BG Still High

Hello again everyone,

First I want to thank everyone for their input each time I post. Den's diabetes is weighing heavily on our family but it's great to have this forum as a resource. I've put in the time to understand how to make his chart on Google Docs and I'm hoping someone could give me their thoughts.

He was once regulated on 1u of Novolin, then became unregulated and we eventually switched him to Vetsulin. The prescription D/M that he was eating was elevating his BG- he's now on a diet that consists of boiled chicken breast and one scoop of Nature's Balance Venison. This food seems to keep his number on the "lower end of high", but he is still almost always over 600 before insulin!

Perhaps it's not helping that sometimes he's in the 300's before insulin so I do not give him the full 7 units that he is now on......maybe I'm making this worse by lowering his dose when I see a lower BG.....Can doing that effect him a couple days later??

I'm very scared at this point..... Any help is always greatly appreciated.

 

Do you know what the carb count is in the Natures Balance? Is it a dry food or wet? It sounds like dry since you say you're giving a scoop, which can be pretty high carb. Not sure about dosing Vetsulin, @Sue and Oliver (GA) do you have any suggestions?

 

I apologize, it's wet food. I do a small spoonful of it in combination with the chicken breast. I posted the nutritional information below but I'm not sure it's that helpful..... I don't fully understand these nutritional labels.


Crude Protein 9.0% Min.
Crude Fat 5.0% Min.
Crude Fiber 1.0% Max.
Moisture 78.0% Max.
Taurine 0.05% Min.

Venison, Venison Broth, Venison Liver, Ground Peas, Natural Flavor, Venison Meal, Salmon Oil, Canola Oil, Vitamins (Choline Chloride, Vitamin E Supplement, Thiamine Mononitrate, Niacin Supplement, Vitamin A Supplement, Pyridoxine Hydrochloride, d-Calcium Pantothenate, Riboflavin Supplement, Folic Acid, Biotin, Vitamin B12 Supplement), Dicalcium Phosphate, Guar Gum, Salt, Minerals (Zinc Proteinate, Zinc Sulfate, Ferrous Sulfate, Iron Proteinate, Copper Sulfate, Copper Proteinate, Manganese Sulfate, Manganese Proteinate, Calcium Iodate, Sodium Selenite), Taurine, Flaxseed Meal, Kelp Meal, Cranberries, DL- Methionine, Potassium Chloride, Calcium Carbonate, Carrageenan, Yucca Schidigera Extract.
Calories

Calorie Content (calculated): ME = 1170 kcal/kg; 180 kcal/5.5 oz. can

 

It looks ok, although peas are a source of carbs, so you could get a lower carb food. As high as his numbers are though, I'm thinking it may be more than just the food. Have you thought about testing him for Acromegaly or IAA? Both of these conditions cause a cat to need larger than normal amounts of insulin. Also, have you been testing for ketones since he had a DKA episode before?
http://www.felinediabetes.com/FDMB/...-other-high-dose-conditions-what-we-know.375/

 

I test for ketones with the strips that test the urine for both sugar and traces of ketones. He always has a lot of sugar in his urine (he reads at one level down from the highest level), but he has never tested positive for traces of ketones....
The ER originally told me the strips would be an important tool for me to detect signs of ketoacidosis, however, his regular vet (well the one who filled in for the vet when she was away) told me they're not useful! She also told me that he needs 7u based on his BG but last week his BG was somehow 211 before insulin so I called to ask her what to do and she said "it doesn't matter what his BG is- give him the 7units, never change the units"........Is that an actual rule???
(I only gave him 1 unit......)

 

I don't know a lot about Vetsulin, but it is an in and out insulin rather than a depot insulin, so, like ProZinc you can change the dose according to the Preshot. @Alexi used vetsulin. Maybe she can advise you on it's dosing.

 

I think this is solvable.

