Dosage advice please

Discussion in 'Feline Health - (The Main Forum)' started by Tim from Toronto, Oct 24, 2017.

  1. Tim from Toronto

    Tim from Toronto Member

    Joined:
    Oct 4, 2017
    Sorry to start a new thread but I couldn't figure out how to edit the subject of my old thread. Here's the background for Bruno. Bruno is 15.5 lbs now.

    http://www.felinediabetes.com/FDMB/threads/what-could-we-be-doing-wrong.184948/#post-2053820

    We are up to 6 units BID of Lantus now. The curve after 7 days of 6 units was worse than what it was before. I just finished talking to our vet on the phone. I had emailed her our spreadsheet and told her that I am considering lowering the dosage back to 3 units and try incrementing by 0.5 units weekly because we had jumped by 1.0 unit instead of 0.5 unit since 2.0 units. We also had a few scattering lower number days back at 4 units. I suspected we might have missed a good dose at 3.5 or 4.5 if Somogyi was involved. Our vet dismissed that and told me that Somogyi could have been possible if our nadir was lower and since our nadir was always in the high teens, Somogyi was less likely. To be frank, I don't even know when his nadir is at because the few curves that I did showed no definite time when the nadir is at. We have also tried different food including Purina DM from the vet and has now gone back to Dr. Lisa's diet.

    She has asked us to go up to 7 units for a week. I have already done 3.0 units for 1.5 days and now don't know whether to defy her and continue to stay at 3.0 units or go up to 7.0 units. I am also leery of jumping back up to 6 or 7 units after 1.5 days at 3.0 units.

    I have agreed to buy a new bottle/pen of Lantus since ours was 10 weeks old now. It's still clear but I am willing to try to rule out that the Lantus has gone bad.

    She did mention that it's possible Bruno is insulin resistant and Cushing decease is a possibility. I asked her whether there are blood tests that can screen for insulin resistance and she said no. Wendy had mentioned a couple of tests(IGF-1 and IAA) that can be done at University of Michigan, I guess our vet does not know about these.

    She said she will consult with an internist and get back to me on Cushing decease. She mentioned that if we are up to 2 units/kg without seeing any effect (In Bruno's case, his weight is about 7 kg so 14 units of Lantus), Cushing is possible. At least that's my understanding from our conversation.

    She told me to get a new bottle and try 7 units BID. I am now at a crossroad not knowing what to do. I could continue at 3.0 units and possibly get a new vet or ease him back up to 6.0 units for a few days and continue onto 7.0 units.

    Any suggestions will be greatly appreciated.
     
  2. Sharon14

    Sharon14 Well-Known Member

    Joined:
    Aug 16, 2015
    I won’t give you dose advice, but I will tag @Wendy&Neko for you as well as @Tuxedo Mom (for Cushings info). My cat has acro and had the tests done at Michigan State University.
     
  3. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Feb 28, 2012
    If you are using a vial of insulin, most people here can get 5-6 months out of it, as long as they don't run out first. Cartridges are an even better bargin - I used them to the last drop. And I think a 5 package of cartridges (in Canada) is a slightly better price per volume.

    High numbers can be due to one of two things. First possibility, the dose is too low and needs increasing. Once cats reach 6 units of insulin, we suggest they get them tested for high dose conditions. One in four diabetic cats has acromegaly, which is one of those high dose conditions. It is caused by a benign pituitary tumour that sends out excess growth hormone, which leads to the need for higher doses of insulin. Another high dose condition is called IAA or insulin auto antibodies - think of it as the cat's body reacting to the foreign body being injected, which is the insulin. Neko had both IAA and acromegaly. Cushings is less common. All three high dose conditions have more info about them in a forum here. This post here tells you how to get the tests done. Yes, your vet is out of date - no surprise, most are, mine was. Mine learned with me. Vets over a certain age were taught "this is acromegaly, you'll never see it". The latest research on it being 1 in 4 is quite recent.

    OK, second possibility for higher numbers is too much insulin. Seems counter intuitive, but the cat's body responds to going low by doing what we call bouncing. Not Symogyi - that is an old theory that we only really see if a kitty was started on too high a dose. The only way you can tell if a cat is getting too much insulin is catching the lows that happen. The majority of cats go lower at night. You have practically no tests at night - we have no idea what is happening. Based on personal experience, I know cats can go low at night and then bounce during the day, often for ages. Try getting at least a +2/3 test or a test before bed every night. It'll really help tell us what is happening.

    I'd also like to see the spreadsheet data for what is happening at 3.0 units. I suspect it's not enough insulin. Going down like that is seldom the best choice.
     
