Hypo? Do I skip insulin tonight or change dosage?

My first (successful!) BG draw: 45. This # is 4 1/2 hrs past the morning insulin shot. My understanding is not to shoot if the # is under 200 (?) for a newbie (?)

My cat is on Novolin 2.5 u. I was aiming for the Nadir but shot a little past the 3-4 hour mark.

Should I skip insulin tonight or reduce dosage? Give some high carb wet food? She's been lethargic.

 

Whenever you get a number that's under about 75 or so, you'd want to recheck within a half hour to see if it's still headed down, or if it's coming up. With a test under 50, you'd want to give some carbs (karo syrup, honey, pancake syrup, gravy from a can of high carb cat food) and then retest in about 20 minutes.

Get a test before you shoot and post here to ask for advice if it's under 200. Often hitting a low number like that will cause a cat's blood sugar to "bounce" causing a high number. Even if the number is high, she still needs a reduced dose. The cat's body releases stored sugars and counterregulatory hormones to save the cat from the perceived hypo, causing the blood sugar to rise. A bounce can cause high numbers for up to 3 days - so don't be surprised if she's high until Monday. It doesn't mean she needs her dose increased - a hard concept to wrap your head around. Not all high numbers mean a cat needs more insulin.

You would want to reduce the dose - if that 2.5u can get him under 50, then it's too large of a dose. I'll let someone with experience with Novolin address how much it should be decreased. But yes, it's too large of a dose.

 

Thank you for your quick response. I have Karo syrup on hand. Not sure the other food is high carb.

What is a good high carb canned food with gravy to have on hand? Too focused on getting my cat's #'s up and her feeling better.

 

There is a list at www.catinfo.org that has all the carb values of the most common canned cat foods. I'd get something over 20-25% - higher is good. There are many, so it just depends on what's in your local stores.

Try to get another test in - numbers don't lie and don't leave you wondering if she's still low or not.

 

What do you use for high carb? Trying to get someone to run out and get something fast. Thanks

 

Friskies or Fancy Feast gravy lovers - anything that lists gravy in the name of the can will likely be ok for the moment.

You can just add a drop of karo syrup to her regular food. It'll do the same thing.

 

The Royal Canins that are on the list (except for Babycat) seem to all be 10-20% carbs - P/D isn't listed.

 

The carbs should take effect in 15-30 minutes, depending on the cat. Most people give a teaspoon or so of gravy or karo or honey, and retest in about 20 minutes.

Are you able to get another test?

 

Good thing you were testing!
The routine for managing low numbers goes like this:
Low test
-> 1-2 teaspoons of high carb gravy or a few drops of Karo/syrup
-> wait 20 to 30 minutes
-> re-test
Repeat as needed until past the nadir, in safe numbers over 50 mg/dL on a human glucometer and rising a few times in a row.
The Fancy Feast Gravy Lovers work well. Squeeze out the gravy part and use that.

 

What number do I want to aim for? Should I skip the Novolin tonight until BG levels reach 200? Then what dose of Novolin should I give?

 

The nadir for N is around +3 to +4 hours post shot. If you are past that, the numbers are above 100 mg/dL, I might switch to feeding low carb food a few periods to see if he would stabilize or go down again. Ideally, he'll start to stabilize.
I would not shoot below 200 mg/dL. I might drop the dose by 0.25 to 0.5 units, depending on if I would be able to monitor or not.
He may bounce - go very high as compensation for going very low. That is normal

 

Just tested and BG reads 38. Could I be doing something wrong? I fed her some Royal Canin and some Karo syrup

Is it normal for BG #'s to go down? Would applying a warm wash cloth (in a plastic bag) and a dab of ointment (which helps bead up the blood) before poking alter results?

 

Once I get above 200, then I should drop the Novolin from 2.5 units to 2 units? Or to 0.25 to 0.5 units?

 

Yes, got a BG reading of 38 after some food (either mod or high carb) and Karo syrup. Number is lower than the first one. Wondering if this is normal or if I am testing wrong. Or if feeding too much food can cause the numbers to drop, to. Thanks

 

Drop to 2 units.

I wanted to go to your profile to see your post list and find the hypo one, but you have blocked viewing your profile, so I couldn't quickly find your most current post.

 

Sorry, not sure how I blocked my viewing profile. Can you see it now?

 

I can see it now, thanks. If you right-click on my user name, and open in a new tab or page, then click on the information tab, you'll see what I mean about finding all content or all posts by a user.

Have you tested again?

 

Yes, BG is now 55, which is more encouraging given that I didn't give Karo this time around because I had to give her food with her med. I did give Karo earlier. Will try gravy food in awhile.

