For those of you who have used both L's

Hello. Using Lantus but I don't know what my protocol is yet, just want to keep it safe.

Chip is 6yo 15 lb Main Coon, ideal weight more like 16 lbs. Meter is relion confirm. FF classics wet food. He's never had steroids and no other known conditions besides diabetes.

Been on Lantus for over a week and I suspect that's what I'm seeing now. 30 to 40 hour flat pink and flat red surfs followed by random dips that may hit anywhere in the cycle. Did I start out too high?

I want to keep using Lantus for now if possible but I fear getting a rebound problem only getting worse as I go up. Perhaps I'm just paranoid about *tight* regulation. But I don't seem to be seeing reliable nadirs to make proper dosing judgements.

Thanks for any thoughts,
Dale 'n' Chip

 

Just looking real briefly at your spreadsheet, you were getting your best numbers at .75u, but you didn't let the bounce clear and then give the dose a chance to settle. Personally if Chip was mine, I think I would drop back to the last best dose (best string of good numbers) and hold the dose a little longer to see if he settles down. Sometimes it works best to drop below the best dose a little bit to stop the swinging, and then use that data to decide how much the dose needs to increase, or possibly decrease...Every Cat is Different there..just depends on where they settle.

Both the L's are gentle but very powerful hormones (because that is what insulin is..a hormone not really a drug.), so a drop one way or the other can have a great effect. When you are where you and Chip are right now with either insulin you start out with doing dose increases in pretty good chunks to youan narrow down the dose quickly. But when you get to a point where one dose isn't quite enough, and the next .5 is too much then you start adjusting in .25 chunks. Then you get to the point where one dose isn't quite enough and the next .25u increase is too much, then you start adjusting by drops.

Also remember they can bounce for a lot of reasons and off any number, they don't have to go to dangerously low. Just lower than what the body has come to except as 'normal'. Some cats what to fast track it and make you dance a tango, and some cats decide very quickly they don't want to dance and go into remission on almost diet change alone, and they there are some cats that love to dance a waltz, and do everything textbook, and then there are those that just have a liver that is dumb and takes forever to catch onto what is normal..One of the reasons why I like the SLGS protocol over the TR...Yeah might take longer but I don't think anyone is really keeping track of all the cats that go into remission without using it. Maxwell went OTJ almost two years ago without it, Musette before she got sick was headed that way, she had spent the first 10 hours of Saturday in double digits without insulin. Didn't use TR with her, and Autumn isn't being made to follow TR and she is waltzing right down the dosing scale. Plus why stick her multiple times a day when I know she is in the middle of a bounce off a lower than "normal" number? Save them for the times when she decides to drop to fast or too low and I need to watch her closely.

Now granted Musette did better on Levemir than she did on Lantus, but I don't see the reason it helped in Chip's spreadsheet. Chip when he bounces he is giving you a very definite pattern of bounce, but you just reacted to those bounce numbers and raised the dose too quickly without letting it settle out. Patience is the key to both insulin. But with Musette her bounces were extreme, Lev let her flatten out so I could make some sense out of her numbers. Plus she was really tense and crabby on Lantus, and she relaxed on Levemir.

After using both and using Lantus again for Autumn, what I see in Chip isn't a problem with the insulin, but the dose.

But that is just my 2 cents worth. Hopefully others will weigh in with their exsperinces as well, because ultimately it is you that will hold the syringes and have to make the most informed choice for what is best for Chip.

Mel, Maxwell, Musette (GA), Autumn & The Fur Gang

 

I agree that raising the dose was probably not the best thing to do. But I also see a pattern that suggests Chip was started at too high a dose on lantus. Why do I think this? Because, the 1.5u dose on H was too high (causing 500s) and the starting lantus dose was based on that amount. Just a comment on the curve on H: when you see numbers above about 350 in a cat eating a low carb wet diet, they are almost always caused by too much insulin. That is my experience, at any rate, and something we generally believe in the lev ISG. Next, Chip got to low-ish numbers off a few days on 1u (on the 26th) and when you stayed at .75u the numbers were flat. Then you went back to 1u and suddenly had the lowest PS yet followed by flat 400s.

Does Chip have any history of ketones? If not, and you can easily test daily for them, I think you would learn a lot from dropping him to .5u and let that settle. If he is getting too much now, that will probably show it with improved numbers. And then decisions can be made on what to do next. Essentially, I am saying start over at .5u. If he needs the dose raised, it would be in percentages not to exceed 20% - so next would be .6u, then .7u, then .8u and then .9u. Those .1u changes actually make a significant difference when the dose is below about 1.5u.

That would be trying to come in at or below best dose so you can slowly raise the dose in increments and numbers will make better sense in relationship to the dose. It's easier to do that then to get the "swings" started by too high a dose and try and figure out what it going on.

 

Well, looking at the ss, you likely did start too high at the 1.5u because once the shed filled on 1u, you got the string of greens, followed by the expected bounce. You did do the right thing to reduce to .75u though.
Then you saw the bounce and went back to 1u a bit too soon.

I know that some cats do better on Levemir, my Shadoe did much better on Lev but my Ollie was OK on both. I do prefer Levemir to Lantus, but I also know that some cats do just fine on Lantus, so after just a week or so, and you are not near finding your good dose, I'd say to stick with the Lantus until Chip's body gets used to getting the help from insulin shots.

As for the tight or relaxed forums, that's all up to you .... I know the TR forum want lots of testing and want people to adhere to the protocol whereas the RL forum is a bit more flexible. There is no reason why you can't follow the protocol but post in RL; you do NOT have to follow that SLGS protocol which uses very little testing and involve food type testing.
The RL forum is good for out of the ordinary conditions. If you test before each shot, get a before bed test, and see if you can get in a curve once in awhile so that you can see how the Lantus or Levemir is working, that's plenty. There are some cats who have food issues as well, so the RL forum would be a better place to try and work out a way to deal with the wonky numbers. There are people who work odd shifts and 12hr days, so the RL is the better place to work out a way to deal with how those owners' lives are set up.

When it comes to insulin, I'd say to give it a good couple months unless you want to try Lev.

Post wherever you like. The TR forum have the most posters, but the most strict rules. If it becomes too strict, or 'tight', you are more than welcome to post in RL.

Remember that it's all about the cat, so go where you feel that you are getting the best of support for your Chip.

