Question about shooting past the right dose

This sounds like a stupid question - even to me. But how do you know if you increased past the right dose? If they're getting too much insulin, wouldn't they be having hypoglycemic events or is it possible to be past the right dose and their numbers be staying too high?

 

Not necessarily - when the liver senses too much insulin, it begins releasing counterregulatory hormones to counteract it. That cycle can last for many days, even weeks, until the liver just can't do it any longer THEN you have that hypo event. The numbers will stay high because the liver release is a different type of sugar that registers on a meter just like glucose.

 

Hmmm... OK. So if you suspect you may have gone past the correct dose, should you walk back the dose you're on slowly? Like a half unit at a time, holding that for several days before lowering the dose again? Or just "cold turkey" them back to the dose you suspect may have been the correct one?

 

If he were mine and I have ketone test strips and can use them, I'd take him back to the last dose where numbers were best and go from there following protocol. Be sure to test for ketones daily just to have a 'heads up' that things aren't well.

Others will chime in as they see your post....

 

Well, here's the thing. He was starting to have some decent cycles in the 100's at 2.5. But I then he started to go up and, in retrospect, I think I raised his dose too quickly. Then, he had a couple of cycles with numbers in the 100's at 3 but went back up into the 300's & 400's and didn't start having any cycles with 100's again until we got to 4 units. Then he went back up into the 300's again and finally, at 4.25 he started to have a lot more cycles in the 100's. Unfortunately, I am currently using a horrible batch of stiff syringes and cannot get a consistent dose at 4.25. Many of his injections were really closer to the 4.5 mark on the syringe so I finally just raised him to 4.5 so I could actually draw the insulin out of the bottle to the line without having to try to adjust the dose from there. I figured more consistent dosing would be better than 4.2 some injections, 4.4 the next. So I guess what I'm saying is, he's had several doses where he's started to respond fairly well, but then started climbing again and kind of stayed back up at his "set point" in the 300's. So I'm not sure if that initial dose he responded to (2.5) was really where he should have stayed and I just didn't stay there long enough or if it's possible that I went past the "right" dose but he still responds to new doses when I increase. We're still pretty new at this (about 9-1/2 weeks in) so I'm still trying to figure it all out. He eats well, acts fine, looks good. He doesn't seem to have any weakness and he's never had a hypo test or exhibited any clinical symptoms of a hypo. When his BG is up in the 300's he drinks more water and pees more. And he definitely seems to have more energy when he's having cycles down in the 100's. He's only ever had one BG reading in the normal range.

 

Part of what you're seeing, as Lyressa suggested, is that your kitty is bouncing. Bounces can happen not only with low numbers but when numbers are lower than what your cat is used to or if there's a fast drop in numbers. The result is that the liver and pancreas release a stored form of glucose along with counterregulatory hormones and number spike into higher ranges. This can make it difficult to sort out if the dose is too high or if the numbers are a reflection of a protective response.

There are people who come here having been told that their cat is experiencing chronic Somogyi rebound. The conventional response is to drop the dose. First, Somogyi is what amounts to an urban myth -- it's not been found in long acting insulin like Lantus and Lev. Secondly, for those of us who have been around for a while, any time we see someone drastically drop a dose (e.g., starting over) as a means of offsetting high numbers, it's never been a success. Ultimately, the caregiver has to raise the dose back up at the expense of losing time.

If the dose is too high, you will see your cat's numbers dropping into dose reduction range. If you're still feeding any dry food, this would be below 90 on a human meter since you would be following the Start Low Go Slow (SLGS) method of dosing. (Your cat needs to be on a completely low carb, canned food diet to use Tight Regulation.

 

Ok ReaAnn , I've got some odd questions to ask you. Does Big Hoss snore? Is his weight stable? Does he have larger than normal spaces between his teeth? Do his paws seem large for his size? Does his lower jaw seem to jut out a bit? It might not pertain, but his numbers remind me of Sophie's when I was trying to get her regulated and she'd be fine for a few cycles, then get worse.

 

I've researched acromegaly. It's possible he has it, but he definitely doesn't have all the symptoms. His weight is stable. He was near 20 lbs when we adopted him (at 5 yrs old) 8 years ago and he's at 19.7 now - even with newly-diagnosed, unregulated diabetes. He does snore, but he always has - even when he wasn't diabetic. He's a VERY large cat (pretty porky) and we've always felt like that's why. He has terrible teeth and had 14 of them removed 15 months ago, but no, there didn't appear to be any unusual gaps and I'm sure the dental specialist (who we know well) would have told us if he'd seen that or an unaligned jaw. His paws are big, but EVERYTHING about Big Hoss is big. He has a big ol' punkin head, big paws, big everything. He is a VERY large cat. So I say all that to say, it's very hard to tell if he has symptoms of acromegaly. He may. But none of his body features or snoring or weight has really changed in the 8 years we've had him, even when he was not diabetic.

 

OK, so what I think I'm understanding you to say is that it's probably not that his dose is too high. It's just that he's simply not regulated yet and he's just going through "normal" bouncing?

