Discussion in 'Feline Health - (The Main Forum)' started by Matthew Brennan, May 22, 2017.
608 at +7. Thoughts?
He might still be bouncing from that recent blue. It's also possible that his dose needs to be tweaked but I wouldn't change anything right now. You're still in a data gathering phase. I see that you're using Freestyle strips in your AT meter. That can work fine just make sure you do a couple of same blood drop tests each time you open a new vial of FS strips. Leave the AT meter at the last cat code you used.
Well... it would seem that the 2u did drop Timmy ok to start with, but because his pre-shot number was so high, the insulin had a lot of work to do. The higher doses dropped him lower, but as we're assuming he is bouncing and therefore lowering the dose, that lower dose isn't doing enough. It starts to become a Catch 22 situation. What we really need to do is get the pre-shot numbers down... that should make life easier. But how to do it is the issue...
We have advised sticking to the 2u dose for a couple of days and I still think it's worth doing that, even if only in an attempt to clear the bounce. But if by midweek he is still so high, you have several options - go right back to 1u and be very methodical about testing regularly to get some accurate data; try the eight-hour dosing regime as Janet suggests - maybe 2u each time; or show your results to the vet and ask for a full discussion about changing to another insulin.
We don't like to bad-mouth Caninsulin as it can and does work for some cats, but for others it just doesn't.
My opinion... I think doing 2 is a waste of time and is keeping the cat in high numbers too long. I don't want to see him develope dka. If it were me I'd go back to 3 or do 2.5 three times a day.
I agree, poor Timmy does need to get out of these high numbers asap. Matthew - you've taken on board what we've been saying over the past few days, this is your call, of course. We are going by the book when we say that a dose should be adhered to for at least a couple of days, but these very high numbers are worrying... if you feel capable and confident of not only shooting three times a day, but testing at intervals in between, that should theoretically get numbers down. If you decide to do that, I'd go no higher than 2.5u for now.
Alright, 3 times a day it is starting tonight.
2.5u, shot times will be 7am, 3pm, 11pm.
Updating the spreadsheet to show the 3 shot times.
Ok let's hope this will help... just be mindful that you will be shooting more frequently and probably at lower numbers than you've been used to and this should produce a different type of curve... when in any doubt don't shoot or shoot a lower dose... and post here with an URGENT heading if you need to.
Good luck! Paws crossed...
Going along with this, I think it's a good idea to start a fresh thread with the new dosing strategy if you're going to a round-the-clock schedule. Otherwise, if you need help during one of the quiet times on the board when none of the other folks on this thread are around, it will be hard for a new person to jump into a 100+ message thread and figure out what's going on currently. On the first post of the new thread, you can put a link in to this one, so that anyone who wants to will be able to refer back for the history.
I'm sorry but I'm too tired right now to think clearly.
Matthew could try what has been decided but make sure Matthew that your kitty eats properly.
Hey-- am I misreading the spreadsheet? It looks like you had a PMPS (at the new time) of 365, after a +14 on the old shot of 664 (so, two hours before the PMPS). If that's true, that worries me, because it would mean Timmy was in the process of a really severe drop at shot time (maybe a bounce breaking????).
If you are reading this, please follow Marlena's advice and make sure Timmy has lots of food available in this cycle, and please keep testing.
@Nan & Amber -I'm reading the SS the same as you and echo your warning about testing and food. That drop of over 300 points especially so late in the cycle is concerning.
Yes-- I'm actually up in the middle of the night and I came here to check up on this, I was so worried. Now I see that the next reading was just the PS for the next shot (572) and that 3U was given.
I am worried that this is a much too aggressive approach. The 3x/day dosing strategy is terribly hard on the caregiver because it's not just a matter of being able to give shots every eight hours, you need to monitor the response to the shot as well, especially with a fast-acting insulin like Caninsulin. If you can't do the monitoring, I don't think it's a safe approach, and that's even without the increase in dose this morning.
Hmmmmmmmmmm I wonder what's going on. That 365 could have been the bounce breaking, as Nan says. I can't see any other reason for it really. Maybe those two extra hours after the last shot cleared the exogenous insulin and made enough difference for Timmy's body not to be panicked. So you shot 2.5u and he is back to a black again this morning, quite possibly another bounce.
