13 Feb - Pedro (UK, RVC trial) eating, back on 0.25U insulin

HELP PLEASE!!

picked Pedro up from the clinic in London on Friday, bright and happy cat, vocal on the journey home. We stopped at a friends where he came out of the carrier, are a little, sat on a kitchen chair while we chatted, the kids playing.

Pedro has shown to be sensitive to insuline, this is the vets' suspicion, and so they reduced his variable dose again, reducing the maximum dosis from 2 units to 1.25 max:

if blood glucose <10mmol/l, give 0.5 unit glargine s/c
if blood glucose 10.1 - 12.5 mmol/l, give 0.75 unit glargine s/c
if blood glucose 12.6 - 15.5 mmol/l, give 1 unit glargine s/c
if blood glucose >15.6 give 1.25 unit glargine s/c

At my friends I tested him at injection time around 8.30pm (17.7 mmol/L, 319) but forgot the syringes at the clinic, so could not inject him. Tested again when I was home later that evening around 11.30pm and injected him with 1.25 units.

Saturday morning I tested at usual injection time around 8.30am and he was 3.9 mmol/L, 70) and I thought this was probably the end of e nadir. I left Graham with instructions to test him around 10.45am and inject him according to the shooting schedule. At 10.45am he was 4.9 mmol/L, 88) and as per plan he injected him with 0.5 units.

Graham didn't respond to these low numbers with quite the urgency I would have and he didn't test him again until 1.30pm when Pedro was down to 2.3 mmol/L, 41. He noticed that Pedro wasn't interested in food and tried to call me, but my phone was off due to a faulty battery. He tested him again at 3pm (1.5mmol/L 28) and then net to pick me up from work.

We were home 35mins later and I tested him straight away (1.8mmol/L, 43), smeared some honey into his mouth and then tried to get him to eat but to no avail. To make matters worse he ran off and hid and we couldn't work out where he had gone.

Graham found him 35mins later tucked away in a hard to reach spot in the back bedroom and we got him out. Tested again (1.6mmol/L, 29) and took him straight to our vets, had called them earlier.

The nurse noticed him having a tremor and helped us jumpy the cue. Tested him for the vet with our Alphatrak (2.4mmol/L, 43) and they took him to the back to administrat glucose intravenously. 10mins later he was positively more perky, a bit more lively, but happily going into his carrier.

When we got home he was and stayed on 10.3mmol/L 183 at 5.3opm and 7.30pm and at his previous shooting time of 8.30 he was up a little to 10.7mmol/L 193.

As we are approaching the adjusted shooting time I tested him, he has come down a little to 9.9 mmol/L 178, but he still hasn't eaten anything. He drank a tiny amount when we came in from the vets, there are sorts of cat foods there readily available but he showed little interest. We had fish & chips for dinner and he hadn't tiny amount of fish, but nothing more. He spent the evening curled up on the sofa head rest behind me next to the warm heater sleeping with periods of loving and warm cuddles and strokes and purring. He also had a wee in the garden after we have come home from the vets.

So, my question is: to inject or not to inject...? If I would inject him I don't think I would go to sleep because I wouldn't want him to drop low. I am concerned that the glucose injection seemed to see him stuck on that 10.3/183 for several hours without movement. I am concerned he is coming down right now again. My instinct is telling me not to inject.

He has been low before and actually this week Monday night to Tueaday, the night before I dropped him off in London he reached a crazy all time low of 1.8mmol/L 32 and for the first time showed signs of hypoglycaemia. It took all night to get him back up, hence th vets adjusting th variable dose. I am emailing them checking to see if there is a cutoff point, ie no injection if below such and such....
.
I can't get hold of the night nurse at the clinic.
What do I do?

Mue x

 

After the hypo, he may be more sensitive to insulin. I would be very cautious.

We set a no shot limit of 150 for folks without a lot of data who are using Lantus or Levemir.
When those folks follow the Tight Regulation protocol, they may shoot very low numbers, even under 100 mg/dL (5.5 mmol/L) ... but that is based on a consistent dose plan, not the sliding scale they've had you use. Plus, they are testing at least 4 times a day and recording the data so they can see what a dose will do.

Do you thing you can eyeball a 0.25 unit dose?

 

I would follow your instincts and not inject. As BJ says he may be more sensitive to insulin after the hypo and with him not eating much I don't think it's worth the risk. Re-evaluate at next shot time.

 

I was thinking a 0.25 dose as well. Either that or skipping until tomorrow morning. If I heard his meow to complain about wanting to be fed I would be the happiest woman in the world.

The vets at the trial also explained that comparatively Pedro is on very little insulin and that he is at a stage where remission is something that might be possible. We briefly spoke about what that might look like, ie the pancreas waking up and producing insulin, cat shooting low numbers and how careful we will need to be with injections.

We also spoke about how each cat being different it seems for Pedro the Hypo threshold is extremely low, but now that we have reached it (with Monday night's low numbers and different behaviour then already) it means things are more delicate.

:/

He is doing extremely well on the trial, fructosamine coming down further.

Attached his check out report.

 

I replied in your original thread but will say it again here. Whilst the glucose might still be wearing off, he might be more sensitive to insulin because of the low and pedro isn't interested in food I would tend to not give any insulin tonight. But I am not experienced at this so I am not actually advising this I think this is just what I would do .

 

He is come up a wee bit again, 11.2mmol/L (202)

But still not eaten or drunk anything for a while, my gut still says no injection.
Rather have him bouncing high tomorrow morning and meow the house down for food.

Do you think I can "jump" him back to the original 8.30am shooting time if I skip tonight...?
Mue x

 

If you skip tonight, yes - you can absolutely adjust back to your 8:30am shot time tomorrow morning.

You do have to go with your gut sometimes. Even though you probably aren't shooting tonight, it could be interesting and possibly helpful if you grab a test or two anyway - it never hurts to have data.

Are you planning on holding a dose steady? A sliding scale is definitely not appropriate for dosing Lantus, and Lantus definitely works best if you're consistently able to shoot the same dose 12 hours apart - otherwise you really do end up with wonky numbers that are all over the map.

 

He's in a research study, so she has to follow their directions.

 

Is he interested in eating yet? That would probably be my deciding factor. If he's eating, I'd go for a small dose. If he's not eating, I'd be more cautious.

yes, if you skip tonight's shot, you can shoot at any point after this, so the next shot can be as early as you want.

