Hypo Situation...Smokey Low again 4/7/20

Good evening all,

This morning I gave Smokey his 1.5u injection after testing him. (The morning test was taken with AlphaTrak meter for the last time, used the last strip I had.) So subsequent tests were given with the ReliOn Prime. I have tracked his BG all day. What I'm needing is input on whether to shoot, or not to shoot. I am definitely backing off of his dosage by 0.25u. If you can take a peek at his spreadsheet, I would be most grateful. He ate at 8:00p. (He was hungry)

 

Yes, you need to shoot but at the new reduced dose of 1.25

I'd try to get a +2 and +4 tonight if you can. It's important to get a few tests on the PM cycle so you don't miss half the picture of what's going on with him at night.

On your spreadsheet, it'll be helpful to have a line all the way across that has something like "Human Meter" so it's obvious to us when you changed. (look at China's spreadsheet on 9/11/18 for an example)

 

Changed the SS, hoping it makes it less confusing.

 

Absolutely agree with Chris. 222 is high enough to inject, but Smokey has earned a dose reduction with those low numbers. So it's time for his dose to be 1.25. Watch him, and get some mid-cycle tests every day as you can, as I expect you will need to reduce again soon.

With the SLGS method, every time Smokey's BGL drops under 90 (human meter) he needs a dose reduction of .25. So on the 1st, when he dropped to 88 (pet meter), you should of dropped dose to 1.25. Instead, you dropped to 1 on the 2nd and then back up to 1.5 on the 3rd, which may have caused Smokey's hypo.

This tells me 1.5 is likely too strong for him period. Remind yourself that ProZinc doses change depending on what the lowest readings of the day are, not the highest. A cat's BGL can bounce quite high after a low like that, but you don't adjust dose based on the higher pre-test readings. So don't be tempted to up his dose back to 1.5.

Watch carefully over the next few days. I wouldn't at all be surprised if you have to drop down to 1 unit. Unless you get some mid-cycle tests (and the human meter is fine for that, it's what many of us use) you won't know when to drop his dose, so they are very important.

 

It is now +1.5 after when I usually shoot him...is that going to make a difference? If I move his shoot time? I just tested and he's at a 240, and had a meal at 8:00p.

 

And if you look at this thread, it gives the history of today:

http://www.felinediabetes.com/FDMB/threads/need-help-please.227881/

 

Can you dose later than usual in the morning? You do have a little wiggle room with Prozinc, but +1.5 is a big gap. You could dose tonight, then try to give his dose maybe 45 minutes late next dose. Or you can skip and dose as usual in the morning. Or you could give a half dose and dose as usual in the morning.

 

I can dose anytime. I'm on stay at home orders and have no where to go! I'm inclined to skip tonight (because I think it will rest easier given he went so low today) and check in the morning and shoot at the "normal" time. Today scared the bejeezus out of me. Does this seem logical? "Permissible"? I think that is what you were telling me on the skip and dose as usual in the morning.

 

Hypos are scary, but you handled it like a champ. No worries about a skip. Don't fret if Smokey reads high in the morning. Give things a few cycles to smooth out, (unless you need to drop the dose again.)

 

Thank you, I owe most of my actions to this board. (People giving direct input and having read the other threads multiple times!!)

 

That's fine...don't forget to change it along the top too...might just change it to say AlphaTrak (changed to human meter on 4/3/20)….or whatever you like. Just want to make sure people know you're using a human meter from now on

 

Got it changed. Also, tested him a couple of times last night (As you can see in his SS) Fed him at 5:30a and tested at 8:00, administered 1.25u and all seems to be copacetic so far. Still keeping a close eye on him today.

 

@DD & Smokey & Sissy
Please keep a very close eye on Smokey Joe today. He's already dropping low at +3 and his nadir is around +4 to +6.
You have several hours to go before he hit's his normal low point.
You may have another hypo potential situation today, Saturday 4/4/20.
I'd recommend you test at least every 1 hour, More often if Smokey Joe's BG's fall below 70.

I think you will need to reduce the dose again. Will need to see more test numbers later today, but I think you want to reduce to no more than 1U for the PMPS shot tonight. Maybe even less, like 0.75U. Won't know until later.

