Help, Minnie’s Low Pre Shot AM number?

Hi All,

For the most part, Minnie has been doing well. Even when she wakes up nauseated and/or vomits, I can manage to give her the ondansetron and wait 30 minutes till she eats to give her the insulin shot. Today, however, it has been a challenge. It started out the same way. She vomited, I pulled her, she ate and I gave her the shot. Almost 2 and 1/2 hours later, she vomited again. I haven't given her the ondansetron again because I think after that long it must have been absorbed, but out of desperation and because my vet suggested that last time we spoke, I gave her cerenia. I shouldn't have because in the past cerenia has made her even more nauseated, she keeps licking her lips, and now she has not eaten anything. She won't even go for tuna. She's drinking water but that's about it. I'm worried because she had her morning shot... and if this continues all day with her not eating, I should skip the pm shot, right?

Thanks

 

Sounds like a pancreatis flare again.
Is one brand of food more than another food causing Minnie to vomit?
Is one flavor of food causing Minnie to vomit?

Can't speak about the dose. Don't see any pre-shot tests. None since the 18th of March.

 

Hi there as Deb said don't see any pre shots since march 18 the
You really shot test morning and night and during each cycle to see how low the insulin is taking Minnie, She went pretty low on on 3-31-20 a 49 @+7 I assume you gave her some food such as medium carb or high carb. In the remarks column you can put what you fed her.
You are using a human meter I presume. It's very important do pre shot and test during each cycle in order to receive any advice on dosing

 

It's really hard for e to get the pre-shot tests in the am with the vomiting and medicating her and trying to get her to eat. Honestly, I forget most of the time since I'm focused on getting the shot at the right time... I take her nadir almost every day. I'm assuming if she doesn't eat, she shouldn't get another shot but I'll get her pm preshot number since that's a lot easier to do. I don't know if it's the pancreatitis or IBD. She's on the omeprazole now too and it worked for a few days then it didn't vet wants me to try pepcid instead now. I was on target to transition her to Hounds & Gatos, but she was only getting one serving of it a day so I can't see how it would be causing the nausea. I don't know, everything else is the same. Same food, same flavors too.

 

Understood that you have a lot going on with medicating Minnie in the morning.
But I thought the anti-nausea meds need to be given at least 30 minutes before food? Or longer to make sure Minnie will hold down her food?

Thought it was worth the questions about the food. To eliminate one possibility for the vomiting.
Is the vomiting food, bile, hairballs, combination? Something else?

The conundrum is, that without pre-shot tests, you don't know how far this particular dose of insulin took Minnie to her nadir.
The risk with not giving the shot because Minnie is not eating, is that she develops HL (hepatic lipidosis) or ketones. Catch 22 situation.

Brainstorming a bit here.
Have you considered a feeding tube? Not even sure if that would be appropriate for Minnie.
Or hand feeding her?
Or syringe feeding her?
What does your vet think of those possibilities?

 

yes, sorry I give her the ondansetron and if she won’t eat, I wait the 30 minutes then feed then give her the shot. Most days she eats right away because she’s not nauseated. It’s difficult deciding if I push the shot or give the food and shoot and hope it will stay in her system. On the other hand if I tried to feed her earlier than it would be too long with food in her before the shot. Oey vey...

she finally ate a jar of baby food (hand fed. I do hand feed her a lot to get is going but when she’s really nauseated even that doesn’t work) half a 3 oz can of tuna and about half of a Sheba pate right about the 6 hour mark when I checked her blood and it was at 72. I don’t thing it’s horrible I was afraid it’s be much lower. I’m checking before the pm shot. Called the vet too and her regular vet is pregnant and not back in for months, but they told me to give her 1/2 the dose of she eats a bit more. Do you agree?

I will try to get her pre shot level tomorrow.
Have not considered a feeding tube. I guess my fear would be force feeding her and causing her to vomit again. I’ll ask the vet. I think I’d be more comfortable with syringe feeding. I used to have to do that with my late cat. I’m going to try switching her from the omeprazol to Pepcid as the nutritionist suggested since she’s said it works slightly different and some so better with one and not the other. It’s so much trial and error with Minnie. I feel better that she ate a bit and I’m going to try to give her a few more small amounts before we got to bed.
Thanks!

 

You have a little wiggle time with the shot timing and Lantus. You can move it 15 minutes per cycle, or 1/2 hour once per day. That should give you plenty of time to get the preshot test, medicate and feed then shoot. Where possible, it might help to combine meds in a gel cap. I'd check with the vet to see which ones can be combined at the same time of course. But I used to be able to load 3 different meds in the same gel cap, so just one pilling.

