Dose Advice Please

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I have read the boards for several months, but this is my first post. I need advice on the dosage of Lantus for my two diabetic cats. Both cats were started on Lantus on December 24, 2009. They are free-fed low carb fancy feast and friskies. I am home testing, but am gone for approximately 11 hours each day for work so I cannot get many spot tests. I would appreciate advice on getting my babies at lower numbers.

Domino is 13 years old and was diagnosed as diabetic about 2 1/2 years ago. His vet at the time put him on a human insulin (I'm not sure now what type that was) and he never was regulated on this insulin -- in fact the vet almost let him die basically telling me to take him home and do the best I could with him because they had no one to monitor him over the weekend. At this time his weight had fallen from about 18 lbs down to 8lbs -- he was skin and bones and could not even hold his head up. I took him to an emergency vet instead and found a wonderful new vet to work with us. This vet was not sure if he could be saved, but after a week of hospitalization he turned the corner. His insulin was switched to Vetsulin in June 2008 and he stayed on this until December, when I decided to switch him to Lantus. During this time he gained most of his weight back (he's now about 17 lbs). He is a big cat, not overly fat. On the Vetsulin he would have preshots in the 400's and 500's but then drop down to between 80 and 150 for a nadir. I was not comfortable with the high numbers and wanted to see if Lantus would help to keep him at a lower number. After much discussion with my vet (who has never used Lantus before) he told me that he had never had anyone willing to test their cats at home but since I was he would write me a prescription for the Lantus. On the Lantus his blood glucose has gradually come down, but I have not been able to get a consistant number. Also, this cat is highly allergic (we have had allergy testing done and he is allergic to approximately 25 different things) especially to beef and eggs. He pulls his hair out and scratches sores when these flare up -- this weekend he started this again after seeming to get better and now he has a Rodent's Ulcer coming up on his lower lip. He has had rodent's ulcers in the past and our first vet treated him with injected and oral steroids (this is probably what made him diabetic, but I did not know this at the time). My new vet has advised that we treat this with a topical steroid rather than injected steroids to try and avoid any further complications with the diabetes. Any ideas if this is the way I should be looking to treat this?

Puff is 11 years old and began losing weight rapidly in May 2009. I suspected diabetes because of what I had already seen from Domino, and my vet confirmed this. He was started on Vetsulin but never was even remotely regulated (his numbers ranged from HI to 400's). My vet then switched him to PZI Vet, and I made a diet change to all low carb wet, and his numbers came down to the 200-400 range. I suspect the diet change caused most of the difference. I started him on Lantus in December and gradually upped the dose to 4.5 units BID, but was getting no better numbers than on a lower dose, so I decided to start over with 1 unit. We still can not get the numbers to fall below 200. My vet has made the comment that this cat may be insulin resistant because no matter what amount of insulin we give him it doesn't seem to cause his blood glucose to come down very far.

Any ideas on how I should adjust the Lantus for my two babies would be appreciated.
 
Re: Need advice on dosage for cats new to Lantus

Hi Welcome to Lantus Land!

We have a couple of members here with double sugar kitties!
Just a question, can u tell us your first name?

Wanted to also say good job on home testing and switching to wet food.
Many people here do work during the day, but are around in the evenings and weekends to fill in the blanks in their spreadsheets, it'll be ok, things like this have a way of working out.

First off you'll want to read the information stickies up above. If you've been on this board for a while now, u may of already read them, but it doesn't hurt to refresh.

Others will be along to help u out, and to guide you along to find the correct dose for both your kitties.
Looking forward to seeing u post daily and getting to know Domino and Puff.
 
Re: Need advice on dosage for cats new to Lantus

Thanks for your reply! I guess some of us were just doubly blessed with sugar babies! I also have two civvies, so we are 50-50 for diabetes. My name is Connie and I have read the stickies many times, but I do find something new and interesting each time.
 
Re: Need advice on dosage for cats new to Lantus

You've done alot so far! I think personally at this point (and because I like to look at data rather than read alot :-D ) it would be easiest for us if you created a spreadsheet with any numbers you have from homestesting (1 for each cat) that way we can see what numbers you had on what doses. Do you keep track at home on your computer or in a notebook? If you enter this into the spreadsheet that we can look at we may be able to better help you work out finding a dose that will bring you some better results. It is difficult when you can't test midays, but there are 2 cycles in a day (each 12 hours) so if you are home evenings you can fill in some of the data in the middle, then on weekends/holidays doing some curves etc.

