Confusion, Trying to get re-started correctly... Expert help needed.

I have started a spreadsheet, but I should preface that we started this journey back at the end of July when Duke started losing weight and acting ravenous hungry. We took him to the vet, find out his numbers were at like 600 and that he was diabetic. My spreadsheet only reflects the past couple of days because a bunch of stuff has happened and we did not have a very accurate set of numbers for the first several months Please read the story and see if you can offer any help/advice and let me know if we're on the right path here...

Duke was diagnosed in late July and we started on 1 unit of Glargine twice daily. Previously he had been on a Science Diet dry food, but almost immediately we got him onto Fancy Feast Pates with the occasional Fancy Feast Medley. We were told by our vet that glucose readings weren't that important so long as we kept him regular. We did readings about once a week as the vet recommended. Truth be told, in the beginning, we were not very good at getting his glucose readings so even one test could result in poor Duke having his ear poked 3 or 4 times. He did not enjoy it and we were improperly trained how to do it by the vet. Ugh. Anyway, in the beginning when we did check, we were getting numbers like 420, 419, etc. But by Mid August lower numbers started to show up. We got an 81, a 212 and then in September we saw 81 a few more times. I almost couldn't believe it, because it seemed awfully low, but it kept showing up.

During this time, we kept diligent on our insulin injections, twice daily, 12 hours apart. We had always checked with the Alpha Trak 2 tester and strips. It was around this time we ran out of strips and didn't check his glucose for a couple weeks. Which in hindsight is pretty awful, but we were only testing once a week anyway so it didn't seem like much of a big deal.

Around the 21st of October something strange happened. Duke began acting weird. He was a bit "off" during the day and we wondered if maybe he had eaten a leaf we tracked in or something. He wasn't overly strange, just a bit off. We went to bed and I woke up to Duke wandering around the house acting VERY bizarre. I actually thought he had went blind. He was walking in areas he never walked before, he was getting "stuck" in spots he could have easily gotten out of if he could see, etc. We rushed him to the vet thinking that something had happened and he'd somehow gone blind. But as we waited to see the vet (several hours had passed) he seemed to be returning back to normal.

The vet ran a litany of tests including checking his glucose (it was 212 on 10/22) and the vet speculated that perhaps his glucose had gotten too low. She speculated that due to our diligence in giving him his shots, changing his diet and his weight loss (he used to be a 15ish pound cat, now he stays at about 10.8) that he could be in remission. We were told not to give him anymore insulin for a bit and then test him each day and report back in a week.

Starting on the 24th we tested each day, with no insulin.

10/24 - 410
10/25 - 327
10/26 - 282, 293 (we checked twice that day)
10/27 - 285, 388
10/28 - 350

It was pretty obvious to us that he was NOT in remission, we called the vet, who admonished us for not giving him insulin (even though it was them who told us not to give it to him, grr) and we started giving him insulin again.

However, I decided we would not give him 2 doses of insulin unless he needed it. The vet told us that he should be within the 80-180 range as "normal" and that even a little over 180 should not be considered high. I opted not to give him his second dose of insulin if he wasn't high. They also recommended doing a new curve, which we are doing today.

10/29 - 154 (1 unit of insulin in the morning, none after)
10/30 - 118 (1 unit of insulin in the morning, none after)
10/31 - 49, 127 (1 unit of insulin in the morning, none after)
11/1 - 118 (1 unit of insulin in the morning, none after)

As you can see, his numbers were quite low each day after giving him one unit of insulin. These readings were taken about 10 hours after his shot and after his morning and afternoon feedings. On 10/31 when his number came back 49!! I made sure to test him again later at night which is when I got the 127.

I am of the stance that obviously the insulin is regulating him, but I refuse to give him insulin when his numbers are so low. The day I got the 49 it was around the normal time he should be getting his second shot. I can only imagine what would have happened had I done that.

Today is his new curve and he has not yet had any insulin. Should I give him some? I don't know.

