? Tantalizingly close to remission, but can't quite get there

Discussion in 'Lantus / Basaglar (glargine) and Levemir (detemir)' started by Peter Moore, Jan 26, 2019.

  1. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Hello everyone! Long time reader but first time poster. This seems like a wonderful community and invaluable resource. I'm hoping to get some insights and advice on our current situation, which in a nutshell is that we're VERY close to remission - but we're having trouble actually getting there.

    BACKGROUND

    My 14-year-old orange DMH, Zelda, has been receiving glargine since July 2018 after becoming badly hyperglycemic, including ketones, and developing pancreatitis. Our suspected culprit is Claro Otic, a long-lasting ear medication which she received a few weeks prior, which I later learned contains a corticosteroid. She had been "pre-diabetic" for 1.5 years prior, and steroids should have been avoided like the plague. Whatever the cause, she had to be hospitalized for 2 nights after refusing to eat solid food for several days, after which we met with an excellent internal medicine specialist who diagnosed her with full blown DM and prescribed glargine.

    We have since been continuing to work with the internal medicine specialist on all dosing decisions. We email somewhat frequently as in person visits are difficult to schedule, and despite my offer he does not bill me for the consults. I think he's an excellent doctor and we like and respect him very much. However, I am not always 100% confident in his reasoning when it comes to maintenance and total picture type issues. She has been very difficult to regulate, and I think a good part of that has been because of some external factors and at least one questionable decision early on, as I'll discuss more below.

    But first, the relevant history. The most recent and interesting history begins around 12/23/18 , but I'm providing the whole thing for reference. FYI, diet is 3-4 Fancy Feast classic pate per day. In October we also introduced a very small amount (1 tsp per feeding) of Orijen Cat & Kitten dry food on Dr.'s advice to add some complex carbohydrates for better glycemic control.

    HISTORY

    7/7/18: Begin 1.0 unit BID
    8/1/18 curve: 60 nadir. Dr. advised remission and to stop abruptly, which I questioned but followed. Symptoms and ketones returned within days. Spot check BG of 402 on 8/6. Dr. advised to resume insulin therapy @ 0.5u BID with frequent curves and urine checks.

    8/6/18: Begin 0.5 unit BID
    8/14/18 curve: Pre-ins BG 221, nadir 92 @ 8 hours
    8/18/18 curve: Pre-ins BG 99. I got spooked and skipped. BG peaked at 374 at 4 PM. Resumed normal schedule that evening.
    8/21/18 curve: Pre-ins BG 274, nadir 154 @ 9.5 hours
    8/21 - 8/29/18: Things are looking good again. Good appetite, gaining weight, better energy. Against my better judgment I proceeded with an international trip that had been scheduled since March, leaving her at home with my good friend who dutifully learned how to inject.

    8/29/18: Hypoglycemic Episode #1
    8/29/18: Hospitalized overnight for hypoglycemia after appetite loss and other symptoms (I was told it was in the 40s.) At first I assumed my friend incorrectly dosed, but I'm confident now based on what happened later that this was not an OD. Dr. advised to reduce to 0.5 SID as a result of this.

    8/30/18: Begin 0.5 unit SID.
    9/3/18 - 9/27/18: Glucose dip sticks are all 0, trace, or 1+. Spot check pre-insulin BG of 342 on 9/4.
    9/28/18: Treated by PCP for relapse ear infection using Tresaderm - another medication which - I again didn't know - contained a corticosteroid.
    9/28 - 10/4/18: 3+ strips, 400+ spot BG, and appetite loss. I finally make the connection between the ear medication, steroid, and BG. I consult with PCP, discontinue Tresaderm on 10/3 and resume BID dosing for a couple days until she stabilizes.
    10/5/18: Symptoms much improved and SID dosing resumed.
    10/10/18: Trace glucose in urine.
    10/11/18 curve: 339 post-insulin, post-feeding (don't know pre-ins), 143 nadir. Advised by specialist to return to 0.5 BID dosing. I agreed because I felt like her overall energy level and health was better on 0.5 BID and at the time I thought maybe 8/29 hypo was a fluke due to depression or mistake by my sitter while I was away.