What to do now...? We are trying almost too many different things now, but we don't know if another 2.5u eight hours on is going to help matters. If you were to wait until late in the cycle again, as at +14 last night, the number *might* show a big drop in two hours again as it did yesterday in which case you'd need to keep testing to see if he's dropping or rising... the trick would be to catch him on the rise. Or you could try a lower dose at +8. It is looking as if "shooting into the bounce" may not be the answer, and it is looking that the 2.5u could be too much. So I'd be inclined to keep testing without giving insulin... see if he starts to drop at any point and then monitor closely for a rise...
Just my opinion... I think we could do with a few more eyes on this so it's worth starting a new thread with very specific heading as per Nan's suggestion.
I set that up badly on the spreadsheet. The preshot last night at 11pm was 664. At 1am it was 355.
That's another BIG drop, not good. Timmy is showing himself to be very responsive to Caninsulin (not a surprise). See how today goes on the eight-hourly schedule - can you post here with a +3 or 4 and also a +7 so we can see what's happening? It may be that three times a day shooting will work better, IF it is sustainable for you with tests in between as well as pre-shots... if not I definitely think it's time to talk to a vet about another insulin.
Ok so that 266 at +3 (?) is a better number - big drop but better to be in better numbers than blacks so much. Try to get a +5 so we can see what direction the bg is going in then.
+5 of 204. If he is still around the 200/250 mark come 3pm when he is due injection 2 of 3 is it safe to do so?
Also, surely by using a lower dose 3 times a day that should stop the big drops and keep him more consistantly at a lower bg?
That's the hope. If the second preshot number is less than usual than you can give a lower dose. Did you do 2.5. Or 3 this morning? You talked about doing 2.5 but I see 3 in the spreadsheet. If the preshot is 250-300 I would give only 2u. If it's over 300 do the 2.5
You are right Matthew. The theory is that dosing 3 times rather than twice daily will keep the concentration of insulin in the system more steady which should smooth out the cycles but the trick is to find the dose that is going to do that for Timmy and right now I think he is bouncing big time which is making the picture blurry. Usually you would take the daily dose and give 1/3rd at each dose but with the drops you are seeing right now, I'd be very hesitant to give another 3u if the mid day pre-shot is that much lower.
If I am understanding correctly, the highest dose you have given Timmy lately has been 4u twice daily and you recently were dropping the dose down to see if you could stop what appears to be major bouncing. This morning you gave Timmy 3u again so if you continue to give 3u for each of three doses today, you're actually increasing his dose to more than you were giving him days ago which I don't think is what you intended or advisable.
I am hesitant to make any suggestion about dose right now till we see where Timmy's BG is just before the next dose is due but I will suggest that it should be lower than 3u and you are going to have to monitor Timmy very closely. To be very honest, I think this is going to be very difficult and wonder if it wouldn't be better to stick with twice daily dosing at least until you can hone in on a dose that gives Timmy a bit smoother cycle. Even if his numbers are a bit higher mid cycle, it's those blacks at pre-shot that you need to get under control right now and I don't think increasing his dose even if it is being doled out in shorter intervals, is the way to go right now.
I'll echo MrWorfMen's Mom's comments. This is a situation with many variables and it might benefit from eliminating some of them. Three times a day dosing might work but takes a lot of vigilance on the owner's part and could be fraught with difficulties in a bouncy cat. If you continue to struggle with getting BG under better control with Caninsulin you might ask your vet about one of the longer-lasting insulins.
I did 3u this morning as his levels where so high. I intend on doing 2.5u from here on out. I am keen to see how his numbers go 3x dosing today/tomorrow.
Matthew, I understand your reasoning but sometimes this sugar dance is counter intuitive and this is one of those situations. Insulin is a hormone not a drug so throwing more insulin at a high pre-shot can backfire to raise rather than lower numbers. While the pre-shot numbers are important, it's the mid-cycle numbers in combination with the pre-shot numbers that needs to be considered. Once you have a stable, somewhat regulated cat, and lots of data that shows how kitty is reacting, adjusting doses according to pre-shots can work, but right now, the goal has to be to smooth out the cycle so Timmy stops bouncing so much and increasing the dose during a bounce just adds exponentially to the bouncing and confusion. This is a marathon not a sprint and patience is key to success.
