Too much or too little insuin??

[jmalasiuk]

Well, Tonka is reading high again: 27.3 [491] at his AMPS, and gradually descending since then (21.5 [387] at +6.5).

I thought we were safe with yesterday's reading of 5.5 [99] at +10 since he was climbing gradually from there: 6.7 [120] at his PMPS, but he was already up to 10.8 [194] at +3.5, after a reduced shot (0.5 since 1.0 has been bringing him down quite significantly from his pre-shot levels), and he appears to have been rising steadily over the earlier part of the night, and was quite high when I snuck in a 2 am reading (25.3 [455] at +7).

So was the reduced shot too little insulin (could he be that sensitive that a half a unit would make that much of a difference? He is a 12-13 lb cat, which is roughly what his "ideal" weight is supposed to be for his size, and is eating only low carb wet food (with occasional freeze dried 100% meat treats).

Or could the climb we started to see at the end of his am cycle be another but slower rebound? (the only reason I'm thinking that he is rebounding so often is that he often skyrockets after a low reading, and given how long he's been in the high levels, maybe even a nice healthy 99 is too low for his body's comfort level? I don't think he dropped lower following his reduced shot - as stated, by +1.5 he was already 194. (By the way: just to be difficult, he never shows signs of hypoglycemia that I've witnessed, including the days that he was down below 2 [36] ... he appeared quite alert and normal)

*I don't know what to do about his rebounding after drops into the healthy range. If I keep him at the insulin level that puts him there, will his body eventually accept the lower readings and level out? Or will that 1.o unit dose of insulin likely knock him too far down once his pre-shot levels are no longer regularly over 20 [360]?

Last night, before he had skyrocketed again, I was planning on reducing him to 0.75 units to see where that took him after a few days. But with the consistent high readings he was getting on 0.5 units and my inability to test for a daytime nadir while he was on that dose, I don't know if that was too little or too much insulin (chronic rebound?). So I'm feeling nervous about even the 0.75 dose right now. I start back at work on Monday, so I won't be able to test him during the daytime other than pre-shot until next weekend.

 

[BJM]

The depot drained when you shot less Lantus, so the control wasn't as good. Have you had a chance to read over the 2 protocols for using Lantus/Levemir - Tight Regulation and Start Low, Go Slow? Each of them provides guidance on what to look for as good control, and how to adjust the dose periodically, based upon your mid-cycle test data.

The most important thing to know is that you want to keep the same dose for at least 2-3 days (Tight Regulation) to 14 days (SLGS) so the response can stabilize and you can get a clear picture of how Lantus is working in your cat.

If you want to stick with 0.75 units for at least 3 days, that might be a good place to start.

Also, see my signature link Glucometer Notes for some cat specific reference values using different meter and measurements (mg/dL, mmol/L, human vs. pet meter).

 

[jmalasiuk]

The depot drained when you shot less Lantus, so the control wasn't as good. Have you had a chance to read over the 2 protocols for using Lantus/Levemir - Tight Regulation and Start Low, Go Slow? Each of them provides guidance on what to look for as good control, and how to adjust the dose periodically, based upon your mid-cycle test data.

The most important thing to know is that you want to keep the same dose for at least 2-3 days (Tight Regulation) to 14 days (SLGS) so the response can stabilize and you can get a clear picture of how Lantus is working in your cat.

If you want to stick with 0.75 units for at least 3 days, that might be a good place to start.

Also, see my signature link Glucometer Notes for some cat specific reference values using different meter and measurements (mg/dL, mmol/L, human vs. pet meter).

Thanks BJM: I'll give it a shot for a few days at 0.75, in that case. But I'm still confused.

I have read both protocols (I'd like to follow tight regulation, but with my wonky schedule, that won't be possible most of the time, so we'll probably wind up somewhere in between), but I'm nervous about injecting him at all when he is already at or close to a normal number because I don't know enough about how Lantus works in isolation.

I do understand that the human meters read lower than the "true" readings of the Alphatrak and that his 6.7 mmol/L [x18 = 120 mg/dL] preshot reading would probably have read closer to 180 on the Alphatrak, but from what I've been reading on the site (including the glucometer link notes), the recommended "no shot level" is higher than that unless "data collection shows it is safe" My vet suggested not giving him any insulin if he dropped below 3.0 mmol/L [~54 mg/dL], but that seems pretty low to give him the same dose of insulin, considering how much he can drop on 1.0 unit.

**My data to date has indicated that he can drop as much as 180 mg/dL from 1.0 unit of Lantus, although this has been variable (again, depending on whether he's in rebound or not?). So that's the question: if a cat drops that significantly from a low dose of insulin when his sugar levels are high, will they drop the same amount when he is lower and that much of a drop does become dangerous? **

And will he eventually stop rebounding from normal/near normal levels if I can't keep him at those levels for a while? i.e. Does the curve start to flatten out after a while purely from the depot?

Sorry to be a pest. I tend to overthink a lot, and it makes me a bit anxious.

 

[BJM]

The interesting thing about Lantus is that the amount of drop may be less when you shoot at lower pre-shots. You have to be data ready to do it, that is, have enough mid-cycle data that you're fairly confident it will be safe, yet you're prepared to intervene if necessary. It can be helpful to first lower your no shot number to 150 mg/dL when your mid-cycle test data show it will be safe.