 

Thanks all. :smile:

No history besides his original DKA. And I can test fairly often without too much trouble, other than waiting for him to have to go. He's actually apparently doing better on these flat Lantus bounces than on the N overdose rollercoaster, as urination is nearly back to normal.

Looks like we are heading into perhaps another blue PMPS, so that should be a good time to shoot 0.5u and hold it for 3 or 4 days to see what the next low is. He's in good shape so I think he can survive this to find out. The most I might lose is 4 or 9 days If it turns out I have to head back up. Better to test that now than after I make it up to 2 or more units. BTW he was essentially OTJ only 3 months ago, so it's not like his pancreas has been under this kind of assault for the last year.

There is also the possibility that 0.5u is too high, however with surely no pancreas activity currently it's hard to tell. The way this current episode started was with a likely mislabeled batch of FF. It seemed to have lots of gravy for a pate, and after two cans of that he was over 200, after normally surfing 75 to 130 with no daily insulin. Since it was over 200 I shot a skinny half unit of N to bring him down and 3 hours later he was over 500. That was obvioulsy a bounce. Once in the bad numbers I tried every thing to clear it from 0.5u bid working up to 3.0 units bid and settled on 1.5. What I should have tried was less than 0.5u N while the pancreas was still functioning. But I was too afraid of those high numbers at the time.

 

I have an entirely different interpretation. What is being described as 'doing better' on a dose of 0.75u really wasn't the response to that dose. The string of greens at that one time dose of 0.75u was due to the insulin depot having been established at several cycles at a 1.0u dose. It takes a few cycles for the depot to adjust to a new dose. As a result, the string of greens reflect the effect of the 1.0u dose. Subsequently, a combination of reducing the dose and a bounce off of the greens spiked the numbers back up.

I do not have a problem with a bounce. Granted, they are frustrating to see and require some patience to wait out. I do think there are a lot of people who live in fear of bounces and want to use either Lantus or Lev to try to squash the bounce. Neither of those types of insulin work that way. The strategy to reduce the dose when seeing bounces may only serve to produce glucose toxicity -- your cat remains in higher than necessary numbers making it even harder to get the numbers to come down since those high numbers begin to reset what your cat's body regards as a new "normal" BG level.

As for which forum, that is entirely your decision. There are a number of people who are using the SLGS protocol and who post on the TR forum. What is requested in the TR forum is a minimum of getting pre-shot tests and one additional test per cycle. I strongly suspect that is not significantly different than what goes on in the RL forum since Lantus dosing is based on the nadir. I would be negligent if I didn't point out that the Tight Regulation Protocol has research published in a leading veterinary journal to support it as being a safe and effective treatment approach to feline diabetes and that it has an enviable track record for getting newly diagnosed cats to go into remission.

 

You may be right. My fear is that the toxicity from the higher bounce is worse than a potentially flat lower level from not quite enough insulin. I've seen Chip in both states and I suspect the high bounce may present worse clinical symptoms. I'm not talking ketones, of course that is worse. Chip was "all on his own" eating med carb dry for two months with no insulin support or concrete evidence he should be without. The Frutosamine said his average glucose for the end of the period was around 300. No ketones and he was hardly worse for the wear. Then after 3 weeks of drastically tapered off N he was essentially back off the juice for real. How could that have been possible if he was diabetic eating nothing but 13% carb dry food for two months without insulin?

Did you see I shot that mid blue PMPS with a full dose and surfed yellow for a while? But then I hit flat red. ohmygod_smile

It's a delicate balancing act but I'd rather "start low and go faster... just make sure I started low enough now before I get up there where the air is thin. :smile:

 

I want to point out that once Dale raised the dose back to 1u after 3 days at .75u, Chip immediately had the lowest PS on lantus, but not his lowest number, followed by a day in the 400s. That says rebound to me. If these insulins are supposed to take several cycles to "fill" or "deplete" the "depot", then the only explanation I have for that 148 is that .75u was too much and the 1u just forced the issue and redoubled Chips rebound response.

I agree with Dale that now is the time to restart at .5u and not much ground will be lost, if any.

I also agree with Dale that the 200s from the gravy food could probably have been dealt with by using a lot less insulin - maybe even none. Beau ate some bread after 3 months OTJ and he initially brought himself down, but couldn't hold it. I shot .05u of lev as needed over a week or so and he was back under control and OTJ.

Dale you can post wherever you feel most comfortable, including here. There is no rule that lantus users can't post here. After all, there are many lev users who post in the RL and TR ISGs.

BTW, for anyone else curious, the core group of lev posters, including myself, have been creating ways to manage our cats while working odd schedules and dealing with other issues for years. We were the original "relaxed" group - although I don't like that term. Cats are doing well here and, I hope, their humans feel supported and welcomed. We have had many cats go OTJ as well, we just haven't felt the need to publish a paper about it.

 

I know you know this Sheila, but none of us from FDMB, regardless of the forum, were authors on the Tight Regulation Protocol paper. The authors are from University of Queensland. And you and others here have been very helpful with respect to dosing strategies when people have complicated schedules that have an impact on dosing.

I think we have a different reaction to the interpretation of that 148 pre-shot. It's within meter variance of several of the other mid-cycle blue numbers. (I'm also wondering if there was a funky test/strip in the mix. There's no way to know but the pattern from a pre-shot of 148 to 399 at +1 and to 276 at +2 suggests that maybe the 399 was a bad test. Seeing Chip in the yellows makes more sense but, who know? He's a cat!) Yes, Chip bounced. I just don't think that a bounce is problematic or that the dosing is too high. It also looks like he bounce higher on 0.75u. I would hate to see Chip spending more time in the 400s because the dose was lowered too much. He spent 1 cycle in the 400s and was back into blue numbers within 24 hours, which is not bad for a cat that is new to Lantus. There is some bouncing but to my eyes, Chip's numbers are leveling off and the dose is beginning to stabilize.

 

I went looking for the link to SLGS protocol and found the method on Binkyspage.

http://binkyspage.tripod.com/SLGS.html

Unless there is some sticky of a modified SLGS, I am not thinking the owners who want to follow that method will be well received on TR. Testing is done once a week on a curve, not before every shot.
Below are the 5 steps and I see this method as something the RL forum would better serve.