Agree with all the above so no point repeating it! Err on the low side now when deciding a dose and if you're monitoring frequently it will be easier to see the true picture rather than one clouded by ongoing bounces.
My FD motto is, "When chaos reigns, simplify, simplify, simplify." You need more baseline data to judge what to do next. Several of the techniques, like TID dosing, are best used after more experience has been gained.
Great motto Kris! My head was beginning to hurt from all the variables. And I agree - said it myself a few days ago - TID dosing is really something to tackle after a little more experience. Matthew, you are doing well and your dedication is incredible... we know you want Timmy to feel better asap (as do we) but this is something you can't hurry if you want to get it right. Softly softly catchee monkey and all that!
I agree with all the points above, but he is up round the 600 mark - a lot. My priority is his health, especially considering he could have been up round them numbers for months due to my (rubbish) vet. I agree gathering data is a big part, but time is of the essence. We have embarked on the 3 times a day dosing. I will keep monitoring him frequently and go from there.
Spreadsheet will stay updated guys. Thanks for all the help.
Exactly, Matthew, poor Timmy has probably been in the very high numbers for a long time and believe me, we all want to see him in better numbers and feeling better almost as much as you do. Definitely want to get him down from those blacks.
Collecting data IS a big part to keep him safe and to give us info for the future, because unfortunately things don't always go according to plan so it's very helpful to be able to look back at responses to different doses during a cycle.
So you've given 2.5u now, will be interesting to see how that goes. We're all rooting for you.
Well the 2nd preshot is better than this morning so that's a good thing! I was glad to see you did 2.5 this time.
I think as long as you are there to monitor and steer if needed you made a good choice.
You do have honey or syrup in case of emergency, right?
Honey at the ready! 4 hours into shot 2's cycle and we are at 149.
Not just yet! That's a nice number. He may hang around there for a bit but test again in half an hour and keep an eye on him too.
OK, you aren't quite at the honey stage yet, but high alert is good! I'd test again in a half hour, no later than an hour from now.
Is 149 too low? I thought 100-180 was the right range? He is half way through this shot, so I would expect to see his numbers rising again shortly - plus he has just had a big feed of food.
Echoing Nan & Diana. Nice number but time for vigilant watching.
149 is a great number but given the 3 times a day dosing and his bouncing there is no telling what he might do so just keep an eye on him and test again in half hour or so. He may spike a bit from the food or he may not if he is sliding downward right now. Knowing what he is doing will allow you to steer him if he is heading down further.
... don't forget he had 3u this morning and another 2.5 eight hours later so he's had more insulin than usual today. We might see a bounce again later. Be very cautious about dosing at next due shot time... post here and let us know what numbers you're getting.
318 is the latest. That feed has put him a fair bit back up. Looks like he will be in the 400's/500's come injection 3 later.
Wow, Timmy doesn't do things halfway, does he?
At least this means you can probably take a break on testing for a while!
I think that is a combination of feeding and bouncing. He's already has 5.5u of insulin in under 12 hours compared to the 4.5 u he got yesterday over 24 hours. If he were my cat, I'd be inclined to stick with 2u - 3 times per day (total daily dose of 6units) for a few days to see if that doesn't level him out a bit. Then adjust accordingly.
My thoughts exactly.
How can you tell the difference between the natural curve and bouncing? Surely once he hit the 100's he was going to start heading back the other way as it was after the mid point of his insulin curve. What stipulates the difference between BG rising from that curve and a bounce?
While the curve using Caninsulin is generally a rounded "V" shape, with what appears to be a steep valley, Timmy just doubled his BG in the span of an hour which would pretty much give you a line going straight up instead of on any angle if you graphed his readings right now. There is no way to tell how much is food influence and how much might be bouncing but it seems the goal of smoothing out the cycle has not be achieved today.
All mammals have a built in safety system that will activate when the body perceives the glucose level is falling to what it has learned to assume are unsafe low levels. This causes a rapid and almost instantaneous rise in BG. That is what I believe we are seeing with Timmy right now. He has become used to functioning in higher BG numbers. He is not used to BG levels of 149 and so his defense system is activating prematurely.
