A question from Paris, France...

Hi Everybody,

As mentioned in the subject of this email, I'm writing you from Paris, so first, I would like to apologize for my poor English.
My name is Capoo, I'm 11.5 years old, and I was diagnosed diabetic beginning of November last year.
Even if I'm quite big, I have a little problem of overweight : 8.2 kg....
When I'm introducing myself, I have also to tell you that I am really not cooperative with anybody that wears a white coat, and that I need an anesthesia for every exam.
So, my cat-owner, Sophie, brought me to the vet in November because I was drinking and peeing too much. The vet diagnosed my diabetes with blood and urinary tests, and thus began the love story with Caninsulin. First, it was 2 UI twice per day, and I was ok with that dose. No more clinical signs of diabetes.
Then, on December 8th, my best friend in the world Anoushka, German Shepard (I was raised with her, more than 10 years of games and sleeps together) died of a ****ing liver cancer.
Less than 10 days after that terrible event, Sophie has to bring me to vet emergencies : I was having a cystitis. The vet told her than it was due to the stress of the loss of my pal. During this event, they measured my blood glucose content, and it reached 2.49 g/L 6 hours after my shot of insulin. Normally, it should have reached the peak of insulin action. Thus, my vet asked to my owner to increase doses up to 3 UI twice a day.
During the Christmas holidays, I was a little bit tired, and I started to drink and pee a lot again.
Beginning of January, Sophie brought me back to the vet. A fructosamine test was performed, and it reached 515. Again, doses were increased up to 4 UI twice a day, still with Caninsulin.
Starting January 11th, my cat-owner started to strictly monitor my conditions, as she was really concerned about me and she had already lost her dog in December. As mentioned above, it is not possible to draw a blood glucose curve as I am not cooperating at all...
And she noticed what follows:
- Injections of insulin are performed at 7h30 AM and 7h30 PM,
- I drink only 500 mL of water per day (around 60 mL/kg/day, that's really not so much),
- I drink 340 mL between 6 PM and 7 AM, and the rest during the day,
- I pee around 6 times per day, but my pees are always done around my injection due times.

Has anyone encounters the same? Does that mean that the dose is too small, or that the insulin isn't adapted?

Thanking you in advance,

Sophie

 

Your English is excellent and I am sure so much better than our French would be.

It would be so much easier if there was a way for you to test Capoo's blood glucose levels, Sophie. It is hard to guess what is going on. Normally with Canninsulin, the lowest levels could be anywhere from 3-6 hours after the shot. In some cats, there is a rapid rise before the 12 hour cycle is done. If the Caninsulin is all that is offered in France (in the UK owners can get a longer lasting milder insulin once they can show the insulin isn't working) there are ways to work with it (like shooting every 8 hours) but that can't be done without testing.

Would you be willing to try to test Capoo's at home? We do have people who have been able to test feral kitties. It may take awhile but it would make your care of her so much easier and safer.

How about starting this way:

Pick a place where you plan to test her. Some people put the cat between their legs; some put them on the bed or couch or kitchen counter. Pet her, praise her and give her a treat she loves (hereafter saved only for testing) and let her go. The next time add touching her ears, rubbing them. Lots of praise and a treat and let her go. After she is alright with that, warm her ears. The two ways that work well are a rice sack (raw rice in a thin sock, knotted and heated in the microwave until very warm) or very warm water in a pill bottle. Again, warm her ears, praise, treat and release. The hope is that by the time you add the poke, she enjoys the treats and the process.

 

Bonjour Capoo et Sophie! Bienvenue à FDMB.

Capoo, I am sorry to hear that you're not feeling as well as you did when you first started getting your Caninsulin. I am also very sorry to hear that you and Sophie lost your dear friend, Anoushka. If you will excuse me being so bold, I am going to talk to Sophie now to suggest some things to ask your vet to look at in the hope that it will help you to feel better again.
(((((((Capoo)))))))

Hi Sophie,

You are doing a great job with monitoring dear little Capoo in the absence of the option to home test. Does Capoo eat more during the day or during the night?