Five Steps to Regulation:

Step 1. Start at a low dose of PZI, Lantus, or Levemir insulin, as recommended by your vet. (Note: Humulin and Novolin Lente and Ultralente, two insulins with good track records in cats, have been discontinued by the manufacturers.) A conservative starting dose is 1.0-2.0 units, twice per day. If your cat’s blood glucose was less than 400 mg/dl (22.1 mmol/L) at diagnosis, or if your cat is on a low-carbohydrate diet, the starting dose should be only 0.5-1.0 units twice per day. Fast-acting insulins such as Humulin Regular, Humulin 70/30, and Humulin N (NPH) are not suitable starting insulins for cats, in the experience of FDMB members because of the high risk of hypoglycemia; Humulin N may be appropriate later on if you discover that longer-acting insulins cause problems for your cat. Vetsulin, also known as Caninsulin, is less harsh than Humulin N, but still appears to carry a risk of hypoglycemia, particularly for cats who are not meal-fed high-carbohydrate food, so please be aware of the risks.

Step 2. Don’t increase the dose until your cat has been on it for at least a week. If you have reason to be concerned about hypoglycemia, or if your cat won’t eat, do decrease the dose and contact your vet. Do test your cat’s urine frequently during the regulation process using Ketostix or Ketodiastix, and contact your vet immediately if the cat tests positive for ketones. Do be consistent in the timing and type of food. Do give the shots at about the same time every day.

Step 3. After 1-2 weeks at a given dose, you or your vet should perform a serial blood glucose curve (blood glucose tests every 2 hours, starting at shot time and continuing until the next shot). Follow the cat’s normal feeding schedule during the curve. The curve should be evaluated by someone experienced at interpreting feline blood glucose curves, in order to check for signs of rebound and other possible problems. If no rebound is present, follow these guidelines for dose adjustment (smaller adjustments may be appropriate for cats on PZI or Lantus):
a) If the lowest point of the curve is above 150 mg/dl (8.3 mmol/L), increase the dose by 0.5 unit.
b) If the lowest point of the curve is between 90 and 149 mg/dl (5.0 and 8.2 mmol/L), keep the dose the same.
c) If the lowest point of the curve is below 90 mg/dl (5.0 mmol/L), decrease the dose by 0.5 unit.
Step 4. Repeat the cycle of curving and waiting 1-2 weeks. As your cat’s blood glucose begins to fall mostly in the desired range [lowest point of the curve approaching 100 mg/dl (5.5 mmol/L) and pre-shot value around or below 300 mg/dl (16.6 mmol/L)], do lengthen the waiting time between dose increases. If you decide to change another factor (e.g., diet or other medications), don’t increase the insulin dose until the other change is complete (but do decrease the dose if your cat's glucose numbers consistently fall below 90 mg/dl (5.0 mmol/L) as a result of the change). Don’t be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat’s blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose.

Step 5. Once you can no longer increase the dose without the cat dropping below 90 mg/dl (5.0 mmol/L) at the lowest point, evaluate the duration of the insulin’s action. If your cat’s preshot blood glucose values are still consistently above 350 mg/dl (19.3 mmol/L), or if your cat’s blood glucose usually returns to preshot values more than an hour before the next shot is due, ask your vet about longer-duration insulins or possible adjustments to your cat’s food or feeding schedule.

That’s it — 5 steps! These steps are general guidelines that work for the majority of cats. Because every cat is different and exceptional situations may arise, your cat’s progress should be closely monitored by someone with experience regulating feline diabetics.

 

I've used both insulins. I have to say I agree with Sienne. The TR protocol has the caregiver (CG) holding the initial starting dose 5-7 days (10-14 consecutive cycles) so the insulin depot can fill. The exception is if kitty is high and flat and then the dose can be raised after six consecutive cycles. The SLGS protocol has the CG hold the initial starting dose for a week as well. Chip came down into blue after three cycles and then bounced back up.

I also think Chip was just getting to the point of the 1u dose really settling in when the dose was taken down to .75u. As Sienne said, the full depot from the 1u was responsible for the green numbers on 5/26. He's now getting into mid blue numbers again and bouncing back up. I might go a step further and wonder if Chip might need a little more insulin down the road. He's clearing bounces now but only into mid blue numbers. I would hate to see him go down in dose and then see his numbers shoot up even higher because he doesn't have enough insulin.

Dale...IMHO, you should decide where you want to post and what protocol you want to use and then stick with it and give it a chance to work. Before TR, the SLGS was the protocol and cats went OTJ on it. TR is a bit more of an aggressive protocol, not in the number of tests you are required to do in a day, but in the frequency of increases. But as Chip's CG, you just need to find a place in FDMB where you are comfortable, follow one protocol, and give lantus a chance. It's an excellent insulin.

If after several months, it isn't working for him, then you could try lev. It is also a superb insulin. The one caution I would have is that many people switch to lev thinking it will stop the bouncing. It might or might not. There are still plenty of bouncy cats in Lantus TR ISG who switched to lev and are still bouncing.

Good luck....wherever you decide to post, you will get caring people to help you.

 

The best argument for trying the lower dose might be here:

Beau's Numbers

Going from Vetsulin to Levimir.

That looks more like Chip there, with what I've seen on N.

If it doesn't reduce the bouncing then I can ease it back up. Or lower. It's not that far from where I am now. :idea:

I wonder if Beau had some pancreas going on coming out of Vetsulin?

 

Gayle --

I don't want to hijack Dale's condo. I can't send you a PM since you disabled your PM feature the last time I tried.

I think the SLGS protocol is ambiguous with respect to home testing. It does not discourage home testing. The protocol clearly states to get a curve every 1 - 2 weeks. It doesn't mention anything else. It neither encourages nor discourages home testing.

The way you seem to be interpreting the SLGS protocol is that home testing is not necessary. Given how every new member of FDMB is encouraged to home test, relegating testing to a curve once a week or once every 2 weeks would seem counter to the culture of all of the ISGs and on Health. Your point about SLGS is countered by the stickys on the Relaxed board -- the information about how to handle low pre-shots and low numbers are posted there. If getting pre-shot tests and spot checks were not encouraged, that information would be unnecessary since it would be feasible for all testing to be done at the vet's office. If members of RL are being encouraged to skip getting pre-shot and nadir tests on a regular basis, I would be very frightened about the information being dispensed in that forum. IMHO, getting a curve every couple of weeks would put the lives of any number of cats in serious jeopardy.