    Last edited: Oct 25, 2017
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  4. Wendy&Neko

    Wendy&Neko Well-Known Member

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    I meant to add a comment to this. It's really hard to tell when a cat's nadir is when they are mostly in high numbers. It becomes much more obvious as their overall numbers get lower. Bouncing all is a fact - numbers wobble all over during a bounce, and nadirs are later when the bounce breaks. Neko on Lantus would nadir from +3.5 to +13, though most often from +7 to +9 in a "normal" cycle.

    Did the vet say why she though Cushings was a possibility? Dose is not the answer. My vet thought we didn't need to test for high dose conditions until we got to 10 units (Neko was 6 kg) - never got there. We've had acrocats on doses as low as 2 units here. The study showing how common acromegaly is found some on as low as 1 unit. Like me, you may have to provide your vet the information on the tests, and ask her to humour you and get the tests done. I gained a lot of credibility at the clinic when I was right and they were wrong.

    Can you tell us a little about Bruno? How is he behaving? Eating? How is his weight trending?
     
  5. Tuxedo Mom

    Tuxedo Mom Well-Known Member

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    Dec 2, 2014

    The simplest,cheapest and least invasive test for Cushing's is the UCCR test ( urine cortisol creatinine ratio) which is sent to IDEXX. All you need to do is collect a urine sample AT HOME so there is no stress involved and take it to your vet for them to send to IDEXX. This will show how much cortisol is in the urine. Higher rates of cortisol can indicate Cushing's. If the UCCR test is positive then an ultrasound is the next step. There are also a couple of other tests which are more time consuming but are useful to determine what type of Cushing;s it is..either pituitary or adrenal. Although Cushing's is considered "rare" in kitties, I have seen a fair number diagnosed over the last 3 years, so it may simply be undiagnosed, If you need more information just tag me.
     
  6. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Thanks, Wendy.

    I personally don't think the Lantus vial is the issue. I will get some new cartridges tomorrow just to remove one variable from the equation.

    I will talk to the vet about the IGF-1 and IAA test when she gets back to me on Cushing decease.

    On the issue of bouncing, are you saying that the nadir might be happening at night time after the second shot and we might have missed it since we never test at night? I will start doing some test at +2/3 starting together. Thanks for the insight as it has never occurred to me that night time could be different than day time.

    In terms of "what is happening at 3.0 units", did you mean it's not a good idea now to go back down to 3.0 units? We have only done 2 days of 3.0 units after being at 6.0 units. I have just updated the spreadsheet for the 2 days we were on 3.0 units.

    I have also noticed that some of the comments I put on the "world" sheet never showed up on the "US" sheet. Practically all of our lower number days happened on the first day we moved onto a new "lower carb" food. That's what led me into start making him the Dr. Lisa diet. I have updated my spreadsheet for that.

    In terms of his behavior, I would have to say that other than the "weak hind leg/walking of his hock part" and the fact that he can no longer jump high(I know it's a big change), he is just like before his diagnosis. He has always been nocturnal, active at night and sleep during the day. As recent as June, he was able to jump up a 5 foot high cat tree. He can no longer jump up a 2 feet high chair now. He walks funny like a humpback and his hock clicks on our wood floor every step. I am able to stop his weight loss at 15.5lbs. I weight him every morning. He was at 19 lbs in June(He has big bone and is very long). He still drinks a lot of water(6-1o oz a day). He pees a lot(I am using double the amount of cat litter compared to before his diagnosis).

    On his better days(<250, for example), he would jump up on the sofa and sat next to me and asks for pats. He used to jump up and sit on my lap every night. At this point, if we can get his number down to around 200, we would be happy.
     
  7. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Thanks. I will keep the UCCR test in mind when I talk to her next time. In term of Cushing's, our vet did mention that it would only be a possibility for tests if we are not seeing any results at up to 14 units(Bruno is at 7 kg/15.5 lbs). She would address whether he is insulin resistant first.
     
  8. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Feb 28, 2012
    The nadir in any given cycle (12 hours time between shots) is the lowest point in that cycle. Some cats nadir at a consistent time, some don't. We figure out how to dose Lantus based on how low it takes the cat. Often those low numbers happen at night - maybe something to do with being nocturnal animals. That's why we encourage getting some tests after the PM shot. Neko once went three months doing low (and sometimes earning reductions) at night, and bouncing and giving me high numbers during the day. If I hadn't tested at night, I would have thought she needed more insulin, but in fact she needed less.

