout the puzzle in addition to the edge pieces, you can tell very well what the picture is. You don't need every piece, just a sprinkling to be able to see the picture and help you have confidence in making dosing adjustments.

Hope you're doing well! Happy Holidays from us in the US!
 
Hi Sienne. Thank you so much for your reply. I have not been filling in my spreadsheet correctly I realised as we are on a late AM and PM schedule and so some of the AMPS where there are more than one reading should be after the PM dose. I will fix that on the spreadsheet. We are back to an early schedule as if today as I will certainly get in more PM tests. This is the first time Lucy has had such low readings and only on one day yesterday and I have never found any other low readings on doing tests. I did worry yesterday though because Lucy's glucose was 6.4/115 at 10+ and 3.2/57 at AMPS. The 10+ was a fasting test and the AMPS was at 12+ and was after eating which didn't make sense. So I worried that maybe during the night the levels were lower but of course I don't know. I have stayed with 2.5 units and so reduced from the increase of 2.75 units and monitoring closely and as I said we are back to an earlier schedule now and I will get more PM tests done. Prior to these low numbers yesterday the tests have shown only high levels above 9.5/171 no matter when I have done tests but it is true I have not done enough PM testing. Thank you again.
 
julie & punkin (ga) said:
I think with your tests the past 2 days, it shows pretty clearly that you shouldn't increase the dose. Did you stay with the 2.5u this morning? If I were you, I'd stay with that or if you're following SLGS, reduce by 0.25u. I agree with Sienne about getting at least one test in the pm cycle. From what you have there, it looks like Lucy is very likely one of those kitties that goes low at night. The 115 and the 128 two nights in a row suggest that her lower numbers are at night.

You asked in the subject line about timing of curves . . . what we typically suggest to people is to always get the preshot test in both am/pm, and then get at least one other test in per cycle. It can be as you run out the door to work or as you come in. In the evening, the before-bed test is really important. Because cats so often go low in the pm cycle, it's a critical time to get a test in to help you figure out dosing. As you probably know, Lantus dosing is based upon how LOW the dose causes a cat to go. To some extent, we ignore the high numbers and focus on the lows to determine dosing. Your 70 and 58 the past 2 mornings, at a time when a cat is usually the highest they get to, suggest that Lucy was lower than those numbers in the wee hours of the morning and ROSE to the 70/58 at amps.

It also is helpful if you vary the times you test mid-cycle. I like to think of the spreadsheet as a jig-saw puzzle. If you have only a vertical stripe on each edge (preshot numbers on the ss), you can't really tell too much about what the picture looks like. But if you have a sprinkling of pieces throughout the puzzle in addition to the edge pieces, you can tell very well what the picture is. You don't need every piece, just a sprinkling to be able to see the picture and help you have confidence in making dosing adjustments.

Hope you're doing well! Happy Holidays from us in the US!
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Thank you Julie and Happy Holidays to you and yours too. I have reduced the dose to 2.5 units and changed to an earlier schedule so I will test in both AM and PM cycles now. The low reading was only one morning as I didn't fill out my spreadsheet properly so I will amend it soon. Thank you again.
 
Vyktors Mum said:
Hi Voula

I'm in Australia too - did you realise that the fancy feast we get here is not the same as they get in the US. Their version is low carb ours isn't, it's full of cereal :( Low carb foods available on our supermarket shelves are Natures Gift, Dine (not all varieties but there are plenty - check the ingredients for cereals), Whiskas tins in loaf varieties only and some of the new pouches that Whiskas are doing (again check the ingredients for cereals), Fancy Feast kitten varieties don't contain cereals and Ultimates - except the one with the rice.

Cheers from Perth - Serryn
Click to expand...
Hi Serryn. Thank you for your reply. Yes I know most of the classic pate fancy feast foods have cereals in them and I only feed Lucy the ones without cereals such as the kitten varieties and good to know about the Whiskas loaf varieties too. I will also check out the new Whiskas pouches and I do feed Lucy the Ultimates too. I need to find more low carb foods without fish so knowing the Whiskas loaf varieties are suitable is a relief as there are ones without fish in them that I can feed Lucy now. The problem with the low carb Whiskas and all the other suitable foods except the Fancy Feast low carb is that they all contain carrageenan which I am not keen on except for some of the Dine foods. I have also been considering a home raw food diet too.
 