    10/13/18: Return to 0.5 unit BID
    10/16 - 10/21/18: Urine sticks 1+ to 2+
    10/25/18 curve: 150 pre-ins post-feed, 111 nadir @ 4.5 hours.
    10/25/18: On Dr. advice, begin introducing small amounts of complex carbohydrates through Orijen Cat & Kitten dry food, supplementing Fancy Fast
    10/31 - 11/2/18: Urine sticks 2+ to 3+.
    11/15/18 curve: 135 post-ins post-feeding, 74 nadir @ 9 hours
    11/19 - 11/27/18: Urine sticks 2+. Confusing why sticks showing glucose while BG numbers are so good.
    12/6/18 curve: 166 pre-ins post-feed, 105 nadir @ 10 hours
    12/18/18: Another ear infection relapse and tresaderm is still deemed the best choice. PCP and I believe that, now that we know about corticosteroid issue and insulin dose is higher than last time, it's a manageable risk.
    12/20/18: Unfortunately steroid reaction is worse than before. Spot check BG 387. Appetite very poor. Dehydration. Discontinued tresaderm that evening.
    12/21 - 12/22/18: Administered subq fluids with PCP vet. Symptoms improved almost immediately.

    12/23 - 1/10/19: Dramatic Improvements
    During this time urine sticks all 0 or trace. DM symptoms virtually gone. Previous obsessive behavior re: water (following us into bathroom, hovering over bowl, etc.) gone. Barely drinking plain water. Playing with toys for first time in a year. Shame on me, I did not do a curve during this time. Was planning to sometime in January.

    1/11/19: Hypoglycemic Episode #2
    1/10/19: Vomited very small amount early morning before feeding, but ate and received insulin normally.
    1/11/19 AM: Vomited again, very small amount early morning before feeding. Again ate normally and received insulin.
    1/11/19 PM: Ate normally. Received insulin at 6:30 PM. Around 9:30-10PM vomited almost entire dinner. Ate supplemental dry food, but couldn't keep it down. Spot BG 73 @ 10PM. Corn syrup on gums and tongue.
    1/12/19 12:00 AM: Spot BG 45. More corn syrup and rushed to emergency vet for IV.
    1/12/19 6:00 AM: BG back to 130, took home. Skipped AM shot. Advised to skip PM shot unless BG was over 300. Eating normally again, no vomiting.
    1/12/19 6:30 PM: BG 364. Administered 0.5u.
    1/13/19 6:30 AM: BG 259. Administered 0.5u.
    1/13/19 6:00 PM: BG 175. Administered 0.25u on suspicion of remission
    1/14/19 6:00 AM: BG 89. Skipped insulin on suspicion of remission
    1/14/19 12:00 PM: BG 185
    1/14/19 6:00 PM: BG 341. Administered 0.5u.

    1/15/19: Begin 0.25U BID
    . At this point I'm strongly suspecting remission and trying to follow universal advice to reduce insulin dose as slowly as possible in such case. I finally hear from the specialist and he concurs. I'm able to reliably measure 0.25u consistently (or very close to that) using the thickness of the zero line in the syringe as a guide.

    1/22/19 Curve: 94 pre-feed, pre-ins, 60 nadir @ 5 hours.
    We did the curve at PCP's office for convenience. PCP advised based on curve to stop insulin, spot check BG and urine, and watch for symptoms. This advice - cease insulin abruptly - troubled me as it did on 8/1. Contacted specialist for confirmation.

    1/23/19: 6 AM: 1+ on urine stick. I make executive decision to inject 0.25u that morning, suspecting remission is still possible but we weren't quite at the finish line.

    1/24/19: Begin 0.25U every 16 hours
    1/24/19: 6 AM: BG 324 pre-ins, post feed. I again inject 0.25u at 7 AM.
    At this point it's clear that BID dosing, even in miniscule amounts, is too much for her, and yet SID dosing is also not enough. I also fear that we will lose progress toward remission if she goes back to being above 300 on a regular basis. I thus did a second injection at 11 PM and have been following 7 AM - 11 PM - 3PM - 7AM since.

    1/25/19: Strips negative, good appetite and energy all day.

    1/26/19:
    - 303 BG spot check, pre-insulin, post-feed. Appetite was slightly lower so I wanted to rule out hypo. Trace urine strip 30 minutes later.
    - Ear infection has again returned in force and is no doubt a factor in BG. PCP is getting amoxicillin compounded into an otic with no corticosteroid (which I wish had been suggested months ago)
    - Finally heard from the specialist for the first time since the Tuesday curve. He does not seem to like a 16 hour schedule, citing the possibility for error/OD, and advises 0.25U SID followed by a fructosamine test in a couple weeks. Did not respond to my concerns about reducing the dose slowly or losing our progress toward remission.

    QUESTIONS

    Phew. So after all that, here are my questions/concerns:

    We have a real dilemma as far as dosing. On the one hand, the tiniest 12-hour dose that is humanly possible to administer with a syringe - 0.25 - seems to be too much or at least dangerously close to the line. On the other hand, our foray into 24 hour (0.5 units!) dosing in September proved to be too little, and any other time a 12 hour dose has been skipped it has a dramatic impact on her BG (+250 in 12 hours sometimes).