With a symptomatic hypo he may be extremely sensitive now to the insulin, even a small dose. Those were some very, very low numbers you've gotten.

 

How is he this morning? Is he back to normal? What are his readings?

 

Morning!
He was just 30.9, has been curled up behind me on the sofa all night as far as I can tell, but I did fall asleep... I think the long journey from London back up to home still in my bones. :/

I can't tell if he has eaten much in the night, some food is gone, but of course there are two cats in this household. This morning when I woke up he was happily purring, and letting me stroke him and cuddle, BUT he doesn't meow, barely a sound. And that's extremely untypical for him.

And then just before he threw up a tiny bit of bile (size of a oreo cookie) which looked a little pink, then another smaller bit and that was clear.

Trying again to contact the clinic to see if they can help.
x

 

Tested again at 10.24 am 36.4 mmol/L (655) and I injected him 1.25 units as per schedule, he drank a fair amount of water, sniffed at the food but didn't eat. :/

He is sitting next to me and I can see some of his fur trembling/flickering, like a muscle flicker, a tremor? Can they have tremors when that high? Is he HYPERglycaemic now...? I mean, go into a similar 'shock' situation like HYPOglycaemia, not merely 'diabetes mellitus' Do you know what I mean?

*hits the internet*

 

I think you might be seeing more of a injection irritation. Do you swap testing sites? Remi got it occasionally as if the injection had irritated him.

You are able to watch him closely today? Although he might be high now (maybe a bounce) I think he could still be sensitive to the lantus and go low again. Normally you reduce the dose by 0.25 units if they go low rather than give the same amount as the same thing may well happen again. I think he is needing less insulin overall and perhaps the sliding scale needs to be lowered again.

Please keep a close watch and try to catch the fall early and feed to keep him up.

 

Ok, cat is curled up next to me, happily purring and letting me stroke him, but trembling/shivering. Back to out vet at 12, in an hour, and RVC are trying to get hold of our vets for me.

Could he have an adverse reaction to the insulin overall? Maybe it's the Lantus itself?

 

Keeping a close eye on him, yes, and I hear you about the shooting site. To be honest I am not varying it as much as I guess I could/should. Usually back of the neck and I shift the area a little around, but it's always back of neck. How much do you vary the places where you inject him?

The 1.25 is a reduction from what he would have gotten before, that is already a reduced dose, reduced by 0.25 from what he was on before, hence I went with that.

Will test him again in a second.
He actually stopped trembling now.

 

Just spoke to the clinic and they are forwarding the info to the vets, (which I have done already, but good to have another line of access for sure.) Getting ready for the vets now. Trembling stopped completely (thank goodness for that!!!!!!!) and the vet of the clinic i spoke to reckons it might just be a case of riding this out. The big question is dosage of the insulin and she is checking in with our clinic vets about that.

Asked that our vets give him a checkover to see if he is ok otherwise.
Tested 30mins after insulin injection and he went from 36.4 to 35.5, down a little bit.
Sits happily next to me, watching me type, purring, attentively turning head towards me and all, just not meowing and not eating. :/

on duty vet at clinic said, he probably feels pretty grotty right now, ride it out, check for bugs or anything else that might be off. She also thought the trembling/tremors might have been from sensitivity of the shooting site.

x

 

Glad the trembling has stopped. Others may be better to advise as to what it might be. I too think he must feel pretty rubbish with such large swings of BG in the last few days. Is he drinking okay? If you lift his skin on the back of his neck does it drop back quickly?

Have you tested for ketones recently?

 

Not tested for ketones ever. One of or local pharmacy sells the ketones test strips for our human glucometer, if it's open today I could get them.

Wouldn't be able to get hold of any alphatrak2 specific ones if there are any. Would that work?

Trembling completely stopped but he just got a jolt at the vets because the owner of a little curious Staffie let his dog run around the waiting room and the dog made a beeline for Pedro's basket before I could do anything. Pedro jumped and arched in his cage (glad I took the big one) and growled. Really doesn't need the extra stress. :/

At the clinic in London they have separate waiting area and the cat one has extra screens built in to separate the cats as well!!!!

Vet is running late, woman just came out of a room without her cat, crying.

 

Gave the woman a hug and held her as she was weeping for her cat, she was utterly distraught. Her friend or sister soon came out and they finalised cremation details and all.

The vet also agrees with the clinic, there is nothing physically wrong, Pedro appears to be feeling extremely low and poorly after the ups and downs and so recommends to entice him to eat, assisted if push comes to shove and they also gave him subcutaneous water as he was a tad dehydrated.

Waiting to take him home shortly. x

 

Can the vet test for ketones for you? Just in case.

Good to get some strips for home anyway. I only have the ketones strips that you hold uNder the cat whilst they are peeing. Then you read off the colour, like the glucose pee sticks. You can buy blood meter ones but not sure where or if necessary for you.

 

A few months ago I had something similar happen with a man and his lovely old dog. We both ends up crying in the car park and I had only met him a minute before.

 

Not eating voluntarily and just shooting low again. honey and food in a syringe right now.

 

So we are at +8 now aren't we? Could this be a bounce clearly I wonder? I wonder if the high numbers this morning were a bounce and perhaps he didn't need that whole 1.25.

Don't leave it to go too low. Is he less than 3.8?

Please update your thread title to today's date-low numbers more advice needed. Or something like that

 

Just looked at your spreadsheet. Definitely go in with the honey and food.

 

Ha! Syringe food and honey = 6.2 mmol/L (112)

 

Good but you know the drill, don't stop testing as the effect of the honey is likely to wear off and then pedro may drop sharply again. Retest in 20 or thirty minutes.

So here is my concern. I know the trial and the sliding scale but this is what I am struggling with. Pedro went low yesterday on 0.50 of a unit. That would have earned him a reduction of 0.25 unit today. But as he went so low he may well have bounced back high. So when you gave a dose based on that bounce/high number it was actually higher than yesterday's dose. Now that bounce is clearing he has gone very low again so we may be in the same position as yesterday. To my mind no matter how high he is when you next give him a dose I don't think it should be any higher than 0.25. Does that make sense. I am possibly wrong here but I am interested in hearing other peoples opinions.

 

Crikey, that is one heck of a drop! And not for the first time, either....