The goal is not to force the BG down to normal levels but rather to coax it down so that Timmy becomes re-familiarized with lower more normal readings and his defenses stop activating so quickly. This means it would be better to have Timmy not reach such a low, albeit safe, mid cycle number just yet. His defenses are kicking into action too quickly and stopping that process and getting it back to working more normally will bring those pre-shot numbers down.
Just looking in here before signing off for the night - been up since 6am... I'm sure Linda, Nan and Janet will continue to post if they can after your 11pm result in an hour's time... my own input would be to dose conservatively, and test again whenever you can... although we know Timmy is prone to bouncing there is always a possibility that he will surprise you and go the other way. Hopefully you're ok with staying up late or getting up a couple of times in the night (many caregivers do). In the longer term, if you revert to twice a day dosing, you will want to pick times that suit you to not only shoot but test again during the cycle... everyone has different routines.
Hoping for some nice numbers when I look in again in the morning!
11pm preshot and the meter read Hi. Done a second test and it was 713!! Im very concerned guys.
I gave him 2.5u, but im worried. I need direction as to the next steps to take.
I have no experience with Caninsulin or TID but just he numbers looks like he's bouncing, a big bounce. Have you tested him for ketones yet? Suspecting his body is also trying to adjust for the TID schedule. Hopefully the others will chime in. I can tag them for you, @MrWorfMen's Mom @Nan & Amber @JanetNJ
that is one bouncy boy! are you very sure he has no infections or anything?... you are feeding just chicken, right? No high carb foods? No chicken with any kind of sauces or sugars on the outside?
Im at a loss. And struggling to find a good vet thats clued up on diabeties near me at all.
Would love for advice on the next steps I should take - dosage wise / 2 or 3 times a day wise.
I have him eating "The feline cuisine company - pulled chicken" cat food. Says complete nutrition on the box .
Looks like severe bouncing from the lower numbers. I'm not sure what others would say but if it was my cat I'd do a "restart" at a moderate dose (2 u?) BID and keep it at least 3 or 4 cycles to get things calmed down. Then I'd increase the dose by 0.25 u increments, holding for at least three cycles.
You appear to have a bouncy, reactive cat - not a bad thing, just a trait of his physiology. These guys don't take well to too many changes and I know that from direct experience with Teasel.
This? Not a bad food. Estimated 5.3% dry matter carbs
Yong, thats exactly it!
So from tomorrow, 2u x twice a day you think?
If it were me I would probably do 2 units each time three times a day for a while.
You could do the 2 units twice a day, but I think he's going to be spending an awful lot of time in dangerously high numbers.
His numbers will be slightly higher in the middle than those low yellows and blues, but it might settle the bouncing a bit. I've never seen a cat bounce back up as fast as yours... that boy is made of rubber. I'm glad you found a low carb complete food for him to eat that he likes.
I'm glad you were able to figure out the carbs... I got a little concerned when I saw it said "in sauce".
Matthew, please read my post #143. This high number is not at all unexpected. Not welcome and worrisome yes but not unexpected. You were reducing the amount of insulin up till today in the hopes of bringing down those pre-shot numbers but your dosing has been inconsistent and the lower doses have not been held long enough to determine effectiveness and that is making it difficult to figure out the right dose to settle that bouncing down. You gave Timmy a total of 8 units of insulin today with the potential for some mild carry over from shot to shot which is technically a dose increase and it looks like he needs less rather than more insulin.
I still maintain you need to drop the dose down to at least 2u (perhaps even back to 1.5u) if you are going to dose 3 times daily and you need to hold that dose for a period of at least 3 days to really see the results. If during that period, the numbers don't start smoothing out, then a further reduction may be necessary. If you go back to twice daily dosing I would try 2 to 2.5u held for a period of 3 days. It's up to you whether you want to dose twice or three times daily. Right now, to be honest, I think the three times daily is just complicating the situation more.
Looking at today's overall numbers, until that last preshot... he was looking much better. he had less total hours in super high black numbers than the previous days. lowering the dose to 2 may even out the numbers a bit more and prevent some bouncing... but I still think 3 shots is working better than two shots for the time being. Ultimately you hold the syringe so you make the decision.
You're probably confused because you're getting conflicting advice re TID or BID dosing. However, I think the consensus is that the dose has to come down. You have to decide for yourself whether you want to dose twice or three times a day. Whatever you do, keep it consistent for several cycles. I think your kitty is quite scrambled right now.