Starting over at 1 U was probably a good idea, you may need to increase it but first we need to see how long you've been consistant on that dose and what for numbers you have in the middle of the cycle. I assume you have read the protocol we use here so you know how to let the dose "settle" and then increase in .25U or .5U increments. because you are unable to test alot during the week, I can suggest what some do is leave the dose alone at the begining of the week and try to make changes towards the end so that on the 2nd or 3rd day after a dose change they are home all day to do a curve and see how it is going.

I think the steroids (even topical) have some effect on the BG as well as when he has active inflamation on the skin etc. will drive the BG higher, but we can't avoid that we treat the diabetes around everything else and adjust the insulin to compensate.

Glad you decided to speak up here!
 
Re: Need advice on dosage for cats new to Lantus

I am by no means a "dosing expert" with Lantus. But I have learned a few things in our 2 months...

Domino and Puff said:
Domino... Also, this cat is highly allergic (we have had allergy testing done and he is allergic to approximately 25 different things) especially to beef and eggs. He pulls his hair out and scratches sores when these flare up -- this weekend he started this again after seeming to get better and now he has a Rodent's Ulcer coming up on his lower lip. He has had rodent's ulcers in the past and our first vet treated him with injected and oral steroids (this is probably what made him diabetic, but I did not know this at the time). My new vet has advised that we treat this with a topical steroid rather than injected steroids to try and avoid any further complications with the diabetes. Any ideas if this is the way I should be looking to treat this?

Beautiful blues on 1/22 and 1/23 and then the allergy flare-up. Cats!

I notice you did some dose hopping early on, but it appears you are trying to stick to the 10 cycle routine now. One thing to remember about Lantus is that it is not dosed based upon the pre-shot number; you have to watch the nadir.

And I'm sorry... I know nothing about topical steroids...

Domino and Puff said:
Puff ... I started him on Lantus in December and gradually upped the dose to 4.5 units BID, but was getting no better numbers than on a lower dose, so I decided to start over with 1 unit. We still can not get the numbers to fall below 200. My vet has made the comment that this cat may be insulin resistant because no matter what amount of insulin we give him it doesn't seem to cause his blood glucose to come down very far.

Puff, Puff, Puff... what's with the pinks and yellows?

I'm speculating that once you started over with the 1u (good decision!) you didn't give it enough time to settle. As mentioned earlier, Lantus *normally* needs 10 cycles to settle. Again, remember it's the nadir and not necessarily the pre-shot with Lantus.

There will probably be more board activity later this afternoon and on into the evening. If nothin else, my response will bump you up!
 
Re: Need advice on dosage for cats new to Lantus

Ooops I see now you do have a SS, it's dinner time I'm hungry, and tired. Since I'm obviously going blind right now, I'll have to take a look later once the windshield wipers on my eyeballs are unfrozen (it's snowing here and I was shoveling :sad: )
 
Re: Need advice on dosage for cats new to Lantus

I did lower Domino's dose a couple of times because of low spot checks - and I wasn't comfortable giving him insulin when he was under 100. I decided to stick with 2 units for a while, but he still is not consistant with that number.

So with Puff should I put him back at 1 unit for 5 days instead of 3? I read the protocol to mean you should keep one dose for 3 days and then increase -- maybe I moved the dose too early?
 
Re: Need advice on dosage for cats new to Lantus

Hi Connie!!

lol, ok, hey I looked at ur SS a few times, u said u work up to 11 hours? Is that recently? Or is it evenings ur away?
Can u tell us a bit about your schedule? Example, you get up for AMPS and at about what +hour are u out the door?
OR if u work nights, the same.

We encourage a couple of really good spotchecks when u have to be away for a long time....the "out the door" and the "before bedtime" check. Also, I guess one more - "in the door" spot check :lol:

But anyway, u have a lot of good data collected! I can't advise u on dosing, others with more experience will be around to guide you with that.
I'm one of the cheerleaders :RAHCAT and spotcheck meanies :mrgreen: (I was a testaholic)
 
Re: Need advice on dosage for cats new to Lantus

Welcome Connie.

