What could we be doing wrong

Hello all from Toronto, Canada.

Sorry for the long post and thank you in advance for any suggestions you might have.

Bruno is around 10 years old and have been diagnosed in August. When he adopted us in the shelter 2 years ago, we were told that he has pancreatitis and was recommended to use Natural Balance Limited Ingredient Diet Salmon and pea variety as his main diet choice. He has been on the dry food version for 2 years and we have given him a can or two of the wet version once a week as a treat.

I began to notice that he was drinking twice the amount of water as usual in July and since we had an abnormally hot summer, I suspected something might be up but was hoping it would go away when the weather cools. It didn't. We took him to our vet who did a blood/urine panel and his blood glucose was 360(since we are from Canada, I just multiply our number by 18). He was 16 lbs when we first got him and he was up to 19 lbs in July. He was down to 17 lbs at the time of diagnosis in August and is now 15 lbs. No ketones in the urine.

I then came across Dr. Pierson's website about the high carb content of the commercial dry food. I got ourselves an Onetouch meter(which is really similar to the one that our vet uses) and started home testing him. Before we tried insulin, we put him on the wet version of Natural Balance salmon and peas(12% carb on Dr. Pierson's chart) for a week. We did a fasting blood sugar test in the morning for a week. The average reading has been around 350 for the week so no improvement.

Our vet recommended that we used Lantus(Glargine) and we started in early August with 1 unit twice a day (8AM and 8PM). Initially we gave him 1.5 cans of the wet food per day and had to move it up to 2 cans to stop his weight loss. Our vet asks us to do a blood glucose reading 6 hours after the AM shot at the end of the week and reports to her. Since we are home all day we did a +6 hours reading every day. I also did a curve as per the instruction in the "Start low, go slow" page but Bruno was hopping mad at being poked 7-8 times a day so we have only done it once.

I kept a spreadsheet of the number of unit of Lantus, his glucose number, what and amount of food we fed him, the amount of water he drinks in a day, number of times he pees(number of clumps in the litter box) and whether he has a bowl movement.

We have tried changing his canned food from Natural Balance's Salmon and Pea(12% of carb) to the chicken variety(10% of carb) and eventually moving over to Dr. Pierson's(0 carb) recipe. We even tried giving him Purina Classic chunky chicken(4% of carb) to see if it makes a difference.

Here's summary of the results.

Week 0 - no insulin, 1.5 cans of NB's salmon. Average reading fasting is around 350. He was 17 lbs.
Week 1 - 1 unit at 8AM/8PM, 1.5 cans of NB's salmon. Average reading at +6 hr is around 340.
Week 2 - 1.5 unit, 1.5 cans of NB's salmon. Average reading +6 hr is around 340. Down to 16 lbs.

We bumped his food to 2 cans since he is still losing weight.
Week 3 - 2.0 unit, 2 cans of NB's salmon. Average reading +6 hr is around 330.

Since there has been no improvement, our vet suggested we increment by 1 unit instead of 0.5 unit.

Week 4 - 3.0 unit, 2 cans of NB's salmon. Average reading +6 hr is around 330.

During week 4, Bruno came down with a bout of runny stools and 2-3 bowl movements a day. We went to the vet and he had a stool test for parasites, urine analysis and bacteria culture test. Everything came back normal. He was on a week of antibiotics (Tylosin 50mg) and his diarrhea is gone by the middle of week 5. I have been thinking of switching from NB for a while since the consistency of the "food" in the can has been erratic and is really "hard" out of the fridge. I have had to put drops of water in before he can eat it. So for week 5, we switched to the chicken and pea variety of NB Limit ingredient diet.

Week 5 - 4.0 unit, 2 cans of NB's chicken. Average reading +6 hr is around 300.

