Sticky LANTUS & LEVEMIR - TIGHT REGULATION: SHOOTING & HANDLING LOW NUMBERS

Discussion in 'Lantus (Glargine) / Levemir (Detemir)' started by Jill & Alex (GA), Dec 28, 2009.

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  1. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    The following articles were written for those following the
    TR PROTOCOL with Lantus or Levemir for Diabetic Cats only!


    *** IMPORTANT DOCUMENTS ***
    Print these out and keep them handy:
    SHOOTING & HANDLING LOW NUMBERS
    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.


    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.



    "Shoot Low to Stay Low" has become the motto for those practicing Tight Regulation. We follow a Tight Regulation Protocol with Lantus or Levemir because research has shown "significantly higher remission rates are observed if good glycaemic control was achieved soon after diagnosis: 84% for cats started on the protocol within 6 months of diagnosis went into remission, and only 35% for cats that began more than 6 months after diagnosis". Not all kitties will reach remission. However, a tight regulation protocol can help towards controlling kitty's diabetes.

    When following the Tight Regulation Protocol, you'll want to become data ready, learn to safely shoot preshot numbers between 50mg/dL - 150mg/dL, and how to manage curves with low numbers.

    New members without much data collected, but are following the TR Protocol in the Lantus and Levemir Insulin Support Group should ask for guidance when presented with a preshot number less than 150 mg/dL. Once you've collected data to support your decisions, the TR "no shoot" number is 50 mg/dL.

    Scroll down to learn how to "Shoot Low to Stay Low" safely by "BECOMING DATA READY", learning "HOW TO DEAL WITH LOW PRESHOT NUMBERS", and "HOW TO HANDLE LOW NUMBERS".

    Ask any questions you may have in your daily thread. The first few times kitty presents you with low numbers can be scary for most caregivers. Please post for guidance and support.


    BECOMING DATA READY:

    Are you data ready to handle a lower preshot number?

    Everyone focuses on the +6 spot check to find the cat’s nadir, but there is a reason to collect data in the very early and very late part of the cycle. The +10s and +11s and +1s and +2s are often the “neglected spot checks,” but they can be almost as important as the nadir.

    Why the +1s and +2s? Let’s say you have a lower than usual preshot. If you have collected the data to know what usually happens after you shoot and how long it usually takes for the insulin to start having an effect (onset), you may see that shooting low is actually very safe for your cat. If your cat typically rises through +1 and +2 before the insulin starts to work between +2 and +3, then you can feel comfortable knowing that your cat will actually be much higher before the insulin starts to work. If your cat typically has little to no food spike or an early onset, then you may need to be more conservative with low preshots. You are not shooting the number your cat is at now – you are shooting the number your cat will be at when the insulin kicks in. You need to know what that number will be. You are then using the lag time (aka overlap and carryover) to your advantage. It is important to note that while Levemir may typically have a later onset than Lantus, that is not true for every cat. Know thy cat.

    Why the +10s and +11s? These spot checks will help keep you out of trouble. Again, let’s say that you have a lower than usual preshot. If your preshot is higher than +10 or +11, you know the insulin from that cycle is waning, the cat is on his way up, and the number is probably shootable. If you have a preshot that is much lower than your +10 or +11, knowing why will help you decide whether or not to shoot. Some Lantus and Levemir users notice a dip at the end of the cycle, meaning that the preshot is always a bit lower than +10 or +11 (but usually still higher than the nadir – the cat dips to a nadir at mid-cycle, then rises, then dips again). If this is your cat’s pattern, then this type of dip is not a reason to delay a shot. On the other hand, if your cat has a bounce clearing and is still careening downhill at shot time (usually characterized by numbers that drop for the whole cycle, without a clear nadir), then you will want to take that into consideration as you make a decision about shooting. Know thy cat.

    Knowing whether your cat is one that dips at the end of the cycle can also help you with dose increases. If your nadirs are not that great and you are considering an increase, but then he dips again at the end of the cycle, you might be tempted to delay the increase. If you know that this is a usual pattern for your cat, you will know that you can ignore that dip and go ahead with the increase.

    Do not forget the “neglected spot checks.” They are more useful than most realize.

    Know thy cat. Be data ready to handle the situation.