Figured I would go try to find it and post since Matthew is in UK. Ireland I think? And most of them are probably in bed now . Except Matthew Much better food than plain chicken too
I like the idea of dropping the dose as it might give him slightly gentler drops than he's been having. Linda said something in an earlier post, how the big drops activate his body's defenses. Also, I don't think you gave enough time to BID dosing while testing. I know he was diagnosed early last year but we only have data for six days .
YES YES YES.
Inconsistent dosing and actually a dose increase hasn't helped. Matthew, you need to take a deep breath and be prepared for this to take a little longer. When you start on a new course of action that one of us suggests, stick to it unless there's a really good reason (eg don't shoot a much lower than expected number that your data shows is on the downward curve). I absolutely understand how it's tempting to shoot those pre-shot black with a higher dose, but if you can stick to a plan I think it will make a lot of difference. We may be divided here over whether to shoot two or three times a day... I can see the potential good and bad in both so read over this thread again carefully and make a decision based on what we've been saying. Things WILL get better... but it takes a while.
Good to see Timmy has a new complete food... I haven't heard of that one. If he's enjoying it, great, he will be having better nutrition now and that will help the overall situation once he's down from these high numbers.
So keep at it, be patient and try not to be disheartened... you're actually doing a phenomenal job. Hard work and persistence will pay off!
I think this is really key. I know it feels really urgent right now when you are seeing these high numbers-- it feels awful to see your little guy up in the reds and blacks and to have, basically, what seems like a quantitative measure of how yucky he's feeling. You want to fix it as soon as possible so he can feel better. But he didn't get to these numbers overnight, and you aren't going to be able to get him into better numbers overnight, either. Soon, we all hope, but not instantly.
You really are doing a great job in a difficult situation!
Wow still dipped down to the low 200's at +4 even on only 2 units. I'm curious to see the rest of the day and if the swings are as dramatic as yesterday.
Overall how does he seem to be feeling today?
Honestly I havent noticed a change much in his general behaviour since starting testing him.
Around injection time and especially for a few hours after he is very vocal, hungry.
Around mid cycle of insulin he is very content, mainly sleeping.
Then as it comes round to injection time very vocal.
He was very vocal before injection time this morning. Now he is sleeping away happy. He is not a very active cat at the best of times in his older age.
Ive found a good indicator is how far away he sleeps from his water bowl. When he is high, he will sleep next to it. When he is below the 300's, he will sleep in other rooms of the house.
Matthew, how often and when in each cycle do you feed Timmy? Sometimes switching up feeding times a bit can help to smooth out those dramatic curves a bit. Timmy may be very vocal early in the cycle because he is feeling hungry due to sudden drop in BG. If you are not doing so already, might be an idea to offer him a small snack between +2 and +3 to see if that helps slow the drop a bit.
I currently feed him when he is looking basically. How much impact will a feed have on his BG - if its regular cat food?
Others will have to weigh in on "how much" in quantitative terms (if that's possible to generalize at all), but it will definitely help to have food on-board early in the cycle for the insulin to work on. That's why (esp. with the fast-acting insulins) you want to have a meal before the insulin starts working-- otherwise, you can get a really severe crash. Since Timmy is currently dropping hundreds of points in the first few hours of every cycle, it really can't hurt to give him some more mini-meals during that time to try to help slow him down. Just getting him to drop 200pts rather than 300 might help reduce the bouncing that comes right afterwards, which will help on the next cycle.
[Edit: just noticed I started off saying others would have to be specific, then went and put numbers in anyway! Just to be clear, this wasn't meant to be a prediction or an average result from adding more food, it was just for illustration of an ideal result.]
Much less dramatic of a drop this afternoon.
Yes I just came over here to look! Holding nicely... really hope he doesn't go zooming up before next shot time... keep us posted, Matthew.
Hopefully this afternoon's cycle is a sign that the extreme bouncing is dissipating.
Fingers and paws crossed here!
I really do agree with Linda here!
What do you guys think about todays numbers? Any feedback?
Despite another black pre-shot, I think todays' cycle was encouraging. I'd stay the course with 2u right now. It often takes 2 or 3 days for bouncing to settle down but the lack of an extreme drop today was exactly what we were trying to accomplish so give 2u a chance. Making dose changes while kitty is bouncing will just confound the puzzle. Takes a lot of patience to deal with these furry kids but slow and steady wins this race.