Sarah is right.
Sliding scales are fine and dandy (I use a sliding scale myself with Bert) but a dose increase shouldn't be made on number that is inflated by a bounce. It's not a 'real' number.
Problems can arise, big time, when you shoot the number that you see, and then the bounce starts to clear.

 

I hear you, and I understand what you say, most of what I read about it all goes along with this. Not all cats of the trial are on variable doses, more are on steady doses but those are cats who need larger doses of insulin.

The bounce is a mix of short-acting and long-acting hormones and insulin would still be needed to break the glucose down for the body, maybe what would be Pedro's maximum dose is still too high with 1.25 units. An added complication is that he hasn't eaten today, barely anything, so the 1.25 units this morning will have brought him down off the bounce on a near empty stomach, technically an overdose...?

Our vet today said to keep him above 3.0 and up to 11 would still be fine.
I think I have a night and day of syringe feeding the cat ahead of me, the vet said they could admit him tomorrow to do this but ultimately I can do that myself, no?

Also expecting to hear from Ruth and Chris tomorrow as they were not in the clinic today.

Well, and the other thought of course (I have to put it down somewhere) is Pedro refusing to eat, not wanting to go on, is he giving up, preparing to die?

 

No I don't think he is giving up. The clinic gave him the all clear. I think his body is just thinking WTF is going on. I think its upset his system.

I think you should keep the dose low and consistent for the next few days. Let him ride out the bounces and settle down. All these highs and lows and dose changes don't allow you to see how one dose is actually affecting him.

 

Oh, sweetie...
Pedro may just be feeling off colour because of his blood glucose levels bouncing around so much.
Is it just today that he's been off his food?

 

Just saw that you are using Alphatrak meter (reads higher than human meter).
Some of those low readings you've had will have been hypoglycemic numbers.

Definitely time for a rethink about dosing....
I agree with Sarah. It'd be good to cut back on the dose and let things level out for a bit.

Huge hug to you,

Eliz

 

Maybe discuss with the researchers reducing the doses for the sliding scale.

 

He is not entirely impressed with me syringe feeding him, but another couple syringes worth and a bit of honey after he dropped back to 3.4mmol/L

He seeks warmth, in front of the fire now, licking his fur, a good sign, right?


I think the suggestion of a low dosage (if his blood glucose is not too low) might be a good idea. A cut off point for not shooting is also needed, ie below 5....?
Am putting another update together for Ruth and Chris and will put all that in.

Cancelling work for tomorrow and hope mil can have Josie so I can focus on Pedro.


Thank you for your encouraging word, this really means lots because as I am "force feeding" him I am wondering when/how will his survival instinct kick back in.

He looks bright otherwise, purrs when cuddled, etc.

 

Take a look here and scroll to the bottom section of the first post - you're looking for the video on assist-feeding. Hopefully that will help you. Think of it as assisting him to eat temporarily. You're helping him - if you're feeling like you're forcing him, that will come through and he will pick it up. Remind both of you that this is just for the moment until Pedro's appy kicks back in.

Because you are participating in a research trial, I suspect it would be important to get the ok from the study folks about what you want to do with his dose. Because his appy is uncertain, I'd lean to the conservative side with his dose until he's a little more consistent in eating on his own.

 

How long is the trial?

 

Had a couple good feeding sessions with the syringe and he just sat in front of the fire drinking a good amount of water I had dissolved a bit of sugar in as well. Held the bowl high for him and he was drinking while I stroked him. He would stop drinking when I stopped stroking so kept stroking him.

The work I do with newborn and little babies and their parents centres a lot around oxytocin, will do some reading about this in relation to cats. If he feels so grotty then all these things, feeling safe and secure, bonding with me, maslow's hierarchy of needs for cats, etc will sure play a role, no?

Seeing that he is at the lower end right now I don't foresee any injection tonight and I will make sure I have spoken to either Ruth or Chris at the RVC clinic before he would be due an injection tomorrow.

 

I think when you give your update to the RVC trial you should mention that following the advice to shoot up to 1.25 unit if you see higher numbers didn't take into account the bounce that occurred from the very low numbers of yesterday and ask the, whether it is now appropriate to see how pedro settles on a low 0.25 dose for a few days.

I agree with you about setting a no dose shot based upon your alpha trak and also speaking to Ruth or Chris before you dose again. Don't be surprised to see some high readings both from the bounce of going so low. Have the trial seen the tight regulation protocol we follow on here?

You are doing great. Just keeping monitoring and encouraging him. I agree your work is probably helping you greatly.

 

Hi Ella,
I think the cats are monitored for a year (that's how long the free insulin (and food if wanted)) lasts, as I recall.
A few FDMB members have gone on the trial. And a couple have gone into remission.
They're trialling Prozinc and Lantus.
This is the the first FDMB member whose kitty has been on a sliding scale during the trial.

 

The trial lasts a year, aim being to get cat back into remission where possible. Ruth said at one point when we spoke about the trial's approach that they are likely to take greater risks when shooting than others normally would. I guess that is ultimately what makes it a trial and since lantus is just not licenced for the UK it is trial s and research like this that can contribute to it becoming licenced.

Ruth and Chris know all the current research and studies into feline diabetes and one of the contributing reasons for us to go to a variable dose was the amount of testing I can do at home, a tight regulation schedule as they see it.

Our next visit would be beginning of April, although I'm open to go earlier if I need to. Pedro also had some fairly intense weeks, 5 - 8 jan to and from London, then again two weeks later and again two weeks later. He traveled some 1200 miles since 05 Jan, I twice as much. >.<

 

Do you have any data from the Feb 4-6 time frame, other than what's in there? dosage and preshots even? It might be helpful to have it there.

What we've seen here is that when a cat becomes more used to normal numbers, and their body begins accepting them as normal, it's no longer safe to "shoot through the bounce" meaning to give one more shot at the previous higher dose after a cat has "earned" a dose reduction. I think what you saw happen with this morning's 1.25 is essentially showing that Pedro can't handle the higher dose anymore - it's bringing him straight back down. But . . . I know his appetite is off, so perhaps that is a factor. I'm not sure how to help you since you've got directions for dosing from the trial vets.

He's a well-traveled kitty! Punkin also got to travel for his acromegaly - we took him 2600 miles to and from Colorado to get the tumor radiated. Two days in the car each way - he was a trooper, though. Mostly just hung out under the seat of the car and didn't complain much at all. Good kitties!

