Hello! My kitty Misha (12 years old, about 14 lbs, neutered male, no other health conditions right now but history of pancreatitis) was on Lantus for several years and went into remission twice, but since his last relapse, we just haven't been able to get him well-regulated--any dose that gave him decent numbers would periodically make him plummet like crazy, possibly because the doses were overlapping. We recently switched to Prozinc, thinking that maybe the shorter duration of action would be good for him. So far, I am not thrilled with how this experiment is going. I've been getting advice in another thread (I'll add a link here in a sec) but everyone rightly suggested that I bring the conversation over here and ask you Prozinc experts for help! I had him on 1.2 u for a week, and after a curve confirmed the crappy numbers I'd been getting during spot checks, I went up to 1.4. His first cycle on that dose seemed ok, but the second one took him from an AMPS of 488 to a PMPS of 52 (I am using an AlphaTrak meter at the vet's request and tested twice at PMPS to confirm that number--other test was 56). For the AlphaTrak meter, this is pretty low. I skipped the shot, obviously. I was then up feeding him high-carb food and re-testing for several hours. In the past, on Lantus, if I fed him a couple of high-carb snacks, he generally leveled out pretty fast and was at a high number in the morning (his lows were always at night). But in this case, it took four hours of steady feeding to get him back into the blue--and this morning's number was still the lowest he's had at AMPS on Prozinc. What is this kitty doing? I have sent all this info to his vet and am awaiting a reply, but for now I dropped the dose big-time (to .8u). I am using U-100 syringes and the conversion chart, by the way. I don't think I screwed up yesterday morning's dose--I've been doing this a long time and have been extremely careful as we've started this new insulin--so I am extremely puzzled about what happened that kept him so low for so long--I thought Prozinc was "in and out"! Any advice is much appreciated, and I'll post here again when I hear from his vet and/or at shot time tonight...thanks, all!!!!! PS He does have a spreadsheet; the link is in my signature.
Some cats can get up to 14 hour duration with Prozinc, which would mean there could be some overlap from the Prozinc dose from one 12 hour cycle to the next 12 hour cycle. It's in-and-out for MOST cats. Misha on the other hand? Who knows. The 10-14 hour duration cited is from the Prozinc USA website, here. http://www.prozinc.us/prozinc.html Which quotes this document: Nelson RW. Disorders of the Endocrine Pancreas. In: Nelson RW, Couto CG, eds. Small Animal Internal Medicine. 4th ed. St. Louis, MO: Mosby Elsevier; 2008: 764-802. Also, his appetite or lack thereof can have an impact on the BG levels. So how was Misha's appetite on Sunday 3/8?
Misha is definitely being special here. There wasn't anything weird about his eating Sunday--he usually does most of his eating at night, with a snack in the morning and another around 5 pm, and I think that he stuck to that pattern. I heard from the vet, who says this is all very weird and does not like how rapidly Misha seems to drop; he thinks that could be triggering a perpetual cycle of bounces (caused by sharp drops, not by low numbers) that make it look like he's always running high. He wants me to stop insulin entirely for 3 days, though continuing to monitor and report any especially high numbers or troubling behavior like vomiting or not wanting to eat and restarting insulin right away if those kinds of things surface. He then wants to restart at a much lower dose, and he's inclined to go back to the Lantus (I still have a half-full pen that's not expired, so that's possible without dropping another giant chunk of change on insulin right now). This plan makes sense to me, as a sort of reset; maybe I was giving him too much Lantus before and he's been bouncing away on his own personal trampoline all the time without my realizing it (I thought he had occasional bounces at night, when he got low numbers, but maybe there were some sudden drops, too, that I didn't pay attention to because he didn't go all that low...I was keeping his numbers in a notebook rather than a spreadsheet for much of last year, so it will be hard to tell). Anyway--guess I won't have any more Prozinc questions for a few days Wish us luck!
Good luck! Please test for ketones while you are not giving Misha any insulin. Not enough insulin + not enough food + infection/inflammation (think bad teeth, UTI, etc) can lead to ketone production. Ketones are produced as a toxic byproduct when the cats body catabolizes fat and muscle tissue to provide energy for the cat. Anything above a trace amount of ketones in the urine is an immediate call to the vet, and may mean your cat is developing DKA (diabetic ketoacidosis). Can happen from one day to the next, with little to no warning. Not sure why your vet is having you stop all insulin for 3 days. Prozinc does not have a "storage area" a "depot" like lantus does. You can switch from Prozinc to Lantus immediately.
Will do! I've got the strips, and he's good about letting me stick a ladle under his butt when he's peeing. I'll also keep a closer eye on his eating. I think the vet's reasoning is not so much that he's worried about lingering effects from the Prozinc as that he thinks Misha has been "bouncing" and his body needs some time to just settle down a little--he also wonders whether Misha might not even need insulin. I don't think that's the case; he's been off it before, when we had a previous vet who believed if we just kept him on a very specific diet (raw food of a particular brand) exclusively, the diabetes would just go away (it didn't happen, though he was only on the diet for 6 weeks or so, and they said it might take longer...basically I just didn't believe them). But we've only been seeing the current vet for a few months, so I can see why he would want this data (what the kitty is like with no insulin on board). Misha came up to me last night and again this morning like "Uh, not that I really want to get jabbed, but...are you forgetting something?" He's such a good little guy. I will definitely keep a close watch on him--and keep wearing my new patience pants when we restart the Lantus (if that's what we do). I'm also still interested in trying Levemir and am getting info together about how to order it online, since it's incredibly expensive at the local pharmacies.