    Every veterinary source (not just anecdotal reports) I can find says that the 1/22/19 curve warrants a dose reduction and indicates possible remission, but that the insulin needs to be withdrawn as slowly as possible to not upset the beta cells and thus make the remission stick. I DO NOT want a repeat of what happened on 8/1/18, which still frustrates me as I fear we squandered a real opportunity there for quick remission by stopping 1U BID abruptly and contrary to the every authority I've since read on this.

    Leaving aside the past, at this point, the only way I can conceive of to meet both criteria of reducing dose, but doing so slowly, is to drag out the 0.25 unit doses to 16 hours until we consistently see negative urine strips and good BGs, then go 18 hours, then 20, then 24, and THEN doing a curve and fructosamine test to see if we are really, truly, in remission.

    I am a little baffled why this isn't a good plan, and I don't think that the remote possibility that I'll make a timing mistake is a good enough reason not to try it, especially when we're only talking a week or two of this. I think we have compelling evidence that just dropping to 24 hr dosing at this point is not going to be enough and we're gonna wind up right back to the drawing board in a month. Heck, I even have doubts about 16-hour dosing being enough based on today's 303, but want to at least give it a few days and kill this damned ear infection before drawing any conclusions. Most importantly I can't find any real reasoning behind our doctor's objection to this weening plan so I have a hard time accepting his advice this time without hearing other views.

    I'm open to any other suggestions too.

    Sorry for the very long post, and appreciate any insights folks can offer. Thanks!!!
     
  2. Mandy & Rex

    Mandy & Rex Well-Known Member

    Joined:
    Mar 22, 2017
    Thank you for all the information. Welcome!

    On this board, we also have 0.1u and the drop dose before we attempt an OTJ (Off The Juice) trial for 2 weeks before remission is official.

    Do you have a spreadsheet so we can look at the numbers? Are you using a human meter or an animal meter? I think the dry food needs to be eliminated. It's too high in carbs for a diabetic cat.

    I'm sure others will be along to add more information and questions.
     
  3. majandra

    majandra Well-Known Member

    Joined:
    Oct 11, 2018
    There is actually smaller dosing- 0.1U and 1 drop.
    To get 1 drop, push plunger in fully, insert needle into cartridge, and release. When you give the shot, make sure you keep the plunger pushed while withdrawing needle. You can confirm that the syringe actually pulls up a drop by doing it with a used needle in water, and eject onto something you can see it on before doing it with insulin.

    I'm not sure if the 1 drop would be something you would like to do, but it's an option at any rate, and is easy to measure.
     
  4. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Hello and thanks both!

    I didn't even think to upload my whole log. Attached. (I think the doctor thinks I'm obsessed after seeing this).

    Majandra, very interesting. I sure could try, but I don't know if 1 drop would be enough.

    How on earth would you measure 0.1U?? Sorry I should search for that, it never even occurred to me 0.1 u twice a day very much feels like something worth trying if it's feasible.

    Am using Alpha Track 2.

    I wondered about the dry food too, it's just such a ridiculously tiny amount (not to mention she freakin loves it). I also thought that with legumes, berries, etc. (no grains) it would be a good choice for glycemic control, and indeed her numbers only improved after eating it for a month. But I'm certainly willing to try eliminating it at least while we're trying to get her past the finish line.
     

    Attached Files:

  5. majandra

    majandra Well-Known Member

    Joined:
    Oct 11, 2018
    I eyeballed it at first for 0.1U, then started using an insulin ruler. I found one specific to the syringes I used.
     
  6. Mandy & Rex

    Mandy & Rex Well-Known Member

    Joined:
    Mar 22, 2017
    I glanced at the log. Do you test daily before each injection and mid - cycle? We need to know more what she's doing.

    Here's a link to our spreadsheet and the instructions. Make sure you choose the one that's set up for the animal meter. Plug in the numbers for January.
     
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  7. Mandy & Rex

    Mandy & Rex Well-Known Member

    Joined:
    Mar 22, 2017
    Also you can find the sticky on how to microdose in this forum.
     
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  8. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Doctor specifically (and multiple times) said not to test BG unless I suspected hypoglycemia, or during a full curve. My compromise was I check if I suspect hypo OR hyper, or anything else being wrong. I assume he doesn't want me doing exactly what we're contemplating...

    I've been begging for him to fit her with the Freestyle Libre and he refuses, saying it'd be "too much information."
     