Finally a little bit of improvement. The first day of week 5, his reading was 208. I don't know whether it's due to the increase in insulin or switching can food so in the fifth day of week 5, I gave him 2 cans of pacific wild salmon that he loves and nothing else. The reading of 192 on the first day and then 240 for the next 2 days. This is what prompted me to try giving him purely meats using Dr. Pierson's recipe. Since we are making a drastic change, we kept the insulin at 4 unit for week 6.

Week 6 - 4.0 unit, 6-9 oz of Dr. Pierson's diet. Average reading +6 hr is around 300.

The reading on the first day was 162. Nothing like normal but a big improvement. It then starts to creep back up in the next few days. We started off with 6 oz (4-6 oz according to Dr. Pierson's suggestions) but he was really begging for food and is down to 15 lbs so we ended up with 9 oz.

This brings up to week 7, this week. We are up to 5 units.

First day's +6 hours reading was 220. PMPS was 270. A step in the right direction and this is the first time that any of our PMPS or AMPS reading being less than 320. However, for the next 3 days, the reading was back up to 300s. The AMPS this morning was 400, the highest we have ever since.

This has been an exhausting 2 months. I have re-read the material I have and tried to come up with new solutions. I have a feeling that 5 units of Lantus is quite high already and our vet says she would be happy with a consistent +6 hours reading of 200.

We had gone to the vet and did the shot in front of her. I have also done this so many times that I know when I screwed up and did a fur shot. Our vet also did a blood sugar test with Bruno with her meter so we know our meters are ok. I also did a reading on myself once a week to make sure.

1. Am I feeding him too much at 9 oz a day? I came up with 9 oz to stop his weight loss. 15 lbs might sounds high but it's heart breaking to see him shrinking. I am also only feeding him pure meat(chicken thighs, chicken livers, eggs, ionized salt and a vitamin soup). No carb at all.

He also has trouble jumping with his weak hind legs. He was able to jump up the 5 foot high cat tree as recently as May/June. Our vet mentioned that the weak hing legs problem could resolve itself once we get him regulated. I will mention methyl-B12 next week when we go see her.

2. The FAQ suggests fixed schedule feeding at around the 2 shot times. Currently our free style feeding schedule is like this.

Bruno would wake me up at around 5:30AM. He gets a small feeding and I go back to sleep. He gets a small feeding at 8AM before his morning shot. He gets a big feeding at 10AM where I usually have to go out for a while. He has a small feeding at 2PM before his blood glucose test. He has a small feeding at 6 pm and one at 8pm before his second shot. He then gets a big feeding at 10PM before I go to bed.

I will try the fixed schedule feeding for the next couple of days to see if it makes a difference.

3. Our Lantus bottle is 1.5 months old. Should we get a new one? They are quite expensive at $80 a bottle and we have been very careful as to not shake it and keep it in the fridge at all times.

What I found interesting and do not comprehend is that the first day of us changing a variable(ie giving him chicken variety instead of salmon, giving him just canned salmon only, giving him Dr. Pierson's diet, going from 4 unit to 5 unit), we see a sizable improvement and then the glucose level will always creep back up over the next few days. I have read that it takes some time for the body to adjust to the new insulin level but it's frustrating to say the least. In hindsight, maybe I was changing things around too much. For now, I will keep giving him Dr. Pierson's diet since I know exactly what's in it. He has no problem with constipation on the new diet and his stools look much better than before.

4. Maybe he needs something else other than Lantus? We have an appointment with our vet next week after our first week of 5 units.

Again, sorry for the extra long post and thank you for listening. The first day I met this guy, he jumped up and sat on my lap. I will do anything I can to make his last few years on this sweet Earth as enjoyable as possible.

 

I can't answer all your questions, but I can answer a few.

1. Diabetic cats who are not regulated cannot get all of the nutrients out of their food. They are hungry. Feed, except for the 2 hours before shot time.
I'm tagging @Wendy&Neko who knows a lot about raw and also high dosing.

