Need urgent help on correct dosage and protocol

Yesterday, I switched Cedric's diet over from high carb dry food, to low carb wet food (Granatapet).

To be safe, I did not administer any insuline. I was happy to see that during the day his BG decreased from 10.5 mmol/l to 8.7 mmol/l. I hoped this trend continued and Cedric's BG could be controlled with diet alone.

I was a bit ahead of things. This morning the preshot was 9.5 mmol/l (very positive!), so I thought no insuline would be required.

But the +2 test was increased to 13.2 mmol/l! So I panicked and decided to give 0,5 U insuline together with a bit more food.

With the dry food, Cedric got 1,5 U insuline every 12 hours.

How do I determine which dosage to give now that Cedric is on a low carb diet?

And more important, would a fixed dosage be the best way to get him in remission? Or should I look into Tight Regulation?

@MrWorfMen's Mom can you assist me with this?

 

@Sienne and Gabby (GA)
@Bron and Sheba (GA)
@Wendy&Neko
Hi guys I see that Matthijs tagged Linda, she will not be back until later tonight, maybe you can give this member some advice, I hope you don't mind the tag, I just felt bad no one replied back Thank you I don't understand her SS and no testing for PMPS

 

In general, giving insulin twice a day is recommended. Caninsulin has a short duration so by the time you are getting to the evening shot, the insulin from the morning injection is gone. Since you don't have any PM cycle tests, you can't see what's happening with the numbers in the evening. (That's my way of suggesting you get a before bed test every night.) Many cats have lower numbers at night. Given that Caninsulin can also drop numbers fast and hard, please get PM cycle tests to insure that Cedric is safe. In addition, without the PM tests, you're missing half of your data.

With Caninsulin, you cannot use the Tight Regulation Protocol. TR was developed for Lantus and Levemir only and they are very different types of insulin (i.e., depot insulins) than Caninsulin. I realize (belatedly) that this is confusing and I'm going to see what one of the other Moderators can do to rectify the confusion.

You should indicate that you gave an injection of 0.5u at +2. Perhaps put "see comments" in the U column and put a note in the comments section of your spreadsheet that you gave a dose of 0.5u at AM+2. Without the information, we'll assume that you didn't give a shot this morning.

Going forward, I have a couple of thoughts. First, you are 2 hours late for your regular shot time. You will need to gradually adjust when you give your shots until you are back on schedule. You have 2 options. You can shift the shot time 15 minutes earlier at each shot time or you can shoot 30 minutes early once a day. This will have a minimal effect on your dosing.

I do think that Cedric needs to be getting insulin twice a day. Even with the results of the diet switch, his numbers on Jan. 3 were outside of normal range. I would suggest keeping the dose at 0.5u unless the test results from today suggest otherwise.

Also, could you check the dates on your spreadsheet? I think you have dates for February, not January and the first entry is for Dec. 7th.

 

Thank you @Sienne and Gabby (GA) for getting back to her

 

Thanks @Sienne and Gabby (GA)! That's really welcome advice. I know I should test more often, but with Cedric it's still a two-man job. I updated the spreadsheet based on your comments.

Yes, withholding insuline yesterday was only meant to safely switch his diet without triggering a hypo. I must say was I was happy to see that Cedric must be producing some insuline himself to get the BG around 10 mmol/l and even a bit lower.

Now I want to resume the twice daily insuline administration, although I hope Cedric is able to go into remission at some day.

What I will do is to reduce to dose from 1,5u to 0,5u as suggested and administer that twice a day (7.30 AM and 7.30 PM).

I will also check the BG nadir at +4 for several days and report back when that is outside normal range.

Can you tell me what I should do based on the the preshot test for this evening? The vet did not mention this, only asked to test at +4. So let's say the preshot BG is below 11 mmol/l, is that a no shoot number? What actions are then to be taken?

 

I found the following source of information about the Tight Regulation protocol for intermediate-action insuline types:

http://diabeticcatcare.com/DCCCOK/I...-Action_Insulin_Types_-_How_They_Work_In_Cats
https://www.diabeticcatcare.com/DCCCOK/Protocol.htm (Dr. Hodgkins' Tight Regulation Protocol)

This seems actionable and also lists Caninsulin / Vetsulin. Is this source wrong?

 

Regarding adjusting the shot time until back on schedule, do I also need to wait with feeding Cedric?

Or can I feed him at normal time (7:30), then do a preshot test at 9:15 and give a 0,5u shot at 9:15?

 

And what they don't tell you with Dr. Hodgkin's version of TR is that they advise to never give HC food. Quite frankly, cats have died using that method. They also don't tell you that Hodgekins developed the the approach for PZI (an earlier iteration of Prozinc). If you notice, she relies on information related to PZI and has had to go back and note that it is no longer available.

