? when (and how) to "reset" insulin dosage?

Hi there,

What are the factors people consider when they decide it's time to reset their cat's insulin dosage? I am learning a lot now, but before I joined this group I simply followed my vet's directions. I started Milo on 2 units of Prozinc for 2 weeks, then went straight to 3 units for 2 weeks (after seeing high bg values when I did a home glucose curve), and then straight to 4 units (when home testing continued to show high numbers). I am learning that it is a ridiculous increase and I should I have been increasing at .25 units not 1 unit

How do I know if I should do a reset? And if I do a reset, what's an appopriate schedule, i.e., when do I increase .25 units? After how many days? What's the right quantity and pace?

Thank you!

 

A. First you need a good collection of data while following the recommended basic testing routine:

1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
3. do extra tests on days off to fill in the response picture
4. if indicated by consistently high numbers on your SS, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
5. post here for advice whenever you're confused or unsure of what to do.

You're doing a good job of getting a lot of test data but have missed the all important pre shot tests we recommend before every injection.

B. With ProZinc you can increase fairly quickly if your SS shows that BG is sitting in too high a range. Hold a dose no longer than 3-4 cycles (1 cycle = the 12 hours after a dose) if it isn't getting BG down into good numbers. The longer they sit in high numbers the more glucose toxicity builds and that impairs their body from responding well to insulin. Toxicity can be reversed by careful, steady dose increases of 0.25 u at a time.

C. You're in ideal dose territory when your PSs are in the low to mid 200s and the nadirs are in the high double digits to low 100s.

It's hard to know what to suggest because of the whole unit dose increases your vet recommended. There's some evidence of a better response to 4 u so that has to be your starting point until numbers suggest otherwise. Have you checked the carb level of the Weruva he eats? Is it strictly wet food? His CKD and hyperthyroidism might also be added challenges in regulating BG.

I suggest you start regular increases of 0.25 u after 3-4 cycles and keep those up until (hopefully) you start to see yellow and blue on your SS. That would tell you the dose is getting closer to the "good range".

 

Thank you so much for laying this out so carefully and clearly! For your bullet C, once we get to those "good range" numbers / ideal dose territory we continue on that dosage until when? Until the values start to get "too low" pre-shot? Then does this mean that we need to start reducing by .25 units? Or does that mean we don't give insulin (is below 200 pre-shot mean no insulin)? I might be jumping the gun, but I do want to prepare myself in the future.

 

I also found some good info in the beginner guide sticky in this message board. So I am reading that too and it's helping me fill in some of the questions I had in my reply but love to hear your thoughts if you have anything additional to add

 

His Weruva carb content is typically between 2-5% and never is it more than 10%. He is strictly on wet now. Two weeks ago his vet had him on k/d hills dry + mobility, but we stopped feeding him that.

 

It can take some time to get to that good range. Some cats are easier to regulate but others never really settle there with a high degree of stability. Regardless, the good range is achieved and maintained by small dose fluctuations over time. It’s rare to find a dose that keeps BG there with no change day in and day out. As is often said here, it’s not “set and forget”. BG status and the dosing to maintain it are dynamic, not static.

 

Another thing that can happen is that the dose needed to control BG drops over time and eventually the kitty’s pancreas takes up the slack more and more until no insulin is needed. That’s remission and kitty is a diet controlled diabetic. Remission doesn’t necessarily happen and if it does it can last a short or long time.

 

Thanks so much Kris! I am just about finishing Milo's latest curve (4 units) and it looks different from the rest of the curves. Everything is saved in my spreadsheet. The nadir appears to be more delayed than before. The nadir today is +9 hours while previous data points suggest closer to +6 or +7. I will test again before the PMPS (so in two hours) but I was planning to up the insulin to 4.25 units but that was before I saw him in the 200 range for three hours straight. I am concerned that his duration seems to be longer and I have read on the message board this could suggest the dosage is too high? However, I understand that I should still give insulin if I am seeing over 200 PMPS, just not sure if it should be 4 or 4.25 tonight. What do you think?

 

I like the yellow! Yes, his nadir was later yesterday but it can move around. Usually we say a dose might be too high if nadir happens at PS. You can try 4.25 u this AM if you see this in time.

I missed your last post yesterday because I was asleep.

 

Thanks Kris! I just did the AMPS and he's at 259. The lowest I have seen him at this time. Just yesterday's AMPS he was at 513 so I am confused with what I am seeing. I have a couple of guesses. Milo is having really bad diarrhea the last couple of days (probably because of his IBD). Could problems with his ability to absorb nutrition affect blood glucose? I also started a new bottle of Prozinc on Friday. I've seen some posts that say new bottle might be more potent?

I am a little nervous to increase his dose today. I will give him his 4 units and check mid-day again to see where he lands.

 

You always have to err on the side of what you're comfortable with. Yes, a new vial of insulin might have a little more ooph so we recommend an extra test or two.

My guess is that poor absorption related to IBD could affect BG but it might depend on where the lesions are or how widespread they are. The opposing factor is the inflammation which tends to raise BG.

 

Hi Kris,

I tested Milo again about a hour after his 259 reading. I had feed him his breakfast immediately after the first test and more than 20 mins had passed and his bg was 241! So... even more confused than before I got even more concerned and only gave him 3 units. Is it bad that I dropped a full unit? Should I have just gone down more slowly (e.g. .25 or .5)? Or is it more crucial to go up a dose slowly vs. going down a dose slowly? Thank you so much!

 

Some spreadsheet housekeeping: if 241 was the BG before you gave his AM dose you need to put that in the AMPS cell. Also, if the AM dose was 3 u you need to change your SS because it's showing 4 u.