    I just meant I didn't see the last couple of days data in your spreadsheet when I took a look. Thanks for updating it. Are you missing entering the PMPS blood sugar data or didn't you get those tests. We strongly suggest getting a test before each and every shot. Cats like to surprise us and a few times Neko gave me a number in the 40's at shot time - which I didn't shoot. From what I see on 3.0 units (and I'm not seeing enough), 3.0 units doesn't look like a good dose.

    Are you giving Zobaline or methyl B12 to help with the neuropathy? As the numbers get better (under renal threshold) the peeing should go down a lot. When I got Neko mostly regulated, she peed about the same about as my other cat.
     
  9. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Thanks, Wendy. We will be doing more tests including AMPS and PMPS from now on.

    No, we have not given him Zobaline or methyl B12 yet. When I mentioned it to our vet, she just shrugged and said that the neuropathy should get better once he is better regulated. We were also experimenting with his diet for the past little while. I guess the B12 could become part of the vitamin soup I used to make Dr. Lisa's diet.

    I got an email from our vet last night. She talked to an internal specialist and they are recommending 2 tests. The first one was the Insulin-like growth factor test to see whether he has Acromegaly. She said 30% of cats have that and it's caused by the pituitary gland makes too much growth hormones. I did not mention the IGF test or the IAA test to her and to her credit she finds out on her own.

    The second is a trypsin-like immunoreactivity test to see whether he has a condition called exocrine pancreatic insufficiency.

    The tests require a fasting blood draw.

    We have also agreed to go back up to 7.0 units for a week.
     
  10. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Feb 28, 2012
    Glad the vet mentioned the IGF-1 test. Sounds like a good IM vet in her back pocket. She probably is disgarding the IAA test - most vets too. But we find the results of that really help us with dosing. And some cats have it and not acromegaly. The blood for that test goes to the same place as that for the IGF-1, so it's not an expensive add on. I would push for the IAA test too.

    Here is some reading on EPI.

    Neuropathy gets better faster with regulation and methyl B12. Search this site for zobaline or methyl b12 in Canada to see what you can use.

    Good luck with the new dose. On this board, we would only increase to 6.5 units at your size of dose.

    Another thing for you to keep track of. Some kitties find Lantus's acid base stings at higher doses. Keep an eye on how Bruno reacts to his shots. Many larger dose kitties go to Levemir insulin instead. It's similar in action to Lantus, but not acid based, and has a later onset and nadir.
     
  11. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Thanks for the link on EPI, Wendy. I will email our vet on the IAA test and see what she says.

    As far as I know, Zobaline is not available in Canada but can be imported with a hefty shipping fee. This is in addition to the possibility of it being confiscated at the borders or have fees tagged on. I will visit our local health food stores this weekend to try to find it locally and might have to take a chance and order it from iLifeLink which seems to be the only one from the US that ships to Canada.

    Should I wait until he is better regulated before feeding him Zobaline.

    I have tried talking our vet into doing 0.5 units increment before and she was not really receptive to the idea. I could just go to 6.5 units on my own but my wife and son who are also helping me out with Bruno do not like that idea.

    I will keep an eye out on Bruno's reaction closely to see whether he has any reaction to the high dose. Thanks for the heads up.
     
  12. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Feb 28, 2012
    I wouldn't wait on the methyl B12. Here is a post on how to get a substitute for Zobaline in Canada.
     
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  13. Tim from Toronto

    Tim from Toronto Member

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    Thanks, Wendy. Vitacost and ilifelink seem to be the only ones that ship to Canada. I will order from one of them if I can't find any locally this weekend.
     
  14. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017

    An update on Bruno. He is now officially an Acrocat. The result of the IGF-1 test was 329 nmol/L. Normal range is 12-92.

    The TLI test was normal. 38.2 ug/L. Normal range is 12-82. We never got the IAA test done even though I told our vet that the test can be done at the same time at Michigan State. Our vet's IM friend was not aware of the IAA test and told us maybe it's something in the literature only(whatever that means). With the report from the IGF-1 test, I now know that the test was indeed done at Michigan State.

    Our vet has recommended we go to Guelph Vet College for a consultation with an Oncologist. They estimate the package cost for the radiation therapy to be about $7000. The cost is one thing, we were also told that it will take around 20 trips to get it done. Guelph is an hour away each way and they are the only vet collage in the province so we have no other choice. Bruno hated leaving the house. Our 10 minutes car ride to our vet is a torture for him so I don't know how he can survive a 2 hours trip 20 times. Our initial consultation appointment would be a good gauge as to how he can handle it.

    Our vet also said it is pointless to increase the insulin dosage any further. I take that as my chance to go up half a unit a week as per "start low go slow". We are up to 8.5 units now with a curve done every 7 days. I understand that there will be a point where the insulin would overwhelm the growth factor and the blood sugar will start coming down.

