Question on Irregular Schedule and Dosing

Hi All,

I'm new to this (two weeks since diagnosis and one week since starting insulin... two days from my very difficult glucose curve, because I have a difficult-to-handle cat), and quite overwhelmed. But I have an urgent question to work out based on my schedule coming up.

I run a theatre and my schedule is generally 10/11am-6/7pm, with special events and such sometimes requiring me to work 12/1-10/11pm or so. However, twice a year there are 10-day events where I'm working every day and some early and some late... and of course right as all of this is happening with my Prufrock, I'm going into the bigger of those starting February 8th. I've been dosing at 9am and 9pm, but coming up there will be several days where I need to work 12p-10:30p or so. Basically, it will look like this:

2/8: 12-9p
2/9: 12-9p
2/10: 12-4p
2/11: 4-9p
2/12: 5-10p
2/13: 11-7p
2/14: 12-10p
2/15: 12-10p
2/16: 12-10p
2/17: 12-4p
12/18: 4-9p
12/19: 4-10p

The ones that concern me, obviously, are in red. I asked my vet about it, and she said she'd never dealt with someone with such an irregular schedule, and didn't know what to suggest. She did say she thought it was more important to keep a constant starting time (the 9am) rather than the constant 12 hour spread, but there will be times where I'm just pushing 14 hours and then the next dose would be around 10 hours. I can little by little change the times throughout to keep it to 12 hours between, but... I want some other opinions of what would be best.

A note: my cat is strong and difficult to handle, so I really need to keep testing to an absolute minimum. His glucose curve was starting at: 143; +2: 157; +4: 114; +6: 97; +8: 92; +10: 154. The vet was really happy with these numbers and is keeping him at the starting dose of 1iu to do another curve in three weeks.

Any advice is very welcome! Thank you all in advance for your help.

 

Welcome! What a cute boy - I love his ears!

Initial thoughts:

• If you can't do frequent testing right now, so be it. Not ideal but there it is. It would be worth embarking on a treat training campaign slowly over time to desensitize him to the handling, etc. Don't rule it out.
• The most obvious solution, although not easy I'm sure, is to find someone you can trust and train him/her to do the PM injection when you can't be there. Given your erratic work schedule I see this as a necessity. Again, don't rule it out.

 

Thank you for your reply. Unfortunately, he's always been a very difficult cat, and has never let anyone else even pet him but me. I live alone and I'm really the only one who can touch him to give him the dose. Even if we could work up to that over time, it's not going to be possible in the short-term. Sorry, I should have mentioned that. The only person who can do anything with him is me.

 

I would be very careful with dosing. Are those numbers from the vet's curve or yours? That are lower numbers than we would suggest a new diabetic get a shot. Our usual beginning no shot range is 200 and above. It they are from the vet, I would suggest real caution. Some cats are 100 points higher at the vet than at home (vet stress)

You might check out the info in our beginner's guide and protocol on the top of this page?

 

They were from my curve at home. I know they are low, and I was surprised she suggested I keep going at the same dose; I thought she would lower it, but that was the advice she gave. Do they seem like he's going into remission or something?

The vet stressed they never advocate changing course based on just one reading. I know people manage their cats more closely than that... I just don't know what to do. I don't want to go directly against the vet's advice... I'm really scared and want to do what's best overall and long-term for my cat. Of course, if that's something that could lead to him being off insulin entirely, that would be amazing...

 

Sue makes a very good point about his dose. If he can't be tested you could run into real trouble.

 

What would be the recommended course of action here with those numbers then? He can be tested, it's just extremely difficult.

 

We usually suggest staying under 200 for a preshot until you have enough data to predict what a dose on a lower dose might do. We suggest not shooting under 150-180 until you have a lot of data, can test without issue, know how to bring him up if he drops low, and are around to test during that cycle.

If he were mine, I would not shoot under 180 at the lowest and plan to get a test in early in the cycle to be sure it doesn't look like a cycle that might go too low. And then I would reduce the dose to maybe 0.5 until you have more data. (You can always raise the dose if your testing shows he is high, but hypos are caused by doses that are too high.)

None of the numbers in that cycle were dangerous. We consider 50 and below to be hypo range (on a human meter. The pet meters numbers are higher). BUT you want to err on the side of caution as your cat gets used to the insulin, and the insulin starts to work in his body. Sometimes you see gradually lowering numbers over the first few weeks; sometimes you see them immediately.

In general, we consider a cat regulated if they are in the mid 200s at preshot and in lower hundreds or double digits at nadir but not below 50. The curve often looks like a smile. Once regulated, then you can make small dose changes, monitoring carefully and move him down into lower ranges. We consider a cat in remission if they are between 40-120 (human meter) without any insulin for two weeks.

 

Thank you so much for this info. I've read through a lot of these posts and know what you recommend here, so I was surprised that the vet didn't change his dosage with those numbers. When you say: "Sometimes you see gradually lowering numbers over the first few weeks; sometimes you see them immediately." do you mean that his numbers are possibly artificially low right now? I was thinking his numbers being all below 200 meant he already was regulated...

I'm so overwhelmed. I can test before I give shots, but I work and won't be able to do more testing through the day. Are you suggesting that I not shoot more than 0.5 regardless for now, unless his numbers get up above 200?

 

What Sue means is that as a kitty's body adjusts to exogenous insulin, they can have a better response to a particular dose - ie., a certain dose will drop their BG to lower levels than it did at the beginning of insulin therapy. This will begin quite soon after treatment starts for some but it can take a longer time for others. If you're not testing at home it could happen without you being aware and a dose that was fine initially suddenly is too high because the cat has begun responding to it more dramatically.

