Dosing advice for Nigel ASAP!

Hi there,

Nigel has been on 1u Lantus for about a week now, and got a Freestyle Libre installed on Sunday. His numbers have been low for the past couple of days and @MrWorfMen's Mom suggested that I don’t give him his morning dose, which he should be getting in a half an hour. Can others confirm?

 

Have you gotten the AMPS number yet?

Can you explain why you are doing 1u in the morning and 0.5u at night? Lantus is best given as one consistent dose. I think if you do shoot, I'd stick with 0.5u for now.

 

The inconsistent dosing wasn’t intentional, but in reaction to his low numbers the last couple of afternoons.

He’s at 118.

 

If you shoot, would you be able to monitor and do you have plenty of supplies on hand? If yes, stay with 0.5u.

Have you decided if you are following TR or SLGS?

 

How long has Nigel been on Lantus?

 

He’s been on it for a week. Unfortunately, I’m not able to stick around today. It was suggested to skip his dose this morning in another thread in the main forum and see how it goes.

What does TR & SLGS mean. Still figuring all of this out as we’re new to all of this.

 

OK, if you are unable to monitor, then skip is the best thing to do.

TR=Tight Regulation
SLGS=Start Low, Go Slow

You can read the stickies about both.

 

Thanks! I’ve read both threads but I don’t fully understand the difference between the two methods. Is it just a matter of how dose increases/decreases are timed and the quantity of insulin that is adjusted?

 

It would be good to reread them and the other stickies, and also print out a copy of the hypo instructions/toolkit. It took me many times reading to mostly understand.

 

If I can make a recommendation, I'd start with SLGS for now, to give you a bit of a break (hopefully). That will give you time to learn more and get your handheld meter figured out. You can always change later if you'd like

 

Hi Grant, and welcome to you and Nigel.
I agree with @Mandy & Rex: The Lantus dose should be consistent. Lantus is a "depot" insulin and builds each shot on the preceding shot. This is one of the reasons for it's success. It doesn't "tank out" when the insulin is "gone". The key is to find a dose that you can shoot consistently and to follow either TR or SLGS with regard to how long to hold a dose and by how much to increase or decrease. You will have to determine which method is best for you and your lifestyle, so re-read the "stickies". If you are feeding any dry food at all, you have to follow SLGS.
At this point in Nigel's diabetes adventure, you have to take into consideration that you are just beginning. It takes at least a week to establish the Lantus "depot". So you should not be jumping around in dose. Every time you change the dose or skip a shot the "depot" needs to recalibrate itself.
Another thing to keep in mind is that Nigel's body needs to get used to Lantus and it may take a few months--even longer--for you to see the effect the insulin has on his blood glucose. Getting regulated and hopefully achieving remission is often compared to a marathon, rather than a sprint.
So ask as many questions as you need. Everyone here wishes the best for Nigel.

 

@Ella & Rusty & Stu(GA) thanks!

So should I be planning on sticking with 0.5u from here on out, given the drops that he’s had on a full unit?

I’ve reread the SLGS thread and will probably need to again. But, if that is the less demanding method, then that is what I’ll use.

 

I just looked up the food you are giving Nigel. That's 11% carbs. We prefer to keep it 0-10% for low carb. 11-15% is medium carb. I think if you look for a low carb wet food, it is possible Nigel may not need as much insulin. Here is the chart we use here.
https://catinfo.org/docs/CatFoodProteinFatCarbPhosphorusChart.pdf

 

I think I would stick with the 0.5U for now. It will permit you to shoot consistently. You can certainly start with one method and later switch to the other if you decide to. TR is considered the more "aggressive" and is based on scientific protocol. The most important thing is to use the method that will work for you.
The food lists in www.catinfo.org that @Mandy & Rex cites are really good.

 

Previous thread

That should give the rest of you some back story- it's long though!
Cliffs notes version: Freestyle Libre sensor, huge drops after shots, low response to high carb dry, the greens have all been food managed with the first set using karo syrup, currently no high carb wet food.

Does that sum it up about right Grant?

 

Also, all of the info and suggestions given here is much more than I heard from the vet. She basically told me that Nigel would have the Freestyle Libre on for ten days to figure out dosing, then he’d have another check up in 6 months to see how he’s doing. She didn’t say anything about modifying dosage on my own.

 

Yes, he’s pretty much been just on low carb wet food for the past couple of days. Before that he was on a combo of low carb and slightly higher carb wet food. I gave him a little dry food last night, since it was all I had with a higher carb content. He’s taking to the Fancy Feast, but there isn’t enough in a can to last the whole day. Guess I’ll have to get a feeder. Should I get him the same wet food with gravy for higher carb food?

