changing food (NF => DM), feedback for beginner + other questions

Hello! It was recommended that I repost my question from the general health forum here.

Here's the gist:

- Quintus has been on Lantus for a week, and we've been going "up" faster than the protocols here recommend, but that's where we're at: 3ui bid since yesterday morning (two before that). Spreadsheet has the numbers and today's readings, whilst still high, seem nice and flat. Improvement, right?
- I want to switch from NF kibble to DM cans. He finds the cans palatable. I'm worried about diarrhea (he has a history of shitty paw in my face at 4am), so I'd like to transition gradually. Does anybody have advice regarding how to manage this transition? Here's what I wrote in my original post:

And while I'm here:

- I find the Lantus pen annoying. I'm going to be considering syringes (I know the consensus here is they're a better choice). I am however curious to hear if there is anybody on the board using the pen directly. And if so, is there anybody using the pen without priming it each time? or is everybody doing that religiously?
- I'm not testing for ketones. This is starting to worry me so I'm considering raising the issue with my vet. Looking at Quintus's numbers, how worried should I be? He pees and drinks a lot (but less than before we diagnosed him 20th Nov and started insulin). He's "generally OK", purrs, plays a little (he's blind and recovering from pancreatitis and has a lot of arthritis, so play is tricky), gets up and walks around (went to the door to go outside twice yesterday, hadn't done that in a while!), etc. So his general state is not worrying me (more).
- glucose toxicity: I've read up on it but don't understand if with the level of glucose Quintus is displaying I need to be worried.

Thanks for any advice or answers you may bring me!

 

Hello, Stephanie and Quintus, and welcome!

Some here might use the pen with pen needles, but I haven't heard of anyone doing that personally. A lot of people have Lantus pens, but dose from them with u100 syringes. It's better than way for cats because we are often dealing with small and incremental doses, so even if he's on 2 units now, should he need an increase or a decrease, that is done by .25 at a time in most cases. I don't think you could dial a 2.25 dose, for example.

Testing for keytones is pretty easy, I would get some ketostix from a pharmacy and start using those to make sure no keytones are present. You can also buy a meter that tests for keytones with blood, just like a glucose meter (different strips).

Switching to low carb wet food is an excellent step, his insulin needs can change drastically when doing that, however, best to proceed with caution there. We have many experienced members here that can give you some insight on the numbers you are seeing and what it could indicate, but I just wanted to welcome you.

Glad you are testing and have your SS up, that helps so much. Read and reread the stickies at the top of this forum, it's a lot of info and can be a steep learning curve, but with all that info and the guidance you can receive here, Quintus will start looking and feeling better and better.

 

Hi and welcome Stephanie and Quintus. If you haven't yet, I recommend reading the yellowed starred Sticky notes at the top of this forum. A lot of info, but keep asking questions and we'll help you navigate it.

First, why the increase to 3.0 units? From the spreadsheet (good job getting that up), it looks like 2 units got him into the 70's. Here we determine dose by how LOW the dose takes the cat, not the highs. We use 68 on the AT as the number below which we give high carb food as it's too low. First thing I'd do is go back to 2.0 units, hold the dose for a while and get some data. Maybe even 1.5 units if you had syringes (more about that below) and if you are planning on going to all wet food. A phenomenon you'll read about in the New to the Group Sticky Note is bouncing, which is the cats temporary reaction to numbers lower than they are used to.

Could you put the meter brand/type in your signature? Our reduction point is different for the AT than the human meters that most of us use and having it in the signature gives us a quick reminder.

Lantus is a depot insulin, it takes a while (6 cycles) to builid the depot. We don't increase any sooner than that. Lantus also likes consistent dosing, so we pick a dose and hold it for at least 3 days before evaluating it.

Food - first of all, you don't need the vet prescription food. It's usually not the greatest quality ingredients. If you search around here, you can find lists of low carb European food. @Gill & George if sh hasn't left for holidays yet, may have that list handy. Her kitty ate Thrive. I would switch slowly from dry to wet. Put out 1 spoon of wet for each meal, next day go up to 2 spoons, etc. It may help to put him on some probiotics (human ones are OK) before hand, to help his tummy flora handle the change.

Syringes - yes, do switch. Kitties are sensitive to the tiniest changes in dose. My Neko, when she was on smaller doses, would notice the difference in a drop or two. You'll probably find the BD Microfines are what you want, you want the ones with 1/2 unit markings, so you can eyeball 0.25 unit changes. Insulin doesn't last as long if you use pens. You have to leave a working pen out of the fridge, so it's expire after a month. I used syringes with cartridges (pen refill) and used them to the last drop, which for Neko was up to 90 days. Insulin is too expensive to waste.

