7/13 Meatball AMPS 497 +3 337 - what to dose tonight?

I started a thread with some questions in the relaxed forum, but moving over here based on what's transpired today. Looking for advice on how much Lantus to give for tonight's PM shot around 7 PM. But first, some quick background...

New diabetic; started Pro Zinc a few weeks ago with our vet who wasn't a huge home monitoring fan. Got involved with an internal medicine specialist about a week ago when we were referred for an ultrasound (result: fatty liver). She's supportive of home testing so we ordered the meter and did our first home curve using Pro Zinc yesterday. After a chat with her yesterday we all decided to switch to Lantus. The protocol she gave us last night was from University of Queensland "Use of Glargine (Lantus) and Detemir (Levemir) in Diabetic Cats with insulin dosage adjustments based on monitoring blood glucose concentration once a week (preferred) or every two weeks with serial measurements every 3-4 hours over 12 hours", which calls for "Begin with 0.5 U/kg if blood glucose (>360 mg/dL (> 20 mmol/L)". http://www.uq.edu.au/ccah/docs/diabetesinfo/link3.pdf

So, we started with 2 units this AM. AMPS was 497 and +3 was 337. As this was occurring I was doing research on this forum and elsewhere and read up more on the "tight" protocol used here, described by the University as "Use of Glargine (Lantus) and Detemir (Levemir) in Diabetic Cats with insulin dosage adjustments based on home monitoring of blood glucose concentration at least 3 times a day." which, as you all know calls for starting with .25 U/kg. I emailed with the vet this AM (post AM shot of 2 units) and she's completely on board with the protocol if we want to follow it - this is important to us, particularly since Meatball is boarding with them this Tuesday to the following Monday while we travel.

So, back to my question - since I started with 2 units this AM, any recommendations on reasonably moving over to the tight protocol and on tonight's dosage. Will post +6 and +9 later. Thanks for your knowledge!

Jo --

I think the version of the Tight Regulation Protocol that the vet gave you is the old version. Initially, the protocol that was available through University of Queensland (Jacqui Rand, DVM) specified that the starting dose was calculate as 0.5 x ideal weight (in kilograms). As you noted, the protocol has since changed based on the article published by Roomp and Rand (2009) and the initial dose formula was decreased. When the initial formula was developed, all of the kitties were in the vet hospital and being monitored very closely. In order to make the protocol safe for the caregivers who are managing their cat's FD at home, the initial dose was reduced.

It you look carefully at the section of the newer version of the protocol that talks about starting dose, there's a caveat. If a cat is being switched from another insulin, the dose of that insulin is taken into consideration. Since Meatball was on 2.5u of Prozinc, starting Lantus at 2.0u seems reasonable. However, what's Meatball's weight? Knowing what the difference is between the weight-based formula for starting dose vs. the 2.0u might be helpful.

One of the big differences between Prozinc and Lantus is that Lantus is a depot-type of medication. This gives Lantus is long duration and allows for overlap between the doses. It also causes a cumulative effect of dosing. However, it takes roughly a week for the depot to form. As a result, you want to hold the initial dose, barring a need to reduce the dose, for at least 5 days. So to answer your question, I would suggest holding the 2.0u dose for the next several days.

With Meatball being boarded at the vet's office, are they there to monitor 24/7? If not, you might want to consider lowering the dose for safety reasons. We strongly encourage caregivers to get a "before bed" test every night. I'm guessing the vet's office closes at 8:00. Even is someone tests Meatball before they leave, it's likely that their last test is considerably earlier than when you would get your last test. Further, the vet's office may not be able to catch a test close to the nadir during Meatball's PM cycle. Lowering the dose may give you a solid margin of safety. (Of course, if they have a 24/7 operation, this is a moot point.)

Sienne and Gabby said:

Since Meatball was on 2.5u of Prozinc, starting Lantus at 2.0u seems reasonable. However, what's Meatball's weight? Knowing what the difference is between the weight-based formula for starting dose vs. the 2.0u might be helpful.

With Meatball being boarded at the vet's office, are they there to monitor 24/7?

Click to expand...