Geez, you've had your hand full. Shame on that first vet! I guess the only good thing that came out of that experience was a new vet! You have been doing an incredible job managing two cats while flying solo. I hope you'll continue to post.

In looking at Domino's SS, the first thing that stands out to me is that at the outset, there were a couple of 0.5u increases. Domino had some numbers that were less than 300, so the increase probably should have been 0.25. It's possible that a good dose was missed, although it may be unlikely. Similarly, on 1/13 when Domino earned a dose reduction, you reduced by 0.5u rather than 0.25. You also reduced the dose after a skipped shot and this wasn't an earned dose reduction. All this is suggesting is that we can probably help you get Domino on a better dose and help you learn how to use the dosing protocol a little more effectively.

I think your strategy with Puff (i.e., starting over) is a good one. Let me encourage you to get PM spot checks in. Just because numbers are running high in the AM cycle, doesn't mean they will be high at night. Domino is a good illustration of how, like many cats, numbers are better in the PM cycle.

Please post questions. Lots of people will jump in and help, offer suggestions, and support.
 
Re: Need advice on dosage for cats new to Lantus

I work during the day (I'm there now) and with travel it adds up to me being away from home for approximately 11 hours. I was able to get the data because I started during Christmas and was at home for a couple of weeks vacation. I also have a daughter in college who is at home occasionally and helps me get a spot check here and there.

I usually am only at home for about 30 minutes after I give the insulin shots in the morning. I haven't gotten much data at night because of a hectic schedule with a husband and two children, etc. Guess we'll have to try harder then.

I upped Domino and Puff by .5 units at a time because they were on a high dose of their previous insulin -- guess I should have only upped by .25 (I decided to do this with Puff the second time around). When I skipped the shot it was because Domino was so low I was afraid to give him insulin and I was not going to be there to check -- the same with the reduction later, I was not going to be there and thought it would be better to be high than too low. I don't know how I should handle this when I am not there to check.
 
Re: Need advice on dosage for cats new to Lantus

These are situations we all grapple with. Everyone here has been in a similar, or in some cases, identical situation which is what makes this Board so helpful. We'll brainstorm with you both in advance and when a situation crops up so you will know what your options are and can make a good decision based on those options. Not to worry. We all know you were doing your best to keep your kitties safe and healthy.
 
Re: Need advice on dosage for cats new to Lantus

ok, do u have these printed up at home? Don't wanna scare ya but it's a good idea to have these printed up and stuck on the fridge or near your supplies.
This will help your family members, especially your helper who can spotcheck for u.

Hypo Signs
viewtopic.php?f=14&t=1122

Treating hypo
http://www.gorbzilla.com/treating_hypog ... elissa.htm

This one also, what to have in your Hypo Tool kit.
viewtopic.php?f=14&t=2354

This one as a guideline for when u get those low numbers
viewtopic.php?f=9&t=147


Good to have these printed out, maybe discuss with your family, and just so you're prepared.
 
Re: Need advice on dosage for cats new to Lantus

Yes, everyone knows the signs and what to do for hypos. We've had some close calls with Domino -- he once went to 28 on Vetsulin and was staggering around like a drunk. We have high carb, caro and a sugar solution from the vet on hand at all times. Puff, on the other hand, doesn't seem to know what low numbers are.
 
Re: Need advice on dosage for cats new to Lantus

Domino and Puff said:
Yes, everyone knows the signs and what to do for hypos. We've had some close calls with Domino -- he once went to 28 on Vetsulin and was staggering around like a drunk. We have high carb, caro and a sugar solution from the vet on hand at all times. Puff, on the other hand, doesn't seem to know what low numbers are.

:? I hated those signs when my cat Luna was on Caninsulin (Canada's version of Vetsulin) made me so upset. But - today is a new day and u are well on ur way with Lantus for your kitties!

Lantus won't show those scary hypo signs, many kitties have gone that low with no signs. But u don't want them to hang around that low without monitoring either.
I 'm glad you are prepared!
Puff will get there - just needs a little bit more help to get those pretty colours.
 
