PMPS Dose adjustment advice

Hi. Henry has been well regulated for years and had a recent setback, so I'm starting all over again.
When I first started out I was using tight regulation, that was all I could find online. Once he was stable I was able to dose 2x a day and keep him below 200.
I could just use a little advice getting him under control using the Start Slow method. He also has CKD and I have experienced some rebound recently, so I don't want to, and can't really remember how to safely do TR.
My plan was to adjust his dose to 1.6 for his PMPS tonight if he is still red or black and 1.4U if he is in yellow?
Would someone be able to look at his SS and let me know if I would be OK?
TIA!
PS This spreadsheet is amazing, whoever created it!

 

Hi Ellen and Henry! Welcome! We don't really do the TR method here, so you're in a good place. It does look like Henry reacts well to the insulin. He's getting some good drops. I think, if it was me, I'd bump him to 1.4. I think you might be seeing some slight bouncing, which isn't necessarily a terrible thing, but smaller dose increases are usually best as they can help make sure you don't skip over the ideal dose and can hopefully help minimize bouncing. Then you want to stick with it for a few cycles to see what it does before deciding to go higher.

Are you testing for ketones? That's important with his higher numbers.

The CKD can definitely make it a bit harder, but we'll be glad to help work with you!

The SS certainly is awesome, isn't it?

 

Hi @Rachel Thanks so much. I ended up working late and didn't relay to my husband to dose 1.4U instead of 1.6U in time, so he got 1.6U
I'll set an alarm to check him at +6 to see what's happening. Should I stick with 1.6U for 3 cycles or drop back to 1.4U in the morning?
I tested his ketones earlier, so far so good. His numbers have only been high like this very recently, so I'm new to worrying about ketones.
I'm trying to figure out what could be causing it. His labs are in his SS too, nothing really stands out. I had stopped trying to get him to eat his Petandim supplement as he doesn't really like it, so I'm starting that up again disguised in a pill pocket. He also got constipated which seems to be when things got worse. I had to give him Laxatone which has corn syrup in it.

 

Oops! It's not a big deal...I don't think 1.6 would be too much, so much as I figured that slowly steadily raising the dose is a good strategy, and the slightly lower dose might help avoid bouncing. I think I'd drop back to 1.4 for at least 3 cycles..get a mid cycle whenever you can, and then we can re-evaluate.

I know those higher numbers suck, but they'll come down. I wouldn't WORRY too much about ketones...just keep up the testing for them so you catch it if they show up.

I don't know much about labs. @Marje and Gracie can read them I think. Anything changed recently in his life?

 

I gave him 1.4 this am. He was back at 598
About a year ago I was away for 2 weeks and my husband was in charge, and well, I just can’t get across to him the importance of timing precision and no off limits treats (we don’t have an eye roll emoji?? ) so he started getting harder to manage after that trip. I had to learn the hard way about rebound causing high middle numbers. I finally figured that out but then 6 months ago we discovered he had CKD. I manage it with fluids and a home made diet and he was still a bit all over the place, but manageable and rarely over 300. Then about a month ago he started to pee in a corner & I realized he was constipated and that’s when the 500+ numbers started showing up. I don’t recall now if they were happening before I had to give him Laxatone (it has corn syrup). I’m also concerned the Miralax may be messing things up, even though I can’t find anything online about it other than one lady asking the same question and a study that showed a small amount of cats got high BG taking it. I picked up some pumpkin and will get some psyllium husk and try those instead of the miralax and see if it changes anything.
He’s in pretty good shape for his age & having both CKD & DM. Good appetite and nice coat, goes up and down stairs and likes to sit outside in the sun. He’s sleeping a lot more the past few weeks but still gets up when he’s hungry on his regular schedule to lets me know it’s time to eat.
I have 3 18 y/os and a 2 y/o. One has hyperthyroid and arthritis from an old injury. I basically run a senior cat assisted living home like those ones in Sweden where college kids live there to keep the seniors young

 

Many people here use Miralax with no adverse effect on BG. Plain pumpkin is another commonly used remedy. There's a supplement called "Natural Moves" (found online) that some have good results with. Adding extra water to all wet food meals can also help because it increases overall hydration.

 

I’m glad you like the SS!!! Let me know if you ever have questions.

I have never used PZ so I won’t give dosing advice but I noticed in your signature block that you are using U100 syringes. I believe that, normally, with PZ, they use U40 insulin syringes. Isn’t that correct @Kris & Teasel and @Rachel?