Here are my thoughts:

I think it's best to check and rule out the most obvious things first, so I'd suggest working with your vet to rule out any infection or inflammation (including gum inflammation and possible dental problems). Also, try to quickly identify any obvious potential sources of stress in Capoo's environment. If that all seems OK then I'd look at insulin dose.

Too much insulin can have the same effect as too little - i.e. numbers may get higher in both cases. When an insulin dose is too high the body has protective mechanisms which cause it to release more glucose into the bloodstream to protect the cat against hypoglycaemia. Increasing the dose in such circumstances can leave the cat still running too high (and increases risk of hypoglycaemia).

I am wondering whether Capoo's blood glucose (BG) levels may have been temporarily driven higher due to his urinary tract problem. I am assuming that your vet has treated the inflammation and that all is OK now. If yes, then it is possible that Capoo's insulin requirements may have reduced as a result of sorting out the urinary tract problem. If that is the case, then the higher dose used when the inflammation was present may now possibly be too high for Capoo's current needs. The fructosamine test may have been high but it only gives you an average value over a week or so: it doesn't show you how Capoo is responding to his current dose in real time. The tricky thing in situations like these is that if you were to increase the dose again it could keep Capoo's BG high (which is no good for him), or put him at increased risk of hypoglycaemia (also no good for him). Trouble is, the next fructosamine test would also likely be very high and subsequent dose increases may not help the situation. As it is, 4 IU (international units) of Caninsulin twice a day is a fairly substantial dose of insulin for a cat. I am speculating here but, based on Capo feeling better and peeing less on the lower dose before the UTI, I think there is very much a case for you to discuss with your vet whether it might be a good idea to try reducing the dose a little and then monitor Capoo closely to see if he starts to feel and act better.

In general, you need to monitor diabetic kitties' urine for ketones as part of their day-to-day care but it is even more imprtant to do so if you are trialling a reduced dose. (In certain circumstances ketones can develop so it's vital that a diabetic cat gets enough insulin to reduce this risk.) Given that Capoo doesn't seem to be a good candidate for blood glucose testing, if you could monitor his urine regularly you can get test strips to check both ketones and glucose levels (e.g. Keto-diastix, Multistix). It's crude compared to blood testing, but better than no testing at all. Since you know that Capoo more often than not pees around insulin time, if you could do daily urine tests at that time it could give you a little better picture of how good or bad Capoo's regulation is on a day-to-day basis. (Note: if you ever do get anything other than 'trace' ketones in a test, it is an emergency and you should get Capoo to the vets straight away so that they can flush the ketones out of his system and prevent DKA.)

Should you and your vet decide to trial a dose reduction for Capoo, if you keep a daily record of his urine tests, how much he's drinking and how he's acting/feeling (clinical signs) it should help you get some idea in real time whether or not a smaller dose is right for Capoo at this time. Needless to say, if Capoo's clinical signs were to get worse you'd need to consult with your vet (and post here for additional input) straight away.

In closing, there could be any it is It is impossible to tell exactly what may be driving Capoo'snu

I hope the above gives you some idea of things to consider and discuss with your vet.

À bientôt!


Mogs
.

 

First, welcome Sophie and Capoo. Sophie, your English is wonderful! And I'm terribly sorry about Anoushka.

A lot of cats are bad at the vet, though maybe not as bad as Capoo. But Sophie, does Capoo let you touch him (or her)? Capoo may surprise you and let you test. But if that doesn't work, testing Capoo's urine should help you better know what is going on. Do try it.

I also agree with Mogs that the cystitis and stress may have temporarily increased Capoo's glucose. If Capoo was mine, I would start urine testing and probably go back to 2 UI twice per day and see if that works.

 

I agree with everyone else, my cat gets so upset at the vets that my vet will not even try to do a curve but he runs to me to be tested at home as soon as I get out the testing supplies so if you can try to test him at home it will probably be much better.