Re: Need advice on dosage for cats new to Lantus

Hi Connie!! :mrgreen:
I have two 12 year old FD kitties...but they are litter mates. The male, Shadow is my problem child and I am posting a condo every day for him. Raja, his sister, went OTJ on Dec 5, 1009...almost two months ago!! :RAHCAT

They were both dx together officially on Aug 5th. We too were on Vetsulin to start which we don't have to talk about anymore. whew. :-D
We began with Levemir in mid Sept and have been very happy with the longer duration insulin.
We have a regular schedule of feedings and that way I can monitor who eats what and they are very used to this instead of the grazing they did while on dry food. We use mostly the FF LC varieties with freeze-dried chicken sprinkled on top some times.

Wondering if you have the ketone stix to monitor for ketones at all.....
Can you also say if/when the last dentals on your two were done? Sometimes there are infections going on that will keep the BGs high even though they are getting lots of insulin and until those infections are addressed, regulation will be impossible...

I am so happy that you began posting here!! You have done an excellent job with your two SS and I hope you will post every day!
It might be easier for you and everyone here if you post two condos...one for each kitty each day. In the first post of each day, you will include the link to the previous days' post so that everyone can quickly get back to the thread. Makes it very easy to keep up with the latest news from each kitty. We usually post the AMPS number and include information about our kitty's behavior...WCR...Whole Cat Report....since there is so much more to the story besides just the BGs....

There is much to read an much to think about...the beginning is always difficult...and you are a busy lady already! Please feel free to ask questions and hopefully the experienced people here on this wonderful board will be able to give you the answers you seek!
Really glad to see you here Connie....these great people have helped the three of us so much...don't know where I'd be without their help!! Feel free to drop by anyone's condo to say hello, k? It's like one big happy family here! :YMHUG: Welcome!!!
 
Re: Need advice on dosage for cats new to Lantus

My two diabetics are not litter mates -- they are not even related! I just got lucky!

We have not been monitoring for ketones - have not had a problem with them as far as we know.

Neither cat has had a dental, but my vet has looked at them both and says they both look fine. They also have no problem eating which hopefully indicates that there are no dental problems. Their blood work all came back fine also. They seem to have no problems other than the diabetes.
 
Re: Need advice on dosage for cats new to Lantus

That's good news then.... :thumbup
(you might make a note on your SS when you test for ketones so there is a quick reference....the note section is good for jotting down anything of note fo the day!)
I looked right away to see if they were litter mates and yes, I guess if you want to say you got lucky...LMHO...
then well yes..you hit the jackpot !! :lol:
Lucky Connie.... :mrgreen:
 
Re: Need advice on dosage for cats new to Lantus

Hi Connie! I'm fairly new myself and have no advice to offer, but I did want to welcome you. Welcome! Glad you posted here in Lantus Land. Everyone is wonderful here and you're in really good hands.
 
Re: Need advice on dosage for cats new to Lantus

Okay -- here's my dilema. Domino has been at the vet's office all day today for them to check out his rodent's ulcer. We are home now at +11 and his BG is 70. They have not checked it today at the vets, so I have no idea how low it has gone. He has shown no signs of hypo. What dose do I give him in an hour?
 
Re: Need advice on dosage for cats new to Lantus

Welcome, Connie!

You've already gotten good advice. Dosing wise, I really think you're on the right track with both cats.

Domino - for right now 2.0 looks like a good dose for him. One thing that is really hard for Vetsulin people to get used to is that with Lantus, the cats DO still get high preshot numbers for a while, but that we don't adjust doses based on preshots. We adjust based on nadirs. We do give some consideration to preshots, especially once we get to the fine tuning stage, but the nadirs are far more relevant. So you work to get the nadirs where you want them, then you sit back and wait for the bouncing to stop. One day the preshots will magically start coming down on their own. We call it Liver Training School - the body reacts to low numbers by releasing glucose into the bloodstream to counteract the lows. We just keep showing them the green numbers over and over again until suddenly the liver learns to not overreact. In some cats it is a quick process to train the liver, in some it takes a long time. We tend to find that cats who have previously spent time on Vetsulin (and sometimes PZI) take longer to train their livers because they have already been programmed by the shorter acting insulins to bounce (dropping from 400 to 60 on Vetsulin is harsh and the liver is right to respond). Domino had a 76 when he was on 2 units, then you increased to 2.25 and that brought him to a preshot number you weren't comfortable shooting (which is fine), so you reduced back to 2 units (which is also fine). What I would do is try to get additional spot checks whenever you can (especially at night) to see if Domino is getting green on this dose. If we don't find any green in a few days, you might want to consider bumping him back up to 2.25. We can teach you how to handle those lower preshots confidently. :smile: I think he's doing fine though.

