5/4 - Warren - AMPS 518

Hi all, BJM has been a tremendous help over in the introduction forum but suggested I start posting over here.

Quick summary, Warren was diagnosed a bit over a year ago, he was on vetsulin and went into remission for 9 or 10 months. When I put him back on Vetsulin, it was not lasting long enough so I started him on Lantus on April 23.

I am having a very frustrating time just figuring out a good dose for him so I can get him stabilized.
I started with 1 unit, but it seemed too high as it was lasting too long and he had one drop into the 40s.
I reduced him to 0.5 but after several days it seemed this dosage was too small.
I've increased to 0.75. He's only been on this dose for 36 hours, so jury is still out, but I was hoping to see better nadirs than we had been but so far he doesn't seem much changed from 0.5. (Disclaimer, it's very difficult to measure 0.5 and 0.75 so these numbers are best effort).

I'd love to get some feedback on his spreadsheet data from people who have been through this .... perhaps 1 unit just didn't work at the time because he was coming off of Vetsulin. Perhaps 0.75 will start to work better in a few days. My wife insists Warren live in the bathroom until he's stabilized because he's having accidents. I can't really blame her, but I feel really bad for Warren who's a very social lap cat and misses his people.

Warren and I thank you.

 

I'm glad you've come over to join us. Lots of eyes here and input. Welcome Warren & Rob.

The first thing I'm noticing on that ss is that black this morning....
if you look at your ss, you can see that when he's gone green, he then bounced to a black number.
So that means it's possible that he saw a green last night during your sleep. ( not guaranteed)
That's imho ( in my humble opinion) This is the pattern I'm seeing thus far.
that doesn't mean a low green necessarily. It could have been a high green. But you have to see it to know.
So with that , the recommendation is what we call sleep testing.
If you get up to use the bathroom ( sounds like he's already there waiting for you ) , grab a test.
If you never get up, then set an alarm.

That's the struggle, sometimes you can miss the low of the cycle ( it can move around) and all you see is the response ( the bounce)

The good news is he's clearing those bounces pretty fast.

 

Thanks for the response. I've been doing my testing in the day as you can see and trying to catch him at +6 to +7 each day. I can add a night one as well.

 

Odd...... at +11 he's at 158. He's usually climbed quite a bit by then. I'd test at +12 to make sure he is climbing rather than dropping before I give his PM shot, but it's food time now so he's going to be climbing anyway. Perhaps I should have held off feeding him for another hour but based on what I've recorded in the past couple of weeks he should be fine.

 

Hello and welcome Warren and Rob. My Neko was on Caninsulin/Vetsulin at first, so I know what you mean about it not lasting enough.

We suggest not feeding kitty for two hours before shot time, as food can influence the numbers for a couple of hours. You don't want to test and have that number artificially influenced by food. Most of us test, feed, and shoot all within 15 minutes or so.

I'll also echo what Rhiannon said - getting a night time test, even just before bed, really helps fill in the pieces of the puzzle. Many cats, including mine, prefer to do their lows at night. Getting a +2 test or whenever before bed it, will help in figuring out what the dose is doing.

 

I took a few night time readings over last night and early morning. I debated on giving him a PM shot as he was 151, but I did just to try to keep things to a regular schedule. He was 154 at +2 when I went to bed. Because it takes several hours for the Lantus to kick in, I gave him a small amount of high carb dry food just to be safe and checked back in on him at +6. In that 4 hour period he went from a 154 (at +2) to a 469 (at +6). Quite a bounce.

 

What can we learn from the readings last night? It looks like he started out the night well, then shot way up and has stayed high since.
Is this possibly indicative that the PM dose is too high and he bounced and is still in recovery?

 

since he didn't bounce to black.... i'm going to say it's likely he didn't touch toes on the green floor.
that indicates his body isn't used to blues either. He just didn't bounce as high.
the dose is right for now ....