Glucose toxicity - yes it can be a concern. But not something I'd focus on first. First I'd start a lower dose. We've had cats insulin needs drop a lot when switching from dry to wet. 3.0 units is too much insulin on dry food. It's easier to start on a lower dose and work your way up.

 

Hello Stephanie and Quintus! This in a great place with knowledgeable folks, so use that to your advantage. Best of luck to you.

 

Thanks for your responses.

The day he ended up with 4.2 mmol/l AMPS I'm pretty sure he hadn't eaten during the night, and had eaten very little during the day. I get that it's a good reading, but if he hadn't eaten, that explains why it's so low, doesn't it? It would have been higher with normal food intake.

We raised the dose because his glucose is not coming down sufficiently. I have trouble with the idea of lowering the dose, or staying on a low dose, when the cat is swimming in sugar for days and days (turning into weeks). I've read the stickies but I don't get how it makes sense to lower the dose at this stage when he barely touches below 20 mmol/l. I understand the depot thing (I think!), meaning that the height of the effect of the insulin is a handful of hours after injection, that most of the effect is gone after 12, but that there is still insulin from that injection entering the bloodstream for a couple of days after the shot. But is that amount really that significant that it ends up amounting to the equivalent of 1 or 1.5 ui over the day? Are there any tables or visual representations that could help me understand the numbers/proportions better?

Quintus doesn't really have meals, but if I try to translate to how we deal with food, I'd give him a spoonful in the morning, have my neighbour give him another one mid- and end- morning, one in the afternoon, and then again when I come back in the evening and before going to bed. And then gently up the amount of wet food until he gets his complete dose of wet food over the day, and take the kibble away. I have a microchip feeder and was thinking of using it for the wet food as it keeps it (somewhat) fresh during the day.

And do I understand correctly that you would do this only after having come back down to 2ui or 1.5ui (so, without waiting for his BG to come down at all?) for at least three days?

Would you want to monitor during the day when introducing the wet food?

This is confusing for me. As I see it, having a lot of sugar in your blood is not a good thing, so we want to reduce that -- amongst other reasons, because of glucose toxicity. Why is it "not enough of a concern" at this stage? I'm starting to be really worried about how many days it's been since his BG levels have been anywhere near acceptable at any moment in the day. Surely this has consequences?

(I hope my questions don't come across wrong. I'm just trying to make sense of all this.)

 

In the FAQ, I found this:

I inject Quintus in the scruff. Is this not a good place to inject?
Quintus has pancreatitis (being treated). Does this mean we will not be able to lower the BG? Or does it just explain why it's not coming down, and if the pancreatitis gets better, it will come down?

 

Eating less food will impact the numbers a bit, but not that much. I still say 3.0 units is too high, especially since you plan to transition to lower carb wet food. We've had one cat go from 5.5 units to zero in one very intense couple of days after dry food was removed from the house. Getting to 4.2 when he wasn't used to it, caused the bounce, which explains high numbers for 3 days afterwards. Bounces can take 6 cycles to resolve (when a cat is new). Always wait 6 cycles when you see a low like that, for the bounce to resolve, to see if he gets back to good numbers, before increasing. You increased after 5 cycles. Then another you might have been seeing something we call, New Dose Wonkiness, which causes temporary high numbers after an increase.

Due to the nature of the depot, the effects of a higher dose can last 4-6 cycles (2-3 days) after you lower a dose. Because of that, I would lower the dose with that amount of lead time from the food change. Changing to wet food can make a dramatic change, usually not as much as above, but we've had many caregivers fighting low numbers because of it. Rather a day too high than a moment too low. Safety first is our motto.

Take a look at other cat's spreadsheets, especially the early days of their diabetes. You'll see Quintus SS looks a lot like other cats. Keep in mind you are using the AT, which shows higher numbers at the high end than the human meters most of us use.

You can overcome glucose toxicity with enough insulin. But safety first. Let the Lantus depot build, increase in safe amounts. With green nadirs, we would only increase by 0.25 units at a time. You don't want to overshoot a good dose. Hypos kill quickly. We usually don't know how long our kitties were diabetic before they were diagnosed. I wouldn't worry about mere days in higher numbers.

I injected Neko in the scruff or just behind the shoulders for 5 years with no problem. She was a long haired kitty and that was the only place with short hair and easy to shoot.

