Dosing questions for Riker

Discussion in 'Caninsulin / Vetsulin and N / NPH' started by BethB, Dec 28, 2018.

  1. BethB

    BethB New Member

    Joined:
    Dec 20, 2018
    Hello!

    I posted for the first time in the Welcome thread today. Since Riker is on Vetsulin, several members suggested I repost my dosing questions here. Riker was diagnosed 12/18/18 with a BG of 430.

    The vet put him on an initial dose of 3 units of Vetsulin 2x a day and also recommended a switch to a low carb diet. Because I didn't have a glucometer at home yet, I was worried that this dose recommendation was too high. I never gave him more than 2u while dosing blind.

    We started home BG testing on 12/23/2018 using an AlphaTrak 2 meter. I was just trying to get the most accurate meter, though now I've learned that I set myself up for extra expense on test strips. I've since learned that FreeStyle Insulinx strips can be substituted with the AlphaTrak 2. If true, that could save me some money.

    BG testing was difficult at first, both Riker and his ears resisted! But we are in a good rhythm of testing 3x a day: AMPS, +5 or +6 and PMPS. Unfortunately, I am shooting with U40s and have been following the Vetsulin dose scale from that other forum. Fortunately, I have been home with Riker all day every day since the Friday before Christmas, and haven't noticed any behavior that would suggest an overdose.

    (Scale I've been using)
    Imperial BG……….Metric BG………..Dose of insulin
    151-170………….……..8.3-9.4……………….0.25u
    171-185……………….9.5-10.2……………….0.50u
    186-200……………..10.3-11.1……………….0.75u
    201-220……………..11.2-12.2……………….1.00u
    221-250……………..12.3-13.8……………….1.25u
    251-290……………..13.9-16.1……………….1.50u
    291-350……………..16.2-19.4……………….1.75u
    351-410……………..19.5-22.7……………….2.00u
    411-450……………..22.8-25.0……………….2.25u
    451-500……………..25.1-27.8……………….2.50u


    He went back to the vet on 12/26/2018 for a BG check. He tested 288 at +4. I explained that I had started home testing and referenced the numbers I'd recorded. The vet reiterated his recommendation of 3units 2x daily, but congratulated us for being so vigilant.

    Here is his BG spreadsheet so far: https://docs.google.com/spreadsheets/d/1WTLPRrfYUQpYNXl4S-lPNqfZ7wpgm13qC2YW2gBIHa0/edit?usp=sharing

    My head is swirling with everything I've read and all the variables. I just really want to get him regulated.

    Questions:
    -Anything I'm not doing that I should, or vice versa?
    -Any advice on how to interpret Riker's BG numbers with regard to dosing/insulin effect?
    -Does FDMB have a different dosing scale for Vetsulin?
    -Should I be feeding in the middle of the night to avoid high AMPS numbers? I have an auto feeder I could use.
    -Yesterday and today, I've noticed his breath smelling bad. Not sweet/fruity, but kind of foul. Is this bad? Or could it be because of the new high-protein food?

    Thank you so much in advance. -Beth
     
  2. Kris & Teasel

    Kris & Teasel Well-Known Member

    Joined:
    Aug 17, 2016
    Welcome! You're already doing so many things right for your handsome boy! :) You're testing BG at home, thinking about dosing issues, paying attention to other clinical signs, have a spreadsheet set up, etc. You have the right mindset to get this done!

    Were there other clinical signs like weight loss, excessive water drinking, voracious hunger? Was the diagnosis made using those and only one BG reading or was a fructosamine test done?

    Yikes! That's very high for a newly diagnosed kitty! Most are started at around 1 unit twice a day.

    That's good advice. The best low carb food for diabetic cats is wet food under 10% carbs as fed. Prescription diabetic kibble is still too high in carbs. Pate versions of Fancy Feast and Friskies are in that category and there are many higher end foods that are fine if your finances permit.

