Elmo 12/16 PMPS......164

Good morning...the Elmo saga continues...

 

Feeding now....shoot in 30 minutes

 

@Critter Mom .....good morning Mogs...getting ready to give insulin in about 15 minutes...any thoughts...AMPS 154.....eating now...

 

@Kris & Teasel @MrWorfMen's Mom @Critter Mom ......good morning all....getting ready to give insulin in about 10 ... minutes...with the AMPS of 154 I will shoot .25 minus full drop as we did 12/14(Wednesday)

 

Good morning Beth. Another one of those "right on the edge" decisions. I think you could do the 0.25 minus small drop as long as you are available to monitor and steer if needed. Having skipped the shot yesterday, he is really holding his numbers well. I'd expect his nadir to be a little lower today than it was last night but only time will tell.

 

Thank u, Linda...being available to monitor is my life ......

 

We did .25 minus small drop last night and he did well, even with it being the pm cycle...

 

Linda,hoping Sweet Menace was a good girl last night

 

Morning, Beth.

Just checking in now. Are you still waiting to give the dose or have you gone ahead and given it?


Mogs
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Just getting here. I'm confused: did you give 0.25 u minus small or full drop? Will you be updating your SS, Beth? The last entries are for 12/14. BTW - SS says PM dose on 12/14 was 0.25 u minus small drop.

 

Yes Menace is behaving (thank you for asking Beth) but I did have to resort to a BCS (Big Chicken Shot) the other night when she honoured me with a PMPS of about 80. Now she is running a tad higher again which was expected and not all bad given my schedule this weekend. I'm going to be somewhat scarce today and tomorrow and Sunday. I have more snow to clean up today (another inch or 2 last night), an appt. this afternoon and have to turn in very early tonight because my Special Olympic curling teams have a day long competition tomorrow. We are expecting yet another major snow blow overnight of about 8 more inches so I'm going to have to be up with the birds Saturday to shovel out my car and get on the road early to pick up a couple of my curlers. While I always enjoy the first pristine snowfall, this daily barrage is getting old really fast. If I didn't have Menace to worry about, I'd be booking a trip to a sunny climate for early in the New Year but I wouldn't trade her for the world so all's well! I'll just have to deal with it.

 

Hi Kris,

The last line of data on the SS is from yesterday (there's an error in the date column - 13th December on two rows).

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Good morning, Kris...went with .25 minus small drop...will update SS now

 

Duhhhhh.....my brain can splutter just like Elmo's pancreas

 

Gave .25 minus small drop...

 

Know the feeling.

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Shows you how bright I am this AM!

 

Kris, will you be around for a few hours?

 

Special Olympics! How wonderful!! My year old great niece was born with Down Syndrome and I cannot wait to participate in helping Special Olympics with her

 

Hurray for you for working with the Special Olympics folks!

 

Yes, I'll be here. It's -24C (-11F) out there right now and I don't feel inclined to venture out.

 

I h

Good plan Kris. I haven't looked at the temperature outside here because they issued a cold weather warning and that's all I want to know! BRRRRR! Wish I didn't have to venture out but alas, no choice today!

 

And yes, Kris, we settled on .25 minus small drop...he did well

 

Kris, I am all fouled up ...going to write up my last few days BG/ shots to make sure no discrepancies between SS and journal....

 

Love ur attitude, Linda. Heard a saying that I recite out loud to myself often:" It's not the load U carry but how u carry the load"....I work at keeping it positive .

 

I'm glad to hear you're around, Kris. My friend is taking me to the bank (rent's due next week!) so I'll be AWOL. Nippy here, but dry and sunny for which I'm grateful (dread having to leave the house - even for a short time).

@Beth 73 - Fingers and paws crossed for a good cycle!


Mogs
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Just double checked and SS agrees with daily journal.....gotta be more mindful on these bleary brain days Going to monitor as usual and post here first then desk top as it can be dodgey

 

Good luck venturing out, Mogs. I'll keep tabs here.
P.S. What about online banking and eTransfer? Could be helpful.

 

Normally it would but the particular account I need to transfer money from only allows me to do it by cheque.

Thank you for the good wishes; much needed.