Agreed.... Nuts how he can drop 200 in an hour!
Keep it going a few more days.
Yes... still a bit of a bounce going on so it may be a matter of lowering the dose a little but def keep at 2u for another day or two... all the tests are important info.
Well done Matthew.
His levels dont seem to be coming down as far today. Is that a good or bad sign?
You may have missed his nadir this morning so that 499 could be him starting to rise again and we don't know how low he may have gone on last night's cycle. I'd still hold the dose for today. I agree with Diana that he's still bouncing albeit not quite as much. I'd start getting a reading around +3 to see if he is dropping by then on the next couple of cycles. If he doesn't smooth out by tomorrow, perhaps dropping him down to 1.5u should be considered. You've obviously got a very bouncy kitty and they can be a tough nut to crack. Hang in there!
Not great... Very hard to say, and data can vary hugely from day to day anyway.
Just one possibility though - could you by any chance have given a fur shot this morning (what we call it when there's some doubt about over whether the dose was given to the kitty... everyone messes up sometimes)?
Good point Diana! Didn't occur to me but certainly something to consider.
My concern (pure speculation) right now is that if he really is reaching nadir around +5, is it possible he's having some hold over of the dose until the next cycle acting like a dose increase for each succeeding cycle. Both night cycles on the TID dosing have shown huge drops by +2 and we have no idea how low he is going by +5 over night. If he is going into the blues overnight by chance, the bouncing is just being perpetuated and the dose needs to be lowered. Thoughts?
No way was it a fur shot, can be 100% certain on that one. I think as you guys say he is on his way back up for the 3pm shot.
Yes that sort of thought was going through my mind too, Linda. This is where the TID dosing may not be so good. It would seem worth a go at lowering the dose (maybe in another day or two if no better with 2u) but the risk in that case of course is that it might not do enough initially to bring the black pre-shot numbers down for very long. TBH I don't really know what else to say except to advise Matthew to stick to the 2u a little longer as we've suggested... test as often as possible, and we can look in as often as we can and comment as appropriate.
Yes-- this is where it would be nice to have some more data on 2U BID, where there would be little or no holdover, to compare nadirs. He dove pretty early and pretty hard at BID, but then he was getting a lot more insulin per dose as well.
Should I switch to BID 2u or stay at TID 2u?
Dunno-- I'm not a fan of TID in general, especially in the long term, but there's something to be said for holding steady (with maybe a dose decrease) for a few more days. It just takes some time to understand the results of a dose, and though we have some guesses here, right now that's all they are.
Let's see what others say about this.
I think TID dosing is the way to go when it appears the BID dosing is not lasting long enough and the sign of that is often kitty nadir being early in the cycle )(anywhere from +2 to +4). I don't know that the insulin is lasting a full 12 hours for Timmy but he doesn't seem to be gulping it down quickly either so even if he is getting 8 to 10 hours of effect, TID dosing would be causing a slight dose increase at the early part of each cycle. As Diana pointed out, the problem is what dose is going to bring down those black pre-shots. If Timmy has no history of ketones or DKA then I'd be inclined to go back to BID dosing at a dose of 2u to see what he does for a couple of days. I would however also make sure I was checking for ketones with those high pre-shot numbers because you don't want to cause any additional problems cropping up while searching for the right dose.
There are arguments for and against both BID and TID dosing, I think we agree. I think we need to keep to the current dose for today though and see what tomorrow's AMPS is... that would be after a full day's dosing of a total of 6u which is still higher than average so there is every possibility that Timmy is still bouncing on current doses. If he is still in the blacks tomorrow morning, maybe try 1.5u - I still wouldn't think that's enough to bring him down much from the very high numbers but you could try a day of TID dosing at 1.5u if only to collect data from that.
Or... still on TID, I'm wondering about a slightly reduced dose for one of the three shots, maybe the middle one... that would reduce the overall daily dose/overlap and hopefully the extent of the bounce, yet still keep some insulin going until the next shot.
Another option is to try 2u BID - that could go either way, ie not last 12 hours and send Timmy rocketing up again, or maybe helping to reduce the bounce.
It's trial and error, pure and simple.