Pancreatitis is painful - pain can cause the blood sugar numbers to go up. How is he being treated? Is he getting pain relief? Typically pancreatitis can cause the numbers to go up, then go down as it's better. Here is a Primer on Pancreatitis.

 

Hi Stephanie,

Welcome! It's hard to get your head around everything at the beginning - I know! My head was spinning for a long time with all of the information I had to learn and digest.

An important thing to keep in mind: this sugar dance is a marathon, not a sprint! You can't go straight to good numbers within a week or two - it just won't happen. It'll take time for Quintus' body to adapt to the insulin, and you'll probably see lots of interesting ups and down over the weeks to follow as that takes place. Also, you don't know how long Quintus had diabetes and was living in really high numbers. I know Girlie got used to those high numbers, and it took time for her body to get comfortable with lower numbers again. Initially low numbers scared her - even numbers in yellow - and she'd bounce sky high for 6 cycles or so (3 days) as a result. This is very common.

I'd really recommend that you look at other people's spreadsheets and posts. I learned so much by doing that. You'll be able to see how even a tiny dose increase (o.25) can have dramatic effects. And you'll see how careful people are about increasing and decreasing doses based on the lowest point in the cycle - not the AM or PM pre-shot tests. I know you're using the pen and don't have the 1/2 unit syringes yet, but see if you can get them from Hyperdrug.uk: I get the BD microfine 1/2 unit syringes shipped to me here in Australia.

But don't look at Girlie's spreadsheet!! She's not your average cat and I wouldn't use her as any sort of model at all.

As you've already seen 4.2 on the AlphaTrak2, be careful: 3.8 is the take action number, as lower than that is a hypo risk. Do you have a hypo toolkit handy? You don't want to try to scramble for what you'll need when you get a really low reading and are panicking...

Here's some info for you:

• on pancreatitis
• on the depot
• on Where can I find...? (commonly referred to posts)

This can all be really overwhelming at first. But this is a great community, and people will help you out.

 

OK, just looked at the SS again. Things started stabilising after last night's shot. He had his first 2ui shot 8 cycles before that. Do you count the cycles for the bounce from the moment it starts going back up? And so would the high numbers seen yesterday AM be another bounce, due to the 3ui change -- and I would have missed the low that lead to that bounce because it was during the night?

edit: What about the stable numbers since last night? Is that just luck or is this "post-bounce" stability? I was finding them very encouraging.

If you wait for a bounce to resolve and we don't get back to good numbers, does it mean it wasn't a bounce? If it comes back to good numbers it confirms it was indeed a bounce?

So if I plan to change food on Saturday, say, you would lower the dose on Wednesday. That means he'd be a bit high probably on Thursday/Friday, but it would prevent him from falling too low on Saturday when food starts changing. Did I get that right?

I guess I'm being too anxious about the high blood sugar. In Quintus's case, as we have a very strong suspicion the diabetes is secondary to the pancreatitis (more about that below), and there was a marked increase in his drinking just a couple or three weeks before I got him tested, it seems that it is a very recent development. Hence, I guess, my sense of urgency to get things under control ASAP. But I get it, we don't want to take any risks going low too fast.

His pancreatitis was diagnosed end September, and it's the chronic kind rather than acute. It doesn't look good on the ultrasound. There are signs of possible necrosis, and one end of the pancreas looks like a "boxing glove" -- much bigger than should be. The vet who did the ultrasound told me (mid-Nov) although we were not certain, many signs were pointing to a possible tumor (bloodwork, what was visible on the ultrasound, clinical signs). Early Nov he did not seem to have any abdominal pain (vet exam). He's been on antibiotics since early Nov (convenia + marbocyl) and I see clear improvement following the convenia injections. I know cats are good at hiding pain, but he seems quite comfy (my observation is heading the same direction as the vet's). He has not been vomiting at all. There were very little clinical signs of the pancreatitis (we stumbled upon it because I asked for blood work before starting my new job and I thought he'd been a teensy bit under the weather lately). Given how he's improved the tumor (at least a cancerous version) seems unlikely.

 

Thanks! I guess I'm in too much of a hurry. I got a sense of urgency from my vet about the high numbers, but maybe it's my interpretation. Checking your signature, Girlie and Quintus seem to have quite a bit in common! Burmese/Asian breed, stage 2 CKD, arthritis, pancreatitis. No asthma or epilepsy here, though.

Which SS would you look at, for starters?

 

Believe me, I'm with you there. Some cats seem to go straight to good numbers and quickly go off the juice; others take a long time; ECID is the rule as there is no rule on this.