Mogs
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Time for a move into the 21st century I say!

 

Checking in....AMPS was 154....25 minus small drop given....at +1.5 116..........I am trying to not knee jerk react and steer when not needed....from 154 what would be a steep drop, Kris...sometimes most drops look steep to my overcautious eye

 

That's a little steep going to +1.5 so I'd try a small snack of regular food first. See where he's at when you get to +2.

 

+2...124.....he ate a little at 8:30.... vet had told me to initially to let him graze til +1.5. So I have continued that, fyi

 

8:30 would have been at +1.5

 

I like that +2 number, Beth.

 

Will be praying for you to enjoy your trip without concern for Menace, Linda. Outings like this are so good for wonderful caregivers like you

 

+3 ...123.... Elmo being kind to his momma AND godmothers far and wide ......stay warm ,Kris....we have sub zero wind chills headed here tomorrow with prospect of only one inch of snow....

 

+4...127.....stay warm , Kris !!!!

 

Elmo's a surfin' Buddha!


Mogs
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...glad you made it back safe and sound, Mogs. I am a bit of a Hobbit myself, prefer home to anywhere but it's good for us to force ourselves to venture forth, even when our brain says" noooooo"..

 

I love being a Hobbit and I'd really like a little house like Bilbo's!

 

Oh my goodness...wouldn't that be just the very best...

 

Kris, can u tell me the difference between vetsulin and pro zinc? Reason is when talked to vet for Elmo Monda appointment she mentioned that they had used Prozinc as an alternative to vetsulin. Just want to go in educated from your point of view as a user . Read some of the pro zinc stickies but want ur trusted expertise.

 

• ProZinc is an in and out insulin like Vetsulin - ie., the insulin is injected, it does its thing and it's gone. There's no residual depot ("tank" of insulin) that remains to keep a little insulin actively working between injections.
• Like Vetsulin, it (ideally) produces a smile-shaped BG curve - AMPS high slopes gently down to nadir then rises gently to PMPS.
• It's slower in onset and longer in duration than Vetsulin for many kitties.
• The U100 syringes allow tiny dose fractions because it's a U40 insulin like Vetsulin - this where you'll do well if you try ProZinc! (nudge, nudge ... )

So - they're essentially similar in the way they act but ProZinc tends to be a bit more "leisurely" about it. Of note, though - ProZinc is $100 -$120 a vial.

 

Thank you, mam..... just got the feeling when talked to them that this is their next step if vetsulin doesn't work. I've read it's gentler than vetsulin, not the harsh crash at first....but that may just be how dear Elmo metabolizes it. Just want to be forearmed and informed for Monday .

 

Info is your weapon, Beth. I know that Mogs has lobbied in favour of an L insulin. Your decision based on our info, what the vet says and, ultimately your gut feeling.

 

Yep , I really don't want to be looking for a new vet right now . Living in a small town with towns around us just a bit larger makes choices limited. Right now it's a one hour round trip which they don't like.Have switched my tabby brothers to another vet in town because this longtime vet where Elmo is currently being seen is nearing retirement and has replacement assistant vets that change every few months. I do not like that when dealing with an issue like Elmo's. Will keep reading up, taking notes for Monday .

 

That's why so many people here have to learn to be FD vets for their kitties. Even with accessible vet clinics, they aren't always given the best advice.

 

I'm sadly seeing that. I see people come in my vet clinic blindly getting the vetsulin and doing exactly what they r told. As they walk out I can't help but wonder how their kitties r doing. When vet gave Elmo back in July, they acted very nonchalant about it, like no big deal, heres some insulin , here's some needles, do it twice a day and call if any questions. Either Elmo is a problem case or other people there are walking a scary road going on the info given/not given.

 

Crazy, isn't it? I'd say Elmo is an ideal case in his generally excellent response to Vetsulin. Have a look at Teasel's SS!

 

+7.5...150

 

Looking good - nice calm day.

 

Kris, your reassurance means so much.....

 

Gee, thanks, Beth.

 

Just taking a break and doing a quick check in. I see Elmo is being very leisurely today which is good. Nice blue "slab" on his spreadsheet.