 

With a spreadsheet that looks like Big Hoss's, I think going way back in dose would be a complete waste of time. He finally saw green at 4.25 units and not at all before then. If you had shot past the good dose, he would have eventually showed you by seeing lower numbers. As Sienne said, you would have eventually seen a number below the reduction point. Which you actually did with that 80 on 4.25 units if you are following SLGS.

However, and this is where the questions that Sue @sbluhrs is asking are important, there are some secondary conditions kitties can have that make it hard to hang onto good numbers once they see them. My Neko had two of those conditions, acromegaly and insulin auto antibodies. If you look at her 2012 spreadsheet, she first saw green at 3.75 units (ignore the first three weeks of a bad monitor), but didn't actually earn her first reduction until 8.75 units. Yes she bounced a lot, worse than Big Hoss, but just couldn't hang onto good numbers because of the conditions causing insulin resistance.

Symptoms with acromegaly can be misleading. And very much ECID. I have seen research showing that only 35% or so of acros have symptoms on diagnosis. Other than Neko's crazy hunger and dose, her only sign was tearing from one eye. Which I didn't know was a symptom at the time, and neither did my vet. It was caused by soft tissue growth blocking the eye duct. She never got big paws, separated teeth, or a potbelly and only at the end did she have a slight whispy breath. She never snored and weight was more or less stable. But she did get arthritis, other soft tissue and bony growths, and eventually heart, kidney, and GI disease.

 

Well, he definitely is a BIG boy and you can see by his picture he has a big round head and fairly large paws. And he does snore like a freight train. So again, I've already been researching acromegaly because I'm having to keep increasing doses and he's a big, snoring cat. But I think I read somewhere that if they get up over 6 units twice a day and still aren't getting fairly consistent numbers closer to a normal range that's when you start looking for other contributing issues. Does that sound correct or do you think we're already at that point? I'm pretty baffled by why he initially responds to a higher dose then kind of goes back to what I'm calling his "set point" up in the 300's. But, it does appear to be trending downward as we increase doses. His highs aren't usually as high now and he's having a lot more 200's and 100's than he did there for awhile. And we're only a couple of months in. So I'm TRYING to give it some time and hope he's just not quite up at the right dose yet, but it's definitely a pretty frustrating disease to manage.

 

Is here any way of getting rid of the dry food from the picture? We have seen more than a few kitties drop in dose with dry food out of the picture.

There isn't really anything magic about the six unit dose size. Other than it's the point we suggest people get testing done for the "high" dose conditions. We have seen cats with acromegaly and IAA on smaller doses, but we've seen very few kitties at six units or above, and on an all low carb wet or raw diet, without a secondary condition. One in four diabetic cats has acromegaly so it's reasonably common.

The scenario you describe of seeing good numbers, but not being able to hang onto them, but still seeing better numbers overall, does sound like you are getting closer to a dose that can get him better regulated.

 

I have three free-feeding cats and a very tiny house. One of my cats (of course it's the only one who isn't fat) will quite literally starve himself to a furry skeleton before he'll eat something he doesn't like and he is not a fan of canned food. So I've had to compromise by picking the lowest carb dry food I could find that they'll all eat and can all tolerate - which is the Dr. Elsey's Clean Protein, which is supposed to be 4.69% carbs. When Hoss was first diagnosed, I started them on Royal Canin Glycobalance Dry but when I switched them to the Dr. Elseys, that's when his numbers started getting a lot better so it's undoubtedly a lot lower carb than the Glycobalance was. I try to give Hoss as much canned as possible to fill him up so he doesn't eat very much of the dry, but I'll probably never be able to get them completely off of dry as long as I have my one super-picky eater.

This is what it says on the Dr. Elsey's website: " Dr. Elsey’s delivers only 4% energy from carbohydrates as compared to leading Dietetic Management foods with levels as high as 13%."

Main Ingredients
Chicken, dried egg product, pork protein isolate, gelatin, chicken fat (preserved with mixed tocopherols)

Vitamins
Vitamin E supplement, niacin supplement, d-calcium pantothenate, vitamin A acetate, thiamine mononitrate, pyridoxine hydrochloride, riboflavin supplement, vitamin D3 supplement, biotin, vitamin B12 supplement, folic acid

Minerals
Potassium citrate, potassium chloride, salt, calcium carbonate, ferrous sulfate, zinc oxide, manganous oxide, copper sulfate, iron amino acid chelate, manganese amino acid chelate, zinc amino acid chelate, copper amino acid chelate, sodium selenite, cobalt carbonate, ethylenediamine dihydroiodide

Additional Ingredients
Flaxseed, natural flavor, salmon oil, fructooligosaccharide, choline chloride, mixed tocopherols (preservative), taurine, salt, rosemary extract

Guaranteed Analysis
Crude Protein (min) 59.0%
Crude Fat (min) 18.0%
Crude Fiber (max) 4.0%
Moisture (max) 12.0%
Eicosapentaenoic Acid (EPA) (min) 0.06%
Docosahexaenoic Acid (DHA) (min) 0.06%
Vitamin E (min) 150 IU/kg
Omega-3 Fatty Acids (min) 0.90%