? Reduce dose after stalling? How much?

SnowKat

SnowKat

Member Since 2020
I had a situation last night where I did not feel comfortable dosing Edward (he was 75 BG at pre-shot). I tested 2 hours later and he was up to 159 after a small LC meal. Should I have given him a shot at that point, 2 hours late? If so, should it have been reduced? Or was completely skipping the right thing to do if I can't stay up all night monitoring?
 
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Also... I am tempted to reduce from 1u to .75u, because of those recent low (for us) evening pre-shot #s. Good idea? Bad idea? I am afraid of him going hypo at night, and I don't want to keep skipping evening doses, as I know how important establishing a consistent dosing schedule is (even though I've been unable to do so).
 
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And I am sorry to bother everyone here - I know you all are just as busy and frazzled as I am. I just keep feeling like I am making so many mistakes, and setting back my baby's progress to stable numbers. Thanks in advance.
 
Hi Kat!

First of all, excellent call on not giving Edward insulin with a PMPS of 75. You are very new at this so knowing what to do and when can be important. Even in a week and a half, there is still a lot to learn.

You're SS says TR? with that question mark but I think maybe SLGS may suit you better right now. TR is a very aggressive dosing method, but even with TR I don't know of anyone that would have suggested you shoot with a pre-shot that low, 75. Your choice in dosing method. If you can keep testing as much as you do now, than you can switch later to another dosing method.

Keeping really good notes in the Remarks column on your SS is really good for us here too, not just you.

1. For future reference, shoot/no shoot BG should be 150 for now. As you gain experience that number can be lowered.
2. Stalling. Can be done for up to 2 hours, IF that lets you stay on schedule for the next 12 hour dosing cycle. If not, then skipping the shot is likely best, AS LONG as there were no ketones or DKA history. If ketones or DKA in past history, than you need to give some dose of insulin to keep those ketones at bay. There was one of those situations for a new member last night and Chris & China were up all night helping on that one.
3. Look at the TR vs SLGS dosing protocol to lead you. Good for general guidelines. Not the whole 'ball of wax' at one go.
4. After a skipped shot last night, Edward is going to be bouncing. You need to be patient for 3-6 cycles to let that bounce clear.

Start a new thread every day and keep the thread title updated with your BG numbers. You may have to edit it to drop off some of those AM test BG readings when you get into the PM cycle. If someone saw that 75 last night, that might have prompted them to take a closer look.

There were 2 or 3 near hypos last night, plus that ketone case I mentioned, so folks were a tiny bit busy.

I'm sure someone else will chime in if I made any mistakes. It's been a while since I helped members in the Lantus ISG. Still know some of the basics.
 
This is a marathon,not a sprint is a favorite saying around here. It took time for Edward to become diabetic, it will take time to get him better.

The signs of diabetes are so subtle that they are easy to miss. Please, forgive yourself for missing those tiny clues and go forward from where you are now.

If I'm signed on and you want to tag me, it's ok with me. Might not get to you right away, if I'm dealing with a lot of other people, but I will get back to you. Not on late at night. Check my watched threads in the morning and prioritize based on what I'm seeing.

Hope that helps.
 
Thank you so much for the response, @Deb & Wink !! OK, 150 is definitely the cut-off at this point. I need to tattoo that on my forehead.

Believe it or not, I actually have read both TR and SLGS protocols probably a dozen times now (I have them bookmarked), and I still have ?s. For example, unless I missed it, I don't see anything in the protocol stickies that address the following:

1. If after stalling, a cat goes over 150 at +2 post-shot time, should should one shoot full dose, or reduced dose? If reduced, by how much? Wouldn't a full dose 2 hours late create some possibly scary overlap at his usual morning dose time?
2. If I do switch to SLGS, would it be appropriate to reduce from 1u to .75u?
3. At some point, I certainly hope his numbers will top out *under* 150 pre-shot. How will I know when it's right to shoot under 150? Would I only shoot under 150 if/when his dose has already been lowered to something really tiny, like .25u?

Thanks in advance!
 
While TR is more aggressive than SLGS, I'd also keep in mind that it has an exceptional record of getting newly diagnosed cats into remission. Given Kat's ability to test, as long as Edward is eating low carb, canned food, TR is an excellent option.

I agree that for someone who is new to managing their cat's diabetes, skipping can be a viable option in light of an unexpectedly low pre-shot number. One alternative to skipping is to not feed Edward and to stall for a bit. If you had seen that his numbers were on the rise, you would have been safe to shoot. It's something to tuck away for the next time. You could have shot last night but you would have to hold off on feeding your kitty so you know the number you're getting isn't a result of a food spike. If you know you can't monitor or you don't have supplies (extra strips and high carb food if needed), then your best option to keep Edward safe is to skip.

If you stall, it has the effect of being a reduced dose. It's the way the depot works. Don't stall and reduce the dose if you can help it. The exception is if the reason you're stalling is that the pre-shot number warranted a dose reduction (i.e., below 50 with TR).

Fundmentally, we want to get people away from thinking in black or white terms. In other words, it's not a "no shoot" number. It's a post and ask for help number.

As a matter of context, it's not that Edward's numbers are too low to shoot. You just don't have the experience yet to shoot lower numbers. I would routinely shoot anything above 50. The times when you have shot lower numbers, you've seen lovely cycles. I wouldn't lower the dose -- but that's me. If you really feel compelled to lower the dose, I'd stick with 1.0u.
 