 

Please see my signature link Secondary Monitoring Tools for some additional assessments which may help you evaluate your cat. There is an older method of diabetes management using regular vet visits, plus some of these secondary tools.

 

First of all, tanks a lot for all your answers!!!
I'll try to answer your questions:
- Capoo is a boy, and he is sterilized.
- It's impossible to test Capoo at home, as he is very reluctant as soon as you try to "tinker" him. It's already a miracle to succeed in having his shots of insulin. I have him for more than 10 years now, and during all these years, I have only seen him once not trying to "kill" the vet when he was trying to take his temperature! All the vets that had seen him during these 10 years gave him the same nickname: the Warrior!
- In France, it is also possible to have other types of insulin (Lantus for example), but you need first to prove than Caninsulin isn't working properly.
- Critter Mom, I don't know if Capoo eats more during the day or during the night, but I will start to look at this also.
- I check his urine every day for ketones, and there is nothing for the moment. But each time, glucose is present.

Now, to give you numbers and to be precise (in any case, I do the shots every day at 7:30 AM and 7:30 PM):
- November, 14th: Capoo was diagnosed diabetic. My vet prescribed him antibiotics for 40 days, and Caninsulin at a dose of 2 IU twice a day.
- December, 7th: First test of fructosamine: 400 µmol/L.
- December, 8th: Death of Anoushka
- December, 10th: I start to use a vetpen to perform injections.
- December, 20th: Cystitis episode. Blood glucose level was measured, and it reached 2.49 g/L 6 hours after the insulin shot.
- December, 21st: Doses of insulin are increased to 3 IU twice a day.
- January, 8th: second test of fructosamine : 515 µmol/L -> increase of doses 4 IU twice a day.
Starting from January 11th, I have started to strictly monitor his pees : each day, it's the same. 3 pees around the time of the morning shot, and the same during the evening.
And now, I have also an Excel table to check the quantity of water that he drinks:
- January 13th, from 6PM to 7:30 AM : 340 mL
- January 14th, from 7:30AM to 6 PM : 145 mL
- January 14th, from 6PM to 7 AM : 330 mL
- January 15th, from 7AM to 6PM : 175 mL
- January 15th, from 6PM to 7:20AM : 200mL.

Yesterday evening was the first evening he has drunk the same quantity of water during the day and during the night.
I have also to say than now, it seems that he really feels good for 3 days. Even if he makes numerous pees always at the same times, he plays a lot, and he's no more tired as before.

But I'm still quite upset by the non-uniformity of absorbed water, and I start to wonder if my vetpen doesn't have a problem....

Has anyone already met a problem with a vetpen? Now, I do the priming scenario before and after each shot, and sometimes, nothing comes out of the needle after the shot.
Sometimes, insulin is still coming out of the needle when I withdraw it from Capoo, even if I'd let the needle more than 30 seconds below the skin. The fur is never wet.

Such a number of interrogations I have...

Sophie

 

Questions are what keep this forum interesting. Ask away!

The vet pen. Is that a vial with the needle attached? Would it be possible to insert a needles into the seal to pull up insulin? Lantus users here do that to give smaller increases than one unit and to give more precise amounts.

 

One can get Caninsulin/Vetsulin in an injector pen like available for Lantus and Levemir. The Caninsulin/Vetsulin pen doses in 1/2-unit increments
http://www.vetsulin.com/vet/AboutVetPen_Overview.aspx

 

Yes, Larry, that's exactly this injector pen.

 

Hi!

Finally, with my vet, we decided today to try to do a curve, and it worked!!!!

This morning, I brought him to the vet at 9 AM, and he succeeded in drawing a curve with the help of a glucometer (not with a blood sample from a syringue, we must remain realistic ).