3. Your Lantus is fine as long as it is not cloudy or contain particles. Do not buy from the vet. It is far cheaper to go to Shoppers Drug Mart or Costco and buy a box of 5 pen vials. The price should be about $110 CDN and will last you a long time. In Ontario, you do not need a prescription from your vet to buy Lantus for a diabetic cat.

 

Thanks for the reply. I check the Lantus under the sun every day and it's still clear.

We actually got our Lantus from Walmart. It's a 10mL bottle for $80. It's a few dollars more from SDM, IIRC. I have asked both of them to see if they have smaller bottles and the 10mL vial is the only thing they carry. We buy U100 needles from the vet and their needles are actually cheaper than from Walmart.

I have not heard about pen vials. How are they different than drawing the insulin out yourself from the bottle?
I will go to SDM to ask them tomorrow.

P.S. I have updated our spreadsheet and embedded it into our signature.

 

What you want to buy is the Lantus cartridges, which are like small vials that are really the pen refills. The 5 pack has 50% more insulin, but not 50% more price. And you can use each cartridge to the last drop and less to toss if something should happen to the insulin. Take a look at the top of the Lantus forum and the Sticky Notes posted there. Lots of good information about Lantus and dosing, including pictures of cartridges, pens, and vials. And a video showing how to draw the insulin from the pen/cartridge vs. the vial.

As for doses, a cat needs whatever dose they need. There are some secondary high dose conditions that cats to need more insulin. One in four diabetic cats has a condition called acromegaly, which is a benign pituitary tumour that sends out excess growth hormone that causes the diabetes. My Neko had that, as well as a condition called IAA (insulin auto antibodies). Think of it like an allergy to injected insulin. She was on raw food too.

Not all cats do better with 0% carbs, some do better with 4-6% carbs. As for amount of food, let the scale be your guide. My Neko (14 lbs) had about 4 oz of raw per day to maintain her weight when she was in good blood glucose numbers. Is your kitty getting taurine? That's an essential ingredient for cats. I fed a mix of premanufactured raw and some made with a premix.

Not all cats have their nadir or lowest points at +6. You might want to try random tests throughout the cycle. My Neko's nadir ranged from +3 to +13 (one hour into the following cycle), when she was on Lantus. Doing a curve, testing every couple of hours, might help you see Bruno's reaction to Lantus, specifically when his onset and nadir are.

 

Thanks for your reply, Wendy. I will check out the sticky in the Lantus board for the cartridges.

Bruno does have a cyst on his neck. We were told it's benign by the shelter. I have also noticed a new one on his spine this past week. I will discuss it with our vet when we see her next week. I see from Neko's profile that you went as high as 8.75 units. I really don't know what to do when the vet asks us to go to 6 units next week.

FF chicken feast is 4%. I will give it a try. Dr. Pierson's recipe is actually not raw. It's half cooked. There is taurine in the vitamin soup, together with Omega 3 oils, B complex, vit. E and ionized salt.

We have done a curve when he was at 3 units. I will do another one this week. I will also try some random time as well.

What was really puzzling is that he would always have some improvement for a day and then revert back to the 300s. It happened on the first day we gave him canned salmon, the first day we fed him Dr. Pierson's recipe and the first day when we when from 4 unit to 5 unit. I would have thought it would take the body a few days to get used to the new variable and then came down to a lower blood sugar level and plateaued. We would then proceed with more insulin. That would have made life so much easier.

 

At the size of dose you are on, we typically only increase by 0.5 units at a time, so as to not miss a good dose.

If you still don't see movement in blood glucose when you get to 6.0 units, you might want the vet to draw blood for a couple of high dose condition tests. Both the acromegaly (IGF-1) test and IAA tests are done at Michigan State University. Those are the two more common high dose conditions where insulin resistance is present. With both, but even more so IAA, the resistance can increase over time and mean a need for higher amounts of insulin. Neko saw her first normal blood glucose number at around 3.5 units, but it wasn't until she got to 8.75 that she earned her first reduction. We have some cats on even larger doses. ECID, each cat is different in what insulin dose they need. One other high dose condition, but less common, is called Cushings.