Oh hey! Keep on testing him even though he is not getting any insulin. You might be getting some useful data there while he is off the insulin. Bet he wanted his post poke treats.
Absolutely! Gotta get that data! I gave him and myself yesterday evening and this morning off--this is the first time I've been able to sleep in in a long, long, long time--but I'll get back on it this afternoon! And he doesn't even get post-poke treats any more (just post-poke snuggles)--he's just a very conscientious kitty. My husband says he thinks Misha knows that I am trying to help him when I do all this stuff to him...I wonder if that's true.
Post post snuggles are good! Treats don't have to be food. Brushing, praise, playtime, singing to him. I do think that cats know we are trying to help them. With all that we do for them when caring for those cats with special needs, how could they not know we love them dearly?
Thank you so much for checking in on us! The vet and I decided to restart the Lantus; we disagreed about what approach to take. He wanted to start at 1.5 u but only once a day; I wanted to start low, twice a day, because everything I've read here suggests that once a day doesn't make sense. I thought if we started low and went fairly slowly, we could try to be sure we weren't inadvertently overdosing him and creating a cycle of bouncing. So we went with my approach, and I started him on .5. That didn't appear to work well, so I went up to 1; made a little progress there but the nadir was still in the yellow zone. So he's now on 1.5, and I'm doing a curve today--I'll get numbers tonight as well since he tends to go lower at night. Next stop 1.75, I guess. He is obviously drinking and peeing more than he should be, but he's not apparently ravenous or losing weight, and there are no ketones. He's doing his usual (unfortunate) thing of sleeping most of the day and being active at night; he's fairly affectionate and not beating on our other cat too much (he does that when he's feeling poorly), so I guess he's managing ok at these higher numbers--but obviously we don't want to stay in this range any longer than we have to (he's getting mostly 400's and the occasional 500+). Advice welcome, as always! How are you doing? Crazy times...
So you're back on Lantus. Time to start posting in the Lantus ISG again. When you switch insulins, you don't reset the dose to 0 or too low. You need to take the current dose of insulin into consideration when you switch insulins. I agree with the twice a day, but not the no insulin for several days and then the low dose of Lantus. Prozinc does not have a depot, so it's safe to switch to another insulin the very next cycle. Well, that's water under the bridge, since you already did that approach. What is a bit puzzling to me, is that BG of 52 PMPS on 3/8 with no (0 units) of insulin. I think you need to increase at least to 1.75U with the pre-shot for tonight, 3/22/20. I see big time bouncing on the SS. Blacks = bouncing Reds = bouncing Unfortunately, the curve today when he is bouncing from that black BG isn't likely to give you much useful information. I could be wrong. Not infallible. And cats are unpredictable. But I'd bet Misha doesn't drop any lower than the mid range yellows and I'd give even odds that he only sees the pinks. Misha isn't dropping particularly low on that 1.5U dose. You've got a lot of room to increase the dose. Looks like you are following TR. Good idea. Because Misha needs his dose raised quickly but safely, giving the "depot" time to fill before you raise the dose again. You need to be more aggressive with the dosing, to get Misha feeling better. You need to get him out of those black, red and pink BG numbers. (Yes, you already know that.) The only way you are going to do that, is to raise the dose. And I wouldn't hold that increased dose more than 6 cycles, unless Misha is giving you a lot of green and a few blues. Not 1 or 2 blues or an occasional green or blue. But more consistent blues and greens. If you felt like crap, not getting enough calories because you didn't have the insulin in your body to process the food you did eat, you'd be beating up on your roomie too. And be rather cranky and irritable. Or if your blood sugar was too low, lower than your body is used to, but still safe, you'd be irritable from hunger too. I know all that sounds a bit harsh. Sorry to be so blunt. p.s. Doing ok here. Surviving in this surreal world of fear and tension.
OK, interesting! Yes, we probably didn't need to start so low, or wait--but I think there was concern that I was giving him too high a dose of Lantus (back in the pre-Prozinc era...) so I wanted to be sure we ruled that out. How can I tell the difference between black/red numbers coming from bounces, vs. his just being in bad shape and having high numbers because he's not getting enough insulin? My understanding now (tell me if I'm wrong about this!) is that a bounce can happen when he goes to a pretty low number (say, under 70 on the AlphaTrak) or when he drops too fast, even if the actual numbers stay high (so, like...maybe from 500 to 300 in the course of a couple of hours?). I have no clue about that one patch of green, either. With something that anomalous, my first thought would normally be a bad test strip, but I tested more than once and got consistent numbers. So my other thought is that maybe I mis-measured the morning dose that day--he has sometimes had *very* late nadirs. I did notice a syringe recently that seemed to have the lines marked in the wrong spots (extra space before the first line), so maybe I had one of those and didn't realize it? But I always try to pay attention to stuff like that. I don't know...he's a mystery to me sometimes. I totally understand why he would be in a truly foul mood, and I would absolutely feel the same way! I hate seeing him like this, but in the past my problem was that I would freak out whenever I saw a really high number and start messing with the dose before he had a chance to settle into it--so I'm trying this time to be patient and tolerate the crappy situation. But perhaps now it's time to take those patience pants off and put them in the laundry! In any case, I'd be delighted to go up on his dose tonight rather than wait for tomorrow, and I could go to 2 rather than 1.75 if that seems more appropriate...would love to get him feeling better ASAP!!!!
