17.01.2016 Rocky - high numbers, frustrated

previous:
http://www.felinediabetes.com/FDMB/...r-failed-vetsulin-regime.150636/#post-1582616
Rocky's BGs are staying high, it looked like he wasn't getting any insulin when his dose was 0.5u of Hypurin.
Decided to increase his dose slightly and we finally saw a lower number which went high again two hours later.
I am trying to learn and understand as much as possible but it looks like trial and error, very frustrating. In my search for information I read somewhere that high numbers and flat curves mean not enough insulin. And what about bounces? Some people say ignore them and carry on with your routine, some people worry about them a lot.
I would appreciate your input and opinions as I am trying to learn, sometimes I think I understand only to come to the conclusion that I've done something wrong few moments later.

 

Hi Marlena. I am not familiar with Hypurin but just looking at your ss, it does appear that you could go up a smidge if you can continue testing.

I think you nailed it by this statement...diabetes is a whole lot of trial and error. It took me about 18 months to figure out Merlin's diabetes where I felt I could almost predict his numbers based on the dose that I would give.

 

Marlena

If I am correct hypurin is a type of PZI insulin available in the UK. If this is correct then there are a few UK users on the PZI forum that could help you with dose adjustments and perhaps a sliding scale. I know the UK PZI is different from the US or Canadian PZI so that would be the best place to get advice.

This is the link to the PZI forum:

http://www.felinediabetes.com/FDMB/forums/prozinc-pzi.24/

 

Not always. Too much insulin can also result in high, flat curves. If a dose is too high, the cat's own bodily protection mechanisms can kick in. The liver starts releasing glucose into the bloodstream and counter-regulatory hormonal mechanisms may work to keep the cat running a bit higher to try to prevent it going hypo. It can take several cycles for the cat's system to calm down. Regular home testing, small dose adjustments, and managed feeding schedules (if possible) are the best means we have to try to minimize these effects.

For information, some cats seem to be 'bouncier' than others.


Mogs
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Hi Marlena, the numbers you're seeing today could just be a bounce from that blue number yesterday.

As Mogs said, some cats are 'bouncier' than others.
Quite often the bouncing will settle down as the cat's body becomes more accustomed to seeing lower (ie. nearer normal) numbers again.
But some cats remain bouncy. And some cats bounce all the way to remission!
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Rocky's numbers still high all day not going down so I don't know when onset and nadir takes place.
Are these stalled numbers due to not enough insulin or bounce and what do I do next, continue with the same dose?

 

This is most likely due to Rocky "bouncing" from the lower number ( for what Rocky is used to )yesterday morning. If you look back at January 12 you will see the same pattern after the lower numbers on January 11. It could take a few cycles to clear.

 

You may need to do a sliding scale but I am not familiar with hypurin PZI. The best person to ask for dosing advise is Elizabeth and Bertie since she has been using the same insulin as you do. To "message" her you can simply put the "@" sign in front of her name @Elizabeth and Bertie . Type in @ and start typing her name. There will be a drop down box you can select her name from.

 

I don't think the high numbers are due to too little insulin, Marlena, because Rocky has had some significant drops from both the .5 and the .75 unit.
My best guess, given the available data, is that these high 'flat' numbers are caused by a bounce.

During a bounce, the body releases glycogen to raise the blood glucose level. But sometimes, counter-regulatory hormones are also released, and the purpose of these is to try to keep the blood glucose from dropping any further. This looks like insulin resistance: It's entirely possible to inject insulin and for it to have no apparent effect whatsoever. This can last anything up to a few days depending on the individual cat. ...When this effect wears off the body becomes responsive to insulin again, and the blood glucose can drop.

Regarding tonight's dose, well, it seems to me that there are a couple of options to think about.
You could continue the .75. ...Rocky is in high numbers and it would be good to see those numbers come down if possible. However, his blood glucose dropped really steeply on the .75 yesterday, and there's a fair possiblity that this is why his numbers are high now. So, giving the .75 risks repeating that steep drop...
The bounce may come down during the night, or it might not.... Previously, it took a few days to clear; but we can't assume that it will be the same this time.

Another alternative - and I know this seems counter-intuitive given the high numbers - could be to reduce the dose to .5 unit for this evening. That way, if the bounce does come down during the night it may not have so much 'welly' to it, and it may not drop so fast. And you could review the dose in the morning...