 

Thanks, Wendy. I will discuss with the vet next week.

A dumb question, so we might have missed a good dose at 3.5units or 4.5 units? Any point of trying those instead of going to 5.5units?

 

Not a dumb question at all. Cat's have an internal system that reacts to numbers that are lower than they are used to, by dumping glucose and counter regulatory hormones into their blood to raise the blood sugar numbers. We call it bouncing. But if you test when a cat is bouncing, you will see high numbers. And if that is what you based your dosing decisions on, you could be using the wrong data. Here we base dose decisions on how low the Lantus dose takes the cat. Too much insulin can look like too little. Similarly, basing dose decisions on tests at the vet instead of home can be misleading, as many cats numbers go higher at the vet due to stress.

Most people here put their blood sugar test data in a spreadsheet. If you can do that, maybe we can help you with dosing. Here are the spreadsheet instructions. http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

 

Bouncing is the concept that I don't quite grasp when I was reading the "Start low, stay low" page. Was the idea that you don't want the Nadir number to be more than half the AMPS number? It mentioned getting someone with experience to look at the curve to make sure no bouncing is occurring.

"Here we base dose decisions on how low the Lantus dose takes the cat." What exactly do you mean by that?

We never had Bruno tested at the vet. We tested him at home everyday and report the number to the vet at the end of the week and she will tell us what to do next. Our vet only wanted us to test at +6 hours at the end of the week.

I have already embedded Bruno's spreadsheet in my signature.

Thanks.

 

Hi @Tim from Toronto ! I live in Belleville so just down the highway from you I'm new to all this as well and I also find that my cat is not really getting very low. What I've started to do recently is spot check at different times as often as I can (as suggested on this board). So some days I might test his BG at +6 and +8 and other days I might be home at a different time & test it at +3, +5 and +9 (and some days I don't spot check at all). It's good to do spot checks as often as you can so you can try to find a pattern & you can fill in the blanks as well. Testing at +6 all the time isn't really giving you the full picture. For my kitty, his lowest doesn't seem to be until between +6 to +9 so you could be missing his lower numbers as each cat is different. I also always test just before his insulin dose so I know it's safe to give him his insulin. I've done a few curves on Merry & my vet reviews them & then lets me know what she thinks I should do. I've never had curves done at the vet, that's not necessary if you can do it at home, stressful for the kitty so raises their BG and it's expensive. Not sure if this is any help but just wanted you to know I feel like I'm in the same boat as you are with an uncontrolled kitty. I'm going to do another curve on Saturday because I should be home enough to test him every 2 hrs and then I think he might need a dose increase but even if my vet suggests to increase him by 0.5 (she's been good at only increasing him 1/2 unit at a time compared to what some other vets do) I'm only going to increase by 0.25.

 

Thanks, Luanne. I will be doing tests at random time this week. If Bruno is willing, we would be doing some curves too.

Merry's chart looks way better than Bruno's.

 

Have a look at Phoebes.

 

You guys are in the 20s. Now I know every cat is different. Say hello to Phoebes for me. She looks like the girl I used to have eons ago.

 

Will do. She's my baby much to her chagrin. Lol

 

The ideal Lantus curve is fairly flat. But at the beginning, kitty is getting used to insulin and curves may not be so flat. What you don't want is steep quick drops in blood sugar, or the blood sugar number going too low. The kitty may also bounce if the blood sugar is still an OK number, but lower than they are used to.

It means we try to do blood sugar tests around when the nadir, or low point of the cycle (time between shots). A typical Lantus cycle looks like a gentle downward curve to the nadir, then back up again. If at the low point the cat's blood sugar is going to low and there is risk of hypo, that is too high a dose of insulin.

 

Thanks very much, Wendy.