Question about Lantus Hypoglycemia and subsequent spikes

Hello,

My recently diagnosed cat was put on Lantus 1 unit two times a day and her pattern seems to be to become hypoglycemic about 3 hours after the Lantus injection and then spike really high following the hypoglycemia. So for example 3 hours after insulin she will be 50 mg/dl .. then Ill treat for hypoglycemia (corn syrup on gums and some food like the vet suggested) and then she'll go up gradually throughout the night but then by 8 am her gluc will be 400mg/dl... I really don't know much about cats and diabetes at this point. I'm trying hard to learn.. Does anyone know what would be causing something like that? thank you.

 

This is a phenomenon called "bouncing":

Here's how it works:

1. BG goes low OR lower than usual OR drops too quickly.
2. Kitty's body panics and thinks there's danger (OMG! My BG is too low!).
3. Complex physiologic processes take glycogen stored in the liver (I think of it as "bounce fuel"), convert it to glucose and dump it into the bloodstream to counteract the perceived dangerously low BG.
4. These processes go into overdrive in kitties who are bounce prone and keep the BG propped up varying lengths of time (AKA bouncing).
5. Bounce prone kitty repeats this until his body learns that healthy low numbers are safe. Some kitties are slow learners.
6. Too high a dose of insulin can keep them bouncing over and over until the " bounce fuel" runs out and they crash - ie., have a hypo episode. That's why we worry so much about kitties that have had too high a starting dose prescribed by the vet and the owner isn't home testing.

It appears that the 1 unit dose is too high. If you're willing to go post on the Lantus forum there are many very experienced people there to help you. Have a look at the yellow info stickies over there to learn more about Lantus.

 

If she is having hypoglycemic episodes, her dose is too high. Do you feed her before her shot? The high numbers are because when she goes so low, her liver releases extra sugars. That causes her BG to go high. This is called bouncing. Once you lower her insulin, it might take a couple of days to get her settled down. If she were mine, I would lower her dose to 1/2 u. Did you call your vet about this?

 

Thank you for your reply. Yes I brought her in last night after it happened. They were talking about lowering her dose when I brought her in. They gave her 0.5 this morning at 8 am when her blood gluc was 400 and then I guess the vet gave her another 1/2 unit at 11 am because the gluc kept rising?? I don't know. I feel like I'm having a hard time trusting the vets too. They don't have the proper syringes at the vet for 0.5 unit. They only have the ones that go up by 1 unit to 100 units. so they estimated 1/2 unit....and said they were going to try and get the proper ones today...

 

Thank you Kris and Teasel for your reply as well. Sorry I didn't see it until now. I think they are trialing her on half unit now and I'm crossing my fingers it works for her. Its nice to hear that their bodies can learn not to rebound quite so high after a healthy low number. Thank you Ill check out the Lantus forum

 

Lantus is a long-lasting insulin. Onset of action isn't even expected before around 3hrs in, giving a second shot then because numbers were still high suggests these vets are not very familiar with treating feline diabetes with Lantus. That's the kind of thing that is only done (at the vet, with close monitoring) with short-acting insulin in very special circumstances (such as a diabetic ketoacidosis emergency situation).

That's not even considering the phenomenon of "bouncing" described by Kris-- there was no reason to be surprised at high and rising numbers this morning. Giving an extra shot sounds like a bit of an overreaction.

Are you testing blood glucose at home, or are you detecting the hypos by external symptoms? If you are monitoring at home, it might be better for you to take over the care of your kitty-- and, definitely, with a lower dose! The Lantus forum has tons of knowledgable people and lots of information in the "stickies" at the top.

If you post about this in Lantus, it's a good idea to add a link back to this thread so that people can get the history-- not everyone there reads this forum every day.

I hope your kitty recovers quickly-- hypos are scary!

 

It seems they aren't very familiar with the action profile of Lantus as Nan said above. We can certainly help you to learn much more about treating FD.

 

Ah-- just saw your post in the Intro forum, and it sounds like poor Ballonee is recovering from DKA. That does change things a bit-- if she's still throwing ketones, or right after a DKA, the vet is right to be more aggressive in insulin dosing (although again, Lantus isn't necessarily the weapon of choice for bringing numbers down fast). With DKA in the mix, it's really important not to underdose insulin.

Do you know if she is currently showing any signs of ketones? If so, I'd revise what I said above and say that the vet may be the best place for her right now, until those are under control.

One option in the current situation is to keep a relatively high dose of insulin to keep ketones down, but also proactively feed higher-than-usual carbs so that blood glucose remains high enough.

