Gucci - Need Major Guidance on dosing method / dose

Original post here - https://felinediabetes.com/FDMB/thr...-diagnosed-with-dka-2-27.287866/#post-3171345

Long story short, Gucci was diagnosed with DKA and hospitalized for 4 days on February 27th 2024 and 2 months later after getting more aggressive with insulin about a week ago and increasing to 2.75 units Lantus, is now in the normal ranges for most of the day. He used to bounce for days and stay in the 400-600 range, but now will spike for only a few hours in the 300s and then come back down in normal range. I was trying to follow TR since 4/20 but now am second guessing that and may want to reduce his dose. His nadir is now around the PM shot (around 70-80 on the Libre 3 which is usually 35 below the Alphatrak 3, so it makes giving his normal dose kind of scary. My spreadsheet in my signature is based on Libre numbers with recent comments on ALphatrak 3 blood numbers. I also have a 2nd tab that shows the actual curve by day with highs/lows throughout the day so you can see the trends. The last week has some promising numbers, but I need to find a way to get these lows up

Last night his BG was spiking up so I gave him his regular dose of 2.75 and then it went right back down and had the Libre showing Lo (<40) - 55 for about 7 hours straight. I got blood from him 2 times out of about 15 pokes with my pet meter which showed 80 and low 70s. I gave him very high carb food (38% DMA) and karo syrup smears multiple times but that would only raise it about 10-15 mg before dropping again. I had to repeat this cycle about 5 times and didnt sleep. Should I continue to give him the 2.75 in the morning (or maybe 2.5) and then at night go down to 2 and keep decreasing if its still too low? Tonight it was climbing up to about 120 and I gave him 2.5 units (decrease of .25) but now im in the same boat with lows and having to apply syrup and high carb food just to get a temporary spike. It went up by about 10mg and went right back down <40 on the libre (76 on the Alphatrak 3 pet meter). I gave him more HC food and this time honey instead of syrup and it has spiked up now in the 140s which should let me sleep for a little bit

I need to be realistic about my expectations since this is affecting my personal life in a major way (job, mental health, social life) I am asking for guidance on dosing. Right now this is what's important to me

1. Having Gucci in a normal range so he has a lesser chance of getting ketones and so his neuropathy resolves so he can walk better. Remission is a bonus
2. Being able to sleep! im averaging about 2-3hrs at night with 2hr naps in the daytime. I can't sustain this and perhaps I need to go back to SLGS? I lead a large software project and need to be available and alert during the day and these last 2 months have been a nightmare
3. Get back to going outside and having a social life. I have to currently turn down all appointments with friends, and am afraid to go to go outside or even to the grocery store half the time. It seems that every time im out of the house the Libre rapidly drops and alarms me to get back home ASAP. I still want to be home when theres a greater possibility of a hypo of course but I can;t stay inside 24/7.

I understand I need to figure a way to get blood more often, and I have followed numerous videos/tips and tricks, but I would appreciate it if we focus on the immediate issues above and revisit poking later. I also tested for ketones and they are usually negative or a weird gray color, which I am also seeing again today and isnt on the color spectrum. There seems to be a correlation to that gray color a day after giving Karo syrup.

Thanks,
Devin

 

@Bron and Sheba (GA)
@Wendy&Neko
@Sienne and Gabby (GA)
@Bandit's Mom

 

@djett
Devin can you add Libre3 /Alpha Trak to your spreadsheet where it say Meter and TR for the dosing method
Also on your signature after you have Libre can you put /Alpha Trak
When you retest with the Alpha Trak can you put that in the cell ,you can just put after that BG number AT so members know ,sometimes they won't read it in your remarks section

 

The choice of dosing method is yours to decide, based on your lifestyle - as long as he's eating low carb wet or raw.

TR has a reduction point of 68 when testing with the AT. Sounds like he was always in the 70's when you got alarms from the Libre. I've seen quite a wide range of differences between hand held meters and the Libre, but the Libre is always lower in low numbers. I'm glad you were retesting with the hand held meter. In the 70's on the AT, you don't generally need to feed HC. I almost think the Libre gives us too much data. Especially when it's so far off and in low numbers. I don't think I could have handled the alarms.