 

Any thoughts then why the evening dose didn't seem to be very effective? Historically the evening doses (at least where I have taken samples) never seem to do well.

 

Good job shooting that 151 last night - he would have been much higher with out that.

You asked about why the night cycle wasn't as good. One factor is high carb dry food. Dry food lasts several hours and can really influence the numbers. We had one kitty go from 5.5U of Levemir to zero after dry food was removed from the house. Next time, try leaving either low or medium carb wet food out if you can't monitor him. And as Rhiannon said, he's bouncing. The other thing that can cause bounces is fast drops, anything in the order of more than 50 points an hour. On the plus side, he's down to blues already.

 

Hi all, would you experts mind taking another look at Warren's spreadsheet? Almost 3 weeks and I still can't find a dose that works for him every 12 hours. I can't see any kind of pattern and I'm giving up hope that lantus will work for him. Let me know if a new 12-18 hour curve will help. Haven't done one in a while. Thanks.

 

I think he's bouncing from that 53 yesterday. Look at how he started in blue at PMPS last night and has gone up and up from there (although not all that quickly) into black tonight. As he didn't quite go under 50, I'd hold the dose he's on until the bounce clears and see where he settles after that - it's possible that those black numbers might be the high before the bounce breaks, or he might wobble around for another day or so before he comes back down. He will get used to being in the lower numbers but it takes time and that 53 was pretty low.

It's frustrating having to wait it out for bounces to clear and better numbers to show up - I think we all understand that only too well here, but it does look as though that's what you need to do for now to see what happens when he clears this bounce.

 

Is Warren still getting dry food? It can play havoc with the numbers. I also agree with April that he's bouncing due to that 53 yesterday. There's a chance he got lower than that. If you can, getting those before bed tests will tell us what is happening at night. Spot checks can be just as useful as a curve.

 

Warren hasn't had dry food in over a year other than if there is concern about low pre-shot numbers and I can't monitor him. I think in this three weeks he's had a *very* small handful of dry food only twice. Also you'll note that lately we are a bit all over the place as far as dose timing. We've had doses last for 15 hours and some for 9. It makes it a challenge in the evening when I have to stay up until 1am waiting for his numbers to rise enough to give his pm shot at +15 or 16, then can't take another reading until am. Tonight I'll get one around +3 or +4 before I go to bed.

Thanks for sticking with me, I've read a lot about the process but wasn't expecting it to take this long to even figure out his dose. Perhaps I should drop back to 0.75 since I've seen 1.0 last too long a few times now. However he wasn't getting much in the way of good numbers with 0.75.

 

Is there a reason you can't shoot every 12 hours? (other than when he's too low to shoot and you can't monitor?)

It really is important for those shots to be as close to every 12 hours as possible. If you have to stall due to a low PS number, the next shot should be at least 11 hours, 45 minutes away. You can work your way back to your chosen shot times 15 minutes per cycle

 

Only reason is the numbers. He was 52 at +14 the other day. I had to wait until +16 before he was low enough to shoot. Then again, a 94 at +12. Same issue. Then he's 325 at +8 after so I shot then to try to get him back on a manageable schedule. If i cant shoot until 1am because I'm waiting for his numbers to rise, I can't manage a 1pm shot because I'm at work.

 

Going to drop back to 0.75 for a dosage. He was a 49 today at +6. I guess I should expect another bounce day or two.

 

Hi guys, it's about the end of the line for Warren unless I can fix this quickly. He pees on the kitchen floor every other day and there's a litter box 5' away in the bathroom. My wife had had enough and wants me to have him put to sleep. He's been on lantus for a month and still isn't regulated. I need help. Please let me know what to do from here. Thanks.

 

I would have him checked out but I'd also get Cat Attract litter.

