When to raise dose? (Lantus)

Jerry has been on Lantus since August 9th and has had multiple dose changes. Although it hasn't been a terribly long time I'm getting a bit frustrated over not seeming to get him just right where he needs to be. He likes to hang out in those high numbers - he seems responsive to changes at first then starts to climb again. I don't know if anyone else has had this issue or if it really just takes months to get them where they need to be. Being patient but feeling discouraged. Part of it may be that though I don't yet have a scale for him due to my own health issues I can tell he's put on weight. Not a huge amount just in the beginning his spine had been bonier than ever and it's not like that anymore, he's re-cushioned so to say. He has had general health improvements besides not being so boney. His water consumption has dropped drastically from 6 bowls to a day later there's still some left of 1 bowl not completely dry as it had been with multiples. Urination isn't as frequent and I'm not having mold issues anymore in his litter box. Even his fur is brighter, he previously had been looking like a solid dull orange cat and now the base orange looks healthier as well as his orange stripes reappearing noticeably. However I don't know how to interpret these readings or what they're trying to tell me so I'd appreciate any feedback on his spreadsheet in general or especially those with Lantus experience.
Thank you!

 

After the initial dose, doses are kept the same for at least 3 full days (6 shot cycles) when following the Tight regulation protocol. You may change the dose after 3 full days if the nadirs are over 200 mg/dL (US).

You may find it helpful to pop over there and read the stickies about Lantus, as well as some posts from current users following the Tight Regulation protocol.

Other things may affect glucose levels - bouncing, food, infection, other medical conditions.

Bouncing - when the glucose drops fast or drops a large amount or drops to a level that hasn't been experienced in a while, compensatory hormones are released to bring the level back up. These hormones release a stored form of glucose called glycogen. This gets converted to glucose and voila! up the level goes. It may take 72 hours for this bounce effect to clear and you just wait it out.

Sometimes, there are batch changes in food production (seems like fall is when this happens due to animals going to slaughter) - monitor the lot numbers on the cans.
The values on food charts are collected at 1 time; recipes, however, vary with what is going to generate the most profit. That's why the descriptions are given on the cans as minimums or maximums.

Check the mouth for signs of infection - gingivitis, abcess.
Check the eyes, nose, listen to the lungs - discharge, coughing, wheezing could be signs of infection or other conditions.

High dose conditions exist - insulin autoantibodies, acromegaly, and Cushings are 3 of them. You're not likely to be in that category yet as your dose is still low.

 

Not sure how you are deciding dose changes but here is a protocol we use -http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=1581 - and summarized below.

Basically you look back at the last 3-5 days and kind of take an average of the nadirs. For example if the nadirs are all pink in the last 3 days then an increase is obvious. Yours have been blue and yellow for easily 5 days so I would say its time for an increase.

The time it gets tricky is if there is a bounce going on, as you might want it to wait for it clear. Or if you have a few low greens in there you wouldnt want them to go lower and would have to be careful about increasing or wait longer.

Anyway you can always come on here and ask. You can also join the Lantus forum where there are more experienced dosing members that can help you - take a read at the forum the stickies etc and see what you think : http://www.felinediabetes.com/FDMB/viewforum.php?f=9

Wendy

"

 

Thank you both for your continued help for team Happy Cat. Feline diabetes is something I hadn't really known existed then treating and learning about it is a lot to take in so it's great to have the support and information here to get him where he needs to be. We really appreciate it!

 

I'm a little surprised that he started on insulin the day after he was diagnosed. Most vets will recommend trying to manage with a change in diet first. If you changed his diet and started insulin concurrently, that makes it more difficult to interpret the BG numbers since you don't know how much is attributable to food and how much to insulin. I would try holding the same dose for a week (unless his readings become extremely low) and also keep track of how much and how recently he ate before each BG reading.

 

i understand your frustration, but hang in there! what you're seeing on his spreadsheet is pretty typical. it can take months to get to the point we think we should have kitty at in weeks.

wonderful! now this is very typical of kitties after being on lantus for a relatively short period of time! these improvements are awesome! treating any diabetic kitty is not just about numbers. your observations are what we call part of the "whole cat report". the 5 Ps... pooping, peeing, preening, playing, and purring are every bit as important as blood glucose numbers.

imho, he's responding well and you're doing a great job collecting data!

