Info How Low Is Too Low?

Discussion in 'Lantus / Levemir / Biosimilars' started by Libby and Lucy, Aug 4, 2015.

  1. Libby and Lucy

    Libby and Lucy Senior Member Moderator

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    Recently I’ve seen some statements about low numbers in the Lantus/Levemir group that I believe merit further discussion.

    “We intervene at 50 (some even say 40)”

    If only it was that simple! The saying “every cat is different?” Very true. Also “every cycle is different.” What is the normal range for your cat? What is his onset/nadir? Is he currently surfing or dropping? Is that normal for him? What has he eaten today and when? Is that normal for him? How much food does it take to make him surf? How long does it take for that food to kick in? What if it doesn’t? If you cannot answer all of these questions, then you should think hard about whether it makes sense to wait until the cat is already very low to intervene with food.

    For two of my three diabetic cats, that advice could have been very dangerous and possibly fatal. For example, if I saw Jazzy dropping fast, I knew it took a long time and a LOT of food to get her leveled out. If I waited until 50 to give a teaspoon or two of high carb, I don't think I would have been able to turn her around in time (and Jazzy was a GREAT eater, no worries about whether the food would go in). Putting on the brakes for her required a whole can of food (a 5.5 ounce can). She wasn't interested in being finessed! I thought it was because she was on a higher dose, and maybe it was, but then I saw the same thing with Kris, who was only 7 pounds and on a much lower dose. In both cases, if they were dropping and hit 100 I would start feeding high carb – not to try to prevent a reduction, but to TRY to get ahead of them so they wouldn’t crash. Kris had a pretty good bounce mechanism (not as good as Lucy's) so chances are he would have been ok, but I didn't trust Jazzy to bounce.

    “Symptomatic hypos are rare (or don’t occur) above 30”

    This statement needs to be thrown out with the bath water. First, I’ve seen cats that displayed hypo symptoms in the 60s. It’s not the norm, but it does happen. 40s and 50s too. Know thy cat. Second, who cares? Just because a hypo doesn’t show symptoms does not mean it’s safe. Do you really want to flirt with hypo? There was a great link on the old board (now lost) that explained the brain damage that can occur even before symptoms appear. DO NOT become complacent about low numbers, and do not let anyone tell you to be casual about them.

    “So What SHOULD I do?”

    Feeding the Curve seems to be a lost art. For Lucy, who responded a little more typically, finesse was more possible. We used to say “teach them how to surf.” If your cat is dropping into green and that’s new for him, or if he typically bounces to the moon as soon as he sees green, try feeding him a little food to see if you can get him to stop dropping and start surfing. For example, maybe your cat is dropping, and you get an 80 at +4 and you like that number. Wouldn’t it be great if he can stay there instead of either plunging or bouncing? Maybe he can. Give him a couple of teaspoons of low carb and retest in 30 minutes to see if maybe that got him to stay in the 80 range. If he’s still dropping, maybe try a little higher carb to see if that works. You want to “bump him onto the surfboard” and see if you can get him to stay in a nice range. Most of the time this will not work in the beginning, but keep at it. One day you will notice that your cat DOES surf. He might surf for just an hour before bouncing, but that’s progress! Next time maybe it will be 2 hours, or 4, then one day maybe he’ll just stay on that surfboard forever. Lucy did.

    “What About Feeding to Prevent a Reduction?”

    This is not what I’m talking about here! Instead, you are feeding proactively to try to get him to surf in nice numbers. There’s a big difference. There are people who do feed to prevent reductions, and there are reasons for it, but that is an advanced technique that is not necessary for very many cats.


    Now you are saying “obviously she is too much of a scaredy cat to do Tight Regulation, we NEED low numbers.” No, we don’t. We need the cat to be in the pancreas healing range. 60-90 is a good target for most cats. The guidelines about dose reductions? It is not our GOAL to get below 50 or 40. That is a safety measure – we want to prevent that range, so if the cat hits that range we need to get them out of it and reduce the dose so they don’t do it again. And if they DO do it again, we need to get them out of it and reduce the dose so they don’t do it again. And so on.


