Insulin Resistance, Somogyi magic, or ineptitude on my part?

Hi there,

I'm new to the site, but have lurked for many years with a previous kitty. I am having a heck of a time getting my cat's blood sugar under control and can't afford to run into the vet very often. I am hoping you wonderful people could take a look at my spreadsheet and give me the benefit of your experience.

I have included a few days of curves at different doses, but I am getting nervous with the insulin dose being so high. He is currently on Lantus and today is at 6.5U BID, likely to increase to 7 soon since he's not responding.

TL;DR: Please help me help my kitty.

 

Welcome. Please read the yellow sticky on SLGS which is the only method we recommend when a cat is eating dry food. You are increasing way too fast and by way too much insulin in my opinion. Too much insulin can act the same as too little. We starting off increasing in .25 increments and with SLGS a curve is done to find the nadir, the lowest point in the cycle.

Also, it’s important to get tests at night as many cats go lower at night. Lantus is dosed based upon the nadir, not the preshot. I think your cat is getting way too much insulin.

 

Are you missing data on the spreadsheet? You should be testing before each and every shot. I think you have been increasing by too much and too quickly. We have two dosing methods here, and with either of them, yellow numbers mean increases are by 0.25 units if you are under 5 units total dose. One dosing method, Tight Regulation would have you hold each dose three days, and Start Low Go Slownp dosing method would mean holding each dose a week. You increases are by 0.5 units and two days apart. Too easy to get overdose.

 

Hi there,

Sorry, I do have more data, I was just rushing to get pertinent info into the sheet to have it looked at.

I am using a pen needle, so I have to adjust by 0.5 units at a time.

I will update the spreadsheet soon with the rest of my data. I agree that the amount seems high, but I haven't been able to get him below 12.7 in a month so I was increasing the dosage to try to get any sort of response. I even stopped him at one point to rule out somogyi and have had no luck. I will look over the methods you have recommended as well.

I also included his lab work in the spreadsheet, in case that is helpful at all.

I can't test at night, it isn't something I am able to do currently with my life requirements. I wish I could, but this is the best I can manage at the moment.

Thanks for your initial suggestions.

 

Okay, I have updated the spreadsheet with my glucose numbers to March 19th.

 

You can get insulin syringes with half unit markings. That way you can do doses in between.

Can you get a before bed testat +2 or+3? Tbatwould be helpful and gives ckueastowhat is going on at night and whether it will be an active cycle.

 

I agree with both of Elise’s points. Syringes are the better way to go, and your pens last longer because you can keep pens in the fridge and use to the last drop if using syringes. Plus anecdotal stories are that the syringes hurt less than the pen needles,.

Getting a test before bed or just s you get up is helpful, unless you cannot because you need 12 hours of sleep. We have had some members with medical or other conditions that cannot test at night, so understand if that is the case.

Lantus is a depot insulin, you need to hold the dose at least three days/six cycles, for the depot to build and see what the dose can do. Try holding this dose for a day or two yet to gather more data once the depot is full. It is possible your kitty has a secondary condition that requires more insulin. It could also be the dry food. What brand are you feeding? There may be a lower carb option that he will eat. We have also had some members feed freeze dried low carb raw, so kitty still gets some crunch.

 

I see on 3/1 you gave another dose 2 hrs after regular dose. That is something you do not want to do. You could have 2 nadirs to deal with. If the first shot had dropped kitty to low, the 2nd shot could possibly kick in at its time and you would have an extended possible hypo episode on your hands. Could be very dangerous.

I hope that makes sense, not sure if I explained it right. Anywho, it's something you don't want to do. Just like if you your not sure kitty got insulin with a shot (for shot) you don't ever give a second shot, you don't know how much actually went in.

 

Hi there,

I am not apt enough to work with syringes. Pen needles are about all I can handle competently, so I'm a little stuck there.

I am feeding Orijen Cat and Kitten, which I have been told is a low Glycemic Index food (for a dry food, that is). I can't do raw as I have kids in the house and do not feel comfortable with it, though I have investigated it in the past. I am planning to wean him off of the 5g as I agree it is not ideal.

