? 4/10 Barsa AMPS 16.9 (304) Increase or decrease dose?

[Vintry]

I have increased the dose today to 2units. Was this the right call? Could you please have a look at Barsa's spreadsheet and let me know what you think. Have I skipped the right dose or not? I can't achieve any regulation so far so frustrating. I don't understand why it's going up, or when is nadir. OK, maybe onset is at +4 but even that is not stable. I keep studying all your spreadsheets, normally it's high pre-shot, then down somewhere half-way then up again. Mine is all over the cycle/cycles If there's a bounce (not somogii effect) then I don't understand when it's supposed to end (lasts for days!). I thought the last bounce have cleared and it will go to green/blue numbers again but no, it now remains in yellow/pink. And ketones come back if Barsa stays in high numbers for long, that's what I noticed. So I give her plenty of food and water but it's a vicious circle. Numbers go blue/green - no ketones, pink/yellow for days - ketones above traces.

 

[Vintry]

There's so much information on this forum and everyone is so helpful but it feels like the more I learn the less I understand. Emotions cloud my judgement and I just end up asking more questions sorry

 

[Bron and Sheba (GA)]

It is good to ask questions Vintry, don't apologise and you have the added worry with the ketones which must be stressful.
Bounces can take up to 6 cycles to clear. I think you are doing a really good job with Barsa and her SS even has some green in it!
It takes time for Barsa's body to get used to the levemir. I can't offer advice, only support. Hopefully some of the experienced people will be around before too long. You said you were giving plenty of fluids and food - that is great

 

[Sienne and Gabby (GA)]

You did good! I would have suggested an increase. Once you start seeing blues or greens as your lows, you slow the increases down to every 5 days/10 cycles. Otherwise, if numbers are mostly above 200, you increase every 3 days/6 cycles if you're following Tight Regulation.

 

[julie & punkin (ga)]

Iryna, I think you're doing better and understanding more than you realize! You've made a very good observation about the connection to between ketones and his high bgs. You're getting the hang of seeing bounces, too.

In some cats a flat yellow cycle like you have today, precedes an active cycle. I would be aware of that possibility. tonight.

 

[Jill & Alex (GA)]

Iryna, Barsa's spreadsheet won't necessarily look like other kitty's spreadsheet because the priority for Barsa is to continue increasing the dose every few days until she's no longer throwing ketones. Her spreadsheet won't look like those of an otherwise healthy diabetic cat. Don't worry about it!

Also, don't concern yourself too much with "protocols" or their guidelines at this point other than to allow the depot to build up for a minimum of couple of days between dose increases if she is actively throwing ketones. We *usually* see the presence of ketones treated with a bolus and basal insulin combination, but that's not happening here. There's a difference. When a bolus is in use we give more weight to "protocol" guidelines.

Speaking of a bolus insulin...
I'd like to re-visit the subject of incorporating the use of a fast-acting insulin into Barsa's treatment plan... a subject which might have been lost in the shuffle. We've seen great success using a bolus insulin along with Levemir or Lantus to fight off ketones.

Copied from your thread on 4/3:

"When there's a threat of ketones and kitty remains in high numbers, some of us will use a fast-acting insulin (bolus) in addition to the Levemir insulin (basal) dose to help bring numbers down. Here in the US, the fast acting insulin is called Humulin R or Novolin R, but other countries have similar choices. A discussion took place in one of suki & crystal's threads not too long ago: Advice on R. You might find it worth reading and discussing with your vet.

Regarding fast-acting insulin available in other countries... here's an excerpt from Crystal's thread:

"Alternatives can be found here: Activity profiles of the insulins (I used a translator I have installed on my laptop).
Normal-Insulin (Alt-Insulin)
- Insuman Infusat
- Berlinsulin H Normal
- Humaject Normal
- Huminsulin Normal 40
- Insulin Actrapid HM
- Insuman RAPID"

Your vet will know what's available in your country."


The BIG advantage to using a fast-acting insulin in addition to Levemir is you can use tiny doses to tap down Barsa's numbers when she begins to bounce from lower numbers. The bolus won't prevent her from bouncing, but it will help take the edge off the bounce.