 

Wow! I hope it all settles in and will work out. Those are some miles you have to cover. Do you get a petrol allowance?

 

No petrol allowance, but if you consider the cost for the food, insulin, syringes and most importantly the test strips it works out cheaper for us than NOT being on the trial.

Pedro was diagnosed 13 Nov and between then and travelling to London on 05 Jan we spent about £330, and if we would source all needed items online and as cheaply as possible it would still take around £130 per month at least. Petrol to and from London = £60 x 6 so far £360 and now it will space out. In the long run it works out cheaper for us. I won't lie, this was one of the factors that helped us make this decision. That and the chance of remission which we would not have been able to do with support of our vets, although probably with help of this board, mind. ^_^

 

I have so far not let Pedro roam free in the car on our journey but this weekend I opened his cage on the way home from the vet to see what he would do. He was a little curious but mostly sat in his cage anyway.

Thinking how to set up a cat loo so he can access it if needed and comfy spaces to travel. Going through all sorts of cat travel contraptions in my mind while we are on the road...

 

Wibke, where are you in the UK?

 

On the Wirral, we live in Wallasey by Liverpool, Merseyside. North-West.

 

Wow, looks like you've been through an emotional ringer the last couple of days. I've had to assist feed a foster kitty (hepatic lipidosis) and it can be something you just need to do to get their own system kick started again. I hope Pedro decides food is good again soon. Try to feed something other than his regular food via syringe - they often develop an aversion to the food that is syringed. My foster kitty went completely off chicken for several months. Offer Pedro plates of something completely different.

Pedro has clearly decided he doesn't like as much insulin as he used to. Good plan to skip tonight.

I saw your post on setting up the travel loo. My Neko also went to Colorado for radiation therapy, 4300 km round trip, 3 days on the road each way. I left the carrier door open, and Neko mostly rested in there. I have a sedan with a split back seat, and I put a litter box in the back trunk which she could access through the one seat back down. She mostly used it when we stopped for food, petrol, etc. Of course, I quickly found that puppy pee pads in the carrier and spare towels were handy. Another arrangement I've seen used is a large dog crate that was enough for a bed, and LB in one.

 

Mue

I know Pedro is on the variable dose trial but I'm wondering if you might want to ask the vets there if it is safe to use the scale when he is bouncing like he is today? I know my mind is trained in the TR protocol where we don't base the dose on the preshot, but I think this can be a learning tool for us all. So it doesn't make sense to me that you have a cat who got as low as he on 1.5u, got no insulin for a few days, then went exceedingly low on 0.5u, skipped (thankfully), and then gave a much higher dose (1.25u) which caused a huge drop again. I don't see the value of this to Pedro. Again....I'm not questioning you following their dosing scale because you are in the trial and you've committed to this. I'm just curious what they will say about this.

I hope Pedro will feel better and eat well.

 

We travel frequently with Rusty. We take his carrier (in case of emergency), but leave the door open. We have a small, oval pet bed that just fits in the carrier and is the same as his bed at home. He usually spends a couple of hours of our 6-hour trip sleeping in his carrier, but he also sits on the arm between the 2 front seats. We pad the arm with a fleece blanket. We have an SUV and carry the litterbox in the back. Never had a problem with the litterbox. We line the back seat area of the car (seat backs are down) with newspaper, in case of a vomit. That way it is easy just to tear off the soiled part of the newspaper and put it in a plastic bag. On long trips we carry Rusty's food in a small cooler. We offer it to him when we stop for a break, but he rarely eats anything during a trip. We also offer him water during a break, but he never drinks.
Cautions: if you have automatic windows, make sure to lock all but the driver's! An ID collar is a good idea. Rusty wears the Road ID plate on his collar. I've had it engraved with his name, our phone numbers, his vet's phone number, and the fact that he is an insulin-dependant diabetic. Here's the link for Road ID:
http://www.roadid.com/default.aspx?...medium=Text&utm_campaign=BikeID&referrer=8942

They ship worldwide. Rusty wears the "Scout Small". It's an engraved plate that fastens on his regular collar. (Edward and I wear Road ID bracelets: they are intended for cyclists and runners, but many people wear them in case of a medical emergency). Not expensive and great peace of mind.

Hope all is going well for Pedro today,

Ella & Rusty

 

Think safety when you travel. Having a pet loose in the car is an invitation to catastrophe if you have to stop suddenly or have an accident. The cat will be flung around the car like a furry, clawed missile and could suffer great injuries. It is the same reason people should wear seat belts.

A 30" crate is about the right size for an average cat to include a modest litter box, a place to lie down, and food and water bowels. Fastening the bowels to the crate will help prevent spills.

 

This has been really useful! Thank you so much!!

 

I also wanted to add a word of warning about having cats loose in the car. I took a phone call at work where a women was desperate as she had lost her cat. She had pulled over to help her daughter with something and her cat, who always travelled loose in the back, slipped out. She didn't realise until she got home over 100miles away and by then the cat had long since disappeared and as far as I am aware it was never found

 

Dr. Lisa has also posted about the dangers of having a cat loose in the car...

 

I will ask them to give me the data they collected in the time Pedro was at the clinic. They connect electrodes to him to get 24/7 data about his blood sugar level and then check with the alphatrak in regular intervals (every 2 hours I think).

I'm thinking about the bounces and the high dose and the drop and all and I remember something Chris mentioned at the check-out, that cat's diabetes is much like a human with diabetes 2, administering a basal amount of insulin twice daily and then small amounts in line with food to manage the blood sugar more tightly and accurately.
So I wonder if ultimately there is something missing in the way they manage the variable dose and that being that each cat needs a basal amount of insulin plus whatever top-up is required for the food/blood sugar/everything that brings the blood sugar up or down.

Do you know what I mean?
Because if, say, 0.25 units is Pedro's basal insulin amount then maybe it takes much smaller top ups of 0.25 throughout the day to manage his BG? Obviously that isn't necessarily realistic for cat owners but what if the answer is two different insulins? Lantus as elongating basal and something else to top up?

Probably futile thinking about this, but whatever better sounding board to explore these ideas?

As for save cat transports, well, the vision alone of having Pedro crawling under my legs and obstructing me driving the car safely is enough to have me thinking about a big metal cage basically that would sit alongside the back seat (in our car the back bench can be taken out in two parts and the floor is level) So big enough for a cat toilet and a resting area. We usually have a break and offered a little food and drink, but he wouldn't usually eat or drink much while travelling. I guess that's not a bad think considering that what goes in must come out again somehow...