As I stated previously, there are a number of people who are using SLGS and who are welcomed and actively posting on the TR forum. Given that they have continued to post there, I am going to assume that they feel that they are well received.

Dale -- sorry for interrupting the flow of information pertinent to your question. As Marje noted, there are wise, caring, and helpful people spread throughout FDMB. When I first came here, one of the questions that I struggled with was who to listen to. At times, people would post conflicting information in Gabby's condo. What became a deciding factor for me was what people's spreadsheets looked like. It was easy to discern who's SS I wanted Gabby's to eventually look like.

 

Dale: I, too, have questioned Lantus vs. Levimir for my Pumbaa, because of his major swings early on.

There are things that I have read here on the FDMBs that make me wish I would have started Pumbaa on Levimir instead of Lantus, but I have also read that Lantus has the highest rate of remission for cats. That is what sold me.

Look at my Pumbaa's SS. As many people have told me, this is a marathon, not a sprint. What they failed to mention is that it's a marathon with an awful lot of steep hills for some kitties. My Pumbaa and your Chip included.

After trying the Tight Regulation Protocol, I dropped Pumbaa's dose way down, and went with the "start low, go slow" protocol, because it appeared that Pumbaa needed much more time to settle into his dose. I could tell this by his personality changes, as you mentioned about Chip. By restarting, and taking longer to see how Pumbaa was settling into a dose, Pumbaa was much better mentally and physically, and we were both less stressed.

ECID = Every Cat Is Different. Some do great on the tight protocol and some do great on relaxed. It's whatever works for you.

Also, it was explained to me that some kitties keep exhibiting higher numbers until they reach their correct dose. That's another reason I went with the relaxed protocol...I wanted Pumbaa to settle into his dose and show me how he was really reacting to the insulin, before I made the determination to increase his dose. The high, flat cycles told me more about what he needed than the infrequent low numbers did.

All I can say is get to know how your kitty is reacting to the insulin, and don't make any rash decisions based on some time frame that Chip may not be dancing to. Neither Pumbaa nor I could adhere to the "6-cycle, make a move" mentality of the tight protocol, especially when bounces hadn't cleared and new dose wonkiness wasn't taken into account during those 6 cycles.

Keep testing as much as you can, because even after nearly 2 months, Pumbaa does not have a true nadir yet, that I have seen. Sometimes what should be his nadir (lowest point on the cycle curve) is the highest point.

This is all about you and Chip, and you making Chip better. And no one knows Chip better than you do!

Suze

 

I think that his pancreas kept trying to get going again on vetsulin, but it wasn't getting the support it needed: steady numbers, below renal threshold. After I figured out that he was rebounding on BOTH .5u AND .4u of lev (something that almost everyone disagreed with) and started lowering the dose, his pancreas got the support it needed.

 

Question since I find this discussion interesting...

What does the inverse curve on the AM cycle of the 24th indicate? Chip dropped 100 points in the last 3 hours of the cycle. Does that mean something, or is it just an oddity since it looks like the only time it has happened?
The high numbers on the days Chip was getting .75u, those are bounces from the greens a couple days prior, right?
Also, with the L's, is it critical to make sure the BG is rising at shot time? The blue PMPS on the 29th sticks out like a sore thumb to me...

Carl

 

If this experiment totally doesn't work, with the way Pumbaa is looking today he's gonna have Chip beat! Lets hope it continues. And if Pumbaa keeps settling down at least I won't be afraid to go higher as long as I can see some true nadirs.

When I weened Chip off Humulin the first time, it was just a gentle easing down, no hypo scares or unexpected green nighmares.

 

That makes sense to me, let the swinging stop to get a better idea where we are at. I came in out of a red humulin bounce. The filling shed operated like a drastic dose reduction for the first few cycles and that seemed to be a smooth decent. So let's see if I can duplicate it. Hopefully as the current shed winds down it may help clear the present bounce without creating too much of another.

BTW I was very fond of Musette from when I first picked up the tale on DCIN. I was lurking here long before I joined so I was following that plus reading everything you posted in health for months. So I was glued to every update, that was such a blow. All I could think was that she did it her way, nobody had to make any decisions. And I feel the only way she could was because she knew you were there because she could smell you.

 

Carl....382 to 428 is flat. That isn't an inverse....that is most likely meter variance. In fact....it all looks relatively flat to me. Yes...the high numbers after the .75u appear to be a bounce from the 50s.

In regard to making sure the number is rising at shot time....depends. For an experienced lantus caregiver, shooting a dropping number (as long as it is above 50) can give great overlap if the CG has enough data to know what kitty will do after the shot....will kitty get a food spike? Is kitty's duration 13 hours instead of 12 and so he'll start going up, etc. Even new members can shoot high dropping numbers....it's the low dropping numbers that we need to teach them to gradually shoot after they have plenty of data and they know their kitty's onset, nadir, and duration.

For lev kitties...they don't usually onset until +4 so it's not a big deal to shoot a dropping number as long as the CG, again, knows the onset, nadir, and duration. Some lev kitties don't even nadir until +12 and they might get a second dip after.

I also think the rates of remission for lantus are higher because not that many cats are on levemir. Most vets never even heard of it. Both insulins are long acting insulins....lev can have up to a very long duration and produce nice, long, flat curves. The TR protocol can be followed in both.

 

I would love to see some truly true nadirs as well, but figure that, since it's Pumbaa, I never will! *LOL* As for Chip, again look at Pumbaa's history, and his black and red numbers until he reached a much higher dose, and his bounces started leveling off and not being so severe. Pumbaa and I both hated those high bounces. You'll get there with Chip, too!

The only good thing about Pumbaa's numbers being so high was the lack of worry about unexpected green nightmares! *LOL* I totally understand where you are coming from! But the hypo scares come from too much insulin, not too little. Not enough (hyper-glycemic) can kill over time by destroying organs, but too much insulin (hypo-glycemic) can kill quickly. So weening off of Humilin shouldn't have caused too many hypo scares, correct? (Correct me if I am wrong.)

As I've been told, many times, just relax and learn to dance to Chip's rhythm. When you relax enough to dance to Chip's rhythm, you'll be so much happier. I now realize I can't control, or predict, how on any given day, Pumbaa is going to react to his insulin. I just have to keep testing, regularly, and react to his dance, and try and do the best thing for him, based on his dance.

