12/19 Mallie: PMPS 232 -was planning on doing overnight curve for 1.0u

Hi!
So this week, as per my vet-I started giving Mallie only 1u every 24hours. I obliged to be able to have the data that it wasn’t going to work for her. Today is her 3rd complete 24 hours.

I’ve been keeping her SS up to date. please have a look. There isn’t much data other then the “AMPS” and the “PMPS” as I haven’t been able to do any mid cycle testing during the work week.

I was planning to do an overnight curve tonight (since I am off tomorrow) and I was going to send the numbers to my vet and say that the 1.0 Unit every 24 hours isn’t working.....but for the first time since we started last Friday evening on lantus, Mallie doesn’t have a bg above 19 with having gone 24 hours without a dose.

I know that giving her a 1.0u dose when she’s at 12.9 will be too much for her tonight. So I was going to do 0.5 or 0.75 and do the curve overnight still.

I am really perplexed. I was not expecting her to still be the same as she was this morning (0.4 less) with her coming up on 24hours.

I’m not sure what I’m asking, or if I’m asking for any advice. Has this happened to anyone before?
My coworker, who’s daughter is diabetic said that Mallie still being the same as she was this morning (although still high) coming up on 24 hours means that her numbers are showing signs that they are stabilizing.

 

It looks like you already shot 0.5u tonight.

Normally you would not do a curve until Mallie had been on a dose for 1 week. Given the once daily dosing and you have changed the dose between 1u and 0.5u a few times, a curve at this point in time isn't going to give you a good representation of how any dose is working. It sounds like you are only doing this to satisfy your vet so if you do it, it probably won't show great numbers which it seems is your goal but you also haven't given 1u each night either which may make the results questionable to your vet and not meet your goal of foiling her once daily dosing advice.

 

Tonight would’ve been the third night that I was to give 1.0 but she wasn’t high like she had been the other nights. I was too scared to give her a full 1.0 tonight so I opted for 0.5.

My vets original rx was 1.0u twice a day but since I had good numbers over the weekend he recommended trying 1.0u once a day, which I started on 12/17.

Tonight is my first opportunity to check her bg every 2 hours since I am off tomorrow since her first dose last Friday.

 

You did get some good numbers over the weekend but for the vet to think reducing the dose 50% was needed, he/she is aiming for numbers higher than we would here which is common and dosing once a day simply doesn't work with Lantus. Would have been better if he/she'd suggested 0.5u twice daily.

 

Hi Aly,

I'm just going to throw out a couple of things which *may* help you understand Mallie's numbers.

Lantus is not an "in and out" insulin. By this, I mean some insulins you give, it lowers the blood sugar and that insulin is used up, so the cat's numbers rise until the next shot is given. Once that insulin is used, it is no longer in the cat's body.

Rather, Lantus and Levimer are "depot" insulins. Very, very basically, this means that some insulin from each injection is stored in the cats body and slowly released over time, so the cat is never "out" of the insulin, it is not *all* used up. The doses have to be consistent in order to build a stable depot, because the depot insulin affects the blood glucose for a while.

Here is an excerpt from the sticky "What is the dose depot" (http://www.felinediabetes.com/FDMB/threads/what-is-the-insulin-depot.150/) which explains how a fluctuating depot from inconsistent doses can affect the blood glucose. Please read the full link to put it in context

"Did you skip a shot or give a partial shot at some time in the past few days? That can result in higher numbers for several days as the depot replenishes some of its lost stores. Did you increase the dose? This can result in a change in the size of the depot and can lead to a temporary adjustment in the amount of insulin available for use. Did you decrease the dose recently? A dose reduction will usually result in a need for less stored insulin. The excess may be released into the bloodstream faster than usual, especially if several dose reductions are done back-to-back."

This depot action is why it is so very important to give consistent 12 hour dosing with Lantus using these protocols...it is only after the depot is built up and stable that we can see how the cat is responding to that dose of insulin. For most cats, this takes 3 days or 6 cycles (6 consistent doses of insulin at 12 hour intervals).