 

Hi all, so Warren has been having his ups and downs, overall things are definitely improving as far as litterbox behavior, but I'm hoping to get a spreadsheet review from you Lantus experts. It seemed 0.75 doses were too high (bouncing). I reduced down to 0.5 for about the past month, but it looks like he's still bouncing. I haven't been able to capture the guilty nadirs but I see readings in the low 100s and then the next two days he's up into the 400s, then repeat. Looks like bouncing to me. I've now reduced him to 0.25 (as best as I can measure anyway) but was hoping to get a 2nd opinion. He's also probably due for another curve.

Thanks.

 

Hi and welcome back. He is going to bounce until he gets used to more normal numbers. Have you had a chance to look at the protocols? With these high numbers I don't think he is getting the correct amount of lantus. We dose based upon the nadir which is usually at +5-7 but can happen as late as the next shot time. We don't reduce based on the preshot numbers or because we see higher numbers and suspect a bounce. When you have a preshot number of 50 you don't want to shoot. That is dangerous.

One of the pros will be on to help.

 

Good news on the litterbox improvement!

Reducing the dose of insulin is not a way to make cats stop bouncing. They will only stop (or reduce the amount of) bouncing, once they have spent enough time in normal number range so that their bodies get used to it. Reducing the dose will just make him go high and flat - which means not bouncing, but also above renal threshold and no where near regulated. It can also cause Glucose Toxicity, which sounds worse than it is. Basically their bodies get used to higher numbers and you have to increase the dose even higher to get them down into normal numbers.

We have two methods people here use for determining doses. They are the Tight Regulation Protocol (TR) or the Start Low, Go Slow Method (SLGS). Give them a read and see what you'd like to follow - our recommendations for what to do on dose depend which of these you are following. Once you've decided, it would be helpful if you'd put either TR or SLGS in your signature so we don't need to keep asking. One thing to consider, TR will require at least one additional test each night, even a +2 test is helpful in telling us what is happening at night. Given the data you've got, I think both methods would mean going back to .5U or higher (get him used to lower numbers), and either get more night tests (TR) or do weekend curves (SLGS).

 

Wendy beat me to the post. Reducing the dose is going to leave Warren in high numbers which can be a challenge to deal with. Lowering the dose generally has the effect of slowing down the process of getting numbers into a better place -- I think of it as prolonging the agony. Bounces are normal. Warren has been in high numbers and that's what his body is used to. When his numbers drop, his system goes into panic mode and his liver and pancreas overreact. This is what causes the bounce. The more time he spleens in normal range numbers, the less he will bounce.

It's also very important to get at least one test in the evening. Lantus dosing is based on the nadir so you need to be able to be certain your kitty isn't dropping too low at night. That 93 on 7/12 at PMPS could have meant Warren dropped even lower and a dose reduction might have been warranted -- or he may have been in dangerously low numbers.

 

Ok thanks, I have read the two approaches, been trying to follow them best I can. It was recommended I drop him from the .75 down to the .5 because of the low nadir I caught a couple of times. I didn't realize bouncing was normal, even when he didn't go too low. I thought it was only a consequence of him hitting dangerously low numbers. I will keep him at 0.5 and take readings more often.

 

Bounces are caused by several things...1. going too low 2. dropping too quickly (like from 400-250 in 2-3 hours) and 3. going lower than the body has gotten used to being at (or any combination of all 3)

You said you read both protocols....do you know which one sounds like it would work best for you? You can't really do both Tight Regulation and Start Low, Go Slow so you need to pick one you think will work best for you and your family. Don't worry...you can always change if one doesn't "fit".

Hang in there...we'll help you learn when he's bouncing and you just have to wait and when it's time to increase or decrease!

 

I started out all over the board, but after lots of learning, I've been following the tight regulation approach.
At 0.75 units, because he hit some 50s, I was advised by the group to reduce him to 0.25.
However looking at his numbers over the past few weeks at 0.25, they aren't very good.
Warren has also recently gotten worse with his litterbox habits. In the past 4 or 5 days, he's pooped twice outside the box, and peed 4-5x outside the box.

