? Snickers BG Readings Confusing

[Eric Minor]

Snickers has been home from the ER one month now after a severe DKA episode (we didn't know she was diabetic prior to that).

I bought the AlphaTrak 2 and have taken many BG readings, including several detailed curves. At times the readings seem to make sense, with a nadir at expected times at +4 or +5. Other times it almost seems like there was no insulin shot at all, with the readings after the pre-shot heading upwards and never heading down. I've given all the shots over the past month right on schedule, but the puzzling readings make me wonder some times if there was a mis-connect on the shot into the muscle or skin.

For example, the curve on 5/28 started in the yellow at 289, went steadily down to 107 at +5, then slowly back up to 284 for the PM pre-shot. Then the next day, it starts at 349 AM preshot, then climbed to 456 at +6.

A week later on 6/4, I did another curve during the day which started at 447 AMPS and headed downwards the entire day, no real nadir, until it was 172 for PMPS.

On 6/7 PMPS, it was 195, then was up from there at 216 and 224 at the +2 and +4 readings.

Today, 6/10, it was 325 AMPS and didn't budge downwards at all and was 351 and 369 at +3 and +4 and was eventually 388 at PMPS.

There are other spots on the chart where the readings seem to "act right" with an expected nadir at +5 and spots where we are back up into higher numbers.

Why all the confusing readings and is this to be expected?

 

[Tanya and Ducia]

Hello Eric,
I wouldn't call myself an expert in the SS interpretation but here is my $0.02 on what I see:
today, 6/10 Am cycle, Snickers looks like she is bouncing high from that lovely 76 on 6/9 PMPS@+4, it is natural response and it will pass. The following cycle 6/10 PM looks as if she tried to break that bounce but because there are no readings posted after PMPS +3 we will never know how low she went. If too low - you will see higher numbers in the following cycles. this is how I see the Black 501 pre-shot at 6/7 AM - no tests taken on the previous cycles, I am guessing here - it is possible Shickers went too low and bounced the day after. Example of bounce :you said"For example, the curve on 5/28 started in the yellow at 289, went steadily down to 107 at +5, then slowly back up to 284 for the PM pre-shot. Then the next day, it starts at 349 AM preshot, then climbed to 456 at +6." - Snickers bounced from low (for her) 107 to higher numbers on the following cycle. Bounce is annoying and frustrating for the care giver, and the only good thing about it is that one can take a break from testing the BG.

It is often but not always that one can tell that the cycle is going to be "active" if there is difference between the pre shot reading and the +2 reading: if it is lower or the same as PS you have you warning to watch out and take tests later on; if it higher than the pre shot - most likely one can expect uneventful cycle and later tests at random times are useful to collect the data on her responses, but not every hour or even every other hour, maybe 1-3 tests.

I used to take curve reading every hour like you did on 6/4 or 5/28 and was very grateful when someone told me that tests every other hour would be just as informative and less stressful/painful for my cat.

There are other spots on the chart where the readings seem to "act right" with an expected nadir at +5 and spots where we are back up into higher numbers.

My cat switched her nadirs from as early as +3 to a late as pre-shot and she will do it again, and again. There is no reason to expect fixed nadir time other than insulin manufacturer manual. Insulin is a hormone not drug and the living organism is not piece of machinery so naturally the responses will vary. Many factors can influence the insulin acting in cats - from dose and food intake to weather and cat's mood, you name it. With better regulation the nadir time will become more apparent, or reasonable expected to happen at more or less fixed time, I was told. But my cat isn't there yet. I quit expecting anything from my cat recently, and it made life easier.

Your spreadsheet is awesome, especially the Remark section. Have you talked to your vet about anti nausea/anti vomit meds for Snickers? I have Cerenia from my vet stashed for the vomit and use 1/4 of a 16mg pill per occurrence. There are other meds for that too.

At times the readings seem to make sense, with a nadir at expected times at +4 or +5. Other times it almost seems like there was no insulin shot at all, with the readings after the pre-shot heading upwards and never heading down.

Why all the confusing readings and is this to be expected?

I cannot tell you how many times I said the very same words. It is confusing in the beginning and you only had started. It is totally expected - to be confused and Snickers numbers being all over the place. You will read her numbers better with time, I promise. Just keep taking test, record and one day her patters will speak back to you. I promise.

I found out about my cat's FD in the very same fashion you have - with DKA episode. I test her urine for ketones at home with human testing dip strips when she is in high numbers (which she has frequently). Sounds hideous but gives you some degree of control.

I hope it is helpful. Others might correct me or add their opinion. Keep posting if you have questions - some peple here are real pros in interpreting spreadsheets - ask.

