Advanced Information for Experienced ProZinc/PZI Users

ADVANCED INFORMATION FOR EXPERIENCED PROZINC/ PZI USERS

As with all the stickies on the ProZinc/ PZI forum, this document has had many authors who gave their time, energy and expertise: Bobbie And Bubba, Carol & Murphy, Elizabeth and Bertie, Kris & Teasel, Rachel, Robin&BB, Ruby&Baco, Sharon14 and Sue and Oliver (GA)

GIVE “START LOW, GO SLOW” A CHANCE TO WORK FIRST.

We, the members of the PZI/ ProZinc forum, feel strongly that, in the beginning, the best approach is to start at a low dose of insulin and increase slowly, based on your home testing. We consider that gathering data over time - with small adjustments in dose if indicated (always reflecting the home-testing data in the cat’s spreadsheet (SS) - is the best way to approach this “sugar dance.”

Remember: Your kitty most likely didn’t develop diabetes overnight.. We often say that treatment requires “putting on your patience pants”. So give your kitty’s system ample time to adjust to your testing and insulin dosing strategy before you consider making changes too quickly.

After - and only after - you have collected at least a month of data and are confident with home-testing, you might consider some alternate ways to use ProZinc/ PZI if regular methods are not getting good results.

Remember that your cat’s blood glucose is a moving target. What has worked for several cycles may suddenly be too little or too much. It is a good idea, especially in the beginning, to try to keep the same dose for 6 cycles. But that is not always possible long term if the cat runs consistently high or suddenly is too low. So in this document are some options for you to try.

Special consideration for cats with a history of DKA: If your cat has a history of producing ketones or DKA, it is especially important to try not to skip insulin shots and to keep their numbers in good ranges. Any of these options should be used only with special caution for any cat with a history of DKA. As always, consult your vet and the members of the forum if you cat has had DKA and you are considering advanced techniques.

We strongly encourage you to post on this forum for the input of more experienced members before you attempt any of the advanced dosing options for ProZinc/PZI shown below, and whenever you have questions or concerns about your cat's diabetes treatment and/or other health problems, please consult your veterinarian.


STALLING/ SKIPPING/ WAITING
Stalling/Skipping/Waiting are not really considered “advanced dosing” options. But they are worth considering when your cat’s blood glucose numbers are running low at pre-shot test time, which is not likely to be early in your feline diabetes journey. (Although this does sometimes occur early in treatment when the starting dose turns out to be too high.)

• If you cat isn’t in a safe blood glucose range at the scheduled shot time, but is relatively close, you can stall: Wait 20 minutes without feeding to see if the blood glucose rises on its own. (This is because food usually raises blood glucose levels. So if you give food, and then re-test and shoot based on that result you could end up shooting a number that is higher than it would be naturally be). So withhold food, then retest: You want to know the number has risen, and that it is at or above your No-Shoot number. You might also consider shooting a little less insulin for added safety when your cat is very close to your target number (meaning within a few points of the Safe-to-Shoot number).
• Another option is to skip the dose, particularly if you will not be around to monitor afterwards. The next pre-shot test result may well be higher than usual, because it will have been 24 hours since the last shot. This is another situation in which you might consider reducing the dose - even if you’re seeing a higher number. The point is that this higher number is a reflection of the cat having had no insulin for 24 hours and therefore is not “true.”
• One more option is to feed and wait 2 hours, until the effect of the food has worn off. If the number is high enough to shoot, you can give insulin. Just bear in mind that you want to be able to wait 12 hours before shooting again. For many people, this option messes up their 12/12 schedule.
• If you had to stall, skip or wait 2 hours, it may be wise to reduce the next dose by a little bit. The goal is to have two shootable pre-shots in each 24-hour period and not have to skip or stall. A little lower dose might help you achieve that goal..
• “No-Shoot” numbers are individual choices. In the beginning, we suggest setting 200 mg/dL {11 mmol/L} as a No-Shoot number, but as you get more data and understand how the insulin is working in your cat, you can choose to shoot at a lower number. For some people, this is 180 mg/dL {10 mmol/L} and over. For some people, it is 150 mg/dL {8.3 mmol/L}. Whatever your target number, be sure that you can monitor that cycle whenever you choose to lower your “Safe-to-Shoot” number. Please note that when using a pet-specific meter like AlphaTrak2, for an added margin of safety you may want to raise your “Safe-to-Shoot” number a bit higher than the recommended 200 mg/dL {11 mmol/L} for a human meter. (Refer to “Beginner’s Guide” sticky for more about this.)

ADVANCED DOSING OPTIONS
If you are 100% certain you have given Start Low, Go Slow a fair shake and:

• Have ruled out any and all treatment errors/ misstepsHave a SS already showing ample data (a month’s worth, at minimum)
• Have a SS already showing aple data (a month's worth, at a minimum)
• Have your cat on low-carb meals to achieve/ maintain optimum weight
• You know for certain that your cat is NOT getting into any contraband food sources
• You have already ruled out any hidden additional health problems with your vet that could complicate treatment ...