 

It's normal for the blood sugar to go down IF the insulin hasn't passed its nadir (strongest action of insulin = lowest blood sugar test).

No, the wash cloth or ointment wouldn't alter the results. You don't want much ointment or it will goo up your test strip, however. I put on a generous amount of neosporin with pain relief at the end of every day, wiped it off in the morning before the first test and it left the ear with a just right amount of greasiness to help the blood bead up without gooing up the strip.

Her blood sugar can wobble around and go back down as the food carbs wear off. Don't stop testing at this point. You can skip the high carb for now and just retest in another 30 minutes.

Your goal is to keep her over 50.

 

Got to 55 this time. Feeling more encouraged. I believe BJM suggests sticking to high carbs till my cat reaches 100.

 

Another 20-30 minutes, then check again, to make sure the numbers stay up.

 

Thanks. I am getting a real work out now chasing after my cat to get the readings.

 

I don't think she means to give high carb until she's over 100.

BJ - I see you've just posted. Would you clarify what you meant on how long to give high carb? Normally we just use HC until the cat's over 50, then switch to low carb to help sustain numbers without sending the cat's blood sugar sky high.

 

That can work too - N just hits so hard sometimes. It depends on if you're coming up after nadir, or fighting a dive towards nadir.

How long has it been since the shot?

 

[

Since 9 am. First testings was done at 1:45 pm. Should I continue high carb till I reach 100, go back to low carb if over 50 BG or alternate between low and high carb?

Regarding the N, do you mean it's harder to regulate the BG levels with this insulin? Should I consider switching to a depot insulin at this stage once BG levels are improved?

Since my cat is on steroids, could her BG levels shoot up more quickly?

 

When you get a low test before the nadir, it can be more difficult to raise the numbers because the insulin is reaching its peak effect.
If over 50 and after the nadir, low carb is OK to use.
If over 50 and before nadir, you may wish to continue with medium or high carb, depending on how difficult it is to keep the numbers up.

It is more difficult to regulate with NPH as it tends to last only 6-8 hours, leaving 4-6 hours uncontrolled.
There are 2 non-depot insulins, ProZinc and BCP PZI, which may work better, since you are treating with steroids, as they may be more flexible for you. An advantage is that you can increase or decrease the dose based on a combination of nadir and pre-shot test data. Also, your vet may understand how to use them a bit better than a depot insulin.

 

Do the ProZinc and BCP PZI have the potential to last longer than 6-8 hours?
Thank you and Julie & Punkin very much for guiding me through my cat's first hypo episode.

 

The depot insulins work best with very constant dosing on a fairly rigid 12 hour schedule. The dose gets adjusted on the nadir, never on the pre-shots other than to skip, stall, or give a reduced amount. They are NOT fast acting insulins. They are very gentle, slow and long acting insulins. Because there is a bit of each dose still working at the end of 12 hours, this results in low, smooth, curves. Think of it like turning a huge ocean liner. A small change today results in the ship turning in a day or two.

The non-depot insulins can be given on a sliding scale where, in combination with test data showing how low a given dose will take the glucose, the dose may be adjusted based on pre-shot numbers using that info. They last up to 12 hours and then are out of the body. If your vet prescribed the NPH, it is likely that he or she is unfamiliar with using a depot insulin correctly. It is more likely that the method of using NPH will extend to using ProZinc or BCP PZI more easily. Educators call it "transfer of training".

Steroid dosing may cause spikes in the glucose and the days on steroid are often higher than the days off steroid. When that is the case, it can be helpful to adjust the dose based on what the steroid effects are. This makes using a non-depot insulin helpful. An alternative, if you prefer to go with a depot insulin, is to use a small bolus of a very short acting insulin should the steroid effects cause variable spikes in the glucose. This means learning how to use 2 insulins, and shooting the cat twice on cycles when it is needed.

 

My cat is on steroids daily for life. No option to alternate days. I give her her steroid med around the same time daily.

Are there any difference between the ProZinc or BCP PZI?

Since these are non-depot, are the doses the same as for NPH?

The vet's rationale for choosing the NPH was it was the cheapest. But I want what will be easiest and best for my cat.

 

To truly compare insulin costs, you need to look at the cost per unit. I have an example spreadsheet here. If you log into your Google Drive account, then go to the link, you can File, Save a copy, to your own account and put in fresh numbers for the example costs to help you compare.