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  9. Tom & Thomas (GA)

    Tom & Thomas (GA) Member

    Joined:
    Jun 23, 2018
    This is the page with some info on fine dosing.

    I was dubious but starting with my 0.25u dose and then screwing the plunger up a bit while still keeping some daylight under the zero line got me something I was willing to call ~0.1u.
     
  10. Mandy & Rex

    Mandy & Rex Well-Known Member

    Joined:
    Mar 22, 2017
    That's not right. If your child was diabetic, would you inject insulin without checking first?

    If it's too expensive to use the pet meter several times a day, you can buy an inexpensive human meter with affordable strips.

    Please start testing today and post the numbers. We will help.
     
  11. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Hello and welcome to the FDMB! If you're willing to key in the last few weeks worth of data on the spreadsheet we use it'll go a long way towards helping us help you. Not everyone has excel and the color coding we use helps make trends and patterns pop out.
    Here's the instructions and explanation of the grid:
    Dosing info can be found in the SYRINGE & INSULIN INFO: HANDLING, DRAWING, & FINE DOSES sticky note marked with a yellow tab at the top of this forum.

    Fine dose gradations:
    • 0.5U = exactly half a unit
    • 0.4U = skinny 0.5 touching the line
    • 0.3U = skinny 0.5 with daylight under the line
    • 0.2U = fat zero with daylight over the line
    • 0.1U = fat zero barely touching the line
    [​IMG]

    [​IMG]


    You also might want to check out the spreadsheets of others. Most of us have our kitty's data linked in our signature blocks at the bottom of our posts.

    Hope this helps.
    Also hope to see you posting often. :)
     
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  12. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Hey no argument here. I really took issue with that statement and still do. He looks at this entirely from the perspective of eliminating symptoms safely, and no more. I don't know if it's because he doesn't think it's possible, or he doesn't have the time to put in to get there, I can't tell you. I like him, he's obviously knowledgeable and professional, but he's a minimalist, and I think we've reached the point where he can't or won't provide us much more help than he has. Hence why I'm getting second opinions now. :)

    That said, I don't fancy the idea of pricking the ear multiple times a day every day. Expense is not an issue (have spent $1000s in ER bills already). It's just stressful for everyone. And while we were getting regular curves at the doctor and her strips were positive, it honestly wasn't necessary. But now that we're on the knife's edge of remission I agree more frequent testing is going to be critical.

    Thank you all I will work on the chart and post it up shortly.
     
  13. Hogan

    Hogan Member

    Joined:
    Dec 5, 2018
    The more data you have, the better decisions you can make.
     
    Last edited: Jan 26, 2019
  14. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Chart's up. Thanks all.

    Yeah, I mean, look I'm not here to complain about the guy. He made the right diagnosis when others were all dancing around it and not willing to call it DM. And he has gotten us this far. But I'm at the point where I believe we're gonna need a lot more work/attention than he is willing or able to give in order to get us to the finish line now. Maybe that means a new doctor, or maybe I can do this solo with your guys' help!

    (Also to be fair his comment was about BLOOD testing. He encouraged urine tests as frequently as possible, and I have tons of them. Entered those in the chart. Frankly while urine was 0 I saw no need to test blood for being too HIGH. I should have tested more often for being too low though.)

    One thing I haven't heard anyone comment on yet is the 16 hour schedule (and I had to rig the spreadsheet to even make it work). I'm guessing that the prevailing view would be that it would be better to stick to 12 if I can actually dose under 0.25, am I right?

    And does anyone think the 1/22 curve with the 60 nadir does NOT call for lower dosing? She's been hospitalized twice now for hypoglycemia and the one thing I'm not willing to do is risk that again.
     
    Last edited: Jan 26, 2019
  15. Mandy & Rex

    Mandy & Rex Well-Known Member

    Joined:
    Mar 22, 2017
    Most vets only get 4 hours (not exactly sure on #) of diabetes training in vet school. So they don't know as much as some of us who have been dealing with or helping others with diabetes for many years. When Rex was diagnosed, I said I'm going to check on things and found this board and never went back for advice. I did contact them when Rex went into remission so it would be in his file.

    That 60 on 1/22 does warrant a reduction. I would try 0.1u and do blood testing for a few 12 hour cycles. I have never heard of 16 hour cycles. We do have 18 hour cycles for special cases.