 

I am testing him every hour. And watching him closely. Yesterday this was about the time things went off the rails, and right now he's acting normal, walked around the house a bit, just ate a little bit, tinkled a little bit, and groomed a little bit. He is now lying next to me on the couch. Thank you for the dosing advice...and honestly, in my gut I felt like 1.0u should have been what I gave him this morning, but went with the advice of "the pros". Will continue to monitor and check back with you folks throughout the day. Thank you again.

 

Would you change your thread title, to put today's date on there. So we know you might need help today, 4/4/20 also. Upper right hand corner at the very top of the thread, "thread tools", drop down box to choose what you want to do.

Something like "Smokey Joe headed Low again 4/4/20" would help.

Thanks.

p.s. I have to do a few errands and chores. Will try to check back in 1 hour.

 

Tested at noon, 97. Gave him some dry treats and put some of his old, dry kibble down. He wasn't too interested in the kibble, but ate the treats.

 

Thanks for the title change. That 97 at +4 looks ok. Let's see what the +5 and +6 are.

 

He's holding steady, a 95 at +5. Will continue to monitor. (Pretty easy since he's laying right here next to me) Two more treats for being a good boy about testing!!

 

109 at 2:00p CDT, or +6. Shared a FF natural chicken treat with sis.

 

Ummm, 2 pm doesn't mean much to me. We live in all different time zones and some of us are early birds and may get up at 5 AM to pre-shot test our cats and others sleep in until 10 or 11 am and their pre-shot test is noon.

So, would you please restate that 2 pm in the + hour format? Pretty please with sugar on top, but none for Smokey Joe.

 

Sorry

 

So what + hour was that 109?

Yes, it takes a bit of getting used to, to think in + hour time format instead of your local time.
No apologies needed. Before you know it, you'll be a pro at saying "My cat got a 109 at +6" instead of saying, at 2 pm.

 

Also, please do not go back and edit your posts. The way the message board works, it takes us to the last unread post. I see you did go back and edit your reply in post #19.

So, going forward, please do a new reply. Thanks.
It takes a bit to learn how a message board like this works.

I'm a horrible speller, so I do go back to correct my spelling and grammar at times. Or if someone else points out that I have made a mistake, I go back and correct it, because posts live forever and I don't want someone else to read something that is wrong.

 

You and Smokey are doing great. Even though that 97 isn't quite the under 90 we look for, I agree with you and Deb that next dose should be 1 unit, with you continuing to look for signs that he may need to drop to .75 rather quickly. That is, if you can dose tonight at all. If Smokey's BGL is around 200ish tonight, you might consider dropping to .5 tonight. There's no way to tell for certain, but it's my opinion that Smokey might be headed straight for remission. That doesn't mean the work is over. Cat's can reach for remission and then end up needing insulin for a little while longer. It's all up to how much Smokey's pancreas has healed, and whether it decides it needs anther break or not.

As my Billy and I can attest, the bit right before remission can be the most confusing and difficult. You don't want to stop all insulin too soon if you want to reach a strong remission. The trick can be finding a dose low enough that you can give it twice a day. It's important not to skip completely if you can avoid it. You need a plan in place. Say, for example, that if Smokey's BGL is near or over 300 tonight, you might give him .75 or 1 unit. If it's nearer to 200, you might give him .5 or even .25 of a unit. If it's nearer 150, you might give him .25 or even just a little drop of insulin. If under 150, you might skip and reassess in the morning. The goal is to find a dose low enough that you don't risk a hypo but you can still dose twice a day.

He could still bounce high. Billy had one incredible bounce over 400 right before he hit remission. Just remember not to fret the high numbers and don't increase dose for them. Keep your eyes on the lows, and stick to whichever plan you decide.

 

His BG at +7.5 was 192 (got busy talking to my mom on the phone and missed +7!!); no treats this time as he is napping pretty good. I gave him 3 dry, high carb treats at +4; and 2 dry treats at +5, because I didn't want his low going as low as it did yesterday. That may have been wrong on my part, but I didn't want to repeat yesterday. I was really concerned & scared yesterday. And thank you for the heads up on the remission confusion/difficulties.