Dennis has had some reasonable APMS numbers recently but the picture is complicated because doses are being changed almost daily - although it is possible to do a sliding scale with vetsulin I think his numbers are too high to do this at the moment. What is needed is some consistency with the dosing and a curve, as well as the food. Looking back at your data I'm making a best guess that his nadir is around +6 with a 200 point drop. The first aim should be to try to hold the dose for a few days to even up the AMPS and PMPS numbers. Getting a +2 would be really useful here as what you are looking for is a small drop at +2. Your first aim should be for red numbers at APMS and PMPS, if you get an unexpected lower number please post for dosing advice as what I am hoping is that the dose can be eased down as better control is achieved and those AMPS and PMPS numbers start to come down.

I am not familiar with your food but it would be useful to try to get a carb % calculation 'as fed'.

I think I asked before but can't find it in his labs - has he been tested for high dose conditions? Others know better about the practicalities of this but it shouldn't be too expensive as it is a blood test but has to be sent away.

Once you have some consistent dosing for at least 6 cycles can you do a curve? This will really help in assessing Dennis's response and at what number a dose reduction is earned. You will need nerves of steel as you are not used to seeing lower numbers but if we can get them evened up we may be able to achieve better control. At those numbers glucose in the urine is inevitable but you need to test for ketones regularly as he has a history of DKA.

 

Could you please tell me what APMS and what PMPS means? And nadir? Sorry I'm not familiar with those terms.
No he hasn't been tested for high dose conditions. He had a fructoseamine done 2 week ago and the vet said his number was "high and in the 500s" so that's why we went up to 7u but the vet said we would likely have to go to 8. I just started him on 8u because I got home from work and he was shaking pretty badly. I tested his urine for ketones but the strip didn't change color at all. Usually it turns slightly pink to match the control color, but it didn't even do that which is odd.

So do you think I should hold off on checking his BG after his insulin until he's been on the same dose for 6 days (12 doses)?

 

AMPS is the test taken before you feed and shoot in the morning and PMPS is the same test, in the evening. Nadir is the point of the cycle where the insulin is at it's peak and therefore the lowest BG. Always check Dennis' BG before every shot and try to get a test or two during each cycle. Fructosamine only gives an average for the week and if you test at home you will get much better info.

 

AMPS = morning pre-shot, PMPS = evening pre-shot, each of these tests should be before feeding and with no food for the previous 2 hours.
+1, +2, etc = number of hours after giving insulin
nadir = lowest point of each cycle = lowest number in that cycle

What I am suggesting is to continue to do the pre-shot numbers, check a +2 test and others as you are able during the cycle, +6 would be helpful as well.

Hold the dose for at least 3 days to try to get red numbers at AMPS and PMPS, at least six doses, it may take more.

Post for advice if you get something lower than a red AMPS or PMPS number during this time.

Once you are getting consistency with both AMPS and PMPS in the red then do a curve, test every 2 hours until the numbers are dropping then hourly, then 2 hourly as the numbers rise again - this will help us to see how he is responding to the insulin and gives a better idea of what dose changes can be made.

Please can you report in daily with progress so we can keep an eye on things.

 

Thank you!! Yes I'll keep posting daily, at least once each day.
If a cat is unregulated how much of a concern is it for kitty to be shaking before getting insulin? I'm wondering how concerned I should be right now.

 

Thank you so much for explaining all of this. I always test his BG before insulin even though the vet actually told me to stop- she said that I'm doing too much but I just don't feel right giving him insulin blindly.

 

Did you test his BG when he was shaking?

 

Yes it was "Hi", which means any number over 600. On his chart I write 600 when I get the reading of "Hi", but the real number is truly unknown.

 

How is he now? Did he eat?

 

Yes he ate, and I gave him 8 units for the second time (his first ever 8 unit dose was this morning). This is his +3 hours and his reading is 240. I know he will go lower for the next 3 hours so now I'm concerned at how quickly his BG is coming down.
Recently, his BG either doesn't come down much, or it drops too quickly after his insulin and then skyrockets again well before it should.

 

Often when they drop fast or lower than they are used too, they bounce, meaning the it body panics at the drop and releases glycogen into the bloodstream thus their BG goes higher. To slow him down, you can give a teaspoon of low carb food.

 

Thank you!! I'll try that now!

 

Great, and update your SS with the numbers you get. This will be useful for dosing advice.