You have the hypo risks, but then you have the hyper risk at the other end. Try to get the ketostix. Girlie ran super high for long periods of time, so I was testing her urine frequently for ketones, which have to be addressed asap. But at least the ketostix will tell you where you are with that rather than wondering. Girlie also was a master super deep diver. I really hope that Quintus stays far away from the diving board!

Everyone's! I'm only half-joking, because every cat is different (ECID). Also, some cats are high dose kitties (with Acromegaly), but it doesn't matter, really - the more you look at others', the more of a sense you'll get of how this disease works in other cats. I know Lizzie's cat, Gizmo, has pancreatitis battles as well. You can go to the 2016 tab on Gizmo's SS to see how he started out. I have gained such a wealth of info from reading other people's condos and looking at their SS. You can see when someone asks about a dose increase as they usually put that in their title. Reading the comments and analysis of experienced people - and looking at the corresponding SS - can help you get a feel for how this sugar dance works and answer lots of questions that you probably never knew you had. Plus, you make a connection with others that's so valuable and heartwarming.

Bouncing took me MONTHS to get my head around: I don't know why. I just couldn't distinguish what a bounce was vs. what signified a need to increase the dose. But I really relied on experienced people here like Wendy & Neko to help with dose suggestions. They could see what I couldn't because of their years and years of experience here.

You're in the right place, Stephanie. Just get your marathon sneakers on! I have to laugh at the number of times I was reminded to "put on the patience pants." But it was always good advice...

 

Hi Stephanie, and welcome to Lantus & Levemir Land, the nicest place you never wanted to be!

I'm on the way out the door, but wanted to take a sec to welcome you and to give you a link to a post we put together to help new members get comfortable with this Forum, and understand some of the stuff we say. The Stickies at the top of the page have TONS of info, but it can make your head swim reading them, so we tried to keep this post a little lighter and easier to digest. You've been given lots of great guidance already, and I'm sure you're feeling overwhelmed. Ask lots of questions - the only dumb question is the one you don't ask. We all remember how it felt to be new at this sugar dance, and we love to help!

Here's that link: http://www.felinediabetes.com/FDMB/threads/updated-tips-for-new-members.173572/ (BTW, any time you see blue text in a post, it's a hot link).

Also, I know you live in Europe, so some info many not apply, but a great website on feline nutrition is Catinfo.org. It's owned by a veterinarian who has been known to post on our site. She has a page in there about transitioning from dry to wet you may find helpful.

 

ketones. Newbie here. I thought ... what catch him peeing and stick a spoon under him?!

I isolated him with a catbox; cut open two gallon ziploc bags and put one at each end of the box (with some open litter for scratching in the middle. Amazed, he pee-d right on the plastic. Just had to put the stick in there. Hope it can be that easy for anybody who tries.

 

where to shoot. So much here, but I've read many times that the near the neck does not generally provide the best circulation (I note someone else with a long-hair said it worked fine for her. But most cats have lots of extra skin all over. More experienced people can say if it isn't -- generally -- best to pick another place than the neck....

 

We shot both our diabetic cats in the shoulder from day one - alternating sides. Seemed to work just fine.

My Cinco, who was also blind for the last year of his life, was so mellow I could stick a ketostix right in the stream when he peed. Harvey, on the other hand, was a stealth pee-er. It was very hard to catch him at it. Luckily, I didn't have to test him very often.

 

Putting a stick under Quintus when he pees will not be a problem. He pees often (surprise) and is stoic. After he had a bad bladder infection once and was urinating blood, every now and again I get worried and slip a piece of tissue underneath to make sure the color is good.

 

Girlie is a very tolerant cat and has no respect for my privacy in the loo, so...

I have a dedicated little ceramic dip bowl that's all hers. When she starts to pee, I just wait for the right moment and then catch some mid-stream. Works great! But she's not shy, so... I've heard that other people have used a long-handled ladle or spoon. There's also dedicated cat litter called Catrine, but it's a bit expensive given how often I had to do the urine tests, so I'm just glad Girlie isn't shy.

 

Sounds like you're a dedicated cat owner, Stephanie - well done you!

 

Here's another post to read if you want more info on bouncing: http://www.felinediabetes.com/FDMB/threads/10-29-jetta-pmps-328-2-339.55306/

 

OK, start the count of cycles the one after the event that caused the bounce. It can be either caused by either a drop into numbers lower than they are used to (some cats bounce from yellows), or a fast drop. I think what happened is that you saw a bounce, then NDW or New Dose Wonkiness, which is starting to wear off. Almost every kitty starts out bouncing when they are new to insulin.

