Advice needed

Piper, four years old, was diagnosed with diabetes with ketoacidosis. He has been home from the hospital for about 5 weeks now and we have performed 4 glycocurves having to increase the insulin each time. His first curve ranged from 586 at its highest to 218 at its lowest. Today's curve has reached 690! I haven't gotten to the lowest yet, but I am very concerned. He came home on 1.5 units of Prozinc. He is now on 4 units and clearly it is not doing its thing. I'm sure my vet is going to want to change insulin brands on Monday. Could the dose just be too high? I'm reading about resistance and rebound and am just plain worried. He was doing better on a lower dose of Prozinc, but not good enough. Suggestions? Am I missing something?

He eats 3 cans of glycobalance wet food a day. He gets 1/8 of dry glycobalance during the day. This totals 281 in calories a day. He is hungry all the time. He was overweight before all of this began. He dropped almost 5 pounds before being diagnosed. It was one of the signs we took him in for. He has gained about half of this back and has remained at about 13.6 He is not losing weight.

 

Leesa sorry I can't help but there are some very good people here that are very knowledgeable. I do hope you can get your kitty's BG under control. I did look up the food you have your baby on and it has some carbs in it. I know when our vet wanted me to try Purina Rx DM after looking at the ingredients it was higher in carbs. We went back to Candi's food we were feeding her Nulo. It is very low in carbs.

 

I just checked it again and this should be the lowest of the curve and it is 620.

The carbs in glycobalance are supposed to be processed differently...can't repeat what the vet said, but we have also used fussie cat and weruva paw lickin chicken which are both lower in carbs. We have tried what seems to be EVERYTHING and he just keeps heading back in the wrong direction.

Thanks for replying Chrissy66. I need any help I can get! I know the vet will recommend changing insulin tomorrow and I am not resistant (no pun intended) to doing that I'm just concerned we keep changing and escalating and don't want to miss giving something a chance along the way and not overreacting to something. I'm very worried at his levels today. I do NOT want him back in the ketoacidosis situation.

 

The glycobalance food is 14% carb. You were better off with the weruva at 3%.

Sometimes too much insulin can look like not enough because of the bouncing. Can you set up a spreadsheet so it's easier to figure out what's going on?

http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

 

I would be happy to set up a spreadsheet. I'll do that next. I have been doing the curves at home:

3/6/18 on 1.5 units for a week of ProZinc
6:30AM 502
8:30AM 446
10:30AM 375
12:30PM 389
2:30PM 218
4:30PM 353
7:00PM 356
10:00PM 241
2:30AM 586
6:30AM 512


3/14/18 on 2 units for a week of ProZinc:
7:00AM 475
9:00AM 506
11:00AM 411
1:00PM 267
3:00PM 428
5:00PM 469
7:00PM 537
9:00PM 417
11:00PM 371
7:00AM 501



3/21 on 2.5 units for a week of ProZinc:
7:00AM 317
9:00AM 376
11:00AM 440
1:00PM 482
3:00PM 445
5:00PM 474
7:00PM 473
9:00PM 345
11:00PM 325
5:00AM 534
7:00AM 528


3/30 on 3 units for a week of ProZinc:
7:00AM 474
9:00AM 496
11:00AM 383
1:00PM 349
3:00PM 323
5:00PM 525
7:00PM 568
9:00PM 405
11:00PM 353
7:00AM 518


Today on 4 units for a week:
7:00AM 551
9:00AM 596
11:00AM 690
1:00PM 620
3:00PM
5:00PM
7:00PM
9:00PM
11:00PM
7:00AM

 

That's helpful. Let me tag someone more familiar with ProZinc


@Kris & Teasel

 

Here are my thoughts:

• You've gone from 1.5 u to 4 u in 5 weeks. That's a large increase in a relatively short time.
• Also, your increases have been in increments of 0.5 u or 1 u - larger than we'd recommend. The good dose range is found more precisely by increasing in 0.25 u increments.
• He's had DKA so getting enough insulin into him is very important. Feeding higher carb food will allow you to do that. The wet RC Glycobalance is 14% carbs as Janet said. The dry is likely quite a bit higher. If you can eliminate the dry I would and maybe try lower carb wet food soon.
• The BG curves show evidence of too much insulin. I'll take them one by one:

Curve done 06 Mar 18: This is closest to what you want to see although the pre shot numbers are high. There's some wobbling and bobbling but it isn't unusual in a newly diagnosed kitty. The nadir range is about 50% of the pre shot BG numbers and the two pre shot numbers are similar to each other. I would have stayed at this dose another week or so to see if Piper would settle a bit. The dose seems to be in the right very large "ballpark".

Curve done 14 Mar 18: The increase to 2 u is causing higher, more erratic BGs overall and that's often a sign of too large a dose. He dropped then rebounded even higher. We call it bouncing. There's some similarity to the 1.5 u curve but it's more erratic. A dose closer to 1.5 u is probably better.