 

I'll do it first thing in the morning (it's much easier from my work computer rather than my iPhone). Thank you so much. I felt so lost just a few hours ago but you've given me some hope!
I never knew diabetes was so complicated.

 

When do you plan to get the next test?

 

I'm going to test again in about an hour and a half (2 hours from the last test). I'll do this through the night until he climbs high again. Unfortunately in the morning I have to give him his insulin and then imediately leave for work so I can't monitor him in the daytime.

 

Good then that you're getting some readings at night. Post the numbers you get.

 

To update from an iPhone you need to download the free app Google Sheets... It works fine but you have to click the check mark in the upper left corner to save the new data.

 

Awesome! Thank you, I'll download the app.

 

I'm wondering if anyone might be able to interpret the results of Dennis' ketone strip? I've had the same result 3 times in a row over the past 30 hours. The result is a pale blush pink. I can't tell if it is closer to "negative" or "trace" and it's worrying me. The only time he ever had ketones was when we didn't know he had diabetes and he was DKA. That was about 4 months ago and he's never had traces of ketones since then.

Although I haven't updated his chart yet, his numbers have come down since last night. Instead of a BG over 600 before insulin, he's been in the 400s thanks to consistent 7u doses and the advise of everyone on this board.

I have a feeling he will be too low to get 7u in the morning.....any thoughts?

 

Looks like it's in between negative and trace to me, but I'm not a pro at reading them...you might want to consider getting a blood ketone meter....the strips are expensive, but it can catch ketones in the blood instead of waiting for them to show up in the urine

You wouldn't have to use it every day, but if you had a special concern, it would be good to have as a backup, especially with a cat with a history of DKA. American Diabetes Wholesale has these NovoMax blood ketone meter kits that include 10 ketone strips

 

We usually suggest if they're over 200 at Pre-shot, that you shoot the scheduled dose

There's a Vetsulin User Guide that might help for you to read over

I've never used Vetsulin so don't have a lot of experience with it, but it would really help to start getting some more tests in to see how quickly and how low this dose is taking him...If at all possible, a +3 on both cycles and another test a few hours later (like +5 to +7) would really help

Another option is to try a longer acting, more gentle insulin like Lantus or Levemir. Novolin and Vetsulin are both similar insulins with similar actions...a depot insulin might work much better for Dennis

 

Please update his chart after every test, those +2 and mid cycle numbers are important to see in order to work out how the insulin is working for Dennis and when he needs a reduction, you will be glad of it if you need urgent advice. Vetsulin dosing is based on how low the insulin takes his numbers and you want to see blue mid cycle numbers. I'll check in later to look at his chart.

 

Thank you, I didn't even know those existed. I'll certainly be buying them but I can't afford them this week. Since Den's diagnosis it seems that all of my weekly savings goes towards his expenses.

 

Thank you. His mid cycle seems to be coming down, which is good news. He made it into the yellow last night!

 

It can depend on how long the strip was in the urine. The instructions on my bottle of Keto-Diastix say to dip it and remove, not let it soak in the urine.

 

Those are nice safe numbers so hold the dose for a few more cycles, what you don't want is to take things too aggressively at this stage and risk him bouncing. What you want to see is a gentle drop in his AMPS and PMPS numbers. Keep those +2 and mid cycle tests coming. Yesterday your AM mid cycle shows at 2.99 - I think you meant 299.

With keto-diastix dip it into the urine and then after 15 seconds do the reading on the ketones, if you leave it longer than 15 seconds the colour may change and give you a false reading. I hold it edge downwards for those 15 seconds to stop the colours bleeding into each other.

 

Yes, 299! I'll fix that. Do you suggest the "catch" then dip technique for the urine? I am usually able to stick the test strip in his stream while he's urinating. I've never had an issue with the result, however, I tend to leave the strip in his stream as long as possible to ensure that it's saturated. That could be the issue. I've also purchased a new box of strips (just for ketones, not glucose because that's all Walmart had left)- I'll be trying these tonight.

 

I catch with a spoon then dip, I put the spoon down in the kitchen sink which is close to the litter box, I find it easier to control that way and to be able to time it better.