    ~ written by jojo and bunny(GA) and Y, edited to update and clarify by Libby and Lucy



    HOW TO DEAL WITH LOW PRESHOT NUMBERS:

    The following guidelines apply to those following the Tight Regulation Protocol only.

    You just tested your cat’s preshot number, and there is a much lower than usual number staring back at you. What do you do?

    There is no one-size-fits all answer, but there are some general guidelines. As with everything else, each cat is different (ECID) and each caregiver is different too.

    The short answer is that most kitties can be shot at +12, almost regardless of the number, once you are data ready to do so. The exception is that shooting 30s or 40s is not recommended for most cats, so if a cat is lower then usually the best option is to wait until they are at a shootable number to shoot. What constitutes a shootable number will vary by cat, but we don't suggest or recommend shooting a preshot number less than 50. While you’re waiting, the depot is draining, so you want to get the insulin in as soon as it makes sense to shoot.

    If it is your first time shooting green, then we will likely suggest that you stall the first time, even if the number is 80-100. That will let you collect data on what your cat will do when you stall. One thing you can do if you are having a low cycle is to get a +10 and +11. Those will give you a good idea of how quickly the cat’s numbers are rising (or not) when preshot time arrives.

    Beyond the general guidelines, there are other factors we consider when we are helping someone with a low preshot.

    • If the low preshot is not part of that cat’s normal pattern or there is reason to think something might be wrong, we will be more conservative.
    • If the cat is not a food spiker or tends to have an early onset/early nadir then they may not want to shoot as low. If the cat has a late nadir, then they will HAVE to learn to shoot low.
    • We will also be more conservative in some cases because of the person – if you are not able to monitor then you want to be more careful, or if you are not sure that you can get back to the board to keep us updated throughout the cycle. Trust me, if you shoot low, we will be watching for your updates and we will worry if we don’t see them.
    • We have to be a lot more careful with the cats who eat only dry food, because they don’t have access to the tools the rest of us use to keep our cats safe.
    • Also, when it comes to very low preshots, there is an unwritten rule that whoever helps that person shoot low should expect to sit with them through any low parts of the cycle. There have been times when I knew a cat’s number was likely shootable, but I also knew that I could not be around to help if the shot resulted in low numbers later in the cycle. For safety’s sake, if I could not find someone else who would be available to support for the next several hours, I would most likely suggest that the shot be reduced or skipped. I will not encourage someone to shoot low and then abandon them.
    • There are a lot of other scenarios, and you always want to keep your cat in mind.
    Some general rules when stalling (ECID):

    ** 50s or higher – don’t feed. The number will bump up on its own soon due to the insulin wearing off.
    ** 40s or lower – you have a couple of choices.

    • When 40s occur at the end of the cycle, it can be beneficial to withhold food and test in 15-20 minutes to determine if kitty is on the rise or hasn’t reached nadir yet.
    • If they are hanging in the 40s for a while, or if they are still dropping, it is ok to feed a tsp or two of LC and retest. This is very tricky. You want to avoid feeding too much while you’re waiting for them to go over 50, because you don’t want to artificially inflate the number with food.
      • --- Example: if kitty is 43 and you feed a whole meal, or feed some HC, and the number bumps up to 52, is that the cat’s natural end-of-cycle rise, or is it food spike? What if it is food spike? Then if you shoot the 52, when the food wears off he might drop back to the 40’s (and when insulin kicks in a couple of hours later, you might have a problem). If the 52 is the cat’s natural rise, then he will probably keep rising for the next few hours until insulin kicks in. If you can’t tell whether the number is food spike or natural rise, it’s safest to wait. Your data will help you here. Study the spreadsheet. How much food spike does the cat usually get? How many hours after the shot does the insulin’s onset usually occur in this cat? At what number is the cat likely to be when onset occurs? If the cat does drop, how easy/hard is it to regain control of the numbers? How carb sensitive is he?
    ** Test often (every 15-20 minutes, or at most every 30 minutes). You want to catch the rise the minute it starts. With most of our cats, once they start to rise they will really zoom. You want to get the insulin in as soon as possible, because it will be another 2-3 hours before the insulin kicks in and you don’t want to let the cycle get too far ahead of you.