Sad to say I often wonder how many cats are lost as a result of the lack of information vets tend to provide their clients. And those that don't mention home testing or worse yet, discourage it, should be sent back to school for giving out reckless advice.

On the subject of ProZinc vs. Lantus/Levemir, I think ProZinc is great for some cats but not all. I was helping out another member with her cat using ProZinc and the wild ups and downs I witnessed with him, made me sorry I ever agreed to go give the cat its morning shot. I never felt comfortable leaving the house afterward because I was afraid of what might happen to him. In fairness, there were other circumstances that might have been playing into the wild swings I saw, but it seemed the ProZinc was not lasting nearly long enough, causing huge swings in his BG similar to Vetsulin or he was constantly bouncing.

You might also want to check on the pricing because human insulin is typically a lot cheaper here than in the US so the price Kris gave you may be low if the difference in price applies to veterinary insulin too. With Lantus or Levemir you can order it from Canada at considerable savings... just don't tell your vet you are going to order from Canada though or that could preclude them writing a script for you due to Federal/state laws! There is generally less waste with Lantus/Levemir because you can use up what you buy. At low doses, I would think you'd end up wasting a large amount out of ProZinc vial. Kris would be able to speak to this possible issue better than me.

 

Sure understanding the terms ECID and sugar dance better. This is a good stretching experience for me... I find great contentment in sameness,the familiar, get into a routine and stick with it...this waking up in a new Elmo every day and not freak is good for me....at least that's what I'm sayin'

 

Hi Linda,
I've asked for your input about the conundrum I'm in with my guy. The choice of Lantus over ProZinc isn't that simple for him. Only if you have time.

 

Thank u, thank u, Linda !!! Yes I waste 2/3rds of the bottle of vetsulin...not like we r made out of money but being over 60 our wants/needs list is short and money saved for the necessary .....like Elmo. You be safe on the snowy roads as you go curling....what fun!!!

 

I agree that low doses of ProZinc might result in a lot of wasted insulin. I go through a vial in about 2 months but I think they can last longer. Maybe a question to ask on the ProZinc forum?

 

My money's on the scary road.

Relatively early on in Saoirse's treatment a vet nurse was teaching me how to use a Vetpen. We were discussing general aspects of diabetes treatment (for dogs and cats) and the conversation got onto the topic of monitoring. She told me not that many people home tested BG and some didn't even monitor water consumption while their animal companions were receiving insulin; they just relied on occasional spot checks or curves at the vets. Needless to say I was dismayed to hear this and I asked what about the animals' safety? With a sad look on her face, she shrugged and said words pretty much to the effect that they were slaves to fortune.

Whereas in an ideal world it would be wonderful if all caregivers did some form of reasonable monitoring of their diabetics but for those who don't/can't monitor it's not right to be critical: they are providing treatment for the animals in their trust. The percentage of caregivers who elect not to treat is heartbreakingly high.


Mogs
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How true, Mogs...we r all trying to do our best..just wish more vets discussed the options of home testing, etc...just let people know and not make them have to dig for it.

 

Hurray for routine, the glue that keeps life together ...

 

......and btw +11 162.....

 

Lovely!

 

@Kris & Teasel @Critter Mom .....Elmo +11 162.....PMPS....164......feeding in 20 minutes....shoot in 50 minutes.....good news is our son came for a visit for first time in a month and commented on how healthy Elmo appeared, so that was encouraging......any wisdom on dose as always appreciated and trusted

 

I say repeat what you did this morning, Beth. You want things to be nice and uneventful (!) until you can talk to the vet on Monday.

 

@Kris & Teasel ....so give .25 minus small drop ??? Feel like I've messed up...last nite I gave minus a small drop and thot I misunderstood and should have given minus full drop.....mercy I've confused myself...at 165 last nite and minus small drop I had a 50 point drop at +1.5....is that ok ???sorry I am all over the place

 

You don't get paid enuf to put up with me !!

 

Yes, I recall that go around. Maybe 0.25 u minus a FULL drop to set your mind at ease?

 

We work for free here, Beth, because we like helping.

 

Again , u don't get paid enuf to be deciphering my babble....thanks Kris....stay warm and give Teasel a scratch from me

 

Oh I know u do...angels, that's what u all are, angels !!

