Lantus - Different AM/PM doses?

[Dawn & Nova]

I've been giving Nova her insulin pretty close to 12 hours apart since the beginning (oct/2009), give or take 15 mins at most. She has always started a little higher AMPS.. gone lower throughout the day, been low PMPS (compared to AMPS) and a little higher following through the night to AMPS.

I've attributed this to meal times and activity level, as she sleeps through the night. I'm currently in the process of trying to eliminate lunch gently (lowering amount and trying to feed it after peak so I can get an idea where her numbers are at without food.. as much as 3 screaming cats will allow).. as I go back to working in the office instead of at home in a week and a half.

The Readers Digest - Nova was diagnosed in the beginning of Oct 09 (blood glucose was about 350), started out at 1U twice a day and worked our way up to 3. Since then with diet change and timed meals we have worked out way back down to 1U and am currently doing a bit of "tweaking" since we are pretty close to where I want us to be as far as numbers.

I've been working very closely with the staff at the vet hospital to manage her diabetes (with much appreciated help from all the information on this board).. so starting Feb 1 I started a spreadsheet that they could track (previously was writing down numbers in a notebook), so the units are non-US (times by 18 to get the usual numbers), and some of the testing times have been removed to make room for feeding amounts. It's modified from the standard one used here, I kept the colour ranges the same but there is only 1 week in it and we've been bouncing around some, so I doubt it will be helpful (http://spreadsheets.google.com/pub?key= ... utput=html).

Her specific numbers are probably not all that important.. the main thing is, I don't want her dipping too low while I am at work and there's nobody home to watch her. I'd like her to stay "in the blue".. with touches of yellow PS..and not really any green (I'm not emotionally ready to get that aggressive about this yet ).

Anyways, my question is, does anyone give different AM/PM doses? I'm thinking about 0.75 for AM and 1.00 for PM. My concern is, any time we've changed doses she takes about 5 or 6 days to get herself completely sorted (not huge changes, but I find she's most predictable 5 days later), and I don't want to send her on a daily roller-coaster ride. The other thing I have been considering is intentionally doing a 12.5 and 11.5 hour split but again I don't know how she will react. I haven't found a lot of information about either of these possibilities and am not sure what to expect/be concerned about/if it's a really bad idea period/etc.. any thoughts?

 

[Lydia--(Rosie & Basil) GA]

Hi,

I'm sure someone with more experience will be along shortly, but I wanted to say welcome and that I am sure you will find that mixed dosing is not recommended. Lantus seems to do best when it is dosed very regularly and uniformly.

I would also say don't be afraid of those greens once you get an understanding of how your kitty's numbers behave. Basil's days and nights have always been different, too. I think it is a natural biorhythm of some sort.

Good luck and hope ot see you around Lantus Land!

 

[Dawn & Nova]

Yeah it's likely that the correct answer is for me to get over shooting her in the PM when shes a bit less then <200. I just always have it screaming in my head not to shoot under 200 and feel rather sick to my stomach every time it comes up (which is almost every PM ). Switching back to working in the office isn't helping much either, since I've been at home watching her for over 2 months and am pretty anxious about leaving her alone in the day.

I think her medical staff feels that I've got my brain around this stuff decent enough to be more aggressive as well. I'm just a big chicken. Yesterday the most recent dose change (down to 1U from 1.75) seemed to start settling in and it's got me a bit spooked and backing off.. which my brain says is a mistake.. and my heart says too low = dead. You would think that having a cat diagnosed with HCM at 1 year old (different cat then the diabetes one).. after 5.5 years (and still going) with him I wouldn't be a cat mommy freaking wreck .

Ah feline diabetes.. just when you think you understand what's going on, the food changes, the cat changes, real life changes.. to destroy your confidence .

 

[Dawn & Nova]

When we dropped from 1.75 to 1U a week ago.. my BRAIN predicted we would likely go up to 1.25 once I looked at the results of the week and did the next curve (due in two days on wednesday).. at the time based on where we were at my best guess was that 1.25 would be good.. but we were having a bit of rebound (we suspect) that caused the dose change.. and I wanted to be absolutely sure it was out of her system so went down a little bit lower.

As Wed comes closer.. my chicken heart is starting to win the battle against my logical brain.. and I really need to stop that. Now since I've wussed out I think I've mucked up the week with my 0.75 last night and this morning . Need you guys to kick me in the butt because I feel like we're so close, I just need stop being such a pansy! .

 

[Lynn and Angel]

Hi. I'm sure more experienced folks will step in to offer advice later, but I just wanted to point out one thing that glared out at me. You mention decreasing from 1.75 down to 1.0 u all at once. The best dose is found by going up or down in only .25 increments. I would suggest not altering your dose so much... you may have skipped the right amt for your girl plus the fact that a .75 decrease could have a lot of "dose wonkiness" going on. Some people (like me) have a cat so sensitive to dose changes that I only go up or down in fats or skinnies (apprx. 1/8 of a unit) whenever an adjustment is called for. Just something else for you to think about. Also, I work full time too and have been doing this for more than a year and also have 3 cats like you. It takes some creativity and compromise but you can find ways to do this. Many of us are away from our fd cats all day. Good luck and I'm sure more help will arrive.

