Thoughts on BG curve from yesterday

Backstory, I am fostering a kitty girl who is diabetic. She was going downhill rapidly on insulin that was cheap and not regulating her at all at the shelter, I'm a human MD so I can handle a diabetic cat. She has been on lantus since July, with her first curve done by the vet and inconclusive due to stress of the vet. Fructosamine monthly by the shelter showed her averaging 350, which they said was ok, but I wasn't really happy with that, but I am in second residency so my hours have been hard for me to do a curve myself (however she does get her shots between 11.5 and 12.5 hours apart, I never skip a dose or have it stretch out). After her last fructosamine, we put her on Lantus, at 1.5u (she was on 4.5 of Novolin at the shelter until July) on 9/27 with input from veterinarian via fructosamine.

Her curve was done yesterday at home with me and she seemed quite comfortable, but her curve is *alarming* to say the least. I'm not an endocrinologist so my diabetes training is limited to what I learned in school, so I am by no means any sort of expert, at all, and am open to any suggestions from the group. I have forwarded this information to her veterinarians for guidance as well. For reference, she is fed a raw diet of ground chicken breast/leg quarters/heart/liver with a bit of egg yolk, and Weruva as she will eat it:

1. Weruva Duck and salmon oh my gravy: 53.60% Protein, 44.5% fat, 1.90% carb, 54 calories
2. Weruva Beef and Chicken oh my gravy: 50.70% Protein, 47.5% fat, 1.80% carb, 52 calories
3. Weruva Chicken, Turkey and Salmon oh my gravy: 46.8% Protein, 53.5% fat, 0.00% carb, 57 calories

So she has been on low carb since July. Her curve is as follows:



Any feedback? Was the stress of the ear sticks just mounting up, so that when she saw me, she started to stress? I made sure to go and pet her/love on her multiple times throughout the day in between sticks so that she wouldn't associate me with pain for the day. I also bought a ketone meter yesterday afternoon when I saw that the trend was not getting better, as I am fearful for her becoming acidotic.

 

I'm bumping you to top of forum, someone will respond @Kris & Teasel @Marje and Gracie @Bobbie And Bubba @Gill & George

 

Hi Real JD and Ophelia. Welcome to FDMB. And thank you so much for taking in a diabetic foster.

I agree the curve is not what one would ideally see however, without more data, one curve really doesn't tell you much. It's a snapshot of one day that may have been a particularly good or bad day. As you know, diabetes is a very dynamic situation and the picture needs to be viewed over a period time to be able to see patterns of how Ophelia is reacting to insulin. I suppose stress could have played into some if not all of those readings but if Ophelia is co-operative about testing and not struggling to get away, I doubt that would have elevated the BG by much if at all.

Are you getting pre-shot tests every day having withheld food for at least 2 hours prior? This the only way to know if it is safe to give the cat insulin. The other thing we recommend is getting mid-cycle tests. Obviously when you are working you cannot always get mid-cycle tests every day but if you can get tests when you are home, it helps to build up your data and starts showing patterns over time that can be analysed to determine if more or less insulin is needed. Getting a test before heading to bed each night is also a good idea as a lot of cats go lower at night than they do in the day cycles.

Fructosamine gives an average BG over a period of 2-3 weeks however, the values can be skewed if some other blood chemistry values are out of normal range not to mention that a few very low or excessively high readings within that 2-3 weeks will also skew the numbers blurring the picture of what's really going on. I personally had 1 Fructosamine done and refused to ever do it again because I was testing my girl at home every day and knew my she was anything but regulated. Her fructosamine however suggested she was in good range.

I find it interesting that Ophelia was on 4.5u of Novolin until July and then switched to Lantus 1.5u as of 27Sept.. What insulin/dose was Ophelia on between July and the end of Sept.? 4.5u is a bit higher than most kitties need and if that dose was too high, that alone could have been causing Ophelia to feel terrible. If it was too much insulin it could have been causing a lot of very high and very low numbers thus skewing the fructosamine results.

I'd suggest you try to get pre-shot every day and mid cycle tests as often as you can and plot them on the spreadsheet. Most action with Lantus occurs between +4 and +8 post shot so randomly testing between those times should enable you to find her nadir. Tests earlier or later in each cycle can also help to complete the picture. When you have a few days of data, it will be easier to offer some suggestions as to dosing etc.

It would be helpful if you could set up a signature (the light grey text below this message) with information about Ophelia including her age, date of diagnosis, that you use the AT meter, type and dose of insulin along with insulin history, diet and any other medical issue if relevant. This helps us help you and we won't keep asking the same questions over and over if and when you need/want assistance. You can also tell us your name or what you'd like us to call you. General location can also be helpful if there are ever questions about diet, supplies etc. Since you already have a link to Ophelia's SS, you can add this info in after the link. Any questions......just holler.