    More food for thought – “hypo unawareness”


    This recent study discusses, among other things, something that we have observed here for years: “… episodes of moderate hypoglycemia are not without clinical consequences. Recurrent episodes of moderate hypoglycemia can lead to decreased sympathoadrenal responses and decreased awareness of hypoglycemia, collectively termed hypoglycemia associated autonomic failure (HAAF)7, which leads to an increased risk of more frequent and more severe episodes of hypoglycemia.”

    We "teach" our cats not to bounce from low numbers by repeatedly exposing them to normal/lowish numbers. It's part of tight regulation, but it does carry a lot of responsibility.

    How many times have people here commented that their cat was in the 20s or 30s and didn’t look for food? Lucy did that. Is that ok? Obviously Lucy survived the 30s, and most cats do. But would she have been just as unaware in the 20s? Or teens? What if she went low at night and didn’t wake up? I don’t know. Personally I feel that it if I push her into tightly regulated numbers that could result in hypo, it is my responsibility to be sure she stays safe. If she isn’t noticing her low numbers, then I have to notice them for her. If I cannot test 24/7 (and I don’t know about you, but I can’t stay awake 24/7 forever), then I need to prevent hypos rather than reacting to them.

    Bottom line: “How Low is Too Low” is very situational and there is no single answer. All that data you have been gathering – use it! Know your cat, then do what is right for him or her. There are others here who can give advice based on their own experience or their observations, but YOU know your cat better than anyone else. Trust yourself, trust your data, and don’t become complacent.
     
    Last edited: Aug 4, 2015
    Reason for edit: spelling
  2. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

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    For safety's sake... this needed to be said.
    Thank you, Libby.
     
  3. Tricia Cinco(GA) & Harvey

    Tricia Cinco(GA) & Harvey Well-Known Member

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    Thank you, Libby. Very good info. Your last section reinforces what Dr. Richard Nelson told me about low numbers. He was more concerned about the damage low numbers do than high numbers (occasional ones, that is). I hope everyone, especially the newbies, reads this and takes it to heart.
     
  4. Libby and Lucy

    Libby and Lucy Senior Member Moderator

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    new members and older ones both. Sometimes I think those of us who have been here the longest can be the most complacent.
     
  5. CarolynE

    CarolynE Member

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    Jul 21, 2015
    Thanks Libby.
    I am VERY new to this - today is Martian's third day on insulin, and first day of home testing (the vet kept him in for testing for the first two days).
    He dropped pretty low both days at the vet, with nadir around 9 - 10 hours. So when I tested him at +4 today and he was 68 I started worrying. Luckily he had just taken himself for a good feed and when I tested him at +5 he was back up to 99. I don't have enough data to really know his reactions yet, but your post makes me happier that I went with my gut instinct on this one.
    I'll keep checking on him during the rest of the afternoon, and I'll probably be asking for advice on whether or not/how much to shoot tonight and in the morning.

    Carolyn
     
  6. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Senior Member Moderator

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    Good information. Thanks for the link to the summary of recent research.
     
  7. Tuxedo Mom

    Tuxedo Mom Well-Known Member

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    Thank you so much for this post. I have been doing reading recently on hypos and your posting reinforces the fact that a cat can be experiencing hypo effects without showing outward signs. The body can be "responding" to a perceived hypo even though the numbers do not justify a hypo alert. Another good article:

    http://clinical.diabetesjournals.org/content/24/3/115.full

    I personally am more concerned about continuous "hypoish" numbers than about periods of higher numbers. Hypos can kill quickly...high numbers slowly effect the body and organs over time. Regular testing and patience are the best approach IMHO

    Another good article although this one relates more to type 1 diabetes:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279554/
     
  8. Libby and Lucy

    Libby and Lucy Senior Member Moderator

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    thanks for the additional links!