 

[Ronnie & Luna]

Hello Dawn,

welcome to Lantus Land, I was just curious, what protocol your vets are using for Nova (cool name by the way)

I've been working very closely with the staff at the vet hospital to manage her diabetes (with much appreciated help from all the information on this board).. so starting Feb 1 I started a spreadsheet that they could track

 

[Hillary & Maui (GA)]

If you look at the starred posts at the top of this section, it goes over the protocols we use here.

What you are proposing different dose for Am and pm is what we call dose hopping. Lantus does not work this way. You need to maintain a steady dose and only make dosing changes after 5-7 days or if the BG's go up or down to a "set point".

Also, we try to stay as close to the 12/12 schedule as possible, as a change in the schedule, can be considered a dose increase or decrease. Your shooting within 20 minutes of your schedule shouldn't be an issue, but do note that if you see a lot of BG swings, it could have an affect.

Sorry, I'd elaborate more, but I'm at work. So, please read the Tilly protocol and the starred posts. It will answer many of your questions.

 

[kate and lucky]

Hi Dawn,

There are lots of other beans here who have to leave kitties for 8-12 hrs a day.
They leave food out, use timed feeders, ice puk the food, only increase on a week end when they can get a curve done across the 12 hour cycle.
There really are ways around this and if food is given in the right amounts, plenty of kitties that surf blue and green with no problem.

Looking at your ss, the drop to .75u may have been a tad premature, may have been about right (76 in US numbers)

There's something called dawn phenomenom. Not proven in cats, but does exist in humans and may offer an explanation for slightly higher AMPS. In preparation for the day the body releases extra glucagon into the system to have energy to start the day.I've seen quite a few 'cases' here where the possibility has been muted.

Consistent dosing has been shown to be the most effective. As Fraay is on a low dose and numbers aren't excessively high, you could try for remission. However that does mean finding some BOS (Balls of steel :mrgreen: )

After an intial dose , dose increases are recommended every 3 days or 5-7 days, depending on your numbers (in Stciky of Rand protocol), however plenty of people (including myself) hold doses for longer because they have found their cat takes that bit longer to show changes in their numbers-this is fine too.
Also as I said above, for those that work, it's best to wait to increase until your home to monitor.


Nadir is usually around +6 (lowest number in your cycle) and this is the one you base your dosing decisions on,. not the preshot tests.

You did do a dramatic drop, but I would be more concerned if right now it was the other way round. We generally incraese and decrease in .25u increments so as not to miss the ideal dose.
Renal thtreshold for a cat is around 220-numbers over this and the kidneys are having to work nharder and damage could be occurring. For a Pancrease to heal any number under ~120 is allowing this and even more so if the cat is in green numbers as the Pancreas is getting a great break

I would try and get some more spotchecks and we can help you to try and stabilise Fraays numbers.
I think you may have your head round the idea of bounces after lows? Even if it isn't a particularly low number but one kitty's body hasn't seen in a while, the body kicks in to defend itself by releasing glucagon cos it thinks kitty is in danger-life saving response. Lucky was 27 (1.5) once, but I wouldn't have known if I hadn't tested her!Just demonstrating that greens aren't something to be terrified of, but yes can take time to get your head round.

 

[Dawn & Nova]

Hi. I'm sure more experienced folks will step in to offer advice later, but I just wanted to point out one thing that glared out at me. You mention decreasing from 1.75 down to 1.0 u all at once. The best dose is found by going up or down in only .25 increments. I would suggest not altering your dose so much... you may have skipped the right amt for your girl plus the fact that a .75 decrease could have a lot of "dose wonkiness" going on.

We do expect we have missed the correct dose.. the change before that was 2.0 to 1.75.. but then we started getting some 100-130 PS numbers.. feed.. wait an hour.. retest.. give insulin... in the AMs.. which gave some overlap in the evenings and everything just went wacky (peaks too)... we had a bunch of days where we were either shooting partial doses or shooting late (that's why we started the spreadsheet, calling in the numbers got so confusing for everyone ).. the diet change went pretty much exactly as predicted (lowered dose at the same time).. things were relatively stable for almost a month at 1.75 (I was getting more comfortable with these "blue" numbers.. so we were about to consider going back up to 2U).. and then she started going crazy on us.. so we sort of went for a do-over.. testing her pee.. and starting over at 1U and climb back up in 0.25s..

But yeah it is a big change.. and I definitely need to take a deep breath and relax about the numbers and let her settle down for a while before I start mucking with things.. now that you mention the dose size change.. yeah it's probably her body trying to figure out what the heck is going on. I need to back off and let her do her thing.

I feel so much pressure to try to get her good in the next week and a half.. but diabetes works on it's own schedule, not mine. And that is a huge mistake on my part. Ugh I feel so bad for last night and this morning!

 

[Dawn & Nova]

And I do need to test more.. chewed through the last 100 strips like crazy and have been backing off a bit as I start to run out of strips, but going out tonight to get some more and more freeze dried treats.. Nova will be very very happy .