I was in tears last night and didn't sleep a wink because I really felt like I've done everything I can and the wife is at her limit. I thought today would be his last day, but then this morning my wife said she thought he looked really good and was behaving very well, so 'let's give him another chance'. That was before she found his most recent accident.

I started taking a close look at his #s and though he had a good reading today for the first time in a while, at 0.75, he was seeing better #s more often, though bouncing a lot more. I do need to take readings more often to get a better picture, I've just gotten a lot of conflicting info as to when I should take them. I believe his nadirs are around 7-9 hours after dose, so I'd think that should be my target? But really regardless of the results, I have very limited possibilities here, it's either 0.5 or it's 0.75. Or somewhere in between that's impossible to measure consistently.

 

Hi Warren.
I have been following your posts on the Main Health forum and I do feel for you and the problems you face.

From the remarks on your spreadsheet, it looks to me like you did give the insulin pretty early yesterday morning. Usually, we advise giving the insulin shots as close to 12 hours apart as possible. I know that things come up sometimes though and we do the best we can. Just be aware that giving the dose early acts like a dose increase.

I would need to see more mid-cycle tests to help you with the dose adjustment questions as Lantus dosing is based on how low the insulin brings your cat's sugars down, which normally happens sometime in the mid-cycle.

Like for example, my cat had a pre-shot test of 346 at AMPS and was 460 at PMPS. This was on March 31st 2014 if you want to look on my spreadsheet. Luckily I tested and found him at 32 at +5. If I didn't get that mid-cycle test, I would have thought he needed more insulin, and if I had given him more insulin then he probably would have gone too low the next time.

Can you get more mid-cycle tests?

That 123 today is a pretty nice number. Keep on keeping on.

 

Hi Rob

I agree with Dyana - with only pre-shot tests to work from, it's really difficult to tell anything much. It could be that he's been dropping into the 90s a lot of days as the last mid-cycle test I'm seeing before today was 10 days ago. I know it's difficult when life's busy, but if you can even get one mid-cycle test most days that would really help us to figure out what's happening with Warren's numbers.

I think if it does get to the point where you're trying to measure an 'in-between' dose, you might well find using calipers and measuring the dose that way would help with consistency of dosing.

 

I'm trying to learn how to figure out the caliper measurement for the Walmart syringes I use. I understand how to use the calipers to measure, just not sure of how to determine what that measurement should be. His readings look so good today for the first time in ages, I wish I could figure out how to keep him at these levels.

 

I took me like a week to get the hang of using calipers.
I think you want to find a "perfect" syringe. One that the zero line is at the top of the syringe (I know how varying WalMart syringes can be as that's why I started using calipers in the first place), and then measure the dose using that perfect syringe and then measure it on the calipers. If you have the locking kind of calipers, then lock that measurement in. It took me some time to measure the doses at first, but they were way more accurate and consistent.

 

I think the only way of doing it is to estimate the dose as best you can...probably a few times - and then measure it with the calipers each time to make sure it's fairly consistent. Once you have the measurement, you'd draw the dose based on the calipers not the markings on the syringe. It should be easier after that first session of figuring out exactly what the measurement should be because then you're not trying to work by the markings on the syringe any more (and those aren't always all that consistent anyway).

 

So it sounds like I will never REALLY know the actual dose, I'm just trying to make sure they are consistent? I didn't get that impression from some of the other threads I've read, I thought there was another step in order to determine where true 0.5 and setting the calipers based on the true measurement, but perhaps I misunderstood and that's why I haven't been able to find the procedure to find the true measurement.

 

Different brands of syringes vary. And the marking on syringes of the same brand vary. That's why on the smaller doses, we recommend using the calipers. They will help you to draw a more consistent dose each time.