Here's an example of using the fast-acting insulin, "Humulin R", from Alex's spreadsheet. You'll notice I administered tiny doses in an effort to gently pull numbers down or prevent them from going higher. Yanking numbers down is counter-productive because doing so serves to set kitty up for another bounce... not what we want to see happen.



Have you had a chance to speak to your vet about incorporating a fast-acting insulin (bolus insulin) along with the Levemir (basal insulin)? What do you think? If you and your vet approve, there are several members who can help you with using a bolus insulin. Actually, we strongly suggest using a bolus insulin under supervision of those who are experienced in it's use until the member gets the hang of it.

Just curious... how is Barsa's appetite these days? How is she acting? Pooping, peeing, playing?
I know this can be exhausting... both physically and emotionally. How are you?

 

[Vintry]

I haven't spoken to my vet yet (got happy too soon after seeing green numbers) but the next time I see him I will ask about short-acting insulin, lab results and also whether the test he did would indicate hypothyroidism if she had it. And it's a weekend again. Barsa is a very active cat, she likes to roam in the garden. But I don't let her out anymore, not until she gains some weight. She gained a little bit - 3.3kg now. Good appetite is underestimation. It's ravenous. She's meowing all day long, it's always for 2 reasons: food and wants to go outside. And she doesn't sleep much. I know it sounds like thyroid problem but then vet did look for underlying deceases and didn't find anything. I do have to ask again. Also, maybe she's hungry because she's feeling weak after dramatic weight loss.

 

[Marje and Gracie]

It would be unusual, although not unheard of, for a cat to be hypothyroid especially if she is very active, doesn't sleep much, and is ravenous. That would be more consistent with hyperthyroidism.

 

[Vintry]

Oh right, I meant hyper of course. I do hope she doesn't have it, high BG makes cats hungry like that too.

 

[Jill & Alex (GA)]

but the next time I see him I will ask about short-acting insulin

Oh, good! Frankly, it's safer to use a short-acting insulin with a long-acting insulin because the effects of the short-acting insulin are out of the system in a matter of hours versus the depot action of Levemir which can take days to subside. In other words, one might have to spend hours trying to keep kitty's numbers up when using a short-acting insulin as a bolus versus fighting the effects of a large insulin depot for days.

It would be unusual, although not unheard of, for a cat to be hypothyroid especially if she is very active, doesn't sleep much, and is ravenous. That would be more consistent with hyperthyroidism.

I agree with Marje. I usually have the T4 and the Free T4 by equilibrium dialysis (T4 ED) done on my senior kitties.

I believe the T3 suppression test can be done to diagnosis hyperthyroidism in cats that have normal T3, T4, and/or free T4 concentrations but appear clinically hyperthyroid.

@Marje and Gracie : You know more than I do about diagnosing hyper-t. Can you confirm my thoughts? Or am I dreaming?

 

[Vintry]

Wow, your princess Gracie is looking good (spreadsheet). Jealous! She has bounces as well right?

 

[Marje and Gracie]

@Jill & Alex (GA) you are correct that the typical way to diagnose hyperT is with totalT4 and freeT4 by ED although the fT4 by ED can be high in cases of GI, liver, or kidney disease. However, some kitties (and I had one) will have normal values for these tests and still exhibit the symptoms of PU/PD, hyperactivity, ravenous appetites with weight loss. This "can be" attributable to a condition call "euthyroid sick syndrome". Some other condition the kitty has masks the high thyroid levels and makes them appear to be normal.

If all other labs are normal for conditions that might also have the same symptoms (e.g. diabetes, chronic kidney disease), then additional testing is required. I have used HemoPet and Dr. Jean Dodds for diagnosis and she will run a tT4, fT4, tT3, and fT3 for cats. The T3 suppression test can also be used to dx hyperT in cats where the other thyroid tests are normal but clinical symptoms are present, as Jill stated.

Thanks, Iryna. Yes, Gracie does bounce