? 8.29.18 Dosage getting high, where to go from here?

I keep increasing the dose and will see a period where glucose seems to be heading lower - then it bumps up again. Once in awhile there is a sudden drop in glucose but it does not stay low. Any thoughts?

 

Unfortunately there's not a clear cut answer. My first thoughts when I'm looking at your spreadsheet is there is a severe lack of testing. I'm not trying to criticize or anything, but I only see a handful of mid-cycle tests since the end of May. I'm not sure if Riley's on Lantus/Basaglar or Levemir, but you dose all of these depot insulins based on how low it takes your kitty, not where he is at preshot times. So it looks like you've upped the dose, but there isn't any data to support the increase. It's possible that the dose is too high and it's causing his BGs to be all over the place. Too high of a dose can also look like too little. So in order to see how the dose is working with Riley, you'll need to do more mid-cycle testing. Are you following TR or SLGS? With TR you can increase more frequently because you are testing more often. With SLGS you test less frequently and hold doses longer, and you'd perform a curve once a week to bring the picture together.

While I can give some general advice, I am not comfortable giving dosing advice. Hopefully one of our experts will be along soon to help with that aspect.

 

@Amanda and a Loudogg if the signature is correct it’s SLGS since feeding Young Again.That being said I totally agree that we have no idea what the nadir is without tests at +5-7.

 

That might be the reason for the drop on May 12 after not receiving insulin for 36 hours. I'll do a 24-hour curve and if the curve is flat, I'll drop back to 5.5. Thanks very much for looking at this.

 

If this were my cat I’d do a 12 hour curve once a week as the SLGS protocol says and get sporadic tests when possible. That will give you a picture. Try for a before bed test. Also since onset is between +2-3 often getting a test then if you get the same as the preshot or lower you know it will likely be an active cycle and a +5-8 will be helpful. Many set an alarm and sleep in between. Just something to consider.

 

I see a couple of issues.

• Like Amanda observed, you need more test data. Lantus dosing is based on the nadir. It looks like you are basing your dosing on the pre-shot numbers. If you're only testing at shot time, you have no idea how low the dose is taking Riley's numbers. My kitty could start the cycle in the 400s, drop into the 40s and then bounce back to the 400s by the next pre-shot time. If I didn't have the mid-cycle data, I would have increased her dose when the dose needed to be reduced.
• I'm presuming that you're following SLGS. Even with SLGS, you need to evaluate the dose and increase after a week if the numbers aren't where you want them. You held the 6.0u dose for 2 weeks. You held the 5.75u dose for even longer. Holding a dose that isn't bringing numbers into a closer to normal range allows glucose toxicity to develop. I can't really tell if this is what's happening because, and I'm sorry to sound like a broken record, you don't have any spot check to tell us anything about nadirs.
• It would be helpful if when you get a lower than expected pre-shot number you checked in with us. There are times when you either shot a reduced dose or skipped when you may not have needed to. Likewise, there were high pre-shot numbers where you increased the dose. Lantus is not the kind of insulin there you can "shoot down" high numbers. That's the way a shorter acting insulin works. Lantus is a long-acting depot type of insulin. It helps to remember that every time you change a dose, you need to give it at least 3 days (if using TR) to stabilize.
• When we have more data on a kitty, if a dose reaches over 6.0u, we generally recommend testing for a high dose condition. And here's the broken record again, without the spot checks during each cycle, we have no way of knowing if numbers are dropping lower at nadir and you've missed the reductions. With the increased dose, Riley may be bouncing and that's what you're seeing at pre-shot.

The best suggestion I can make is that you stick with the instructions in SLGS. Hold the dose for one week providing you don't see numbers drop below 90, which warrants a reduction. Please start getting spot checks, as well.

I'd encourage you to re-think this. Because a curve is flat, doesn't mean you need to reduce the dose and certainly not by that much. You can have a flat curve in the 400s or a flat curve in the 90s. You wouldn't reduce the dose with a curve in either of those ranges.

 

If I have gone too high with the dose due to not enough testing, how would I know?

 

The numbers will be your guide. However you have to catch the signal. Along with the recommended curves, try sprinkling your mid cycle tests, both AM and PM cycles, at different times day to day, so that when you step back and look as the ss as a whole there are not any wide open spaces with no data.