With my last cat, my vet had said I could dose an extra time during the day if I was seeing high numbers. Thank you for the note about the risk, I will avoid this in the future. On the plus side I did test him a bunch that day, so hopefully I would have been able to counteract any issues. Still, I won't risk it again

Unfortunately, with my schedule and other obligations, night testing isn't really an option, and many times his feeding time isn't 12 hours apart, often 12 to 15 hours from morning feeding to evening feeding. I know this seems like I'm slacking, but I am doing my best with what life is throwing at me.

Thank you for your comments. I will keep him at the 6.5 units he is currently receiving for a bit and update my spreadsheet accordingly. It seems the consensus is that I am giving him too much insulin; can you suggest the dosage I should try taking him back to and whether I should step him down slowly or just taking him back to it?

Thanks for your time

 

I didn’t realize you were at 6.5 units already. The spreadsheet is missing the last couple of days of data. Can you post the new data for us to see if that is what you should continue with.

Low Glycemic index does not necessarily mean low carbs. If you are in the US, I believe the Dr. Elsey’s Clean Protein or Young Again dry food is low carb. The YA you have to order on line but I think they will send you a sample. I know nothing much about it, but it is rich and have heard causes tummy upset in some. It has also helped some kibble head kitties.

Thanks for explaining your situation. I think that means we should use an abundance of caution and try to lower his numbers some, but still keep him safe. Speaking of cautions, any change to a lower carb dry food should be done very slowly. It can make a huge difference in the size of dose needed. I would only switch when you can monitor closely for a few days.

 

I have updated the spreadsheet to contain all of the information I currently have.

I'm actually in Canada, and I don't recognize those brand names, but I will look into whether I can obtain them. However, I am going to be working on removing his dry food all together once he is at an insulin dose that I am going to be sticking with for a bit. And I totally agree with you, that change will be gradual and only when I can monitor him.

My biggest concern is that I have never seen him below 10mmol/L (180mg/dL) and that concerns me. That's why I've been a little more reckless than I normally would be. I read a lot of different information online and most suggested that if he was over 20mmol/L, the dose should be increased by 1U, so I thought I was being safe doing 0.5U increases most of the time. My Vet is only familiar with Caninsulin and recommended a high Carb diet, so I pushed for Lantus and a low carb diet because I read that this was the best shot for remission and I was a little familiar with this insulin.

At the time it seemed logical to move up more quickly (as I was scared, and still am, that his poor organs were/are being damaged), but hindsight is 20/20 and now I have to find a way to dig myself out of the hole I have dug. That being said, I am 5 cycles in with 6.5U and still not seeing a drop below 12.2mmol/L.

When I plot my curves, they look far too flat and high, which is why I was wondering about insulin resistance. Considering his bloodwork, it would not surprise me if there was something else going on. I initially thought it was just because his teeth were so bad, but these numbers suggest that is not the case. I can google and understand just enough to know that I have no clue what is going on :/

I will continue to update the spreadsheet, and any thoughts or suggestions would be appreciated.

 

I too am in Canada. Unfortunately, there isn’t much in the way of low carb dry food here. One Canadian tried the freeze dried raw. It’s not as bad as fresh raw for handling. Let’s see if @MrWorfMen's Mom Linda has any ideas. Her girl was a kibble addict, until she wasn’t.

When cats get over six units on a low carb diet, we suggest getting testing done for acromegaly and IAA (insulin auto antibodies). My girl had both, one in four diabetic cats has acromegaly, a benign pituitary tumour that puts out excess growth hormone causing the diabetes. Not all cats with these conditions have high doses, but we sometimes call them high dose conditions. The tests are blood tests sent to Michigan State University. They cost quite a bit from Canada due to shipping, so it would be good to remove other possibilities first. We had one cat here on 5.5:units of Levemir and theoretically eating all wet. Turns out he was sneaking dry and when it was removed from the house, he went into remission, over a couple of scary days of plummeting numbers.

Thanks for updating the spreadsheet. My girl once spent three months going low at night (and earning reductions), then bouncing with high numbers during the day. Hence my issues with relying on just day time data. That would have caused me to increase instead of reduce the dose. But you gotta do what you can. You do a good job getting day time data. Let’s stay at this dose another day or so to get more data.

