opinions needed on my curve #s

We upped the dose for Oscar to 1.5U last Friday. We started getting a resemblance of a curve Saturday through Tuesday, but all of a sudden we are getting a flat line again, along with slightly higher trace levels of ketones. What gives? Is this type of a number change normal? Should we think about switching to a different type of insulin?

 

I too do not like the flat curve. I would give it another day and then make a decision. Yes, maybe an insulin change is in order.

 

I agree today's #s don't seem right (inverse curve?), and I certainly do not like ketones. I don't have enough insight into his #s to give you any PZI suggestions, sorry! I would suggest that you post in both the Lantus and Levemir forums with the same info/questions as here, and see what responses you get. There are also former PZI-ers in both spots, so hopefully they would be in a good position to assess whether there is something obvious you can change to make PZI work better for him.

Have you already posted on Health to get advice on the ketones? I don't want to repeat if you have (and don't know a huge amount about them myself) but I do know that if you can get extra food & fluids into them that is very important, and a vet check is in order if there is any suspicion of possible infection, and/or if the ketones get worse or he stops eating. I don't know the #s with ketones, i.e. what level is considered trace/minor and what is "get to a vet!!!", so please don't construe my suggestions to mean a vet trip is not needed - it might be, I just don't know enough about ketones to know where the cutoff point is for home treatment vs. something more aggressive is needed.

Ketones begone!!!! cat(2)_steam

Hope things improve for you guys soon.

[p.s. hey Larry, I grew up in McLean! small world! ]

 

First priority is those ketones! I don't know if you've read up on Diabetic Ketoacidosis but if it ever happens once it means huge vet bills, lots of pain and quite possible death for your cat within 24 hours. So forget the curves, get some insulin and fluids into Oscar, and if you have any more than "trace" ketones any time, run don't walk into Emergency Vet care.

Read up a little here:

http://petdiabetes.wikia.com/wiki/Ketoacidosis
and here
http://en.wikipedia.org/wiki/Diabetic_ketoacidosis

The primary cause of DKA is insulin shortage, but usually one or two other of the following have to happen:
* Dehydration
* Infection
* Lack of food

Note of course that lack of insulin can lead to high blood sugar which can in turn lead to any or all of the other three, so the first order of business is to make sure there's insulin in that cat. Next is to make sure there's both food and water in there too.

Once this is dealt with and there are no ketones in urine, then we can talk about whether those high curves come from diet, insulin underdose, or insulin overdose. (My guess is underdose since overdose doesn't generally cause ketosis...)

Best to Oscar,

 

Believe me, I have done plenty of reading on ketones since they showed up in his blood. Right now, they are still within trace limits, but I have noticed that the 0.6 levels equate to Oscar being more picky with his food, though he still eats pretty well. I mix at least a 1/4 cup of warm water with his food at each feeding just to try to get extra fluids in him. I already posted a thread in the diabetes general health forum about it.

That inverse curve today made me wrinkle my nose. I have no clue what is going on there. We just took a trip this weekend to TN with him to pick my husband up from the Army. Could temporary stress cause elevated levels like this? What is odd is he curved better and ate better while at the hotel than when he came home!

 

Stress causes the release of cortisol (same as cortisone) which raises blood sugar within a short time (minutes to hours). It can also cause the release of epinephrine (adrenaline) which can raise blood sugar within seconds (for a burst of energy.) So yes temporary stress can easily lead to temporary high blood sugar. It's meant to.

Of course in a healthy individual, that blood sugar comes down again when the stress goes away. With inadequate insulin that doesn't happen.

 

I knew about stress causing higher bg numbers. I guess I am wondering if stress like that can cause elevated ketone levels too. I figured the stress would cause higher bg numbers while we were at the hotel, but once we got home, I would expect things to go back to normal.

 

I just looked at Oscar's spreadsheet.

It seems to me he just needs more insulin, plain and simple. He's responding to the slowly raising doses with lower numbers, but I haven't seen a single two-digit peak yet, so it's time for more.

And I haven't seen any indication of a week-long settling time after you raise dose, either. On the contrary, your best results come right after raising dose, and then he settles in and wants more.

And now he's showing ketones, which generally means inadequate insulin.

So all put together, I think you're being too cautious with your dose raising and it may be dangerous to keep them so low for too much longer. I'd consider raising dose by 0.2 every other day until you see most peak numbers in the green (40-99) region. And then try to keep in that region for a few hours each day!

Ketones should resolve themselves if you can do that soon.

 

Just got back from the vet this morning. Oscar is down to 0.3mmol ketone level, so there is hope of zeros in his future there. We have been battling asthma too, and this week his lungs sounded much better. He still mouth breathes a little, so he had blood drawn to test for heartworms and heart disease too. Our vet wanted to up his dose a lot since he isn't curving much and we have ketones (to 2.5 already from the 1.5 he is at now), but I feel more comfortable with a 0.5U increase now, and another 0.5 in a few days depending on numbers. I'd rather not have to deal with a rebound after a hypo nailbite_smile

 

I'm glad you decided to raise the dose. I wanted to tell you last night, but others kind of said it all.

Personally I think it's a bit fast to switch insulins, before you even get up to a therapeutic dose. PZIR seems pretty gentle. Have you had a hypo experience already? I know if you work and are gone all day, it has to be scary. Hang in there! ;-)

I like your idea of .5 now , .5 later if needed.

 

No hypo experience yet. I just bought a bottle of karo syrup today because of how much we are upping his dose in the next few days. I am trying to avoid a hypo, but we may be too passive with his dose changes because of it.

 

There's a certain amount of "hypo-terror" that comes along with this board that seems to infect people after just a short time here, and it's way out of proportion to the risk.

In addition, there is a certain lack of respect for Diabetic Ketoacidosis and the dangers of hyperglycemia. People wisely counsel "don't panic", and "go slow" with dosing, but they never say just how slow. What seems to happen is that people keep rounding the time to dose change upward, from 3-5 days, to 5-7 days, to 'at least a week', to 'weeks', and eventually it gets ridiculous.

My grumpy rant: If the cat's not getting enough insulin to see a peak below 100, either they're overdosed or they need more insulin right away. If you've been raising from 0.5 units and only by 0.5 unit increments, with consultation from your peers, every 3 days, you won't be getting rebounds. Raise the dose. Every 3 days is quite adequate for PZI, every 5 at most for the longer-lasting Levemir or Lantus. Any more is just risking hyperglycemia danger and prolonging the agony.

After hanging about here for 5 years, though, I can tell you that the total number of deaths by hypo I've heard about (including Toonces who was overdosed by a factor of at least 10 and held on, brain-damaged, for another few years) is approximately 2.

On the other hand, the total number of timidly-dosed cats who have died of DKA or related issues is definitely well over 10. It seems to happen nearly every month here. And though hypo can be treated instantaneously and effectively at home, DKA generally needs a very expensive emergency vet intervention and has a substantial risk of death even so.

Nuff said.

 

we shot 2U last night, and I wake up to an amps of 153! I am shooting 1.8U this morning because I can't be around him and my husband will be home to monitor him. Wow am I glad I didn't shoot 2.5U last night :shock:

 

Good show!

I think 2U was a great idea, and 1.8 a good duck this morning. If you keep up that kind of responsiveness, adjusting in SMALL changes and not overreacting, but frequently, you should zero in on a good dose fast.