Some comments I can give you, though you have decide what is best for you and your cat. You need to be able to take care of yourself to take care of Gucci too. It's a learning process to learn what works for Gucci so you can have a life and a diabetic cat.

First, I loved late nadirs. That's what Neko had both on Lantus, and even more so when on Levemir. It meant preshot was often her lowest number. Her Lev onset was also late (around +5). I could feed, shoot, and be out the door for 4-5 hours. That meant I started going out to dinners and movies again. Good friends would time things for dinners at their place so I could have appies and dinner, then go home and test/feed/shoot and go back for dessert. After setting the autofeeder if I needed to. That friend (also in software) had a boss with a diabetic cat so very sympathetic.

Gucci's cycles with later nadirs look like bounce breaking cycles, where the nadirs to tend to be later. A bounce breaking cycle looks like high start and numbers sliding down all cycle. The cycle after that can be quite active, as you found out the 25th and 26th PM cycles. If you see a bounce breaking cycle leading into a PM cycle, you could give him some higher low carb food for dinner. By that I mean 8-9% carbs.

One other thought on carbs, take a look at the ingredients that provide the carbs. People have seen different results with the carb is wheat vs. potatoes vs. peas, etc. Honey may be better than syrup. You have to experiment and figure out what works for your cat. Also, what works best at different times of the cycle. Early in the cycle when the insulin effect is stronger, you'll need more carbs than later.

Neko was "complicated". She had two secondary endocrine conditions (acromegaly and IAA), one of which was treated. Both those conditions had large impacts on her dosing. After treatment, her dose needs went through periods of plummeting - always always earning her reductions at night. When I got too tired for both me and taking care of Neko, I'd do a temporary reduction for a couple days, so I could catch up on sleep. Sometimes those reductions held. In Neko's case, I wasn't trying to heal her pancreas (it worked already) and thankfully didn't have ketones as an issue.

If you are exhausted, it's not the worst thing to dial his dose back for a few cycles to catch up on sleep, as long as you can keep testing for ketones. By the way, you can always test yourself for ketones as a baseline.

And finally (for now) Gucci is still relatively new to insulin. Their bodies take a while to learn how to use it properly. Over time, and as he sees more normal numbers, he won't bounce as much. Less bounce means flatter cycles and a lot more predictability. Try to look at Gucci's cycles and see if you see any patterns. Patterns typically go over a few cycles. Before bed I used to do what my DH called "reading the tea leaves" - seeing if I could spot a pattern and whether I needed to get up at night. And I started playing "guess the BG" when I poked. I didn't have a Libre back then of course, which was both good and bad. It made me really look at the data.

 

Devin -

I've been on this board since 2009. I can say with absolute confidence, I hate reading spreadsheets from cats whose caregivers use the Libre. The amount of information is overwhelming and not trustworthy. Numbers on the Libre that are below 100 are typically inaccurate. Both Marje, one of the other moderators, and I were testaholics and the amount of data from the Libre makes us look like slackers. There's not a good way to get some visual distance from the numbers and look at patterns.

Is there any way you can start doing more testing with a hand held glucometer? There may be some tips we can suggest (e.g., make sure you're using a wider gauge lancet until the capillary bed in Gucci's ear better develops) that could be helpful. I realize you don't want to get into this now but it is something to consider.

I agree with what Wendy posted, with one exception. While Neko had a late nadir, Gabby had an early nadir. It worked for my schedule. I was Gabby's sole caretaker, I worked full time, and had a fair amount of responsibility attached to my job. I moved my shot time to 5:00 (and I'm not a morning person). It meant that I could test, feed, and shoot with a couple of hours before I left for work. If Gabby's numbers were dropping, I would bump them up with high carb and make sure to leave a feeder to keep her numbers propped up. If I needed to schedule an evening meeting, I had enough time to run home, take care of Gabby, and get back to the office. Likewise, with an early nadir and friends who were cat parents, they under were understanding of my need to take care of Gabby.