 

I would still argue for an L insulin. Substituting one in-out insulin for another - where response isn't, in truth, all that likely to be much different to the current response to Vetsulin - doesn't really have much to offer in terms of treatment benefit (and the sliding scale dosing method recommended for Prozinc could see Elmo's numbers become less stable, as Linda touches on above). I think there is a very good chance that there would still be a lot of prannying around with microdoses and skipped shots on Prozinc, too.

Ultimately the treatment avenue which offers the greatest potential benefit to Elmo at this juncture is tighter regulation so that his pancreas can rest further, hopefully recovering more beta cell function and thus improving his prospects of achieving a strong remission. Going with tight regulation protocol means Lantus or Levemir are the available choices.

On remission rates, there is a ticking clock in terms of how long after initial diagnosis treatment with a depot insulin is initiated in order to give a cat the best chance of achieving remission. From the Roomp-Rand published, peer-reviewed article (PDF attached below):

Remission Rates Comparison
There is only one controlled prospective study in 24 newly diagnosed diabetic cats that compared remission rates between glargine, PZI, and porcine lente insulin. Blood glucose curves were initially performed weekly, and insulin dose adjustments based on an algorithm were also performed weekly. Cats were fed a low carbohydrate diet (<8%–10% metabolizable energy). The reported remission rate for glargine was 100% (8 out of 8 cats), and this was significantly higher than the remission rate for PZI (38%, 3 out of 8 cats) and porcine lente insulin (25%, 2 out of 8 cats).30

The largest study for cats treated with glargine involved 55 previously treated diabetic cats. In this cohort, 91% of the cats had been previously treated with another insulin, predominantly porcine lente insulin, for a median of 15 weeks. Most cats were also fed a very-low-carbohydrate wet-food diet (<6% metabolizable energy) on the first insulin, yet did not go into remission. On switching to glargine, they continued to be fed a very-low-carbohydrate diet. Cats were monitored using home blood glucose measurements at least 3 times daily. The insulin dose was adjusted using an algorithm aimed at achieving euglycemia. Provided the protocol was initiated within 6 months of diagnosis, high remission rates (84%) were achieved. For cats that began on the protocol more than 6 months after diagnosis, a much lower remission rate was achieved (35%). The overall remission rate for all cats, regardless of when the protocol was initiated after diagnosis, was 64%.3

For detemir, a cohort of 18 diabetic cats, previously mainly treated with porcine lente insulin, was evaluated using an insulin dosing protocol aimed at achieving euglycemia and fed a very-low-carbohydrate wet-food diet. The remission rates were very similar to those achieved with glargine: the overall remission rate was 67%. Again, there was a difference between cats that initiated the protocol shortly after diagnosis and those that did not; for cats that began the protocol before or after 6 months of diagnosis, remission rates were 81% and 42%, respectively.6

No significant differences in terms of remission rate could be identified between glargine and detemir.​

Time spent treating with Prozinc - possibly with no net gain - would eat away at the 6-month window of opportunity where statistically chances of remission are perhaps 50% higher provided the cat receives treatment with an L insulin following a protocol which aims to keep blood glucose levels within the euglycaemic range during that time.

Upon review of Elmo's current BG regulation it is possible that the vet will argue for him to be put on an OTJ trial. The concern I have about this is that Elmo currently spends the day in the upper part of the euglycaemic range - and it doesn't take long for his numbers to start drifting upwards if he skips a dose. If he were to stay in this 'prediabetic' range following withdrawal of insulin support it wouldn't take much to push him into diabetic numbers again.

Anecdotally it has been observed at FDMB that the chances of achieving a more solid, long-lasting remission is greater in cats who experience a reasonably long period where BG levels stay in the lower part of the euglycaemic range the vast majority of the time (approximately 70-120mg/dL on Alphatrak; better again if range is 70-100 for a significant proportion of each cycle) before withdrawing insulin since it reeducates the body to run in lower, healthier numbers. Switching to an L insulin and following the tight regulation protocol would offer that opportunity to Elmo.

My two penn'orth.