 

Kudos to you for helping this kitty! If I understand you correctly she's been on Lantus since 27 September, correct? First off, her curve isn't really alarming for a kitty recently on Lantus. It takes a while for them to adjust and we can help you find the good dosing range.

Here are my thoughts:

• her raw diet is low carb but I don't know the % carbs as fed in those Weruva varieties. If they're above 10% and she eats enough of them they could boost her BG. From what you say, though, this isn't a big issue.
• from the curve I see that her BG is fairly flat and higher than ideal but not horrible. It rises around 10 hours after the AM injection, indicating either a lack of duration (on this day - for any number of reasons) or a dose that's too low
• the rise on the curve after the PM shot is most likely a food spike from the evening meal.

A curve is a snapshot of one day's response to insulin so is of limited usefulness in assessing the current dose. We need to know what came before at this dose and what will come after. It's possible that 1.5 u is too low a dose but I wouldn't go by a single curve in making a definitive judgment. That's why we're big proponents of a regular daily testing routine. Once that's happening and you amass a good body of data on the spreadsheet we use here we can see at a glance what a dose is doing and can make suggestions about how to proceed.

Here's the routine we recommend:

1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
3. do extra tests on days off to fill in the response picture
4. if indicated by consistently high numbers on your spreadsheet, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
5. post here for advice whenever you're confused or unsure of what to do.

Cats are notoriously tricky to regulate and some very much more than others. Better BG control is always possible though and we can help.

 

Hi there and welcome to L, B, & L ,and how wonderful that you are home testing and feeding her raw food and low carb wet food!

First a few questions. How much does your foster kitty weigh? And am I understanding correctly that she has been on Lantus since 9/27? And this is the first curve done since then? And it's great that you were able to do the curve because staying at the vet all day can cause so much stress that the BG's can easily hike up another 100 points and then the dose would be increased on those inflated numbers and then possibly going to low later.

As of right now, it looks like she could use some more insulin but without more data it would be impossible to say as she could have gone lower the day before yesterday and is bouncing into higher numbers.

Could we get you to set up a Spreadsheet,( SS) like we use? And then set up a signature and link it together? The instructions for setting up as SS is
Here

 

Ok, I'll go through these questions asked, so that I can be sure I am providing all information:


Mr Worfman's mom
Are you getting pre-shot tests every day having withheld food for at least 2 hours prior? - I am not testing daily, I am transitioning to this, this week. I have been a lurker for the late summer but haven't posted because I haven't been following the kind of unspoken rules of the board, due to Kitty girl's anxiety over being in a new home (she is still very skittish, I am not sure what happened to her prior to the shelter, but she is so lovely and continuously scared of everything. I am desperate to have her feel at home with me so I thought pricking her ear would only add to her anxiety and she might never come around)

What insulin/dose between July and the end of Sept.? - Kitty girl was on Lantus 1 unit BID from July 21 until September 27th. She was having fructosamine tests, which showed everything was ok, but reading more and more here, I knew that blood glucose testing was what she needed for a real shot at making it to remission (my ultimate goal though I am not sure if that is possible, I don't have a history on her and neither does the shelter. She was dumped off with her brother who was also diabetic. He got adopted out but she didn't for months. Having a sibling makes me think there is a genetic component).

Kris and Teasel
The foods referenced, according to Weruva website, are less than 2% carbohydrate per container, so I am hoping they are actually that content:
1. Weruva Duck and salmon oh my gravy: 53.60% Protein, 44.5% fat, 1.90% carb, 54 calories
2. Weruva Beef and Chicken oh my gravy: 50.70% Protein, 47.5% fat, 1.80% carb, 52 calories
3. Weruva Chicken, Turkey and Salmon oh my gravy: 46.8% Protein, 53.5% fat, 0.00% carb, 57 calories

Bobbie and Bubba
How much does your foster kitty weigh? She weighed 11.5 pounds at the vet on 9/27. She has fluctuated between 9.9 and 12.5 since July (her lowest being when she was at the shelter). Kitty girl turned 9 on 9/20.
am I understanding correctly that she has been on Lantus since 9/27? No, she has been on Lantus at 1 unit BID since July 21.
And this is the first curve done since then? She had a curve at the vet on 8/1 but it was inconclusive due to stress the vet felt. So we did a fructosamine at the end of August and again on 9/27. It was then that we upped her dose to 1.5u BID

Could we get you to set up a Spreadsheet,( SS) like we use? I have the link posted, I still need to add some labs once I track down the data from my vet vs the shelter vet. It is showing on my end, hopefully you all can see it as well. I consulted with my veterinarian and he suggested to bring her up to 1.75 units BID, I am going to test her this evening prior to food. My vet did tell me that the 1pm feeding wasn't optimal, it is hard though, she is a bit of a grazer, and feeding her canned solely with raw, if it sits out, she won't eat it or it isn't safe in the case of raw, so she's not getting her calories per day (she's averaging around 125 calories, and she theoretically needs close to 200). I know she isn't emaciated, but I want her to be in an optimal metabolic state if I hope to get her blood sugar under control.