What is she eating currently?

 

Thank you for your replies.. I know its long acting and I'm feeling pretty sick about his decision I actually called a different clinic and am considering getting her care transferred. I asked if they had vets experienced with feline diabetes and she said they had a couple new cases just this week. So maybe that is a consideration. Thank you for your help. I called the hospital that shes at right now about an hour ago questioning the lantus decision and no one has called back yet. I am monitoring glucs at home. Thank you all for your help. I am looking forward to learning more from the forum.

 

Shes eating a diabetic wet food formula.. "purina pro plan dietetic management" thats what the vet gave us. She is out of DKA now. No Ketones were shown in her blood work or urine for the last 2 days now.

 

That's what my cat eats, mixed with Friskies. Eating and no ketones are good signs. I've been through DKA with my kitty so I understand the need for enough insulin.

 

That's great!

 

When you are able to talk to the vet, be sure to ask what their current treatment goals are. If they're concerned about prevention of another DKA and/or aftereffects of a symptomatic hypo, and feel that she needs closer monitoring for a while, that may be reasonable. If they say "to get her regulated" or "to find the right dose", that's probably not a realistic short-term goal for a cat and you can do it better at home.

As for lantus-- it's in general a very good insulin for cats, it's just the double-dosing strategy we're questioning.

 

Current treatment goals are to regulate her on insulin (i.e find the right dose) but mainly to prevent the hypoglycemia she is experiencing. So the other vet called me back and basically said he didnt agree with the vets decision to give another dose of Lantus four hours apart. They discussed what to do.

The plan is 0.5 units bid for about 2 weeks to see what happens basically. And food with both of those shots of course, but they aren't feeding her a diabetic formula at the moment. Not sure why. Right now she is running high on that but they basically said they want to see how the 0.5 units twice daily works out over time. My thoughts: maybe if she doesn't experience the extreme lows that were happening on the 1 unit twice a day, she won't rebound and have the extreme highs. Maybe her body will adjust? My other thought is, if she is running high on the 0.5 maybe they should be feeding her the diabetic formula since her gluc will lower on that?

Thank you so much for your help

 

One strategy in a post-DKA cat is to feed higher carb food for a while, so that may be part of what they're doing. The reasoning is that you need to be able to give enough insulin to be able to hold back ketones, but without sending them into hypo. Sometimes a cat will need more insulin to counteract development of ketones than is necessary to maintain a normal blood glucose-- so you have to up the carbs in the food to boost the BG. It's a tricky balance, for sure.

Hard to say on the bouncing-- some cats are just always going to bounce, but definitely a lot of cats will slowly acclimate to "normal" numbers and (sometimes slowly!) reduce their bounces. But it's not an instantaneous process, usually.

For a DKA-prone cat, often the goal (if you are home-testing) is to keep the cat in the low-mid 100's for BG-- a good safety margin away from hypo, but low enough that the system isn't under a lot of stress.

If you aren't already, you'll definitely want to be testing for ketones at home. The easiest way is with urine dipsticks (sold with human diabetic supplies in pharmacies). Some cats let you stick the dipsticks themselves, or a long-handled spoon, into the stream when they pee, otherwise you can put some plastic wrap in the litter box to gather some droplets.

How long do they think she'll have to stay at the vet?

 

Thank you for the information and rationales. There is definitely so much to learn. I will need to get Ketone urine strips to test.

They think she will have to stay there until tomorrow but I guess Ill see how she does overnight.

I'll keep posting my questions as they come when she gets home. Quite nervous about managing her on my own. Thank you for your support.

 

Hi Spencer,

I see from your introductory post that Ballonee is a thin cat. Is she still underweight? If yes, then this might make insulin dosing a little bit trickier than for a cat who has a bit more meat on its bones, and may produce the situation where BG levels can swing from very high to quite low values after insulin administration.

I suggest you do a forum search for posts containing the term 'brittle diabetes' posted by member @Meya14. There you may find useful pointers to discuss with your vet on how to approach insulin treatment and diet to help your little one regain weight and achieve smoother BG levels. (See this post also.)

We can all relate to how nerve-wracking the early days of treatment can be but hang in there; you will more than likely pleasantly surprise yourself at how well you will manage Ballonee's FD as you learn more and sort out a routine that works for both of you.


Mogs
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Here's a very helpful post by Meya14 on brittle diabetes and treatment avenues for underweight cats:

http://www.felinediabetes.com/FDMB/threads/vets-cant-stabilize-glucose-levels.165787/#post-1790343

From Meya's post:

[Emphasis mine]

Definitely worth chatting with your vet about this, methinks.


