Help! Diabetic cat with stomatitis not responding to insulin

Discussion in 'Feline Health - (The Main Forum)' started by tackeee, Jan 9, 2019.

  1. tackeee

    tackeee Member

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    Jan 9, 2019
    My 11-yr-old cat was recently diagnosed with diabetes (Dec 18) and hasn’t been responding well to insulin. I’m using a Lantus pen and he started on 1 unit after his blood sugars were tested at 500. A week later they were down to 400, so he got upped to 2 units. Two weeks later, he’s lost over two lbs in total and his blood sugar is still around 400. He’s eating and drinking, but clearly uncomfortable. He has been upped to 3 units on the Lantus.

    I also worry because he has stomatitis and it’s flared up over the past month and seems to be causing him more pain. The vet says we can’t do a teeth cleaning when he’s not regulated. I’ve bought the alphatrak monitor and will get it tomorrow to start home testing. I’m not sure what to do and the vet isn’t sure either.

    Is it possible to get BG numbers that are too high with a too high insulin number? Also should I be using the pen as is or getting a syringe?

    Stuck and worried. My vet initiated the “quality of life” conversation yesterday and I am worried he’s uncomfortable and in pain!
     
  2. SpotsMom

    SpotsMom Member

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    Feb 10, 2018
    Welcome, you've come to the right place!

    Its good that you're going to start testing. That is a very quick increase in dose and without testing at home its impossible to know how well he is really reacting to the dose. It is very possible that too large of a dose looks like too little with just a periodic spot check at the vet.

    Many vets don't know how to treat feline diabetes (they tend to treat cats like they do dogs, and that just doesn't work), so don't be too concerned about the quality of life conversation just yet. There are several things you can do to help get him back on the right path. Start home testing, change him over to low carb wet food if he's not already, and I'd also encourage you to go browse the yellow stickies in the Lantus forum to get a better idea of how the insulin works and the recommended protocols for dosing.
     
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  3. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Feb 18, 2015
    Unfortunately dental issues are quite often responsible for elevated BG levels. Many vets suggest regulating the cat before doing the necessary dental procedures however, that's really counter productive and often times impossible. There are veterinary dental specialists or perhaps another vet with a better understanding of the impact of dental issues, who could and would do the cleaning. If I were you, I think exploring other vet options might be the best way forward.

    As mentioned above, too much insulin can look like too little and given you have raised the dose by a full unit each time based on tests done in the vet's office, it's quite possible the dose is too high. Our cats tend to get stressed out with vet visits and this all too often leads the vet to raise the insulin dose too quickly.

    I'm so glad you are planning to home test. That is the best tool we have to keep our kitties safe and get them regulated. We have a spreadsheet available where you simply plug in your BG readings and it colour codes them so you can recognize patterns and easily see how kitty is doing. The instructions for setting up the spreadsheet are HERE and THIS document explains how to use it. If you need any assistance, please let us know as there are members here who can set up the spreadsheet for you.
     
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  4. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Aug 5, 2016
    Welcome!!

    First take a big breath because all you are dealing with is quite overwhelming at first, but diabetes can be controlled it just takes time.

    You are off to a very good start since you arrived here, and here is the best place you can be you never wanted to be, and you are already planning on testing at home, that is what is going to really help in knowing what is really going on with his blood sugar and how he really is reacting to the insulin, so as soon as you get the glucose monitor start testing , easier said than done so please be patient and ask here if you need any tips or tricks on how to do it.

    After you start testing record all your results in the spreadsheet they mention earlier

    Stomatitis and dental issues impact on his blood sugar levels (actually any kind of illness) which means he may need a bit more insulin than a cat without any of those issues but we will be able to determine that once you start testing.

    Regarding the Lantus pen, we actually use it as a mini vial, and we extract the insulin from it with syringes (if you can get the ones with half unit markings those are the best ones ) because to really regulate your cat you will need to make increments and decrements on 0.25 units and the pen mechanism only allows 1 unit changes

    I also agree that is too soon to start with the quality of life talk just yet, yes he is probably feeling bad at the moment but once he's on lower numbers ( even if he's not totally regulated ) he will start feeling as his old self.