I wish I could reassure you that managing Gucci's diabetes is going to be easy. The reality is that it does involve some sacrifices. However, you also need to take care of yourself. While TR is a more aggressive approach to dosing, it also has the best support for getting a cat into remission. In the bigger picture, getting Gucci into remission means that her diabetes is diet controlled and there are no more shots! Short term sacrifice for long term reward. But, TR is not for everyone and there are plenty of cats who have gone into remission using SLGS. It's a method that was developed here and doesn't have the formal research to support it but it works.

 

Unfortunately i've run out of room on my signature, but I'll try to get a chance to modify the spreadsheet format in the near future! Unfortunately its been a 70+ hr work week. I have had TR on the spreadsheet for some time now, although I'm not sure if thats really accurate since I'm kind of doing a hybrid now so I can sleep from time to time. Do you have any recommendations on what to put there? I can leave at TR if thats fine. Regarding the Alphatrak,. do you think it would be more beneficial to have the libre values and alphatrak values on a separate tab? I feel that if I mix the two together I wont know which one is Libre vs Alpha, and I agree that the comment section is not a good place either.

In a perfect world I'd be getting more blood samples, and i'm getting better at it, but unfortunately sometimes his system doesnt cooperate and I cant get blood after poking him 5+ times in a row. Also it may be beneficial for newbees like me to have an example spreadsheet for those that rely on the libre more than BG for various reasons. I understand the numbers aren't as accurate as BG but for some of us its our best bet.

 

Thank you all for the replies!! Been a hectic weekend but trying to digest all the info

 

Thank you. Its been strange, because at first when he eats food there used to be spikes and then a nadir in the middle of the day, and lots of bouncing. Now the bouncing has significantly decreased and its a toss up whether or not eating will make his BG rise. I've even see it stay the same or even drop even after a large meal! Most of the foods im giving him currently are around 7.8-8% carbs on a dry matter basis since I also have to get food that is good for CKD. Good info on the carb content, ill look more into tht, and I did give him honey the other night when his BG was in the low 70s on the alpha which did seem to work better than karo syrup! the karo syrup seems to only raise his BG by a marginal value.

Since hes not really spiking much and since it seems i need to lower the dose, does that mean his pancreas is starting to work correctly? I know I still have a long road, but just curious as to what this new progress means, or whats going on under the hood. Just a little over a week ago I was used to numbers in the 400-600 range almost the entire week since March! It feels good to finally have him in the normal range and he looks alot better, but the lower the numbers also the more scary ha!

 

Totally understand and thanks for all your help thus far, but for us caregivers that arent able to consistently get blood (1 draw out of an average 10-15 pokes), its all I have. But trust me I do understand that its probably frustrating, and I do understand the libre numbers arent always accurate especially when low, although I just drew blood an hr ago and scanned with the Alphatrak3 twice in a row and one reading gave me 210, and the next one 30 seconds apart gave me 170, so seems like meters/monitors may be a little unreliable in general, and seems like we cant really depend on a single number, but moreso trends and curves.

Another weird thing is that it seems during the day his insulin dose wont cause his BG to drop very much and will stay flat most of the day, while at night it will drop significantly and stay low for the majority of the night, wish it was reversed! lol, But that makes the dosing difficult because it seems that now 2.5 is a good morning dose but anywhere from 1.5-2 seems like an appropriate night time dose. I dropped to 2 units last night and his glucose still dropped on the low end for the majority of the night

 

@djett - not sure if you've tried it, my apologies as I didn't read all the comments here.. but Kona was hard to draw blood from the ear and still kind of is.

The warmed up rice in a baby sock really works for us. Have you tried that yet? I just hold it against her ear for about 10 seconds or so, she likes the warmth too.

Good luck!

 

What you saw the after the reduction, on the night of the 26th, was the impact of the depot of the 2.75 unit dose. The larger depot can influence 4-6 cycles after a reduction. I'd still stick with 2.5 units day and night. Our dosing methods work best with consistent dosing. The impact of the reduced dose you did at night will show up in later cycles.