 

I just finished reading your other condo. Wow, you had some excitement this week. I'm glad you are skipping today, too!

If you look at the chart, you can find other FF flavors that have higher carbs - ie gravy added. If you need to give HC to boost his numbers, it's suggested you squeeze the gravy out and give that, not the food itself. Gravy is where all the carbs are.

 

Yes the same food with gravy is good.

 

Grant, I know you purchased the Relion Prime meter and that I suggested you take the time to learn to test while the Libre is in place so you can continue to monitor without missing a beat when the sensor runs out or in the event that it falls off early. Having done some more investigating into the use of the Libre I was quite surprised to find the following on the MyFreestyle site itself.

The FreeStyle Libre Pro sensor is not a replacement for self-monitoring of blood glucose.
Continue your normal testing routine while wearing the sensor.
​

I also found multiple user reviews suggesting the readings humans were getting on the Libre were sometimes high and sometimes low when compared with blood testing. It seemed both low and high BG level readings were problematic. Because the Libre is reading from interstitial fluid rather than blood, it's understandable that readings might not be identical to a blood test however the degree of difference noted in the comments I read were significant in some cases (50 points or more were reported).

So it seems to me that while the readings you are currently getting provide some relative information, I'm not convinced they are completely accurate as far as BG levels are concerned. I think for the sake of getting accurate readings, it would be best if you start learning to test Nigel's blood sooner rather than later.

While I know you are questioning whether Nigel is diabetic at all and I agree the diagnosis was arrived at, with less than what I would consider optimal medical testing, it's still possible Nigel is diabetic and needs a small dose of insulin so being able to test Nigel going forward is of paramount importance to keep him safe. Even if it is determined that Nigel is not diabetic now, I would strongly suggest that periodic testing of his BG would be prudent to ensure he isn't perhaps borderline. Catching diabetes early and treating ASAP increases the odds of the cat going into remission.

Please have a look at the testing videos if you have not already done so and ask any and all questions you might have about testing. I really think it will be time well spent in the search for a definitive answer regarding the diagnosis and keeping Nigel safe and healthy going forward.

​

 

Thanks for this @MrWorfMen's Mom ! I’m going to watch another video and give him a test with the Prime tonight.

So, the FL is showing him at 198 now. Should I hold off on the insulin tonight?

 

Do you think you could try to get a test done with the Prime as well before his usual shot time?

Eta: what food did he eat today? You mentioned being out of fancy feast.

 

Is that a +10? Looks like he may need a bit of insulin (I'm thinking less than half unit right now) but with his BG behaviour the last few days, I'd rather wait until closer to shot time to render a final opinion. Do you think you can try for a blood test arountd +11.5?

 

I assume he's only had access to low carb food all day? Is that correct?

 

What's his sugars at now?

 

Yeah, he had FF today. I just fed him and tried the test on him twice with the Prime with no luck. Tried it on myself as well and it didn’t work. Not sure if I got a dud or if I’m doing something wrong. I read the directions. Anyway I tested him with the Freestyle Libre as well and got 238 so have him about 0.5u. Seem like the right idea? I’ll try to figure out what could be wrong with the Prime. He hates the test by the way and doesn’t make it easy.

 

Ok so you know the drill.......+1 and +2 tests to see what Nigel is up to Ok?
The prime takes a bit more blood than some other meters so that may be the problem you are running into . If Nigel doesn't like his ears played with, make it a habit to play with them a bit at every opportunity without trying to test. Get him used to it one step at a time. More to follow shortly.

 

When you test, always give a treat. He will eventually associate tests with treats.

 

Good call in the treat. He shrivels up his ears when I play with them, so will try to do it more. Both times I used as much blood as was recommended but nothing happened.

Generally he’s acting kinda naughty tonight. First he knocked over a full beer and then I caught him licking the lube off of a bike chain.

 

Alright, I got it to work on myself.

 

Did you find what the problem was? for me it was inserting the strip too soon.

 

Thanks for the giggle. I have a little menace too.....hence her name!

When testing, it can be helpful to warm the ear first. If you have an old Rx pill container fill with hot water and hold it on Nigel's ear for a few seconds before testing or use a hot washcloth in a baggie (don't get ear wet). It also helps if you put a thin skim of Vaseline on the spot you intend to poke. It helps the blood bead up so you can catch it with the strip rather than have it spread out into the fur on the ear.

Since he doesn't like his ears touched, if you can get a blood bead, you can catch it on your fingernail and then test from there. Just make sure your hands are clean so nothing skews the test results.