Whatever dose you give, I would suggest that you try to get a test a couple of hours after the shot, as that may give you an indication of how the cycle might go.

A couple of questions (sorry if I've already asked this, my old brain forgets sometimes...)..
Is there any chance that Rocky has an infection (dental, urinary tract?)
Is there any chance that he's eating food elsewhere that may be raising his blood glucose (ie. going into other cat's houses, or snaffling food put out for birds/hedgehogs/foxes...)?

I'm going to tag Juliet @Dr Schrodinger to see what she thinks.

Hugs,

Eliz

 

Dear Eliz,
Thank you very much.
Regarding infection - he has a little bit of gingivitis and the vet said it was not bad. Not so long ago he had a course of antibiotics for that.
Last blood test for kidneys (about 10 days ago) - all fine. No urine test as he does not use litter tray but we can test his urine at the vets (they need to squeeze his bladder - ouch!).
No chance of eating anything outside really - he only goes in the garden to do his business and straight back home. Some years ago he had been traumatised and injured (he had to be treated by the vet and had stitches) by another cat and since than he is very nervous outside and stays in the garden with us or his personal body guard (his big brother Rottweiler cross). It is a shame as he used to be a very good hunter and enjoyed being in the fields (we live in the sticks).
Apologies for grabbing your attention again as I understood I had to wait and see and be patient but I have such high level of anxiety when I check the glucometer that it makes me insane!
I have given Rocky his 0.75 u but due to difficulties I think it was more like fat 0.5, maybe not quite 0.75!
I am ready to test him again tonight and maybe at night.
Best regards,
Marlena

 

A little lower number this morning, maybe we are finally moving in the right direction?
Very hopeful Marlena

 

He may be starting to drop out of that bounce, Marlena.
Keeping fingers crossed here that things will settle down soon.
.

 

Yep, he certainly looks like a bouncy one!

It's difficult to hold your nerve when your kitteh doesn't respond the way you hoped, isn't it? I really feel for you & remember it well. I actually remember getting very angry with Milo for his numbers not coming down for a while - and for not being compliant when I wanted to inject him- poor Milo - he had lost so much weight that there was hardly any flesh to inject into, so it must have been sore. We got over that with a bit of positive reinforcement training (Thrive dried chicken pieces are like heroin for cats!), and I did a lot of deep breathing and calming down, and he got a lot of gentle full body massages.

We must remember that our cats are ill, and they are all ill in different ways, and for different reasons they will respond to treatment in different ways, and in their own time. This is the tenth day of Hypurin, isn't it? So still, really early days for a poorly kitteh.

Thankfully, you haven't seen any black numbers in Rocky (and hopefully never will!) 17.5 is a great morning preshot number, and hopefully today will be less bouncy, and calmer for all! It may not, though. He may continue to pinball, and we will deal with whatever happens when it happens.

 

What a profound statement!!! I too remember feeling "angry" with my kitty...partly because of poor responses and I was so worried that he was never going to show any improvement and partly from being exhausted and stressed out from very little sleep.

Marlena you have some wonderful people guiding you on Rocky's treatment. However long it takes you are on the right path!!

 

Mary Ann,
I agree that I am lucky to have such wonderful people helping me out and patiently guiding me through this very complicated puzzle of FD!
I do hope that all this effort will pay off and we'll get this wonderful puss regulated specially that he cooperates with me and lets me poke him with needles so many times a day - his is very patient!
Best regards to you and your furry children,
Marlena

 

Juliet,
it looks like you went to hell and back with Milo but in the end you had the best of outcomes.
Luckily Rocky never went into black numbers so I am really hopeful that we'll achieve regulation.
I am trying to, mentally prepare myself for a bumpy road and really remember that we still going to see some problems so it won't be too stressful. Your encouragement means a lot to me, I feel I've got somebody behind me, I am not on my own.
Marlena

 

And don't forget the magic Pants!


Mogs
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Well, that was a nice run of numbers today, Marlena.

I'm guessing you gave the .75 unit because you're anticipating a bounce?
If so, you may well be right.
But do try to get some tests in soon to check that he is bouncing.

If he doesn't bounce and the numbers drop instead then this will be new territory. We don't know how low he'll go from this lower pre-shot number.
If his numbers look like dropping too low, and low carb food doesn't steady them, do you have higher carb food available if necessary? Or some source of simple sugar (honey/liquid glucose)? You may well not need this. But it can be helpful to think things through in advance.