Best of luck to you and Snickers.

 

[Kris & Teasel]

Tanya has given you a great response. Have a look at my cat's SS and you'll see all sorts of chaos there. I'm used to it now. The point is that it's not all that unusual for cats to be unpredictable like this.

Re urine ketone testing at home: I slip a shallow, long-handled spoon under Teasel's backside to catch a little pee. It's easy to do. Some people crumple up plastic food wrap over the favoured area in the litter box to catch pee in the folds/depressions. Some have luck just slipping the test strip into the urine stream. My guy had a bout of DKA two months after his diagnosis so I'm always aware of that risk.

 

[Gill & George]

Hello and Welcome Eric and Snickers
Tanya made some great observations but just want to add a few things

The following cycle 6/10 PM looks as if she tried to break that bounce but because there are no readings posted after PMPS +3 we will never know how low she went. If too low - you will see higher numbers in the following cycles.

If your amps is low yellow or blue, it may well signal that the am cycle of 6/11 is going to be the active one, some kitties broadcast their intentions of having an active cycle by having a flat yellow/blue cycle preceding the drop. However, if Snickers is in high pinks or more, in the morning it is likely that she either dropped fast or went low (for her, not necessarily into dangerous territory) and she is starting a bounce. Bounces are triggered by either fast drops, or kitty's BG dropping into levels that she is not used to, they can last up to 6 cycles, but can clear sooner, it looks like snickers has been clearing in 4 or 5 cycles (of course they can and do change it up)

She got quite low, (though still in safe numbers) on pm cycle of june 9, it's possible that was her low, but equally it's possible that she may have dropped a little further. If ever, I got a drop like that, I would always get another test one hour later, to confirm that she is either staying flat, or back on her way up, As Tanya has said the nadir can change up too, FWIW George nadired as early as +2 and as late as +13, though he more usually nadired at around +5/+6, as Snickers gets more regulated, we would expect her nadirs to become more predictable.

I agree with Tanya, you don't need to test every hour, on the testing front what you will find more useful to help you determine patterns is to get a couple of spot checks (at least in every cycle) if those numbers suggest that snickers is having an active cycle, then you might need to monitor, if they suggest a bounce is underway, you can both have a break and save your test strips.

I would, to begin with try getting a test at +2, Snickers, does seem to like early drops, if you get a +2 that is significantly lower than the PS, then that's your heads up to an active cycle, what action you take would depend on the speed of the drop and how low she actually is at +2. eg if she was 200 at amps and dropped to 100 at +2, though 100 is a safe number, there is still a ways to go with the insulin cycle, so you might want to at that point give her a little snack of LC food at +2, checking her BG an hour later. The little snack can help to put the breaks on the slide and get the cycle to flatten out. Why do we want to do this, well the theory is that if we can slow them down a bit it can help delay the bounce and what we achieve is having them in good numbers longer, in turn the longer they spend in the lower ranges, and the more their little bodies get used to the new normal, and with any luck they may flatten out all together and give up on the bouncing,
An important thing to remember, is that when it comes to making dosing decisions, we ignore the bouncing and look for the low points (nadirs), it is those that govern our dosing decisions.

If the +2 confirms she is bouncing and is running high you can have a break, and grab another test later in the cycle (whatever fits with your schedule)
Of course it goes without saying that you should always get amps and pmps, it's important to be sure that the BG is high enough to shoot.
With that in mind, I would say, that with the recent history of DKA, it is very important that Snickers gets enough insulin, skipping shots would not be advisable at this stage of the game.

In the PM cycle I always grabbed a +1 or +2 (for George, the +1 was very useful, if he was lower at +1 than PS, I knew I was in for an exciting cycle/ if it was about the same, then active but not too exciting) and then I would grab a before bed test (usually around +4 or +5 for me)

Try to think of the SS as a jigsaw puzzle, scattering the checks at different times, can help build a clearer picture, than if you have all you tests at the same time, with big 'holes' in the puzzle.

I notice in your remarks you mention somogyi rebound, just so you know it's been disproven in humans and was never researched in cats, when we talk about bouncing we are not referring to the same thing, here's a thread discussing it and there is links to more recent research.
http://www.felinediabetes.com/FDMB/threads/somogyi-and-bounces.138412/#post-1480698


below is an explanation of bouncing taken from the new to the group sticky, as well as some of the other terms that are important to get your head around when dealing with a depot insulin, it will help you understand the nuances of the cycles.