    Also and since he's with high numbers right now and with a flare of stomatitis (probably nor eating too well) is important that you monitor his urine for ketones (and if he develops ketones you need vet intervention as sap) , you can buy test strips for this in the pharmacy, the ones for people work just fine or get some for cats

    Please keep asking as much as you need/want
     
  5. tackeee

    tackeee Member

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    Jan 9, 2019
    Thank you for this help! I had started browsing the Lantus forum, but hadn't delved too deep yet - I'll look for the stickies! I also saw some of the forum posts on the Fancy Feast pate as an OK low carb option. I picked some up, and he gulped it down, so I hope that helps him feel better too. I was prescribed for him the glycobalance, but he won't eat the wet. He's been eating the dry, but I know it's higher carbs and I can imagine the big pieces are hurting his mouth. Not sure if it's worth continuing on it, or perhaps doing a bit of both?
     
  6. tackeee

    tackeee Member

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    Jan 9, 2019
    Thanks for this info! I'd been reading about this too. They don't have dental X-rays at my dentist. I've got a plan with Banfield, so taking Little One elsewhere is an even bigger financial problem. I wonder if he could get dental X-rays elsewhere and they could still do the cleaning at Banfield. He's had two back teeth successfully removed there in the past. My dentist was talking about the need to see the roots to help them decide next steps. She said doing full extractions would be the best bet. Though, he also has a heart murmur that they're not sure about. It's a lot of factors in the air!! I'm also a grad student/adjunct teacher so funds are limited, and I'm already putting so much money into his care (and happy to do so).

    Thanks for the links to the spreadsheet for his glucose monitoring. My vet said his numbers will be slightly off because his insulin just increased, but that I should do smaller curves and then do an official one in one week.
     
  7. SpotsMom

    SpotsMom Member

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    Feb 10, 2018
    A word of caution.. it’s a good idea to wait until you are home testing to switch from dry to low carb wet food. Food can have a dramatic effect on blood sugar and it may be the only thing propping up his numbers right now if the dose is indeed to high. Once you start testing you can monitor closely to make sure he doesn’t drop too low when you switch foods.
     
  8. tackeee

    tackeee Member

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    Jan 9, 2019
    Thank you. I was reading about how to use the Lantus pen as a vial. You just insert the syringe where you'd insert the needle cap? It doesn't affect the pen's system?

    I'm relieved to hear from all that there are still steps to be taken to help him feel back to himself. He's definitely family and the thought of losing him is too much. I don't want him to suffer, but I also think there's other options out there that don't just mean huge bills!

    He just had a urine test at the vet. His initial UTI is gone and he has no ketones (and his kidneys are functioning well). I'll pick up some test strips to use at home too. I'll check back in once I get some numbers back on his BG.
     
  9. tackeee

    tackeee Member

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    Jan 9, 2019
    Thanks, I'd read this too. He's had fancy feast in the past, so just adding it back in. I'll keep him on small amounts of dry until I start home testing!
     
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  10. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Yes you insert the syringe there it won't affect the pen or the insulin and since you won't be using the mecanism because you won't be mesuring the insulin with the pen it really doesn't matter
     
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  11. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    This is a good idea and once you are monitoring him you can discontinue the dry completely
     
  12. tackeee

    tackeee Member

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    Jan 9, 2019
    So I did his first day of at-home testing (a "mini" version of a curve for my first attempts). After he ate his BG was 445 at 10am. Then an hour after 3 units of lantus at 11am, his BG was 507. Then three hours later at 2pm it had gone down to 397, and then two hours later at 4 (which was supposed to be the lowest), it was at 429. This is definitely not a curve and the ups and downs are way confusing. Any insights?

    Also* He had the insulin upped to 3 units as of Tuesday night, so it has been 2.5 days only since the increase.
     
  13. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Feb 18, 2015
    While you may be expecting the nadir (lowest reading) to occur at 6 hours after the insulin shot, that is not always the case. Every cat is different and some reach peak action earlier or later. The nadir also can and does change so it's not always at exactly the same time everyday. Lantus can peak anywhere between 4 and 7 hours and sometimes even later in some cases. Looks like today's nadir may have been around the 4 hour mark.