My vote is to Keep doing what you are doing for at least another 3 days. I think changing again is not letting us see a clear picture. his numbers didn't come down as far today and that's ok. we don't want him dropping 70% each time. I think just give it a little more time and then re-evaluate. I think if you switch back to 2 units twice a day your cat is going to be spending 8 or more hours a day in black numbers.
if it were my cat I'd keep with the 2 units three times a day for a few more days and see what happens as it seems the bouncing is lessening. it's doing exactly what we intended with that drop from 2.5 units to 2, which was to lessen the drop from preshot so the curve isn't so sever. Now of course we want to see that preshot come down. The fact is his cat has probably been in VERY high numbers for a VERY long time and his body is used to being in those high numbers. he has to get used to being lower and that's going to take a while.
Be very sure he's not getting any food for at LEAST 2 hours prior to preshot tests. we don't want those preshots influenced by food at all.
Lots of options here for you Matthew... none of us has the magic answer but go with your instinct...
Matthew, do you have or can you get, any records of curves done at the vet's office before you joined FDMB or was the vet using fructosamine tests to determine the degree of regulation? Just thinking that a peak at what the vet was seeing on a curve, even though it was no doubt elevated by vet stress, might provide a bit more data to see how Timmy has been utilizing the insulin back when the vet suggested he was doing fine.
It may well be a good idea to check a few things with the vet... I would be really interested to see his/her comments on Timmy's numbers as per his up-to-date spreadsheet. If a vet says this is "fine" then they are sadly misinformed (that's the polite version of what I would really like to say).
Having said that, it's always possible that Timmy's numbers have been better and this recent data is caused by something else... Matthew, you said that Timmy had a cold... that could well affect BGs and he may need treatment for it. He may even have other underlying conditions that are producing these numbers... we on FDMB are aware of these but only a vet can examine and diagnose.
Other thoughts... go back to basics. Is the insulin stored upright in the fridge, are you rolling it between your palms before use, is it still within the maximum recommended useage time from when it was first opened? All these things could affect the results you're getting.
I would be inclined to ring the vet about Linda's comments (records of past data) and ask for a discussion of your spreadsheet (some people email the link to their vet). The vet may not be experienced in FD but there is no denying what is there in black and white, and as a professional animal healthcare person it is their responsibility to at least say something constructive. Try it - you have nothing to lose.
There was no curve done, it was a simple 5 minute test - so im not sure how useful that data would be?
Do you guys think the vet will be able to add anything valuable over what is available here? Surely this will just recommend a dosage to try?
Question, if we stop the bouncing and it holds steady between 400-600. Then when we start to increase the dosage to get his levels down wont he start bouncing again?
Sounds as if the vet just did a spot check which could have been at any point in the cycle and as such, worthless.
I just think that the vet - who is, after all, primarily responsible for Timmy's health while on insulin - should be aware that he is not "fine" and that in fact his blood glucose is all over the place. He/she will probably dispute why the 4u is not being given, so you would have to say that you have sought advice elsewhere and the consensus is that the dose was too high. So no, the vet won't add anything on dosing as such but as I said, with numbers like these that may have been going on for a long time, it could be that there is an underlying issue that needs to be checked out. It may be that Timmy is just a very bouncy kitty and we need to find the right dose, but if it were me I would soon be looking for a complete check-up.
If we're able to stop the bouncing, it should mean that pre-shot numbers will be lower and the curve should be gentler and somewhat more predictable, allowing you to determine a "usual" dose. We don't know what that dose is yet, we're still collecting data. On the correct dose to bring BGs down without panicking his body into producing more insulin, he shouldn't bounce.
Sounds like the vet did either a quick glucose or possibly a fructosamine test. Either way, it wouldn't add anything useful to the picture. While fructosamine can confirm the diagnosis, it can also give one a false picture of regulation. I had the vet tell me my girl was doing well based on a fructosamine test but I was home testing and had copious amounts of data to prove otherwise. The fructosamine was NOT reliable for determining regulation in my world.
I think Diana's idea of talking to the vet about the numbers you are seeing is worthwhile. Whether the vet can offer any useful suggestions or not, it could be an opportunity to educate the vet about their current practices. I agree it's possible Timmy was better regulated in the past but right now, he is running high and it would be worth having the vet give Timmy the once over to ensure there isn't an underlying condition contributing to his BG levels. You mentioned a cold and dental issues can sometimes cause symptoms similar to a cold. When was the last time the vet checked Timmy's teeth? Dental issues are often found to be the cause of elevated BGs with our sweet furkids.