Suze

 

Thanks, I might take you up on that. :smile:

After 6 cycles at half a unit, the wild bouncing appears to have settled down. Looks more like real numbers, and I would assume at this point in time (with this particular pen) his ideal dose is not less than 0.5 unit since it's no longer bouncing much.

Should I wait 2 more cycles to be sure, or proceed with 6 cycles @ 0.72U? According to the Levimer protocol since he is staying over 150 I should raise it 2/10ths? I'm using Lantus of course but 0.72 looks easier to measure than 0.75 which is what most Lantus protocols would dictate.

And BTW my last 0.75 were really 0.82 since I was centering the clear space, not on the front of the marks.

0.72U (back of the 0.5 mark) looks doable subject to the consistency of this current batch of relion syringes. May need to get a jewelers workstation to load these doses.

BTW Shelia your magnified pics of the drop method microdosing are the best I've seen.

 

I would wait another day. One of the things that makes me wonder if he truly does need more than .5u is the fact that he was OTJ until recently and was in the 200s before you started insulin. Now he is in the 300s and higher a lot of the time - on insulin.

If we go back to Beau as an example, he looked like .4u was not enough (high, flat), but on .5u the numbers really starting swinging. I did not see improvement in numbers until I got down to .3u. From early July until Aug 6th when I dropped to .3u I kept trying .5u and .4u and not getting anywhere.

The thing to look for if you increase the dose is the start of swinging again.

 

Let it ride.
No complaints from Chip. dancing_cat

 

1.0U seems to offer nothing over 0.5U, other than that unexpected (unwanted?) green surf on day 4 followed by all that bouncing.

O.5U has a similar range yet with a lower overall average, and perhaps less red.

Does this mean I need to try 0.5U minus a bead = 0.4U? Or for that matter what would I expect the numbers to do if I did 4 days of 0.25U and that turned out to be too little insulin? Where *should* the numbers go for instance after no shots for a few days, when he should be needing at least some? That last one is a hypothetical, don't worry I'm not going to try it. ;-)

It seems obvious now that 0.5U is surely not too little?

What the vet always found during the initial Humulin dosing, and what I learned when I first started home testing was with Chip less always seems to be more.

The only remaining question how do we break through that mid-blue barrier, a barrier Beau didn't seem to have on his first day of Levimir. My sense is that isn't a nadir it's a liver barrier. When not the bounce, then it's the liver barier keeping us from seeing the true nadir. Do we have to squash it down hard with dangerous higher doses, or is there some way to ease it down? :?:

The way I'd want to try that with humulin (or prozinc?) is ease him ever lower with strategically micro dosed whiffs just avoiding the rebound blowback until he gets used to 150, then 120 then 90.

 

If I were you, and you and your vet have found that "less is more" with Chip, then I would try reducing to at least .3u. So, .25u would not be unreasonable to try. Please test for ketones.

I tried skipping several days of insulin when Beau was on vetsulin to get an idea of where he would be on his own. There is some variance, but he stayed in the mid 200s for the most part. That was with a low carb, wet food diet. After that, I knew that high 200s and above for him were most likely due to some rebound.

What I think - and you have to decide if this makes logical sense or not - is that too much insulin causes rebound to higher numbers. Drop that dose a bit, but still too much and you have high, flat numbers. Drop it some more and you might have higher bounces, but lower nadirs. Drop it again, and the bounces ease and the highest numbers are lower, nadirs even lower than before. As you near the best dose you have lower numbers, no bouncing and nadirs in the "normal" range. Why? Again, my theory: the overdosed insulin and the rebound response exert equal force against each other. Ease up on one side and the other side overpowers it. So, if you ease up on the dose the rebound overpowers it and numbers are higher, but as the body recognizes that the force it was fighting is weaker, it too eases back. Beau's response to decreased doses shows this very well.

The other option is to keep raising the dose until the insulin overpowers the rebound response and experience sudden drops to low numbers. You might have been seeing this at 1u. With each drop to low numbers you reduce the dose.

There are no guarantees that either approach will work, but if you try to lower the dose below where he needs to be, you will see better numbers and raising to best dose is easier than lowering to it. If the numbers don't improve after 3-4 days, you raise back to .5u and then take it from there.

 

Makes perfect sense, I always seem to agree with your logic. I don't subscribe to some the *mythology* here surrounding the "shed" either. The individual deposits work together in a harmony of sorts. But the way I see it they are all deaf dumb and blind to each other. Not like some dynamic borg collective with constant feedback. Instead they just sit there (Lantus) and do their own thing, oblivious. Not sure where Levemir is after it binds to albumin. BTW I should have gone for Levemir but If I switch, the new hands off vet (who wrote the Lantus) will think I'm crazy if I ask for that now. :roll:

I think I will try 0.3U (as 0.5U less two beads) if I think I can load that. 0.25U (as the back of the flange to the front of the half unit marker) is doable but it looks like so little.

If Chip could break green I'm quite sure this approach would work. But we will just have to give it a try and see where we are at. His daily average glucose level now is better than where it was on the most recent Humulin overdose. So he's no worse for the wear for a few more days. He's actually feeling his oats now.

I'm not at all looking forward the tight regulation sledgehammer if that is really what it takes. nailbite_smile

 

Hey, PapaDale,

Sorry to see you are struggling with these bounces and dosage issues, but I am happy to see that your cat seems to need so little insulin. That must be a good thing meaning his pancreas isn't in such bad shape. Good luck. Max and I are thinking of you both . . . well, Max is a cat, and he's oblivious, but if he knew, he'd be at least indifferent, lol. I'm hoping you get this figured out soon and the stress eases up. You are doing a great job. By the way, I need a jeweler's glass glass for .25 and .75, I think! :?

 

Insulin depot as Borg Collective - I love it! :lol:

What syringes do you use? On mine I found that the flange and the lines were about .2u (I think closer to .17u, if I remember correctly). So the back of the flange to the front of the .5u line would be closer to .3u. I now use the relationship of flange to lines and space between the two to measure, with occasional drops or half drops off, but with Beau I did the drop method the whole time, drawing to .5u and beading off drops. It just takes practice. And believe me, I practiced until I got 5 drops from .5u and then 10 drops from .5u so I visually knew what a drop and half drop looked like.

