Varying lantus dose due to poor eating/low numbers? (was Meter Accuracy and TRP)

This is scary stuff for me, so I'm starting a new thread, migrating from http://www.felinediabetes.com/FDMB/...ad-first-experience.177971/#post-1964664...in case it helps others, too.

So as posted on the other thread, I took Livvy and our new Alpha Trak II to the vet today. The tech took a vial of blood and tested a drop of it with the vet's glucometer and another drop of it with our glucometer.

Ours read at 188, and theirs read at 145.

This was at about +9.5.

Two things have my head spinning:

1.) Those are some really different results...and based on a small experiment that I did (testing two drops of blood five minute apart with the Alpha Trak resulted in readings 26 points apart), I'm wondering how different they "really" are (over time, upon repeated measures). How do I feel confident interpreting these? The vet said that his meter is comparable to our in terms of giving cat-specific readings. But what if our meter happened to read low that time, but on average isn't that different than ours? Would the adjustments that we make be biased/incorrect/dangerous? More specifically...

2) The vet looked at his reading and at ours and gave the following guidance. Please recall that Livvy is on 3u/dose. If her PS reading on our Alpha Trak is:

- between 101 and 150, give 1.5u
- between 71 and 100, no insulin
- 70 or lower, be concerned, give her Karo plus some food, and if she perks up, great, but contact him. If she doesn't perk up, get her emergency care.

Please recall that these guidelines are specific to what he has interpreted as the scale that our meter is on - a biased scale that tests higher than reality. But the differences between our meters was 43 points!!! 43!

Do these guidelines seem reasonable given the context?

I feel very confused. I guess that the clinical signs must be more important than readings, because readings seem to be very imprecise.

Any perspective that you can offer will be appreciated for sure.

 

Apparently there can be a 20% variance in readings

 

Yes, so I guess the right way for me to explain what I'm feeling is, that 20% variance is what has me nervous. It seems like it's a little hard to trust with the glucometer is telling us. And, I'm not quite sure that it's right to conclude that our glucometer is any particular number of points "biased", simply because if we had done another test or two or three with the Alpha track, we might have found that are reading was really similar to the vet's. Of course, we didn't do that (kicking myself).

 

So the variance of 20% can be higher or lower. We look for trends. In tge lower ranges the differences are much smaller. The idea is to keep them safe which using a human meter does. You can periodically run a fructosamine to see what gas happened over the past two weeks. Look at all tge cats that have gone OTJ here or are tightly controlled. My IM vet became a believer and we almost never discussed dosing. He also told his veterinary students about this site. Max had to see him often for his other issues and he was in normal range every time.

 

Thanks, Elise. By your statement that, "The idea is to keep them safe which using a human meter does.", do you mean to say that the Alpha Trak doesn't serve that purpose - keeping them safe - well?

And, are there success stories if cats like Livvy getting OTJ for a second time? She was in remission for many months after initial diagnosis and a brief stint on insulin at the vet's - to put her in remission we did DM food only, 2/day, no grazing allowed. Now she's back OTJ; could TRP get her off again?

 

No, AT keeps them safe and is fine although the strips are expensive. I personally don't think they are worth the cost. There are several cats here that are OTJ a second or third time. DM is higher carb than most feed here which is 10% carbs or less. Those that go OTJ for good often don't continue to report their success here.

 

It would be great to get her OTJ again. It's nice to know that can happen a second or even third time for some.

Thanks for clarifying your point of view on Alpha Trak.

I'll read more about food. We have another cat who has a history of liver disease, and the DM is the only food that we could find (so far) that he deemed appropriate for both cats. He's doing great, so we have to be careful not to jeopardize that...and feeding them each something different would be really tricky.

Just a little added complexity!

 

I don't really see your numbers as significantly different. Its not too often a variance that size would make a difference in dosing.

Lantus doesn't really do well with change so a sliding scale based on preshot numbers isn't really the best for the way it works. If you find you are adjusting the dose too often, you may find that the numbers won't stabilize. Having dose reduction ideas for staying safe when they get low is a good idea tho, so those numbers might just be a stay safe plan. The numbers do look like they are based on an AlphaTrak scale (slightly higher than a human meter), but using a human meter and following those safety adjustments will just have you reducing the dose a little quicker and staying safe.

Many of us use a human meter without much thought on the difference (I've use the Accu-chek Aviva through 10 cats, 8 into remission), but some people just can't get comfortable with the "variance" from the AT and if that is the case, get the AT. No reason to be constantly second guessing and double testing.