    One more thing to add for those looking at my spreadsheets. Lucy did hit 30s somewhat frequently when she was on insulin, especially when she was running down the dosing ladder. I did my darndest to prevent it, but it does happen and sometimes she was pretty hard to bring up. I knew I was in control and I stayed with her (control is the key - you do not want 30s to accidentally turn into 20s just because you're not paying attention). Now that she has been off insulin for over 6 years, I know that her normal range off insulin is in the 30s and 40s with my meter. That's not the norm and I wouldn't try to excuse too-low numbers that way unless you happened to test your cat enough before he was on insulin to know what his normal non-diabetic range was. ;) If she ever goes back on insulin, I'm still going to try to keep her above 40-50 because of the control factor. I believe (and have seen over and over) that tight regulation and remission can be achieved without pushing the boundaries too far.
     
  9. Critter Mom

    Critter Mom Well-Known Member

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    Excellent post, Libby. I would really like to see this as a forum sticky.

    I know that there is some debate about equivalence of reference ranges between human and Alphatrak/other pet-calibrated meters and that more definitive reference ranges for these meters are currently being sought from Dr Rand. On behalf of myself and other pet-calibrated meter users I'd like to put forward a request that somewhere on this thread there could be included some appropriate 'interim' reference range numbers they could use in order to make the opening post more easy to relate to their glucometers (together with any disclaimers deemed appropriate).

    ----

    Libby and @Tuxedo Mom - Thank you both for the valuable links.
    .
     
    Last edited: Aug 5, 2015
  10. Tuxedo Mom

    Tuxedo Mom Well-Known Member

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    I am quite interested in what Dr Rand has to say. The study gave some guidelines for the variance but mainly at the low end of the readings. I have a tab on my spreadsheet that shows same blood drop comparisons between the AT2 and FS Lite meter. I had more earlier but did not keep a record. Although there is of course a +/- allowable error range, there seems to be a basic % pattern overall. For people like myself, using a pet meter makes it very hard to request advise on doses etc since the majority of people here use a human meter. I choose a "higher" number as my "hypo alert" than many others would and do not aim for as low a number to surf at.
     
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  11. lovey11

    lovey11 Well-Known Member

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    I agree this would be a great addition to the sticky notes. It gives a good perspective to keep our pets safe and to understand our pets responses.
     
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  12. Patricia & Noodle

    Patricia & Noodle Well-Known Member

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    Thanks for this information, Lucy! It's really helpful, especially for those of us with cats that have perfected the swan dive. I've found feeding the curve, even if I have to use some HC, (I use honey thanks to a suggestion from @Bron and Sheba and @Sienne and Gabby ) has helped manage the severe drops so much. If I waited to feed until she was under 50, she'd be bouncing up and down the dosing scale with no "good dose" in sight.
     
  13. Shiloh & Rhonda (GA)

    Shiloh & Rhonda (GA) Well-Known Member

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    Thanks Libby. This actually hit home for me.
     
  14. Marycatmom

    Marycatmom Well-Known Member

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    I, too, would like to see this become a sticky. So much helpful information!
     
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  15. Marje and Gracie

    Marje and Gracie Senior Member Moderator

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  16. Paula

    Paula Well-Known Member

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    Bump
     
  17. Gill & George

    Gill & George Well-Known Member

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    Love the explanation Libby, haven't seen that one before Marje thanks for the Bump.
     
  18. LemmiwinksMommy

    LemmiwinksMommy Member

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    Thank you so much for this!!! I am so new at all this. My Lemmiwinks just decided that he was gonna go from the 200's to the 80's. I do understand that we are shooting for those good numbers, but was also a little nervous of what to do with them. I want to do whatever I can to help him. This was just what I needed....THANK YOU! :bighug:
     
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  19. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

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  20. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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  21. Tuxedo Mom

    Tuxedo Mom Well-Known Member

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    Thanks for bumping this Leslie. People REALLY need to read this over and over and over!!
     