Well, and as for our evening, things have been going well with the syringes so far, he is cooperative in eating what I feed him via the syringe, and has been holding healthy low numbers early evening and is now at 8.8 (158), down from 9.2 (166) an hour ago. Sleeping and resting, shall wake him and feed him again now. As per recommendations feeding him actually gravy vicious food as he turned his nose up to Purina DM the last 30 hours and if syringe feeding potentially is putting him off the food used then that's not the food to use if the trial relies on it so heavily.

Cancelled work tomorrow and my lovely mother in law is picking Josie up so she can have a more entertaining day than watching me monitor the cat.
Hurrah!

Can't wait to talk to Ruth and Chris and hear what they think!

 

That's not futile thinking at all. Many of us have used Lantus or Levemir as a basal insulin and then used "R" insulin, either Humulin R or Novolin R, which are quicker acting insulins, as bolus insulins as needed. However, I doubt any of us would suggest that it would be a good step for Pedro to have a secondary insulin. That would likely not fit with the whole dosing protocol of the trial. Usually we reserve the suggestion of a second insulin for cats that either have a high dose condition (acromegaly, insulin autoantibodies or cushing's) or for cats who have really given a good effort to following the TR protocol and still need some extra help. It's used much in the way you described. See, you are more forward-thinking and brilliant than you knew.

I would double-check with your trial people to find out what they want you to dose when Pedro is in normal blood sugar. Following the TR protocol, we would hold the dose the same and not skip or reduce the dose unless the person was new to FD, the cat wasn't eating normally, or the cat couldn't be monitored after the shot. I would ask specifically about this so you know what to do next time you are confronted with a lower preshot. Once you start getting green preshots you often will find them happening again, and it's good to have a plan. With Lantus/Lev being depot insulins, when you skip a shot the depot will drain some and it can influence how flattened out you can get the blood sugar. If that makes any sense at all.

 

Right, I am off to bed for a little while.

Wrote a long email to Ruth and Chris and also checked Pedro's bg every hour, it has steadily been climbing back up and was just 15.4 mmol/L (275)

He is taking ok to the syringes of food and water but I think I need bigger syringes, because the ones I have are tiny! Pharmacy tomorrow!!

Night night!
Mue x

 

Absolutely.
I have a friend who lost her kitty that way. My friend had a minor car accident and wasn't hurt herself, but the kitty was knocked unconscious and died later that day.

Sometimes, when I've brought a rescue/foster kitty home for the first time, I've put their cat-carrier straight into a large dog crate. There is room in the dog crate for food, water, and a small litter tray (I make disposable ones from cardboard to fit the available space). Then I open the door to the cat-carrier inside the crate, and the cat has access to food/litter tray etc, but still remains confined in a small space.
Maybe something like this would work for your long journeys?

If it seems feasible then you could set it all up indoors a while before the journey, so that the kitty has time to get used to it (perhaps put some cat treats inside to tempt kitty to explore).
Maybe a friend or neighbour has a folding crate you could borrow? If not, they're not expensive to buy, £30 to £40 maybe for a basic crate. You'd need to be sure to get one that had a door big enough to get the cat-carrier inside; and make sure the crate would fit in the back of your car.

Eliz

 

Love the idea of a custom size recycled cardboard letterbox, Eliz! Genius!!

So, time for an update!!

Went to bed last night when he was stable in the mid tens and when I woke up this morning he was 24.8 mmol/L (446) at 8.15am. I had a long conversation with

Chris and shortly after with Ruth at the clinic and here is what we spoke about:

Dose reduction and cut off point, variable vs steady:
For the next couple of days we will go with no insulin if he is below 10 mmol/L (180) and once he stabilised a bit more it will be no insulin below 7 mmol/L (126).

They expect his blood sugars to be quite 'out of control' for a couple days and we are reducing the dosage, however we will stick with the variable dose rather than going steady for a while. We spoke about steady dose versus variable at this stage and felt that where it worked best was with the numbers at the lower end, however more work is needed to calculate the right dose to account for the 'bounce'. We spoke about the similarity to Diabetes 2 in humans and the idea of a basal dose (say 0.25 units for Pedro) and a bit more to accommodate his glucose, food, the bounce, etc, but it needs more observation of the bounces and finding ways to calculate this.

Considering Pedro's sensitivity to the insulin we are also reducing all dosages by 0.25 units although the next couple days will be mostly about shooting after consulting with Ruth and Chris.


Food and drink, nausea:
Chris and Ruth also echoed what their colleague at the clinic had said as well as my vet and you all: Pedro not eating was not about hime retreating from the world, from life but down to feeling rotten and Chris suggested to go and see our vets again today to get an anti-nausea injection or tablets. He said he wouldn't usually want to 'mask' symptoms of nausea in healthy cats but he felt that with diabetic cats it is helpful to get them back on track with feeding. He also suggested to get Pedro more subcutaneously water if needed (albeit with a smaller needle, slower pace and water heated to 30 - 35 degrees Celsius.) He also suggested to observe him when squeezing his tummy to see if he might be in discomfort and if necessary administer a mild painkiller.

As for the assisted feeding, he was not too keen on it, mostly down to the food aversion that can develop. He said unless Pedro would lick drops coming off the tip of the syringe he would not really recommend it but instead create an environment in which the cat is more comfortable and happy to eat. So raised bowls, great variety of fresh foods (blanched fish, etc.) and such like. He said to use the syringes as last resort.

He called my vet and explained all of these things and preliminary booked an appointment for me later this afternoon.

So far so good!

MEANWHILE in the living room...

When I got up I woke up Pedro who was sleeping by the heater on top of the sofa headrest and he greeted me with cuddles and all. I went upstairs to get dressed and much to my delight Pedro came upstairs, tail erect, alert, initiating lots of stroking and cuddles (he paws me gently as if to tap me to say "Hey, cuddles! Now!!"), he even meow'd a couple times!!! Sweetest sound EVAR!!! He also did his usual morning thing of walking ahead of me down the stairs, turning round regularly to make sure I was still behind him en route into the kitchen to feed him. AMAZING!!!