Allowing for meter variance of 20%, 259 and 241 are essentially the same BG number. You could have given the full 4 u dose on 241 but that judgment will come with experience. A proper dose assessment weights the nadir numbers more than the PS numbers. You need the PS number to know that the planned dose is safe - ie., BG is high enough to support it.

You're still at a point of gathering data to see his response to insulin. As long as your PS is above 200 and you don't get a lime green number mid cycle you don't reduce the dose. Rather, you increase in 0.25 u increments until the nadir numbers are high dark green or low blue. Post here for advice any time you're unsure.

The reason for maintaining a stable dose, provided it's safe, is to avoid the erratic numbers that can come from too much dose hopping.

 

Thanks Kris for the housekeeping tip. I was planning on giving him 4 units and did not update the spreadsheet as I ran out of the house for work. 241 is the reading before I gave him the dose, but it's not the reading without 2 hours of no food. I guess I should put 241 in the AMPS and maybe the 259 in the notes?

I updated Milo with a couple more numbers today. And will continue to test him before I do the PMPS. I contacted my vet and asked for advice. I wanted to know what number I should see before I don't give any insulin or reduce the insulin. Is that number 100 I asked? And she emailed me back - "If he is eating and does not seem lethargic, don't try to check BG. Just give 4 units." I was very frustrated with this answer! UGH.

What are your thoughts if I get a PMPS that is below 200? Below 100? What dosage do you recommend?

 

Under 100, no shot for sure. We wouldn't recommend that for anyone.

Under 200, first stall for 20 min WITHOUT FOOD and retest. It might come up high enough to shoot. You can do that for up to an hour depending on your schedule. Other than that, I'd probably post here for help. The dose we'd recommend can change as the numbers you're getting change. It'll also depend on the amount of data you have, what dose you're giving at that time, etc.

 

Thanks Rachel. I reread the Prozinc protocol and I have a question about the section I pasted below.

It sounds like its all or nothing, i.e., that if I don't get a number say around 225 because I am using Alphatrak then I just skip the shot. Should I adjust the shot down or that's only done under another set of circumstances? I am just worried that my cat's panaceas has started working again because just yesterday his AMPS was 500 and today the AMPS is 241 and that could mean 4 units is now too high? Or am I jumping to conclusions as I still don't have enough data? Vet put him on 4 units because his bg were in the 600s and he's been on 4 units for several weeks now and I am shocked that now he's in the 200 when he was not anywhere near these numbers despite being on 4 units for so long. So I am worried 4 is too much now, but I understand it's best not to be adjusting units before every shot so sounds like the advice is no shot at all if I get a low bg?

• The proper sequence for dosing insulin is: Test/Feed/Shoot. In the beginning, if your cat’s BG is not up to at least 200 mg/dL {11 mmol/L}, if your schedule allows, you can stall (without feeding) for 20+minutes, then retest the BG. You are looking for a number that is rising, not falling and up to 200 mg/dL {11 mmol/L}. If you stall once, but can’t do another round of stalling and your cat hasn’t reached a BG of 200 mg/dL {11 mmol/L}, you’ll need to skip the dose and wait until the next cycle. NOTE: Because pet-specific meters (such as the AlphaTrak2) often read higher than human meters, you may want to adjust the NO-SHOOT number to 225 mg/dL {12.5 mmol/L} or even 250 mg/dL {14 mmol/L} This gives you an added margin of safety when using an AlphaTrak2 or other pet-specific meter.

 

The rules change as you accumulate data and learn your kitty's responses. The no shot unless over 200 on a human meter is for new people and is set at that to give a large margin of safety. As you get more data that no shot number can drop and you can sometimes also adjust the dose. Those are trickier things to do safely so aren't recommended early on.

The experiment at 3 u today is revealing. I like those yellows a lot more than those reds and blacks. It seems that the 4 u dose is too high so I wouldn't go up again. Try 3 u for a couple of cycles. This is a hard thing to sort out when the vet has bumped up the dose too high and too fast, leaving the kitty bouncing up in the rafters. It's guesswork trying to decide how much to lower the dose.

 

Thanks! Just tested again and at +9 hours we are at 202 so essentially the same as +6 when we got a 208. Is this looking more like a flat curve? I've read about them a long time ago, but can't remember what they signaled and what should I be concerned about. I'll try to find more info on the web.

 

Also, the latest advice from my vet is "I don't want you to spot check BG. Not super helpful and will stress out Milo." While I find her knowledgeable, responsive, and professional, I also feel like she's not up to speed on the food options and the bg testing guidelines. Are comments like this signs I should consider a new vet? She is an internal specialist so I appreciate that since Milo has several conditions going on, but.... any thoughts?

 

Meh. For some reason, a lot of vets feel the same way. I was super lucky in that my vet encouraged home testing (she didn't push it like she should have, but she did mention it and even told me to use a human meter!). A lot of vets say that they think it will stress kitty out and not to do it. Well of course it stressed kitty when THEY do it ! They're the vet! My vet wasn't up to speed on food either...pushed the prescription crap. I just ignored that.

It's kind of up to you. You may not find a vet who's any better, but you could surely try! Might ask on Main if anyone is near you and can recommend a good vet. You could also call around and try to get an idea of how others treat diabetes to see if there is another vet nearby you want to try. After all, you don't have to stick with a new vet if you try....you could just take him in for a second opinion and then if you like a new vet, stick with them...and if not, go back to your old vet. You don't even have to tell them you're trying other vets.