To shoot any lower that a pre-shot of 150 mg/dL, you'd want to be following a protocol that works with your situation, which sounds like might be SLGS, and posting in the Lantus/Levemir forum. For that protocol, you earn a dose reduction if the glucose goes below 90 mg/dL on a human glucometer.
If testing mid-cycles on many days or nights can't realistically work, I would not shoot lower than 150 mg/dL.

 

[jmalasiuk]

Okay, so in those cases it sounds like you just have to accept that he'll likely go right back up to a high level, for the sake of protecting him from dropping to low when you can't be there and hope that he levels out eventually - yes?

Does reducing the dose short term rather than skipping it entirely have no effect in dropping him halfway? That would work with a shorter acting insulin, but not so much with the "depot" insulins, I take it? That's unfortunate.

I can test him mid-cycle on weekends, and stay or get up at night for night-time nadir readings when I'm in town (should be so consistently now until at least April). In any case, the mid-cycle readings that I have been able to get during the days do show him dropping like a brick on some days, and only gradually or not at all on others. The non-drops appear to be when he's rebounding from a lower reading; the slow drops when he's first coming down from a rebound, and the more extreme drops when he's coming out the tail end of a rebound. We haven't had many actual "curve" days that I've been around to record. Sigh. Just have to get him down gradually, somehow. So hopefully the 0.75 unit dose will do that.

 

[BJM]

Pretty much. Any time you're concerned about him going too low, unless someone with lots of experience is there to give you feedback and you can monitor when you try something new, it is always best to err on the side of safety.

Better too high for a day, than too low for a moment.

 

[Wendy&Neko]

Hi there, just wanted to drop in and say Hi to a fellow western Canadian. Yesterday was a really beautiful cycle. Over time, you'll gather enough data to see how Tonka responds when you shoot lower numbers. If he ever gives you a lower preshot number and you will be home to monitor, feel free to post over in the Lantus and Levemir forum for help, and usually you can find someone who can walk you through options and stay up with you for part of the cycle. Although it seems counter intuitive, Lantus (and Levemir) work better when it starts on a lower number. With Neko, I've given her insulin in the 80's, and had her stay there the entire cycle. Once you've got some experience shooting lower numbers when you can monitor, you'll feel more comfortable doing it.

The other thing that a lot of people find helpful is to leave food out for kitty to eat, if you are going to be away. A lot of us have automatic feeders, scheduled to open around the low point of the cycle.

If you are interested in TR, we do have some members who've got schedules where they can't test much during the day. Here a post on Doing TR with a Full Time Job that might provide a few tips how to do it. But we also have a number of people who do a combo of TR and SLGS.

 

[jmalasiuk]

Okay. Dosing him 0.75 tonight (he was down to 18.1 at pre-shot, so still on a gradual descent). Here's hoping that he continues to drop nice and gradual and doesn't just rebound again. Thanks for the feedback!

 

[jmalasiuk]

Although it seems counter intuitive, Lantus (and Levemir) work better when it starts on a lower number. With Neko, I've given her insulin in the 80's, and had her stay there the entire cycle. Once you've got some experience shooting lower numbers when you can monitor, you'll feel more comfortable doing it.

The other thing that a lot of people find helpful is to leave food out for kitty to eat, if you are going to be away. A lot of us have automatic feeders, scheduled to open around the low point of the cycle.

If you are interested in TR, we do have some members who've got schedules where they can't test much during the day. Here a post on Doing TR with a Full Time Job that might provide a few tips how to do it. But we also have a number of people who do a combo of TR and SLGS.

Hi back! That's good to know, that Lantus tends to effect them less at the lower readings. Thanks to both BJM and Wendy for that information - it was the biggest concern that I had over keeping his dose constant. I'm too used dealing with ultra-fast acting insulin (in humans) and the constant fluctuations in dosage that that can entail/allows for.

I do leave food out for them (started watering down what they leave after the first portion is eaten), and they rarely finish it all before the next meal. Funny, because both cats used to be gobblers, but have lately turned into grazers wanting less and less of the food offered (right now they're eating approximately half of their recommended calories, but both are older cats - 12 and 14 - and not especially active outside of "crazy hour", so I'm hoping they just don't need that many calories anymore).

I'd read the post on Doing TR with a Full Time Job. I wish my workplace wasn't so far from home. Getting home at noon, which seems to be the best option, just isn't feasible. We'll just have to continue with spot checks on weekends and those nights that I'm up stupidly late (sadly, this is not unusual) or can haul my butt out of bed at the alarm to check his night time nadir. If I could just get him to a more predictable pattern, I'm hoping that spot checking would be enough, as long as I left any dose increases (or injecting when his pre-shot level is too low) to weekends when I can watch him more closely.

Thanks again

 

[Wendy&Neko]

It's all about data gathering. Neko does not have a consistent nadir, but over time I've got an idea what her patterns look like. It also means looking at previous cycles leading into the current one. We've got many people who work all day and can't get home for a mid day test. Just try to get a test when you get up, another when you get out the door and get back home if you can. That plus night time and weekend tests will give you an idea of what a dose is doing. And sometimes you may have to leave medium or higher carb food out for the day to make sure Tonka is safe.