In the kitchen he made all the usual moves about wanting food, paws up against the kitchen cupboard, circling round me legs, moving forth and back, etc., but he was not best pleased with the selection, sniffing at it, drinking a little water but not eating anything. He went outside for a quick stroll and probably a wee and when he came back he was throwing up bile and grass. At the time I was on the phone to Ruth to discuss what to do with his morning injection.

Ruth and I agreed to inject him 0.25 units (GAAAAH! Are there any smaller syringes?!?!?!) and obviously close monitoring and so at injection time (still "late" at 10.45am) he was 22.6 mmol/L (407), down a little from the 24.8 mmol/L (446) he was at 8.15am. She said we would be extremely unlucky to see him drop as quick and low on that low a dose but obviously I am home today to make sure I can monitor him. Incidentally his glucose is coming up and has gone into black figures 28.6 (515) at 11.54 am and 28.8 mmol/L (518) at 12.55pm. I will let them know in a moment to see if they want me to do anything about it.

Well, and then my lovely mother in law came to pick up Josie and Pedro came in from another stroll round the garden and came for cuddles and then he crouched down and ATE PURINA DM DRY FOOD FROM A BOWL! He ate!!! He ate he ate he ate!!!!! He ate!!!!

Best news EVAR! He finished the bowl, not a huge amount but a great start!

So I am feeling giddy and excited and sooooooo relieved! Obviously plenty more to do, he needs to eat considerably more to catch up to his usual portions and I am out to get some fish in a moment, but what a lucky turn! Yay yay yay!! And then we need to stabilise his blood sugars, no biggie.

Mue x

 

Loooook!!!

 

Confirmation of the reduced variable dose for the next couple days and beyond:

Next couple days: no insulin below 10 mmol/L
once his blood sugar stabilised again a bit more: no insulin below 7 mmol/L

While he hasn’t picked up food properly yet I stay in close consult with the clinic over his dose.

After that:
if blood glucose <7mmol/l, give 0 unit glargine s/c
if blood glucose 7.1 - 10mmol/l, give 0.25 unit glargine s/c
if blood glucose 10.1 - 12.5 mmol/l, give 0.5 unit glargine s/c ?
if blood glucose 12.6 - 15.5 mmol/l, give 0.75 unit glargine s/c ?
if blood glucose >15.6 give 1 unit glargine s/c ?

Mue x

 

Sorry BJ, couldn't resist it....
.

 

Mue, that's super-duper news!
Fingers crossed that his eating will continue and increase.

It sounds like you covered a lot of ground in your conversations with the vets.
So, the insulin sliding scale has been reduced by .25 of a unit? It's good that it's been reduced (but I have to say that I still wonder if that is too high a dose...and I think it needs to be watched really closely (which I know you will.))

Here's a link to a page from the Lantus forum that has photos of small doses in a syringe. You need to scroll down the page a bit, just past the diagram of the cat (and injection sites).
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-new-to-the-group-please-read.18139/

Please do post on the forum if you have any concerns that Pedro's numbers show signs of dropping too low at any point.

Hugs to you, and chin scritches to Pedro.

Eliz

 

I am so glad that you had a discussion with the vets and went through the different scenarios such as bouncing. I am hoping that at the lower doses he will stabilise and you won't see these swings in numbers and your dosing won't need to be adjusted quite so much.

 

Pedro didn't repeat his eating trick yet unfortunately and when I took him to our vet this afternoon as arranged by Chris they gave him 100ml of water under the skin, apologising that he looked a bit bloated but reassuring me it would be absorbed soon... They also gave him an anti-nausea injection which they reckon shoud last around 24 hours.

When we got home he was a bit unsteady, I imagine all that extra water in the system probably, and he curled up and slept by the fire. I tested him every couple of hours and he actually has come down a fair bit now, just a few minutes ago he was 9.4 mmol/L (164), so we still have about 30 - 60mins to injection time but since it's unlikely to come up again by then I don't think he will get any insulin again tonight, especially without having ate anything of substance. In fact in a conversation with Ruth after the vet visit she reckoned no insulin if under 15mmol/L and not having eaten a proper amount. And if he would have eaten a small amount then only 0.25 units.

So, not quite there yet.

Just picked josie up from he Nan and came home to a very active Pedro, initiating lots of contact, wanting to be near me all the time, cuddling, looking at me intently and all. Also watching Josie play with our other cat Enzo, following a thrown toy mouse with his eyes and all. He is purring, licking/cleaning himself and generally awake and alert, lovely sight!! Hope it's soon followed by him raiding the cat food buffet wee have set up for him.

Anyhoooooo, I will have to settle Josie and then it have to syringe feed him if he hasn't eaten by then.

Let's see.
Will keep you posted!!
Mue x

 

Good luck mue. I am sure things will settle down eventually. So glad you have the close support of Ruth and the other trial co ordinators.

Come on pedro eat for your momma.

 

Wishing you more good luck and appy vines for Pedro

 

Those, too ...

Glad to see he is eating again.
Another concept that might be useful to discuss with the study folks - with a low pre-shot, stalling for 30 minutes without feeding to see if the glucose is coming up or not. (options, not mandates!)

 

Just looked at Pedro's SS, Mue. That is a lovely run of blue numbers.
.

 

Morning!! It is, isn't it?

I had a chat with Ruth this morning to catch her up on our night.

After out visit to the vet Pedro drank a little but mostly rested near the heater, initiated lots of cuddles and stroking and in the evening, very unusual, he ate only a little when I stroked him quite strongly. It reminded me of newborn kittens who drink and get licked by their mum to reinforce the positive behaviour...? Might interpret too much into this, but he stopped when I stopped stroking and started again when I started stroking again. Usually our cats don't want to be touched when they eat. He mostly licked the gravy off the gravy Sheba (trying to get a boost into him yesterday evening as his numbers came down a little) plus a couple bites.

I stayed up with him a wee while, and watched his numbers coming down gradually, by 8.30pm he was below the threshold of injection which was 15mmol/L for grazing and 0.25 units and by actual injection time around 10.30pm he was below 10mmol/L. So no insulin.

And this morning basically Pedro is still only grazing, not eating properly, and he was deeply offended when I blended his food to make it easier to lick Other than that he is active with initiating cuddles and stroking, not meowing much, but happy to sit, licking/cleaning himself, went out for a wee, steady numbers, so far so good. Obviously they're still below injection thresholds.