    Now that you are testing, it would be very helpful for those offering opinions and suggestions if you could get a spreadsheet set up for your kitty. We rely on the data you collect to make recommendations for dosing/feeding etc.

    The dose increases of 1 unit at a time may mean you have missed the ideal dose. We generally make dose changes in 0.25u increments to ensure we don't miss the proper dose because sometimes too much insulin can look exactly the same as not enough.
     
  14. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Congratulations on getting your first tests!!!

    Just remember that you need always test before you shoot and you need to withdraw all food 2 hours before the preshoot test to make sure this result is not food influenced and is safe to give insulin, the rest of the day you feed as you usually do and test you do not need to withdraw food every time you test just the preshoot tests

    At the beginning odds are you are not going to look at a very nice curve it takes time before you can get him regulated
     
  15. tackeee

    tackeee Member

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    Jan 9, 2019
    That's what I'm worried about! Not sure what to do with current vet; waiting on her call.
     
  16. tackeee

    tackeee Member

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    Jan 9, 2019
    To clarify: the first test of the day (AMPS) should be tested two hours after morning food? He's eating once a day in the am and once a day in the pm, and I have been instructed to give his insulin roughly 30 minutes after he eats. What should I change?
     
  17. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Don't change your schedule, just test before you feed, check your result and if it is safe to give insulin feed and then shoot or shoot and feed at the same time once you are sure is safe to shoot is ok to feed, specially with Lantus since is a long lasting insulin and it will take a while before it kicks in hard
     
  18. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    You do not have to wait to give insulin after eating. Many of us give insulin while our cats are eating. Feeding 30 minutes before insulin is necessary with some of the faster acting insulins but not with Lantus. You can withhold food for at least 2 hours then test and shoot (provided AMPS test is high enough) all within a few minutes without any issues.
    Most of us feed our cats multiple small meals throughout the day/night. Some use an autofeeder for the nighttime meals. Feeding several meals/snacks helps level out the BG to some extent by making food available to work with the insulin throughout the day and night cycles rather than only at the early part of each cycle.
    I can see your spreadsheet for Little One.... YEAH!
     
  19. tackeee

    tackeee Member

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    Jan 9, 2019
    Thanks to you both! OK. So I'm a little slow here. So let's say I feed him breakfast at 9am. It'd be better to test BEFORE he eats(where he hasn't had access to food for 2+ hours) and then see what it is? And then I can give him the insulin right away with his food?

    And then as many times as I might test throughout the day as I'm getting him regulated. And then again do another AMPS test before he has "dinner" (after withholding food for at least two hours) and then give him insulin shot w his food?

    So other problem: I've heard that feeding smaller meals throughout the day is always better and the cats prefer it. However, Little One with his stomatitis needs wet, and w/ his brother who will get in his food if I'm not around, means I can only feed him if I'm here. I work from home some days, so it's more feasible. Other days I'm gone like 12+ hours a day. So - I've also heard consistency is super important. Better to feed him twice/day and keep consistent, or change up his feeding schedule for when I'm around?

    Thanks!
     
  20. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Aug 5, 2016
    Yes

    Yes

    I do think is better to give smaller meals, my cats actually almost free feed but I'm also out of my house for many hours so I'm pretty sure some eat a bit more than others still I give breakfast and then leave some food out as I'm going out the door, I have a time feeder that would open around noon and then I give them dinner at night. When I'm at home they all get spoiled and pretty much get to eat when ever they want ( Babu actually asks me for food several times around the day when I'm at home and he gets some bites every time :rolleyes: )
     
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  21. tackeee

    tackeee Member

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    Jan 9, 2019
    Cool thanks! And when is it technically not safe? I mean I’ve never seen his numbers low enough to have that worry yet, between the vets tests and mine at home
     
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  22. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    I think you've got it but just to re-iterate.
    If you normally give insulin at 9am, then you withhold food from 7 to 9. At 9 you test, then feed and shoot insulin either with or right after his meal.

    Your issue with the civvie getting into Little One's food is the opposite of what I always struggled with. It really depends on how fussy either cat is about their food. My extra sweet girl was extremely fussy so I could leave out food for my civvies that she did not like avoiding her overloading and she was the one in my house who would eat everyone else's food. So in your case, if you could find some food Little One likes and is appropriate but your civvie dislikes, it might work. My extra sweet girl also did not like cold food so I would freeze some food and leave it out so the boys could harvest some before it got warm.