An excellent - although expensive - food if you can get it where you are is Ziwi Peak. It's easier to find on the east coast than over here (one supplier in Perth and having it posted so far is prohibitive). Two of the three varieties don't contain fish and it doesn't show any plant products. They have a website you can check out. Most of the whiskas loaf varieties and Dine aren't listing plant derivatives either - I'm assuming that would be where the carrageen is. One or two or each do but it sounds like you're on top of the label reading and will notice that :)

I was reading the other day about carrageen perhaps being responsible for inflammations. Is that why you don't use it? I'm wondering if I should banish it too, especially from mums cats diet since he's had cystitis. Have you noted any specific problems for Lucy if she eats it?
 
Thank you for the reminder about ziwipeak as I can get it here and I have heard good things about it too. Yes I am very careful about reading labels now. I have not noticed any issues from carrageenan with Lucy and she likes the Whiskas food too. But I have read conflicting information about carrageenan and blood glucose control with some positive reports and some negative reports so I am hesitant now about it. People with inflammatory bowel disease often avoid carrageenan but I have noticed no issues from it and I have Crohn's disease.

Vyktors Mum said:
An excellent - although expensive - food if you can get it where you are is Ziwi Peak. It's easier to find on the east coast than over here (one supplier in Perth and having it posted so far is prohibitive). Two of the three varieties don't contain fish and it doesn't show any plant products. They have a website you can check out. Most of the whiskas loaf varieties and Dine aren't listing plant derivatives either - I'm assuming that would be where the carrageen is. One or two or each do but it sounds like you're on top of the label reading and will notice that :)

I was reading the other day about carrageen perhaps being responsible for inflammations. Is that why you don't use it? I'm wondering if I should banish it too, especially from mums cats diet since he's had cystitis. Have you noted any specific problems for Lucy if she eats it?
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Hi everyone. I have amended our spreadsheet to more clearly show the PM tests. Because we had been on a late AM and PM dosing schedule I was entering some of the PM tests as AMPS. Does this make a difference to the opinions given to not increase the dose from 2.5 units to 2.75 units? Thank you.
 
Hi! I think I'd still hold the dose. Our guidelines suggest that whenever you have a furshot or a skipped shot, you give a full 6 cycles at one dose after the missed shot. The reason for that is to allow the depot to stabilize after the missed shot. You've got 5 cycles now after the "incident" so I'd give it another cycle at least to see what you get. Also, there could've been a bounce reaction to the 58 - when you combine a lower number that might cause a bounce along with a skipped/missed shot, you can see high numbers either from the bounce or the missed shot. No way to separate what you're seeing, so we typically wait and let things settle down before adjusting the dose. With the bounce you can see high numbers for up to 6ish cycles - so she could still be in the midst of a bounce as well.

For your spreadsheet with those times that you have 2 tests in the same cell, you can "stack" the numbers and keep them all on the same line.

For example, on 12/24 at amps, in one cell it could like like this:

24.12 12=70
............12.5=58

Then leave your blinking cursor in that cell while you move the arrow to the top of the spreadsheet and look for the icon that looks like a beaker pouring out. Click there and then click on the color that the number range should be in, which in this case was green. When you click the green, it will fill the cell with green. Keeping all the data for one day in one line is really helpful for being able to tell what's going on.

Go ahead and start a new thread for each day - that helps keep the threads (condos) from getting too long and keeps everyone posting each day on the front page. You can answer things from here on a new thread.
 
Thank you so much Julie. That is great information and so helpful too. I have a lot to learn and your post has helped so much. Two doses after the low reading were a bit late so perhaps we should stay on 2.5 units until six cycles of on time doses. Would that be the right thing to do? So after six cycles where I am still seeing high readings do I increase the dose again? How do I know when I should increase the dose? I will amend our spread sheet now as you suggested and thank you again.
 
Voula....if you look at China's spreadsheet, you'll see how I deal with "stacking" the cells ....On 12/23/14 during the PM cycle (at +3) you'll see that my first test was a 39 and my next test (at +3.5) was a 46

The way I did that was to just post the 39....then when it was time to post the 46 I hit the SPACE bar (to separate the 39 from the next entry) then entered 46 SPACE @ SPACE 3.5

Then you go to the little icon that looks like a tipping bucket of paint and choose the correct color coding for that cell

Once you have 6 consistent doses (both in timing and dose amount) if you're not getting the numbers you want at nadir, it's time to increase
 
Remember Lantus dosing decisions are made primarily on the LOW numbers in that 6 cycle time frame. Until you feel confident about dosing it's a good idea to post a few hours before shot time and ask for dose help or "should I increase dose?" In the subject line of your post. Someone will help you figure it out.
 