On his labs, his phosphorus is way too high. Are you giving him a binder, like aluminum hydroxide powder, mixed into each meal? Let me know if you aren’t and I’ll give you some info but you really need to focus on getting that down through diet and binder. Phosphorus levels have been linked to longevity in CKD cats. You want it much, much closer to 4.5. There is also huge concern when the calcium x the phosphorus is 70 or higher due to potential tissue calcification and he’s approaching that number. It’s easier to get the P down than the Ca.

Are you giving him subq fluids because for his creatinine level, he’s not likely able to stay on top of the dehydration at this point. If you aren’t giving him daily subq fluids, I would discuss with my vet starting him on daily fluids using Lactated Ringers Solution. If you’ve never given them, HERE is a video we did with our CKD cat at the time, Gus, on how to give them at home.

His hematocrit (HCT) is still above 30% which is great but as it trends below 30%, he’s anemic. Between 20% and 30%, it can help to give B vitamins. I’ve done this with all four of my CKD cats and none of them ever dropped below 20% (which requires some big gun intervention). I’d also keep an eye on his potassium. You want it to be 4 or above and he’s at 3.9. The LRS has potassium in it so that might help. IMHO, potassium supplements are not needed right now as long as he doesn’t drop further.

I hope that helps. Please tag me with any questions.

 

Yes, ProZinc is a U40 insulin but you can use U100 syringes and a conversion chart (elsewhere on the forum) in order to have more dose fractions of the o.2, 0.4, 0.6, and 0.8 u size. That’s what Ellen has been doing.

 

Thank you. Now that you mention it, I do remember seeing it. Just wanted to be sure.

 

Thank you for coming by and checking out those labs, Marje!

 

Thanks @Marje and Gracie, @Rachel & @Kris & Teasel! I do the conversion for 100U needles, yep. (I was doing TR in the beginning but wasn't able to keep it up and don't feel like it's suitable when I'm travelling nearly every month).

He gets fluids 2 x a week right now per the vet. I was concerned about doing it more frequently without checking with the vet and causing an electrolyte imbalance or anemia, but I would be happy to do more if it won't cause any problems. He does drink A LOT of water.

I currently make raw food for him as low in phosphorus as I can, from what I've found online, and plan to do a consult with Dr. Pierson soon to refine it. I was waiting to get the most recent labs back so we'd know where we are at. If I run out of homemade food I use one of the canned foods on the list that is lower in Phosphorus (Cats in the Kitchen Chicken Frick-a-zee). He does not have a phosphorus binder, if you could share that info that would be great.

After getting the last few days info into the spreadsheet and looking over the trend, do you think it might be worth dropping back to 1.2 or even 1 (the dose that used to keep him stable before he got all out of sorts) to see what happens? I am going away for a few days and trying to get my husband set up with a solid plan as he has a really hard time wrapping his head around what he's supposed to do. He also will be working every day so won't be able to do nadir checks.

Thanks!

 

I wouldn't drop his dose down. His numbers are quite high overall and that would increase the risk of ketones. When are you going away? If you have several days at home ahead of you I'd increase to 1.6 u soon - weekend maybe?

 

I leave tomorrow morning & back Monday afternoon. I had planned to have my husband stick to 1.4 while I'm gone, but just noticed as I was looking at the SS that the only day he got into blue was when he got 1.2, so wondered if there's any rebound going on. I think I've been dealing with some serious rebound for a few months & not realizing what it was so now I'm paranoid

 

Yes, there's a lot of bouncing going on. You could stay at 1.4 u until you're back. It's hard to know what those two blues at the 1.2 u dose mean because you don't have data before they popped up.

 

I just wanted to stop in and tell you how much I relate to the house of seniors! 3 senior cats-1 diabetic, 1 hyperthyroid, and 1 male cat who used to pee everywhere (before we started adding water to his wet food) and now has a tiny non-cancerous growth over a pressure point that will open up after some rough grooming and bleed all over the house. An 11 year old dog with (controlled) epilepsy and a 5 year old dog with reactivity, and finally a 21 year old horse. I've had my horse since he was 1 but the rest of my old guys I started rescuing when I was 18...I never thought about how time-consuming and expensive they'd become when they got old! On some of the more overwhelming days I wonder why I was crazy enough to think that this many animals was a good thing but then I think about if they had gone somewhere else, possibly to a less loving home, and it breaks my heart and reaffirms that I am so grateful they are mine. Just wanted to share with some fellow cat ladies! Good luck getting Henry on track!

 

I understand completely!