Why are PM numbers so out of control?

[AZJenks]

I hope that my spreadsheet is filled out correctly.

Mid-cycle daytime numbers seem to be trending down nicely. We had our first blue today!

But the nighttime numbers are terrible, and they are going in the opposite direction of the daytime numbers with no apparent reason.

After his AM shot, he often eats several small meals throughout the day and is generally awake and as active as he can be. In contrast, he only eats one meal with his PM shot and then sleeps for most of the night. Could that account for the difference? How?

Any insight into these numbers would be appreciated.

 

[Larry and Kitties]

I do not see any AM preshot numbers?
Does Jenk eat the same amount at same time during day and during night?

 

[BJM]

I understand you may want to follow the guidance of your vet ... but you just raised the dose 1 unit and dropped the dry food which may drop glucose levels 100 mg/dL. And tests done at the vet's office may be from 100 to 180 mg/dL higher than at home. If you don't get more tests in to monitor for changes, you may overdose your cat ... to death.

It is very possible that some of the high numbers you have seen are because the cat either dropped to a much lower than accustomed glucose level (maybe the 174 yesterday) or dropped rapidly over a short period of time. Thes situations can trigger compensatory hormones which release stored glucose (glycogen) and raise the levels back up. There is a limit to how long this can go on when giving too high an insulin dose. Eventually the reserves are not able to compensate and the cat becomes hypoglycemic and can die.

Please always test before you shoot and if under 200, wait 30 minutes without feeding and re-test. If still under 200 at 2nd test, post here for suggestions.

Continue getting tests in the +5 to +7 period to check the nadir values which are used to increase or decrease the dose after at least 3 full days on it, in 0.25 to 0.5 unit amounts.

 

[AZJenks]

I do not see any AM preshot numbers?
Does Jenk eat the same amount at same time during day and during night?

I'm not around to do AM preshot tests. I can barely sneak back to do his AM +6. His other human is squeamish enough as it is just giving the insulin shot, so presently there's no way to get them to do a BG test.

Currently, we're just trying to get as many calories in him as possible following the removal of dry food. Because he gets shots at 9AM and 9PM, he always eats then. During the day, hey may get several more meals on demand depending on his mood. If he's in the kitchen asking for food, we'll put some down for him. So he will have anywhere from 1 to 3 small meals during the day. I'd estimate that he eats 1/3 to 1/2 of a 5.5oz can at any given sitting. After his PM feeding, however, he usually goes to sleep for most of the night without additional food. He doesn't typically each much at the dinner time feeding, typically consuming 1/3 or less of a can.

I understand you may want to follow the guidance of your vet ... but you just raised the dose 1 unit and dropped the dry food which may drop glucose levels 100 mg/dL. And tests done at the vet's office may be from 100 to 180 mg/dL higher than at home. If you don't get more tests in to monitor for changes, you may overdose your cat ... to death.

It is very possible that some of the high numbers you have seen are because the cat either dropped to a much lower than accustomed glucose level (maybe the 174 yesterday) or dropped rapidly over a short period of time. Thes situations can trigger compensatory hormones which release stored glucose (glycogen) and raise the levels back up. There is a limit to how long this can go on when giving too high an insulin dose. Eventually the reserves are not able to compensate and the cat becomes hypoglycemic and can die.

Please always test before you shoot and if under 200, wait 30 minutes without feeding and re-test. If still under 200 at 2nd test, post here for suggestions.

Continue getting tests in the +5 to +7 period to check the nadir values which are used to increase or decrease the dose after at least 3 full days on it, in 0.25 to 0.5 unit amounts.

I appreciate your concern and can assure you that someone is here to monitor him 24 hours a day. And we're all prepped and stocked to identify and respond to a hypo episode.

I understand your worry about the potential for an overdose under the circumstances that you mentioned. Just to clear up any confusion, the readings here are exclusively from home testing. There are no inflated readings from testing done at the vet's office.

How does one test to see if compensatory hormones are an issue? Do I lower the PM dose? How much? Do I not shoot at all? What happens then if the untreated BG goes to above 600 then? Doesn't that risk ketoacidosis, which seems more dangerous than low blood sugar? Over what sort of period would I do the experiment? What would cause these compensatory hormones to only act up at night, but not during the day? Please know that I'm not asking to be argumentative. I genuinely am trying to understand what's going on because I'm desperate to get his night numbers under control so he can start the road to recovery.

I thought I have been doing well testing the nadir? The last several nights were 400s, 500s, 400s. How do you interpret those numbers? And this pen only works in increments of 1U. Is there a different model that uses 1/4 or 1/2 units?

 

[BJM]

You'd need to observe a low number, followed by the higher than expected pre-shot numbers , or see him drop rapidly from pre-shot to +3 or so to know if you were observing a bounce in response to either of those. Unless he goes below 50 mg/dL, you wouldn't lower the dose. A bounce can take roughly 3 days to clear, depending on the cat, which might explain some of his high numbers.

It is possible the night time numbers do reflect bouncing, given the black and red values after a blue value in the past 2 days.

Testing around the nadir (which, by the way, can move) is great ... but the info you don't have is where he started. If he started low and you don't know that, giving him more insulin than he needs may result in higher numbers because he started low, started going lower, and either was dropping too fast, or too far, then the hormones triggered to push the glucose back up by the time you tested around nadir. There's no way to know if this is what is happening without the pre-shot test. Your other person might try practicing on an apple, or even a finger or forearm to get a literal feel for the process and become desensitized to doing it. Mentally imagining doing it also can help reduce anxiety over the process, as may observing you doing it.

We use insulin syringes and draw the insulin out of the pen with those. Take the cap off and treat the rest like a mini-vial. This lets you refine your dosing. While syringes don't mark the quarter unit increments, we eyeball them or use calipers for extra consistency in measuring the dose.