At 7:30 AM his level was 93
At 9:30 AM (after he'd eaten his first meal of the day) it was 107
At 11:30 his level was 175

At this point I'm not sure if/when I should be giving him his insulin. I understand the concept of giving it to him twice daily to regulate him, but that is clearly what caused his day of confusion and since we've been giving it to him once daily, his numbers have always come back good.

At what point today should I give him his insulin? Do I wait until his numbers go over 180 during the curve?

Why is this all so confusing? I just want to do what's right, but the vet has not been a lot of help with this and there is so much information out there, it's overloading. I want to do what is right and safe for Duke.

Any and all advice would be greatly appreciated.

 

Rover had an incident of what the vet called "brain blindness." It was very scary, and in some cases, can be permanent.

It is great that you are testing. It is the only way to keep your cat safe. And good that you have been giving low carb food. And thanks for getting a spreadsheet set up. We are fairly data driven.

I'm flying out the door so am tagging a few other members who can respond in detail. @Marje and Gracie @Bobbie And Bubba

In the meantime, please read

• How to treat HYPOS - THEY CAN KILL! Print this Out!!
• jojo and bunny's HYPO TOOL BOX

We can help find a consistent dose for Duke. Lantus (Glargine) craves consistency, but not to the point where Duke is having hypos.

Hang in there.

 

Lantus does like consistency and two doses a day, 12 hours apart. On 10/31 that 49 earned him a reduction in dose.

A few questions: Did you not give any insulin today so far? The SS unit cell is empty. If I am understanding correctly, from 10/29 through today he has only had 1 unit of insulin only once a day and he got that 49 on that.

I am so glad you are doing a curve today and updating the SS.

If so, it is clear that he should be getting a lower dose. But what, is the question...I am thinking that maybe taking his dose to 0.5 giving it twice daily and get as much testing in as you can to see how low that 0.5 is taking him. And then we can go from there.

Usually we raise and lower the dose in increments of .25u. But with that 49 on just 1 unit of insulin only once a day several days, I am being conservative.

Let's see what others think.

 

Certainly no more than 1 unit at any time.

How about 0.25 units every 12 hrs? PLEASE make sure you get a test right before giving it, each time, in case it isn't safe to give.

 

He had insulin on 10/31 in the morning around 7:30... When we checked his glucose around 6:30 we got the 49 reading. Obviously we did not give him any more.

But we did give him insulin again on 11/1 around 7:30... When we checked his glucose around 6:30 that day it was 118.

He has not had any insulin today. We just checked his reading again (as we're doing it every 2 hours) and it was 215. I just added it to the spreadsheet.

Again, any help is very much appreciated.

 

If you didn't give insulin this morning, there's really no reason to test every 2 hours. Doing curves is mostly for seeing how they do with insulin.

It's obvious that 1U is too high a dose so I'd try going to .5 twice a day. No insulin works 24 hours in cats so we need to find a dose that not only keeps him safe, but can also be given twice a day.

Do you have syringes with half unit markings?

Next, I'm not sure when you're feeding in relationship to testing/shooting. With Glargine, you should test/feed/shoot....all within about 5-10 minutes. You Test to make sure he's high enough for insulin at all, Feed to make sure he's at least willing to eat, and Shoot.

Glargine doesn't usually start to "kick in" for 2-3 hours after it's given, so it's not really important that he eat a specific amount before shooting. Just as long as he's willing to eat.

It's also important that when you do your "Pre-shot" testing, he hasn't had any food for the 2 hours immediately before shot times. So if you shoot at say 6am/6pm, you should make sure there's no food at 4am/4pm until Pre-shot test times.

 

He’s on the rise so I think at +12 shoot 0.5 u tonight. But only if you are able to get a get more test in tonight to make sure he is safe.

Give him a break now since you did not give insulin today.

I’d grab a +2 tonight . If that number is the same or lower than the pre shot number, it could indicate an active cycle abd you might have to test more. If it’s higher , then give him a pokey break and try to get a test in around +5 or 6 to see how low that 0.5 took him. And depending the numbers, and he doesn’t go too low, hopefully you will be shooting the same dose 12 hours later.