I know it seems like so little but I can attest that even .05u makes a difference when the cat is nearly OTJ, so .25u would make a difference for one with pancreatic contributions happening.

 

Hey, someone else "got" the "Borg Collective" comment

Sounds like things are going well. Awesome!

 

They are relion and they look very similar to your pictures. The drops are a challenge but I raised back to a half anyway, since I may have just the slightest tinge of pink on the ketone test. It wasn't trace by 15 seconds but it was off the beige of negative, I've never seen that before. And in a few minutes it was looking more pink than beige. I've let it go before and it just got darker beige so could this be the earliest warning?

It's probably nothing but I've never seen anything but pure beige before. Could the clavamox be affecting this? He is eating very well and feeling great.

Perhaps it's not time to reduce the dose with these numbers. Maybe I should edge up to 0.72? He doesn't seem at all dehydrated but I wonder if I should shoot some subQ ? Never given him subQ but it should be easy.

 

I would get another ketone test as soon as you can, and test yourself as well. It would have been a bad or expired strip, but better to be cautious. And if they are trace, better call your vet. SubQ fluids will help. Maybe start with 50? They can't hurt unless he has heart disease. Something is ask the vet.

And, no I would not reduce the dose until you get this cleared up. I don't know what to tell you about raising it. You could be going into the "sledgehammer" mode, possibly, but if he is developing ketones you need the numbers down.

 

I got another test in 4 hours and it was closer to neg than trace @15 seconds so I think we are ok. Just the fact that I need to look so close is not a comfort. Tested myself and it went a little pink in time but was solid beige @ 15 seconds. He is definitely slightly pinker for whatever reason. The ketone strips have only been open for 6 weeks and always closed tight. He is acting fine even racing around at top speed and has already eaten 3 cans of FF classics which is ahead of schedule for him. He almost always eats more as he's going lower and eats less when he's sitting higher. Maybe that is some hint he actually need *more* insulin this time?

"With" and "without" him on the bath scales suggests he's (roughly) up to 16 lbs since we started lantus (from an official 14.9 lbs at the vet getting the script) and that matches my observations. That is a vote against needing more juice, or should I say a vote against needing more than 1U, but I already knew that. I've lost about 6 lbs since starting lantus, overall a plus. Sort of. The lantus diet plan.

Just as proof of concept I gave him 50 cc of lactated ringer and boy is he a wiggle butt. Wanted to give 75 but it took to long. Wouldn't go in, he's so plush and muscular and not at all dehydrated. Tried 22g utw, 20g utw and the 19 g monoject harpoon and it was even worse. Had to waste half a dose filling his line but I will leave it capped and hanging for a few days. Somehow I figured that was gonna be easier.

I really need to bring the numbers down a little. Most guidelines say when over 300 for 24 to 48 hours raise by 0.5U. Pretty sure I don't want to do that and hit him with the jackhammer. He is going below 300 even surfing there a bit about every day so it's close. But since he did have DKA initially I should probably treat him as ketone prone?

So the question is if I try 0.72U for 3 days am I just losing ground? Might that bring it down a *bit* now that he's had time to decompress? Too bad I'm such a wuss about this but if I had a serum ketone test or a ketone test meter that would perhaps be more conclusive. He's not sick, he's eating more than plenty, so that just leaves "needs a bit more insulin"?

(there I go again down that slippery slope) :roll:

I need a *pinch* less excitement and a *parcel* more sleep. :mrgreen:

 

I certainly hear you on the sleep front....

In this case, I would have to err on the side of caution with respect to the DKA/ketone possibilities and say go back to .72u (why is that easier than .75u?) and see what happens. And remember that there are several dose possibilities between .75u and 1u if you feel one of those doses is close, but not exact. Maybe .8u would have worked before?

There just isn't a lot of data to go on, which is what leads to speculation based on a few clues from his OTJ days and when he was on other insulins.

I don't envy you trying to give subQs to a "healthy" cat. I have only even given them to seriously weak cats and it was no contest.

 

I'll start that in the morning, I held the dose since he seems to go yellow overnight anyway. The clinical signs are so good I just don't see how there could be any problem.

And I need to double check the *odd* numbers because the relion flange is thicker than the one in your pictures. The marks look the same so anything to the back of the flange will be off. That's why 0.25 looks like nothing compared to yours since the flange is thicker. But I'll check for something around 0.75 and run that for a few days.

What kind of syringes were those? I'm sure I will be back on the way down at some point. Hopefully next time with numbers out of the pink.

The reason I held the dose is because I figured it would be less likely to cause a bounce for now.

 

I get my syringes at Hocks, but they were out of stock for a while. They are GNP brand, 31 gauge, 5/16" needle.

Oh, they have them back in stock, hmmmm....here is a link:
http://www.hocks.com/diabetic-suppl...edle-1-2-unit-markings-gnp-brand-100-box.html

Hope he gives you some decent yellows overnight.

 

Ugh, giving subcues is a pain. I assume you warmed the bag up in a pot of warm water. I have noticed that I have to dip the tubing into the warm water, too. Even that initial amount in the tubing is enough to make him jump and make the needle fall out or stab him in the muscle.

It was sugggested to me to put the cat on an ironing board so that he's off balance -- with a pad on it for him to dig his claws into. I tried it, and it helped, but trying to make the fluid go faster in that position is hard. It seems that I have more luck with that if he's on the floor instead of at my waist level. If you can get someone to help you when you put him on the floor, do. For me, it is really hard to see the bag when I'm holding my cat on the floor, and I need someone to watch the bag and turn the fluid on and off.

Try to have a good night. I think it will be a long one for us, too.

 

I just read back through and apologize if I missed it....but what is he on Clavamox for? Did he have a recent infection?

 

Possible UTI or anything else, nothing obvious. He was on this same dose of clavamox his first round of NPH a year ago, and hasn't had any AB since.

Looks like they were pretty decent yellows for Chip overnight. ;-)

Let's see if this new dose can ease him a bit down without the red and black trampoline effect.

We'll just forget about yesterday. But it may show it wasn't yet time to reduce him that much without obvious pancreas? Or it may show I was just sleep deprived. Seems like he can survive the bounces as long as he's still getting enough to nadir in yellow and blue when they clear.