No, upping the dose too quickly could wind you up in a situation where you bypassed the correct dose. So no, my recommendation would be to only go up to 1.75U. A 1/4 of a unit increase. Please, keep those patience pants at hand. Do I need to send you more? What color this time? If you see a yellow number in your curve testing today, hold off on the increase. For at least 1 or 2 more cycles. See if the bounce is clearing. A string of flat yellows usually means the bounce is clearing. You need to be more aggressive with the increases, but patient at the same time with the dose increases. I know, a bit of a contradiction there. Smaller increases of 0.25U at a time. Not jumps of 0.5U with a dose increase. Yes, syringes can be "off" from batch to batch, box to box, even syringes within the same box can contain syringes that have the markings on the syringe barrel in different spots. Some brands are worse for that than others, like the Relion (Walmart) brand. It's why some people use calipers to measure the dose each time, and don't rely on the syringe barrel lines too much. That's a tough one. How to tell the difference? The blacks at pre-shot test is one way to tell, if the numbers the night before were in a more normal range. (Hard to tell, because you did not get a single test last night except for the pre-shot test) It's context. It's looking at the SS and seeing those waves of action in the BG readings. It's experience. Actually, back on 3/19 I would have held off on the increase. Those low yellows on 3/18 PM caused the BG to jump and that black was a bounce at the AMPS the next day on 3/19. Then you increased by 1/2 a unit instead of the recommended 1/4 unit the the morning of 3/19. If the cat NEVER gets down to the yellows, blues or greens despite increasing the dose, the cat may be overdosed on insulin. It's why those +2's and some random checks throughout the cycle can be so useful. You may catch one of those lower numbers and know that your cat is dropping lower and you may want to hold off on an increase for a cycle or 2. If you've raised the dose too quickly, haven't given the depot time to fill when using Lantus, you can't tell if the lower dose was the right one. Also, your cat could have a high dose condition. Either IAA (Insulin Auto Antibodies) or Agromegaly (pituitary tumor). Tests are expensive and usually not done until a cat has reached insulin doses of 5 to 6 Units per cycle. I doubt that is the case right now. Yes, too low (<68 Alphatrak), dropping too fast even though the numbers are safe and high (500 to 300 in your example) can result in bouncing. His body is not used to lows. They don't even have to be unsafe lows, lows under 68 mg/dL, simply lower than his body is used to. For now, those "lower than his body is used to BG's" includes the yellow ranges and below. Notes in the Remarks column on what and when you are feeding Misha can be really helpful when looking back at the SS for patterns. For example, 3/15 AM cycle, did Misha get food before that +4 BG reading? Notes should be broken into AM and PM cycles and expressed in the + hour format. Yes, it's a bit more work for you, but it can make a difference in interpreting what is going on with his BG readings. How about starting those notes?
Hoo boy, I can add food notes where possible, but he is pretty much free fed--he has a special box with a microchip reader in the door that our other kitty can't get into, and I keep it stocked with his favorite freeze-dried raw food--which he tends to eat during the night when he's out and about. I also offer him food at shot time (usually canned Tiki Cat), but he just takes a few bites. He's kind of a nibbler. (The other one, alas, is a gorger.) I will definitely keep the patience pants on and continue to be cautious with the increases, and I'll try to get a few more random readings in. Maybe I need to move his shot time--I've been doing 8:30, but that means I don't usually get more than a +2 at night, unless I manage to drag myself out of bed at one of the times when he comes and sits by my head and grunts. (The times I've tested him during the grunting, he has not been low--just bored, I think. When he's low, he meows in a really harsh way, which is helpful--he really does his best to let me know what's going on.) Looks to me like we're staying in the pink zone for now, but we'll see what happens in the next few hours! Thank you so much for taking the time to give me such detailed guidance!
I'm usually pretty horrible at those short and sweet answers. Succinct is not in my makeup. With lantus, you can move the shot time in 15 minute increments per cycle, or 30 minutes in a 24 hour period.
Just reporting in: high, flat, and pink at 1.75 u. Planning to go up to 2.0 tonight and will hope to hear from the vet tomorrow or early next week... I haven't been tracking the food--I just don't know if I'm going to be able to do that. I am trying to note any time I feed him anything unusual (like the one night where he actually made it to a blue number and I gave him a little of Weruva's Steak Frites, which is 6% carbs as opposed to the 1-2% carb stuff I usually give him, to try to prevent any bouncing).