Could you just put in your signature what time zone you are in since we are all from different zones and we talk in SS + talk here.

 

So if I understand this correctly, we should re-do the curve tomorrow with insulin?

We do not have syringes with half units. The syringes we were given we were told were the smallest and they do not have half units. I can eyeball half of 1 unit, but obviously I cannot eyeball .25 of a unit.

I am on CST.

Since his numbers are going up, I am considering giving him a half dose (per recommendation) at 7:30 PM CST which is 4 hours from now. That will allow me to give him another dose at 7:30 AM tomorrow.

Presumably, unless you guys say otherwise, I will do a pre-shot test tomorrow just before 7:30 AM, then feed him and give him insulin at 7:30 AM and start a new curve. Does that make sense? Is that a solid plan?

How long should the curve run? I was told 12 hours. Just want to make sure that's right.

Lastly, should we ALWAYS test his glucose before giving him insulin? Every time, for all eternity? Just curious as that is not what we were told and I want to make sure we are doing this right.

 

Don't forget the clock change tonight! If you'd like 7:30 to be the regular shot time going forward, you might want to shoot at 8:30pm tonight. Then, with the time change, 7:30am will be 12hrs later.

 

Good call Nan.

 

lots of brands carry half unit syringes. If in the US, you can get ReliOn brand at Walmart. In Canada you can get BD Uktrafine at any human pharmacy. They make smaller dosing much easier.

 

I think I would hold off on a curve until he has been at the new dose of 0.5 twice a day for about 6 cycles since that is how long it takes the depot to fill. BUT , ALWAYS get a pre shot test to make sure it is safe to shoot and try to hit the nadir which typically can be anywhere from +4-+7

No disrespect to your vet , but most are not very knowledgeable with Feline Diabetes. This board has a wealth of knowledge and experience and if you keep posting , we will help.

 

PS: Do get a test in tonight prior to shooting so we know what his starting number is prior to the insulin.

 

You do not mention in your story when you are feeding. It is best to test, feed a meal and give a shot, then give small snacks throughout a cycle. Just pick up any food at +10 so that the number you are shooting is not food influenced.

 

Hi there and welcome.

I do agree that he needs a reduction from that 1u.

Suggestions going forwards.
Always get a test pre shot (PS) morning (amps) and evening (pmps) you need to make sure it is safe to give insulin in the first place.
Getting a curve today may be of limited value given that lantus is a depot insulin and it takes a few cycles to see the effect of a dose. Having said that, if you are home all data that you can gather at the moment well help us guide you better and keep your little guy safe.

Depending on your schedule if you are able to get a couple of tests in each cycle other than the PS tests that would be a good place to start.

 

First, if you are going to give a shot this evening, your shot time should be an hour later than usual. This will allow you to be back on schedule tomorrow morning given Daylight Savings Time ends.

If you can get a prescription for syringes today or tomorrow, it would be great if you could pick up a box. The information for syringes is:

• U-100 3/10cc syringes with half unit markings are the best to use for drawing Lantus, Basaglar, or Levemir from vials, cartridges, and pens.
• BD Ultra-Fine, CarePoint Vet, Monoject, GNP, UltiCare Vet Rx, Sure Comfort, and ReliOn are just some of the brands available with half unit markings.
• Syringes come in ½ inch or 5/16 inch needle lengths. Needle gauges are 29, 30 or 31 (31 being the thinnest)

Because doses are changed in 0.25u increments, syringes with half unit markings are the most helpful

I agree with what everyone else is saying -- 1.0u is too much insulin. I do suspect that episode of "bizarre" behavior was a symptomatic hypoglycemic episode. Many cats insulin needs will drop after an event of this kind. Again, as others have noted, Lantus does best when dosed twice a day. I would lean toward a small dose -- 0.25u if you feel that you can draw up that dose. This is what it would look like:


The difficulty is that you don't have syringes with half unit markings yet.