ETA Even if your test attempt is unsuccessful, give Nigel a treat so he comes to associate all the fuss with a treat.

 

I’m not sure exactly. For whatever reason it was showing an arrow flashing before when I inserted a test strip, and this time it showed a blood droplet. ‍♂️

 

I think I’ve managed to get enough blood. The issue seemed to be something having to do with it not starting up correctly.

 

Alright, success at last. He was 127 with the Prime and is showing 188 on the FL.

 

Ok. I am not familiar with the prime but experienced the same type of problem with a different meter. It seemed to be the way the strip got "seated" in the meter. I started putting the strip in and making sure the meter turned on properly, then pulling it back out just enough to turn the meter off so that when I was ready to get the sample on the strip, I could just push the strip back in quickly with it already in the right position.

 

now that is a difference!
Please grab a reading off the FL 15 min after the test you just posted. I'd like to see the time lag.

 

Ok, that is both good and not so good. Great that you got the test. CONGRATS! GOOD JOB! A difference of 60 points is however significant and confuses the picture.
I'm going to suggest that you test again with the Prime at +2. Nigel may not have been as high as we thought at PMPS or he may have dropped a lot in this first hour. No way to know.
I like @majandra suggestion. Let's see what that adds to the mystery here.

 

The FL is showing 158 now.

 

Hmm, still quite higher than the prime. I'm curious to see if the FL will reach down to that 127, and how long it takes to do it.
I agree about getting your +2 with the Prime as Linda suggested.

 

Well that didn't really tell us anything much except that the reading on the FL are all over the map. I know BG changes constantly but that just seems a bit too erratic. I wouldn't bother trying to chase the numbers right now. There is the graph that we can look at tomorrow and see if it does match up within a half or full hour. Obviously it doesn't in 15 minutes. There's something to be said for the old technology!

 

The graph is pretty hard to read too. Would be good if you could zoom in.

 

I'm not sure what you did to share the graph the first time (Yesterday) but it was actually not too bad. The second one today was a bit smaller and harder to see.

 

I just thought of something- did your vet do anything special to calibrate the sensor?

 

It cannot be calibrated. That was something else the human users were complaining about.

 

Ok, well there went that thought!

 

Got a reading of 107 on the Prime. Not sure about what I should do with the spreadsheet at this point.

 

Grant, your SS is showing a +1 tonight of 202 but I thought you got the Prime reading of 127 and the FL reading of 188 at +1. Can you clarify the difference please.

We need to be consistent here with what you're reporting here and what gets logged so anyone else helping is not totally confused (we are confused enough with the differing readings and we know what we are doing). I think now that you have been able to test successfully with the Prime at +2 we should start logging the Prime readings and put a note in the comments that the PMPS for tonight is from the FL and the rest are the Prime meter.
We can add a row to the spreadsheet below todays date and put a note there "Started use of Relion Prime".

 

That was 10-15 after +1. I’m thinking now that I know that I can use the Prime, that maybe I should reserve it for when his BG dips into lower levels? I’d rather not have to prick him every 15 minutes during this period of bouncing numbers as long as I have the FL installed. Or do you think it’s too far off to trust it?

 

The problem is that with dropping numbers, you don't want a meter/reading that may be reading high. So while it's possible the Prime is reading a bit low I'd rather trust it and be able to take action as soon as needed than deal with a inaccurate high reading and not take action. Hypoglycemia is something you don't mess around with and a 60 point difference is very significant even at the higher numbers. It could be deadly at lower numbers. Sorry to both you and Nigel, but until we figure out what Nigel is doing, I think the safest thing is to use the Prime.

 

Feed Nigel some LC food now and then test him 30 minutes later. Hopefully that will prop him up a bit. Many cats tend to go lower at night so it's better to deal with the dropping numbers earlier in the cycle.
Tomorrow, assuming you will again be out all day, do not give Nigel any insulin until you get a confirmation of what dose to give. It may be that the 0.5u is fine but it may also be that for safety purposes right now, a quarter unit would be better. I'm saying this because of the significant difference in the FL and Prime readings we got tonight. Needless to say, this discovery is warping the picture yet again. If per chance the PMPS from the FL tonight was an inflated reading, then his PMPS may not have warranted a dose of 0.5u. We just don't know and it's all a guessing game right now.

Dose is not based on how high the pre-shot reading is. The dose is based on how low it is taking the BG at peak action. The pre-shot tells you if it's safe to give insulin and gives you a starting BG to gauge the drops the dose causes for Nigel. The insulin works best if we find a consistent dose you can give both day and night rather than changing it every cycle.

