Help me understand why a smaller dose might work

Greetings,

Emmy is currently at 2.5u Lantus which isn't, as far as my uninformed brain can see, doing anything. She was diagnosed 12/23/14 and still is not regulated. We've tried 3u, which did regulate her, but her nadir was low at 50. That's when she was reduced to 2 and now she is up to 2.5u.

To get some questions out of the way, she is on an entirely low-carb diet, some EVO and mostly Tiki and low-carb wet food from The List. She only gets Halo Liv-A-Littles as treats. My vet is very cooperative, has the link to the spreadsheet, monitors there and is amenable to change. Some posters here have asserted that her dosage may be too high and that by moving a .5u each time, we may be missing a good dose. My vet points out that most people can't eyeball less than a .5u change, so their practice has been to make dose changes at that level.

I have read most of the literature on the site including the Start Low Go Slow and the AAHA recommendations. I have an appointment with the vet Thursday. I want to talk to her about the possibility of having missed a dose, but I can't, because I can't see the logic myself - e.g., why would 2.75u work when 2.5 doesn't and 3u seems to have been best so far? Is it okay if she goes so low in the cycle? I would not normally be home at +6 to monitor her.

Emmy has displayed some shakiness in her back legs and has just started a course of Adequan but I'm afraid it's neuropathy so I want to get her regulated as soon as is safe to do so.

Can someone please explain in English?

Thank you so much,
Judy&Emmy

 

I see calipers in your future. Given that syringe markings can and do vary from batch to batch, using calipers will enable you to measure less than 3 units and more than 2.5 units consistently by comparing the syringe volume to the caliper setting. it looks as though 2.75 units might be optimal base on the spreadsheet.

For safety, we don't want her glucose below 68 mg/dL on an AlphaTrak because she could develop hypoglycemia and die or suffer permanent brain damage. There is a bit of built in margin to that number, as over the counter meters may read +/- 20 % from what a lab would get.

In the event it is neuropathy causing the back leg unsteadiness, methylcobalamin should be helpful.

 

Yes I was afraid calipers were in my future. My spare bedroom looks like a vet's office.

Can you help me understand why a smaller dose may be appropriate? That's the part I can't wrap my head around. Dear Doctor, 2.5u isn't working - let's try 1?

 

Oh sorry - I just reread - so 2.75 might be the best which makes sense to me too (intuitively). Thanks for the recommendation on methylcobalamin. Do you have a recommendation on calipers? Thank you!

 

Just did a search on calipers to find previous posts (there are many)
Harbor Freight sometimes has them
And someone has put together instructions and a video here.

 

Many thanks

 

I'm not the best at explaining..... but I'll give it a shot.

when the dose is too high, some cats respond with a hormone dump to counter ....
it's easy to miss a low drop , especially if it happens quickly.... then the bg bounces up high.... and instead of getting a dose reduction, the caregiver increases the dose in response to the high numbers . And then it becomes a cycle.

this is the hard part for some vets to get their head around....
Lantus dosage is based on how low the cat goes in the cycle...... you don't respond to those ugly high numbers. ( and that's what most want to do because that's how dog insulin works)
It takes experience to recognize it in a spreadsheet.

and I'm guessing you work, or really like your sleep, or have a medical condition.....
you don't have any pm cycle data.

perhaps you could start getting a +2 in the pm cycle.... that's a good indicator or a possibly active cycle that night where you might want to set an alarm and see how things are
going at night.
Many cats drop lower at night, and if you miss it, then all you see is the morning response to the lower numbers.....
and you think the cat is high all the time.....

that's key to figuring it out.....


I myself didn't let my vet get involved with the daily management because they just don't get it. They chase the high numbers.....
If the appointment is just for that discussion.... I would save my money ....
and ask here instead.....

I think you are on the right path..... just need some nighttime data....
we can help you with calipers... and dose adjustments...

and you'll want to get some http://www.ilifelink.com/zobaline-for_diabetic_cats-3_mg_x_60_tablets.html
for the neuropathy.
I can also give you a capsule form where you can just sprinkle it on the food if you like.

 

Thanks Rhiannon - that was a great explanation! I haven't done a PM cycle because I do work and I do have sleep issues. Once we're done at 7:30 I like to know there's no more medical stuff for the night, but I can get some +2-+4s on the weekend - I'll try tonight.

Emmy has both the leg weakness and has developed scabs/sores around her neck. She is scratching there and only there. I have a topical spray for it. This is a general re-check of the whole cat. I am not going to be dismissive of my vet - I wanted to print out some reference material and show her the "Lantus dosage based on how low." I need to remember that myself.

Thank you for the link for the Zobaline. We'll check it out. Emmy's not too exciting to pill but those Liv-A-Littles win her over every time! I'll be back for help with the calipers.

Thanks again
Judy&Emmy

 

I'd just like to add that some cats' BG can actually spike if they go too long between meals. For example, Saoirse's BG might be 2-3 mmol/L (32-48mg/dL) higher if she didn't eat all her overnight timed feeds. Also, morning AMPS values may sometimes be significantly higher than the rest of the cycle (a bit similar to dawn phenomenon in human diabetics where the body releases hormones that have the effect of spiking BG). That's another reason why mid-cycle tests are critical for homing in on the optimum Lantus dose.

 

if you prefer to avoid giving pills, this one is what I used. http://www.vitacost.com/vitacost-vitamin-b-12-methylcobalamin-5000-mcg-100-capsules-4
it has no taste. It does have a trace of rice flour but my cat isn't carb sensitive so it didn't affect her any.
dosage is 3 -5 mg..... or in this case 3000 -5000 mcg
It is pink so it turns the food pink.

B vitamins are water soluble so the body just takes what it needs and pees out the rest.

I would get started on it right away because some cats see quick results but for some in can take 2 -3 months .... Neuropathy is painful so you want to get ahead on that issue.


sounds like she does need her itching /sores checked.
Are they around the shot spots?


you might want to print this to share with your vet.... it explains dosing... the nadir ( lowest point each cycle) is the determining factor.
http://www.felinediabetes.com/Roomp_Rand_2008 dosing_testing protocol.pdf
and
http://www.tillydiabetes.net/en_6_protocol2.htm

 

Thank you so much for the reference, and the vitamin link, on my way to order now. The sores are on the back of her neck, from ear to ear, but well away from where I inject (they shaved clear spots for me down on her scruff, at least 2" south of the irritations). She's clearly irritated by them, she's been checked for fleas, etc. She does have a bit of acne on her chin so wondering if that's related. Her ears were checked and look good - but it has just started since we started insulin. Correlation not causation, I know ;-)

Thanks again!
Judy&Emmy