Then you may want to consider trying one of the advanced dosing options shown below. Before you proceed, please post on the forum for advice from experienced members of this forum and consult your veterinarian if you have any questions or concerns about safe treatment of your cat.

SLIDING SCALE DOSING

If your cat is having pre-shots in different ranges and it seems dangerous or ineffective to shoot the same dose for each pre-shot, you can consider shooting different doses for different ranges. (For example, giving 2 units on a 400 mg/dL {22 mmol/L} pre-shot can produce different results than giving 2 units on a 200 mg/dL {11 mmol/L} pre-shot.) Note: It is best to have an experienced member look at your spreadsheet history and suggest some ranges/ doses. Once you are comfortable with the concept, you might adjust on your own.

11/13 OR 13/11 DOSING

If your cat consistently has a lower AMPS or PMPS (or vise versa) AND IS NOT BOUNCING CONSISTENTLY, you might consider shooting early for the higher pre-shot number and later for the lower pre-shot number.

If the AMPS is high or normal, but 12 hours later the PMPS is too low either because of long duration and/or the nadir is late, you have two options:

• 1. Shoot the am dose one hour early (+11 relative to previous night’s pm dose) and leave the pm dose at normal time which will then be +13 since the am dose.
• - OR -
• 2. Leave the am dose at its normal time and shoot the pm dose one hour later which will be +13 since am dose. Either way, you need to see this as an issue and pattern over a few cycles to go this route.

This technique can also be used if the PMPS is high and the AMPS is too low.

The hope here is to smooth out the cycle and have two shootable numbers every 12 hours. It would, as always, be wise to seek advice from your vet or on the forum about this technique.

NOTE: If you are confused about bouncing, see the ProZinc/ PZI Protocol sticky or ask on the forum. You do not want to use this technique if your cat is continually bouncing from lower numbers.

MICRO DOSING/ CHASING THE DOSE

When your cat is consistently in numbers too low to shoot at shot time (and you are continually stalling or shooting late), and the cat is already in low BG levels throughout the 12-hour cycles, you might consider micro-dosing. This process should be guided by your vet and on the forum by experienced members, and will require more frequent testing.

You may be shooting at times other than the 12/12 schedule, perhaps whenever the blood glucose levels rise enough to require a small dose of insulin. You will need to pick a number somewhere near the 150 -180 mg/dL {8.3 - 10 mmol/L} range at which you will plan to shoot, being sure that the number is indeed rising. The dose at these low numbers will vary with each cat and its patterns, so advice should be solicited. But you may be considering doses below 0.25 and even considering a “drop” of insulin. At this point, U100 needles marked on the half-unit and the conversion chart are required.

It may also be important during this period to offer small frequent meals. You can also experiment with the lowest carb foods to help bring down the numbers. (To avoid the toxicity of excess mercury, we suggest you avoid feeding seafood-based formulas more than once or twice a week.)

DOSING EVERY EIGHT HOURS

If your cat is consistently having an early nadir and the level is consistently rising 6-8 hours after the shot, the insulin may not be lasting long enough. You might consider shooting more often than every 12 hours. BUT PLEASE BE AWARE: This method is very hard on the caregiver because you need to be available to monitor more often and to shoot every 8 hours. If you can’t make that kind of commitment, don’t try shooting every 8 hours. But if you do decide that your cat’s situation warrants trying this, here’s how it’s done:

• First, divide the total amount of insulin you are already giving over 24 hours by 3.
• Then divide your 24 hour schedule into (3) eight hour sections.
• The first time you attempt this it’s wise to do start during a curve, checking the BG levels every 2 hours.
• If, by +8, the levels are rising, no longer falling, and to a level above your No-Shot range, you could give another shot.
• Then wait 8 hours, test to be sure the level is rising, not falling, and is above your No-Shot range and give another shot.

Often this method is not long term, but allows the levels to stabilize in a few weeks. Make sure you only try this method with the guidance of this forum’s members and your vet.

INSULIN RESISTANCE/ GLUCOSE TOXICITY: Worth knowing about

If, after months on insulin, your cat’s diabetes still remains unregulated, glucose toxicity may be something you should discuss with your veterinarian. If you have followed all the recommended treatment steps to the letter, and your kitty’s numbers remain high, it’s time to rule out any and all conditions that may be complicating and impeding your cat’s progress toward good blood glucose control and better health.

The following brief explanations (italicized excerpts) about insulin resistance, glucose toxicity and the effects of carbohydrates and obesity in relation to type 2 diabetes (which is the type most diabetic cats have) are from Dr. Lisa Pierson’s Catinfo.org website:

Type 2 is characterized by two problems. The first, as in Type 1, is a diminished ability of the pancreas to secrete insulin. The second issue is one of insulin resistance. In other words, the receptors on the cell wall that would normally open the door to the cell to let the glucose in when insulin 'knocks', stop 'listening' to the insulin. The cells 'resist' the signal that the circulating insulin is sending and the glucose is not transferred to the inside of the cell, resulting in an elevated blood glucose (hyperglycemia) and cellular 'starvation'. The elevated blood glucose, in turn, sends a signal to the pancreas telling it to secrete more insulin. The elevated insulin may somewhat override the insulin resistance resulting in more glucose entering the cells, but eventually the pancreas can become exhausted or 'burned out'.

