Pre-shots Variations?

I've been having a hard time getting my boy stable. If you look at my chart going back to the beginning of the year, there are periods of a month or more where he is pretty much in the blues and low yellows, and then out of the blue, he will start with pre-shots of 300, even more sometimes.

So, I try to follow the advice in Tilly and "Queensland" protocol and raise the dose .25 and hold for at least 3 days and then its like he straightens out for a few weeks and then bounces again.

What's most confusing is the constant second-guessing if I am giving too much or not enough (from what I read, both can cause the same symptoms). And even more so, why was he doing so well all Jan, Feb and late March to end-April. It is especially weird that this is happening on Levemir (although its maybe a little early to tell).

Recently I put him from Lantus to Levemir. He was on 1.75U Lantus and started him on 1U Lev; I have increased his dose .25 every 4-5 days. He will still range from pre-shot of 200 and up to 300 12 hrs later.

I am concerned that this bouncing is hard on his metabolism, as he is losing muscle in his thighs.

Is there a way to rule out if "bouncing" (if we can call this that) is caused by too much or too little insulin?

Notes:
he is fed FF classic chicken - no dry food whatsoever to cause spikes
has history of low-level pancreatis (which could be the cause of this)
he gets 100ml sub-qs EOD

 

You havn't any recent mid-cycle tests, which are how the depot insulins are adjusted - both Lantus and Levemir. The pre-shots aren't very useful, other than setting a no shot number.

You need to get some of those before adjusting the dose.

 

Hello there

BJ nailed it. Without mid cycle tests you really dont know whats going on. He could easily be dropping into blues and greens and going back up for the end of the day... and maybe even too low when you have a blue preshot.

I would suggest two more tests a day - one midday ( if you can 7-9 hours after morning test) and one before bed (3 hours after pmps) for the next 3 days. If you are working during the day, then switch it around. Do that for 3 days .. Hold the 1.5 dose meantime. Keep us updated and we will see how it goes and advise from there.

Wendy

 

I'm going to do this over the next week or so. Its hard for me to test middle of the night b/c of sleep issues, but what I will do is:

his am and pm shots are at 9am and 9pm. I am going to test him between at +7-9 around 4-6pm and again +3-4 after his pm shot at around 12-1 am.

note: this am at 9 he was 297 and then now at +9 he is 10.2

 

You might try a urine test, to check for ketones and glucose, using KetoDiaStix o=r generic.
Ketones suggest not enough insulin; more than a trace is an emergency vet visit.
Glucose in the urine means the glucose exceeded the renal threshold since the previous void. May support doing an increase, in addition to your mid-cycle tests when you can get them.

Urine tests will give you info on what has happened since the previous void, so they aren't super exact.

 

Thats perfect.. as well as preshot tests right?

 

yes, those too - so four tests every 24 hrs: 9am & 9 pm, 6pm, 12am.

 

I remember reading the AT meter can test for ketones but am not sure.

How to test his urine? (could I still do this with clumping litter?)

 

I dont know if the At can test for ketones. Heres how to test the urine ( clumping litter wont work) : https://docs.google.com/document/d/1quta5WLEjdO0Y_t2dAYSwN84h-LNZWxOdtVsJDKZ16A/pub

 

No, the Alphatrak 2 meter can not test for ketones, only the blood glucose levels. I used to have one for Wink before I gave it back to the shelter.

If you are ever up at around 5-7 am, you might want to test then. It's another option since Levimir has such a late nadir in most cats.

Looks to me like he could be having mild bouts of pancreatitis and then getting high numbers. Pancreatitis flare ends and the numbers go back down.

Also, just wanted to verify that you are giving the sub-q fluids and the insulin injections in widely separated areas on his body.

What is he getting the sub-q fluids for?

 

I will try to get some early am readings too.

I give him the sub-qs 3-4x a week (whenever the numbers start to creep up as a precaution against p-titis) between his shoulder blades (100ml with a 18g 1") and then I inject him with his insulin around the high flank/shoulder blade area and sometimes close to the scruff, where oddly enough, he seems to absorb it the best.

Weird thing is that when I try to give it to him on the left side of his body - anywhere, it doesn't seem to register.

 

Re: Pre-shots Variations? (update)

I've gotten some more numbers and it doesn't look good.

What's happening is that the Levemir seems to kick in sometime (during the day) at +7 - +9, and then his pmPS is close to his amPS..

But then just three hours later, he seems to be climbing 100 or so in three hours right after his pm shot and staying high and flat all night.

This raises three questions:

Is this to early to tell if he's getting too high a dose?

also, what does too high a dose typically look like?

and how soon can one tell after raising a dose that its too high?



(note: if its a p-titis flare that's causing this, I am giving him subq's 100ml 3-4x a week and some pepcid and transdermal codeine, which would likely be the exact protocol if he tested positive for it)

 

We need more tests to know what he is doing.

Last nights pinks could be a bounce off a low during the day - a low followed by high and flat usually means a bounce. I would get more tests in for the next 2 days and if its a bounce it will clear and he will come down.

Although Levemir is usually +7 to +9 , cats nadirs (low points) do vary. He may have gone low between AMPS + 1 and +6 yesterday. Or he could be bouncing off that blue 9.3. Although I wouldnt assume the 9.3 was his nadir.