One other thing, that 49 you got on 3/31 means the Lantus dose is too high and should be reduced. You seem to be doing a lot of tests at +7. The Lantus nadir can move around a bit, so it's good try testing at other times too.

 

Eating is back to normal today

I do combine the meds in a pill pocket. Kinda like what you suggested. I was able to get the wading pre shot this am and it was 243

it seems like that 30 minute window would be enough but when she throws up and won’t eat and has to be medicated twice because she vomited the meds and I have to wait again to get food in her, it could be over an hour past the shot time

anyway, I did adjust the dose that day I got 49 but it went back up so the dose did too. I was trying to get the test at the same time everyday for comparison but I can do different times too. Minnie is going to fluctuate a lot because of these flare ups and I’m not sure chasing the dose regularly is a good thing. Thoughts?

I’m giving her the am shot now back to normal dosage

thanks again!

 

Maybe not. While in an ideal and perfect world, the steps with Lantus are test, feed, shoot within a 15 minute time frame, there are exceptions. I think that Minnie vomiting is one of those exceptions. You do want the pre-shot test before food. But the shot could be a bit later.

How long do you think it should be, between the medications, the food, the shot of insulin? Let's see if we can come up with a workable plan.

No, chasing the dose is not something that works well with Lantus, or with Prozinc or some of the other insulins. With lantus, the insulin "depot" keeps draining so that can lead to even more fluctuations. It's usually a vicious circle to try and chase the dose and change the dose too frequently.

You want to try and hold the same dose for 6 cycles, or 3 days with TR (Tight Regulation) protocol. Longer if you are using SLGS.

So let's see if you can get those pre-shot tests, and then vary the mid-cycle tests, naybe +5 one day, +6 another, to see how Minnie is doing.

p.s. Somehow the very top row on the SS got cut off or lost. So we can't see the diagnosis date or the dosing method you use. It's there on the template tab on your SS, so you can see what I mean.

 

Your spreadsheet says you are following SLGS for dosing. Anytime you see a number under 90, you should be reducing the dose. Yet again yesterday Mnnie told you the dose is too high and should be lower to 3.75 units. We determine how to change the Lantus dose based on how low the dose can take the cat. 4 units takes her too low.

 

Thanks Alessandra for fixing your spreadsheet, and putting that info back at the top. So we can see the dosing protocol you use.

 

when she’s fine like today, I medicate her and feed her half an hour before shot time then feed her again with the shot. On days like yesterday, I medicate half an hour before but she won’t eat and vomits within minutes no medicate again so at this point we’re just at the shot time and I have to wait another 30 minutes for to eat and then the shot is late by at least 30 minutes.

Not always though. She will be on 4 and well over 100 for days. Her numbers today are well over 200, which tells me I should not have changed her dose last night. At least not by 1/2 as the vet said. I should have gone by the numbers not the fact she didn't eat. I will keep her above 90 and if she drops I'll adjust. Am I aiming to keep her under 300? I thought the low range should be 80-150...

 

According to the Lantus SLGS dosing protocol we use here, any time your cat drops below 90 md/dL, you need to drop the dose immediately by 0.25U. Here is the "Sticky" or pinned post, from the top of the Lantus ISG (Insulin Support Group) forum on the protocols we use here. You might want to read it several times, and maybe even print out a copy to have to refer to.

Sticky Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR) for Lantus/Levemir/Basaglar.

Minnie is bouncing, when she gets back up to those >100 BG readings after a low. You need to be patient, and wait out the bounces. Flat yellows like Minnie is getting today, 4/8/20, is often a sign a cat is getting ready to clear a bounce.

"Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles)."

You're aiming to keep Minnie feeling as well as you can and get the BG levels so she is regulated. You are looking for improvement in her signs and symptoms, not only the BG levels. Improvements in peeing, in pooping, in playing, in preening, in purring and her appetite.

Then you want to try to get the BG levels back under renal threshold, (180 -250). Then get the BG levels lower and lower at pre-shots as well as at the mid-cycle times.

In the last 3 weeks, I see about 6-7 times when Minnie's dose should have been reduced. It's very likely, that she is being overdosed. Having the pre-shot tests will help us with that determination.

 

Okay, so under 250 is ideal with lower numbers at the preshots and mid-cycle but still not lower than 90... Her behavior was only off yesterday. She's been eating the same everyday. She pees twice a day and doesn't drink a lot of water. Even her poop has been stable lately. She purrs, grooms, plays (she was never a big player, but she wants to go out into the yard. She goes up and down the deck stairs and sits out looking at the birds and squirrels).