He didn't go below 68 on the AT, so no, he doesn't need to have his dose lowered if you are following TR as your dosing method. It does mean that you are at or close to a fitting dose. If he starts to see more time between 68 and 120 on the AT, that will allow his pancreas to start healing.

 

Thank you! Yes unfortunately i've tried the rice sock and a number of other techniques, and hes also not very cooperative either which makes it difficult, but average 1 draw every 10-15 pokes. And the poor guy is starting to not trust me when I walk into the room, he used to be so affectionate!

 

This may not help with getting blood when you poke but I would randomly (and frequently) play with Gucci's ears and give her a treat. It should help with getting her to associate your handling her ears with treats, especially if you're not poking.

It does sound like you're working at poking her ear. What size lancets are you using?

 

No problem Devin, you can just add TR to your spreadsheet and for the meter just put Libre 3/ Alpha Trak
When you test with the Alpha Trak after you get a Libre number in the cell a lot of members will put for EXAMPLE
200 Libra/190 AT
@djett

 

Thanks! I’ll try to update my spreadsheet tonight. So this is strange.. but last night as Gucci was eating his PM meal, I fell asleep and woke up 3 hours later, and also got a message that the libre sensor had stopped working.

I was able to get his BG with the Alphatrak and it was only 103 and since I needed to sleep more I skipped insulin. I woke up at 3am and his bg was 167 so I gave him a 1/2 unit just to maybe bring it down a little. This morning I woke up and about 20 min ago it was only 106! I’m going to take it again since I’m having luck poking him but I’m wondering if I should drop his insulin dose even more? It seems to be staying in normal ranges even after almost skipping a dose

 

If you skipped yesterday evening, you should write NS on your SS so we know there was no shot.
I would not decrease more, with TR you hold the dose and decrease if the BG gets 50 or lower, 68 or lower on the alphatrak. You should not give insulin outside of the shot times either, Lantus works best if given 12 hours apart.
Can you update your SS to show the skipped shot yesterday evening and the half unit during the night?

 

Please remember that with Lantus, if you shot anything at 3:00 AM, Gucci's next shot is at 3:00 PM. I'd be surprised if 3:00 is a good time for you to be giving Gucci her insulin. Needless to say, if it were me, I would have skipped the 3:00 AM bit of insulin.

If you are going to follow TR, the only time you reduce the dose is if numbers fall below 68 (on an AT meter) or if your cat is in mostly green numbers for a week. Neither of those conditions apply. The numbers in the 40s on the Libre are not trustworthy. Thus, Gucci's numbers don't warrant a dose reduction yet. You do not want to rush dose reductions. You do want to give your cat's pancreas as much time to heal as possible.

 

Thanks, yeah I didn't intend to change dosing at 3am, just saw that since it was higher and since I had skipped the shot, was hoping to get something in his system so he has some insulin, i'm assuming that was the wrong choice, I wont do that going forward.

Regarding dosing method, I believe thats the help i'm seeking in this post. I'm not sure my schedule and mental health is well enough right now to stick with true TR right now, so i'm asking for a little guidance right now on dosing method. Ideally I want Gucci to stay in the normal range most if not all of the day (<180), and after 1 1/2 months of being over 400 hes made significant progress and his walking is alot better. I think as time goes by and I get into more of a rhythm then maybe I can take more risks and try to be aggressive in finding the nadir to see if its under 68. Realistically I can only poke him about 3-4 times a day tops and the rest of the time monitor via the freestyle libre 3 to get somewhat of an idea of where he is. Thanks everyone for helping out I am so overwhelmed with everything in life right now and just don't have the time to figure this all our on my own so I appreciate the help.

I updated my spreadsheet so that the first tab is only BG readings from the Alphatrak 3. I have other tabs for Libre 3 data, but didnt want to mix the 2 or it could show to be a pretty inaccurate curve. Please let me know if this is ok, or if theres another spreadsheet somewhere I should be mimicking instead? There seems to be some differing opinions on spreadsheet content and signature content, so just want to make sure I'm satisfying the majority.