Daily meds make using a depot insulin easier. They do tend to give one sticker shock up front, unless you buy from Canada (ex Mark's Marine)

Since the dose lasts longer, you'll likely find that adjusting the dose may be necessary; starting at the same dose may be OK.
BCP is less expensive than ProZinc up front. It may be obtained in U-40, U-50, or U-100 concentrations (the number of units per mL). U-40 insulins may be injected with a U-100 syringe IF you use a conversion chart.

 

Can you clarify what you mean by "you may not use the full vial before it loses effectiveness"?

Is the Lantus 5 pack equal to 5 pens?

Helpful point about the cost per unit.

Would you suggest I try the BCP PZI first or just switch to a depot insulin?

 

A 1,000 unit vial at 2 units per day would last about 500 days ... except that Lantus often peters out in 6 months * 30 = 180 days, so you'd be wasting a lot of insulin if giving a low dose.

It is completely up to you what insulin you want to use. I liked the schedule flexibility of a non-depot insulin, plus the ability to adjust the dose based on collected data.

 

Thanks. Sounds like the BCP may be worth a shot. If I did use that and was using 2 units of NPH, would I use 2 units of BCP?

If I went with a depot insulin, would I likely have less chance of a sharp spiral downward in BG levels?

 

It isn't exact. You could start there, or at 1 unit BID, and then based on your testing, adjust the dose.

ECID = Each Cat Is Different. Some cats dive; some don't. Some cats bounce; some don't. If a cat vomits, refuses to eat, or has diarrhea, it can affect the glucose levels. That is why we home test.

 

I see it a little bit differently. My experience is with Lantus, and I confess I have a definite bias towards the L insulins because of how well they control blood sugar. I haven't seen a tightly controlled cat on one of the other insulins, so perhaps it can be done. I don't know. I do know that with Lantus or Levemir, once you get to the right dose you can see the cat's blood sugar maintained with as little as a 10 point variation throughout the day. Diabetic people have said it feels awful to have your blood sugar go up/down, and I assume (and have seen in my own cat) that flat blood sugar feels better. We have several cats on the Lantus/Lev Insulin Support group that use steroids, both on a daily basis and on an intermittent basis. I haven't seen people experience trouble with adjusting the dose to work with steroids. It's straightforward and easy to do.

If I were starting with insulin now, I would choose Levemir or Lantus before trying anything else. I'm not sure how you're calculating how long a vial would last, BJ - it would depend completely on what dose the cat needed. With a high dose cat we never threw away any Lantus, and none ever went bad before it was used up. Most people buy the package of 5 pens to start with. All insulin has an expiration date. The 6 months you're mentioning begins once you start using that particular pen or vial.

In any case, outside of our own experiences and opinions, here are a couple of articles that are worth reading:

Here is one article addressing which insulin to suggest for a cat: Integrative Veterinary Care Journal

Here is a second article published by the 2014 World Small Animal Veterinary Association - page 156 deals with the question of "Which Insulin in Cats?" Hopefully what I"ve linked will go straight to that page.

Your welcome for the help yesterday. You did a great job handling things!

 

Of course the duration of a vial would depend on the dose. That was an example, with math provided, not a rule, and noted "if giving a low dose".

And I have had the experience of alternate day steroid dosing causing alternate day glucose spikes, with Spitzer (GA). Since Lantus and Levemir work best with consistent dosing, you need to accommodate those spikes somehow.

 

I couldn't have gotten through this without both of your expertise. Thank you again.

Excellent articles, Julie.

The impression I get is that the ProZinc offers more flexibility or can I achieve the same with Lantus? It would be great to avoid another hypo crash. My cat was acting fine till the crash.

 

It really is up to you and your vet. Read the protocols over and see what may work best for you and your cat.
Tight Regulation for Lantus/Levemir
Start Slow, Go Slow for Lantus/Levemir
ProZinc/PZI protocol

 

Thank you, BJM.

 

I have used a Lantus vial for about a year. It worked fine all the way to the end. The Lantus came with Badgar when I adopted him. The previous caretaker did not how test. I thought that the Lantus lost its effectiveness based in the BGs I measured on Badger so I changed to Levemir which I was using for my MurrFee. However, I thin used the Lantus vial form my Patchwes who wa on Lantus and it worded fine and I used up the vial on her.

 

Your signature line mentions you used BCP PZI for Badger. Did you switch from this to Lantus/Levemir? Did BCP PZI ever work?

 

I just updated my signature
I originally tried the BCP on Badger but it did not do any better. I then tried ProZinc which seems to be better. I also use a little N to hep avoid a large post-feeding BG spike.
Since I had some BCP PZI left over I decided to try that on MurrFee. Not reason to discard it. MurFee was doing marginally OK on 18 units Levemir twice daily so I substituted some Levemir with the BCP. MurrFee is now doing better on 13 units Levemir and 8 units BCP twice daily.