And to answer your question, yes - the only way to safeguard your cat and prevent an unnecessary episode of hypoglycemia is to test every, single, time before you give a shot. Not to scare you, but insulin/hypoglycemia can be lethal. We do everything humanly possible to keep your kitty safe.

 

I like my vet for most things, but they have not been particularly helpful with this diabetes stuff. Aside from some of the aforementioned issues, they actually suggested UPPING his dosage to 1.5 after we had taken him off the insulin for a few days (because they had told us to do that) saying his numbers were high. Well no duh, his numbers were high because he hadn't had insulin in like a week. And they weren't even as high as when we started, so why on Earth did they suggest going up? Especially after he'd just had an episode that they believed was a result of too much insulin. Needless to say I was able to argue with the vet and get them to walk that diagnosis back, but long story short, they aren't following this as closely as I am so having a resource like this is so very helpful.

I will give it to him at 8:30 to adjust for DST. Good call on that. I have to make sure he's getting it at time someone is home to give it to him, so 7:30 is what works.

Right now we have BD Insulin syringes, 3/10ml capacity, 8mm (5/16") length and 31 gauge. We like these needles a lot so I'd say moving forward we'd like to get 5/16 31g needles with the half unit measurements. The challenge will be getting our vet to write that prescription because they still think we should be giving Duke whole units. I'm still not sure why you even need a prescription to buy syringes anyway, but that's a rant for another day.

I did some "eyeballing" and I think I can get a .25 dose. Worst case scenario it's a tad more or tad less but it wouldn't be terribly off (and still much less than the full unit he was getting) until I can get new syringes.

So is the consensus I shouldn't do another curve until next Saturday? Not only is that the next time I'll really be able to have 12 hours available, but that would be also be 6 days or cycles since he started on the new dosage.

Also, one last quick question... Let's say I give him the insulin later, but when I test in the morning, his glucose is still low, do I go ahead and skip it and try again at the time that would normally be the second insulin time? And is a "normal" level 80-180 as the vet told me? How low is too low to shoot?

Lastly, THANK YOU, THANK YOU, THANK YOU all for the help thus far. Everything with this has been so daunting and overwhelming and so much of what the vet has said has been confusing (or just outright wrong at times) that it's really nice to be able to ask some questions and get some advice that makes sense. You have no idea how much I appreciate the help thus far. I just want to be able to give my little guy the best care he can get while dealing with all of this.

 

Okay! I use Relion syringes with 1/2 unit marks( or I should say I used... we are OTJ , OFF THE JUICE). No RX necessary for these Walmart brand syringes. Very cheap, 100/ 13 bucks.

Eye ball the best you can whether you do 0.5 or .25 u. And like you said, less than 1 unit! It might not be a bad idea to go lower with .25 as Sienne suggested since he could very well have had a symptomatic hypo event with that 47. That was a good call ! Remember, 68 is the “take action “ number for using a AT 2 meter. If it proves to be too low of a dose , you can always go up .

 

Here are some thoughts about the syringes.

If you bought the syringes at a local store, call and see if they have the half unit syringes in stock. Plead as pathetically as you can that you misunderstood the doctor and you need syringes that are in half units. Do NOT say this is for your cat. Refer to needing the syringes for your "baby." Hopefully, you'll get a sympathetic pharmacist or tech who will swap out the box.

If you want to be completely honest, get one of your syringes and make a "mock" syringe. Using a colored liquid, draw up the dose. If you are satisfied with how much you've got, use that syringe as one you can compare against. It will be easier than trying to eyeball the dose every time. With little doses, draw off more than you need. Twist the plunger (don't push on the top of the plunger) in order to dial in on the amount in the syringe.

If your vet will give you a prescription, tell the vet you found a really good online outlet for the syringes. ADW is a very reliable source for diabetes supplies. I believe all they need is an Rx for U100 diabetes syringes. You can order whatever you want as long as they have the Rx. I know when I needed an Rx, that's how my vet wrote the prescription. It will let you chose the needle length, gauge, etc. And if your vet insists on being way too compulsive about the script, you'll be faxing or sending it as an attachment. Just sayin, if you need to add a little White-out.....