Ruth and I spoke about Pedro's extreme sensitivity to the insulin and the word 'remission' was uttered, although of course with what his body has been through the last 4 days this might well be a fluke and not the beginning of anything as he isn't eating properly. He also lost quite a bit of weight because of it, he was 4.3kg when I picked him up Friday in London, he was 3.7kg on Sunday.

I asked Ruth to explain the extreme sensitivity a bit more, i.e., does it mean that the insulin works even better or does it mean it doesn't actually work very well at all and the answer is it works extremely well, meaning far less is needed for his blood glucose to come down.

And with this in mind his variable dose schedule was revised yet again. Ruth sent me an email to confirm this:
"As for dosing Pedro tonight, I think he can have 0.25U if his blood glucose is more than 20 mmol/l and he is eating only tiny amounts. If he eats well (Here’s hoping…) he can have 0.5U as long as his blood glucose is 20 mmol/l or above, or 0.25U if his blood glucose is 10-20 mmol/l."

A friend is opening my shop for me this morning, I just got to head over for 1pm, so a bit more time with Pedro to entice him to eat and I am back at our vets this evening to get Pedro another anti-nausea injection (they tend to last around 24 hours) and some pain killers as Ruth suspected he might be masking any discomfort. Am cooking chicken and fish for him as well to see if he fancies anything like this.

Really could do with him eating so I can go to bed a bit earlier tonight...
Mue x

 

Looking good

 

Most fascinating to observe Pedro's curve. Very gradually his blood sugar is rising, we left th blue numbers behind and are into yellow figures now, although not high enough to shoot as per Ruth' adjusted variable dose.

He also isn't eating.

Am torn between Chris' recommendation of not feeding by syringe and letting him sit this out and trying to get some food into him. :/

He weighed 3.86kg and he really could do with food. *sigh*

 

If he won't eat, I'd try syringe feeding. He's lost quite a bit of weight. Cats can get hepatic lipidosis after a couple of days of not eating. Think of the syringe feeding as supplementing his diet, he needs to get calories into him. What did Pedro's regular vet say about assist feeding?

 

I'd be trying to tempt him to eat or assist feeding him too. cats, unlike people, can't tolerate going more than a day or two without eating enough. The hepatic lipidosis that Wendy's referring to is when they lose weight, their fat actually clogs their liver. it's very serious. Have you seen the post on stimulating a kitty's appetite? Maybe something there would help.

 

After 2 days of not eating, a cat may go into hepatic lipidosis. This complete disrupts digestion, making the cat very ill. It is potentially life-threatening. Do whatever you can to get food in. It may work best to do small amounts frequently, rather than large amounts which may cause vomiting.

 

Back in blue numbers.

For the last two days he has been eating very small amounts of food when I bring the bowl to him and stroke him, fuss him lots. So not completely without food, but small portions, 1/4 to 1/3 of a portion maybe once or twice a day.

This evening around 9pm uk time, (it's 6am now) I brought Sheba flakes to him and he quite greedily wolfed down a bit more than 1/3rd of the portion but then had enough. After having gotten water before he didn't seem to fancy any to drink.

After he went outside for a wee and I imagine a poo but we don't get to see those, he seems to do them in someone else's garden.

Will try him again now to see if I can tempt him.
Thank you for the encouragement!!
Mue

 

Just tried him on Sheba flakes and he eagerly hate a fair few bites, just under 1/3 of the pouch I reckon. Trying to do this again later on and before work.

Syringes at the ready if needed. I learned that our little herb blender is great for cat food... Don't tell Graham...

 

He is drinking!!! and made a beeline for the leftover flakes but didn't fancy them apparently...

 

Second time lucky!!! I ate probably about 50g this morning now!!! Please please please let this be the start of something...

 

Hope Graham doesn't notice that his food has taken on this strange new meatier flavour...

Keeping everything crossed here, Mue, that Pedro's appetite keeps improving.

Numbers still holding in those blues...
.

 

In won't tell him if you don't...

Was out all day and Pedro was sitting on his new favourite place when I came home.
Numbers blue as before, 8.6mmol/L (155) and when I brought him a bowl of food he ate a small amount and then later went back to finish the bowl, approx 40g of food (Sheba flakes...)

Tried to dig in the Purina dm /Sheba flakes mix I preented him shortly later and didn't seem to fancy the Purina dry food, but at least he didn't think it needs burying...

Haven't seen him drink water yet so will give him half an hour and then present him with some to see if he drinks it and otherwise it's syringe time.

No vet tonight, no anti nausea injection, no painkiller and no extra water under the skin. (My credit card is rejoicing...)

Mue x

 

Pedro just had another 40g of Sheba flakes, no other cat food will do, and a fair bit of water. Yay!

11 mmol/L at injection time (198) so no insulin.

No other changes.

Glad he is eating, all without anti-nausea injection and pain relief, just hoping I will see a bit more of the old Pedro back soon.

Puzzled by these eerily calm curves, especially since he did eat some food today. Fascinating.

Mue x

 

Great to hear that Pedro is eating. Is the Sheba a lower carb food? What percent of his daily calories do you think he's eating?

I too am fascinated by the blues. It can take 6 cycles for the depot to reduce, he's going into cycle 5, curious to see what the next couple of cycles bring.

 

He had a bit more food, probably had about 60g now. ^_^

I have been wondering about the depot and how his worked seeing that he got a variable dose. I wonder how "large" his depot is, iykwim?

Wish we could look at his bloods.

I also wonder how long his nausea will last and considering how dramatic and intense these last few days were, his extreme curves, the eery ca- *STOP PRESS* he is eating yet more food!!!!!!!

The eery calm of the curves, even those extra trips to the vet sat, sun, mon, tue, have been stressful for him. Needles, water shoved under his skin, the painkiller the vet on Tue gave him must have stung because he jumped - this cat has been through the mill.

My poor fur baby.

 

I think the Sheba flakes are not quite below 8%, will have a look, been meaning to check or calculate!!

 

That's great to see.

If he isn't drinking much then I would add a little water to his food. I would also be tempted to syringe it in to his mouth carefully as long as it doesn't stress him out too much. With no insulin and raised blood glucose you need to help ward off ketones.

Are you testing for ketones?

What was his no shot number again?

 

Fingers crossed that he perks up and starts eating normally again.

Sending our best to you guys!