Questions:

1. Is there a hybrid dosing method? I dont want to be super conservative as the SLGS approach, but I also cant afford to get to aggressive with true TR. Its as if I want to follow TR but instead of 68 being the breaking point, use 100 so that I can still continuously get lower but not risk a hypo, and instead of increase the dose when it hits 100 just hold that until I can get my mental health and life back on track. Does that seem doable?
2. For TR people, how often are people testing with meters or how many times a day are you drawing blood? Should be consistent like every +2? Or can it just be AM/PM shot with maybe one poke in the middle? Trying to find a rhythm since i'm getting a little better at drawing blood, although there are still days his ear wont cooperate even after warming/rubbing so I can only do like 4 a day it seems (which unfortunately is about 15-20 pokes :-()
3. If you're only using a meter to draw blood, how can you be sure you know what the Nadir is? For example even if you draw blood every hour, and at +4 you see its 80 on the alphatrak, and then at +5 its 90, how can you be certain that it didnt dip to 65 at +4.5 before going back up to 90? Or how can you have piece of mind that youre not going to run into a clinical hypo event when youre at +4?
4. When I saw Gucci at 76 the other day on the Alphatrak, I wanted to draw blood every 10 minutes because I was worried it was going to drop further. Since thats not sustainable and I needed to sleep, I opted for Karo Syrup although its possible that could have been premature, however it allowed me to get a few hrs of sleep and not panic. What do you guys do in these situations if you're not pairing testing with a Libre 3 to see trends in where the glucose is going via the arrow? Do you risk a clinical hypo or do you test every 15 min? If its in the middle of the night and you're sleeping do you also risk hypos?
5. Can someone please refer me to a spreadsheet that has been filled out

Thanks,
Devin

 

It is overwhelming, but it will get easier, and yes, please ask as many questions as you need here
I'll try to answer as best as I can.
1. You can do a custom metho but it is better to rtry and stick with one at first, until you know your cat very well, how he racts to food, insulin, etc. You can do TR, look at the stickies about TR while working full time, for example: https://www.felinediabetes.com/FDMB...ion-possible-with-a-full-time-job-yes.129378/
2. With TR, you need at least 4 tests a day: one at both preshots, and one around +2. The +2 number gives you an idea of how the cycle will be. If it is same or lower than the preshot number, the cycle will probably be active and it's better to get at least another test to be sure your cat is in safe numbers.
About the number of pokes necessary to get one drop of blod. It WILL get easier. At first I cried a lot, poked a lot and did not get anything, it was very difficult. My cat was patient but we had a learning curve! It gets easier, their ears start bleeding more easily, you will get more confident, and cats get used to it: my Bella waits in our testing spot when she wants food, she knows. You can read this page, lots of good tips and videos: http://www.felinediabetes.com/fdmb-faq.htm#glucose
3. You are trying to get the nadir, but you might not be sure every time, and it's fine. Try to get tests at different times over several days to get an idea of your cat's pattern. The nadir time will change, too. You want to look at the numbers relatively: I mean, if the preshot is high and then your +2 is 80, then get a +3. If the +3 is flat (similar to +2), you can relax more than if it is going down by a lot. You will also learn to know your cat. Watch him, and by all means if he is acting weird, test him. Most of us here do not have a Libre.
How are you feeding Gucci? You can spread out the feedings. I give Bella a meal at preshot, then a smaller one at +2, +3 and +4. That helps preventing her to go down too fast.
4. When my cat is close to 50 (68 in your case, but you can also get a human meter, by the way: the strips are way cheaper ), I test her often. You want your cat to be flat or going up over 2 or 3 tests. You can feed him high carb food, Karo is not necessary if he is not below 68. Give small amounts of high carb food and retest after 20-30 minutes to see which direction he is going. Of course if he starts having symptoms, you would test earlier.
As for spreadsheets, just click on any of us's links: in our signature, at the bottom of the post, you have a link to "cat's name SS".
Be patient, it will get easier, and Gucci is already doing so much better