It's true that the BG curve numbers your vet got early on shows a very good response to the 1 u dose. These were obtained at the vet clinic I assume so are quite possibly higher than they would be at home because most cats are stressed in that environment. Stress can raise BG and if a dose is decided on based on these (inflated) numbers, it can prove to be too high at home. If you don't test you won't know.

I like Sue's suggestion to lower the dose to 0.5 u for now and test as much as you possibly can. Before each shot is great. That way you'll know if your planned dose is too high or not. If you can get one more test before your bed time whenever that happens to be, that would be good info to have.

The protocol we promote here is aimed at keeping your cat as safe as possible - ie., avoiding an episode of hypoglycemia which, if severe, can kill quickly.

 

Thank you for this further info.

I want to repeat, because I think it's not been clear, that the glucose curve numbers are from HOME TESTING two days ago, not from the vet, so there's a minimum of inflation to the numbers.

 

Shooting before each shot is vital so if you can do that, it would be great. You want to know what his levels are before the shot so you know that the dose you plan to give is safe. You never know when they will throw a lower number than usual. Some people get an out the door test and a before bed test so they have more data. Then on any day off, try to get some midcycle numbers. That kind of data will help you see how he is reacting to the insulin and help keep him safe.

I would also work on getting him used to the testing. Here are some tips:

It is all about conditioning the cat to expect a favorite treat. So first, find a treat he is crazy for. PureBites and Bonito flakes are popular at my house; other people bake some chicken without spices and cut it up into bite sized pieces and freeze. Decide where you want to test; some people use the kitchen counter, some between their legs, some on a towel on the floor, some on a couch or bed. Take him there, pet, praise, play with his ears, treat and release. After a while, add warming his ears, pet, praise, treat and release. The hope is that, by the time you add the poke, he will be so interested in the treat, he won't notice.

The numbers from your home curve are still lower than we usually see with beginning diabetics. How did your vet diagnose the diabetes? Did they do a frutosamine test (takes a couple days to get back) or a test in the office? Does he have any infection or a UTI? What are you feeding?

 

I'm sorry - I misunderstood that. Congratulations for getting that curve done on your own! That changes the picture slightly. Those are excellent numbers for a first time curve. However, if your cat's response to the 1 u dose should increase, the numbers might drop too low at nadir (usually between 5 and 7 hours after the AM dose). The rest of what I said above still applies.

Re regulation: if your cat consistently responds with numbers like this over a significant period of time then, yes, he would be regulated. you need data going forward to see if this is the case.

 

The way I have to test him is with his paw pad, because I'm alone and have to do it with him sitting in my lap facing forward. He struggles and bites my hands, but ultimately lets me do it. I can't get him to sit still and have enough hands to do the ear prick. I did all the steps with him minus the prick for five days going up to the glucose curve with treats (and he's been getting his claws trimmed and other unpleasant stuff in the same place in the same way since he was a kitten, so he's as used to the routine as possible, and knows he'll be getting a treat), and he still just got upset once I stabbed him. Again, I can do it, it just leaves me a shaking mess, so having to do it in the morning before work is very challenging.

[QUOTE="The numbers from your home curve are still lower than we usually see with beginning diabetics. How did your vet diagnose the diabetes? Did they do a frutosamine test (takes a couple days to get back) or a test in the office? Does he have any infection or a UTI? What are you feeding?[/QUOTE]

He was diagnosed with an in-office blood test, and they got the results the next day. He had a terrible incident at a vet ten years ago, so he can't be easily examined, has to be wrestled down and sedated to get blood drawn or any exam. However, the doctor said he had great muscle tone for his age, his heart, eyes, ears, teeth, all good. Pancreatic enzymes elevated, of course, but liver normal. No sign of infection. Only symptoms were increased water, urination, and some increase in appetite. All energy and playing, etc. good. He's been on limited ingredient dry food for years because when I tried to move him to wet food (knowing that otherwise he'd be a risk for diabetes), he developed some reaction to the canned food and raw wasn't any better. He has granuloma and food sensitivies that make feeding him challenging.

So here's how it happened: vet test (with high distress) two weeks ago today BG=455. I moved him to low-carb wet food immmediately and tested him the morning he went on insulin five days later, and his BG=326. A week after that is when I did the glucose curve and he started at BG=143.

Thank you for your responses and help with all this.

 

Thank you - that makes much more sense.

 

There are others on the forum that do the paw pad testing. I truly understand the high stress level you have doing this. My cat is very cooperative but I'd feel ill anytime I injected improperly and he protested. Similar reaction if he squeaked when I poked his ear. It's not the same as dealing with anger but my emotional responses to these types of incidents are minimal now. I can be far more clinical and detached.

 

Well, it could be that the number at the Vet was elevated because of vet stress. And if he was eating dry food, that can mean much higher numbers. When we switched Oliver from dry to wet, he dropped 100 points overnight. So he might be a kitty who just needs a little insulin to jump start his pancreas....combined with a switch to wet low carb.

Using a kitty burrito might be helpful. We used it when we first started testing. I wrapped him up in a towel, sitting on the sideof the couch against the arm, with just his head showing. (You'd want a paw out too). I could lightly press him against the edge of the couch so he would stay. Gave him a few pieces of the treat and poke. Then more treats. After a while, he knew the treat was coming so I could just poke without the burrito.