? 12/27 Dose help, very low blood glucose numbers

Hello! Armani's blood glucose numbers have finally come down once I got some advice on here about increasing his dose. He is an acromegaly cat, and has been doing ok with about 27 units twice a day, but his numbers are getting too low. His spreadsheet is all updated if anyone can take a look.

The past few days he's been under or around 50, but has been acting fine. I've been getting up in the middle of the night to test him and give him a little high carb kibble if he tests under 50 during the night. I have been giving a shot that's been reduced by a unit or so each time, so we've come down gradually to 22, but still this morning, he was the lowest ever (38) and for the first time showed symptoms of hypoglycemia, seeming disoriented and wobbly. I fed him and he ate normally, his normal friskies, also some high carb kibble and a little chicken baby food with a bit of honey mixed in. He seemed to feel better right away, and I have not given insulin, but his numbers are still in the 40s and aren't coming up though I've given him a few more bites of high carb kibble throughout the morning (I've tested a few times and this is being written about 4 hours after his breakfast). I'm pretty worried. (EDITED TO ADD: we are up to about 5 hours after breakfast and I just tested, he is 100)

Lately in general his numbers aren't raising as much after food as they used to.

I have some questions if anyone has the time to look them over:

1) I'll keep a close eye on him, keep giving him bites of high carb kibble, but I'm wondering what I should do otherwise. At what point today do I give insulin, and what dose? Assuming he comes up into the 70s or 80s, I was thinking a half dose? At this point should I wait until his dinner shot? What about a dose tomorrow?

2) At what number should insulin not be given? Is 50 the limit, as long as one is around to keep an eye on him?

3) For regulation, are we aiming to keep their blood between 50-100 (nadir)?

4) With acromegaly, is it normal for their insulin needs to change suddenly and dramatically, both up and down?

5) If this happens again and he starts getting too low, should I reduce the dose more dramatically than one unit at a time since his dose is so high? Since it is a depot insulin, it seems like dose changes take a long time to kick in, and his blood sugar numbers can be widely changing, which makes me unsure what to do.

6) At what number will a cat have hypoglycemia? Does it vary by the cat?

Thank you very much for the help!!

 

When did you start giving Cabergoline? Please put it either in the spreadsheet and/or your subject line. I suspect you may be seeing some results from the cabergoline starting to work.

Trying to answer your questions in order, along with some of my own.
1) what is his normal diet? does it usually include kibble? I'd get rid of any kibble and get some high carb wet food for when he goes low. Or you can add karo/honey/syrup to his normal wet food. Kibble can increase numbers, but it takes longer to wear off than wet food so might make you think he's risen enough but it's just the dry food doing it. Looks like he's starting to come up as I see a 100. I'd test again in a couple hours to make sure, but I think you can restart insulin tonight. And that means his new dose, but a full dose. You already skipped this morning.

2) If you are following Tight Regulation for dosing, no insulin below 50. If following SLGS for dosing, no insulin below 90. I suspect you are using SLGS because until this last week you haven't been testing enough for TR. Also, we find that it's easier to dose, and you get more consistent numbers, if you stick to the same dose. I see a lot of dose changes in a row. I honestly can't guess what size the depot thinks it is.

3) Tight Regulation is generally 50-100, but you don't test enough for TR. SLGS goal is 90-150, which is still regulated, but not tightly. With an acro on cabergoline, don't worry about tight regulation. A better goal is as much time as possible below renal threshold. An even better goal is to keep him safe as the cabergoline lowers his dose.

4) With acromegaly, there are dose changes, but not usually suddenly and by large amounts. A acrocat on cabergoline is a different thing, though it varies a lot by cat. I have seen some drastic changes, including a few that have gone completely off of insulin.

5) Think of dose changes as 10-15% of the size of the overall dose. For a dose over 20 units, that means changes around 2-3 units at a time. If it truly is the cabergoline starting to take effect, you may have to take even larger reductions. Given that you can't always test as often, I would reduce his dose anytime you see a number under 90. Even for people who can test enough to follow TR, I suggest raising the reduction point to 70 for safety. It's quite scary to see you were shooting numbers in the 50's and 60's and not getting anymore tests that cycle. Even scarier to see you shooting with preshot in the 40's. Even the most experienced person never does that. I might try 20 units as his next dose.

6) A hypo number is also somewhat meter dependent. But we do not want any cat on insulin going below 50. Cats not on insulin can test in the 40's, but the 40's give you no wiggle room. Better higher for a day than too low for a minute.

With cabergoline in play, cat safety is the most important thing and beats the dosing method. It's OK to skip doses or give 1/2 dose if you see a lower number at preshot time and then cannot monitor. If you see low numbers and want to drain the depot, a skip or half dose can help do that.

 

Dear Wendy,

Thank you for your help! I appreciate your time responding to my questions. To answer yours:

He started cabergoline on May 20, 2021 (I added this to the top of my spreadsheet). You've been so helpful with all my questions, so this is my biggest one - would it take this long to see results? I've been very consistent giving it to him every 48 hours. It's been 7 months, and I was expecting results after 2 or 3 months. His dose was very low before he was diagnosed with acromegaly, so we started upping this dose and started the Cabergoline at the same time (with the acromegaly diagnosis), so there wasn't a way to compare how cabergoline affected his dosage.