 

Is Badger on meds that cause the BG spikes or is it just from food? You can mix a depot and non-depot insulin on the same day? Your profile indicates you're doing that with several cats. Looks so complicated.

 

I would not encourage anyone new to even consider using 2 insulins. It's difficult enough to start out with one, and simply for the cat's safety you need to completely understand the action of the insulin in your cat's body, how to adjust the dose and what to look for, before you should even consider adding on a second insulin. For the vast majority of cats, one long-lasting insulin is all you need. Larry is a vet tech (i believe) and experienced, so he may try something new that wouldn't be advisable for a new person.

Some people buy insulin on Craigslist - I did once from a woman whose diabetic dad had passed away. I bought 4 boxes of pens and they were fine. I asked her whether the insulin was stored in the fridge, and what the expiration dates on the boxes were. You just have to be careful if you buy from anything except a regular pharmacy - you can't be certain how the insulin was cared for.

Often pharmacies that serve hospitals and nursing homes will break open a box of pens and sell them one at a time.

What I have seen in studies is that Lantus and Levemir have a duration in a cat's body in *most* cats of about 12 hours. ProZinc lasts about 10 hours. There are no others that I am aware of, that last as long as these 3. They are all good options.

 

I can't imagine giving my cat more than one kind of insulin, certainly not at this stage, and hope to never need to.

Is drawing insulin from a pen as easy as from a vial? With the pen or vial, which syringe needs to be used? For the NPH, I was using the syringes for U-100. Can I use these with Lantus or Levemir?

 

Lantus and LEvemir both use u-100 syringes with the half dose marked.

ProZinc uses u-40 syringes.

You always want to make sure you've got the right syringes for the right insulin.

Drawing the dose is easy from either one. I did a video on how to draw a dose with Lantus several years ago here. It's worth learning how to do it so you start out handling your insulin correctly so it doesn't get contaminated, and it lasts as long as possible.

 

Great video, very helpful. Thank you. Is the needle used for the Lantus/Levermir in the video a 31g?

You state never to shake/roll the Lantus/Levermir vial or pen. I did shake the NPH vial because it said to do so on the box. Wondering now if I wasn't supposed to do that.

 

NPH is rolled because it is a mixture and you want to mix it back up after it has been still and settled.

 

Good to know. Thanks

 

I checked with Costco and they don't carry the 3 ml SoloStar Lantus pens, only the 15 ml 5 pack pens. Julie's video, I believe, mentions the 3 ml SoloStar pens. Can I get the 15 ml 5 pack pens instead? I want to be able to get something quickly. Of course, it helps to get it at the best price.

As for the vials (a 10 ml vial), one refrigerated could last up to 1 or 2 months or is it less?
5 pens could last up to 6 months?

 

The 5 pack is 5 pens of 3 mL (300 units per pen).
Store on a refrigerated, non-moving shelf for longest life - 6 months in general.

 

Thanks. What is the shelf life for the 10 ml vial?

Trying to find a place that sells the 3 ml pens so I can pick it up quickly.

 

Ask your local pharmacies - try Target - if they would sell you 1 pen (US). Check Craigslist. Sometimes hospital pharmacies will sell 1 at a time.

When you have a moment, could you add a few tidbits to your signature? It will help us give you feedback without having to go look in all your past posts.

Editing your Signature

In the upper right corner of the screen, within the dark blue bar, you will see ID, Inbox, and Alerts

Click on your ID.

On the left, under Settings, Click on Signature.
This is where you will put information that helps us give you feedback.
This is where you paste the link for your spreadsheet, once it is set up.
Add any other text, such as
your name,
cat's name,
date of Dx (diagnosis)
insulin
meter
general location
any other pertinent issues like if there are any food issues, history of DKA, hepatic lipidosis, pancreatitis, allergies, IBD, etc.
Click the Save Changes button at the bottom.

Always click the Save Changes button at the bottom when you have changed anything.

 

Whatever container of Lantus you open is potentially good for about 6 months. Some people find they last less. Most people want to buy the pens because unless a cat needs a larger than average dose, they likely are able to use up every drop of a pen. If you get the 5 pack you can also sell some of them to another diabetic cat owner if you don't think you want to hold onto them in case you'll need all of them.

http://www.felinediabetes.com/FDMB/threads/lantus-levemir-info-proper-handling-storage.151/

• Lantus is available in a 10ml vial, in a box of five 3ml cartridges designed for the refillable OptiClik Pen,
  or in a box of five 3ml prefilled SoloStar Pens.
  
