? insulin control

Hi,
I am posting in main health as I think there may be others curious about the following,

@julie & punkin (ga) had told me at one point in order to regain control of a failed reduction I would probably need to increase above the last "good dose"
I have read others threads as well with that information and it has been absolutely right.

I am wondering why this is the case? Is it just the way it works or is there a physical reason?
If the dose was good and got us in healthy numbers just days before why is it not effective again?


We are dealing with a failed reduction now (after allowing for 3 drops and being a fairly new diabetic)

So I am thinking I will now need to go up from 1.75 to 2 units to gain control again.

My biggest concern is his organs remaining as healthy and not holding a dose too long, that being said I am not experienced enough to take up his dose too aggressively.

Thoughts and theories welcome!

 

I'd put this in the Lantus/Lev group primarily because "failed reductions" are a phenomenon of a depot insulin (Lantus or Levemir) and are specifically named only in the Tight Regulation Protocol. Failed reductions aren't named with the Start Low Go Slow dosing method because with SLGS, all doses are held for a week before being re-evaluated.

However, I can answer the reason for the scenario you're describing is because of glucose toxicity.

When you reduce the dose, ideally the cat's blood sugar stays in the same range that caused the reduction - a green number in the spreadsheets that we use. This is specific to a depot insulin because with an in and out insulin decisions on dose are made by the preshot number. Each shot stands alone when one is using a non-depot insulin. With Lantus/Lev you get a nadir that causes you to reduce the dose. You reduce the dose, then watch to see if the numbers trend upward. If they trend upward and you realize it right away, you simply return to the last good dose. That's often the end of things if you've caught it quickly.

If you haven't caught it quickly and the cat has been sitting in higher numbers for a period of time, the cat can develop Glucose Toxicity - which means that the cat's body now accepts higher numbers as their normal range. To move them out of that higher range, it often means increasing the dose higher than you were previously.

Hope that helps a bit. Perhaps others will have more to say about it.

 

A simple way to look at it is in the event of a failed reduction one will have to take the dose back up. We already know that part. It's a given. However, the old dose which was good only days or weeks prior to the reduction may not be enough to get back to the numbers kitty was at prior to the reduction if glucose toxicity has set in. At that point, one might have to take the dose up once again (surpassing the last good dose) to take care of the glucose toxicity that has set in while one was figuring out if the reduced dose would hold or fail.

Make sense?

I disagree. Failed reductions are not "a phenomenon" of a depot insulin. Failed reductions can and do happen when using any insulin.

TR and SLGS for Lantus or Levemir: A failed reduction is specifically mentioned in the Tight Regulation Protocol, but only as part of a guideline as to when to take the dose back up. Failed reductions are not specifically mentioned verbatium in the Start Low, Go Slow Approach, but logic and common sense should prevail while "evaluating" weekly. The only difference is, generally speaking, one protocol (TR) reaches the conclusion faster than the other (SLGS).



Failed reductions can and do happen when using any insulin for our diabetic kitties. Glucose toxicity can set in when using any insulin. The need to break through any glucose toxicity that has set in (higher dose) can happen when using any insulin. Failed reductions and the possible need to surpass the last good dose to cause a break through is not specific to Lantus or Levemir use, or any protocol/method/approach.

In conclusion, common sense, logic, and data collected would indicate the need for an increased dose in the event of a failed reduction... and then again if glucose toxicity has set in... no matter the protocol or insulin.

 

I would like to add some further things to consider about dosing of in-out insulins which I hope may be helpful to members treating their cats with some of the harsher in-out insulins.

The preshot number is very important when making dosing decisions for in-out insulins but attention should also be paid to the nadir - particularly when using harsh insulins like Caninsulin/Vetsulin and Novolin N which tend to produce quite steep drops in BG after administration. For safety you need some idea of how much a dose may potentially drop BG levels. These harsher insulins can absolutely tank blood glucose levels from very high preshot levels - sometimes by several hundred points (mg/dL)* / tens of points (mmol/L). The cat may then rebound straight back up into high numbers for the next preshot (and possibly stay in high numbers for a while after). If there is insufficient or poor-quality mid-cycle data available (not enough spot checks / home curves; or vet-run curves & spot checks only) dosing on the preshot only can lead to situations where vets prescribe potentially ill-advised increase after increase and some cats end up on way too high a dose of insulin and consequently at the mercy of all the issues and potential dangers that ensue therefrom.

When using the likes of Caninsulin/Vetsulin if a cat is spending time within the normal range when the insulin action is at its peak I personally would place increasingly greater emphasis on the nadir when making dosing decisions for safety reasons, since even a microdose of these harsher insulins has the potential to cause quite a precipitous drop in BG levels. For a cat starting to run a lot of the time in healthy numbers - especially if it is a good candidate for fairly imminent remission - there isn't a lot of wiggle room for unexpectedly steep drops if the pancreas suddenly decides to help things out.


Mogs


* Case in point: One member's cat being treated with Vetsulin recently saw a drop in BG level of >= 500 mg/dL / 27.8 mmol/L within three hours of dose administration.

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