Bailey got his wings... June 26, 2014

[Rubytuesday]

Re: Regulating Bailey

Hi Geoff, I had some questions.

Date Time mmol mg/l comments
18-Nov 8:19am 23.8 Fasting (Started Humalog) 0.5 IU 428.4
18-Nov 9:06am 29.2 525.6
18-Nov 11:12am 28.3 509.4
18-Nov 12:06pm 22.4 403.2
18-Nov 1:06pm 21.5 387
18-Nov 2:03pm 17.9 322.2
18-Nov 4:00pm 16.7 300.6
18-Nov 6:04pm 14.2 255.6
18-Nov 7:43pm 13.5 243
18-Nov 10:00pm 18.7 336.6
When did Bailey get his evening meal and was the humalog dose given with the meal?


19-Nov 4:19pm 15.7 282.6 Raised to 1 IU
19-Nov 6:12pm 16.8 302.4
19-Nov 7:56pm 15.6 Fasting 280.8
19-Nov 10:04pm 21.7 390.6
Here it look as though you gave the 4:19 humalog as a correction, but without food. Did he get any Humalog with the meal?

20-Nov 8:20pm 25.8 464.4
20-Nov 10:26pm 20.4 367.2

22-Nov 10:06pm 12.4 223.2
22-Nov 10:40pm 18.4 331.2
22-Nov 11:17pm 18.6 334.8

23-Nov 6:22pm 10.2 183.6
23-Nov 10:31pm 19.8 356.4

25-Nov 8:12am 16.8 Fasting 302.4
25-Nov 11:41am 30.8 554.4I wonder if this is one of those times when he went longer then 12 hours past his last injection and that is also reflected in this high number
25-Nov 1:01pm 22.8 410.4
25-Nov 2:03pm 21 378
25-Nov 4:15pm 12.8 230.4
25-Nov 6:15pm 12.6 226.8
25-Nov 8:07pm 11.3 Fasting 203.4
25-Nov 10:08pm 18.3 329.4
25-Nov 11:17pm 23.4 421.2
Assuming the humalog was given with the meal it looks like the food rise is out lasting it
26-Nov 7:09pm 18.8 Fasting Fed at 8pm 338.4
26-Nov 9:09pm 27.3 491.4
26-Nov 10:27pm 29.6 so going up not coming down!I see this with Ruby as the food rise can last as long as 6 hrs. with her so once the humalog wears off she starts to go back up again.

Don't get discouraged, I see the humalog working. I think you are just working with an insulin that you haven't gotten familiar with yet. I think the humalog is working for about 3 hrs. and when it is gone the food rise is still there so the bgs start to climb again.

There are a lot of approaches you can take to help with this depending on how much flexibility you have in your schedule.....which I know isn't a lot.

*You could increase the humalog, but I would go slowly and do small increases if you choose this route. What you don't want to run into is having a big disparity between when the humalog is working and when it wears out. For instance, you don't want to drive him down to a 90 to have him jump back up to a 300 as soon as the humalog wears out.

* You could increase the protophane to bring the fastings down just a bit more. It looks like his lowest number was the 183 which leaves you a nice cushion. I would only increase by 1/4 and I wouldn't change anything else until that change was evaluated say in 5 days. The nice thing about his trend is his nadir is happening at his fasting so it is more convenient to catch lows.

* the approach I am favoring now and which is working for my dog is giving the basal insulin 2hrs early. It takes a little time to go to work, can then clear some of her mid 200 fasting and then is more powerful when the food rise kicks in. I do still have to incorporate the fast acting with her meal but I am using less so I am not getting as much of the zig zag numbers mentioned above. There are three points at which I might give humalog: around 3pm to correct if her insulin is running out, with her meal if the 3pm humalog wasn't needed, after the 3pm humalog runs out to counter the remaing food rise. This last humalog dosing is trickier because it is dependant on how her food was absorbed and how potent the basal insulin is then, which remember was given early. Luckily Ruby's belly starts to grumble when her bgs are on the rise, so I can test and see based on how far past that last humalog dose and what the numbers are, what I should give her.