If you see him drop into blue again, get more tests more frequently (hourly) to see if you can catch a green.

If he drops under 50 at any point, his dose is too high. Note he could drop under 50 and back up again in a couple of hours and you could miss it - hence the request to test more often if it looks like he is dropping.

Am i making sense?

Wendy

 

thanks for this - its like the Levemir is taking effect quicker than usual with him.

but there is one thing I am unclear about:

could it be that he might not even get to a 50, or even 100 and still be bouncing (or phrased another way: could his dose be too high even though he doesn't get under 100)?

If he still does this same pattern for the next two days (or more), say until Monday am or later, would that indicate he is bouncing and needs reduction?

(am thinking too, if this were caused by some mild p-titis flares, he would tend to stay elevated, regardless of dose changes)

 

Re: Pre-shots Variations? (update)

+3 after his am shot and he is climbing higher - if he is still high and flat by tonight or tmmrw am, should I lower dose back to 1.25?

 

To anseer your questions

He still could be bouncing because his liver hasnt seen enough of normal numbers for a while and so thinks 50 or 100 is too low (which it isnt.) So when the liver sees low numbers it panics and takes action to cause the blood sugar to rise. This does not mean the insulin dose is too high. Just that the liver needs to be retrained! So the answer really is no, if he isnt dropping below 50 then the dose isnt too high.

It depends. If he drops below 50 then we will decrease. If he doesnt show anything green or enough blue, we would increase. So its key to try and find out how low he is going.

Looks to me like the bounce might even be clearing - his PMPS will be interesting - you might even want to get a test before that . And if PMPS is also blue - get a PMPS+2 at least.

Wendy

 

So, what you are saying that if this is a case of him having had such long-term cycles of hyperglycemia that to his system, a 170, looks like a 50 (where the liver might overreact), the only way to resolve this is to hold the dose until we see more blues?

is there a time-frame (or some other means) where we could see that this pattern isn't changing, which would suggest raising or lowering?

I am thinking that I will hold this dose and testing intervals for a couple of days. It wouldn't surprise me that he might be close to "normal" tonight and overnight, and then late tmrrw, the higher numbers will cycle back again (what would that tell us?)

 

Yes and no. Yes to him a 170 looks like a 50. But we resolve this by forcing his blood down into lower numbers and eventually the liver gets used to being there. He will likely bounce for a while up and down.. until one day the liver learns and he stays down all the time = remission or regulation. So for the next few days we find out how low he is going (in between bounces) and if he isnt spending enough time low, we increase the dose to force him there.

3-5 days. The bounces usually last 72 hours so that timeline gives them a chance to clear to see how low the insulin is actually taking him. Here is the protocol on dosing: http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=1581

Sounds good on the testing but if he starts to drop into blue I would test hourly till he goes back up. Also I think the bounce is clearing - can you get a +10 or is it too late now? If he doesnt come down into green by end tomorrow I would be inclined to increase to 1.75.

Wendy

 

Is one clue here to know that we are not giving too much, is that he is going up and down and not being high and flat? (would that be like somogyi? )

Is there a chance that if he were getting too high a dose here that he readings might look exactly the same? (or is the fact that he doesn't drop to 50-ish is more or less suggestive that isn't getting too high a dose?)

Another way of looking at this then would be > the only way to rule out if he isn't getting too much is if he stays high and never gets low greens?

(the reason I am asking this, is that the thing that drives me most crazy about this is that the readings of too much and too little insulin can tend to look the same)

 

With somogyi the bounces are more extreme - so you get a low green ( under 50) and a fast rise to a big nasty high red or black. Thats why I dont think its somogyi.. no reds or blacks.

Could be - but we havent seen any greens that would indicate too high a dose yet. If anything he isnt getting enough insulin.

Pretty much - too much insulin would pull him down too low at some point, between the bounces. We arent seeing that

Subtle differences, but again I think its more likely now he isnt getting enough. Do your syringes have half unit markings? I am thinking 1.75 tomorrow unless we see a green today but he is still coming down yay!

Wendy

 

geez, this is bad, he is up to a 360 now at +3 after his am shot, where he was 285. So that's a big jump up, real quick, which makes me worry about raising him.

I have 1/2 U30 spikes and am using Levemir. (could it be that the Levemir is stronger than the Lantus he was getting? (Roomp/Rand said that the dose range for Lev is 70% of Lantus) So, does this mean that the equivalent of the 1.5 he is getting now would be 2.25 Lantus?

 

Another thing to consider is:

Since the main guideline is that we aren't seeing greens or anything close to them, we are assuming that he isn't bouncing as in chronic overdose.

But with this cat, he has had ongoing spells of pancreatitis for the past 2 yrs, so could it be that there is a residual inflammation in his pancreas that is keeping him from getting that low? Or, since he has been high for long, maybe another factor keeping him from being low for long?

 

These are good questions but I don't think so. I do think he needs an increase but let's get some others to chip in here.

I would recommend you go to the lantus tight regulation board (also applies to levemir) and ask if they think he needs a dose change and link to this thread so they can read through. There are a lot of way more experienced people than me on there that can comment.

Here's the board http://www.felinediabetes.com/FDMB/viewforum.php?f=9