Curve done 21 Mar 18: Average BG is higher (around 400). He stays up high for much of the cycle. Looks very much like too much insulin.

Curve done 30 Mar 18: Average is a bit above 400. Too much insulin.

Curve today: Definitely too high a dose!

Here's what I suggest:

1. Go back to 1.5 u for another week. Get some strategic testing done (info below).
2. Keep feeding the same wet food for now - no dry if you can manage that.
3. Do another curve next weekend.

Basic testing routine:

1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
2. test at least once near mid cycle or at bedtime daily to see how low the BG goes (between +5 and +7 if you can manage it)
3. do extra tests on days off to fill in the response picture - a curve if warranted
4. if indicated by consistently high numbers on your spreadsheet, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
5. post here for advice whenever you're confused or unsure of what to do.

We're in many time zones so we refer to times after a dose as +2 hours, +5 hours, etc. rather than clock times. Also - vets often want to increase in too large an increment and it gets people into the situation you're in. It's possible the ProZinc isn't the right insulin for Piper but it's far too early in his treatment to know for sure. It can take months to get a kitty responding decently. It can't be rushed.

I hope this helps.

 

Hi there. Could you give us a little more background & let us know about your dosing times & the pre-shot numbers? It would help to have all of the info in your signature too. That’s easy to fill out. Age, weight, when diagnosed & any insulin you’ve had. The best thing is to continue with a low carb, all wet food at this time. I’m not the expert at dosing but I’ll tag too & see what the experts say! It’s strange to keep rising. You are dosing every 12 hours, correct? @Djamila & @Kris & Teasel @Rachel
I’m lost! ...



Thank you Kris!

 

Thank you Kris and Becky & Baby Girl Kitty.

I will work on the signature and spreadsheet.

The dry is only because he was accustomed to eating breakfast from an auto feeder in our master bedroom before any humans were awake. My son got it for me for my birthday to help me me able to sleep past 5:00am! Pre-diagnosis all food was dry food. Now I have just given him 1/8 of a cup of a diabetic prescription dry food in the morning (MUCH less than he had before) to continue with the prince treatment he had grown accustomed to. Everything else has been wet food. We have done quite a bit of research on foods, carb content, etc. We are still tweaking this. I'm willing to continue to change.

Do you think it is safe to drop to 2 units tonight or is that too big of a jump considering how high his numbers are today? I can tell the vet in the morning that I want to go back to the 2 units for two weeks before changing brands if you think this is a good option. Or I can change brands and start back moving up more slowly. My vet has always been very good at listening to me and talking things through. I know you don't have a clear view yet without the spreadsheet and signature information. I will complete these today. His last test was 590 so it is slightly lower, but so high! This should be his lowest number of the day. Yes, we give him his injection every 12 hours with food. He also gets a snack mid day of a can of wet usually weruva or fussie cat. These are both very low carb.

I can switch the methods for checking his glucose from a curve to what Kris was recommending and wait for two weeks to do the next full curve.

 

Oh! Forgot to mention on the days when he was scheduled to do a curve we did NOT fill his auto feeder for his early morning "breakfast". His first draw was on 12 hours post injection and food.

 

Piper is 4 (this month)
Weight: 13.6 (had been around 16 then lost about 5 rapidly before diagnosis)
He gets his dosage at 7:00am and 7:00pm EST with his meals
The only insulin we have been on is ProZinc

 

You can drop his dose from 4 u to 2 u tonight if you want. The high numbers today are probably that rebound phenomenon I referred to that we call bouncing. I'll explain more below. It's possible that 2 u is still a bit too high but more days on it and testing should allow us to sort it out.

I've already given you some of this but I'll repeat it as part of this new member's handout I made up:
______________________________________________________________________________________________

It would help us if you set up your signature (light grey text under a post). Here's how:

• click on your name in the upper right corner of this page
• click on "signature" in the men that drops down
• type the following in the box that opens: kitty's name/age/date of diabetes diagnosis/insulin you're using /glucose meter you're using/what he eats/any other meds or health issues he has.

Another thing that will help us help you now that you've started BG testing at home is to set up a spreadsheet like the one we use here. We can all see it and look at it before offering advice: http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

.................................................................................................................................................................................................................................

Here's the basic testing routine we recommend:

1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
3. do extra tests on days off to fill in the response picture
4. if indicated by consistently high numbers on your spreadsheet, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
5. post here for advice whenever you're confused or unsure of what to do.

.................................................................................................................................................................................................................................

Here's an explanation of what we call "bouncing". It explains why a kitty's BG can go from low to sky high:

1. BG goes low OR lower than usual OR drops too quickly.
2. Kitty's body panics and thinks there's danger (OMG! My BG is too low!).
3. Complex physiologic processes take glycogen stored in the liver (I think of it as "bounce fuel"), convert it to glucose and dump it into the bloodstream to counteract the perceived dangerously low BG.
4. These processes go into overdrive in kitties who are bounce prone and keep the BG propped up varying lengths of time (AKA bouncing).
5. Bounce prone kitty repeats this until his body learns that healthy low numbers are safe. Some kitties are slow learners.
6. Too high a dose of insulin can keep them bouncing over and over until the " bounce fuel" runs out and they crash - ie., have a hypo episode. That's why we worry so much about kitties that have had too high a starting dose prescribed by the vet and the owner isn't home testing.