* another approach you may consider is feeding Bailey once daily. I switched to it for multiple reasons and it isn't without it's own kinks to work out. What I like about it is that the hoops this disease makes me jump through I only have to jump through once a day. I do the approach listed above at night when I am ordinarily home anyway and during the day she gets a reduced dose. Right now we are trying to see if I can give her a snack that she won't regurge (megaesophagus) so that I can increase her daytime dose to give her enough duration. In this case the food rise is a good thing as it doesn't take much food to get a good rise. With Bailey you could probably just give him a couple of biscuits laced with syrup and be good.

Hope I haven't thoroughly confused you!

Tara

[jesse girl]

Re: Regulating Bailey

i wouldn't say the numbers are getting worse maybe about the same some better some not

are you giving the fast acting everyday at shot time i did see humalog given early on the 19 or is this a normal time

it does look like it does have an affect on rise after eating thats probably the biggest problem and that what i would work on

i would stay consistent for now and give the fast acting at mealtime with the basal insulin he normally gets i would stick with the one unit and just test a few hours after shot the goal like you said is to reduce that rise

just a thought hand held meters can be quite a bit off at higher levels and some of the numbers do seem a bit out of place if you are giving the fast acting 1 unit at mealtime everyday

it is important when doing curves to give times and type of insulin given so there isnt any confusion

you would like to stay consistent with the dose for now as far as timing so the body has time to adjust

[BoJanie]

Re: Regulating Bailey

Is Humalog the only fast acting you have tried? We use Novolog for fast acting and I like it better because it is shorter acting, so it is very predictable that it won't interfere when the basal insulin Levemir starts to kick in. And it seems to have an effect on the bg's the rest of the day (generally lower). This is not scientific of course and wonder if anybody else has observed that or if it's just our experience? We only use it occasionally though, 1 unit, when bg is approaching 500 (at fasting) and a meal is going to be given. Our goal is to rely on the basal insulin as much as possible to carry us through the day and mostly it does unless it runs out before the 12th hour.

[Geoff]

Re: Regulating Bailey

Hi Geoff, I had some questions.

Date Time mmol mg/l comments
18-Nov 8:19am 23.8 Fasting (Started Humalog) 0.5 IU 428.4
18-Nov 9:06am 29.2 525.6
18-Nov 11:12am 28.3 509.4
18-Nov 12:06pm 22.4 403.2
18-Nov 1:06pm 21.5 387
18-Nov 2:03pm 17.9 322.2
18-Nov 4:00pm 16.7 300.6
18-Nov 6:04pm 14.2 255.6
18-Nov 7:43pm 13.5 243 Evening meal and both insulins given after(13Prot and 1IU Humlaog)
18-Nov 10:00pm 18.7 336.6
When did Bailey get his evening meal and was the humalog dose given with the meal?


19-Nov 4:19pm 15.7 282.6 Raised to 1 IU
Sorry, dose was raised in the morning to 1IU and given at morning mealtime.
I always (more or less!) feed Bailey at 8:00pm and my wife at 8:10am or so. I am giving 13 units of the Protaphane and 1 IU of the Humlaog at each meal-time

19-Nov 6:12pm 16.8 302.4
19-Nov 7:56pm 15.6 Fasting 280.8
19-Nov 10:04pm 21.7 390.6
Here it look as though you gave the 4:19 humalog as a correction, but without food. Did he get any Humalog with the meal?

20-Nov 8:20pm 25.8 464.4
20-Nov 10:26pm 20.4 367.2

22-Nov 10:06pm 12.4 223.2
22-Nov 10:40pm 18.4 331.2
22-Nov 11:17pm 18.6 334.8

23-Nov 6:22pm 10.2 183.6
23-Nov 10:31pm 19.8 356.4

25-Nov 8:12am 16.8 Fasting 302.4
25-Nov 11:41am 30.8 554.4I wonder if this is one of those times when he went longer then 12 hours past his last injection and that is also reflected in this high number

Shouldn't be as I feed him around 8pm, 8:05, 8:01: 8:07 etc but always around the same time.

