Need Help with Lantus Dosage Reset

lbeachstace

lbeachstace

Member Since 2022
I need help please.

Our cat was at 6 units of Lantus and we restarted his dosing to one unit on 12/4 after his numbers were erratic (using AlphaTrak2).

He was at 1 unit for 10 days and has been on 1.5 units for 12 days with no downward trend.

Based on previous Lantus history, we had no movement until 4.5 units. Are we doing the right thing by going this slow? Or do we assume, based on his past history, that these low numbers won't get him lower until we reach a higher dosage?

We are unsure what the right strategy is to get him regulated and could really use some help.

Thanks
Stacey
 
Hi Stacey,
It is not a good idea to restart the Lantus dose back at 1 unit if you were giving 6 units.
By doing that you are risking ketones forming in the urine which I note he had at diagnosis. Ketones can rapidly progress to DKA which can be deadly.
Lantus dosing is based on the nadir or lowest point in the cycle. Not the preshot BG.
Looking at Buddy’s SS I can see you frequently don’t test the Bg before giving the dose either in the am or pm cycles and never test during the pm cycle. Cats often drop lower at night and unless you are testing you will have no ideas what is happening. It is also very possible you have gone past the best dose at 6 units.

Here is what I would do if I were you.
  • I would go back to 5 units twice a day now.
  • Test before every dose of insulin
  • Get at least 1 test in during both the am and the pm cycles every day.
  • Test daily for ketones at the moment. If you don’t have any Ketostix to test with, I would buy some from Walmart or a pharmacy and follow the direction on the bottle. This is important.
  • I note you are feeding twice a day. I would recommend you also feed several small snacks during all cycles. A snack is a teaspoon or two of low carb food. Snacks can be given up to three times every cycle and best during the first half of the cycles.
  • I would post daily so we can help you with the dose.
  • if he drops under 90 you need to reduce the dose.
  • Have you chosen a dosing methods. Please look at these 2dosing methods DOSING METHODS
  • This is the only way you will have a chance of getting him regulated.
  • Please keep asking questions.
 
Hi @Bron and Sheba (GA) - and thank you.

Please know - i have been testing for Ketones regularly and will continue to do so. So far he's been negative.

Some questions for you (my replies are in red below):
  • Most important to understand: I would go back to 5 units twice a day now. After 3 weeks at the 1 and 1.5 units, is it safe to go to 5 units immediately? (His next meal is one hour from now.)
  • Test before every dose of insulin - okay, i will continue this
  • Get at least 1 test in during both the am and the pm cycles every day. - okay
  • Test daily for ketones at the moment. If you don’t have any Ketostix to test with, I would buy some from Walmart or a pharmacy and follow the direction on the bottle. This is important. I have been and he's been okay, so far.
  • I note you are feeding twice a day. I would recommend you also feed several small snacks during all cycles. A snack is a teaspoon or two of low carb food. Snacks can be given up to three times every cycle and best during the first half of the cycles. Can you explain why this is recommended? is this in addition to his regular size meals?
  • I would post daily so we can help you with the dose. yes, i definitely will
  • if he drops under 90 you need to reduce the dose. - this is based on a AlphaTrak system? How much do we reduce by and how long do we stay at that dose?
  • Have you chosen a dosing methods. Please look at these 2dosing methods DOSING METHODS - yes, we've been doing SLGS
  • This is the only way you will have a chance of getting him regulated.
  • Please keep asking questions. - i definitely will. We are confused and upset by so much conflicting information from our vet and on the internet. We just want to help him <3 Thank you again for your response and encouraging me to post daily for help.
 
Hi Stacey.
Looking at your spreadsheet it says Trace ketones in the remarks section for today. Trace ketones are a concern, and I would test again as soon as he pees again. Check the result at exactly 15 seconds or whatever the instructions say. Let us know what result you get. You do not want them to go up any higher. If ketones are starting he needs food and water and insulin to combat them. I will try to get more eyes on your dosing question.
 
Thanks @Dyana. I will test his ketones and monitor him all day.