And here below are the results (sorry, French units, in g/L of blood):

9 AM : 5.5 g/L. At that time, my vet injected 8 IU of Vetsulin (usually, it was 6 IU, but given the high level, he decided to increase the dose)
11:30 AM : 4.81 g/L
3 PM : 1.4 g/L
5 PM : 0.88 g/L
6:45 PM : 1.03 g/L.

I have also to tell that my cat didn't eat for the whole day.

Tonight, when I returned to the vet, he told me to perform only one shot per day, with 8 IU of Vetsulin.

He told me that with this type of curve, it is normal to have a lot of pees in the early morning: the shot of the evening put him in hypo, and a Somogyi effect occurs. So the shot of the evening has to be forgotten.

May I kindly ask for your advice, or comments? Have you already met such a curve?

Sophie & Capoo

 

Sophie,

I know we are strangers an ocean away from you, but I need to say that I am very concerned about your vet's ideas. Capoo's numbers were dangerously low at the vet. We start to intervene to stop a hypo at 2.8. Capoo's numbers were a lot below that for a number of hours.

It doesn't make sense to give one shot a day. The insulin will only last 12 hours, so the kitty will go down for the first 10-12 hours and then rise. The levels will continue to go up for the next twelve hours until the next shot. We describe it as being on a roller coaster. Our advice would be to cut the dose in half and give it every 12 hours. We can find information from the insulin manufacturer and or scientific studies for your vet, if you think it would help. A treatment that puts your kitty into hypo ranges and then high levels is not safe.

And 8 units of insulin is a large dose. The majority of cats here get about one unit twice a day.

Is there any other choice for you for a second opinion?

 

Thanks a lot for your comment Sue. But I think that we have a problem on units conversion. I gave you my numbers in g/L. According to this units scheme, the renal limit is at 2.2 g/L, and the hypoglycemia is at less than 0.6 g/L.

 

And we have also tried the following doses without success (morning shot/evening shot):
2 IU / 2 IU
3 IU / 3 IU
4 IU / 4 IU
5 IU/ 5 IU
6 IU/ 6 IU
6 IU / 4 IU
6 IU / 0 IU
6 IU / 2 IU

And now, we are starting to test 8 IU/ 0 IU.

 

I'm sorry. I don't understand. Can you convert them for me? To US would be great, but if not, to metric?

 

The numbers I gave you are in gram of glucose per liter of blood. What is the US standard?

 

Does this help?

http://www.diabetes.co.uk/blood-sugar-converter.html. When you gave us your first numbers, you used US numbers.

 

Hi Sophie - and welcome!

Most of us here from Europe are used to seeing blood glucose measured in mmol/L
I'm wondering if your reading of, for example,

...is equivalent to 10.3 mmol/L, or 181 mg/dl in US measurement....
Going to have a search online..... Be right back...
Edited to add: my conversion above seems NOT to be correct. See post below...
.

 

Sophie, please be patient with us, we're trying to work out the equivalent of your blood glucose numbers....

.... Just found this page online:
http://www.diabsurf.com/Sim/SimImp/Itypcvr.php

"La conversion des g/l en mmol/l est obtenue en multipliant les g/l par 5,5.
g/l x 5,5 = mmol/l"

So....according to this..(somebody please correct me if I'm wrong...)
11:30 AM : 4.81 g/L , x 5.5 = 26.45 mmol/L (or 476 mg/dL)
3 PM : 1.4 g/L, x 5.5 = 7.7 mmol/L (or 138.6 mg/dL)
5 PM : 0.88 g/L, x 5.5 = 4.84 mmol/L (or 87.12 mg/dL)
6:45 PM : 1.03 g/L, x 5.5 = 5.66 mmol/L (or 101.9 mg/dL)

Can somebody please check my calculations (I'm tired and it's entirely possible that I've made mistakes)...? (Or can anyone find another reference for translating the numbers?) Thanks!

.

 

The math looks right to me, Elizabeth. I had not heard of g/l before. Does it seem right to you, Sophie?