It is possible that kitties will do a one time good numbers, then not again. But we don't know until we've waited at that same dose. Lantus teaches patience, never my strong suit. Try to avoid overanalyzing each cycle - yeah, ask me how I know how tough that is. You are looking more at trends and overall picture. Insulin is a hormone, not a drug - don't expect to see incremental improvements with each dose increase.

 

So, I'm going to call it a night (past midnight and shooting at 6.30am). So far: I'm going to wait to change his food, understanding it could be dangerous if I rush it.
I'm hesitant about 2ui vs 3ui for tomorrow's shot. I understand the rebound idea and indeed it makes sense with the numbers I have. But the readings have been nice and flat the last 24 hours, and I'm hesitant to "mess" with the course of action we planned with my vet. Also, it would mean changing a dose again after just 4 cycles.

I'm still not 100% confident that the reading at 75 is something we can rely on. If a cat is fasting vs. eating, it should have quite an impact on that number, no? Let's imagine he had a quarter of his daily ration during the previous day and fasted all night. Why would we trust the value of the next morning to determine how much to shoot?

 

If the NDW is wearing off, what is the risk of staying at 3ui if it is indeed "too high" and we landed there because of the bounce?

Tomorrow is the last day I can "try stuff" or "observe stuff" as I'll be away from home 15 hours straight both Monday and Tuesday, which is worrying me a little.

 

Re: being away for 15 hours: a dilemma that all of us face and that causes lots of

A piece of advice I always go with: better a day too high than an hour too low.

 

I think what others have mentioned is that we don't base dose changes on the AM pre-shot or the PM pre-shot number on one particular day: a dose change is based on the pattern of the lowest numbers over a period of consecutive cycles (2 cycles in a day as 2 shots in a day). Does that make sense?

 

It does... But in this case, the 75 we're talking about (Tuesday morning) was a pre-shot. So, does that mean he had a near-hypo during the night? But if he hadn't eaten (and what he had eaten was mostly low-carb food -- I was messing around with his diet then), wouldn't that be expected -- I mean, isn't the value an indicator of the lack of food, rather than excess of insulin?

If I look at the low value for today, well, it was in the 300s (I just did another measure now as I'm still awake... 470). I'm really having a hard time wrapping my head around the idea that I need to decrease the dose when I'm seeing such numbers.

 

Not necessarily. It's possible that he had a very late nadir (ie., at the end of the cycle). BG numbers will sometimes trend downward from the start to the end of a cycle. This can mean the dose is too high - or not.

Not necessarily. Absorption of insulin, mobilization from the depot and physiological response to the insulin can vary hour to hour, cycle to cycle and day to day. There's no consistent linear relationship between size of dose and lowest BG achieved, especially in an unregulated diabetic. It's a hormone that's involved in a variety of complex physiologic processes.

 

Late night confusion: I decided I needed to change the food because I assumed the high values I was seeing were due to him eating. Maybe not, then, if they were due to bouncing? Is it viable to keep him on NF for the time being and stabilise him like that?

Also, realised I won’t be there tomorrow for my 6.30pm shot. Will have to do it at 5ish. The schedule part is starting to stress me out, I hadn’t realised it needed to be so precise :-(

 

Hard to say what he did over that night. Gaps in data just mean we have to guess. I will point out that he had some 1.0 unit doses in the days prior, so that 75 was seen without the full 2.0 unit depot in play. Otherwise he might have gone even lower. Not all of the insulin you shoot goes to counteract the food he eats. When cats have anethesia and can't eat, vets usually suggest 1/2 a dose is safe. When Neko was being fussy, I was happy if she got at least 2/3 of her food in her.

When looking at dose questions, we ask the question "how low is this dose capable of taking my cat?". In Quintis's case, the answer for the 2.0 unit dose was the 70's, which is just above the "take action - close to hypo" point. Remember how I said not to look at individual cycles but rather the bigger picture across cycles at a dose. You are now on 50% more insulin than a dose that almost hypo'ed him.

Getting him on low carb food will make it easier to stabilize him.

Shooting early is like yet another dose increase. You are already on too high a dose. I would strongly suggest lowering the dose tomorrow morning. We suggest moving shot times by 1/2 hour once a day, or 15 minutes every cycle. When you know you have a day you have to shoot early, like tomorrow night, start moving the shot time up earlier. Here is a post on Getting Back on Schedule. I had to move Neko's shot time around some evening commitments, and it was all doable with planning ahead.

 

232 this morning. Gave him 2. Back to sleep.