25-Nov 1:01pm 22.8 410.4
25-Nov 2:03pm 21 378
25-Nov 4:15pm 12.8 230.4
25-Nov 6:15pm 12.6 226.8
25-Nov 8:07pm 11.3 Fasting 203.4
25-Nov 10:08pm 18.3 329.4
25-Nov 11:17pm 23.4 421.2
Assuming the humalog was given with the meal it looks like the food rise is out lasting it
26-Nov 7:09pm 18.8 Fasting Fed at 8pm 338.4
26-Nov 9:09pm 27.3 491.4
26-Nov 10:27pm 29.6 so going up not coming down!I see this with Ruby as the food rise can last as long as 6 hrs. with her so once the humalog wears off she starts to go back up again.

Don't get discouraged, I see the humalog working. I think you are just working with an insulin that you haven't gotten familiar with yet. I think the humalog is working for about 3 hrs. and when it is gone the food rise is still there so the bgs start to climb again.

There are a lot of approaches you can take to help with this depending on how much flexibility you have in your schedule.....which I know isn't a lot.

*You could increase the humalog, but I would go slowly and do small increases if you choose this route. What you don't want to run into is having a big disparity between when the humalog is working and when it wears out. For instance, you don't want to drive him down to a 90 to have him jump back up to a 300 as soon as the humalog wears out.

* You could increase the protophane to bring the fastings down just a bit more. It looks like his lowest number was the 183 which leaves you a nice cushion. I would only increase by 1/4 and I wouldn't change anything else until that change was evaluated say in 5 days. The nice thing about his trend is his nadir is happening at his fasting so it is more convenient to catch lows.

* the approach I am favoring now and which is working for my dog is giving the basal insulin 2hrs early. It takes a little time to go to work, can then clear some of her mid 200 fasting and then is more powerful when the food rise kicks in. I do still have to incorporate the fast acting with her meal but I am using less so I am not getting as much of the zig zag numbers mentioned above. There are three points at which I might give humalog: around 3pm to correct if her insulin is running out, with her meal if the 3pm humalog wasn't needed, after the 3pm humalog runs out to counter the remaing food rise. This last humalog dosing is trickier because it is dependant on how her food was absorbed and how potent the basal insulin is then, which remember was given early. Luckily Ruby's belly starts to grumble when her bgs are on the rise, so I can test and see based on how far past that last humalog dose and what the numbers are, what I should give her.

* another approach you may consider is feeding Bailey once daily. I switched to it for multiple reasons and it isn't without it's own kinks to work out. What I like about it is that the hoops this disease makes me jump through I only have to jump through once a day. I do the approach listed above at night when I am ordinarily home anyway and during the day she gets a reduced dose. Right now we are trying to see if I can give her a snack that she won't regurge (megaesophagus) so that I can increase her daytime dose to give her enough duration. In this case the food rise is a good thing as it doesn't take much food to get a good rise. With Bailey you could probably just give him a couple of biscuits laced with syrup and be good.

Hope I haven't thoroughly confused you!

Tara

A little confused yes but also less discouraged than I was last night so thank-you. I will increase his Basal insulin to 13.5 (very hard to do 1/4 with my needles although I now have some .3 syringes down from .5)

His food rise must be large and the Humlaog is having a hard time stopping it, I would of thought it would at least stabilize. That said, he has a sore eye at the moment so that always throws a spanner in the works. I was looking for a silver bullet with regards to bringing his spike down but so far missing the mark!