 

Thanks! I'm feeding two big meals 30-45 min before insulin and then little snacks in between. Today was a good day as far as getting blood, I entered some good info on the spreadhseet, but right now is when i'm supposed to give him insulin but his BG is even lower than it was before I fed him, so this is the part where I get nervous and makes it hard to follow the dosing method :-(. I feel like 2.5 units is way too much given the fact that it hasnt gone up! but 2.5 in the morning is just fine, i'm so confused, I almost want to skip again tonight so I can get some sleep, i'm exhausted. Any advice will be appreciated!

Thanks,
Devin

 

I would not skip, given his history of ketones, but you can give a smaller dose if you are more comfortable and will not be able to monitor. But do not give him more insulin later tonight, wait 12 hours for the next dose.
Normally with Lantus you test, feed and shoot at the same time, all in a few minutes, you don’t need to wait after feeding.

 

I am going to tag more experienced members about dosing help.
@Wendy&Neko
@Bandit's Mom
@Angela & Cleo

 

1. There is NO hybrid dosing method. For a good explanation, see post #37 on this thread: Protocols: Myths Debunked
Some people, over time and with a lot of data, and understanding completely their cats onset, nadir, and duration and reaction to carbs do move to custom dosing. Which is different from hybrid dosing. Given the amount of data you have on Gucci, I would say you aren't at a place to do custom dosing yet.
2. I tested on average 5 times a day, when Neko was on Levemir. She got a lot more predictable then, and I got a lot better at predicting her. I'd test more if she was going low. I didn't test at +2, even when she was on Lantus, because it told me nothing. Neko onset late, a +3 or +4 was a better number on Lantus, even later when on Levemir. Unless of course she was dropping into preshot, cause occasionally she's nadir between +12 (the next preshot) and +15.
3. Nadirs can and do vary. I used to joke that Neko's Lantus nadir was anywhere from +3.5 to +13. Later if a bounce breaking cycle, earlier if she was thinking of a reduction, but most often in the +7-+9 range. How did I find out? By testing more sometimes. And learning her patterns. Patterns go over several cycles. If you see numbers are getting lower, towards a reduction point, you test more often. You also learn your cat's reaction to food. If Neko was angling downwards and I had to go out for a couple hours, I knew how much of what carbs to give her to keep her safe while I was gone. The autofeeder was also my friend.
4. Even after giving karo, you still need to test 20 minutes later to make sure it did the job and took Gucci high enough to be safe - or at least until the karo wore off. At which point numbers could come down again. I found/find HC food lasts longer than karo, though karo/honey are good if kitty is too low (for me below 40 human meter) and I wanted her up NOW. Above 40 HC would do the job. Cats differ in how carb sensitive they are. Your job is to learn Gucci and how much carbs he needs at particular times in the cycle to do what you need it to do. Typically later in the cycle, when insulin is wearing off, you need less. Keep track of extra food you feed and when in the Remarks in the spreadsheet - it's a good tool for help you learn how much carbs to give when in a similar situation.

Most of here do test, feed, then shoot, all within 10-15 minutes. The 30 minutes feed before insulin is what you need for some of the harsher faster onset insulins like Caninsulin/Vetsulin. Lantus is more gentle and multiple small meals is better on a healing pancreas too.

DKA is too close in the rear view mirror to skip. You can do a reduced dose, but due to the nature of the depot, the first part of the cycle may be like you shot full dose.

Next day you post, please start a new thread. I almost ignored this one because it was an old post.
POSTING GUIDELINES PLEASE READ

For spreadsheets, look at what Jill did for Alex. Alex also experienced DKA. She overtested, but intended it to be a teaching tool. 2006 LANTUS & 2009 thru 2014 LEVEMIR DATA
Side note, back in the day, all greens were lime green in spreadsheets, only later was safe green made dark green, so don't freak out at the amount of lime.