His normal diet is friskies pate, he never gets kibble normally. I had some on hand for the other cat, so that is why he got some of that. That makes sense it would stay in his system too long. Can you recommend a high carb wet food I can keep on hand for emergencies?

Thank you for your help about dosing. I was doing Tight Regulation starting this summer, but as I've been working a lot and haven't been around to test as much, I will switch to SLGS. I have been trying to be very consistent with his dose, and only started changing so often because I was seeing such low numbers, which is new for us and I started to get worried and confused. So thank you for helping me get back on track.

Can I ask what is the renal threshold? That is a term I haven't run into yet.

I will try a dose of 20 tonight, thank you for this advice. I'll keep this and if he has nadir lower than 90, I'll reduce by 2 or 3 units as you suggest. And if he seems particularly low at shot time, skip a dose or give a 1/2 dose. If he is having high numbers, should I go up by 1 unit, or since he is high dose, 2 units (10%)? Early on, people told me I was holding a dose too long. I will re-read the material about SLGS, but how long do you recommend holding a dose before increasing?

Thank you again for everything Wendy!

 

Most people here tend to do cabergoline every day. The EOD day seems to take longer to take effect, though I've seen some be a few months.

Renal threshold is the point at which there is so much sugar in the blood that the kidneys have to work harder to clear it out. When you get a urinalysis done on Armani, you will see there is a glucose measurement for the urine. If below renal threshold, the glucose would be zero. The point at which this happens varies by cat, but is somewhere in the high blues to mid yellow range.

As for high carb food, does Armani have any food allergies? You want something above 15% carbs. There are lots out there. Many people use the Fancy Feast Gravy Lovers. Neko couldn't handle wheat so I switched first to one of the Merricks, but when she got her CKD diagnosis I had to cut the phosphorus so moved to either one of the Weruva Cats in the Kitchen pouches (17-18% carbs), or Grandma's Chicken Soup (in cans) that was over 20% carbs. Cats differ in how carbs sensitive they are. It didn't take many carbs to bring Neko up, but I'd add a drop of corn syrup/karo if she was below 40.

If he has has higher numbers, post for help. You'd want to make sure the higher numbers aren't just a bounce clearing. Which would mean you just need to be patient on the higher numbers. SLGS says to hold a dose for 7 days, unless he goes below 90. Soon you'll be below 20 units, which would mean going to 1.0 or 1.5 unit increases, should he need them.

 

Hope Armani is doing ok today. I think Wendy made really good points - you should be ready to aggressively (a few units) decrease insulin doses based on low pre-shot BG numbers. The lows are where it's really critical to be responsive. Please don't give insulin when below 50 pre-shot; wait a couple of hours and test again. Many people would not even shoot below 90, but if you decide to shoot in the higher double digits, I would encourage you to only do so if you are able to test a couple of times over the next few hours. Concerning high pre-shot BG values, I would really hesitate to increase his dose at this point, but I agree with Wendy that posting on the forum for help would be a good idea.

Regarding hypoglycemia - it's not a hard and fast number. When blood sugar starts to get low, your cat may become disoriented, and then the symptoms get progressively more severe (up to and including coma and death) as BG gets critically low.

 

Thank you Wendy and Sally! Armani seems to be feeling well this afternoon and was in the 200s at his last test. I've got a plan from now, and if his numbers seem high I'll post again for help. Thank you for all of the information!

 

Not true - here we base Lantus and Levemir dosing decisions on the nadirs, not the preshots. With some cats, nadirs can be at preshot, but more generally it's somewhere mid cycle. Ask yourself the question "do you know how low this dose is taking the cat?" If the answer is no, you need to test more mid cycle. If the dose is taking the cat below 90 when following SLGS, reduce the dose.

With time and data you can lower the point at which you give the full dose at preshot. I was following TR, and after a while I had the ability to safely shoot when she was in the 50's. But that's what worked for my Neko. ECID - learn your cat and how it responds to the insulin. You want to figure out the time of onset, generally when nadirs are, and what sort of duration you are getting. And you need to know how carb sensitive your cat is, so you can feed appropriately to keep him/her safe.

• Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose
• Peak/Nadir - the lowest point in the cycle
• Duration - the length of time insulin continues to lower blood glucose

 

Wendy, I'm wondering if I can get your advice again? I tested Armani just now when I got home from work, and after a morning preshot of 182, he is down to 51 again. Last night and this morning I gave him 20 units as you recommended, so I'm wondering what to do tonight. Based on experience, I don't expect him to go up much from that number, though of course I'll test before his shot. Should I skip tonight, give a half dose, or reduce perhaps to 17 units (3 unit reduction)? Thank you for your help!

 

Since you are following SLGS, that means a reduction earned at that 51. Either 2 or 3 units down from where he is now. As to what to do tonight, it depends where he is at PMPS. Did you feed after that 51? I would test again 20-30 minutes after feeding to make sure he's going up. I suspect that you are still seeing the influence of the 23-25 unit depot today, in spite of the skip.