 

I'm only asking because of your assessment of trace ketones. Ketones are present in conditions in which metabolism is increased. Infection is a big one of these and is often the main precursor to DKA. Testing is the most important preventative measure as it can alert you to a potential problem. Other "fend off" actions are increased fluids (either sub-q or added to each meal), increased food (because of increased metabolism), and of course, sufficient insulin to ensure that the body is able to use the glucose it needs as the energy source.

Sounds like you are on top of all of these things. Behavior wouldn't necessarily change until a true problem existed, so keep up the testing and extras that you are doing!

 

Jessica, I am interested in your comment on increased metabolism because I had not heard that before. Would hyperthyroid be a factor in DKA? Or cancer? Does cancer increase metabolism? I should know that but I'm not sure. I know the tumor(s) suck up nutrients to feed themselves, so in a sense they have an increased metabolism, and we all know that cancer causes weight loss so I would be suspicious about this.

I have noticed first a decrease in Jeddie's BGs and now an increase. I just restarted him on prozac, so maybe that is a factor with the BGs, although I had not noticed that before.

 

I think if you are using the ketostix that they will get darker eventually which is why you need to use the freshest of pee and count for 15 seconds.

Sneakers also did that blush to trace from negative at count 13 or 14 for a while which really teed me off sometimes- "Are you or are you not??!!!" :lol:
I've seen some of her ones that I saw 5, 10 minutes later and they would be in the moderate range.

Good luck.

 

Ketone test strips can be tricky. You MUST look at it only at the 15 second mark, throw it away, don't look at it again! Also, it is very important to try to look at it under natural light. The lighting can make negative look like trace if you ask me. There's not quite enough color variance between the 2 samples.

 

Hyperthyroid definitely increases metabolism and can absolutely be a factor in DKA.

Cancer is an interesting one that I need to really think through. It increases the uptake of glucose but this increased metabolism is in the cancer cells themselves, vs. being in all normal cells of the body. I would suspect that the normal cells are still metabolizing at a "normal' rate. It also makes sense to me that you could see a drop in bg's because Jeddie's "normal" amount of circulating glucose is now being used by the cancer cells; and depending on the metastasis rate, these numbers could swing significantly. I wonder if the subsequent upswing is the same thing we've all seen when a cat is getting too much insulin (because of the increased glucose metabolism of the cancer cells). If this holds true, you may find yourself in a constant search for the right dose because of the rapid changes in the cancer.

 

Looks like no and no, but it still needs time to settle. :smile:

0.5U seemed like a somewhat safe holding pattern.

But was it a holding pattern to nowhere? What do the protocols say about numbers like that: Low pink to occasional mid blue, with almost "sort of" nadirs?

What *might* an abrupt change to Levemir bring to this situation? :idea:

 

Not liking the looks of this. :-|

To quote someone: "You got to know when to hold 'em, know when to fold 'em, Know when to walk away and know when to run." :razz:

Question is: it it too much or too little? It sure looks like too much, however...

Code:

Parameter used for dosage adjustment                                     Change in dose

Phase 1: Initial dose and first 3 days on glargine or detemir                        
Cats with a history of developing ketones that remain >300               Increase by 0.5 IU
mg/dL (17 mmol/L) after 24-48 hours                                                 

Phase 2: Increasing the dose                                                                
If nadir blood glucose concentration >300mg/dL (17 mmol/L)               Increase every 3 days by 0.5 IU    

Phase 3: Holding the dose. Aim to keep blood glucose                           
concentration within 50-200 mg/dL (2.8 – 11 mmol/L) 
 If nadir or peak blood glucose concentration > 200mg/dL (11mmol/L)       Increase dose by 0.25-0.5 IU depending on if cat on                  
                                                                         low or high dose of insulin and the degree of hyperglycemia
                                                                         throughout the day.  

According to every scenario above I should increase to around 1.25U for 3 days? grumpy_cat

 

It was 1u that got you to the blues and greens - and the big bounce to red - so I would not jump from .72u to 1.25u, but would next try 1u and see if he can settle on it instead of bouncing. That might work because you are raising to the dose and not lowering to it.

Some cats, apparently bounce a lot on lantus. If that ends up being the case, maybe switching to lev would help. So many cats stop bouncing on lev. Something to think about - actually, I know you have been

 

Well if we were talking about you right in front of your back, only hope we didn't build the expectations too high, and make promises you can't keep. :mrgreen:

I'm impressed that the clan of Lev don't roam the land evangelizing. That's just because everyone ends up here in the end by the natural force of gravity. They spend a lot to time and energy out there preaching but all you have to do is look at what they practice not what they promote.

I've been mulling the next dose. Not a lot between 1.5 and 1.0 but it looks like back of the flange to front of 1.5 mark might be 1.2. Something bold, I can always say it's just because I fear ketones. ;-)

 

Huh?

Why are you thinking of going above 1u as the next step? Even if you want to look at it as going back to the last best dose, those greens were from the three days at 1u. That is a 38% increase. IMO, that is where you should go to next. If his numbers don't start to come down than you consider going to 1.2u.

FWIW, probably "back of the flange to front of 1.5 mark" is more like 1.33u. Front of the flange to back of the 1u line would be about 1.17u.

 

Hard to tell, but this flange is fatter than the marks. So 1.2U looks like a fat 1.0 really, not much. MommaOfMuse made a good point that I need to get the numbers down. This isn't significantly more than what I had been doing earlier but hopefully the clavamox may be kicking in.

I did finally figure out why he refused two cans of his favorite tender beef feast. No one else would touch them either very strange. But Chip finally ate 1.5 cans of classic chicken feast so maybe the "scare" today was premature.

If this doesn't work then I will likely need to come up with a strategy to get a script for Levemir.

 

Once we get past the I told you so's I wonder where we go from here? ;-)

The Humulin N is not looking so bad all of the sudden, especially with my newfound *precision* in microdosing. :smile:

Should I convince the vet of Levemir, sounds like it would still take up to 3 weeks to get here from half way around the world? How can it survive unknown temperatures and handling all that time? Even if I had the big bucks to get some locally who knows the chain of command there either?

 

I was wondering as of late if I was the only one feeling this...... I love the gentle nature of both Levemir the drug and Levemir the clan.

 

I have found you can't rely on the Relion syringes. Every single one I take out of a pack of 10 have the flange line up differently to the zero mark, and they never, ever, ever fill completely. I have had wonderful results with the syringes from Walgreens, though. Much better consistency with markings, alignment, and many less wasted syringes and insulin due to air bubbles.