Mogs
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Mogs, your experience and knowledge are a treasure. I feel I must go armed with info on Prozinc as that is my vets backup choice. I want to have my own knowledge about it in case he tries to pressure me ....which I am hoping he won't....makes my stomach hurt if I think too much about it. I especially relate to the info in your last paragraph...that will definitely be one of my main points for it makes perfect sense. Thank u, thank u once again .

 

Well said.

 

Again I suggest you give your vet a copy of the published Roomp-Rand article attached to my previous post. It might give him sufficient information to look positively on prescribing a depot insulin for Elmo. Lantus is also recommended in the AAHA Guidelines for diabetes management in cats and dogs (2010 - not sure whether they've been updated since then).


Mogs
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The ISFM also recommends longer acting insulins as ideal and their recommendation is in documentation dated 2015 attached.

If you go in with both barrels loaded, how could they possibly say NO?!

 

Well I could always pitch a big ole fit and/or cry....heck I might cry anyway....tired of watching him crash AND losing sleep

 

Btw. +4. 124 after minus full drop

 

Comfy number.

 

Beth,

I've thought of a real-world case for you to look at. Here's a spreadsheet for a kitty called Romulus. (Mama is Sue484.) Over the course of this year he was treated with Caninsulin, then Prozinc, and in the last few days he has just been switched to Lantus:

https://docs.google.com/spreadsheets/d/1JI_2ANvHbmb8rcGNKreaxTQ6mHE9mSw35QR8KUdAeUw/edit#gid=0

The only insulins currently approved over here for use in cats are Caninsulin and Prozinc. Under the UK drug cascade rules both of those insulins must be tried before a vet can issue a prescription for any non-approved insulin (e.g. Lantus, Levemir, Hypurin Bovine PZI). Sue would have preferred to go straight from Caninsulin (aka Vetsulin) to Lantus but by law the vet had no choice but to prescribe Prozinc first.

It will take a few days for Rom to settle with the Lantus (takes time for the depot to fill and stabilise) but you'll be able to get a good look at his responses to Caninsulin and Prozinc. Granted Rom is not at the same stage of regulation as Elmo is currently but you'll be able to see that, within his own context, there's not that huge a difference in Rom's overall response to both of these in-out insulins.

I'm posting the link to Saoirse's 2014 spreadsheet again for you. If you look at her BG levels in July and August you'll see a real-world example of a cat needing to come off Caninsulin/Vetsulin (C/V)for safety reasons (my decision). Our main vet (good with feline diabetes - he had a sugar cat himself) was convinced Saoirse was in remission but I disagreed. Within a very short time after withdrawal of insulin treatment Saoirse's numbers started climbing again; the remission didn't hold because Saoirse had not spent enough time in the optimum healing BG range with insulin support.

https://docs.google.com/spreadsheets/d/1W_6vprqOticH1qB5duGq911swDj32Qw2olXPsmQS3CM/edit#gid=10

I did a lot of customisation on Saoirse's spreadsheets. Look to the left of the normal columns for BG numbers and you'll see that I've added a column showing the average and maximum BG values for the day and the week. If you look at the data from 12 August onwards (12.08.14 in UK date format) you'll be able to see the marked difference in the BG range (highest and lowest levels) over the course of each cycle between C/V and Lantus. You'll also be able to see the steady downward trend in average and maximum daily/weekly BG from the time Saoirse starts on her Lantus.

Pale green shading in the spreadsheet cells indicates where Saoirse is below the renal threshold; mid-green shows her in the high end of the normal range and the dark green cells are where Saoirse spends time in the optimum healing range. As is clear from the spreadsheet, Saoirse spends a lot more of the day in really good healing numbers on Lantus than on C/V.

Most important of all, Saoirse felt much better with the smoother, gentler action of the depot insulin - and according to his spreadsheet remarks so does Romulus! That's the reason why we do this crazy sugar dance.

I hope you will find the above spreadsheets to be helpful illustrations of the effects that the different insulins may have on blood glucose levels. I certainly find that seeing real-world examples helps me to better understand the difference in the way they work.


Mogs
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More thanks to you...just pray vet is willing...I believe armed with this info I will do well to plead Elmo's case.

 

And duh...meant +2 124... I gotta get some sleep