I'll wait for the bounce to clear then aim for those numbers and adjust, possibly to 3.75 twice a day, depending on the numbers. I'll try to get the pre shots for the next few days am and pm. oey very THANKS

 

93 Nadir today but her pm preshot was 168. I just reread the sticky notes and I should have lowered the dose and only given her a token one of 20-25% right? Urghhhhh, I’ll get this eventually I promise. I’ll check in the am and I’d it’s around the same number I’ll give her 1 unit only. Does that sound correct. Today is the first day after her bounce

 

I got 62 this am so I’m skipping the morning shot. She was already low at 163 pre shot last night and i should have given her a token dose right?

help and thanks!

 

I think skipping on that 62 makes sense at this stage. One thing you could do is to stall (without food) for 30mins, and re-test to see if she's moving up.

She is definitely telling you that she wants a lower dose, though! Please reduce to 3.75 tonight.

I don't see any nighttime cycle tests on your spreadsheet. Is there a reason you can't get those? It can be really helpful in figuring out what is going on with your kitty.

 

I agree with Nan if you can you need to some cycle tests at night, most kitties go lower at night time and you also should be doing pre shots for both cycles. Please fill in the pre shot for AMPS today 4-11-20 you said it was 62, its important to keep your spreadsheet up to date

 

Agreed. What do you mean by nighttime cycles? Probably because we’re both sleeping. I could try to get one more test 2 hours after pre shot

 

I’ve been doing the preshots for both cycles. Am and pm. What about the food? Do I need to always do the preshots before giving her food? With all the nausea and vomiting, I’ve been feeding smaller amounts throughout the day and I worry if I wait to feed her right before the shot that she won’t eat and the shot will be late...

 

Another question, with the 163 last night, I should have given her the token dose and not the full one right? I haven’t gotten an answer to that and I’m trying to get all my ducks in order here so I know what I’m doing when yall sleeping ha! Thanks

 

What we mean by night cycles is testing a couple hours after the pre shot, maybe @+2( 2 hours after you give the insulin) if the number is dropping you would have to keep testing , if it's really low you would have to intervene with food and check 30 minutes later @Alessandra Franco

 

I don't see any pre shots for 2-17-20 through 2-21-20 both am and pm
Then no pre shots starting with 2-23-20 through 2-28-20 both am and pm
No pre shots starting with 3-2-20 through 3-17-20 am and pm
None for 3-19-20 through 4-7-20
Nothing filled in for 4-11-20
If you skip you should put NS. No shot
I don't see that 163 filled in for last night did you mean to put 168?
You should always test pre shots first, then feed and then shoot usually within 15 minutes
With lantus it usually doesn't kick in for about 2 hours after shooting
So you can still feed Minnie within those 2 hours

You can feed smaller amounts through the day, just don't feed her 2 hours before pre shots @Alessandra Franco

 

@Nan & Amber (GA) hi Nan if possible could you answer this question for Alessandra, thank you, I'm not that experienced to answer that Thank you
I think she meant to say 168, I looked at her SS

 

@Alessandra Franco I see Wendy told you this above
I'm quoting what she told you
Your spreadsheet says you are following SLGS for dosing. Anytime you see a number under 90, you should be reducing the dose. Yet again yesterday Mnnie told you the dose is too high and should be lower to 3.75 units. We determine how to change the Lantus dose based on how low the dose can take the cat. 4 units takes her too low.

I looked at the SS again
On 3-16-20 she was 67 @+7 you should have reduced to 4 units
On 3-20-20 she was 83 @+7 you should have reduced to 3.75 units
On 3-25-20 she was 79 @+7 you should have reduced to 3.75 units
On 3-31-20 she was 49 @+7 you should have reduced to 3.75 units
On 4-7-20 she was 72 @+7 you should have reduced to 3.75 units

 

@Nan & Amber (GA)
@Wendy&Neko
Hi guys I'm trying to help out Alessandra here about when to
reduce, I'm not an expert on dosing and I don't want to give her the wrong information, god forbid
Can you please take a look at #24 and #25 or maybe read all of the posts again
I appreciate it also
@Deb & Wink
I see the three of you had replied to some of her posts, that's why I tagged you

 

The 62 is not filled in on your SS, you should also put NS for No Shot
It important to keep the SS all filled in because members cannot go back and read all of your posts to find what you did and any BG readings

 

With Lantus, there are 2 specific dosing protocols, SLGS and TR.

