START LOW, GO SLOW METHOD (SLGS)WITH LANTUS OR LEVEMIR FOR DIABETIC CATS Adaptation written from suggestions provided by members of the FDMB community *** IMPORTANT DOCUMENTS *** Print these out and keep them handy: SYMPTOMS OF & HOW TO TREAT HYPOGLYCEMIA - what to do if your kitty experiences a hypoglycemic event Jojo's HYPO TOOLBOX - what to have on hand in case of an emergency REFERENCE NUMBERS GIVEN ARE FOR BLOOD GLUCOSE METERS CALIBRATED FOR HUMANS, NOT PET-SPECIFIC METERS. THEREFORE THE USE OF PET-SPECIFIC METERS IS DISCOURAGED. Every protocol or method has safeguards built into it's guidelines. It can become problematic or even dangerous to combine guidelines or suggestions from different protocols/methods. The START LOW, GO SLOW METHOD (SLGS) with Lantus or Levemir for Diabetic Cats has been adapted from the FDMB's original 5 Steps to Regulating Your Diabetic Cat. Adaptations were necessary to accommodate the action, nuances, and exceptions of the newer Lantus and Levemir insulins. REQUISITES WHEN FOLLOWING THE START LOW, GO SLOW METHOD: Learn the signs of and how to treat HYPOGLYCEMIA and prepare a HYPO TOOLBOX. Test regularly for ketones and know about DIABETIC KETOACIDOSIS (DKA). Use a human meter, not a pet-specific meter. Reference numbers given are for measuring blood glucose with a human meter. Use U-100 3/10cc syringes with half units marked on the barrel for fine dosing. Most kitties are easier to regulate when fed small meals throughout each cycle. Others adapt well to free feeding. Starting Dose: 1u BID if kitty is not on a wet/canned low carb diet 0.5u BID if kitty has been switched to a wet/canned low carb diet If the cat was previously on another insulin, the starting dose should be increased or decreased by taking prior data into consideration Generally, shots are to be given 12 hours apart. Hold the dose for at least a week: Unless your cat won’t eat or you suspect hypoglycemia Unless your kitty falls below 90 mg/dL (5 mmol/L). If kitty falls below 90 mg/dL (5 mmol/L) decrease the dose by 0.25 unit immediately. After 1 week at a given dose perform a 12 hour curve, testing every 2 hours OR perform an 18 hour curve, testing every 3 hours: Note: Random spot checks are often helpful to "fill in the blanks" on kitty's spreadsheet. If nadirs are more than 150 mg/dl (8.3 mmol/L), increase the dose by 0.25 unit If nadirs are between 90 (5 mmol/L) and 149 mg/dl (8.2 mmol/L), maintain the same dose If nadirs are below 90 mg/dl (5mmol/L), decrease the dose by 0.25 unit As your cat's blood glucose begins to fall mostly in the desired range [lowest point of the curve approaching 100 mg/dl (5.5 mmol/L) and pre-shot value around or below 300 mg/dl (16.6 mmol/L)], do lengthen the waiting time between dose increases. If you decide to change another factor (e.g., diet or other medications), don't increase the insulin dose until the other change is complete (but do decrease the dose if your cat's glucose numbers consistently fall below 90 mg/dl (5.0 mmol/L) as a result of the change). Don't be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat's blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose. Lather, Rinse, and Repeat! How to handle a lower than normal preshot number: In the beginning we suggest following the guidelines in the FDMB's FAQ Q4.4: Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection? A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines. Below 150 mg/dl (8.3 mmol/L), don't give insulin. Between 150 and 200 (8.3-11.1 mmol/L), you have three options: a.) give nothing; b.) give a token dose (10-25% of the usual dose); c.) feed as usual, test in a couple of hours, and make a decision based on that value. Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise. In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine. Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher. Keep in mind these are general guidelines, and they should be personalized to your own cat's response to insulin. If your experience is that your cat does not became hypoglycemic with a dose which is close to her usual, then personal experience should be your guide. With experience, you may find that lowering these thresholds may work well for your cat. When you have reached that stage, the following guidelines are suggested for Lantus and Levemir users following the Start Low Go Slow approach: If the preshot number is far below usual preshot numbers: Do you need to stay on schedule? Then skip the shot. Do you have some flexibility with your schedule? Then stalling to wait for the number to rise might be a good option. Don't feed, retest after 30-60 minutes, and decide if the number is shootable. Repeat until the cat either reaches a number at which you are comfortable shooting, or enough time has passed that skipping the shot is necessary. If the preshot number is near usual preshot numbers: Look at your data to see what numbers you have shot in the past and decide what would be a safe, shootable number for your cat. Don't feed. Stall until kitty reaches the preshot number you've decided on and then shoot. We usually don't suggest or recommend shooting a preshot number less than 90 mg/dL when following the SLGS Method. Remember that with SLGS, your goal is to achieve flat numbers that are greater than 90, so there is no need to push a cat into numbers lower than that. Remission: Remission is reached when kitty can go 14 days without insulin. Most cats will remain in the range of a healthy cat 50 - 80mg/dL (2.7 - 4.4 mmol/L) with only sporadic higher or lower BG numbers. However, some will experience infrequent BG numbers higher than the norm. Continue feeding low carb food. Test the cat's BGs once per month. If BG numbers begin to trend upwards, it's time to bring kitty in to see your vet for a check-up. Common reasons for kitty falling out of remission include dental issues, infection, inflammation, pancreatitis, etc. Just about any illness or disease can do it. Glycemic Status and Predictors of Relapse for Diabetic Cats in Remission Sometimes there are circumstances such as ketones present, an unusually low preshot number, a caregiver leaving the cat with a sitter, loss of appetite, infection, a schedule change, ability to monitor, etc. which may call for adjustments to these guidelines and suggestions. Please ask for guidance if any of these or other circumstances present themselves or are of concern. RANDOM NOTES: In the case of a furshot, NEVER give another shot. there's no way of knowing how much of the first shot "got into" the cat NEVER give a second shot because "numbers are too high" in any given 12 hour cycle Test often for ketones Be consistent in timing and type of food KNOW THY CAT. Shooting early or late is a practice best reserved for those who have a full understanding of the insulin used and it's effects on their kitty. Because of the cumulative nature of Lantus and Levemir, please be aware: Shooting an hour or two early *could* act like a slight dose increase. Shooting an hour or two late *could* act like a slight dose reduction. Please ask for guidance if you're unsure. A "cycle" refers to the period of time between shots. There are 2 cycles in one day when shooting twice a day. Sometimes a dose will need to be "fine tuned" by adding some "fat" or "skinny-ing up" the dose. These are "general" guidelines which have worked for many cats. However, "Every Cat Is Different". Learn how YOUR cat responds to the combination of food and insulin. Please be aware: There aren't any "dose advisers" on the FDMB. The FDMB is an open board subject to peer review where laypersons with varied degrees of knowledge and experience are free to share their own thoughts and opinions through explanation and by making suggestions. We are not veterinarians. It is not our intention to take the place of your veterinarian. Please discuss dosing, methods, medications, and care for your cat with your veterinarian.