    There are feeders you can get that will only open for a specific cat using either a microchip or small tag on a collar. They are quite expensive but would solve the problem.

    You can certainly stick with two meals a day for those days when you are not available to play waitress for several meals. Consistency while helpful, is not always possible given our schedules are not always predictable.
     
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  23. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Usually when you are starting is recommended that if the test is under 200 you do not feed and post in the Lantus forum and ask for assistance before shooting or maybe skip the shoot (depends on the number ) later on the number is quite lower but you will know by then how he reacts to insulin
     
  24. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Until you get more data, we recommend no shot unless the pre-shot test is over 200. If Little One is right around 200, stall for 30 minutes without feeding (if your schedule allows) and then test again to see if BG is rising without food. If you have any concerns, post for assistance.
     
  25. tackeee

    tackeee Member

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    Jan 9, 2019
    Yeah, he was just 434, so he got his normal dosage. I wish he was nearer to 200! I talked to the vet who seems to think his dosage is not too high because there was still a slight dip and then it went back up in the numbers today. She said to keep him a full week at 3 units and then do a full curve in a week and make a choice from there about the dose.
     
  26. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    I would argue that the cycle today has been pretty flat. There is a certain amount of variance allowed in meter readings (20%) and when you look at the readings for the day, there is no more than a drop of approx. 50 points except between the 507 and 397. The 507 was a food bump (up from the 445). So if you look at the AM pre-shot and nadir, and nadir to PM there isn't much difference in those numbers. We'd call that a flat cycle and that can indicate the dose is too high.
     
  27. tackeee

    tackeee Member

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    Jan 9, 2019
    What would you recommend regarding talking to my vet? Particularly how do I advocate for him when I'm completely new to this? She's also wary that he just got upped to 3units on Tuesday night and says the body needs some time to adjust to the insulin. If it is a flat reading, would we see it drop at any point? Is his liver just sending sugar out perpetually because of the insulin so it never drops?

    Sigh.
     
  28. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    To be honest, most of us don't consult with our vets about dosing and have adopted a nod our head at the vet technique and then we read the data we collect and dose accordingly. Vets are great at most things but this sugar dance is very much a hands on situation and most vets just don't treat that many felines with diabetes. They may be wonderful vets but if they only have one or two diabetics in their practice, they don't have much hands on experience nor do they have the time to really understand the finer points of how insulin works. Some are used to using the faster acting insulins and think Lantus works the same way which is not the case. Vets actually get very little training in diabetes and what they do get encompasses different species.

    The problem right now is that dosing has been based on in clinic readings which are usually elevated due to stress. If the dose of insulin prescribed is too high or raised too quickly and you home test, you still see high numbers. In your case, you are also dealing with the stomatitis which is likely elevating his BG too but how much elevation is due to dental issues, how much is diabetes and how much could be from too high a dose is the big question. Until you get more data, it's really difficult to say what exactly is going on but the flat cycle today suggests the dose may be too high.

    I'd suggest you get a test before bed every night to see how much Little One has dropped after his PM shot. Once you have a bit more data, it should be easier to determine if a dose reduction or increase is needed. I would strongly recommend dose adjustments be done in 0.25u increments and definitely no more than 0.5u so using syringes instead of the pen is recommended. Get mid day tests when you can. Any data is good data. One you have a few days of information, it will be easier to make more concrete suggestions.

    Remember you are the one holding the needle so what you do at home is entirely up to you. We can help you understand the data you collect and make suggestions to help you get Little One on a better path.
     
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  29. tackeee

    tackeee Member

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    Jan 9, 2019
    I'll keep the insulin where it is and collect data over the next couple of days (not a full curve) to give the poor guy a break. I'll do the before shot in the morning, around 4pm, before dinner, and before bed for the next couple of days. I plan on doing a full day curve again likely Thursday when I'll be at home a bit more.

    I'm wary of doing too much too quickly in either direction...

    I really appreciate your help and will check back in over the next couple of days as I can put more numbers in the chart.
     
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  30. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Sounds like a good plan. I agree that doing too much too quickly can be problematic too.
     

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