.................................................................................................................................................................................................................................

Here are some tips on how to do urine ketone testing (VERY important if BG is high and kitty isn't eating well!):

• put the end of the test strip right in his urine stream as he's peeing
• slip a shallow, long handled spoon under his backside to catch a little pee - you don't need much
• put a double layer of plastic wrap over his favourite part of the litter box and poke some depressions in it too catch pee.

Most test strips have to be dipped and allowed to develop for 15 seconds before viewing the colour change in very good light.

 

Thanks. I check the keytones about once a week. He was negative today so that is good! I completed the signature additions and the spreadsheet.

 

Hi Leesa! Kris has given you some great info about your dosing. I agree 100%...looking at your numbers tells me that Piper's dose is just too high. Dropping back and following the testing routine will help I think. Note that it may be a bit before you see a big change. Most cats need a few cycles to settle in to a dose before it can really take effect. Don't be discouraged if you don't see an immediate downward trend tomorrow morning.

 

Thank you for getting this done so quickly! I didn't see that 1.25 u dose data when I looked at your plotted graphs. The SS data tells me that was the best dose so far. The recommended starting dose is 1 u twice a day. Did he start on that? Was a curve done? I'm looking at the two yellows he had on the 1.25 u dose. They show that he responded well to the ProZinc, if a little dramatically. I'd say all the doses above 1.5 u are likely too high. He's quite bouncy but many cats are and they can settle over time.

 

I'm just stopping by to 3rd it. Yes to everything Kris and Rachel said. Those curves look suspiciously like too much insulin. The testing recommendation that Kris shared will be helpful in uncovering if that's the case, or if there is something else going on.

Because your kitty has a history of DKA, please keep posting daily with your numbers for awhile so we can keep an eye on how things are going and make adjustments as needed. You're not going to want to lower the dose and then just sit at it for two weeks.

Please ask any questions you have, or any concerns that come up for you. This is a LOT all at once and we are here to support you!

 

Thanks everyone! I have a call into the vet as well. I haven't heard back yet. He was at 525 this morning on 3 units last night and this morning. I was worried about dropping too fast so I dropped one unit. I will continue to drop to get back down unless the doc says to go all the way back down or change insulin brands. That is what I expect her to want to do. I have no issue making my voice be heard with her. She has always been open to dialog so I'm not concerned about her and I not finding agreeable ground. I'll keep you all posted! What are your thoughts on changing brands?

He did start on 1.25 units. He was sent home from a 4 day hospital stay (ketoacidosis) and we did his first curve 7-10 days after release.

 

The DKA is a vital piece of info to put in your signature because it'll affect the advice we give. He needs enough insulin and his numbers need to come down. Add warm water to all wet food meals to provide extra hydration and help to wash out ketones. Buy some urine ketone test strips at any human pharmacy and try those tips I described in my new member's handout. Test as often as you can. Daily is best when he's this high.

The high numbers, whether from too much or too little insulin, still put him at risk of developing ketones. As Djamila said above, keep testing and posting your numbers so we can sort out what's happening. Do you have any data for today? You don't need to do a full curve, just the basics in my handout.

 

I tested for keytones yesterday and test about once a week or so for these. He is good for now. It is something I will continue to monitor.

The vet has requested that I change to Glargine/Lantus tomorrow starting at 2 units. She said he was not "bouncing" because we have done 24 hour curves. He never goes low. With somogyi effect he would go really low, as well so she is really concerned the ProZinc is just not right for him. She agreed to the morning, mid and night testing for two weeks though once we start the new brand giving him a little more time to adjust before a full curve again.

I'll keep up with the spreadsheet so you all can see. Any suggestions are welcome! I dropped his ProZinc to 3 last night and this morning, but haven't tested today. I will tonight when it is time for his injection. I can't get the new insulin until tomorrow afternoon so either way he will have tonight and tomorrow with ProZinc. I will keep you all up to date. I appreciate your help.

 

Good luck with the Lantus, i hope it's a better fit. There is an ISG dedicated to that insulin, and I'm sure they'll give you any help you'd like as you make the transition.

http://www.felinediabetes.com/FDMB/forums/lantus-glargine-levemir-detemir.9/

Bounces can actually last six cycles (three days) and even longer in some cats. That being said, I do hope Lantus gets you closer to the results you're wanting. You might take a look at the detailed information in the Lantus/Levemir forum today so you can start to think about which protocol suits you best and introduce yourself to the folks over there.

 

Good luck with Lantus! When you intro yourself over there, be sure to mention the DKA to them. It will affect their advice to you as it does ours.