He finished eating and we gave him 4.5 units, we were nervous to go too high and we know from the past that 4.5 was an accepted amount without his body reacting too much.

Is this why snacks were also recommended during the day?

Thank you for taking the time to answer.
 
Snacks are recommended as it is easier on the pancreas if they get more frequent meals (snacks) throughout the day, and they help to bring up the blood glucose in the first half of the cycle as the insulin begins to do it's job.
I would get a +3 or maybe even a +2 to start this cycle.
You'll also need to start getting some tests in the PM cycle, as cats often go lower at night time. I know it's hard, but is necessary.
Do you have a hypo kit for just in case?
 
On this board, in most cases we do not recommend restarting the Lantus dose. Generally, you end up losing time. A great deal depends on whether you've been systematically increasing the dose. So, that's my caveat.

From what the entirety of Buddy's spreadsheet looks like, you've been holding doses for too long of a time or at the very least, not following SLGS. Vets do not follow this method since it was developed here. The risk of holding doses that aren't getting your cat's numbers in a better range is that your cat's body begins to treat the higher range numbers as the new "normal." This is called glucose toxicity.

There are a couple of basics I would recommend. First, with SLGS you need to get a minimum of 4 tests per day -- your AMPS and PMPS along with at least one additional test each cycle. We encourage getting a "before bed" test every night. I don't know if you weren't logging your test data. It's crucial to always test before you give insulin. Otherwise you have no way of knowing whether it's safe to administer a dose. It's way too easy to assume that numbers don't change. Cats do not like to be predictable. You've seen some lower numbers and the likelihood is that when Buddy drops into lower ranges, his numbers bounce back into a higher range. If you're not routinely getting test data, you may make an incorrect assumption. As an example, my kitty started the day in the 400s and ended the cycle in the same range. It would have been reasonable to assume that a dose increase was needed if I hadn't been testing. She dropped into the 40s and a dose reduction was indicated.

I would not immediately raise the dose to 5.0u. We can, however, "fast track" your dose. It is even more important that you are testing more often if you want to do this. A couple of our more experienced members would agree to lend you a hand. Given that you already raised the dose, fast tracking isn't necessary. We generally change doses in 0.25u increments. I would also strongly encourage you to get several more tests in over the next few days. Given that you gave a very large dose increase, there's no way to know how your cat will respond.

There's no reason to feed a diabetic cat two large meals only. Actually, there's no reason to feed any cat 2 large meals daily other than it's convenient for us. Most animals in the wild graze. For a diabetic, eating large meals puts a great deal of pressure on the pancreas. More frequent, smaller meals makes the process a bit easier especially if a cat's pancreas is healing.

Regarding your questions about dosing, this is a link to the post on Lantus dosing that includes the guidelines for SLGS. Like Bron noted, there's a lot to digest so please ask questions. We're here to help.
 
Yes, we have a hypo kit.
  • If we are giving him snacks, are we then cutting back on the meal portions, so he is getting the same amount of calories everyday or is this in addition to meals?
  • Are the snacks temporary, while we try to get his ketones to negative, and get him regulated?
  • How soon after his meal should I give him a snack?
  • How many snacks/day and how often?

Thank you.
 
@Sienne and Gabby (GA) - thanks for the clarification.

  • Is there any negative consequence to upping his dose from 1.5 to 4.5?
  • Our interpretation of: "I would go back to 5 units twice a day now" - was that we were to up it immediately. Did i misunderstand and is there any danger to what i have done (other than the risk of hypo)?
  • Would the increased dose show a reduction in ketones before we see a reduction in BG?
 
I wish I could give you a hard and fast answer regarding meals. The first question is easy. As long as Buddy is at a good weight, you can divide his calories into smaller meals. My diabetic cat was prone to dropping into low numbers early in the cycle and she had an early nadir. As a result, I would feed her at AMPS, +1, and +2 and sometimes at +3. For most members, they will give their cats snacks up until when their cat's usual nadir occurs.