Her use of the term, "Tight Regulation" is misleading. TR was developed by Roomp & Rand based on their research with cats on the German Lantus board (where Levemir is also used). I haven't a clue what research Hodgekins' did or didn't do. I would be very reticent to suggest you follow what you've read on the DCC website. We will not be able to provide you with assistance if you are following a method we are unfamiliar with.

As for the PM shot, you might want to give him a snack at his usual shot time. Remember, though, that with Caninsulin you do need to have food on board at least 30 min in advance of shot time. Feeding Cedric his entire meal 2 hours prior to shot time could be a set up for numbers to plummet.

 

Thanks for clarifying the TR protocol. Looks like there is more research for me to do. I had not considered switching insuline types yet.

Can you teach me what to do with preshot test results? Do I need to take a no shoot number into account?

(by the way, did your message get truncated? It looks to start halfway a paragraph)

 

@Sienne and Gabby (GA)

Just got a preshot reading: 10.0 mmol/l

Do I proceed to give 0,5 U insuline or not?

 

The post was complete.

If you are nervous about shooting below 200, since it's been almost 30 min., re-test and see if numbers are rising. If they are heading higher, you should be fine to shoot. I would get a test no later than +2 -- preferably earlier.

Also, you have the 10 in your +2 column. It is your PMPS test. I know this can be confusing but the pre-shot value is always 12 hours from your previous shot. Just put a note in your comments that you are adjusting the times due to the late shot earlier today.

 

Okay. After a discussion with my girlfriend we decided to give Cedric a small bit of food and 0,5u insuline. That was before I saw your post.

I did not want to leave him hanging around 10 mmol/l as we did yesterday and you are right to notice he does require a twice daily dose of insuline. It's immediately noticeable when his BG is high. He drinks a lot, is restless, searches for food.

Unfortunately I had to wait for my girlfriend to arrive home late this evening, otherwise I would have tested earlier, but I cannot do it by myself yet.

We will do a last test before going to bed, but that's roughly an 1,5 hours after his shot. So we can't stay up until the expected nadir (+4).

 

You seem to be wanting to dose based solely on pre-shot BG readings and that is not recommended for any insulin. You need to know how low a particular dose is taking BG so mid cycle tests are still of paramount importance and have to considered when making dosing decisions. You've been doing great getting day time mid cycle tests but essentially not much on the night cycle. Since many if not most kitties go lower at night, I would strongly suggest you work on being able to test Cedric with one person only so that some night time tests can be obtained. Even one test before bed every night will provide clues as to where the cycle is heading and whether more monitoring may be necessary.

Once a cat is regulated, it is possible to set up a sliding dosing scale but until kitty is regulated and the cat's reaction to the insulin is consistent, it's better to stick to a consistent dose for several cycles (6 minimum) so you get clear data to see how that dose is working. If the dose is not dropping BG to adequate levels, then an increase of 0.25u can be started. Likewise any time BG is dropping lower than 5 (90 US), a dose reduction of 0.25u is recommended.

When you get more data, and can reliably test Cedric with one person if need be, then the no shoot number can be adjusted down a little at a time but in the early days it's best to use 11 (200 US) as a no shot limit.

This AM Cedric dropped to 4.4 (79 US) which is a bit lower than recommended on Caninsulin (suggest aiming for no lower than 5 (90 US at nadir) in the early days without much data because of the steep, quick drops in BG it can cause. When you get a reading that low, feed Cedric some LC food and retest in 30 to 60 minutes to ensure he is not continuing to drop.

For now the 0.5u dose appears to be working relatively well as long as you are diligent in monitoring Cedric. If you cannot monitor, then dropping the dose to 0.25u would be a safe option.

 

Hi @MrWorfMen's Mom, sorry it took a while before I found the time to reply. Thank you for taking the time to write such an informative post.

We keep on trying. He keeps jumping away unless he is held firmly. Usually we are both at home in the evening, so doing some more PM tests to get an idea about his evening cycle should be doable.

We have only been instructed to use a VetPen, so dropping the dose to 0.25u is not an option right now. The lowest setting on a VetPen is 0.5u.

So that's why we keep asking ourselves if we should skip on a low pre-shot number. For instance, this evening pre-shot number was 6.5, I stalled for an hour and tested 6.9. Rising, but still below the no-shot limit of 11. So I concluded that it's not safe to shoot 0,5u, because we cannot observe Cedric during the night.

 

That's fine for now and you were right to skip the shot with that low a pre-shot. The other option is to get syringes with half unit markings and use the Vet pen similarly to a vial so that you can give a smaller dose when it's safe to do so.

 

Getting the confirmation that I'm making the right decision in caring for my cat means a lot to me! This is all pretty overwhelming and I already feel a bit uncomfortable deviating from the vets advice of twice a day "blind" shot of 1,5u combined with S/O dry food.

 

I think we all felt uncomfortable in the beginning when we didn’t follow the vet advice. But thank goodness you looked for more information to help Cedric. You are his advocate and he is lucky to have you.
You are doing a great job!