Glucose toxicity results from chronic hyperglycemia. Glucose toxicity wreaks havoc on the entire body - especially the pancreas and its insulin-producing cells. A vicious cycle then ensues as the insulin-producing cells are damaged resulting in less insulin being produced.


This is how we use this concept on the forum: If your cat has been on ProZinc/ PZI for quite a while, remaining in “high and flat” BG numbers throughout his/ her 12-hour cycles at the current dose, the dose may need to be increased every 6 cycles by a small amount, until you reach what we call a “breakthrough” dose.


Carbohydrates, Obesity and Diabetes (Again, from Dr. Pierson at Catinfo.org )

Most people are aware that diabetes is more common in overweight humans than it is in people closer to an optimal weight. The same is true for cats. Fat (adipose) cells produce a substance that causes the cells of the body to become resistant to insulin. This increase in insulin resistance is the hallmark of Type 2 diabetes. As mentioned above, this is the most common form in the cat.

Cats are designed to utilize proteins and fats for their energy - not carbohydrates. They are lacking the necessary enzymes to efficiently utilize carbohydrates to meet their energy needs. When the carbohydrate level of an obligate carnivore's diet is higher than it should be - remember that a bird or a mouse is only 3-5 percent carbs and that most dry foods contain between 35-50 percent carbs - the excess carbohydrates are stored as fat. The increased fat cells, in turn, promote Type 2 diabetes via an increase in insulin resistance. That said, if calories in exceed calories out - no matter whether the calories come from protein, fat, or carbohydrates - the cat will gain weight. This is why portion control is important no matter what diet you are feeding.


Causes of Insulin Resistance in Cats
Common concurrent diseases that can cause or exacerbate insulin resistance/glucose toxicity in diabetic cats include:

• pancreatitis
• hepatic lipidosis
• cholangiohepatitis
• urinary tract infection
• renal failure
• hyperthyroidism
• inflammatory bowel disease
• acromegaly
• heart disease

Please note: Treatment with steroids or progestagens can precipitate what is known as “transient diabetes” in cats. This “drug-induced” diabetes can resolve fairly quickly once the prescribed drug is stopped and/or insulin treatment has begun. In this situation it is especially important to monitor BG levels closely before each dose of insulin is given, and to do some mid-cycle testing as well. This is because a cat’s blood glucose can rapidly return to more normal levels after the effects of the drug have fully worn off. In these cases, careful monitoring is especially important to help avoid a sudden hypoglycemic event after the steroid or progestagen therapy has stopped.


Of the above-noted causes of insulin resistance/ glucose toxicity, here are two of the most commonly seen and discussed on the FDMB forums:
Pancreatitis
Pancreatitis is a common and frustrating problem; it often complicates treatment of diabetes. Because both the body’s demand for insulin and the appetite can fluctuate with the severity of inflammation of the pancreas, clinical signs of poor glycemic control often coexist with an increased risk of clinical hypoglycemia. If your cat is diagnosed with pancreatitis, post to this forum for support, as there are others here who have had experience of this in their own cats.


Bacterial Infection
Bacterial infection is an important cause of insulin resistance in diabetes. Diabetic cats are at increased risk of bacterial infections, especially of the urinary tract. (Some of us only learn that our cats are diabetics when we’ve taken them to the vet because we’ve noticed symptoms of urinary difficulties in our cats.) In studies though, it’s been shown that only 40% of the cats with urinary tract infections exhibited clinical signs. Some studies also have noted that bacterial infections are common concurrent diseases in diabetic cats. Bacterial infections commonly occur in the oral cavity (bad teeth, gum inflammation/ gingivitis), the skin, and the biliary tract. Getting any infection diagnosed and treated can result in a significant shift downward in your cat’s blood glucose numbers - so again, careful monitoring of BG levels during and after treatment for infections is important to help ensure against a sudden hypoglycemic event while your cat’s BG levels start to improve as the infection clears.

These are "general" guidelines which have worked for many cats. However, "Every Cat Is Different". Learn how YOUR cat responds to the combination of food and insulin. Please be aware: There are no specific "dose advisers" on the FDMB. The FDMB is an open board subject to peer review where laypersons with varied amounts of knowledge and experience are free to share their own thoughts and opinions through explanation and by making suggestions. We are not veterinarians. It is not our intention to take the place of your veterinarian. Please discuss dosing, methods, medications and care for your cat with your veterinarian.


Sometimes there are special circumstances such as: the presence of ketones, an unusually low pre-shot number, a caregiver leaving the cat with a sitter, relatively high flat curves, loss of appetite, infection, a schedule change, ability to monitor, etc. which may call for adjustments to these guidelines. Please ask for guidance if any of these or other circumstances present themselves or are of concern."

Last edited: Today at 12:29 PM
ProZinc/PZI protocol
Guide for using ProZinc/PZI