the action of lantus is cumulative, meaning one dose can affect up to what you see over the next three days. in other words, it could take up to 3 full days to see what effect the adjustment will make on kitty's numbers... whether you're increasing or decreasing the dose. when attempting to interpret a lantus kitty's spreadsheet you want to look for what i call "waves of action". i don't look at single cycles. i look at what happened over at least the 3 days prior to explain what ever i'm trying to figure out... especially when kitty is relatively new to insulin therapy.

for example:
on 8/22 and 8/23 there were two injections at 1.5 units before the dose was dropped back to 1.25 units. remember, the action of lantus is cumulative. if you count three days from the last injection of 1.5 units you come to the AM cycle on 8/26 where he dropped to 77. you can see how those two injections of 1.5 units influenced the AM cycle on 8/26 even though the dose had been dropped back to 1.25 units on 8/23 (PM cycle).

BJM mentioned "bouncing" in her post above. after beginning insulin therapy, *most* kitties will react to numbers their bodies are not used to after a drop. some kitties bounce harder than others. jerry appears to bounce hard. don't worry. it's normal. as frustrating as it is to see higher numbers caused by a bounce, his body is reacting the way it's supposed to react.

if i were in your shoes, given the time already spent at 1.25 units, and giving ample consideration to the amount of testing you're doing... i would take the dose back up to 1.5 units if your goal is to bring Jerry back to greens. however, bringing kitty into green numbers requires some preparation on your part. please take the time to read through the "stickies" (posts marked with stars) at the top of the "Topics" section in the LANTUS (GLARGINE) - Tight Regulation group. there's a ton of information contained in those stickies... much too much to absorb all at once, but pay special attention to how to handle low numbers and putting together a hypo kit. you can post in that group whether you wish to follow a Tight Regulation Protocol or not. ask any questions you may have. the sheer size of the group can be intimidating, but they're a friendly lot! But... if you're not ready yet to take that step... it's ok. :mrgreen:

i feel obligated to comment on and clarify wendy's comment about averaging nadirs to help determine whether a dose increase is warranted because the statement scares me. in fairness to wendy (she went on to post guidelines for making dose adjustments) , i think her explanation was simply a poor choice of words, but because the explanation could cause harm if her post was not interpreted correctly... the post begs for clarification.

we don't "average" or consider "percentages" of anything when it comes to making dose adjustments. not ever.

let me give you an example:

day 1 nadir: 265
day 2 nadir: 35
day 3 nadir: 365
average of the three days = 261

using an "averaging" system/method, one might increase the dose by 0.25 (rather than decrease the dose) because the average of the nadirs is greater than 200, but less than 300. this could put kitty in danger real fast.

many kitties are started on insulin immediately after being diagnosed for various reasons. kitty's vet usually makes that call based on other issues we may not be aware of.



just my thoughts...

 

He certainly is a bouncer and likes to keep me guessing. For instance his PM shot reading was 224 tonight and a test 4 hours later was at 250. That probably would be because he had been able to sweet talk me into extra pate or maybe because he's hardly ever so low for his injection. I had been nervous to do a dose increase when he was at 224 since that's the lowest he's hit with me confident to shoot so far then go figure he spiked so that increase will be starting tomorrow. All of it has taken adjustments and we're still trying to get all the details straightened out. His diet did start around the same time of insulin but had a few days head start. That may very well be part of his happiness he doesn't feel he's on a diet or restricted and he's indicating he wants more. It's all pieces of the puzzle though slowly coming together.
Speaking of which the Lantus links and information have been great. Jerry the Happy Cat is the prime example of the saying, "it takes a village." We did find a vet whose good and able to deal with the issue unfortunately he doesn't work with Lantus so he doesn't have knowledge on it. This site has already helped Jerry especially from his initial 3 unit dosing (based on their insulin) as I don't think that would have ended well. The vet can make sure things aren't getting worse or if I'm on the right track but there are no accurate answers for Lantus dosing/increases and bouncing information is based on their type of insulin(s). I was thrown into this all blindly minus being intuitive enough to diagnose him and the vet confirmed it. I'm nervous about anything bad happening to him in my care. I have looked up the emergency kits to boost his bg level and I'm ready if need be, I had been ready to save him if he dropped much further from his 77 thankfully it didn't come to that.
Thank you very much to Jill & Alex for the excellent thorough breakdown. Certainly backs up the idea of the dose increase hitting much better numbers when the 1.5 dose was effective. I think we'll have good results going up to 1.5 or I'm certainly hoping so. I'm glad that his health improvements are an overall good sign especially because the saying is the first half is the hardest part and progress is definitely reassuring. Though results take time wish me luck with the increase and as always feedback is welcome as I will be updating the spreadsheet. :razz:

 

you're welcome!

you'll do just fine. you're already off to a good start! if you have any spare time, start reading through some of the threads in the Tight Regulation Insulin Support Group. you'll pick up a lot just from reading about other kitties.

continue asking questions... and good luck!