Mogs
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Thank you so much. I've actually never heard of that. Definitely worth talking to my vet about.

 

Meya is extremely knowledgeable. I've learned a great deal from her invaluable contributions to this forum. It's well worth reading her backposts about DKA, too (a veritable goldmine!).


Mogs
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I apologize for asking this in advance but my vets are giving me conflicting info and Im just confused. Im getting Ballonee back from the hospital tonight. Im super nervous. One vet said to treat for hypoglycemia under 6.0 mmol (106) the other vet said to treat under 4.0 mmol (72). I'm sure this information is posted somewhere obvious and I just cant find it because Im anxious, so Im sorry for asking in this particular convo

 

I'm so happy Ballonee is coming home tonight! You'll do great, don't worry.

As for hypo treatment: in general, we use a "take action" (time to feed some high-carb food) number of about 2.8 mmol (using a human meter) and about 3.8 mmol (using a pet meter). Your spreadsheet is for a pet meter (AlphaTrak), so I assume that's what you're using? So that's in agreement with vet #2.

However: in this case, I don't think it would be a bad idea, at least for the first few days, to take a more proactive approach as suggested by vet #1. Cats who have gone through hypos are often more sensitive to insulin than before, plus she's underweight as discussed above. It might be good to have a larger safety margin while you're still figuring out her new patterns. So if you want to use the higher cutoff for your take action number, I think that's a good idea. After a few days when things are more settled and you have some more information about how she's reacting to the insulin, and how she reacts to the high carb food, you could go back to the regular cutoff point.

Another technique that might be useful is to give an extra small meal when you see her dropping quickly (say, more than 5-6 mmol in an hour), even if she isn't yet close to the cutoff line (this meal can be low-carb). We've found that doing this can often slow them down and dampen the downward momentum, flattening out the day's numbers somewhat and hopefully preventing a serious hypo. How often do you normally feed her?

 

Thank you so much! I'm picking her up in about an hour and a half!

So again, vet #1 said feed her 2x a day 1/2 can of wet food with each Lantus shot. Vet #2 Said to feed her 3x a day 1/3 can of wet food at each meal at 7am (with Lantus), around 2pm, and then again around 7pm (with Lantus). I think that if I end up feeding her twice a day I'm going to need to give her an extra small meal (as you suggested) when she drops. She usually is normal/high during the day and then at 9 pm she always gets hypo It's technically her 1st day on the 0.5 unit dose twice a day so hopefully that helps with the hypos.

Thank you!

 

A lot of us feed many small meals over the course of the day (schedules vary); it seems to be easier on the pancreas and help keep them more level in BG. If she's underweight and coming out of a DKA, I'd be inclined to err on the side of giving her more food.

The one time you want to restrict food is in the couple of hours before the shot. This is so you can test her BG before the shot and be sure that she's high enough to shoot, without any food influence on the number. The order is test, feed, shoot-- test to make sure it's safe, feed to make sure she's at least willing to eat before giving the insulin.

How high has she been at that 7pm shot time? Just wondering how fast she's been dropping, and if maybe the descent sometimes starts earlier.

 

So it's interesting because in the morning she will have her Lantus and her lowest number for that will be around 7.0mmol, but at night she always goes hypo about 2-3 hours after the shot. For example she will be 14.9mmol at 7pm and then by 10pm she was 2.8mmol. Hypoglycemia doesn't seem to be an issue with her AM dose of Lantus.. just occurs with the PM dose.

 

... and then by morning she is around 22.5 again :/ which is why I thought it may be re-bound hyperglycemia. I'll start filling out my spreadsheet when she gets home so I can start seeing patterns and maybe get some guidance.

 

That is interesting. What I'm wondering about is what she is at 5pm or 6pm (by the way, because we're all in different time zones, we use times in hours from the last shot-- so, for you, 5pm is usually +10, 6pm +11). For her to drop so much at the evening +2, I'm thinking she must be already dropping before the shot, and then the Lantus starts to take affect around +2 and the bottom falls out.

Sounds like there's definitely some rebounding going on as well, so there's a lot going on here.

I'm sure she's going to be super-happy to be home again!

 

Thank you for letting me know! I see that on the spreadsheet as well (hours from the last shot). Yes, definitely a lot going on :/ I'll be monitoring her closely though and hopefully get it figured out. Thank you for all of your help. Wish me luck tonight