This following document, in the blue text, explains the dosing protocols, the methods we use to determine when to raise and lower a dose, how to decide what to do if your cat's BG level is lower than you are used to, etc. Simply click on the blue words and this link will take you directly to that document. I've printed out a copy for myself, and made extensive notes on it.
Sticky Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR)

Alessandra, you might want to do the same, print out a copy and make notes on it.

So according to the SLGS guidelines for lantus, the BG (blood glucose) that you got at PMPS of 168 was >150 and <200 mg/dL so a token dose of insulin would have been right. Or even better, you could have stalled, retested and seen if the BG was a rising number and perhaps you could have given the full dose. But the full dose should have been a reduction to 3.75U.

It's important to test during the nighttime cycle, as well as during the daytime cycle. A cycle being the 12 hour dosing and testing period. At least 1 more test, each PMPS cycle, at +2 would be a very good idea. Many cats drop lower at night, so without some PM cycle data, you don't know if that may be happening with your cat. You may need to set an alarm occasionally, to get a +6 test at night. Not fun to do that, but necessary sometimes.

You might also want to move to the Insulin Support Group (ISG) for lantus, where there are more experienced lantus users to keep an eye on you and your extra sweet Minnie. It does get busy there, so they have a specific formatting for the thread title, and ask that you post a new thread each day and link your old post at the top.

Your choice on what to do. Stay here in Feline Health, or move to the Lantus ISG forum.

I know that you have a lot of issues with Minnie vomiting. But try to get that PS (pre-shot) test maybe as part of your routine for giving her the medications?

One more thing, even though you skipped the shot this morning, 4/11/20, do try to get at least 1 or 2 mid-cycle tests. To see how high her BG's go with only the insulin "depot" to help her along.

p.s. I prefer to see 0 (zero) in the units column if a shot has been skipped, versus a NS notation. Either way works.

 

okay this all makes a lot of sense! I was planning on testing her mid cycle to see where she’s at. And I’m going to update the spreadsheet in a bit, dealing with both cats being freaked out over the painters nextdoor this am urghhh

so if I waited last night and retested, it would have been okay if the shot was late one hour or more? I’m having a hard time figuring out when it’s okay for the shot to be late versus just not giving her one. Why are vets not well versed in this stuff. I feel like I should be paying you guys not them ;-)

thanks Deb for always being so detailed and explaining things like I’m a 5 year-old because trust me when it comes to this I totally am! Much appreciated

 

thank you Diane! I updated the SS. Sorry we had a hectic morning over here and I thought it’s be enough to add it to thread until I could get to it

 

First thing I do on opening a thread I'm watching, is to open the spreadsheet, to see the latest data.

Know what you mean by hectic. Found some liquid food stuffs leaking in my kitchen cabinets. Got most of the mess cleaned up, but there is still more to do. What a mess!

That's a judgement call. When Lantus dosing is delayed, then means you need to readjust your shot schedule. A late dose can act like a dose reduction, an early dose can act like a dose increase.
1 30 minute adjustments per 24 hour period, 15 minutes per cycle. (So 2 15 minute adjustments per 24 hour period.)

 

Thank you Deb for replying to the tag

 

No problem just a reminder, we all get busy at times, I totally understand

 

Alessandra sent me a PM, and is not sure how to copy and paste what she asked there.
So I'm copying it here for her.

 

@Deb & Wink don't mean to hijack your thread Alessandra
Deb don't know if you saw my tag on my thread today if you would please take a look, Thank you

 

I did reply @Diane Tyler's Mom
Been busy trying to get some things done for myself. Calgon, take me away!
Liquid refreshment, of the non-alcoholic type, leaked in one of my kitchen cabinets.
What a mess.
At least it didn't leak down behind the fridge, I think.

Trying to catch up and respond to about 30 alerts and a dozen tags, in the last 2 hours.

 

Yes Deb I saw you did reply back to me on my thread , thank you
You have a lot going on, now I can see how some one could get a whopper of vs headache helping people and being on here for long periods of time, I have a whopper of a headache now , You are amazing at what you do helping everyone out, when I know I can give the correct advice to someone I do, I just don't want to I tell them something that isn't correct. Hope you can get that leak under control

 

Yes, 25% of 4U (units) is close to 1U (0.9375 U) so round it up to 1U.
10% of 4U is 0.4U Close enough to 0.5U, so you could have tried that 1/2 unit dose.