From everything I've read in the forums, the dosing should be based more on the lows than the highs. (Better high a day than low a minute) It appears that his low today was 95. I'll continue to test today and keep his spreadsheet/and you folks updated.

And I apologize for editing, my strong suit has always been grammar and spelling. It's habit for me, but I'll keep in mind how the board works. It has been years since I was on a board like this. (As in, probably back in the 90's!!)

 

Well, if that 95 at +4 was propped up with some high carb treats, and Smokey Joe got some more high carb treats at +5, then I think a dose reduction is DEFINITELY in order. Thanks for mentioning the treats at those times. I was kind of on the fence, about suggesting a dose reduction before, but that comment totally changed my mind.

The question is, what should the reduced dose be? Personally, I'm leaning more towards 0.75U for the dose for Smokey Joe vs the 1U. It's up to you. Worst case, the 0.75U dose isn't enough, and we find that out in 3-6 cycles and you have to bump the dose up a smidge.

No worries on getting a +7.5 instead of a +7. Talking to your Mom is important too.
No apologies needed on the editing bit, I just wanted you to know how the board works, and that those changes you made might not be seen.

You don't have a lot of mid-cycle test data yet, to know how low the insulin takes Smokey Joe. Really, you only have 5 1/2 days where you had some mid-cycle tests. So, for now, the decision point threshold for what to do should be 200 mg/dL. After you gather more data, that decision point threshold could drop to 150. But for now, you should keep it higher.

It does not mean you should totally skip the dose if the BG's are <200. What you want to do, is stall for 20 minutes, no food, then retest. If the BG number is rising, and I mean by a good 15-20% or so, then you could go ahead and give him the insulin. You can stall for up to 1 hour with Prozinc, and still stay on schedule for the next cycle time. Use that same wait 20 minutes, no food, retest cycle during that 1 hour time period while you are stalling. Wash, rinse, repeat as we say.

If the BG during stalling is staying pretty much the same, within meter variance, then you'll want to either give a greatly reduced dose, what we call a "token dose" of between 10-25% of his normal dose. When I say normal dose, I mean for tonight the reduced dose of 0.75U.

If the BG's you get while using the stalling technique are dropping, you're better off skipping the dose and picking it back up at the next cycle. Not always the case that skipping is the right thing to do, with all insulins, or with all situations. Ketones or DKA (diabetic ketoacidosis) or HL (hepatic lipidosis) make it important to give at least some insulin.

For now, I'd recommend skipping the dose if the BG's are under 150 mg/dL. That will not hold true forever. Simply until you gather more data on the mid-cycle lows or Smokey Joe decides he has had enough of this "insulin shot thing" and decides to surprise you and go OTJ, (Off-the-juice, insulin being the juice), aka diet controlled or in remission or "honeymoon."

p.s. Would you start making notes on the SS in the Remarks column on the far right, when you have done things like giving him treats or food? Having the notes on food and treats in that column, helps us to interpret what is going on with the BG readings. + hour times please.

 

At +9 he is at 223. I will go into the spreadsheet right after I finish here and add the comments about the treats. Luckily, I'm home until April 30th (I work for the State of Texas and we're following governor's guidance) so I'll be home and able to test a lot this month. My trouble will be staying up late. I stayed up late and set alarms last night, which I can do on weekends, but harder during the week since I do have to work and be somewhat productive. (Or at least I think that's what my boss wants...LOL!!)

 

At +11 he is at 264 and playful. I found his string today (while cleaning out) and he wants to play and play. Smh, goofy boy...and very thankful.

8:00p is his shoot time. Are we still thinking 0.75?

 

Absolutely. No more than that.

 

Very good, thank you for your assistance the last couple of days!!!

I hope you are feeling better, too. Sending lots of positive thoughts and prayers!! ❤️

 

Not bad numbers for Smokey today, especially with him being a bit bouncy and skipping a dose last night. Not bad at all. If it we're me, I'd stick to that .75 (unless he goes under 90 at some point and needs a drop in dose) for at least 3-6 cycles and see where his number ends up when his body adjusts to the dose and the bounce clears. Smokey Joe is doing great!

 

What Juls said.