 

[Dawn & Nova]

welcome to Lantus Land, I was just curious, what protocol your vets are using for Nova (cool name by the way)

We've been going with the uh.. lets call it the Nova protocol haha.. they may have a name for it.. but I don't know what it is.

By the.. lets call them the FDMB standards, they are probably too relaxed for peoples tastes around here.. as I have become more comfortable with things and got more involved (they suggested this board for more information actually.. as some of the information I was finding on-line was incorrect) in learning how to manage things "properly".. we've been doing the learn together as you go method..

They had a lot of success with their ways in the past.. but Nova and I, with the help of this board, are edging them towards more aggressive treatment. That's why the spreadsheet is more for them and me.. Nova is sort of a test case.. they haven't had any cat mommies so interested in diving so deep and testing lots before.. it is most definitely a journey I want to continue to make with them, with some assistance from you guys.

We probably have made a lot of mistakes so far. But in our defense, Nova is unfortunately #2 as far as health concerns in this household. As I'm sure many of you can appreciate, in a household with 3 special needs cats, with vastly different diseases.. there's a careful balance to be maintained. Try to do the best we can for all of them, but primarily limiting high risk for each. It's a balance their doctors/techs are well aware of and certainly go the extra mile to help me maintain. And that support and relationship is something I absolutely need.

 

[Dawn & Nova]

I think you may have your head round the idea of bounces after lows? Even if it isn't a particularly low number but one kitty's body hasn't seen in a while, the body kicks in to defend itself by releasing glucagon cos it thinks kitty is in danger-life saving response. Lucky was 27 (1.5) once, but I wouldn't have known if I hadn't tested her!Just demonstrating that greens aren't something to be terrified of, but yes can take time to get your head round.

I've noticed the bounces.. but didn't understand why. Your explanation helps a lot. I've had it happen before that she comes close to or into the green (green once before out of nowhere, 61.. was a while ago).. and then things go wonky.. but not up to as high as she is now.. and I would typically see some sign of sanity the next day..

How long do these bounces typically last?

Definitely thinking something new is going on though.. even near the beginning when she was on 1U and high carb dry food she wasn't this high midday. Going to get a new pen tomorrow I think just to rule out that I wasn't sleep walking and tried juggling with it or something. Maybe her pancreas has been helping out for a while and decided to go on strike.. ah well..more testing..more waiting.

But she's still acting like her normal self.. in a good mood and teasing me just like normal (tortie and we guess half siamese, acts exactly as one would expect ).. she knows I want her to pee on the stick.. last attempt at getting her to do it she dug a hole, assumed the position..and poo'd.. she thought it was pretty funny.

 

[Sienne and Gabby (GA)]

Welcome Dawn!!

If you haven't found it yet in the starred notes at the top of the Board, we do use a dosing protocol - the Tight Regulation Protocol for Lantus & Levemir. It's a little tough getting through on the first read, but it does explain how much and when to make dose increases and decreases. We use a modified version of the protocol. Those posts at the top are exceptionally helpful in getting you oriented to Lantus Land.

Since Kate mentioned it, here's a link on dawn phenomenon as well. Part of what happens in this situation is that cortisol, a steroid hormone, is released which then increases BG levels so metabolism is amped up to start the day.

You asked how long a rebound lasts. It can take up to 72 hours for the hormones that are released in response to a bounce to clear. However, the more time that a cat spends in normal BG numbers, the shorter these bounces become. In part, it's a matter of retraining the liver to not panic when BG levels are in a normal range.

Great job getting your SS up and running. If you check in the Tech Forum, there are instructions for linking the SS to your signature so you don't have to remember to copy and paste it all the time. Likewise, there are instructions there for creating a profile. The profile will have info on what you feed, medical history, etc. All of the questions that we will otherwise keep nagging you about.

Please ask questions. Read other threads (we call them condos) and look at our SSs. If you opt to post regularly, the people here will do their best to lend you a hand getting Nova regulated. This is an international group so there is usually someone around 24/7 if you have a question or need help.

 

[Dawn & Nova]

Since Kate mentioned it, here's a link on dawn phenomenon as well. Part of what happens in this situation is that cortisol, a steroid hormone, is released which then increases BG levels so metabolism is amped up to start the day.

You asked how long a rebound lasts. It can take up to 72 hours for the hormones that are released in response to a bounce to clear. However, the more time that a cat spends in normal BG numbers, the shorter these bounces become. In part, it's a matter of retraining the liver to not panic when BG levels are in a normal range.

I've actually read about the dawn phenomenon before (the name caught my eye at some point in life ). I just wasn't aware cats could have it too or that it would work properly in a diabetic cat.

I think (hope) she's starting to come down now.. hopefully tomorrow will be a little more normal. Unfortunately I have meetings a good chunk of the day and can't be home to test as much as I would like to.. but.. gotta pay the bills.

As for rebound and retraining her liver.. probably just as big a part of it is retraining her human. I believe I've seen Nova bounce a few times... and now that I understand it a bit better hopefully I can be less scared of those lower numbers that have caused it in the past. But I have seen my Type 1 human friend hypo twice.. and blocking those out of my mind is a little bit tougher.

Thank you all so much for your information, welcomes and support.