If in doubt then DO post on the forum for help. There's usually someone here 24/7.

Eliz

 

Marlena, I don't know if you've seen this but here is the link to the 'Hypo' advice document. It can be a good idea to read through it and then print it out and keep it somewhere handy, just in case you need it at any point:
How to treat HYPOS - THEY CAN KILL! Print this Out!!
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If you need urgent help, start a new thread on Feline Health, use the 911 prefix and use a thread title that tells members you need help because your cat is in low numbers. Also, on the off chance that you don't get a prompt response on Feline Health and you really need help, try posting on the Lantus and Levemir insulin support group's board. (That board gets a lot of footfall.) Again, use the 911 prefix if required.


Mogs
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hang in there--FD is a dance--I think we all understand the frustration of trying to do everything right and things not moving fast enough --
try to relax and know that FD did not happen overnight and it will take a little time to regulate and/or revert.

 

Hi Marlena,
I see we have a 24.1 this morning... Although strange as is probably sounds, I actually breathed a sigh of relief when I saw that number (high as it is), because I was quite worried about what might have happened during the night.

Yes, it's a bounce. But we don't know when/what he bounced from.
He may have bounced from yesterday's low/normal numbers. Although it was a nice settled run of numbers, and there was no indication by PMPS that a bounce was going to happen.
Or he may have bounced from even lower numbers (or a steep drop) during the night. And I think that is equally possible. But there were no tests during the night so we simply don't know...

It's easy to think that because a cat has bounced, that they will bounce the next time they get a similar number. But it ain't always so. Cats can just stop bouncing without any warning.
.

 

What an excellent day he had yesterday! Marvellous! Beautiful curve!

Please don't be alarmed by his red score this morning. Let's see what today brings for him.

Thinking of you both. xxx

 

What a dear, dear picture of Milo! I bet he's lying in his favorite sunny window!''

"If you need urgent help, start a new thread on Feline Health, use the 911 prefix and use a thread title that tells members you need help because your cat is in low numbers."

Mogs, thank you for telling us newbies about using the 911 prefix in an emergency thread! What a brilliant idea!

Ok, I must ask: What are "Magic Pants?"

 

People often talk about the need to have patience when dealing with feline diabetes, and in FDMB-speak that is jokingly referred to as putting on your 'patience pants'. Mogs posted a pic of a very nice pair here:
Starting Hypurine after failed Vetsulin regime

I think it was these that Mogs @Critter Mom was referring to.
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Too funny! Put me down for a pair of those!

 

Marlena, there are a number of things you can do when you see a 'lower than expected' pre-shot number.

If the number is too low to actually shoot, you can 'stall', ie. wait a little while, without feeding, to see if the number comes up to a shootable level on it's own.

For numbers that are potentially shootable, but are lower than is typical, there are several options:
You can skip the shot.
This way you'll know that the BG isn't in danger of dropping into numbers that are too low. But you risk high numbers at the next preshot. And with Hypurin, you'll be losing overlap. But, if you can't test, this is the safest option.

You can given a 'token' dose.
Sometimes, an alternative to skipping the shot is to just give a tiny token amount of insulin, so that that cat has at least something in it's system.

You can give a reduced dose.
The amount will depend on the preshot number. But this might, for example, be a slightly reduced dose, or maybe half of the usual dose.

You can give the full amount.
But giving the full amount on a lower than usual preshot can be very risky. And if doing this it is advisable to monitor the kitty's BG very carefully afterwards in order to ensure it doesn't drop too low. (And it may be necessary to take action to keep the BG numbers up if they do drop too low/fast.) This is the least safe option.

In Rocky's case, you could also wait a while (if time permits) to see if he is going to bounce, before deciding what to do.

In all instances when giving insulin on a lower than usual preshot it is advisable to monitor the BG afterwards. This may just be a single test if a token dose has been given. But could require a number of tests if more insulin is given.

The choice of how much insulin to give is ultimately down to the caregiver.

Sometimes it is difficult to decide which course of action is best. But we have a saying here that, in terms of the cat's BG levels, "it's better to be too high for a day than too low for a minute."

(Note: Where the cat has a history of ketones the caregiver may decide to give insulin rather than to skip, and to monitor afterwards.)

Eliz

 

This. Very much this.



Mogs
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