 

Elizabeth,
I have found the same coefficient of 5.5 to convert g/L into mmol/L.

 

Oh, I've been really stupid! Ha-ha! Duh, silly me!

All that is needed is to multiply by 100 in order to get US numbers....
So, 4.81 g/L becomes 481 mg/dL.... Tada!

That is the case, isn't it...? Somebody please correct me I'm wrong...? @Carl & Polly & Bob (GA) ?

Sophie, @Capoo I am SO sorry about the confusion. We're just not used to seeing numbers represented as 'g/L'....
The majority of folks here are from the US and their numbers are represented as mg/dL rather than g/L. So, if you multiply your numbers by 100 then that translates them into numbers that the US folks here are used to working in.

Most folks outside the US use the mmol/L system of measuring blood glucose (and we multiply our numbers by 18 to get the US equivalent).
.
.

 

I'm going to put those figures into a different format for folks here.

(Sophie, @Capoo , a quick note on the jargon that we use here:
Most of us test our cats' blood glucose immediately prior to giving an insulin shot. And we refer to the morning test as 'AMPS' (am./morning pre-shot blood glucose level), and to the evening test as 'PMPS' (pm/afternoon pre-shot blood glucose level).
Test results between insulin shots are referred to by the number of hours that the test takes place after the insulin shot. So, a test an hour after the shot is '+1', a test 2 hours after the shot is '+2', etc.)

AMPS 550, 8 units Vetsulin given
+2.5, 481
+6, 140
+8, 88
+9.75, 103

So, that 8 units dropped Capoo's blood glucose a lot.
And it also looks like his blood glucose was still dropping quite late into the insulin cycle. Many of us who've used Caninsulin have found that the lowest number of the cycle often happens between 4 and 5.5 hours after the insulin shot; after which the blood glucose rises. But Capoo's blood glucose seems to be still dropping at 8 hours after the shot.
That may be because he's getting very good duration from the insulin. Or it may be that the higher dose caused a longer cycle. Or there may be some other reason: For example, some cats have long curves because they have some function in their pancreas and are producing enough insulin to be able to keep their numbers down. It is possible for cats to recover pancreatic function and to go into remission (ie. become diet-controlled diabetics).

There are a couple of other factors to take into account regarding the blood glucose levels in this curve.
Firstly, Capoo didn't eat at the vets. And because of that the numbers may be lower than they would otherwise have been at home.
Secondly, cats often feel a lot of stress at the vets and this can cause numbers to be higher than they would be at home.
For these reasons it is hard to know the accuracy of curves done at the vets. And this is one of the reasons that so many of us test our cats at home.

I do understand that you don't think it's possible to test Capoo. But I do wonder whether it's worth trying to introduce him to it gradually.
My cat has real 'attitude' and I thought he would be impossible to test; but he loves his food, and I found that I could test him while he was munching on a few cat treats.
I started out just by briefly holding/rubbing his ear and then giving him a treat. And he soon came to associate having his ears touched with receiving the treat.
I'd also set out the blood glucose test kit, and click the lancing device so he could hear the sound, and then give him a treat.
So, I introduced him to testing very gradually, and gave him treats ('positive reinforcement') at each stage.
I'm not saying that this will work for Capoo, but I wonder if it's worth a try...?

Eliz

 

Thanks, Elizabeth. Math has never been my strong suit.

Sophia, now I can see what your vet is looking at. He sees that low number at the end of the cycle and thinks it is too low for another shot. But, like Elizabeth, I think the conclusion he is drawing is wrong. Capo starts at 550 - a very high number. After 8 units of insulin, he drops to 88 in 8 hours. That is a huge drop and I would argue, very hard on his body. Then he goes back up into high ranges before the next shot, 24 hours after the first.

Generally, I think the object is to keep the kitty in good ranges all day every day and night so their body can heal. Careening from highs and lows can't feel good, nor does the pancreas have the time to start healing.