  22. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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    Agree, all of these make more sense with more experience. I reread them constantly!:bighug:
     
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  23. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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    I think this info post is where I learned to feed the curve to keep Gussie surfing, to keep him in green to let his pancreas heal, why what you guys were telling me made sense.
     
  24. Tuxedo Mom

    Tuxedo Mom Well-Known Member

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    So important for people to know that numbers are not written in stone. ECID....(Every Cat is Different) Know your cat and use the protocols as a guideline!!
     
  25. Photorecon

    Photorecon Well-Known Member

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    This comes at the right time, just when I was questioning stopping feeding between cycles as it doesn't
    seem to have any effect. Might be a life saver one day.

    Extremely interesting, thanks.

    .
     
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  26. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

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    Bump for newer members! :)
     
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  27. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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    This should be required reading..thank you! And thank you!
     
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  28. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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    Adding another bump with thanks to @Bobbie And Bubba for reminding me to read it again! Gussie's hypo or at least consensus was pretty sure it was was one of the ones in higher numbers than expected...
    Thanks again..bumpity bump
     
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  29. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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  30. Kathy and TiTi

    Kathy and TiTi Well-Known Member

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    For months now, I've cast a baleful eye at the aggressive pushes downward that I've sometimes seen. I've learned that as long as TiTi is in the 70-123 range, she's perky, healthy, and bright eyed. To me that seems good. I think, well, I hope that she's healing in this range.
    I didn't know until I read this that 50 0r even 60 can be a hypo. However, I've never liked it when TiTI hits low 60s to 50s, because in the early stages of her cycle, she can drop quickly, especially at night, so I got into the habit of feeding her a tsp or two of LC every few hours, and always after testing. Seems to keep her smooth. At night I give her at least 2 TBS of food before I hit the sack - just in case.
     
  31. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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  32. Kathy and TiTi

    Kathy and TiTi Well-Known Member

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  33. Marlena

    Marlena Well-Known Member

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    Thank you Libby for a very informative article!:cat::cat::cat:
     
  34. Gussie's mom (GA)

    Gussie's mom (GA) Well-Known Member

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  35. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

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    Bumping per request.
     
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  36. Tanya and Ducia

    Tanya and Ducia Well-Known Member

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  37. Krystina & Nelli

    Krystina & Nelli Well-Known Member

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    Bump
     
  38. Photorecon

    Photorecon Well-Known Member

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    Hi everyone,

    Not that long ago when Small Kitty was taken care of by a petsitter I came back and sugar kevel was at 36. He was in the kitchen mot moving that much.. He was stii breathing had a normal appart from staying where he was. As I didnt know if he was still going down I gave him some maple sirop. Little after he was ffime if my memory is fine.

    Each time Small Kitty goes down his sugar level goes crazy (end up being purple) and it takes several days to bring him back down. That's the price to pay of a dose that is too high.

    Hope this hells others, have a good one

    Seb
     
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  39. Bobbie And Bubba

    Bobbie And Bubba Well-Known Member

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    Good to see this again!
     
  40. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

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    The OP in this thread wrote this post for those practicing tight regulation. It came about because there was a growing trend among those practicing Tight Regulation to become nonchalant about low numbers... numbers mostly in the 20s, 30s, and 40s. Since their cats weren't showing symptoms, they were allowing the cat to ride in those low numbers without any apparent concern or worry because they did not want to 'shorten duration' or mistakenly think they would 'contribute to the bounce' by intervening with high carb food or syrup.