Puff - might be a higher dose cat, but starting over is a good way to find out for sure. Even if his dose does turn out to be 4 units or more, we have plenty of cats here who are on doses around there. Mine was on 4.25 units and she eventually went OTJ. If you can get a couple of spot checks tonight and maybe tomorrow, we can see what needs to happen with his dose. Because he is getting lots of yellow, our norm here is to increase every 6 cycles (3 days) by 0.25 units at a time (but I would rather see some night spot checks before recommending that you increase his dose). Once he starts getting blue, then we slow down and wait at least 10 cycles (5 days) before increasing. Once he starts getting green, then we slow down a lot (basically stop increasing) and start fine-tuning. I don't think you need to worry about insulin resistance yet. We do have some cats here who have various high-dose conditions, but we usually don't start thinking about those conditions too much until the cat's dose gets up to around 5 units with no real response. Let's give him some time on the new dosing regimen first.

I hope you'll stay around and post every day! It's always good to have lots of eyes on your spreadsheet, people can help you spot things that you may not notice.

edited for spelling
 
Re: Need advice on dosage for cats new to Lantus

Domino and Puff said:
Okay -- here's my dilema. Domino has been at the vet's office all day today for them to check out his rodent's ulcer. We are home now at +11 and his BG is 70. They have not checked it today at the vets, so I have no idea how low it has gone. He has shown no signs of hypo. What dose do I give him in an hour?


with a BG of 291 this morning? And he's at 70 now at +11? thats pretty awesome!
are u around to monitor tonight?
IF u have to stall the shot - how long can u stall for? Based on your schedule for next day.
u have HC food.
U have test strips.

Hang tight for feedback ok?
 
Re: Need advice on dosage for cats new to Lantus

Domino and Puff said:
Okay -- here's my dilema. Domino has been at the vet's office all day today for them to check out his rodent's ulcer. We are home now at +11 and his BG is 70. They have not checked it today at the vets, so I have no idea how low it has gone. He has shown no signs of hypo. What dose do I give him in an hour?

I posted my long reply before I saw this. :smile:

Can you please test again about 15 minutes before his shot? He might go up a lot before then, or he might not. Most likely he didn't eat all day at the vet so that might be why he is lower. When you post that number, please change the post title in your FIRST post to indicate Dose help please! and then post a reply to that post with the information (that will bump you to the top so you'll be noticed)
 
Dose Help Please

I have checked again at +11.75 and he is at 77. I will be here all night, but I do have to be at work in the morning, so I prefer not to take him too low that I have to be up all night. If I stall too long tonight, his AM shot would have to be moved up because I usually leave home within 30 minutes of giving him his shot.

Food was sent with him to the vet and they only sent half of it back to me, but I don't know if he actually ate it. He usually does not get too stressed at the vet -- he is a really laid back cat.

He has went low like this before for seemingly no reason and then came back up really high for the next day or two.
 
Re: Need advice on dosage for cats new to Lantus

Bouncing high for a couple of days after hitting lower numbers is normal at first.

Here are the choices when faced with a lower than usual preshot:

1. Stall for 15-30 minutes (without feeding) and test again. If the number is higher or about the same, or when you get a number you are comfortable shooting, then shoot full dose. If the number is lower, repeat every 15-30 minutes until you get a number you are comfortable shooting. Always get a +1 and +2 after shooting your lowest preshot in case he continues to drop, at which point you would intervene with food to control the cycle. This is usually the preferred option once you have some experience here. It looks like you did shoot low once (1/7) but otherwise you have shot in the mid-100's. Since that is the case, I would say you may not be comfortable (or have the data) to shoot much below 100. You can test again at +12 or +12.25 to see if he's above 100, he might head up fast once he starts climbing.

2. Shoot a reduced dose. You can determine the amount to shoot based on your comfort and your ability to monitor. Shooting a reduced dose will probably affect his numbers for the next 2-3 cycles because it will partially deplete his "shed." Good option when you don't have time to stall, or when stalling would mess up your schedule too much, or when you don't have data to shoot lower and don't want to wait.

3. Skip the shot. This option definitely affects the shed and will have the most impact on future cycles. It's good when you are faced with a low number and won't be home to monitor.