We suggest trying first for regulation: a pre shot number in the mid 200s at both ends of a 12 hour cycle, with a dip in the middle down into safe ranges. Think of it as a smile curve from pre shot to pre shot. This can be accomplished with a shot every 12 hours, giving the insulin the optimum time to do its work.

I also agree that you could start conditioning Capoo toward testing at home. Find a treat he loves and uses it only for testing. Start with taking him to the testing place, praising and petting him and playing with his ears. Then the treat at the end. After a while, add warming his ears. Again, many times of doing this with praise, petting and a treat at the end.

Testing at home is the only way to be able to see consistently, day after day, how low the insulin takes him and how high
he goes. Then you can safely adjust the dose to give him the best chance for regulation, and perhaps remission.

 

Elizabeth, Sue,

Thanks a lot for your answers. You convinced me: I have ordered a glucometer on Internet, and I'm waiting for it.
I will try to test Capoo at home. Fingers cross....

My vet also advised me a brand of food, only available on Internet in France : Orijen. He told me that a lot of vets have obtained good results with this food. So a pack is on the way home.

Normally, we will wait for lets say 4 to 5 days to see how Capoo reacts to his new dosage. If results aren't good, we will switch to Lantus.
I have also to tell that I have returned to classical syringes instead of my injector pen. With the pen, it was impossible to know whether the dose of insulin has been injected or not, and I'm quite sure that on Tuesday and Wednesday (the curve was drawn on Friday), the pen didn't work, and Capoo received no insulin. This could maybe explain the high numbers on Friday morning.

My vet looks very concerned about my cat, and he posted his case on a forum dedicated to vets. We are waiting for an answer from a well-known professor of endocrinology, that should arrive at the beginning of the week.

Sophie

 

Welcome to the FDMB Sophie and Capoo!

Now that you've introduced yourself and have become acquainted with a few of our members, I'd like to invite you to join us on the Feline Health - (The Main Forum). The Health Forum is where we help members learn about feline diabetes, hometesting, diet, and such. It's also a place to talk about any of your concerns and answer your questions.

Whenever you're ready, please start a new thread on Health.
Hope to see you over there!
~ Jill




@Robert and Echo

 

It sounds like you have some good plans in place, Sophia.

 

Sophia, I'm glad you have some plan in place and waiting answers from other vets. In my opinion and mine only, Vetsulin is short term. Of course 8u will drop his numbers but if given only once a day he will be high again before he gets another dose. Fructosamine is an average over a 2 week period. Only daily testing will give you the truth of what's happening. Until you receive answers I would split the dose and give 12 hrs apart. Again only my opinion. When I was using Vetsulin and it lasted 6 hrs, 8 if I was lucky. But Smokey felt the effects of the ups and down and he was not a happy cat. Keep us posted.

 

Hi everyone!

Yesterday evening 6:00 PM, I went to my vet, and he lent me a meter (mine is still in transit from the US).
So, yesterday evening, I started to test Capoo at home, and it works!!!!
The first try was a kind of a butchery (20 minutes to obtain a blood drop worthy of the name....), but we are learning!
My vet asked me to test Capoo at home, and to immediately send him the results via SMS.
So, on Friday morning, Capoo received 8 UI of Caninsulin at 7:30 AM.
At 8:00PM (+12.5), he was at 397 mg/dL (first try of home testing. 20 minutes of "handiwork")
At 10:00PM (+14.5), he was at 429 mg/dL, so me vet asked me to inject 5 UI.
This morning, 8:00 AM(+10), he was at 3.7 mg/dL, and my vet asked me to inject 6 UI.
At 11:00AM (+3), he was at 215 mg/dL. No reaction from my vet.
He has asked me to test him today at 4:00PM, 7:00PM and 10:00PM.
That's what we call a "live curve"

 

Great that you are home testing, that's the best way to keep your kitty safe and get him regulated. It will get easier the more you do it. Why don't you start a new thread in the health forum. There are are more people there that can help you with any dosing questions you may have.