    Great meter but the strips are $$$ and there are times when you use a lot of them. Yes, there are people here who use the Insulinex strips successfully. @JanetNJ is one of those people.

    Best tool to keep your boy safe and figure out his good dose range! "That other forum" does things differently than we do here. We suggest a consistent dose for the most part and save any version of a sliding scale for finessing the dose after you have tons of data and kitty is pretty well regulated or near that. Using the scale above will contribute to more BG volatility at this point. Check out this excellent guide for using Vetsulin the "FDMB WAY". It was put together by people who are very knowledgeable about Vetsulin.
    http://www.felinediabetes.com/FDMB/threads/beginners-guide-to-caninsulin-vetsulin.186099/

    I'd start by reading our Vetsulin User's Guide and ask a ton of questions.

    I think the inconsistent dosing is contributing to his volatility. I suggest you try 1 u twice a day for 3 days or 4 days both AM and PM unless the pre shot test BG is low (below 250 or so for now). Post here for help.

    We don't use a dosing "scale" per se. It's more like:
    • choose a reasonable dose (eg. 1 u)
    • give that dose AM and PM if a pre shot test is above 250 and food has been withheld for two hours prior so you know it's a non food inflated BG. Do so for several days.
    • collect BG test data from the middle part of the 12 hour "cycle" - between +4 and +6 hours generally
    • look for the lowest BG that dose has produced. This is KEY and missed by many people at the start. It's how we assess the effectiveness of a dose. The pre shot BG numbers are NOT reliable for this.
    • adjust dose up or down by no more than 0.25 u at a time if necessary.
    Many people do this and an autofeeder is a great way to do it.

    Cat food isn't particularly pleasant smelling but dental issues can definitely cause bad breath. Has Riker had a dental checkup in the recent past? They can also cause extra problems in getting BG regulated.

    I hope this helps! Ask a ton of questions. We're here to help. :)[/USER]
     
    Last edited: Dec 28, 2018
  3. BethB

    BethB New Member

    Joined:
    Dec 20, 2018
    Hello Kris and Teasel,

    Oh gosh, thank you so much for your reply. Your encouraging words brought a tear of relief to my eye!

    As for clinical signs at diagnosis, yes: For about two weeks before we brought him to the vet, Riker was constantly drinking water and asking for food. There were also a few "outside the box" urinations. Despite his eating, he lost a noticeable amount of weight. All of a sudden we could feel his shoulder blades and spine when petting him. His coat was also noticeably dull. In addition to BG testing at diagnosis, the vet also did full bloodwork and urinalysis. They went over the results with us, and said everything was normal besides his BG and the amount of glucose in his urine.

    Your advice about inconsistent dosing makes a lot of sense! Constantly changing the doses and his resulting volatility was really making me feel crazy and scared for him. Your suggestion of sticking with a consistent dose and tracking mid-cycle makes a lot of sense and I will do so.

    Dental work: The vet did a full physical on the diagnosis date, including visual dental check, and noted that except for a little gingivitis around his back teeth, and some gum recession around his fangs, his teeth looked good. The vet and tech seemed surprised lol!

    Thank you again for your quick reply and clear advice. I'm sure I'll be back with more questions soon!
    -Beth
     
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  4. Kris & Teasel

    Kris & Teasel Well-Known Member

    Joined:
    Aug 17, 2016
    Glad to help! Stick around. :smuggrin:
     
  5. BethB

    BethB New Member

    Joined:
    Dec 20, 2018
    Hello all, I'm back with an update and request for advice.

    As suggested earlier in this thread, I've been giving Riker 1 unit of Vetsulin AM and PM and testing AMPS, PMPS and somewhere around +4 or +5. I know it's only been a couple of days, but I'd love your opinion the numbers I've been getting, and whether an adjustment is warranted at this time.

    I'm very encouraged by the lower readings at +4 and +5 but equally troubled by the recent BGs in the 500s that he threw this morning and last night (and seems on track to throw another high PMPS tonight). I know it can take some time for things to level out from the whacky dosing we were doing before.