[Geoff]

Re: Regulating Bailey

Is Humalog the only fast acting you have tried? We use Novolog for fast acting and I like it better because it is shorter acting, so it is very predictable that it won't interfere when the basal insulin Levemir starts to kick in. And it seems to have an effect on the bg's the rest of the day (generally lower). This is not scientific of course and wonder if anybody else has observed that or if it's just our experience? We only use it occasionally though, 1 unit, when bg is approaching 500 (at fasting) and a meal is going to be given. Our goal is to rely on the basal insulin as much as possible to carry us through the day and mostly it does unless it runs out before the 12th hour.

Hello, yes Humalog is the only one I have tried. My diabetic friend here at work uses Novorapid and he is happy to give me a vial to try. It is similar I believe to Humlaog (different brand)

[Rubytuesday]

Re: Regulating Bailey

Geoff, After reading Jesse Girls post I would defer to her approach.
Yes, the 183 lowest number gives you some cushion to increase, but if you at some point wanted to increase the humalog you don't want to reduce that cushion, at least not in the experimental phase.

Tara

[Geoff]

Re: Regulating Bailey

Fair enough thanks! At one point he was 12.4 (below) which was great 2 hours after eating. Then one assumes the Humalog wears off and he goes up. Will keep with it! Thanks!

22-Nov 10:06pm 12.4 223.2
22-Nov 10:40pm 18.4 331.2
22-Nov 11:17pm 18.6 334.8

[Geoff]

Re: Regulating Bailey

OK, took a BG reading at 7:56pm tonight which was 21.4
Feed him at 8pm, gave him 13 units of protaphane and 1 IU of Humlaog at 8:05pm. Re-tested at 9:11pm and he was 27.3

One would assume he is not getting enough Humlaog. So do I increase by 1/2 IU? I want to take this spike out of his....system?! I am not sure the Humalog is doing anything at all as earlier curves appear markedly similar.

I could try novo rapid from my friend to see if different insulin will make a difference?? I hate to swap to and for though...

Geoff

[Rubytuesday]

Re: Regulating Bailey

Geoff, hang in there!

Not sure which numbers you are comparing these with. I didn't go back and look at old ones as I think he was on different foods and different basal insulin dose and those will all change the comparisons. Honestly my head sometimes spins trying to keep another dog's variables straight in my head so I will just give you some of the foundational knowledge that I work from when trying to treat Ruby.

When evaluating the effect of the humalog I look at the 4 hrs. after the shot was given. A lot of things can affect results. For instance, rate of absorbtion and digestion which may vary from day to day. Then you will also want to start looking at what is happening before the humaog and meal to evaluate how well a humalog dose is doing. Jesse Girl talks about how it is hard to figure out if rises are due to food or just the body rising at the same time food is given. Now, I do think Bailey gets a pretty hefty food rise, but there may be times when the body is rising even before food and then paired with the food rise is what makes it look like the usual humalog dose isn't working. It took me a long time and a lot of testing to be able to differientiate between the two.

I used to go back and forth between R and humalog depending on how much duration I needed, but I found that I couldn't get a handle on things and now that I am sticking to just the Humalog her picture is much clearer to me. I would discourage you at this point to try working with a different insulin.

If I remember correctly I think he may have been jumping higher and it may just be that he needs more, but it can be easy to overshoot with the fast actings. I would rather try to approximate a 1/4 increase even though you would need to do it by eye, as I know you don't have the 1/2 u marked syringes.

While trying to find the right humalog dose I would often set my alarm to wake up during the nadir time just to be sure that number was staying in a good range.

Also whenever calculating a fast acting dose you always need to consider the fasting number. When you get to a point that the fasting numbers are lower you may need to start cutting your humalog dose proportionately.

You might check Craig's thread "Annie getting too smart" as he uses R to correct the food rise.

A lot to consider I know.

Tara

[CraigM]

Re: Regulating Bailey

OK, took a BG reading at 7:56pm tonight which was 21.4
Feed him at 8pm, gave him 13 units of protaphane and 1 IU of Humlaog at 8:05pm. Re-tested at 9:11pm and he was 27.3

One would assume he is not getting enough Humlaog. So do I increase by 1/2 IU? I want to take this spike out of his....system?! I am not sure the Humalog is doing anything at all as earlier curves appear markedly similar.