Thank you Chris. I looked at your spread sheet and that looks good. I have a few doses to go until we have six consistent doses in timing and amount. Then I will increase from 2.5 units to 2.75 units based on nadir results and then monitor closely doing more tests in each cycle and making sure I get in more PM checks too. The 3.2/58 reading was the lowest we have had but as I know now that is a good reading and not to panic but to observe through testing rather than give honey and high carb food like I did. I have also learnt not to dose unless the level is 150 and rising for relaxed lantus and not to dose under 50 for tight regulation but I think not dosing under 150 is what I will do as I am relatively new to this and we have not had low readings before the low reading a few days ago. What I don't understand is that the nadir has been between 5+ and 8+ since we started insulin and by 10+ the test results are higher and yet the other day at 10+ the reading was 7+ and by 12+ it was 3.2. At 10+ when the test result was 7 I fed a small low carb meal and yet the glucose level fell even more two hours later to 3.2 which I don't understand as usually the lowest readings but not that low have happened about midway between insulin doses. I had only given two doses of 2.75 units, increased from 2.5 units, by that stage. Thank you again.
 
julie & punkin (ga) said:
Remember Lantus dosing decisions are made primarily on the LOW numbers in that 6 cycle time frame. Until you feel confident about dosing it's a good idea to post a few hours before shot time and ask for dose help or "should I increase dose?" In the subject line of your post. Someone will help you figure it out.
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Thank you Julie. I will post a few hours before the next dose is due rather than test just before the dose is due and then wonder what to do. So far mid cycle tests are showing high readings and today I will get a few more tests in rather than only one test between doses. I think we will stay on 2.5 units today and tomorrow and do extra testing and then decide whether to increase the dose. I feel more confident now thanks to you and Chris and everyone else who has replied too.
 
What I don't understand is that the nadir has been between 5+ and 8+ since we started insulin and by 10+ the test results are higher and yet the other day at 10+ the reading was 7+ and by 12+ it was 3.2. At 10+ when the test result was 7 I fed a small low carb meal and yet the glucose level fell even more two hours later to 3.2 which I don't understand as usually the lowest readings but not that low have happened about midway between insulin doses. I had only given two doses of 2.75 units, increased from 2.5 units, by that stage.

Bounces occur when a cat either has gotten into a range that is lower than they are used to, or they've gotten into low numbers, or their blood sugar has dropped too fast and their liver has reacted to what it perceives as a hypo. The cat doesn't have to get into dangerously low numbers for this to happen. For example, if a cat has been hanging out in the 300's and it gets to 150, that could be enough to set off a bounce and send it back up to 300+ again, where the body has gotten comfortable.

When the bounce happens, it can last as long as 3 days. The more a cat gets used to lower numbers, the less they will react to it. The bounces get shorter in duration, and they can get less high in intensity. For example, if a cat has been spending a lot of time in green numbers but it's not 100% used to them, they might have a mini-bounce that only goes to 150 or 200 and only lasts for a few hours. The best you can do is to keep getting a cat into green numbers to help their body get accustomed to that range.

The reason I'm explaining all of that is because a bounce overrides the basic Lantus curve. When the bounce occurs, the cat goes high and you don't really see a normal curve. Then when the cat's body clears out the hormones and the bounce clears, that also overrides the normal Lantus cycle. What you saw on 12/23-24 with the low amps was the previous 12 hours were a bounce-clearing cycle. That's why you didn't see a normal nadir. When a cat is in a bounce, you often see bobbling around of numbers - so it goes up to 350 and down to 250, but it doesn't get down into green numbers. Then when the bounce clears, whatever the low it gets to tells you how low the dose can get the cat's blood sugar.
 
Thank you Julie. I understand now the way you explained it. Do you think we have experienced bouncing before on lower doses or simply that the lower doses were not very effective as we have had quite flat curves with only occasional lowering between doses on lower doses. I am not seeing any low readings so far or before on the reduced dose of 2.5 units from 2.75 units. But I will do several tests after the PM dose and see what the levels are after tonight's dose as most of my tests have been after the AM doses.
 
most cats bounce. By the time they are diagnosed they often have been in high numbers for a while and may have gotten used to them. That's what causes bouncing. So yes, it's likely Lucy's been bouncing before.

I'll be curious to see what you have tomorrow. :)
 
Thank you again Julie. All the tests so far continue to show high blood glucose after both AM and PM doses. I have two doses to go to make up the six doses since lowering the dose back to 2.5 units. The first two doses at 2.5 units were not on time so I didn't count those in the six doses.
 
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