    Perhaps the most important guideline in shooting low is that any time you shoot your lowest ever number, you should get a +1 and +2 to give you an idea of how the cycle will go. If the +1 is not higher than PS, or if +2 is much lower than PS, that means “pay attention” over the next few hours. Those tests will also help you become even more data ready for the next time you are presented with a low preshot reading.

    Using the overlap by shooting low is a great way to take advantage of Lantus/Levemir’s long, flat cycles, once you have learned to do so safely.

    ~ written by Libby and Lucy



    DON'T PANIC! or HOW TO HANDLE LOW NUMBERS
    The following guidelines apply to those following the Tight Regulation Protocol only.

    First, try to not panic. Post to the Lantus & Levemir Insulin Support Group or on the Health Board. Make sure your subject line indicates you are concerned about a possible hypo and/or add the 911 prefix to the first post in your thread. People who are experienced in dealing with low numbers will be there to help. After posting, remember to refresh your browser periodically to see if people have replied.

    It’s important to recognize that just because your cat may be experiencing low BG numbers doesn’t mean that your kitty is critically hypoglycemic. Many cats will have low numbers and never have symptoms. It’s important, though, to bring those numbers up into a safe range.

    ALWAYS make sure you have a stock of test strips, high carb (HC) canned food that contains gravy and is over 15% carb such as Fancy Feast grilled, marinated, or Gravy Lovers varieties (see Dr. Lisa's Cat Food Nutritional Composition List for a full list of options), and/or a simple sugar solution such as Karo/corn syrup, honey, maple syrup, etc.

    If your cat is experiencing symptoms, especially if those symptoms are severe, you need to rub Karo syrup, honey, or maple syrup on the gums or, if symptoms are very severe, administer rectally and get your cat to the nearest 24-hour emergency facility. Take the bottle of syrup with you to administer on the way if necessary. (Note that it is rare that we see episodes of symptomatic hypoglycemia with Lantus and even rarer to see severe symptoms. But, you need to know what to do should they occur.)

    The symptoms to be concerned about include but are not limited to:

    • staggering, uncoordinated movements, 'drunken' walk, wobbling, balance problems
    • ataxia - usually lack of muscular coordination, but maybe changes in head and neck movements
    • disorientation (yowling, walking in circles, etc.)
    • twitching
    • stupor
    • convulsions or seizures
    • coma

    If your cat is testing in low numbers and you are not getting a quick response to your post, there are several things you need to do. (Low numbers are under 50mg/dL or 2.8 mmol/L.)

    • Depending on how carbohydrate sensitive your cat is, feed approximately a teaspoon or less of gravy from high carb food or high carb food only. (If you have a cat with GI issues, using a couple of drops of syrup plus low carb food is an alternative.)
    • Test again in 15 – 20 min. Depending on the numbers, give more HC food.
    • Repeat the above steps every 15 – 20 min. until your cat tests in the 50 mg/dL (2.8 mmol/L) or above range for 2 consecutive tests. Continue to feed in small amounts to keep numbers in a safe range.
    • Test in 30 - 40 min. and repeat the test and feed process until there are 2 consecutive tests where numbers are stable or rising.
    • Test in an hour and follow the same steps.
    DO NOT become complacent. If number have risen after one or two tests, it’s important to continue testing. Numbers may bobble up and down as the HC food and/or Karo wear off. DO NOT get one test where your cat has risen from low numbers into the 50s and go to sleep or leave the house. You are putting your cat in a risky situation. When in doubt, leave HC food out.

    In the case of an accidental overdose or should there be symptoms of hypoglycemia, even if you have caught this in the early stages, you may need to monitor for literally 16 or more hours. Lantus and Levemir are long acting types of insulin. This means if your cat is over dose, you will need to stay alert for hours in order to closely monitor and to keep your cat safe.

    Please post your numbers. Those people who are helping you will not abandon you. In fact, they are staying up with you. The experienced people will even work in shifts to make sure your cat is safe and you have the support you need. Remember to refresh your browser to see new posts and keep posting so we know all is well.

    ~ written by Sienne and Gabby






    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.
     
    Last edited: Jan 11, 2016
    Reason for edit: update
  2. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
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