 

Thanks, Melanie! We've been home-testing for only theee days, and it looks like we're going to have an adjusted dose again this morning (she was 143 AMPS). She's eating now, and I'll give the shot shortly. This will be the third adjusted dose of the most recent five doses...the third adjusted dose since we started home-testing.

We're trying to test as much as possible given work schedules, wondering is she has the Somogyi effect going on. She is drinking a lot of water and peeing a lot. I thought that insulin is supposed to make that better! I believe that the prescribed dose for her is too high.

So per the vet's instructions, I'll give 2u momentarily. This weekend we'll try to get a full curve. It's hard to piece together the data that we have with all of the dose adjustments.

I feel much better about out meter now. Thank you for your input. Ten cats! That's a lot of testing and dosing. You have had some very fortunate kitties!

P.S. The variance that I find distressing is the big difference between the vet's animal-specific meter and our Alpha Trak...both purportedly on the "cat scale". I understand that a human meter would be on a "human scale" - but we don't have one of those. I don't understand why the TRP guidelines discourage use of a pet-specific meter. Couldn't pet meter readings be used to inform TRP just as well as human meter readings? I know that there's a difference in the reported scales, but aren't both types of meters equally accurate?

 

Another thing to consider is that most cats are stressed at the vet's office and will read higher than at home. Your vet is sure changing the dose often. Lantus likes consistency and it can take as little as 3 up to 6 cycles or more to see how a cat will do with a given dose.

 

I need to read through my AlphaTrak package inserts again to try and find the origin of this often cited 20% variance reference. Is that a test to test number or an overall accuracy number? The acceptable control solution result range is large: 100 to 185 mg/dl. My strips always fall close to the middle of that, 137 to 141. When I have retested with the control solution, I repeat numbers +-1. (I would probably call AlphaTrak support if I got strips outside of the 137 to 141 range. They are helpful on the phone.) The package insert says something about the glucometer having a -1.6% bias relative to Antech Lab measurements and an average coefficient of variation of 5.3% (wrt Antech). That said I have seen lab samples and alphatrak samples taken close to each other but not simultaneously vary by more.

 

I agree that Livvy's dose isn't staying consistent - not for the past three days at least. On 5/16, Livvy's appetite wasn't great, not in the am, so we reduced the dose per the vet's instructions. In the PM on that day, she fooled me into thinking that she wasn't going to eat much, but she ended up eating pretty well. She seemed better on the lower dose (2u am, 2.5u pm). This this morning she tested low, so I gave 1.5u per the vet's instructions. So her dosing is all over the place. I think that 3u is too high of a dose for her, but I don't have enough data to prove it...yet. So in short, the variability in the dose has been because of inconsistent eating and/or low readings. I've half a mind to change her dose down to 2.5u, or even 2u, but I don't know if that's the right thing to do. Thoughts?

 

Thanks for sharing this information. Our Alpha Trak has been in the 137 to 141 range with the control solution as well. Yes, the control solution range is really quite large! I have to get used this not being high-precision, and making judgments based on the readings plus clinical signs. It's scary using judgment when I still feel so uninformed - I'm working on that, but this is complicated stuff!

 

I agree with @tiffmaxee. You are building and draining the depot so it will be hard to find your sweet spot dose. You have up to two hours after injection to have Livvy eat. With Jones - as long as he ate like a couple of tsps, I gave the insulin. Now that you are testing at home, you can monitor and of course the people are always here to help.

You got a green a few days ago but it is hard to tell what dose got her there. I think your vet is trying to get you to a good dose but is not really being methodical in their approach considering it is a glargine insulin your using.

 

Yes it is very scary at first. My first few weeks treating Yum would have been so much more difficult without the expert advice and emotional support from this forum.

 

My impression after talking to the vet is that he believes that 3u is the right dose for her...based on only one 3u dose given during her brief hospitalization. Between then and when we got the Alpha Trak and started home testing, we've been faithfully giving 3u per dose, and telling the doctor that she's drinking and eliminating large amounts of water, and that she's lethargic most of the time. We brought her in for him to test because we were concerned that her blood sugar was still out of control; when he saw 304 at +8, his assessment was that we should continue with 3u. Now from the extensive and very helpful information out on this site, I am convinced that he really didn't have enough BG data to make that decision. The clinical signs that we report (the water, the lethargy) don't seem to come into play with the vet's decisions.

I'm pretty sure at this point that 3u is too high and that she has the Somogyi effect happening. We are reluctant to keep giving her 3u per doctors' orders because she is suffering! But to what dose to reduce? 2u? 2.5u? To your point, it's difficult to conclude anything.