 

In the moment his shooting schedule is

0.25U if his blood glucose is more than 20 mmol/l (360) and he is eating only tiny amounts
0.5U if his blood glucose is more than 20 mmol/l (360) and he eats well
0.25U if his blood glucose is 10-20 mmol/l (180 - 360) and he eats well

Not tested for ketones yet and not bought the test strips for my human glucometer yet.

Pedro had a little bit of water, just went out to pee. Clockwork cat.

 

*squee* nearly ate the whole pouch now!!!!

HE FINISHED IT!!!

 

14.7 mmol/L (265) after having eaten practically a whole pouch of Sheba. The plot thickens!!!

 

Sorry, my finger hit something on my iPad and I can't figure out how to delete this quote! i didn't intend to reply!
Ella

 

You have to select Edit, below your name on the post. Then you can remove or alter what you want.

I am forever fixing my spelling and grammar (Miss OCD, here).

 

Yay that his appy's picked up! Sounds like he's high enough to get some insulin in according to your vet's guidelines.

ps- BJM - I do the same thing. Read and reread, press post and THEN see Just One More Thing that needs fixing. hahahhahaha

 

Are you feeding the Sheba fine flakes, Mue?
I just calculated the carbs on the Poultry selection from an analysis I found online and according to that it seems to be very low; only around 1.6% calories from carbs.
I notice that it also has a high water content, 85%. So every time Pedro eats he's getting a bit of water too (and you can add a little more water to the food also).

It's interesting that he went up to 14.7 and then came down again shortly afterwards. It looks like his little pancreas is doing a fair amount of work.
Worth noting too that these are Alphatrak numbers, and so appear a tad higher than we would see on a human meter.

Eliz

 

Major improvements this morning, greeted by both cats downstairs, followed into kitchen. Put Purina dm (trial cat food) down for both of them, Pedro initially ate about 1/4 of a tin and has since gone back to have more, by now ate not quite 1/2 a tin, what would be his usual portion, also had some Purina dm dry pellets, had a little water. Amazing!!

At 8.30am this morning he was 124 at 8.30am (AMPS) and 227 half an hour after eating, no injection as I can't monitor him, have to go to work. Also it appears the pancreas might be doing SOMEthing...

In awe.
Mue x

Ps: he is having more food as I type...

 

Updated Ruth and Chris, this is what she replied:

Hi Wibke,

I think Pedro’s progress sounds very encouraging. However, I’m sorry it’s given you quite a stressful time of it over the last few days!


I am very happy for both cats to be on Purina DM while you get Pedro re-established. Let me know if you suspect he’s growing to dislike this and that this could be contributing to any poor appetite.


I think his blood glucose values are very good considering that he’s eating reasonably well now and hasn’t received insulin since Monday morning. However, his numbers are still a little higher than most cats who are in remission. This might mean that he still needs some low-level insulin therapy. However, while his appetite is still improving and his numbers are reasonably good, I think we should just continue to monitor his blood glucose 2-3 times daily as you have been doing, and see what he does. At the moment, the only time I would give insulin therapy would be the following scenario:


Blood glucose 20 or more at the time of injection and has eaten well: can have 0.25 U glargine.


I think the above should be safe and should prevent him from spending too long markedly hyperglycaemia, which would not help our attempts to get him into remission.


I hope the above makes sense and well done on all of your excellent care of him over the last week!

I’m going to put a supply of Alphatrak strips and needles in the post for him today. Please do keep Chris and I informed of how he and his blood glucose values are doing.

Best wishes,

Ruth
.....................................

 

You might want to pick up some KetoDiaStix to monitor for urine ketones (ask the pharmacist; you may have a different product in the UK). While not common, even in moderate glucose levels, it is possible for ketacidosis to develop.

 

Ok, so maybe not quite healed just yet...
Tested a moment ago 27.4 mol/L (493)

On the plus side it I was greeted by two animated cats when I just came home, Enzo as always and Pedro eager to say hello, get cuddles and strokes, initiating head-bumps, hopping on my lap to let me test him and all. No meows still, but the progress I saw this morning definitely still here now. After the test I gave them both food, both Purina DM, not quite 1/2 a tin each and I know there is some left over as I heard Enzo wanting to dig it in, but we are on a good path.

He must have had a substantial insulin depot if 1/2 a tin of Purina DM sent him THAT high. I had a look around and there was no sign he would have had any other food or licked anything he shouldn't have and there was opportunity.

Onwards and upwards! PMPS will be 8.30pm, let's see where he goes from here!
Mue x

 

Hi Mue,
It looks to me like Pedro was doing fine until eating the Purina DM food (if you were feeding Sheba fine flakes they're much lower carb, I think (see post above)).
Was it only after eating the DM food that his numbers came up? Or have I got that wrong? He had a beautiful 6.9 this morning (which might be around 5.9 on a human meter).
.

 

Oh my, that is a good point! I don't actually know how the Purina compares overall, carb-wise. It's supposedly diabetic management, AND I presume the sponsor of the study. Evil Nestle. >.<

The texture of the food is a bit weird, it being a pate. Pedro doesn't know whether to lick it or bite it and ends up squishing it into all corners of his bowl and finds it hard to get more out of it iyswim. I have to then scape it together into a heap in the middle. He finished his bowl, not quite 1/2 a tin which is about the right portion for his weight.

Says Catinfo.org:
Purina DM canned is sufficiently low in carbohydrates (~7%) but it is expensive and it is predominantly liver which should not make up the bulk of a cat's diet. There is absolutely no reason to spend money on this product.


Now, with these numbers the shooting regime would be 0.25 units as per Ruth' email above, so I might have a short night ahead of me if his super sensitivity means it takes him right down.

The Sheba flakes would be a much, MUCH better choice with considerably lower carb content... And a range of meats, not predominantly liver. How long would it take to proof this theory? Should I stick to Purina for a few days to see if his numbers stay high OR go straight back to Sheba fine flakes and see if his numbers come down. How quick would he respond?

Will email Ruth and Chris also to share this observation. Thank you so much, Elizabeth!!
Mue x

 

Don't forget it will take a few days to build up the depot again and so tonight he might not go that low but hopefully over the next few days the 0.25 will get him where he needs to be. Ofcourse with pedro anything could happen

 

Morning!

Pedro tested high again this morning.
Not heard back from Ruth and Chris yet, so sticking to last proposed routine, 0.25 units this morning, he is eating well.

He even meowed and there are more signs of the old Pedro being very nearly back! With high blood glucose, mind...

x