    Currently, those in other insulin groups do not practice tight regulation like you've been doing nor do they 'teach a cat to surf' in low numbers. If the post was appropriate/applicable for the general Health Forum, Moderators would have made the decision to post on Health, the other ISGs, and/or in the Health Links/FAQs Forum. We did discuss at the time, but didn't want to confuse those using other insulins with TR practices, or worse yet... let them think mid-greens are ok/the goal when using all insulins. :confused:
     
  41. Ti-Mousse (GA) Pepe (GA)

    Ti-Mousse (GA) Pepe (GA) Well-Known Member

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  42. Tanya and Ducia

    Tanya and Ducia Well-Known Member

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    (bump)
    I knew right away that such valuable post could not have been just discarded even before I spotted the yellow Info sticker at the top. If I had any knowledge about other insulins I would (probably) have figured it out myself but my mind is so very Lantus.
    Now, after you pointed it out, I can certainly appreciate the wisdom behind the decision not to post. I personally was very taken by the “Hypo Unawareness” expression -it fits Ducia’s antics to the letter.

    My post in Health already sank to the bottom and should not cause much confusion. Although what I hoped it had done is helped our newer members to overcome their fear of home testing and, more specifically, to circumvent their “vets” order not to test at home. “Vets” have not being helpful in that regard at all
    I hope no one died. Was it really worth the risk as in any of them got OTJ? Ducia started to have violent seizures at BG 33/29, and was none responsive/comatose at BG 22 when we got to the ER; she had encephalopathy (of the unknown degree) and her vision was temporarily gone. Was any other damage done? IDK. Do I want to know at which low point exactly she crashes or brain damage become apparent? I think not.

    I want no cat “to swim with the sharks” to prevent that cat from ending up “sleeping with fishes”. [Sicilian expression from The Godfather meaning “dead”]. No do I want anyone to develop HAAF. It sounds like an expressway to Hypo.

    I appreciate the re-post and especially the talk, thank you
    @Jill & Alex (GA)
     
  43. Bobbie And Bubba

    Bobbie And Bubba Well-Known Member

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    Tanya, I so appreciate how this info sticky got your attention. I remember the hypo day with Ducia like it was yesterday. It was probably the most stressful day on this forum that I ever went through. Ugh. Thank you God that there was a happy outcome for you and Ducia.
     
  44. Tanya and Ducia

    Tanya and Ducia Well-Known Member

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    Bobbie, :bighug::bighug::bighug:
    I forgot (as if) the details but what I won't ever forget is your and all of the gals help and sticking with us till the latest whilst being almost sick to your stomach
    but especially (please forgive my awkward attempts at humour, I mean to make a joke) that rectum syringe, lol, I told you before that it is how she survived the trip to ER, the doc listened so attentively when I told her what I did and I believe since that she used the tip for her patients.

    I am so very sorry about Forrest departing, Bobbie.
    :bighug:
     
  45. Bobbie And Bubba

    Bobbie And Bubba Well-Known Member

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    :bighug:
     
  46. Bobbie And Bubba

    Bobbie And Bubba Well-Known Member

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    It was the first and only time that I instructed someone to use a feeding syringe with Karo syrup or honey and shoot into the rectum because the kitty was in seizure with it's mouth clenched tight. I hope I never have to again, but I will do so if necessary. It was lucky for you that Ducia had been discharged from the hospital from DKA and you had feeding syringes on hand.
     
  47. Bobbie And Bubba

    Bobbie And Bubba Well-Known Member

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    Hmmm, feeding syringes...that might be something that everyone should have in their hypo kits.
     
  48. Tanya and Ducia

    Tanya and Ducia Well-Known Member

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    a must to have item, for sure.
    we were even luckier - DCIN :bighug::bighug: paid for the E-Tube.
     
  49. Amina&M'row

    Amina&M'row Member

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    Great, great article; I downloaded it so I have it at hand. Like many kitties, M'row is asymptomatic at scary low numbers; important to keep this in mind and hometest. I do before every shot, and am not scared to skip the shot if needed. The first time he went low he wound up just about covered with Karo, LOL, but came out fine.
     