    As for frequent blood testing, if you give Zelda a treat each and every time you test, she will not struggle with you. There's one person here who has a very hard time with her cat for weeks, but then the cat realized she gets a treat for it and now she jumps up into her testing spot when she thinks she needs a test. :)
     
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  16. majandra

    majandra Well-Known Member

    Joined:
    Oct 11, 2018
    From some vet literature I had found a while back (sorry I don't have the links), it suggested that negative urine samples were possibly indicative of hypoglycemia, in a situation where the cat's blood glucose wasn't being tested at home. Since you can test at home, you should. The urine test is delayed results. A cat could go hypo in between voiding and the urine would still show glucose if at any point in that period it surpassed the renal threshold.

    Don't beat yourself up for the past though! We all wish we had done things differently.

    I'm not sure what to say on the 16 hr schedule- I have not seen it, and I am also inexperienced. Prevailing viewpoint is to shoot what can be safely shot every 12 hrs as you have read. If you get no replies on it, maybe update title, or start a new thread.

    Btw, your charting is quite impressive :) I kept a google note with absolutely everything, as well as photos of the urine sticks (I wasn't able to get near as many tests as you!).
     
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  17. Sue and Luci

    Sue and Luci Well-Known Member

    Joined:
    Nov 3, 2017
    Welcome! It looks like you've got a lot of information to absorb! Best of luck on that. Information is power! The more testing /aka/ information you have, the more power you'll have to help your kitty.

    I just have to add, there isn't a single vet alive today who has as much experience in FD as the collective experience you'll find in this forum. If you've been reading the forum, then you know that already. I don't mean to dis or be harsh on vets, but they are 'diluted' in their training and experience as they have to know how to treat a huge variety of conditions on a large variety of animals. So unless you've been dealing with a Feline Endocrinologist with years of experience in feline diabetes - then it's time to take your knowledge and advice from an organization who does.

    You don't have to be confrontational with your vet at all. You can continue to see them and exchange ideas, but you 'know' what's best for Zelda...so test, test, test. Toss any dry food out of your house...and you'll soon start to see better results. Looking forward to reading your posts daily on Zelda's progress. :bighug:
     
  18. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    So I updated the chart with Nov. and Dec. info too. (It's all in my post but I realize the chart is much easier. :) )

    The vet actually is an internal medicine specialist with a residency, though not board certified. I doubt he's ignorant of the literature or lacking in experience. Rather he just doesn't seem to believe in tight regulation, at least not in our case. Maybe he's watched too many animals die from hypoglycemia and/or he's terrified of a lawsuit. Maybe there's something he's not telling me and he thinks she doesn't have long to live and remission is a moot point. (They did see "something" on the pancreas during an ultrasound in July 2018 when all this began, but they said it could just as easily have been from pancreatitis as it could be malignant, and couldn't say definitively without cutting her open, which I declined. Since then there's been no indication of serious illness beyond the DM, and no one's told me any reason to think she won't live at least a few more years).

    Whatever the reason, I'm very disappointed he did not volunteer to me the benefits of tight control toward likelihood of remission and give me the option to find another doctor who was willing to undertake such a regimen even if he wasn't. Instead he authoritatively stated that tight control wasn't "the goal" and discouraged me from doing blood testing at home. I am more convinced than ever that it's time to move on so that's what we'll be doing.

    As for the princess, we're still on the 16 hour schedule. This morning (7AM) was food with no shot, and we saw trace glucose in urine 1.5 hours after a hearty meal this morning. Stopped the Orijen dry food as advised.

    I'm leaving for a short two day trip tonight, during which she'll be in the hands of her other dad, who I've already taught how to do 0.25 on the 16-hour schedule, so we're not changing anything up until I get back. Moreover, I think this ear infection is bad enough where it could easily be interfering with her blood sugar, so I don't think we can decide anything until it's at least on its way to being resolved. (It also adds more difficulty and possibly pain to blood testing).

    But, looking at others' charts, and seeing even trace glycosuria after meals, I'm leaning toward by week's end going back to 12 hour dosing and trying to do 0.25 "minus" and more frequent BG. Even the tight-regulation-hating vet didn't get too upset by the 60 (which was a fasting curve) and said that there really should be no risk of hypoglycemia from 0.25 units if she's eating normally and frequently.

    As for reducing beyond that, I think there's merit to the drop option when we get closer. But I'm a little skeptical, I have to be honest, that a consistent 0.1 is really possible because of how variable the syringe markings are. I use the BD 3/8" 31g which should be the best, and I did look at the guide posted here which was really interesting. But I was measuring with calipers the other day and there's still a significant (in the context of these doses!) variance in the position and thickness of the zero line, which makes using that as a reference seem pretty dicey to me.

    If there's a way to ignore the zero line, that might be a different story. I'm intrigued by the "insulin ruler" concept and may try that.