To be honest, my two cats get their meals spread out over several hours. Neither is diabetic. The older cat was used to getting fed on the same schedule as my diabetic and when Gabby died, I kept the same feeding schedule. My kitten is on the same schedule. If this is problematic for you, many people use a timed feeder.

We generally don't have members increase the dose by as much as you did. The most negative consequence is that numbers drop. Please be sure you have everything you need in your hypo kit. Even if you have high carb food, please make sure you have Karo (corn syrup), honey, maple syrup, or any other simple sugar in liquid form on hand. I don't think you misunderstood. Bron is an experienced member here and I'm sure she would have stayed with you in case you ran into trouble. I'm a bit more conservative. My worry is that we don't know your cat or how your cat will respond and there's not a lot of information on your spreadsheet to guide our thinking. The ketone question is a good one. It's just hard to answer. More insulin, more food, and more water can all help to offset ketones.
 
Any of the Walmart ReliOn meters are good. I have both the classic (not made any more) and the ReliOn Premier. It’s a good meter and easy to use and strips are $17.88 for 100 of them.
 
I agree that you can get a +4 or +5 as long as you are keeping an eye on him. Just remember that his depot of Lantus will be building and so the response that you see today is most likely not the same as what you will be seeing in a few days. I guess that is my way of saying to keep up the testing. :)
 
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I agree with Suzanne. And please keep us updated with any ketone tests you get.
Can you take naps or something to get the night time BG tests?
 
As Dyana mentioned the ketone tests… it would be good if you noted somewhere in the spreadsheet about the ketones. I had a column for the numerical value pf the ketones (but I used a blood ketone meter) and a lot of people just write something like “ketones neg” or whatever the result is - in their spreadsheet in the remarks section.
 
@Dyana and @Suzanne & Darcy - i have a timer set and we will test him again at +4 and based on how he is, maybe we push that to +5.

I do have a column on his SS for Ketones. He hasn't used the litter box again, yet. I post it there - is that what you mean, @Suzanne & Darcy?

I will do some night testing, even if I am tired the next day, it's fine. I am lucky to be able to work from home most days.

Thank you all!!! :bighug:
 
You're welcome when you do start testing with the Relion Human meter you will need to add that to your signature such as Relion and the date
Also on your SS add that where you have the Alpha Trak listed
Make a blank line on your SS above the date when you start testing with the Relion and just type switched to Relion
The last 2 color codes that are up top will need to be changed the dark green will now be 50-99 and the neon green will be BG<50
I don't know if you can change them yourself if not let me know and I can tag a member who can change it for you
@lbeachstace
 
lbeachstace said:
@Diane Tyler's Mom - will do! i also saw there's a SS for the human meter - so maybe i will add that tab for the start of 2023, to make it easier.
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If you don't plan on using the Relion until 1-1-2023 that's fine then just be sure to add the date to your signature also if you can fit SLGS to your signature that's the first thing members look at, if you can't for it you can get rid of where you have currently at 1.5 units /2x/day because the dose is always changing
@lbeachstace
 
@Suzanne & Darcy - was just reading about the depot and have a much better understanding of how this works.

Do we run a high risk of his numbers dropping into dangerous territory over the next couple of days because of it? Are we to give 4.5 again tonight? or depending on his BG numbers, will that depend?
 
It will take several days for the depot to catch up to the dose change. There's no way to know if Buddy's numbers will drop due to the change or if it will take several days for the depot to catch up to the new dose. Again, the difficulty is that there's not a great deal of test data from when Buddy was at 6.0u. We don't know how he was responding. The high numbers could reflect bouncing but there's no way to know if his numbers were consistently high or if there were lower numbers interspersed that were causing bounces.
 
lbeachstace said:
@Sienne and Gabby (GA) - okay, yes, we understand...and we will make testing the priority moving forward.

He's been sluggish/weak and out of it for a couple of days - his behavior today is not different than it's been. We did give two snacks today and he ate both. He's still not used the litter box, so i've not been able to test for Ketones.
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Random question; has he been tested for acromegaly? 6 units is a lot, I remember reading someone saying that anything above 5 warrants a test for acromegaly? Not sure though.