The pattern seems fairly siniliar the past 3 days (TID 2u). Are we sure he is bouncing, and its not just that the insulin is wearing off too quick, letting him drift up to the 600's?
Are we absolutely certain that less and less insulin is correct and not that he doesnt actually need more?
No we're not certain, Matthew. Certain conditions can mean that cats require very high doses of insulin, or metabolise it inconsistently, and that's one reason a good vet's opinion and advice would be good. We can suggest one course of action here based on what we have heard, ie insulin dose probably raised too quickly, but without any early data we cannot be sure. That's why Linda asked if you had any curve results from the vet.
If you can't find a good vet very locally to you, you may have to look a little further afield. I'm sorry to keep on about it - finding a vet who knows what they're talking about - but if Timmy has been in these numbers for a long time they are doing him no good at all. A vet could also take blood tests or diagnose an infection and prescribe antibiotics... we on FDMB can do none of those things, we can simply talk you through the theory.
Any recommendations of what to look out for when searching for a decent vet?
Ring some practices and ask if any of their vets have a special interest in cats, specifically with experience of treating diabetes in cats. More and more cats are being dx with diabetes, caused at least in part by a dry food diet, so the whole area of FD is one that more vets should be paying attention to. I have found that it is the vets a few years out of vet college who realise things like this and take it upon themselves to study more (ie as opposed to vets with a long career during which time they may not have treated many cases of FD, let alone wised up about it).
Matthew, no one can tell you 100% that Timmy isn't going to need more insulin. That remains to be seen. And whether the insulin is lasting long enough is another question but my read on the data we have is that we can put that hypothesis to rest because Timmy doesn't seem to be metabolizing the insulin overly quickly i.e in the early part of the cycle between +1.5 to +3 . From your testing it looks like he is not reaching peak action until somewhere between +4 and +5 hours post shot so with TID dosing he should be getting reasonable insulin concentrations for the full 24 hours.
What is clear is that when he drops, he drops a lot, often by 50% or more of his pre-shot reading and that is a recipe for bouncing. While his mid cycle numbers are not quite as low as they were, his pre-shot numbers appear to possibly be gradually coming down albeit slowly. His body has become used to high numbers and over reacts to those big drops in BG and his perception of a big drop is out of kilter and needs time to recalibrate. Some cats are very prone to bouncing while others bounce and then smooth out quickly. Getting the major bouncing out of the picture will allow you to slowly adjust the dose to find the optimal dose whether that dose is ultimately more or less than what he's getting now.
Given we don't have historical data, this may very well explain why your vet may have wrongly assumed Timmy was doing fine. He may have always been bouncing into these high numbers. If the vet took readings like the 205 on the 26th at +5, 201 at +5 on the 30th or the 149 at +4 on the 30th in the 2nd cycle of the day, the vet could very well assume Timmy was attaining acceptable if not optimal BG. Some vets prefer to have their feline patients running higher than optimal simply because they are on insulin. Your vet's error in declaring Timmy's numbers as OK may have come from not seeing the whole picture as opposed to misinterpreting what they did see.
Now that you have data throughout the cycles, your vet may very well have a different take on how well Timmy is regulated. I think it's worth checking in with the vet or getting a 2nd opinon if you prefer.
Thanks again everyone for the super comments and useful information given - always appreciated.
The vets test was always at 11-12, so would have been +2/+3 from the shot. My worry with that vet is that they never suggested home testing, curve, or anything like that. Been ringing round a few vets, for a second opinion, if anything a fresh pair of eyes wont hurt.
Matthew, THIS might help you when interviewing a new vet.
Many vets don't suggest home testing, because they are afraid owners won't want to make the commitment to their pet and will choose to euthanize if told they should do hometesting. Some don't suggest curves because they are expensive, and, again, many owners won't do it. Not saying that's what is going on with your vet, just giving you a possible alternate explanation for the hands-off approach.
I do think a second opinion would also be valuable, and it's always a good idea to rule out additional health issues when trying to sort out insulin dosing.
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