 

That was my plan and I was going to ask for input, but you guys beat me to it!! Thank you all so much ❤️

 

Good evening all, just took Smokey's BG and it is really low, 71. I am thinking I need to skip the evening dose. (I also just gave him 2 Friskies Party Mix treats) Is this part of the bounce? I gave him a "day off" today because our weekend was so intense. Hindsight tells me that might now have been the right thing to do. TIA for assistance!!

 

You were perfectly right to skip the dose. His numbers are coming up nicely. It's not dangerous unless it dips under 50, but feeding and a couple of treats are always a good idea to make sure he's going back up. Since the injection was skipped, you should not have to worry about a hypo this cycle.

It's time to reduce dose again. Take it down to .5 of a unit, if his BGL is high enough to dose in the morning.

 

Hour later and he's at 91. Skipped shot, giving some dry kibble. (I wrote that last night and apparently failed to hit 'Post Reply'. This morning it was 300, so I stayed with the 0.75, mostly because I didn't see your message until after his shot. I will monitor today and update his SS. Thank you for the reply!!

 

Good call on the skip last night. That was too low to shoot insulin.
He's bouncing this morning, since he did not have insulin last night and probably a bit from the higher carb food. No worries, the BG's will come back down again.

Suggest you make a note for yourself, attach it to your meter, to reduce the dose to 0.5U for tonight.
As Juls said, it's time for a reduction.

Giving his ears a break was probably not a good idea in hindsight, as you said. Don't you wish you could see the future, and know when he needs to be tested? We all wish for that, a time machine to let us look ahead a bit.

Do you have some triple antibiotic ointment with pain relief? That or a cool wet washcloth in a plastic bag could sooth Smokey Joe's ears. Just be careful not to put too much ointment on, and wipe off any excess. It does help to take the sting out when you poke yourself too. Been there, done that.

If he was 71 at PMPS last night, he may have been much lower before that time. Good thing you are testing at pre-shot, every cycle. Can you imagine what his BG levels would have been if you had given him insulin last night, without a test? Scary is what I think it could have been. But it wasn't because you tested! Excellent!

p.s. Please put 0 (zero) in the dose column and put a note in the remarks column that you skipped. And add today's 300 reading to the SS. Notes about the dry high carb treats also. If you would please. Thanks.

 

I shudder at the thought of having given any dose last night. Makes me sick to my stomach!! I have no problem testing, he does, but I don't. I am a Firm believer in testing pre shot. I've read too much and helped through a hypo situation, I'm going to do all I can to avoid that!! I have made the note to reduce and will do so accordingly.

I updated his SS for this morning (would have sooner but had a conference call I had to present on) I have massaged some Polysporin on his ears. VERY small amount after I've rubbed it between my thumb and forefingers.

Thank you all again ❤️

 

That is a bit more than a 50% drop already, so please monitor.
No more hypo's for Smokey Joe.

Hope the conference call went well.

 

I think you want to test again in no more than 1 hour. That would be by +6 at the latest.

That 76 at +5 is a bit low, and you don't want it to drop under 50.

That 76 is another earned dose reduction, dropping below 90.
Please remember to reduce the dose to 0.5U this evening.

 

That 44 is too low, Please feed at least 1 teaspoon of his regular food, and retest in 20 minutes.

 

Done. Looks as if it is coming back up at +7.5 with a 62.

 

You want rising numbers for at least 2 hours.
A bit more food if he'll eat it.
It not, put some in his mouth and get him to swallow.

I think you should only try giving Smokey Joe a 0.25U of the Prozinc insulin at PMPS.
And then, only if his BG levels are high enough to warrant that.

 

Understood. What would be a threshold you would use to determine "Yeah, he probably needs his shot" or "Nah, that's probably too low." 150? 200?

He is full now (as in not interested in eating too much else), but he is also NOT acting abnormally. (No vomiting like last Friday) Walks straight, not overly vocal, etc.

 

Nothing <100 right now. That's too low.
Nothing <125 right now. That's too low.

I think a BG pre-shot of 150 would be ok to give him his shot. NO MORE than 0.25U tonight, 4/7/20. Change that note I suggested you put with your meter to reflect that.

Between 125 and 150, I'd suggest you stall, no food, retest in 20 min to see if you have a rising number. By rising, I'm talking a good 15% rise. Not a little bit of a rise.