The ketones are concerning, along with his sluggish behavior. You probably already know this but monitor carefully, DKA can go from sluggish/a little off to a genuine medical emergency that requires an animal hospital for potentially a week or even longer. Increasing the dose was definitely the right move.
 
@chuckstables - I don't believe he's ever been tested for acromegaly - I've never actually heard of it. Is this a specific test or is it identified in regular blood work?

We are watching him like a hawk. He's not gone to the litter box, so I've not been able to re-test his urine yet today.
 
What would be recommended for his 10pm feeding tonight in order to give him a full shot?

He's been eating about 1 can of the Weruva WX at mealtime - do we want him to eat the same?
 
lbeachstace said:
@chuckstables - I don't believe he's ever been tested for acromegaly - I've never actually heard of it. Is this a specific test or is it identified in regular blood work?

We are watching him like a hawk. He's not gone to the litter box, so I've not been able to re-test his urine yet today.
Click to expand...

Acromegaly is a chronic disease caused by a benign tumor on the pitutary gland. It causes the gland to release stupidly high levels of something called Insulin Growth Hormone (IGF). This causes some growth and acromegaly cats can sometimes be overweight. It also causes tremendous resistance to insulin, causing diabetes.

As far as I'm aware there's only one place in the US that does the test. Your vet would get the blood work and send it off to them. Keep in mind the only real cure is to either essentially brain surgery or radiation therapy, which are both incredibly expensive (I think the surgery is above 20k USD, radiation is probably cheaper but far lower success rate). Acro cats can be controlled with Insulin, they often require far far higher doses (I've seen some acro cats on 25 units twice per day of Lantus).
 
We do suggest that people have their cats tested for acromegaly and IAA (insulin auto antibodies), once their cat gets to 6 units with increase done safely to know that's what they need. We aren't sure yet that Buddy's wasn't overdosed at 6 units. Also, not all acrocats have high doses - there have been some with doses the same as non acros. Recent research shows one in four diabetic cats has acromegaly (or it's more proper but longer name, hypersomatotropism). The blood test is done at Michigan State University.

BTW, my girl had both acromegaly and IAA, at her lowest, her dose was 0.25 units, and she spent most of her diabetic life under 3 units, once I had the acromegaly treated. And unlike what @chuckstables said, there are newer treatments that are cheaper - like a daily medication. I know a tad more than he does about acromegaly. ;) And the treatments. Should this ever be an issue with Buddy, I can give you the real scoop on treatment options and costs. But this is putting the cart well before the horse so don't worry about it for now. I just wanted to correct the information given above.

Not sure if anyone has asked this question, but why the dose reset? It's not something we'd suggest here. I see a reset when he switched from Vetsulin to Lantus, and again on Lantus recently. When my girl went from Caninsulin (Vetsulin is the US brand name) to Lantus, my vet suggested a dose reset. Unfortunately that cost us 3 months in the fight to get Neko regulated.

Best of luck with the new dose.
 
lbeachstace said:
What would be recommended for his 10pm feeding tonight in order to give him a full shot?

He's been eating about 1 can of the Weruva WX at mealtime - do we want him to eat the same?
Click to expand...

If that's a low carb food then great, I wouldn't really change his diet much. He probably will be a little erratic over the next week while he builds up the depot again and gets used to lower numbers. How much does he weigh? If those are 3 oz cans then that might not be enough depending on his weight. Is that all he eats throughout the day? Or does he snack a bit (that's totally fine on a longer acting Insulin like Lantus by the way, we all give our cats some snacks throughout the day for the most part).
 
Wendy&Neko said:
We do suggest that people have their cats tested for acromegaly and IAA (insulin auto antibodies), once their cat gets to 6 units with increase done safely to know that's what they need. We aren't sure yet that Buddy's wasn't overdosed at 6 units. Also, not all acrocats have high doses - there have been some with doses the same as non acros. Recent research shows one in four diabetic cats has acromegaly (or it's more proper but longer name, hypersomatotropism). The blood test is done at Michigan State University.

