Hi Dr. X,
Sorry it’s taken me so long to get this to you but I wanted to find the best resources possible and, since I’m still learning myself, I keep adding to it.
A lot of this I’m sure you already know, but I figured I’d include everything just in case I missed something. First off, here’s the link to Michelangelo’s spreadsheet, per your request.
Since I had been noticing Michelangelo hitting these seemingly low points during the day, I had a feeling this was being caused by hypoglycemia and started looking into it. The first thing I read was the AAHA Guidelines for diabetic pets and they strongly advocated home blood glucose testing to help reduce the risks of hypoglycemia, neuropathy, DKA, and/or CRF. This also helps get more accurate numbers that are not artificially inflated due to stress hyperglycemia from being at the vet. (Once I was able to start testing Michelangelo, that’s when I saw that he was indeed hitting borderline hypoglycemia and slightly decreased his dose.)
I found a veterinarian website that introduced me to diet change (low carb, wet food) and the concept of following a regimented Protocol, which is responsible for over 86% remission of diabetes in cats within the first 6 months of diagnosis. Since that website is mostly for use of PZI (now ProZinc) insulin, I had to find one for Lantus (glargine).
The Tight Regulation (TR) Protocol follows a very strict guide for increasing/decreasing insulin doses based on pre-shot BG numbers and BG numbers at nadir/peak, plus a weekly curve (a culmination of spot-testing throughout the week that, when combined, will show the data for approximately every 2 hours over a 12-hour period – see below). A quick summary of the Protocol:
• First change their diet to a low carb, wet food only diet. If they’re already on insulin, it is imperative that home testing is done since diet change alone can lower BG levels by 100 points or more and send a cat into hypoglycemia.
• While on insulin, the recommendation is to never give insulin to a diabetic cat whose BG is under 200 but to continue testing until it tops 200 and then either give a delayed dose or skip the dose altogether.
• If at any time throughout the day the cat’s BG drops below 50, the dose needs to be reduced by 0.25 units for a minimum of 7 days in normal range before reducing the dose further, if needed.
• If the low point (5-7 hours after a Lantus injection) is continuously greater than 200 for 3 days (6 cycles), increase the dose by 0.25 units. If it’s greater than 300, increase the dose by 0.5 units. Using this sliding scale of testing for insulin dosage adjustments allows the cat’s pancreas to start producing insulin on its own again, leading to eventual remission.
Of course, this all required that I learn how to test Michelangelo’s BG levels and use other ways of monitoring his BG levels. For his BG testing, I picked two glucometers: The Accu-Chek Nano and the ReliOn Micro. The Accu-Chek I use as a backup because it requires more blood and the test strips are super expensive. The ReliOn is much easier to use and less expensive and the test strips (when bought in a store) are around .35 cents each (online, they’re even cheaper). It is actually a pretty easy thing to do and once you get started, within a week or two, both you and the cat become much more comfortable with it. In fact, in this last week alone, Michelangelo now seeks me out to get his blood tested because he knows he gets a treat when we’re done. If any of your other diabetic pet owners wish to start home testing, there are a lot of online videos and websites out there that show how it’s done. Please also feel free to use me as a reference and I’d even be willing to show them how to do it if they wished.
I also stumbled across this wonderful website, catinfo.org (written by another veterinarian), who helped me convert Michelangelo off his dry food onto a wet food only, low carb diet. She also maintains a commercial cat food nutritional values list that is updated approximately every six months and has proven invaluable to me. This allowed me to discover what those “minimums” and “maximums” on cat food really meant and for me to be able to see which foods contain the recommended less than 10% of carbs for diabetic cats like Michelangelo.
Please feel free to let me know if you would like any more information about a particular aspect as I have a ton more links on everything from low carb food and treat lists to cheap places online to buy test strips to how to create a hypo toolbox for the emergency you wish to never have. Thanks for all your help so far with Michelangelo and your interest in his care. He’s a bit difficult to manage at times because he keeps having these growth spurts that skew the numbers, but I am grateful to have found such an incredible vet and such great online resources to deal with these issues as they come up.
Cheers,
KP
An example of a typical Lantus Curve:
+0 - PreShot number (aka AMPS for morning)
+1 - Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number.
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 - Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (may dip around +10 or +11).
+12 - PreShot number (aka PMPS for evening)