I updated her spreadsheet so that the group can see that she's been consistently on 3u/dose for some time until the last couple of days (due to poor appetite on one day, and due to a low pre-shot read this morning).

 

This is a terrific resource. It's already gotten us so far! We're testing at home now, thanks to this forum. I feel hopeful about Livvy's potential to get back to good health more now than I have in weeks, thanks to this forum.

 

The vet guided us that if she eats nothing, not to give insulin. If she eats very little, give 1.5u. If she eats a full portion, give 3u.

This begs a question for me, if Livvy starts to eat, then I give the injection of 3u, and she decides not to finish her meal - let's say she only eats a couple of teaspoons. Now isn't she at risk of becoming hypo? I've been giving her 30 minutes to an hour to eat before giving her insulin. Is that wrong? I've felt like I needed to do that to know whether to give the insulin or not and, of so, how much. But maybe this is interfering with the insulin's ability to do it's thing - should I be injecting her when she takes the first few bites? She takes her sweet time about eating.

 

Do you usually inject whilst Livvy is in the process of eating? Or do you wait for her to finish? I didn't understand it.
How often do you feed? What is the reg amount per feeding?

When Lantus kicks in - ECID but likely in 2 - 3 hours you need Livvy to have food in her or you need her to have appetite to eat some more to steer the BG numbers up. There is too little data in the SS to analyze.

I cannot tell you right or wrong ECID but I try to test/feed/give insulin to my kitty in 10 - 20 min. I am not saying it is ideal - it is ideal for my cat and for me to collect the data and to know her eating/getting hungry patterns.

IMHO - I would think that it would stress the kitty, she might grew anxious to eat in your presence especially with the syringe in hand. If insulin is given SQ it will work regardless of the food. The question - how to keep her safe.

Does your schedule allow to feed by smaller portions thru the day?

lantus works best if given in consistent doses 12 h apart. To define if it works its best a dose needs to be chosen and stuck with for at least couple of cycles - if numbers aren't too low, of course. There are Stickies at the top of the LL Forum re TR protocol and SLGL methods - which one do you follow? There are instructions as to when to change the dose, or how long to keep one.

Do you mean the Unit Column? It has 3 units recorded from 4/20 - 5/15 but no test results. Test results taken at various times in 24 hours is what needed to analyze the response and to assess the dose requirement.

I hope I answered your questions to the best of my ability and that it helps. If not please post your question/concerns. My reply will bump your post up and grab attention of more people so hopefully you will get advise you need.

 

Right now, I try to give Livvy enough time to finish her meal before injecting. I have noted that some people wait only until their kitty has eaten a few bites before injecting. My question is, should I be doing that - injecting with the first few bites - or should I do what I'm doing now, which is to wait until she seems to be finished so that I am confident about how much food she'll have in her during the cycle?

We have been feeding Livvy 3/4 of a large can of DM wet foot, twice per day. This has been her routine for about 18 months, since she was first diagnosed with diabetes, and during most of that time her diabetes was in remission (no insulin except for the first few days after her diagnosis). The vet has stressed to us the importance of "giving her insulin receptors time to rest" between meals to encourage her body to "produce its own insulin".

Back to the feed/shoot question - I try very hard to give her enough time to finish her meal, but sometimes I need to leave the house before she is completely finished. She is a very slow eater! Per the vet's instructions, we allow her to have access to food for about three hours after we start feeding her. We have timed feeders. I feed consistently at about 5:15am. If I have to leave before she's finished eating, I pop the food bowl in the timed feeder, and access to the food is taken away by the feeder at 8:15am. Same routine at night.

If she finishes her whole portion during the first 30 minutes or so of feeding, I give her seconds - usually another 1/4 can.

This would be a big change - giving Livvy more food in 2-3 hours. We could do it for sure, but it's counter to the established pattern. It seems like we need to change her feeding schedule now that she's on insulin. The vet never mentioned this, and in fact we asked specifically if we should continue with the same feeding pattern. What you're suggesting - a few small meals throughout the day - actually makes more sense to me. Except, free-feeding would be a problem for Livvy, because she would eat all day long, one bit here, another there, and that seems to have thrown her for a loop and knocked her diabetes out of remission in the first place. (We were out of town for a few days just before she ended up on insulin in mid-April, and the vet suggested free-feeding dry food in addition to the pet sitter feeding wet twice per day...and when we got home, her blood sugar was out of control/her remission was over/she ended up on insulin...so I'm reluctant to free-feed again, or even give multiple meals.)

We could do that if it would be better for her...but see above for concerns.