    Riker's BG sheet: https://docs.google.com/spreadsheets/d/1WTLPRrfYUQpYNXl4S-lPNqfZ7wpgm13qC2YW2gBIHa0/edit#gid=0

    Questions:
    1. Should I stick with the 1 unit of Vetsulin 2x daily for now, or do you think it's time to adjust to a slightly higher dose?
    2. Do you think I'm feeding too much or too often? (I typically give him around 1/4 to 1/3 of a 5.5 oz can several times throughout the day, and some snacks of plain cooked chicken, but always withhold food for at least 2 hours before testing)
    3. Would a midnight meal help with the elevated AMPS numbers? I have an auto feeder I could set up to make a meal available while we're asleep, say 1 am.
    4. How important is it to stick with one type of food while trying to get regulated? I found a cheaper wet food, Luvsome Turkey and Giblets Pate, that was 7% dry matter carb. I fed that for the first time today for his lunch. And 2 hours later he threw a BG in the 400s.

    Thank you as always!!
    Beth
     
  6. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

    Joined:
    Feb 18, 2015
    While Riker may need a more insulin, the first thing I would do is grab a few tests earlier in his cycle at around +2 or +3. Vetsulin starts to work early in the cycle so if you see Riker dropping quickly or a lot (more than 100 points) then feed him a little snack to slow him down.

    What you are seeing is bouncing which is caused from the BG dropping quickly, dropping a lot and/or dropping to levels that kitty has become unaccustomed to. It is a defense mechanism in mammals that goes into action pumping out hormones and stored glucose to boost BG levels when the body perceives a drop in glucose it "thinks" is dangerous and because of the diabetes, the body needs to be recalibrated to understand those lower BG levels are normal. That recalibration can take a bit of time but you can use food to try to limit the bouncing.

    A snack early in the night cycle and 3 hours before AMPS may help bring the pre-shot BG down.

    You can offer a variety of food as long as it's under 10% carbs and preferably under about 7%.

    Did you get the dry matter carb % for the new food from the manufacturer or did you use a carb calculator? Without the As Fed values from the manufacturer, the guaranteed ingredients numbers when plugged into carb calculators can sometimes give you percentages that are lower or higher than actual.
     
  7. BethB

    BethB New Member

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    Dec 20, 2018
    OK thanks, MrWorfmen'sMom. I will start gathering +2 and +3 readings. If they're more than 100 lower than his AMPS, I'll feed (he'll be thrilled!)

    I have been giving him a little snack when we go to bed, about +2 or +3 after PMPS, but I'll experiment with an autofeed in the wee hours as well.

    Yes, I used this carb calculator. Shoot, is that unreliable? How do I get As Fed values?

    Thank you,
    Beth
     
  8. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

    Joined:
    Feb 18, 2015
    I thought the carb calculator might have been in the picture. That is a good calculator but it's only as good as the numbers we plug into it. The only way to get as fed values is to write to the manufacturer and ask for them. The problem with the online calculators is that the Guaranteed Ingredients are often Min/Max Values and that can lead to some less than accurate results. The other thing to take into consideration is that some cats do quite nicely on low carb 3-6% but don't do well on 0-5% for instance. It may be that Riker is more sensitive to carbs and if that food turns out to really be 7% , perhaps that is too much for him. It's a bit of an experiment in the early days. :)
     
  9. BethB

    BethB New Member

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    Dec 20, 2018
    How opaque of them! GAHHHHHH... Ok thanks for the info. I will embark on an 'as fed' adventure once the holiday has passed :)
     
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  10. BethB

    BethB New Member

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    Dec 20, 2018
  11. Kris & Teasel

    Kris & Teasel Well-Known Member

    Joined:
    Aug 17, 2016
    Actually I'd recommend an increase to 1.25 u. The yellow is a good sign but he has lots of room to drop before hitting the 68 boundary for an AT meter. It would be helpful to get a before bed test as often as you can because many kitties drop lower at night and that sets the stage for bouncing higher in the day. It can lead to dose changes that might not be required.
     