 

I suspect if you provide the vet with some of our references, he could get up to speed fairly quickly.
2010 American Animal Hospital Association Diabetes Treatment Guidelines

Articles by Dr Rand at the University of Queensland here.

 

Thanks for clarifying Jill. thats why i said "kind of" and "The time it gets tricky is if there is a bounce going on, as you might want it to wait for it clear. Or if you have a few low greens in there you wouldnt want them to go lower and would have to be careful about increasing or wait longer. " But I guess it still wasnt clear.

Wendy

 

I dropped off some of the Lantus information to my vet when I went to drop off syringes and lancets to be safely disposed off. Not sure if he'll begin recommending or look into it but definitely worth a try!
Thank you Wendy you've helped Jerry and I from the start it's been great information and we definitely appreciate feedback to get us on the right track.

 

Good morning guys. Just had a couple hopefully easy questions since you've been very knowledgeable and great at reading spreadsheets. We did raise the dose Wednesday to 1.5 units. Though it may not be related to the increase since it just started we had probably our weirdest sets of numbers for Wednesday, for him anyway. Please see his spreadsheet for the specifics but he hung out in the 300's mainly all day and where there have been days hes varied almost 400 points today it was I think a 102 variance. Is he blatantly telling me he needs an increase now? Or is this what it actually looks like to not bounce so hard just hanging out in a range? (Though not the target range) He certainly likes to surprise me so from how surprising he's been should I be expecting some drastic lows coming up here in the very near future? Thank you very much for the help!
confused_cat

 

Sometimes after a dose change, you may see erratic glucose levels. It happens often enough we have a phrase for it; we call it "New Dose Wonkiness".

You give it a few days for the dose to settle, barring tests that are too low (below 50 mg/dL in a diabetic for less than 1 year) and indicate a dose reduction.

 

Hold the dose! It may very well be NDW like BJM said.

Patience pants for you, in a lovely, calming, slimming blue.

 

How cute! And sent just in time!
Wednesday was a day of not bouncing really.
Thursday was a day of really decent numbers.
Friday not so great. Besides high numbers we hit our record high and it's scarier every time.
Will he always do this?
I'm kicking myself wondering what I may have missed overnight even though it was similar/higher even than his AM mid test on Thursday. Bouncing wouldn't be so bad except I get worried about organ damage or failure going so high. It really frustrates me that his numbers go drastically higher than when he was untreated. I can read on bounces all day long but I still don't understand why having normal readings cause him to bounce through the roof. Happy cat, frustrated owner.
:sad:

 

Well at least your kitty is Happy! Deep breaths- organ damage takes a long time and given he is spending half his day in better numbers it isnt consistently high and gets a break from it. Bouncing is very common so dont worry and that nasty black looks like a bounce so you might want to get spot checks at night if he does drop into blue to see if he drops any further.

However I am thinking you might want to post on the lantus board.That board has lots of very experienced dosing members on it and is a great sense of community.Since you are now up to speed with testing etc I think they will really be able to advise you better on dosing etc. I post there myself every day or two to get their eyes on my cats... as are Bj, Deb etc.

http://www.felinediabetes.com/FDMB/viewforum.php?f=9

Here’s how to post:
Every day ( or as often as you can) you open a new thread/post. We call them "condos" (short for condition report, or the home you live in and the cat trees some people have)

Subject line: The subject has the date/cats name and BG readings ie 09/06 Happy Cat AMPS 578 +6 357. You add a ? icon if you have a question. You should update your subject line in the very first post for the day as you get a reading, or whenever you have a question. For your first post put "newbie" also in your subject so everyone can welcome you!

Contents: The contents of your post have a quick update on how your cat is feeling as regards the 5Ps ( peeing. pooing, preening, playing and purring) and any questions and a link to your previous post ie : Today Happy was in a good mood, playing and eating well. But he is peeing a lot and his BG was really high this morning. Is this a bounce?

There is no rush to post there. I like to suggest that people go over to their insulin specific support group and check it out. Read the Stickies at the top of the Topics section. Read a few condos posted by other members. Get a feel for how the forum works. See if you think it would be a good fit for you.

But you are always welcome to post here in the Feline Health forum for as long as you want.

Wendy