 

The Orijen Cat & Kitten is around 18% carbs so it is amongst the lower carb dry foods available here. There are 3 slightly lower carb options but they still exceed the recommended 10%.
Nature's Variety Ultimate Protein - 14% (someone here got company as fed info more recently that suggested it is only 12% now so they may have changed the formula slightly since I contacted them a couple of years ago.)
Go Fit and Trim - 14%
Nature's Variety Original Chicken - 15%
Good luck weaning The Old Man off the kibble. My girl wouldn't even acknowledge wet food was edible for the first 6 years of her life, (diabetes was diagnosed at 4yrs old) so you've already got a good start at the battle.

 

Hey everyone,

Thank you for the dry food suggestions. I have taken hime back to 4g of dry food now, watching as we go, but even that doesn't seem to have affected these ridiculous numbers. I am going to keep stepping him back, bit by bit.

My other two cats are on dry food, but my Old Man can't get at it: I have to feed them all in separate cages or they get into each others food and it just doesn't work. Once they finish, the food all goes into the fridge until next feeding time, and the extra food is locked up in drawers and a vittles vault. So at least I know he's not sneaking it

I recognize what you are saying about the night time numbers. Once spring break is over, I'll see if I can grab one or two over a couple of nights to try and get a feel for where he is.

I have updated my spreadsheet again and still haven't seen too much in the way of movement of his numbers, so I did increase him to 7.0U this morning to see what happens (I'm home and can watch him today).

I whole-heartedly agree that he is on way too much insulin, I don't like this amount and it terrifies me. I did want to ask something though. If I am massively overdosing him for this long, would I have seen a hypo incident, or can Somogyi or something else keep him high this long?

The Acromegaly has crossed my mind, the IAA is new and I appreciate the ideas to look into. When you say to remove other possibilities first, are there any particular ones I should be listening for when I see the vet next? I think with these numbers that the insulin isn't doing what it is supposed to and I need to take him in again. I called to find out what the vet's office thought and the receptionist told me not to bother bringing my glucose curves, so my back is up a bit and I would like to go in with some ideas of what my vet should be looking into, just to make sure the money I can budget for this is going to good use.

Thanks for your help and advice.

 

A cat needs a much insulin as they need. My girl got up to 8.75 units before she turned around. We have had some with high dose conditions on much higher doses. So, as long as a cat isn’t overdosed, it may not be too much insulin. Symogyi is pretty much an old vet’s tale. Recent research has shown it’s rare in cats started on long lasting insulins and increased safely. If a cat was way overdosed, you would eventually be seeing signs of hypo, but it wouldn’t necessarily happen during the day time. It’s great you will be able to grab a couple night time spot checks. Even a +2 would be good data.

The other possibilities I mentioned include dry food, any secondary health conditions such as infection or inflammation, bad teeth or pancreatitis being examples. Other conditions such as heart or kidney conditions or hyperthyroidism can cause some insulin resistance. Though not usually this high a dose unless severe.

 

I didn't know that about Somogyi, thank you for the info.

I think I'll keep trying to step him up and see what happens. Hopefully we find a sweet spot and can get his blood sugar under control and then figure out why on Earth it takes so much insulin to get him to respond. If I can at least get that under control, he'll feel better than he is right now, and then the vet can focus on finding any underlying issues rather than on the blood sugar itself.

If I can't get him to respond over the next week or two, I'm going to take him into the vet. I'll keep updating my spreadsheet and post with any pertinent updates.

Thanks for your help. It makes me feel a bit better knowing that I'm probably not overdosing him, or I'd likely have killed the poor thing by accident by now. I'll work on getting some night time numbers and see where he sits.

Have a great week.

 

I'll update my spreadsheet soon, but for now I wanted to share a small victory. It's not perfect, but it's better than I've seen so far so I am excited.

Today's NADAIR seems to be 10.7 (193 for the other measurement)!!!! That's the lowest he has been since this whole thing started. I am guardedly optimistic that I might be able to control his raging sugars.

This is at 7U, which is terrifying, but it's progress. So, we are going to stay here for a bit longer and see where he settles out, then decide if he might still need more. Fingers Crossed!!!

Thank you again for your help and encouragement.

 

Woohoo! That first blue is major progress,like a light at the end of the tunnel. How is the Old Man feeling/doing, other than his sugars?