There is another common phenomenon that occurs that is called "bouncing". This is when the cat's body puts out stored glucose as an emergency response, which causes a rapid increase in blood glucose to high levels; these levels take a few days to settle back down. It is important to understand that this "emergency response" can be to a "low" (hypoglycemic episode) or to a perceived low. What I mean by "perceived low" is that, to a diabetic cat who has had higher blood glucose numbers for a while, those high numbers are the cat's normal. When the cat drops into lower numbers (that are not necessarily hypo numbers, just lower than the cat is used to) the cat responds in the same way as it would to a hypo event....it puts out stored glucose in an effort to raise the numbers and save it's life. Again, this results in high numbers for a few days until they settle down. Bounces can also occur from a sudden drop from high to lower numbers.

I don't know whether Mallie's numbers are a result of bouncing from her drops from high to lows, or from the inconsistent dosing. Both may be a factor.

Regarding dose adjusting and curves:

Lantus is dosed base on how *low* the dose is taking your cat; this is called the nadir. Doing a curve is a great way to see where your cat's nadir may be; so is doing "spot checks". For many cats, it is around +6 hours. For many cats, it can be another +hour. And for some cats, it can vary...Willow had nadirs from +6, +12, and at the end nearing remission she nadired at +1.5. But knowing when your cat is likely to nadir is essential both for keeping her safe, and for adjusting doses.

We recommend at the very least a "before bed" test to give us an idea how fast/far the cat is dropping (since every night can be different) so we know either if we should test again for safety's sake or if we can be reasonably assured it's a safe night to not check. Also, many cats drop lower at night than during the day.

I don't know if you've looked at the "stickies" at the top of the Lantus/Levimer forum? They're labeled at the top of this page. A lot of info.

I hope this somehow helps. Let me know if there's anything I can clarify.

And as always, if anyone noticed I messed up, please clear it up and let me know!

With love, Nikki

 

I agree.
I think 0.5u twice a day would have been a better place to start. I like this vet, and he took me on after I had the falling out with my previous vet, so I did not want to brush off his recommendations without trying them first.
I agreed to do the 1.0u once a day in hopes to show him that it was allowing her to go low and then climb back up above 20s as it wore off and we reached the 24hour mark, but tonight she wasn’t near the 20s at all.

As I said, this is the first opportunity I have had to do a “curve” of checking Mallies bg every two hours, so I don’t know what speed her body metabolizes the lantus. My original plan was to actually do a full 24 “curve” so I could show the vet what her body was doing with that 1.0u given in the evening.
Yes it would’ve been better if I had given her 1.0u tonight, but I wasn’t comfortable with doing that given her two night “history” last weekend of having 0.5u in the evening (because she was 10-12) and then being 4.6 in the morning, 12 hours later.

Even as it is, I’m unsure of what I should do now in the morning. Do I stay on the 24hour schedule as per my vet....with her only having 0.5u tonight I feel like she is going to repeat what occurred on Sunday possibly. She’ll be <5 in the morning and then around 20 by the time 6pm comes around.
Or do I take this opportunity to try twice daily dosing at a lower dose?

 

And to be honest-my anxiety is starting to play on me and I’m starting to worry if I even got the 0.5u in her. I’m 99.5% I did-but that thought has crossed my mind a lot in the last 3 hours.

 

4.6 (83 US) is a perfectly safe BG but it's hard to tell if 0.5u is a good dose or not because with the dose changes, the depot is unstable. Until a cat is regulated, a low BG at the end of the cycle could suggest dose is too high. I have to wonder how low BG might have dropped during the preceding night cycles when those 4.6 (83 US) AMPS occurred.

It's possible you didn't get all the insulin in tonight or it could be that numbers are just wobbling due to the dose changes and once daily dosing.

If I were you I'd go to twice daily dosing with the 0.5u dose and monitor but it's up to you how you want to proceed. I think you have proof that once daily isn't doing what you want.

 

Mallie is at 21.5 now +4 from the 0.5u

I’m really doubting if I got the 0.5u in her. I have a memory of hearing an audible “shhshs” from the syringe as I pressed on the plunger and I thought to myself “I’ve never heard it go in before” so now I’m thinking that for whatever’s reason, it wasn’t actually in her skin-though I did feel the poke initially.
Ugh. I feel awful.

 

Don't sweat it. Fur shots have happened to all of us. Make it a habit to swipe your hand gently over the injection area after shooting or sniff the area for a medicinal smell to check for a fur shot. You may have got half in and half not so never ever give another shot if you suspect a furshot.