 

Thank you Wendy! I didn't feed Armani after the 51. I'll be giving him his dinner here soon, and I will wait 30 minutes afterwards before giving him his insulin to make sure his numbers are going up. If it still seems quite low at his PMPS I'll write back here! Thank you so much for all of the help!

 

Hi again Wendy, I just gave Armani dinner and checked his number, and it has gone down to 43. I was thinking to skip insulin tonight, and give him some honey in wet food to get his numbers up, and check him through the night. Then, assuming it is up in the morning, give him 17 units. Does this sound ok, or do you recommend something else? Thank you for your advice!!

 

Skip to drain the depot is a good idea. Whenever he is in the 50's, please don't wait so long to test him again. You don't want him dropping below 50 and need to give higher carb food the moment he drops below 50. Who know who long he was in the 40's this afternoon? Or if he went even lower.

 

Ok, I understand, thank you very much Wendy!

 

Wendy, I'm wondering if I can ask your dosing advice again? I'm sorry to keep having so many questions, but his levels are staying low despite bringing down the dose. I just checked him before dinner, and it was 62. I think this means another reduction. His spreadsheet is all updated, so you can last night he dropped very low again despite reducing the dose, and I reduced his dose again by 3 units this morning. Should I skip tonight, or just reduce? He just ate dinner but I didn't give insulin yet. Thank you so much for your help!

 

If he were my cat, given that you may be seeing some cabergoline effects, I would reduce to about 14-15U since we don't know for sure how low he went today (so I'm being overly cautious). You still have some larger depot in play so you may need to take him back up after a few cycles, but always easier to go back up vs deal with lows. Do not shoot that tonight yet until you answer questions below -

Have you fed him? How far past shot time are you? Can you be off schedule in the morning? Can you monitor him tonight?

 

Thanks for your help! Last night I gave him 17 units, but since he went low during the night, I reduced to 14 this morning. Armani was decreasing gradually all day today, he doesn't usually have curves where the lowest point is half way between his two shots, so I think the 62 is the lowest so far today. To answer your questions, I did feed him dinner, and am about 45 minutes past his shot time. It is fine to be off schedule tomorrow. I can monitor him tonight, but I've been up with him at night a few times this week, and it is pretty rough (as we all know!). Thanks for your ideas!

 

I see your message as I was typing this one - I'm often a little more overly cautious in dosing than Wendy, so take this with a grain of salt - if he were my cat I would reduce again down to 11U. You still have some larger depot, but with a skip and two doses of 17U he was back in action pretty quickly. Look at my SS from July when you get a chance, it was a mad scramble to decrease doses and stay ahead of him. It's not necessarily the norm, I'd just rather reduce a bit too much and go back up if needed

If you get a preshot and you're not sure what to do about it stall without feeding, post for help, and retest in 20 mins. You can continue to stall without feeding for up to about an hour. If flat or rising, it's generally safe to shoot if you can keep an eye on him. I'm sorry nobody was around, this is a fairly low traffic part of the forum.

If you already fed him, no harm, but we don't have a reliable way of knowing which way he was headed. So your options are to skip the shot, or what we call a Big Chicken Shot (BCS) - a one time reduced dose, about half the usual dose (so in this case about 5-6Utaking the reduction into account). With the BCS you will still need to keep an eye on him tonight, and you'd be about an hour off schedule in the AM. He handled the last skip pretty well and his numbers are fairly low, so I don't think you'll go wrong either way. If he were my cat, I would give about 5-6U and keep an eye on him tonight.

Unfortunately I can't stay up with you, whatever you choose if you need help I would post on the main forum or Lantus forum

 

It's always easier to go up in dose than fight lower numbers. With cabergoline in play, if that's what it is, I'm fine with being cautious.

 

Thank you for your message! I appreciate you taking time to answer, and I did look over your SS from July, I see what you mean! I understand this forum doesn't have as high of traffic, and if I have an emergency I'll definitely post in the main forum. Thank you for your help!

 

And I meant to add, those numbers today mean a reduction with SLGS anyway. You can start the new lower dose tomorrow. What you do tonight depends on your ability to monitor.

 

Thank you Wendy for looking this over too! After the past few days, I'm wanting to be cautious too.

 

Hello. Another acromegaly cab mom here. I have been following this thread for several days now and you have been in Wendy’s capable hands. Looking over your spreadsheet, if it were my kitty I would do a big chicken shot of one half to two thirds of the normal dose and monitor. Something is definitely happening with Armani. I am glad to see some more frequent testing in the last few days. Good job.

 

Thank you Suzanne! You're right, something is definitely up with Armani, and I'm so grateful for Wendy and everyone's help. Hopefully he will settle down soon, this is very stressful, but I'd be happy to see him settle into a lower dose if this is where it is all headed.

 

He definitely seems headed in that direction. It’s exciting! And tiring, of course! Hang in there!

 

How is Armani today? Nothing on your spreadsheet so I get worried. Sorry to bug you.