    Also, one useful thing the specialist vet did advise yesterday (6 months after telling me Fancy Feast was the best option...) was to transition her to Purina DM, so I ordered the wet "original canned" (NOT the one with wheat - WTF is with that?) that will arrive this week and will start transitioning her diet to that.

    Between better food, tighter control, reading the literature and seeing your guys' stories, I'm still very optimistic. Thanks so much for all the advice and warm wishes!
     
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  19. majandra

    majandra Well-Known Member

    Joined:
    Oct 11, 2018
    Using the caliper, and especially if you use it with the insulin ruler, you can get accuracy. Ignore the lines completely.
    Others have suggested Monoject syringes being more accurate, but I have never used them.
    This is the insulin ruler I used. Make sure it matches your syringes, and is printed the proper size.
     

    Attached Files:

  20. Sue and Luci

    Sue and Luci Well-Known Member

    Joined:
    Nov 3, 2017
    Excellent! Thanks for doing that :)
    Good decision. Long story short - If I'd listened to my vet - Luci would be dead. He told me that regulation is difficult to impossible; Luci will not cooperate with testing; 'If it were my cat, I'd put her down' - his words!

    I moved on - fast forward - we're over a year later - Luci is still on Lantus x 2 a day - she's doing just fine - perky, happy and I'm so glad I moved on...
    We've found that Fancy Feast pate's generally are very low carb, easily found in the stores and many cats seem to like it (Luci loves her FF's pate's)... here's Dr. Pierson's food chart as a reference to the carb count (and other information)...it's quite comprehensive. https://docs.google.com/spreadsheet...m6PPfEUz9YmzMGMxkmcBk6uRR0/edit#gid=113878384

    Hope you'll be able to update your 'signature' soon - so that everyone can see a bit of history and you and Zelda - look at other's sigs for examples of what types of info is helpful - that way people are asking you the same questions every day. We'll be looking for your posts in the coming days :)
     
  21. Mandy & Rex

    Mandy & Rex Well-Known Member

    Joined:
    Mar 22, 2017
    I don't have time to respond to everything, but you need to return the DM food. Friskies and Fancy Feast are popular here.
     
  22. majandra

    majandra Well-Known Member

    Joined:
    Oct 11, 2018
    The Purina DM is pretty high in carbs. 12% IIRC
    I had some of their gravy version left over from before I knew better- I kept it to use as a medium carb food for steering.
    You mentioned looking at others' spreadsheets. A word of caution on that- ECID, so it's best to ask for advice rather than only following someone's spreadsheet. There may be factors in the dosing decisions that aren't listed in the spreadsheets. That said, when you start to know the people around here and follow their threads, they can be a pretty good guideline for similar situations. You can always tag someone whose sheet you looked at by typing their name like this @Peter Moore to ask about it.
     
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  23. Tom & Thomas (GA)

    Tom & Thomas (GA) Member

    Joined:
    Jun 23, 2018
    If you haven't already, take a graze through Dr Lisa Pierson's catinfo.org. A lot of good information, including much specific to diabetes. And she pretty strongly believes there is no reason to spend any money on the "prescription" foods.
     
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  24. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    I'm one of those folks who likes data. Seeing your spreadsheet and the Excel file, leaves a lot of questions. Many members here will say their vet will advise against frequent blood glucose (BG) testing. Most of us have the experience that home testing is the best way to insure the safety of our cat. If you look at many of our spreadsheets, mine included, you'll note that if I wasn't testing, my kitty could have been in trouble. Gabby was quite capable of starting a cycle in the 400s, dropping to the 40s, and bouncing back to the 400s by the next shot. If I'd not been testing, who knows how low that number would have gone and, I'd have increased her dose vs reducing it. Home testing saves lives. (And frankly, you don't have to give your vet all of your test data. I agreed to disagree with my vet about the frequency of home testing.)

    No disrespect to your vet. I think vets have an unenviable task. They are expected to know everything about every species of animal that they see in their practice. Only a handful specialize or even subspecialize. Your vet may be a wonderful diagnostician but not see all that many diabetic cats in his practice. He may have greater interest in some of the other areas of internal medicine. All we do here is focus on feline diabetes. And, you are correct -- many vets get nervous with seeing caregivers manage the lower range numbers associated with Tight Regulation (TR) and will advise keeping a cat in a higher range than normal numbers and look for a goal of regulation vs remission. There are also caveats associated with following this protocol -- namely a low carb, canned food diet and the ability to home test with regularity. TR isn't for everyone and we do have an alternative where the number signaling a dose reduction is higher (Start Low Go Slow method).