Thank you! Meatball's weight is 9.5, which we think is probably an ideal weight (down from 11 lbs earlier this year). Fortunately, the vet is an emergency vet and so, yes, they do 24 hour monitoring. That was part of our desire to go there. There are always folks around. Interested in, based on meatball's weight, if you still think 2 units feels right. I certainly don't think it'll hurt him - his numbers have been high on Pro Zinc and we were starting to inch towards 3 units there. Thanks again, Jo

+7 was 386. Think we may stick with 2.0 units tonight and for the three-day period (subject to reducing per the protocol). Any thoughts?

+9 401

Welcome Meatball

I think the 2 units tonight will be fine. Try to get a before bed test tonight and post the number.

I think you're fine to stick with 2.0u.

The "official" version of the protocol does stipulate to hold the initial dose for 3 days. You can hold the dose for longer is you think it is necessary.

just to give a different perspective, if Meatball were mine, assuming no history of ketones, I would probably restart at 1u and fast-track the dose if necessary (fast track just means moving a bit faster than every 6 cycles, maybe even every 4 cycles, if you're seeing no response initially).

Here's my reasoning:

• Meatball has only been on insulin for a couple of weeks (still a very new diabetic). It's as good a time as any to start over. If it turns out that he does need 2u or higher, it will only take a week or two to work your way back up to that dose. The difference is that you will KNOW he needs that dose rather than having to wonder.
• Starting at a high dose and (maybe) working your way down is MUCH more stressful for a new member than starting at a lower dose and working your way up. You'll never have that "comfort zone" most of us have because we know for sure our dose is not too high.
• While we do consider the dose of any previous insulin, there is little data to know whether 2u actually was a good dose of Prozinc or not. In fact, there are a couple of steep drops on 2 units, so it's possible that 2u was too high a dose on Prozinc too. I know that when you are new, it doesn't make sense to look at high numbers and think the dose is too high, but high numbers can actually be caused by a dose that is too high (the body reacts to lower numbers and/or to steep drops by releasing extra glucose into the system, usually leading to high numbers). That high curve you had on 7/12 might have been a bounce from some lower numbers or from that fast drop the night before.
• Lantus works on a cumulative basis. It usually takes at least 3-4 days to see for sure what a dose can do. Some cats take more time, some less. That means that we would not expect to see good numbers today. In fact, if Meatball is going to respond to this dose, it will probably happen on Monday or Tuesday, just in time for you to leave.
• You asked in your Relaxed Lantus thread why the protocol had changed. The 0.5u/kg starting dose is very aggressive, and that protocol is more appropriate for cats that are hospitalized the first few days. In the hospital, the vets can monitor around the clock and give glucose if necessary. The idea is to immediately get the numbers down, expecting that the cat will need dose reductions before they go home. I know they did something like that when Lucy was hospitalized - gave a high dose of insulin, then when she plummeted they added dextrose to her IV to keep her numbers up. 0.25u/kg is safer for home use, since most of us cannot monitor around the clock, and you can always increase quickly if it doesn't work. The Roomp/Rand version is the most up-to-date protocol currently published for Lantus and Levemir in cats.
• Many of us reduce our cat's insulin dose when we will be boarding them or leaving them with a petsitter. Cats might not eat as well when they are not home with you. Do you know how Meatball will eat when you're gone? If he has fatty liver, does that mean he has not been eating well? Or what is going on that made you get an ultrasound?

Of course, the fact that you'll be gone for a week makes fast-tracking harder, so really any choice has pros and cons. Talking with your vet is a good idea, as well as considering whatever other factors are at play. Are you able to get a lot of tests between now and Tuesday? With the higher dose, I would like to see a lot of testing so you'll have some confidence in the dose by the time you leave.

Thanks so much! Libby and Lucy, decided to stick with 2 units for today, but your reasoning and questions were great for us to consider and discuss. Much appreciated. Meatball has been eating well, though I am worried that may not be the case at the vet. We're hoping to meet with her Tuesday before we leave Meatball to discuss the specifics of our "away" plan. All definitely more stressful than I'd thought it would be!