Do you have high carb wet food on hand? (something like Fancy Feast varieties with gravy)? We all have those on hand to help us guide low numbers. If not, then mixing syrup into low carb food would work too. I would not do option #1 or #2 tonight unless you have high carb food or syrup to mix into your regular food, and also plenty of test strips. You probably won't need it, but it's like a safety net, you should have it just in case.
 
DOSE HELP PLEASE

I was asked to change my first post title to Dose Help Please, but alas, I can not figure out how to do this. Help please?

I do have high carb food, Karo syrup and a sugar solution from the vet on hand if he goes too low.

If I stall, at what point would I give a reduced dose and how much? Or at what point would I say "no shot"?
 
Re: DOSE HELP PLEASE

Domino and Puff said:
I was asked to change my first post title to Dose Help Please, but alas, I can not figure out how to do this. Help please?

Go to your first message, and you'll see an EDIT button in the lower right side. Click on EDIT, then go up into your SUBJECT and change the wording. Then choose SUBMIT.
 
Re: DOSE HELP PLEASE

Domino and Puff said:
If I stall, at what point would I give a reduced dose and how much? Or at what point would I say "no shot"?

It sounds like you are on a pretty tight schedule in the morning, and since the morning shot will be due 12 hours (or at least 11.5 hours) after this one, you probably can't stall very much. I would probably test again now, if over 120-ish (or whatever you're comfortable with) then shoot the full dose, and otherwise shoot maybe 1/2 dose for tonight.

If we find that you're stalling shots because the numbers are too low for you to comfortably shoot, then sometimes what we'll do is reduce the dose by 0.25 units to let things slow down a little. We'll probably need to increase back to this dose soon, but that would give you time to collect some data and work your way toward being able to shoot low. We can talk about that after we see how this cycle goes.
 
looks like you shot 2 units at this number on 1/10, are you comfortable doing it again? At this point it is mostly about your comfort level. Domino is showing a rise and will probably continue to go up, so it's a matter of waiting until you get a number that you like.
 
My gut tells me that he will continue to rise. That is usually the case when he gives me low numbers like this -- he's usually high for a couple of days.

So do you think I should go ahead and shoot 2.0? If I do this now, I would only be early by about 30 minutes in the AM.
 
that works for me if it works for you (it's what I would do if Domino were my cat, but then again I've done this lots of times before so it's not new to me!).

Then you'll want to get a +1 after his shot and post that so we can keep an eye out and make sure his cycle is going the way we want. If he does drop, it's easy to control those drops with food.
 
Hi Connie,

Welcome to Lantus Land. You'll find there are almost always generous people around willing to help here.

You really do have your hands full with two! I have only one FD kitty, one civvy kitty with arthritis and one seizure dog. I sometimes feel like an animal hospital!

Hope to see you around here every day! It becomes somewhat addictive, especially as you see your kitty and others doing well.
 
Hi Connie, Domino and Puff
Welcome to the world of LL (Lantus Land)
You are in a great plce and you will get a lot of support here.
You seem to really have a terrific handle on this, which is great.
Libby was mentioning to you about higher dose cats, well Max right now is 1 of them.
We started off at 1u back in November and have beedn following protocol to our current does of 5.5u and tomorrow migt be 5.75.
Always try and remember, which has been told to me many times, they are more than just numbers so you have to look at the whole package.

Good luck with your 2 sugar kitties. Looking forward to your 2 condos.
 
I just confused myself with the two kitties...hey Connie, Puff has a different shot time than Domino?

Someone suggested opening two condo's - one for each kitty - if that works for u - something to try.

Other than that, maybe when u need dose feedback - add the kitty in question (their name) to ur subject line?

I'm glad ur here with us, u have gotten a lot of good help and support and I hope u will post daily!
We already like your two kitties! cat_pet_icon cat_pet_icon And what's not to like? They're kitties!!
 
Normally we do not have two different shot times. I was off a little tonight because Domino was low and we were trying to decide when and how much to shoot so Domino's shot was delayed by about 30 minutes. Will try to get one more check before bed.

Puff is holding at about 325 -- no worry about being too low anytime soon. I am still giving him 1.25 units. How long should I hold this?
 
good, looks like Domino is surfing!

For Puff, as soon as you can get a couple of spot checks (preferably around nadir, but something around the middle of the cycle anyway) we can recommend a dose.
 
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