 

That all makes sense. I’ll report back momentarily.

 

Will wait for your update then I need to crash for the night

 

Well, it’s low. Showing 65 on the Prime. He did just eat some more food though.

 

105 on the FL. He’s acting normal still. Playing right now chasing ghosts.

 

Do I need to do anything?

 

When did he finish eating? Just now or half hour ago.

 

You are in good hands Grant, goodnight, and Nigel, no swimming with sharks tonight!

Ps- update your ss

 

Yeah, I guess it would have been around 15 minutes ago.

 

I'm floored by the difference in those readings. Both are safe but they are 2 different animals especially at this hour of the night. 65 is low enough to warrant either higher carb food to prop him up a bit or keeping an eye on things for awhile but with 105 a little more LC and off to bed with a test at bathroom break would suffice. The strange thing is that Nigel seems to be hitting peak action early and he really drops quickly.
Curiosity, which way was the arrow pointing on the FL display with that 105 reading?

 

The arrow was straight. He’s eating more LC food right now.

 

Mix a drop of karo into whats left in his bowl.

 

By straight you mean pointing to the right? Curiosity...... take another FL reading after Nigel finishes eating.

 

He didn’t wanna eat it but I put a little on my finger and put it in his mouth. Will a little dab be enough?

 

I wish I knew. He hasn't seemed to be very carb sensitive up to now. Check his BG with the FL and see which way the arrow is pointing now.

 

95 and still to the right.

 

Test him again now with the PRIME.....sorry, but those FL numbers are totally bizarre. He's dropped 10 points by its measure yet it seems to think he's steady.

 

81 on the Prime. That gonna be OK to get some rest or do I need to try to boost him up with Karo again?

 

I think if you leave some LC food with ONE drop of karo down for him to munch on if and when he needs it and then test again just for safety sake at a bathroom break tonight he should be fine.
Off to bed we all go!

 

Sounds good. Nighty night! Thanks again for all of your help, Linda!

 

I checked with the FL in the middle of the night at +9 and it was 180 then 124 just now. Will test with the Prime, but is it looking like no shot this morning?

 

If the difference is as large as it was yesterday, quite possible.

 

The routine here in Lantus forum is to start a new thread (known as condo) every day. For a title, you can use "Date, Nigel AMPS #" we also put a link to the past thread (this one) in the today's new condo for history like you did when you came over to Lantus from Health.

 

Should I feed him before testing?

 

No test first please.

 

He’s at 74. No shot?

 

Yup, Feed Nigel and have a worry free day. Going forward I think we are going to have to look at lowering the dose to 0.25u. It would be really helpful if you could pick up some syringes with half unit markings.

 

For now, see if the pharmacist will sell you a pack of 10 rather than a full box of syringes. No point stocking up till we figure out what is going on with Nigel.

 

Can you post a pic of the graph off the FL for us to look at when you can spare a minute please? I'm really curious to see last night's graph and whether that will shed any light on what's going on when compared to the Prime readings last night.

Just to be clear on moving forward..........

Add some high carb gravy food (FF with gravy is fine) to your shopping list.

Test Nigel with the Prime (you can take FL reading too for curiosity sake if you want) when you get home (assuming that will be roughly an hour or 2 before normal shot time). Post that number so we can see if it looks like Nigel might need insulin.

Do not feed Nigel for 2 hours before his normal shot time.

Get a pre-shot test with the Prime and post for advice. You can take an FL reading for curiosity sake only. Remember we dose based on more than the pre-shot number and right now there is a lot to take into consideration so let's discuss before giving any insulin tonight. I'm sure after 3 nights of monitoring intensely for several hours, you don't want to be in that boat again tonight if at all possible.

The substantial difference between the FL and Prime readings as well as Nigel's reactions is making dosing decisions more difficult than would normally be the case.

 

Well, I just tested him with the FL and it showed him at 87. Put some Karo in his food and made him eat more. He tested 69 on the Prime. I have to go to work as it’s my busiest day. Hope he’s ok. I bought some gravy food yesterday.