 

It doesn't matter as much if your 0.25u is the same as my 0.25u measurement as long as the measurements you're using are consistent day to day. That's where calipers can help you - I don't think there is a list of specific measurements for each brand and type of syringe available but, as Dyana says, the calipers can make sure you're giving the same dose each time.

 

Thanks, I ordered the 4" calipers. Also reading up on getting rid of air bubbles. These Relion syringes are terrible, though I suppose I can go back to my old ones once my calipers arrive since I will no longer need the 0.5U markings. Hope this all makes a difference for Warren. I can tell my wife is peeved that I have some renewed hope and energy . I really think the sweet spot for him is somewhere in between 0.5 and 0.75, I hope being able to measure microdoses will finally help get him regulated. I'd rather he need 2 or 3U per day where a 0.1 difference wouldn't make a such huge difference in his numbers.

 

Also I've been feeding him 100% fancy feast classic pates. Is it possible a better quality food may help in getting him regulated? I figure low carbs is low carbs, but thought I'd ask.

 

With me, the problem was getting the cats to eat the more expensive and better for them food. Hopefully, Warren won't be as picky.

 

Yeah I can totally understand that.
My 9 yo daughter caught a 34" stripped bass the other day, I had more fish than I knew what to do with. 3 of the cats refused to eat any of it, Warren ate a decent portion though.

 

For most cats it shouldn't make a difference. But ECID and he might react to something that other cats don't. Or an undiagnosed allergy could mean that some low carb foods spike his BG too.

Feeding better quality food is, of course, more expensive. But it might be worth trying at least to see if he's one of the cats that it does make a difference for - everything's worth trying even if you find it makes no difference at all and finish up going back to the Fancy Feast!

 

Darn, just like that... in 4 hours he went from having a great day to jumping 250+ points

 

That's ok - bouncing is a normal part of this. In case you're not familiar with a bounce, take alook at the second post in this thread for an explanation.

I think you've likely got a fairly bouncy cat - and because the key to Lantus dosing decisions are the low points, you really want to catch the low points when the bounces clear. I'd get a test during the day cycle, anytime between about +3 and +7/8, and in the evening before you go to bed. That number of tests is enough for us to be able to help you figure out dosing. Right now the 0.5u looks pretty good!

Can I ask that you start a new thread with each new day? I started reading just now from the top of this thread and waded through a bunch of old posts before I figured out that this is several months old. I must be oblivious or something! But we do ask people to start a new thread (condo) here each day so the length of the threads are manageable.

Your girl's got quite the skill with fishing! nice job!

oh, and I'm not sure if you're still giving dry food or if that was months ago, but dry food, even a couple of crunchies, can raise the blood sugar by 100's of points and keep it there for another day in some cats.

Have you had Warren checked for a bladder infection?

 

He's been checked for a UTI (3x now but I assume any bladder bacteria would show up in a UTI). He may also have been specifically checked for bladder but I don't have a copy of the actual test results.

He has not had dry food in many many months other than once in May (?) I gave him a small handful when he dipped into the 40s and I thought that was the correct protocol to get his levels up, but was then told not to do that by this forum.

He's had some better numbers the past 3 days, but he pooped on the floor again today. My wife insisted we have him put to sleep tomorrow, I was able to buy him a few more days to see if his numbers finally stabilize and his bathroom behavior improves ... frankly I don't have a lot of hope that a few days will make any major difference in his behavior though. I think he needs to regulate first and then over time at his regulated numbers he will improve. I'm going on 4 months of attempting to regulate him and my wife was out of patience a long time ago. He's living on borrowed time now.

 

Going to start a new thread on his #s. He has a temporary reprieve while I try prozac and B-12.

 

Hi rob! I'm so glad to hear that there is something new to try with Warren. I hope these help. You're a good soul to be so committed to him -I bet he's worth it!

I looked but didn't see another thread for Warren. Definitely start a new thread with your next comment. This one is from May, lol!

 

Seems like you care for Warren very much. Your wife needs to get on board.