A full understanding of the following concepts will go a long way in helping you regulate your kitty's blood glucose when using Lantus or Levemir:

• Carryover - insulin effects lasting past the insulin's official duration
• Overlap - the period of time when the effect of one insulin shot is diminishing and the next insulin shot is taking effect
• Insulin Depot - a "spare tank" of insulin, which has yet to be used by the body
• LANTUS & LEVEMIR: WHAT IS THE INSULIN DEPOT?
• Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

A couple of questions, what are you feeding Snickers? and what is her feeding schedule?
I notice she eats dry as well, What dry is she eating?

 

[Eric Minor]

Thanks for the advice everyone. I largely did the 1 hour curves as a nod to the internist -- he had asked that my regular vet do a curve with 1 hour readings. I had chosen to disregard several of the internist's recommendations (he said take no BG readings save for maybe 1 every 3 days at expected nadir so as to not over-manage the situation and also recommended Prescription Diet which I ignored in favor of Young Again Zero), so I wanted to try to accommodate him on that request (thought it was done by me and not my vet). I found the more complete data on the 1 hour curve to be of some value but will not do it often -- agree that every 2 hours will usually be fine.

A couple of questions, what are you feeding Snickers? and what is her feeding schedule?
I notice she eats dry as well, What dry is she eating?

Snickers is getting a twice daily dose of Amoxicillin antibiotics to resolve her pyelonephritis. I give her a small treat of canned tuna/chicken/salmon at the time of each shot to use as a vehicle to deliver the crushed pill. Other than that, there is Young Again Zero kibble available for free feeding at all times.

 

[Wendy&Neko]

Hello from just north of you (North Vancouver BC).

Folks on this forum feeding dry food follow the dosing method called Start Slow Go Slow or SLGS. The reason I pointed this is that you have seen a couple of green numbers below 90 on the 3.0 unit dose. With SLGS, that would mean Snickers has earned a reduction down to 2.75 units as her new dose.

Another thing that could be happening is the antibiotics are working. Infections can raise the blood sugar but once the infection is being fixed, the blood sugar needs can come down.

As for shot timing, you do have a bit of play. You can move each shot time by 15 minutes a shot or 1/2 hour once a day, without it impacting anything.

 

[Eric Minor]

Folks on this forum feeding dry food follow the dosing method called Start Slow Go Slow or SLGS.

I'm glad you mentioned SLGS. This first month has been semi-chaotic, with readings up and down and all over. I read the SLGS and TR protocols and have *kind of* been following the SLGS protocol in that I did start pretty low at 1.0 units (though I jumped pretty quickly and at once to 2.0 given the recent DKA history) and have gone pretty slow, only nudging up to 2.5 and then 3.0 and keeping pretty consistent.

I've been meaning to post a new question thread asking about one thing that confuses me on the pages for both the SLGS and TR protocols. Both of them start with a very bold pronouncement not to use pet specific meters and that the reference numbers are for human specific meters. However, the spreadsheet that everyone seems to be using specifically calls for a pet specific meter like AlphaTrak. (And I am using the AlphaTrak 2.)

Because of that confusion (and because my internist warned me against making a bunch of micro-adjustments...advice which I may or may not adhere to) I haven't been making micro-adjustments yet. So, if you can clear that confusion up for me, perhaps I will start nudging the dose around a bit.

 

[Wendy&Neko]

You are correct in that both dosing methods were written for people using human meters. Back then, few if any used the AT. Often people will switch from the AT due to the cost of the strips, and that it is harder to get the strips if you run out suddenly. We don't have any way of translating between the AT and human meters, so we just use the human meter values, except for the reduction point in TR with is 50'for the human meter and 68 for the AT. For SLGS, we just use face value so amnumber below 90 on the AT earns a reduction in dose.

.25 unit changes are not microdosing, but rather standard size dose changes here. Cats only need that small a change in insulin dose. Neko would often react to a .125 unit change. I used digital calipers to measure her dose when she needed smaller amounts of insulin. I would encourage you to drop Snicker's dose. The current 3.0 unit dose is too much insulin and could potentially cause a hypo. I hope you have some high carb wet food and/or Karl or honey on hand.

 

[Eric Minor]

I do have Karo on hand as well as wet food. I'm going to post same question as new thread in Lantus group to get a bit more feedback. It confuses me a bit more that for TR there is a translation from 50 to 68 for the two different meters but for SLGS there is none, with 90 being the low threshold for both.

 

[Wendy&Neko]

TR was developed and published in a scientific paper so has more formal stufies behind it. The initial version of TR only had values for the human meters, the AT reduction value was added late. SLGS was developed in FDMB before then, and people didn't used the AT at that time. Using 90 for either meter as a reduction point still means you have a reasonable margin of error above hypo numbers.