Yes, her numbers will be higher at the next cycle usually, since the dose was only a fraction of what it normally would have been. Lantus insulin has a "depot" or storage area, so if you only give a "token dose" that drains the "depot" a bit. But that "depot" will still have an effect on the BG numbers for several cycles. From 3-6 cycles usually.

The larger the dose, the larger the "depot."

You have gotten a few low numbers, <100 the last 2 weeks, which indicated the 4U dose was too high. You didn't realize you should have reduced the dose by 0.25U immediately, but you should be down to an insulin dose of no more than 3.75U for now.

The dose changes with time and as you gather data. Minnie probably dropped low overnight, if you got that 62 at AMPS today, 4/11/20.

The logic behind testing BEFORE the INSULIN dose, is so that you don't shoot the insulin when your pre-shot test is very low.
The reason you want the pre-shot tests before food, is because food raises the BG levels, as it gets into the bloodstream, just as you thought.
If you feed before the pre-shot test, within 2 hours BEFORE, you could get a food inflated BG level and then your cat could drop even lower at insulin onset, around +2.

As long as you test at the beginning of the cycle, before food, you can give her insulin shot later than the pre-shot test. You do not need to test again after Minnie has eaten her main morning meal. Or her main evening meal.

Yes, it's ok to test 30 minutes before the shot. Yes, it's ok if you don't test immediately before the shot.
Yes, it's ok to feed Minnie after the insulin dose is given. Many people front load the food, and feed at +1 and +2, as well as the main meal after the pre-shot test.

Example.

7:00 AM AMPS pre-shot test
7:05 AM Give Minnie her medications
7:10 AM Give Minnie her food.
7:45 AM Make sure she keeps her food down, does not vomit her food.
8:00 AM Give Minnie her shot of insulin.
9:00 AM That is now your +1, since that is 1 hour after you gave Minnie her insulin.

So the test, feed, shoot sequence is drawn out over a longer period of time, than the typical 10-15 minute time frame usually suggested. But you have to make sure Minnie gets her meds and eats at least some of her food.

As long as Minnie eats within 2 hours after the insulin dose, there will be some food in her system to counteract the onset of the insulin, which is about 2 hours later.

Questions?

 

I did what you suggested with the Lantus forum a few hours ago

no you covered it all! No and if you’re not a teacher must have been one in your past life

It’s great to know I have some time to get food in her and can shoot before. I was trying to feed her first and then waiting 30 minutes then giving shot but I’d much rather do the reverse so the meds have time to work. Of course when she’s feeling well she wants food right away, and today is 4th day in a row she’s not been nauseated I think the Pepcid is working better then the omeprazol, it makes the preshot year harder because she can be very demanding my little princess, but I’d much rather deal with that then the nausea and the vomiting

It could have waited till tomorrow but I appreciate it as always and hope you’re having a nice tall glass of wine my friend!

Minnie says thanks auntie Deb )

 

Deb excellent explaining this to Alessandra, so thorough, I think she will get it now. Amazing job as always

 

Awh Minnie is so adorable, too precious

 

I'm an "Auntie" again!

Nope, never was a teacher, computer geek though. That probably helps.

Where I'm really bad, is giving short, sweet answers. (No pun intended.)
I like to provide the "why" behind the response. It would be easier to say "Do this, do that." But then people don't learn for themselves.

My goal, at least one of my goals, is to share knowledge and get people to make decisions on their own. It's a learning experience for sure.

 

Thank you!!!

This is the duo after sneaking out in the rain and being dried out against their will ha!

 

100% and I’m naturally curious so short answers just leave me with more questions. I need to understand the logic so I can makes sure it all sinks in. Never edit yourself when answering my questions, the longer the better haha!

 

Minnie is on the right, so who is that on the left side?

 

Oh god they are to adorable who is the black cat, name please
I love the pic of them in the fridge

 

They were still kittens under a year in the fridge pic. I have a lot more pics of them together when they were young. They’re less bonded now, it’s odd. Anyway, Bobo is the black male cat. I found them as kitties in a shoe box at the beach in Brazil literally 3 days after my late cat passed away, but couldn’t leave them there obviously so I was going to foster and find a good home but #fosterfail

 

Glad you took them, who the hell would leave them there in a shoe box

 

Thread is getting long @Alessandra Franco
Moderators would like us to keep posts at 50 replies and under when possible.
Keeps the database behind the scenes more efficient too.
So please create a new thread, link this older one at the top, and we'll go from there.

Thanks.