  12. BethB

    BethB New Member

    Joined:
    Dec 20, 2018
    Interesting! Just double checking... previously you had said:
    • "choose a reasonable dose (eg. 1 u)
    • give that dose AM and PM if a pre shot test is above 250 and food has been withheld for two hours prior so you know it's a non food inflated BG. Do so for several days."
    Was 250 just the cut off when he was bouncing all over the place? And 68 is the official low reading for an AT2?
     
  13. Kris & Teasel

    Kris & Teasel Well-Known Member

    Joined:
    Aug 17, 2016
    That suggestion was made when you had just arrived here and the goal was to get him settled at a lower consistent dose to see how he'd do. I gave you a capsule description of how we dose here on FDMB - no sliding scale, etc. You now have 5 days in a row of data at 1 u and the emerging pattern suggests that there's room for him to drop. That's why I suggested a bump up to 1.25 u. Make sense?

    The 250 cutoff for "no shot" is for safety at the start until you have lots of data showing how Riker responds. You use an AT meter so the cutoff is higher than for a human meter that reads lower (we'd suggest 200 with one of those). As you get more data you'll be able to push the envelope more by dropping the no shot number a little, giving a full dose and watching his response. There's art as well as science involved in dosing. ;)

    Re the 68 cutoff for an AT meter: that's the BG at which we say he's dropped too low (but not to hypo level) for comfort and you need to prop him up with food, usually medium carb level at that point. It would also be wise to reduce dose by 0.25 u because a 68 at nadir is too low for Vetsulin. It's a strong acting insulin so it's best to have a bigger "cushion" for his lows. High double digits or low 100s are good. The dose is always judged based on the lows it produces.

    Have you checked this out yet? http://www.felinediabetes.com/FDMB/threads/beginners-guide-to-caninsulin-vetsulin.186099/

    This is very overwhelming at first and you will probably ask yourself how in heck we know what to suggest. We try our best to use what we've learned from looking at dozens of spreadsheet over time, our knowledge of how particular insulins work and also the user guides that the forum has for every type of insulin. We also draw on personal experience but temper that with the qualifier that ECID (Every Cat Is Different). This is why we always ask to see a spreadsheet of data before offering advice. :)
     
    Last edited: Jan 3, 2019
  14. BethB

    BethB New Member

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    Dec 20, 2018
    Yup I have read the Beginner's Guide but maybe I should do so again now that I'm not quite so frantic about everything :cat: Thanks so much for your detailed reply! It makes sense. Hooray for progress...I hope!

    Beth
     
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  15. Kris & Teasel

    Kris & Teasel Well-Known Member

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    Aug 17, 2016
    Feel free to post here often with any/all questions you have. Yes, you'll definitely continue to calm down over time. :)
     
  16. BethB

    BethB New Member

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    Dec 20, 2018
    Hi All,

    Back for a spreadsheet check-in. Midday test times have been a little inconsistent, but I'd love to know what you think of Riker's numbers. Still seems pretty all over the place to me, unfortunately. He's had some decent days at 1.5u of Vetsulin, but then he'll swing back up again. One thing to note is that we switched from AT2 to Freestyle InsuLinx strips (still an AlphaTrak meter) on 1/9/19.

    Spreadsheet: https://docs.google.com/spreadsheets/d/1WTLPRrfYUQpYNXl4S-lPNqfZ7wpgm13qC2YW2gBIHa0/edit#gid=0

    Questions:
    Is it time to bump him to 2 units?
    Would it be detrimental to switch him to a new wet food right now? He's been on Purina Pro Plan True Nature Chicken & Liver. He loves it, but I'm thinking about switching to FF or Friskies pate so that it would be cheap enough to feed to our non-diabetic as well.