Plus, get that +11.5 test before the pre-shot test. So you have a bit more data to base that judgement call on, weather to give Smokey his insulin or not. Yes, I know it's tough on his ears, but he's dropping too low since 4/3/20 to give his ears a break on the testing.

Here is a picture of 0.25U in an insulin syringe. Shows a U100 syringe, but the positioning of the plunger is the same concept with U40 syringes.

 

Very good. I plan on testing him at LEAST every hour until PMPS. I have the U40 syringes, so I think I can get the 0.25 basically like I did the 0.75.

 

Big jump in BG levels for Smokey between +10 and +11.
But I'd still suggest you only give him 0.25U of insulin tonight.

Bouncing and/or the insulin does not have the full 12 hour duration.
You need to be patient and wait until those bounces clear.
Duration, not much can be done about that.
Although sometimes, when a cat is on insulin a bit longer, the duration extends also.

 

Thank you, Deb. I just tested again and he jumped again. But, he had 4 treats and some dry kibble. I will do 0.25U tonight and recheck periodically. ❤️

 

Too low this morning for insulin, so I see you skipped the shot. That is exactly what you should have done.

Still thinking that Smokey Joe is trying to go OTJ.
Let's see where the BG levels head today.

Next lower dose is 0.1U, basically a drop or two.
Want to practice the drop dosing technique?

 

Yes, how does the drop technique work??

 

I wrote this up some time ago, since I was helping people learn how to drop dose.
Drop Dosing

How many drops do you get from your insulin syringes if you draw the liquid up to the first line? Not the first line with a number next to it, or the shorter line that shows half unit markings. The very first line on the syringe. What we think of as the zero mark.

• Practice, practice, practice to see how many drops you can get out of the syringe.
• Use some sort of colored clear juice like apple juice or colored water.
• Mark the syringe well. Painter's tape, duct tape, masking tape at the top of your “practice syringe”. So you don't forget and use that syringe to draw up insulin.
• Draw the "test liquid" up to the first line on the syringe.
• After you have drawn up a tiny bit of “test liquid”, point the needle up towards the ceiling and give the syringe a "finger flick". To move/push the air bubbles to the top of the syringe. Push the air bubbles out of the syringe.
  
• Slowly “twist” the syringe plunger to push out all the “test liquid.”
• Then when one small drop of “test liquid” is all that is left on the beveled tip end of the needle, draw the syringe plunger back to "suck" that 1 drop back into the syringe.
• You are looking for consistency.
• Try to get evenly sized drops.
• Practice, practice, practice until you get a consistent number of drops.

Do you think you have the technique down for the drop dose?

Then let me know.
When it’s for real. You’ve practiced and are ready to give a tiny “1 drop” dose.

• Draw up a tiny bit of insulin, needle pointed up to the ceiling and give the syringe a "finger flick. Push out the air bubbles.
• Slowly “twist” the syringe plunger to push out all the insulin.
• Then when one small drop is all that is left on the beveled tip end of the needle, draw the syringe plunger back to "suck" that 1 drop back into the syringe.

"Finger flick” technique - make a circle with thumb and first 2 fingers tucked into first thumb joint. Quickly “snap” those first 2 fingers against the syringe barrel held in your other hand. That will force any air bubbles up to the top of the syringe. Then you can push the air bubble out.

Syringes have a lubricant inside. Before you draw up insulin, moving the syringe plunger up and down a couple of times helps the plunger move more easily.

Give the shot. Monitor.

Later, if you need to, you could increase the number of drops.
Some people use calipers to measure the dose. But I think that would be too difficult and not accurate to use when you only want to give your diabetic cat a single drop or maybe 2 drops of insulin.

Some people refer to those tiny doses as "needle juice" or "some insulin".

 

Heartily agree with Deb. Time for drop dosing. Smokey Joe says he's trying to make all his insulin his own self, and that's awesome. Even the .25 was too much. Even if his pre-shot test looks high, I wouldn't do more than a drop for at least the next three cycles. And be prepared to skip even that drop if his BGL is too low.

 

DD, would you please start a new thread, and link this old one into the top.

Moderators like to keep threads <50 posts if we can. Makes the database behind the scenes of the message board more efficient too.

Thanks.