Suze

 

Levemir has many fans and I would hope that the Lev Clan does as well. I have always wanted to be a member of a clan! Must be my Scottish heritage coming out after a couple hundred years in the New World :lol:

 

That alone makes me want to switch Pumbaa to Levemir.

Suze

 

Suze wrote:

Wait! What? What do you mean they don't "fill completely?"

I've been using Relion syringes since the beginning. I'm not microdosing, but I may have to. Could this flange business be part of the problem?

Also, I noticed that they all have air in the syringe, air that I have to push out before I load it. What's that about?

 

That's normal so you can tell an unsued syringe from a used one. The relion syringes aren't what they used to be last year but they are still decent, at least the box I'm using now is. They always have bubbles but I found a foolproof way around that for Lantus.

First I push out the air and hold the plunger depressed, and insert the needle into the pen and pull out half a unit, then remove the needle. Hold the syringe with the needle pointing down and draw the plunger slowly out stretching the glob of Lantus along the wall of the syringe, until via surface tension, the bubbles all pull into the open space. Turn the syringe needle up and ease the glob of Lantus onto the plunger and push to the top expelling the bubble from the hub. So now I have just less that half a unit with no bubbles. Reinsert the needle in the pen and draw out a bead more than the needed dose, remove the needle from the pen. Fine tune the dose.

I do all that best in sunlight with 3X reading glasses and a large magnifier. Amazing how precise that can be. I also eyeball the size of the dose overall just to make sure it looks correct, nothing gravely wrong with the syringe.

 

This is why I have always liked GNP syringes. They come individually packaged. You can't use it if you don't open the wrapper first!

 

This is on page one, but if anyone is interested, these are the syringes that I use and Vicky is talking about:

here is a link:
http://www.hocks.com/diabetic-supplies/ ... 0-box.html

They are sometimes mis-printed, so I ALWAYS check for flange to zero line alignment before drawing a dose and adjust where the draw needs to be based on that check. Right now, i seem to have a box with the zero line above the barrel end by .1u to .15u, thus making the .5u line actually a .35u dose. It is unusual to have so many misprinted one. Usually it is maybe 1 in 10 or 15 that is not correct.

 

Good grief! Misprinted insulin syringes?! Nearly 10% of them? That's just nuts.

Thanks for the info, both of you.

I think I'll check out Walgreen's,

and I'll suppress the urge to go on a rant about where things are manufactured, under what working conditions the people manufacture these things, how much fuel it takes to get these things to us, and how the poor quality of nearly everything is making me insane not to mention the rising cost of these poorly manufactured things . . . blah, blah, blah . . .

 

Um, Dale, deep breath..... getting all upset only raises your blood pressure and has no effect on the decision makers at the manufacturing facilities....

I have no idea what the "miss-print" rate in on say, BD syringes, but those damn things are horrid for developing bubbles and not being able to let them go. At least with the GNP ones, they draw smoothly and bubbles are infrequent and easy to get rid of. And they are a lot cheaper than the BD ones too.

Walgreens brand are OK, if I remember correctly. That's the brand I used to get (had to have a script).

 

Dale: I totally agree with your rant about the poor quality of some of the products we purchase.

I know some people use the Relion syringes and have no problems. The box of 100 that I initially purchased has been nothing but problems. Just this morning, I had one that simply would NOT fill. And the Relions cause me to waste a lot of insulin because of having to way overfill them to compensate for the big air bubble that always remains near the plunger during the filling process. Yes, I can usually get the air bubble out, but I still have to overfill in the meantime.

I didn't have any problems with the Walgreen's syringes, so I will be getting more of those one day soon and take Relion up on their offer to refund my $$$$. It's the least they can do for all of the insulin I have wasted due to their product.

Suze

 

I hope I can too. ;-)

If Levemir is less fragile do you think it can survive unknown temps and handling for the trip around the world 3X from NZ via the People's Republic of China, or wherever it goes for three weeks to get here from Canada?

 

That is a good question. It really depends on how they handle the shipment - well, how it is packed. I am not sure I would risk it. At least if you bought it at a local pharmacy and it was bad, they would have to replace it (I think).

It used to be that you could get both the pen cartridges and the penfills - the former being just the cart and the later being the cart encased in the pen. One of those comes from Turkey or something and the other they stock there, so it is only shipping from Canada. Still, you are looking at time on a delivery truck where temps can get into the low 100s this time of year.

I know it is an outlay of money, especially bought at a local pharmacy, but the set of 5 penfills will last years depending on dose. Which reminds me to say check the expiration date before accepting the insulin. You might also be able to find someone to split the costs with you, or to sell you 1-2 of there supply. I sold 3 out of the first 5 that I bought.

 

After the repeated insistence from Venita I applied for assistance with DCIN. I guess beggars can't be choosers, as they only order from Canada.

If it was only a difference of $100 (and I had $100) I wouldn't want to risk it. But surely very well mixed, slow cooked Levemir will be better than no Levemir at all? @-)

However it's still subject to the careful playing of the second (or third? or forth?) "convert your vet" card to get another script. *Sigh* If all these things don't break just right it may be down to making another serious run with NPH, too bad there really is no ISG for that. For some unfortunate kitties it may be the only option. :-|

 

So sorry you are stressing so much, PapaDale. Sending vines to you and your kitty.

 

I know it's a little late...

I use these syringes and have found them to be pretty accurate. They even talk about the flange line up in their description.

I'm also guessing most people know this @-) @-) but there's also a "generic" relion test strip that's much less expensive. If you buy 4 boxes of 50, you get one free so the total for 250 strips is $70.00.

 

Jessica, I just received those Monoject syringes from ADW, and love, love, love them! Measuring the dose is so much easier due to the thinness of the flange and the printed lines, and I'm wasting a LOT less insulin because of a lack of air bubbles.

I've also been ordering those Arkray test strips from ADW, and saving $0.08 per strip over buying them at Walmart really adds up over time! ($0.28 each for the Arkrays vs. $0.36 each for the Relion brand).

Lancets are also a whole lot cheaper via ADW...$2.18 for a box of 100 vs. nearly $8.00 for a box of 100 at the drugstores.

ADW has my stamp of approval, that is for sure!

Suze

 

My stamp of approval too Suze ;-) ;-)