    Bruno has been on methyl B12 for 2 weeks now. I have not seen any improvement in his "weak hind legs" yet. I hope it will improve over time. I bought enough B12 for 6 months. I have also bought some ketostik and is testing him twice a week. So far, the tests have been negative.

    I have learned about the clinical trial on carbergoline over at the RVC. I will discuss it with the Oncologist at our appointment.
     
  15. Juliet

    Juliet Well-Known Member

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    Nice to see a fellow Torontonian on the board.
     
  16. Juliet

    Juliet Well-Known Member

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    Sep 8, 2017
    Tim I’m in Toronto. Get ordinary B12 tablets from shoppers or any other pharmacy. Just check the ingredients and ensure it’s methcobalamin and no sugar. I use Jamiesons. Only $10 for 100 tabs. I get the 1000mcg - anything he doesn’t need he will excrete out. I give using pill pockets from petsmart. My cat was back to his normal self in two weeks so I would not wait until he is regulated to give it.
     
  17. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Thanks, Juliet. I had looked at Jamieson as they are readily available from Walmart. However, I had read that they might contain Sorbitol which is a no-no for sugar kitties. I ended up ordering from vitacost. They are a bit more expensive but a few on the board have used them before. They are also in capsules so I can sprinkle a bit on his food throughout the day.
     
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  18. Juliet

    Juliet Well-Known Member

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    Sep 8, 2017
    Try a different brand. I’m on the train so can’t check which one I use. I bought at shoppers drug mart. Has no sugar or fake sugar like sorbitol. I bought my first kit from vita cost until I found some in shoppers. I’ll post pic later in case you need more.
     
  19. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Feb 28, 2012
    Sorry to hear about the acromegaly diagnosis, but you are not alone. :bighug: Since you are using Lantus, you may wish to start posting over on the Lantus/Levemir board. There are quite a few members with acrocats over there. Too bad you didn't get the IAA diagnosis. But you aren't alone.

    As for treatment, your vet is talking standard linear accelerator radiation, not current technology. Those 20 visits also mean 20 anethesias, which is way too hard on a kitty. Stereostatic radiation therapy (SRT) or cyberknife is the current go-to method if doing radiation. It requires one day for a CT scan, then 1-3 days for radiation. I took Neko to Colorado (she also hated the 10 minute trip to the vet) from Vancouver by car. She complained for the first hour, then settled down. We stayed there one week, then returned. Some people fly with kitty to reduce the travel time - I did fly with Neko too. This post here has a list of places to get SRT, though it is a little old, there may be more now. Saskatoon is the closest in Canada to you. I went to Colorado State University cause at the time there were a lot few places doing SRT, they had the most knowledge, and were cheaper. We had a great radiation oncologist - who is from Toronto.:)

    If not doing radiation, cabergoline is a more popular option. We have several kitties on the Lantus/Levemir forum using it, and one who even went off insulin. Here is a discussion post on using cabergoline for acromegaly.
     
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  20. Wendy&Neko

    Wendy&Neko Well-Known Member

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    I forgot to comment on that. A cat needs however much insulin they need at a given point in time. I've seen acros on 2 units, and some on close to 100. We have one acrocat on the L/L forum who started the year at 30 units, and is now on 1.5 units. Insulin needs change. You goal should be at a dose where he spends as much time under renal threshold as possible. Acromegaly is hard on kidneys, so can diabetes if always in high numbers. If you can, I would try getting a few more spot checks at night. Many cats go lower at night.
     
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  21. Juliet

    Juliet Well-Known Member

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    Curious - what is acrocat and acromegaly?
     
  22. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Acromegaly is a condition caused by a benign tumour on the pituitary gland. This tumour sends out excess growth hormones, which causes excess production of IGF-1 (insulin growth factor) that in turn blocks insulin from getting into the cells. We call it a high dose condition, because a number of these cats need higher doses, though not all do. It is the cause of diabetes in one in four diabetic cats. Acrocat is just our way of saying cat with acromegaly.
     
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  23. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Thanks, Wendy. I will post an update on the L/L board after we see the Oncologist. I will try doing more night testing. There has been days where the AMPS number was lower than the PMPS number so it's entirely possible that his numbers were lower at night. Our goal is really to get his number under the renal threshold, which I believe is 10/180.