    Urine glucose testing is problematic on several counts. Consider how long it takes for a human or cat to produce urine. Whatever you drink has to be processed through the genitourinary system/kidneys, collected in the bladder, and then excreted. This can take hours. So when you're testing urine, you are not getting the up to the minute results. You are getting a number that's hours old. (BG testing tells you what the number is now.) In addition, urine test strips do not give you low range or high range numbers. You may get greater accuracy in the middle vs. at the top or bottom of the range. When it comes to knowing if your cat is in unduly low numbers, that's unsafe. The International Diabetes Assn came out with a position statement several years ago noting that urine testing may be what's available in 3rd world countries but if you are able to test blood glucose, it's highly preferred for the above reasons. (Keep in mind that their statement is directed to humans but the reasoning is similar.)

    The other concern that I have is that while Zelda is certainly seeing lower range numbers at some points, it does not appear that the vast majority of her numbers are in the normal range. You're still seeing numbers above 300 at pre-shot times along with high 100s and above during the cycle. For the kitties here, we look to see a consistent pattern of normal range numbers when a cat is approaching remission. Again, there's only a smattering of data to draw any conclusions from but it is another vote for more test data.

     
  25. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Hmm., not sure about that. The analysis for "original canned" (what I ordered) says 2.0% crude fiber plus 0.4% unaccounted for:
    https://www.proplanveterinarydiets.com/products/dm-dietetic-management-cat/

    That's better than Fancy Feast classic chicken (1.5% fiber plus 2.25% unaccounted for):
    https://www.fancyfeast.com/gourmet-...s/classic-pate/chicken-feast-12-pack#readmore

    The Purina DM "savory select" on the other hand looks like it might have up to 6.95% carbs. Not touching that one!

    Don't doubt that you guys have great success with Fancy Feast though. She has too. Still, I did order it so I might give it a shot. (Also FF looks to have discontinued a number of the classic pate flavors! I can't find any reference to Beef or Chicken & Liver Classic on their web site. Anyone else notice this?)

    As to that point, my feeling is that urine tests have been useful when they are POSITIVE in that they show that we failed in our goal of keeping her below renal threshold at some point earlier in the day, but that they are less useful if they're negative because you have no idea how low the BG actually got. At least that's how I've been interpreting them. Is that not the consensus?

    Yes, indeed, and as I note in the history above there have been a number of missteps and swings back and forth on this road - corticosteroid use, premature declaration of remission, another premature dose drop to 24-hours, etc. Not all of it was human error, but some of it definitely was. It's only been since the last week of December that both clinical symptoms, strips, and then blood numbers on 1/22 really got to be what I was considering consistently very good. (And also realize that really until two days ago I was operating under the belief that anything under 150 was great news, so some of those curves in October-November were encouraging too). And like I said now my biggest concern is not squandering that progress by again prematurely declaring victory.

    To me, an ideal scenario would be if I can find a local doctor who believes in tight regulation and is willing to work with me to get there. That, or I have to develop a plan and then stick to it. The only thing I'm wary of is getting an overload of opinions, from any source, be it medical or lay, on a dynamic situation. But yes the message to test more frequently is heard loud and clear. That's probably the single most important takeaway from the last week.
     
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  26. Tom & Thomas (GA)

    Tom & Thomas (GA) Member

    Joined:
    Jun 23, 2018
    For carb levels, most of us go to Dr Pierson's list. She pesters the manufacturers to get real numbers out of them.

    Both of those FF flavors I still see in the store.
     
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  27. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    The issue with the food is that you really can't rely on the numbers on the can. What you're looking at are guaranteed analysis numbers (i.e., they are listed as minimums or maximums). In order to truly know the carbs in what you're feeding, you need "as fed" values. The Feline Nutrition website that people have mentioned will go into detail about counting carbs as well as provide a reasonably accurate food chart. The only way you can get the information for "as fed" values is to contact the manufacturer and they never let us know if they change the formulation.

    Without knowing what the calibration on the strips you're using may be, it's entirely possible you're keeping Zelda below renal threshold. That's the good news. What you don't know is if her glucose levels are at 150 or 20. That's the issue.

    It is ideal if you can find a vet who embraces TR. Not all do. I moved a few years ago and my search started with a cat only vet. I got lucky. She looked at Gabby's spreadsheet, said, "You know what you're doing." and didn't ask anything else. There are any number of people here who use their vet for everything except managing their cat's diabetes. They come here for dosing questions. You need to do what you're comfortable with.
     