    Thanks!
    Beth
     
    Last edited: Jan 12, 2019
  17. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

    Joined:
    Feb 18, 2015
    On the food front, switching to FF or Friskies pates would not be detrimental at all... rather a good switch but note that the carb level of those foods is a bit lower than the Purina Pro Plan Nature Chicken and Liver and that may reduce Riker's insulin dose needs a bit.

    It looks like Riker does need a dose increase but we usually only increase by 0.25u so your next dose would be 1.75u. Are you using U40 syringes with half unit markings or U100 half unit marked syringes? For a dose of 1.75u you have to eyeball the dose. Being exact is not as important as consistency. You could draw up what you think is 1.75u with coloured water in a used syringe and use that as a gauge.
    Are you testing Riker for ketones? With those high BG levels it would be a good idea to do so. Ketostix are available at any local pharmacy or Walmart.
     
  18. BethB

    BethB New Member

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    Dec 20, 2018
    So on the food question, the CatInfo.org sheet I've seen circulated and recommended in this group has Pro Plan True Nature Chicken and Liver listed at 1% carbs, Friskies pates are listed around 4% and 5% and Fancy Feast classic pates are listed at 3% (unless I'm totally misreading them?) I chose the Pro Plan because I thought it was the lowest at my local store. Can you explain more why Pro Plan is higher?

    I'm using U40s with half unit markings. Yes, you're right. 1.75u would be the next dose. Yup, I eyeballed the 1.25u dose and I think I was pretty consistent.

    I'm not testing for ketones. I've looked at DKA info, and other than high numbers I don't think he shows any of the other symptoms. (His breath doesn't smell sweet, he's actually put on weight since diagnosis and has regained energy as well) Still test? And if he does have ketones in urine, what then?
     
    Last edited: Jan 12, 2019
  19. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Feb 18, 2015
    On the listing I have the ProPlan True Nature Chicken and Liver is 10%. The list I am using is HERE.
    The first or second ones on the list are what I use.
     
  20. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Feb 18, 2015
    Glad to know Riker has had no problem with ketones up to now but ketones are something that can affect any diabetic cat. WHile they usually are the product of high BG, an inflammation or infection and not enough food/insulin, it's a good idea to test especially when the BG numbers are this high. Infections or inflammation can elevate BG too so sometimes ketones are the first warning you get of a medical issue that needs attention. Using the Ketostix, any reading above trace means a consult at least by phone with the vet is in order. Some cats are more prone to ketones than others but it's a good idea to check for them just as a precautionary measure even in a cat with no history of them especially until you get Max better regulated.
     
  21. BethB

    BethB New Member

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    Dec 20, 2018
    Yeah! The first food chart in the list you linked is the same list I'm looking at. HERE. The image below is what I see for Pro Plan True Nature (on page 46). The third column from the left is carbs...isn't that 1%?
    [​IMG]
    The second food chart in the list you linked (the sortable version) has just one listing for "PURINA Pro Plan Veterinary Diets" (9% carbs) but that's different from what I'm buying/feeding, which is OTC.

    Sorry, I appreciate your help and am not trying to be contrary!! I just really want to get him on the best food I can, and somehow I keep getting the carbs wrong.
     
    Last edited: Jan 13, 2019
  22. BethB

    BethB New Member

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    Dec 20, 2018
    OK that makes sense, I'll get some strips. Thanks for the explanation.
     
  23. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Feb 18, 2015
    That's interesting because this is what I see on the sortable list (second on the list). And even more puzzling is the different protein, fat and carb %s. HMMMM!? Something to investigate further.
    Pure Plan carb percents.PNG
     
  24. BethB

    BethB New Member

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    Dec 20, 2018
  25. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Ok I may have figured this out. I imported the list to Excel and sorted from there. It appears this may have mucked up the data in some fashion. I'll have to investigate further and see what the devil happened. :oops:
     
  26. BethB

    BethB New Member

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    Dec 20, 2018
    Thanks for letting me know! No worries.
     
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