Thank you, @Sienne and Gabby (GA) ! I have a few follow-up ?s for clarification:

1. "If you had seen that his numbers were on the rise, you would have been safe to shoot." So, let's say I withheld food and tested after 15 or 30 minutes and saw his numbers going up, would it have been prudent to give him the full dose at that point, even if he was still under 150?
2. "If you stall, it has the effect of being a reduced dose. It's the way the depot works." I'm really trying to wrap my mind around this... wouldn't a late full dose have the effect of basically "overlapping" with the next normal dose, effectively *increasing* the dose?
3. "If you really feel compelled to lower the dose, I'd stick with 1.0u." We've been at 1u, but those two low pre-shot evening #s (2 out of the last 4 nights) have scared me into thinking I should overall reduce his dose to .75u. Are you saying that you think sticking with 1u would be better? If I do stick with 1u, should I expect a lot more of those "questionable" pre-shot #s, i.e., under 150 or even under 100?
4. What does "DIB" stand for? As in, 1u DIB? I looked for it in the Slang Dictionary sticky but haven't found it.

I sincerely thank you (as well as Deb, and anyone else who chimes in...) for taking the time to educate me and help me navigate this process.
 
SnowKat said:
Thank you so much for the response, @Deb & Wink !! OK, 150 is definitely the cut-off at this point. I need to tattoo that on my forehead.

Believe it or not, I actually have read both TR and SLGS protocols probably a dozen times now (I have them bookmarked), and I still have ?s. For example, unless I missed it, I don't see anything in the protocol stickies that address the following:

1. If after stalling, a cat goes over 150 at +2 post-shot time, should should one shoot full dose, or reduced dose? If reduced, by how much? Wouldn't a full dose 2 hours late create some possibly scary overlap at his usual morning dose time?
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If you give the full dose, 2 hours later than normal, you would need to readjust your testing and dosing schedule by those later hours. With lantus, you can adjust your shot times. By 30 minutes a day or 15 minutes per cycle. To avoid that 'scary overlap' as you put it.

Your AMPS and PMPS times would be 1 hour 45 minutes later for the next AMPS, your PMPS that same day would be 1 hour and 30 minutes later the next day, and so on until you are back on schedule.

Reduced doses are another option. I'll let someone else tell you about that aspect.
2. If I do switch to SLGS, would it be appropriate to reduce from 1u to .75u?
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Yes. The difference is that the doses are held longer with SLGS but also the reductions are taken at higher BG levels. With that 75 BG reading last night, or any number below 90, you reduce by 0.25U. So with SLGS, Edward's new dose would be 0.75U for the next cycle.
3. At some point, I certainly hope his numbers will top out *under* 150 pre-shot. How will I know when it's right to shoot under 150? Would I only shoot under 150 if/when his dose has already been lowered to something really tiny, like .25u?
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You'll know, because as you gather more data, the folks here will help you know when to shoot under 150 PS test. You can and will lower that "shoot/no shoot" threshold. Or as Sienne calls it, the "ask for advice threshold."

When stalling you DO NOT FEED. so Edward may get really hungry and start to nibble on your leg if you wait too long.
 
1. "If you had seen that his numbers were on the rise, you would have been safe to shoot." So, let's say I withheld food and tested after 15 or 30 minutes and saw his numbers going up, would it have been prudent to give him the full dose at that point, even if he was still under 150?
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It depends on how much the numbers rose. If they went from 75 to 85, I'd keep stalling. If they jumped from 75 to 100, it would likely be fine to shoot. At the end of the cycle, it helps to remember that insulin is wearing off, it takes 2 hours for the next shot to start working, and you'd be feeding your cat which boosts the numbers.

2. "If you stall, it has the effect of being a reduced dose. It's the way the depot works." I'm really trying to wrap my mind around this... wouldn't a late full dose have the effect of basically "overlapping" with the next normal dose, effectively *increasing* the dose?
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A late shot acts like a dose reduction. An early shot acts like a dose increase. In the latter case you're increasing the degree of overlap between the two cycles. In the former situation, you have less overlap and as a result, it's like shooting a reduced dose.

3. "If you really feel compelled to lower the dose, I'd stick with 1.0u." We've been at 1u, but those two low pre-shot evening #s (2 out of the last 4 nights) have scared me into thinking I should overall reduce his dose to .75u. Are you saying that you think sticking with 1u would be better? If I do stick with 1u, should I expect a lot more of those "questionable" pre-shot #s, i.e., under 150 or even under 100?
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The more you reduce the dose, the greater the likelihood that you're going to see higher numbers. It's entirely up to you. Mine is one opinion of many.

What does "DIB" stand for? As in, 1u DIB? I looked for it in the Slang Dictionary sticky but haven't found it.
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Did I type that? If I did, it's a typo. I have't a clue what it means!!
 
Thank you both for the detailed replies. Lots of food for thought. I’m going to re-read a few times tonight and discuss with my husband as to how we want to proceed, and things to keep in mind. I’ll try to keep any follow-up ?s to the minimum, I promise!
 
After ruminating on these replies, I am coming to the conclusion that stalling & late dosing is not an option right now, considering our work schedules and how we’d have to shift the subsequent doses after a stall & shoot. We will also be out of town next week, during which time I would have wanted to slightly reduce his dose anyway, just the be on the safe side. Therefore, I am leaning toward sticking at .75u x 2 for now, to establish some consistency over the next week and a half, even if it means I won’t see much if any greens.

Once we’re back, I’m considering shifting our dose times to accommodate the stalling that TR seems to require for slightly higher doses.

Does this sound like a reasonable, and more importantly, SAFE approach, all things considered?

Basically, I’m thinking... SLGS for the next couple of weeks, and then give TR another try after our trip and at better shot times.
 
SnowKat said:
Does this sound like a reasonable, and more importantly, SAFE approach, all things considered?

Basically, I’m thinking... SLGS for the next couple of weeks, and then give TR another try after our trip and at better shot times.
Click to expand...
Sounds good to me. Especially with an upcoming trip planned.
 
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