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  28. JoyBee&Ravan

    JoyBee&Ravan Well-Known Member

    Joined:
    Feb 17, 2018
    In the beginning my Vet,( has his own practice for over 30 yrs.) was against home testing. This is just how they were all trained years ago. I ignored his advice & followed the advice of the
    very experienced people here. ( some have been advising about Diabetes for many years.) These very knowledgeable people donate their time to help people like you & me. They are paying it back for the advice they received.
    I was very reluctant to poke my cats ears multiple times a day. I was stressed out & my cat felt that. Now when I call him he jumps up on his chair & accepts being tested. ( I don't give treats) except for a lot of LOVE.

    Everyone here wants to help. The experienced people really do know more than most vets. I printed out my cats spread sheet & gave it to my Vet. He was very impressed! He's now very accepting of the knowledge of the advising people here.

    There are Yellow sticky notes that have a lot of very good info. The more you learn the easier it will get .
    Zelda is only 14 yrs old. I've had cats live to be 23. She has a lot of years to go!:)

    Best of luck to you & Zelda. ( i've seen cats go into remission when all dry food was removed)
     
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  29. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    One thing I haven't found on this community yet is people giving specific vet recommendations. Is that not something that members here generally do? I sure would feel more comfortable with someone that another parent here had experience with. (Chicago area, btw).
     
  30. JoyBee&Ravan

    JoyBee&Ravan Well-Known Member

    Joined:
    Feb 17, 2018
    We've discovered that the "EXPERIENCED" people here really do Know more about Diabetes than the Vets! I like my vet because he's open minded, but I wouldn't recommend him for a cat with Diabetes.

    Are you aware that the people come here for advice from all over the world?
     
  31. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Hey someone still needs to write prescriptions...

    I was also hoping to find someone who would fit her for a Freestyle Libre. That also (for reasons unknown to me) requires a prescription.
     
  32. Erin & Scott

    Erin & Scott Member

    Joined:
    Jan 11, 2019
    There are some fairly recent threads here about the meter - you might send a PM to someone who has used it.
     
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  33. Mandy & Rex

    Mandy & Rex Well-Known Member

    Joined:
    Mar 22, 2017
  34. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    Oh that would be PHENOMENAL.

    I hope no one gets the wrong impression that I'm not interested in, or not going to value, the advice here. Quite the opposite. But, besides someone needing to write the 'scrip, I'm just going to be much more comfortable doing this knowing that a licensed professional, who is EXPERIENCED with this, is aware of and endorses what I'm doing. I guess I'm just old fashioned. (I'm also a licensed professional, i.e. the law profession, so I'm a little biased I guess :) ). But you can rest assured, never again am I going to blindly follow advice (from a doctor or otherwise) that doesn't sit right with me or that I can't understand the rationale for.
     
  35. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
  36. Sue and Luci

    Sue and Luci Well-Known Member

    Joined:
    Nov 3, 2017
    If you know how to go about setting up a Class Action Suit against the pet food industry I for one would be interested in hearing about that.

    Since Luci's diagnosis last year I've been appalled to learn that thousands of pets have been adversely affected by the very thing that is supposed to make them healthy - the pet food industry is based on lies and complete mis-information.

    Getting off my soap-box now...but I'm angry about that and wish I'd known years ago what I do now about pet food.
     
  37. Peter Moore

    Peter Moore Member

    Joined:
    Jan 26, 2019
    HAH. Well, no actually it's not funny, I know exactly how you feel. Hill's "Perfect Weight" (full of rice and other idiotic ingredients for a cat) made her obese (12 lbs at one point) and I have 0 doubt was responsible for her pre-diabetes. (On the other hand, corticosteroids pushed her from "pre" to actual, but that's a whole 'nother long story).

    I used to defend clients against class actions occasionally, but only the really stupid ones. This one, could well have merit. You just need to find a really successful plaintiff's firm willing to bankroll it. Unfortunately those were circles in which I did not socialize, for obvious reasons.
     
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  38. Sue and Luci

    Sue and Luci Well-Known Member

    Joined:
    Nov 3, 2017
  39. Carol in Chicago

    Carol in Chicago Member

    Joined:
    Apr 5, 2017
    I am in Kane county. I consider my vet to be a member of my family. He is a great teacher but perhaps even more important, he has been interested in learning about the practical experience shared by this group.

    He did not initially recommend home testing, but ultimately found great value in it. Again, I don't think you will find a vet with more experience with FD than the collective info available here. What you need is someone willing to spend the time it will take to review data and partner with you. In my case, we agreed to follow TR, dose was left to me. He helped me with several difficult complications (all which ultimately had an impact on BG).

    If you are in the city, I have heard great things about cat hospital Chicago. If you are in the far west, PM me and I can refer.

    Best wishes and welcome. Your first post has the attention of several very experienced members. :cat: :)
     

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