I could try novo rapid from my friend to see if different insulin will make a difference?? I hate to swap to and for though...

Geoff

His reaction to Humalog isn't what I'd expect either, although I've never used it myself. Before increasing the Humalog, I think I'd do the one unit another time, with follow up test, just to be certain it wasn't a fluke.

When evaluating the effect of the humalog I look at the 4 hrs. after the shot was given. A lot of things can affect results. For instance, rate of absorbtion and digestion which may vary from day to day. Then you will also want to start looking at what is happening before the humaog and meal to evaluate how well a humalog dose is doing.

Again, I don't have personal experience with Humalog, but am wondering about evaluating after four hours. I thought Humalog was suppose to be in-and-out of the system much faster than that? As you know, I use a mix of "R" and "N" and I believe the nadir of the "R" is around three hours in Annie. By four hours there is sometimes a small rise in her BG before the "N" fully kicks-in. (This observation was using Novolin insulin, still trying to get things figured out with the switch to Humulin insulins) Of course, "every dog is different"

[Rubytuesday]

Re: Regulating Bailey

Again, I don't have personal experience with Humalog, but am wondering about evaluating after four hours. I thought Humalog was suppose to be in-and-out of the system much faster than that? As you know, I use a mix of "R" and "N" and I believe the nadir of the "R" is around three hours in Annie. By four hours there is sometimes a small rise in her BG before the "N" fully kicks-in. (This observation was using Novolin insulin, still trying to get things figured out with the switch to Humulin insulins) Of course, "every dog is different"

Sorry if I confused. Yes Humalog is usually out of Ruby's system in about 3- 3.5 hrs. When I monitor up to 4 hrs. what I am looking for is if there is a jump after the humalog runs out. I was thinking this would be a way for Geoff to be reassured that the Humalog is working because he would probably see the uptick in numbers when it was gone.

Hopefully that makes sense.

Tara

[CraigM]

Re: Regulating Bailey

Again, I don't have personal experience with Humalog, but am wondering about evaluating after four hours. I thought Humalog was suppose to be in-and-out of the system much faster than that? As you know, I use a mix of "R" and "N" and I believe the nadir of the "R" is around three hours in Annie. By four hours there is sometimes a small rise in her BG before the "N" fully kicks-in. (This observation was using Novolin insulin, still trying to get things figured out with the switch to Humulin insulins) Of course, "every dog is different"

Sorry if I confused. Yes Humalog is usually out of Ruby's system in about 3- 3.5 hrs. When I monitor up to 4 hrs. what I am looking for is if there is a jump after the humalog runs out. I was thinking this would be a way for Geoff to be reassured that the Humalog is working because he would probably see the uptick in numbers when it was gone.

Hopefully that makes sense.

Tara

OK, perfect sense. Sounds like your duration with Humalog isn't all that much shorter than "R" is in Annie. Again, "every dog is different (edid)"

[Geoff]

Re: Regulating Bailey

OK, thanks all for the support and info. So, to re-cap. I should test Bailey and then inject him with 1IU of Humalog then re-test hourly for 4 hours to monitor the Humlaog? That is, a random time say midday or something? Or, could I not just do a slight increase at meal times to see if it makes the slightest difference? Say tonight, 8pm, 1.25IU of Humalog? Then monitor.

[CraigM]

Re: Regulating Bailey

OK, thanks all for the support and info. So, to re-cap. I should test Bailey and then inject him with 1IU of Humalog then re-test hourly for 4 hours to monitor the Humlaog? That is, a random time say midday or something? Or, could I not just do a slight increase at meal times to see if it makes the slightest difference? Say tonight, 8pm, 1.25IU of Humalog? Then monitor.

Yep. I'd be really interested to see what duration you get.

[Geoff]

Re: Regulating Bailey

So which one should I go for? Since I am not home at midday, how about I increase his dose tonight and test?