  US RESIDENTS: Effective March 31, 2011, Lantus cartridges will no longer be available for use with the Lantus Opti-Clik Pen.

• Levemir is available in a 10ml vial or in a box of five 3ml FlexPens FlexTouch® pens.

The syringes I used aren't available anymore, unfortunately. The manufacturer discontinued making them. I don't remember what size exactly, the needle was. It might have been a 31g.

 

Thank you for the info. My cat's BG went from 141 this AM to 75 awhile after I gave her her steroid med and food.

 

That's actually good progress. If it's at all possible for a cat's pancreas to heal and for the cat to become diet-controlled, they typically need to spend hours in the range of normal blood sugar of a non-diabetic cat.

Blood sugar changes all the time - I'd assume by tomorrow morning's shot time she'll need another shot. If not tomorrow morning, perhaps tomorrow evening. Don't assume that because she got to 75 that she'll stay there for any length of time - that would be very unusual.

Did you give 2u of the Novolin this morning?

 

I assumed the steroid would spike the numbers up. I also assumed since NPH doesn't stay in the body so long, the numbers would charge up quickly. So much I have yet to learn.

I haven't given Novolin since Tuesday morning. Should I resume Novolin? I am afraid of having another hypo episode. From an earlier post on this thread from BJM, my understanding was to wait till the BG gets to 200 before giving insulin again.

 

Yes, i agree with BJ that you could wait to 200 before giving any insulin - my only point was to not assume how long that might be. Sometimes people will see a number under 100 and take their cat off of insulin thinking that it means that the cat is now in remission. My vet actually did that with us - i just meant that you should continue to test twice a day so if it goes up you know it.

 

Yes, keeping a close eye on the BG levels daily.

 

Day 4 off insulin. AM BG 105. Vet thinks there's a chance my cat may not need to go back on insulin if numbers stay good and low-carb diet continues. Also if my cat does ok on a reduced dose of steroids given daily. Close home monitoring will continue.

I'd be stunned but absolutely thrilled if my cat didn't need insulin again while on long-term steroids. Is that a possibility?

 

Eh ... ECID (each cat is different). If you are really, really lucky, stick with the low carb diet, feed mini-meals to keep the glucose from having large spikes, you might be able to go diet-controlled.
With long-term steroids on board, though, I would be running a curve weekly just to make sure the glucose was at a good level consistently, as the risk is pretty high that having needed it once, it would be needed again. And be especially vigilant during infection - dental, bladder, respiratory are common ones.

 

That's my next step, learning and doing the weekly curve.

When you say "be especially vigilant during infection - dental, bladder, respiratory are common ones", are you saying these increase risk of diabetes?

 

Even without using insulin, your cat will be a diabetic - diet-controlled, if lucky.
Infection raises the glucose. Combined with the tendency not to produce enough insulin, it is likely that infection will result in very high glucose levels that will need treatment.

 

This is helpful to know.

 

BG #'s still good since off insulin. Close to reaching the 1 week mark. Appetite is improved and my cat is acting like herself again.

Am I correct to assume after 2 weeks off insulin, she'll officially be in remission?
Will there be a point where I mat not have to test BG levels daily?

 

At 2 weeks, she'll officially be off the juice. You might go to weekly, then monthly. Do keep an eye on the Secondary Monitoring Tools in my signature link - food intake and output, dehydration, behavior changes - on a regular basis. A scale is great for detecting weigh changes over time, which may be an indicator of an emerging condition.

 

So far BG #'s are still very good but I haven't done a BG curve yet. Where can I find instructions on how to do the curve?

 

A curve is testing from am meal to pm meal, every 2 hours.

 

From 1 pre-shot to the next, so 12 hours.

 

When you have a moment, could you add a few tidbits to your signature? It will help us give you feedback without having to go look in all your past posts.

Editing your Signature

In the upper right corner of the screen, within the dark blue bar, you will see ID, Inbox, and Alerts

Click on your ID.

On the left, under Settings, Click on Signature.
This is where you will put information that helps us give you feedback.
This is where you paste the link for your spreadsheet, once it is set up.
Add any other text, such as
your name,
cat's name,
date of Dx (diagnosis)
insulin
meter
general location
any other pertinent issues like if there are any food issues, history of DKA, hepatic lipidosis, pancreatitis, allergies, IBD, etc.
Click the Save Changes button at the bottom.

Always click the Save Changes button at the bottom when you have changed anything.

 

Done. Started to do a curve till a member pointed out one isn't needed while OTJ. Since BG #'s continue to be in the 70s and 90s, I haven't seen a need to create a spreadsheet at this time. Thank you again very much for your help and expertise.