 

Good morning Grant, You didn't shoot this morning so not reason to worry he would be ok

It's been quite an ordeal for you, and things have been more complicated than usual, and it appears that Niegel is a diver (likes to go down a lot and fast ) does make me go back to when Babu and me started he was also a bit complicated but really I does get easier down the row. (A message from Babu to Niegel, he does say Nigel better start behaving because Babu doesn't want to lose his diving championship)

On more serious matters after you get the pre shoot reading and we see how he's doing (and if he needs insulin at all) I would still consider to start with a very conservative dose 0.25 u and start monitoring, let's see what others think

I do remember that at least the brochure and instructions that I got when I bought the FL did mentioned that one should be careful on low numbers and "maybe" double check later on I did find some information pointing to the fact that the FL was not very accurate in low numbers which are usually when we need more readings and more precision

 

Grant, if there is no insulin given there is no need to give him karo. Karo is used as a rescue tool ONLY when you have give an insulin injection and numbers are low.

 

@Veronica & Babu-chiri I found some info yesterday that suggested the FL is not to be used as a replacement for blood testing. I also found numerous reviews suggesting it's not only low numbers where the FL seems to be off compared to blood testing. It seems some find it reads high, some low and some folks complained about both problems and it didn't seem to be consistently with either low or high numbers. Last night we got a 60 point difference on one reading, 40 on another, and in both cases the Prime reading was lower. When dealing with dropping numbers, I'll go with the lower readings anyday. Not really sure the FL is quite the amazing technology it's being marketed as.

 

So is it a problem that I gave him Karo? I just poured a tiny bit on his food.

 

Well under normal circumstances I would say no ( it's certainly not going to hurt him), however, it will raise his BG temporarily which means that when we (or the vet) look at the graphs or BG history on the FL, there will be an artificially elevated BG there when no insulin was given. This could give the impression his BG is running higher than it actually is and we don't want to do anything to artificially raise his BG right now when the ? of diagnosis and need for insulin is on the table. If he had had insulin this morning and his numbers were dropping, then you do what you have to bring numbers up, otherwise let nature take its course. He will not go hypo if he didn't get insulin.

 

I’m still wondering if he was misdiagnosed or if he is prediabetic. Like I said in my first post, the diagnosis was based on heavy drinking/peeing after a diet change that stopped shortly after changing his food back, the vet wasn’t convinced of diabetes until a blood/urine test (no fructosamine test) and he’s never lost any weight or showed any changes in behavior.

 

Your suspicion is IMHO totally warranted and Nigel is certainly not responding as expected in many ways which is why we have been taking this a step at a time and being cautious. When there has been no insulin given, feed Nigel as you normally would (lower carb food is fine and a good idea) so we can see what he does without insulin in the picture. The only caveat to this right now, is that there is still a depot of insulin in his system which is playing into the picture too. With the suspicion of diabetes, you don't want to withhold insulin if needed however if he isn't diabetic, you don't want to be dosing him either. And right now, with the readings we've seen, the picture is still a blurry.

 

The fact that something and stress did raised his numbers over normal numbers and it did took a few hours to go down does put him at least as borderline diabetic ( or prediabetic) it also could be that he's diabetic but since you caught it early his pancreas is not totally broken but working a bit hence this abrupt changes which will mean that he may benefit from getting some insulin to help his pancreas heal and go into remission , in any case feeding him only low carb food from now on is going to help him even if it turns out he doesn't need insulin (fingers crossed), actually it even helps non diabetic cats, mine became more active and even their coats improved.

 

No luck finding syringes with 0.5 unit increments at two different pharmacies. Any ideas of a chain that has them?

 

Walmart generally does

 

Many can order too if you give them the info for the ones you want. May need an american to help with that

 

Are the measurements of the ones at Walmart the same otherwise? Do I just ask for syringes with half unit increments it are there any other specs that would differ from these?

 

ADWdiabetes.com has a variety and are used frequently here but ordering that way will take time. Walmart staff do not know they have syringes with half unit markings. Ask to see what they have. It should say on the box or you should be able to look at them. They are also 3/10ml. syringes not .5ml. Perhaps that might be the reason they said they didn't have any?

 

You need 3/10ml, 31 gauge, 6 or 8mm needle length with half unit markings.

 

Alright, got the syringes.

And here is the graph from the FL (got home a litttle late so there’s a small gap in the data. Do you think Nigel’s gonna need insulin today? Could test with the Prime now as well or wait until closer to shot time.

 

Tested with the Prime and just updated. So his ears are getting pretty scabby. Do you prick the same spots over and over or should I not prick a scab?

 

I don't see your results on your sheet- what is his bg with the Prime?

 

If you don't have to poke scabs, then don't, but not a big deal if you do. He will be less scabby soon, once his ears get used to it. He's likely scratching a bit too.

 

Oops, wrong box. Fixed. It’s 110.

 

Perfect!
So far, I'm leaning towards skipping tonight. He is in normal range right now, and didn't get overly high even after Karo with his breakfast.
Let's see what he is at closer to shot time.