    As to whether we go SRT or Cabergoline, hopefully I can get some answers from the Oncologist. To us, it's all about risk/reward and quality of life. We don't know whether Bruno still has 6 months, 1 year, 2 years, 4 years with us. We just want to give him a good quality of life for his remaining time with us. He is 10.5 years old which is around 60 years in human, I think. I have learned through my family history that sometimes a supposedly simple operation could turn into something much more complicated easily.
     
  24. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Hello,

    Just a bit of update on Bruno. We had the initial consultation in Guelph and talked to the resident a couple times afterwards. They do have SRT at Guelph. However, the resident only know of 3 cats who has gone through SRT in the 3 years that he's been there. That's not really encouraging.

    I will summarize the information from the initial consultation in another post. I think the information might be useful for other acrocats, especially those in Ontario who might be facing similar risk/reward decision in the future.

    We are up to 9.5 units now. Bruno had an excellent(for us anyway) 1.5 week. I was staring at a green(3.5) for the first time and I had to do a re-test to make sure. I was also staring at a low number(for us anyway 6.8, 9.3, 8.8)at preshot, not knowing whether to shoot or not. The conservative side of me had decided to either shoot half the units(4.5) or skip the shot. I then came across the sticky on the lantus board about the need to have data points at +1, +2 and +10, +11 to see if the number is trending up or down to get a better sense on making a decision to shoot or not. I will spend the next few days to try to get the data points. For now, I will err on the safe side and either skip the shot or shoot half only.

    If anyone could look at the spreadsheet and offer any suggestions, it would be greatly appreciated.

    For the past 10 days or so, he has been jumping up onto the couch to sit on my lap or next to me everyday. Just like old times. The couch is about 3 feet high so his hind legs are stronger. I also think his walk is better too although that is harder to quantify. He is definitely drinking less water, from 7-8 oz a day to 5-6 oz a day. He has gained about 0.5 lb back. He has also jumped onto my son's bed and sleep there during the day and at night like he used to do. I think both the relatively lower numbers and the B12 helped. Hopefully we might be turning a corner.
     
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  25. Chris & China

    Chris & China Well-Known Member

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    May 10, 2013
    What we actually suggest is that you stall, don't feed and re-test in 20-30 minutes

    Knowing if his numbers are heading up on their own without food can make the decision to shoot a lot easier.

    The first few times you shoot a lower number than you're used to, we suggest you post for help. Someone will usually agree to stay with you as long as necessary to make sure you're safe (or find someone else with experience to take over)....it's a promise we make around here....that if we tell you to shoot a lower pre-shot number, we'll be available to watch out for you
     
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  26. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    T
    Thanks for your reply, Chris. I was referring to this sticky on getting the data on +1, +2, +10 and +11.

    http://www.felinediabetes.com/FDMB/...regulation-shooting-handling-low-numbers.147/
     
  27. Chris & China

    Chris & China Well-Known Member

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    May 10, 2013
    Scroll down a little further to the section on HOW TO DEAL WITH LOW PRESHOT NUMBERS:

    Here's a couple of sections I've pulled out

    If it is your first time shooting green, then we will likely suggest that you stall the first time, even if the number is 80-100. That will let you collect data on what your cat will do when you stall. One thing you can do if you are having a low cycle is to get a +10 and +11. Those will give you a good idea of how quickly the cat’s numbers are rising (or not) when preshot time arrives.

    ** Test often (every 15-20 minutes, or at most every 30 minutes). You want to catch the rise the minute it starts. With most of our cats, once they start to rise they will really zoom. You want to get the insulin in as soon as possible, because it will be another 2-3 hours before the insulin kicks in and you don’t want to let the cycle get too far ahead of you.

     
  28. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Thanks, so no food, test often and shoot when the number starts to rise.

    But why would no food make the number rise on its own? In our case, we feed about every 4 hours. So we would have fed him at 4pm and test preshot at 8pm. He would have gone without food for 4 hours already.
     
  29. Chris & China

    Chris & China Well-Known Member

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    May 10, 2013
    No...we don't feed when we stall because we want to know that the last shot is wearing off and the number we're getting isn't influenced by food.

    Food makes the numbers go up....so we don't want to feed for the 2 hours immediately before shot times (so we get a "true" number and not one influenced by food)

    Example....at PMPS you get a 90....you don't have a lot of experience or data so you stall, don't feed and test again in 20 minutes.....the number goes up to 110....that's a pretty good indication that the last shot is wearing off and it's OK to go ahead and shoot.

    IF you'd fed when you got that 90 and then tested again 20 minutes later, you wouldn't know if the 110 was due to a "food spike" or if the last shot was truly starting to wear off.
     
  30. Tim from Toronto

    Tim from Toronto Member

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    Oct 4, 2017
    Understood. Thanks for the explanation.
     

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