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  50. Elizabeth and Bertie

    Elizabeth and Bertie Well-Known Member

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    Bump... Such a good thread. Very worth reading....
     
  51. Sandi&Maxine&Whispy(GA)

    Sandi&Maxine&Whispy(GA) Well-Known Member

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    Agreed. A feeding syringe and a bulb syringe (like for sucking boogies from a baby’s nose) which is more gentle if you have to insert Karo into the rectum, have always been in my kit.
     
  52. SnowKat

    SnowKat Member

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    Phenomenal post. Bookmarked and bumped. It totally confirms my very recent decision to lower my boy's usual dose (even though I loved seeing those blues and greens), after a few lower than usual numbers (and other factors as well). I know we all hope and pray for remission, but I'd rather be "safe than sorry" with my baby. Thanks again.
     
    Last edited: Jan 29, 2020
  53. Teri & Disco NoFurNo (GA)

    Teri & Disco NoFurNo (GA) Well-Known Member

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    I have both in my vet supplies cupboard and they’re going into my hypo kit right now
     
  54. Pamela & Amethyst

    Pamela & Amethyst Well-Known Member

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    Thank you!!!!
     
  55. Pamela & Amethyst

    Pamela & Amethyst Well-Known Member

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    Thank you SOO true especially with an ACRO!
     
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  56. Pamela & Amethyst

    Pamela & Amethyst Well-Known Member

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  57. Sonia & Leo

    Sonia & Leo Well-Known Member

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  58. Cherryl & Mouzer

    Cherryl & Mouzer Well-Known Member

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  59. Scdal

    Scdal Member

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  60. JL and Chip

    JL and Chip Well-Known Member

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    In addition to “know they cat,” I would also add “know thy meter.”

    Specifically, have a clue whether your human meter tends to run on the “lower” side or “higher” side of things.

    Reading that “normal” for one person’s cat was in the 30’s or 40’s (or even 20’s) is predicated very much on that person’s meter and should not give a false sense of security to others who see that number.

    My go-to meter was an old One Touch Ultra which usually read reasonably close to lab values. A 60 or 70 on that meter was pretty “normal” whereas my Relion read much lower on the same drop of blood, making “normal” for that meter more like a 40 or 50. I also had a Contour, an Asencia Elite, and others (I was a bit of a meter junkie back in the day). I never really used those other meters much, just kept them as a backup for an emergency and did some comparisons out of curiosity. My point is not that you need to know the absolute value of the BG reading, which is almost impossible, but rather that you know when a number is “safe” vs. when to be concerned.

    I tested my meters on some of my non-diabetic cats to get a general feel for what “normal” was on a particular meter. If several of the non-diabetics threw me 40’s or 50’s, then that was a pretty good clue about how that meter ran and gave me a general point of reference. My OTU gave me 60’s and 70’s, so that set the bar for me. A 30 or 40 on the OTU would have (and did) send me scrambling.

    Another consideration (which I almost hate to mention because I don’t want folks to stress unnecessarily) is that anemia can cause artificially inflated BG readings ... meaning that the cat’s BG is actually lower than what the meter is telling you. I mention this in the spirit of Libby’s original post, which is that we need to know thy cat, always look at the big picture and other considerations, and never become cavalier about low numbers.
     
  61. smorgasbord

    smorgasbord Well-Known Member

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    Great info. Bookmarked and took notes.
     
  62. Julia Rae

    Julia Rae Well-Known Member

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    You rock Libby and bumpty bump
     
  63. Jay Dee

    Jay Dee Member

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    Thank you!
     
  64. Heather82372

    Heather82372 Member

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    Dec 28, 2009
    Yes thank you! This reinforces what everyone has been trying to explain to me. I've been so "jealous" of those who got their kitties OTJ and that was my "goal." Now my goal is just getting his pancreas to heal and try to keep him as level as possible in safe low numbers.
     

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