BTW, my girl had both acromegaly and IAA, at her lowest, her dose was 0.25 units, and she spent most of her diabetic life under 3 units, once I had the acromegaly treated. And unlike what @chuckstables said, there are newer treatments that are cheaper - like a daily medication. I know a tad more than he does about acromegaly. ;) And the treatments. Should this ever be an issue with Buddy, I can give you the real scoop on treatment options and costs. But this is putting the cart well before the horse so don't worry about it for now. I just wanted to correct the information given above.

Not sure if anyone has asked this question, but why the dose reset? It's not something we'd suggest here. I see a reset when he switched from Vetsulin to Lantus, and again on Lantus recently. When my girl went from Caninsulin (Vetsulin is the US brand name) to Lantus, my vet suggested a dose reset. Unfortunately that cost us 3 months in the fight to get Neko regulated.

Best of luck with the new dose.
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Haha, I'm sure you know more about acromegaly than I do. I'll defer to you on that one. Forgot that pasireotide was a thing now. The highest quality study I found was this https://rvc-repository.worktribe.com/preview/1400950/9490.pdf. I'd like to see one with a higher sample size though (it kinda ruins the statistics that they're doing, but the effects were large enough that I don't think that would really matter). I didn't really think of it given the similar cost to the other options, but definitely true. It is an option.
 
@chuckstables Let's stop this topic of treating acromegaly unless we find out it's needed in this case. And no, I wasn't talking about pasireotide as a medication, as it makes the surgery option look cheap. I have been in communication with the RVC feline remission clinic (authors of that paper) as well as another well known researcher on acromegaly in the US, and at the time, neither of them had see another caregiver try pasireotide because of it's cost. Go on over to the acromegaly forum if you want to learn the new and practical.
 
Wendy&Neko said:
@chuckstables Let's stop this topic of treating acromegaly unless we find out it's needed in this case. And no, I wasn't talking about pasireotide as a medication, as it makes the surgery option look cheap. I have been in communication with the RVC feline remission clinic (authors of that paper) as well as another well known researcher on acromegaly in the US, and at the time, neither of them had see another caregiver try pasireotide because of it's cost. Go on over to the acromegaly forum if you want to learn the new and practical.
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Gladly ;) :)
 
lbeachstace said:
@Wendy&Neko - the resets were due to advice from our new vet (our last vet wouldn't switch the Lantus, so we switched vets), and the current reset was due to the advice of a moderator FD FB group.

Our hearts are hurting and I am kicking myself for not asking here before listening to either of them. But we are here now and we will do whatever we need to for him. :(
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Don't beat yourself up. Lots of us have been given wrong advice by vets lol. My first vet wanted me to give him caninsulin and just kept raising his dose until he was getting seriously hypo everytime I dosed him. Can't change the past, all you can do is the right thing moving forward. You're doing great, keep it up.
 
lbeachstace said:
@Wendy&Neko - the resets were due to advice from our new vet (our last vet wouldn't switch the Lantus, so we switched vets), and the current reset was due to the advice of a moderator FD FB group.

Our hearts are hurting and I am kicking myself for not asking here before listening to either of them. But we are here now and we will do whatever we need to for him. :(
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That happened to me as well… in 2020… bad advice about resetting the dose way back from a different group on FB. And I came here in desperation and never looked back. Here is where I found the real help for my boy. We finally made progress. It’s okay. It’s a new day!
 
lbeachstace said:
@Sienne and Gabby (GA) - okay, yes, we understand...and we will make testing the priority moving forward.

He's been sluggish/weak and out of it for a couple of days - his behavior today is not different than it's been. We did give two snacks today and he ate both. He's still not used the litter box, so i've not been able to test for Ketones.
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This is the reason why I purchased a NovaMax Plus Blood Ketone meter from ADW Diabetes. The strips are expensive but I couldn’t take a chance after his DKA. Just keep up with the testing and you can keep him safe. May I ask what is your time zone?
 
He does not need to eat a huge amount. Just a small meal will be enough and then a snack or two of a teaspoon or two before you go to bed. It looks like you gave several snacks today? Is there a concern he won’t eat?
 
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