We have been militant about dosing 12h apart. We aren't following a protocol as yet. We just got the Alpha Trak II a few days ago and started home testing. We've been following the vet's orders - 3u dose - until the last three days or so.

Yes, I populated the unit column so that the group can see that we have been doing 3u doses for a long while...and per the remarks column, Livvy's clinical signs suggest that it is not right for her. Yet, the vet hasn't recommended any adjustment. I can see that we now must take matters into our own hands. That's what's scary.

Thank you so much. You really did help. We have so much to think about. I wish that the vet had recommended home testing the day that we brought her home from the hospital, syringe in hand, to start her insulin journey. Instead, it took her not doing too well, and us doing much research (on this site and elsewhere) and then asking him if he is a believer in home testing. Now - even after only three days of testing - I wouldn't want to shoot without testing first. I shudder to think what her numbers have looked like at times over the past few weeks.

I really like our vet - we have seen two doctors there, and they are kind and seem well-intended - I'm just starting to think that the folks on this forum - the folks who have cared for diabetic kitties themselves, day in and day out, may be more knowledgeable about what works. Thank you for sharing that knowledge.

 

P.S., I understand that it is recommended to use a human meter for the TR protocol. We just bought our Alpha Trak II three days ago, and I'm reluctant to go out and buy another meter. Is there a way to use the AT for the TR protocol? I understand that there's no linear conversion between the human scale and the cat scale, but if I can adapt this, I would like to try TR.

 

IMHO it depends on cat and her caregiver(CG) and the CG working/family schedule. What works for both of you is good, no rules about it as far as I know. My reason for waiting about 5-10 min after Ducia is done with her food is to be sure the food stays down and she is not going to vomit. She eats her supper at around +8.5 and has over 3 hours to develop good appetite by the Pre-shot meal and eat eat it quickly.

The best thing to do in my opinion is to keep the schedule as it is and to collect more data for Spread Sheet. Once you see her BG at the different times after food/ after the injection you will know what is to be changed - if at all. Now that Livvy is on insulin gathering more reading throughout the day is your only guide as to what best in term of safety and therapy effectiveness.

Small portions are also better for the pancreas human diabetics are advice to eat in small portions, too.

Most here are using human meters but many do Alpha. There is tech support forum where you can post and ask for help with Spread Sheets/ Conversions - or try reading the Sticky note. As long as you test - the Pre-shots especially - it doesn't meter which meter. I however won't be able to help much because I don't understand the Alpha readings and I am no techi. I understand that the testings strips for the Alpha are expensive and not as easily accessible us the ones for human meters. I do go thru a lot of strips in a week - price and immediate availability is key for me. So far human Relion Walmart $15 and its strips $35/100 works fine for me.

I understand and relived to hear it - my cat survived Hypo by a miracle. It hurt my eyes t read that well intended vets recommend high-ish doses of insulin and then advise against home testing time and again. I don't get it.Hypo kills in hours.

 

ECID - with that disclaimer out there...Jones is a grazer. Always has been and always will be. He has food available almost all the time - which works for him. I have tried the small meal idea but with all the civvies and the way he is - this works for us. So for me, I offered about 1/2 can of the 5.5oz can or a 1/2 of the FF - I would try to get him to eat half of that. If he did, I gave the shot. I would then given more food in his feeder before I left for work. At night or the weekend it is easy to run around every 2-3 hours and put the can under his nose to eat.

It is what works for both of you. And I am not sure that a vet is always the best source for information on this disease. My IM vet just told me that I could keep doing as I was doing in regards to the FD - he was going to help with the IBD side.

Jones is a little special case as the diabetes was brought on by steroid use.

 

Thanks for your message, Tanya. This is really helpful. I'm so sorry about the hypo that you and your kitty went through. How terrifying.

After researching online here and elsewhere, I'm horrified that we waited this long to get her meter. I think that the standard of care for feline diabetes is poor at best in the general veterinary clinic.

Thank you for pointing out the sticky. This will really help. And data! Data will help. We're going to hold her dose at 2.5u for 6-10 cycles (as long as she doesn't go too low or not eat enough).

Thanks for the Relion prices. That's not bad! I'm starting to think that it may be worth the investment; we'd save the cost of the meter in just one box of strips. We just paid $53 for a box of 50 AT strips on Amazon! Gah!

 

So glad that you found something that works.we may indeed have to make a change for Livvy.

I feel so bad - took me three ear pricks tonight to get a sample. Most of the time it all works like a charm, sometimes not.

I know that it'll get easier, faster and smoother. I'm hoping to collect some really useful data this weekend. Wish me luck!