6 days is 12 cycles. Each day has an AM and PM cycle.

Like Chris, I would encourage you to get as much data as you can. You've been seeing a lot of variability and given what I'm assuming were very low numbers and not a lot of test history, the more information you can gather, the more we can help. It doesn't have to be an official curve. Getting in the door and out the door tests is good. A before bed test every night can tell you if numbers are dropping from earlier in the evening and let you decide if you need to get more tests. Right now, you need to sort out when Lantus onset starts and where nadir falls. Curves help with that but so does getting test at random times.

I would suggest that if you get a number at AMPS that you're unsure about, post and ask for help. We have several members who live in various places around the globe. On a good day, we have coverage here 24/7.

 

Cycle=12 hours.
Six cycles=three days.

 

Okay so it's 8:30... And his glucose number is 138. So should I not give him insulin? I mean it's went down from earlier this afternoon (1:30 PM) when it was 215.

And again, he's had no insulin today and not any insulin since yesterday morning around 7:30 AM.

 

Hmmmm. That is quite a drop from +7. When was the last time he ate?

 

He last ate at noon.

He usually eats at 7:30 AM, Noon, 6:30 PM and then a snack before bed at 11:30ish.

Today he didn't eat at 6:30 PM, we held him off until now since we were going to give him the insulin. But haven't since his number was low.

 

I’m almost inclined to say don’t shoot and see where he is in the AM.

We usually tell newbies not to shoot anything under 150 .

ETA : hopefully others will weigh in.

 

@Sienne and Gabby (GA) what do you think?

 

Hmmm... Well, for my part I'm inclined to agree. 138 on an AT is awfully low for a newbie, and since he's been on 1 shot per day for a little while anyway, I think it'd be OK to skip tonight's shot and start fresh tomorrow morning. So, that's one more vote for a skip, unless a re-test shows a dramatic upswing...

 

Okay update time!

So after the advice here to switch to .25, we started on the 3rd of November with that.

We ran out of strips on the 4th (oh the joys of this whole process) so I couldn't test him the next morning, so I skipped his shot. I got the strips in time for his night time shot.

I have not ran a new curve because if you look at his spreadsheet, you'll see that Duke is almost never over 150 twice a day. With his feeding schedule, he eats during the day but after like midnight he doesn't eat until the next morning, so his glucose always drops during that time. By the morning time, his glucose is almost always in the low 100s.

On 11/9 his reading was 255 in the morning, but that was only because he didn't get his usual night time feeding (I fell asleep early) and he ended up getting fed much later at night (nearly the next morning) because of my screwup. Point is, that's the only time he's spiked over 200 since we started the new dosage.

I'm not sure what to do. I know that he's supposed to get it twice a day, but he never seems to really need it more than once. I feel like we have him pretty well regulated on the diet itself only with the occasional insulin shot.

Should we try a lower dosage? I bought the new needles which makes it easier to get .25, but how much less can I realistically give him?

Again I'm open to advice. I know we probably need to give him a new curve but since he hasn't had a full set of cycles, it seems pointless. And after the scare where his glucose dropped so low, I am very hesitant to give him insulin, even .25, when he's under 150.

Any help, advice, etc would be appreciated.

 

Here's what I'm struggling with... Lantus dosing is based on the nadir (lowest point in the cycle) and not on the pre-shot numbers. You're basing your judgements on the pre-shot data. Some of the pre-shot numbers are in normal range but most are not.

Is there any way you can get some spot checks during the cycle? We need to know where Duke is at during times other than pre-shot. I do suspect that he needs a bit of insulin. However, with they way you are dosing, you are losing the advantage that Lantus gives. By giving an occasional shot, there is no depot and this is what gives Lantus its duration. It may be wiser to reduce the dose a bit so you can give a consistent, twice a day dose. This is what a 0.1u dose would look like:


Alternatively, or in addition, you could give Duke a higher carb food (e.g., 8%) as a way to consistently shoot either 0.25u of 0.1u.