Also, I got a ketone meter, but my vet said he didn't recommend blood ketones/meters, and only urine dipsticks are really relevant to cats. What are your all's thoughts on that? I am going to research the board, I bought the Novamax I saw recommended here, I would much rather blood test her for ketones, than urine, because it is a whole other set of dramatics that is hard to deal with when I am working four 12-16 hour shifts during residency, each week. Thank you!

 

I understand your reluctance to push the home testing with a skittish cat and am happy to hear you are working toward that goal. It not only keeps kitty safe but is really the best tool we have to ensure that dosing is done in a logical and methodical manner. Lantus is dosed based on how low it takes BG at nadir and pre-shots ensure it is safe to give insulin. It may be necessary to do some de-sensitizing with Ophelia (or is her name Kitty Girl?) by playing with her ears or paws (whichever is your/her preference) in a specific testing spot in your home and then offering her a treat without actually doing any testing. Once she gets used to the extra handling and associates it with a positive experience, then you can work on mocking actual testing. Many of us have cats who actually come to get us at testing time and many like my girl are not what you would call lap/snuggle cats. If you run into any problems let us know as we have tips and tricks to make testing as easy as possible on both you and kitty.

We generally increase doses in increments of 0.25u in order to avoid missing the right dose. Half unit increases are huge when dealing with such small doses.

I have no idea why the vet would tell you 1pm feeding is not optimal. Most of us here feed our cats several meals/snacks per day. It is not only more satisfying for the cat but also helps to smooth out cycles. I agree leaving out raw food would not be ideal but the canned Weruva can be left out. Many people use auto feeders to dole out small snacks throughout the day and night. You can also freeze some canned food in ice cube trays and then leave out a cube or two (depends on size) to thaw and be available and fresh later in the day when you are not home. Diabetics cannot adequately utilize the food they consume so I would definitely try to get more calories into her. If based on ideal weight she needs 200 calories, she may need a bit more until she is regulated just to maintain her weight.

Ketone meters are a great idea with cats. They do not register the same for cats as they do for humans much the same as human glucometer readings are not the same as pet lab values. Ketones start to show up on the meter at 2.4 to 2.5. If you do a search here for "ketone meters', you will find more information on using a meter for cats.

I hope Ophelia starts to come around for you. She is indeed lucky to have you to care for her.

 

Have you tried giving her a little pokey treat? Many of us will give a freeze dried all protein treat or a little piece of poached chicken. When first starting off testing, it is really nerve wracking even with a kittie that has been in our home for some time. What you can try is to lure her to your testing station,( mine is on top of the cat buffet that I feed my boys on) and simply rub her ear a few times to get her use to you touching her ear. Then give her a treat and let go about her business. Do this multiple times through the day and soon she will associate the handling of her ears with a treat.

As far as the raw feeding and leaving out, I have a PetSafe 5 feeder. If I know I won't be home for a certain feeding, I will either freeze a raw portion in advance to put into the feeder so that it is slowly thawing or just use canned food and I put one ice cube on top of canned or raw to add moisture and keep them from spoilage. The PetSafe 5 feeders have a space where you can put a small thin refreeze able ice pack.

I use a ketone meter too ; I could find Bubba in the litter box to catch a urine sample. And the ketone meters are an instant snap shot of ketones right now where as it can take up to 4-8 hours for ketones to show up in the urine. Linda all ready gave you at what reading ketones show up on the meter for cats.

 

I call her kitty girl, she seems to respond to that, rather than her shelter given name, though she looks elegant enough to have warranted a name like Ophelia. My vet stated that feeding every 12 hours was optimal for diabetic cats, maybe he "doesn't trust" that I am not leaving high carbohydrate dry out for her to graze on, as he is a very good vet from what I gather on this board, as he does recommend low carb over diabetic food, does advocate for home testing, etc. I basically have taken on the complete cost of her care, as the shelter didn't want me to switch her from her very cheap insulin, to a more expensive one, so they won't cover the cost of that. Nor do they advocate using glucose meters or testing, due to cost, so I figured if I was taking on the entire cost of everything related to her management, I would switch her to a vet that is not driven as much, by saving every dollar possible to the (in my medical opinion) detriment to the animal.

I completely forgot about auto feeders, I need to look into getting one for her. I know I priced ones that have cold packs in them, but I never got around to buying one. Now seems like a good time. The only reason I don't adopt her is because I travel a lot for work, and the boarding she would require is in the realm of a couple hundred dollars a month, so I coordinate with a foster to watch her while I am out.

 

Thank you! Do you use the NovaMax as well? I tried to buy what I saw pop up a few times in the threads already here:

https://www.amazon.com/gp/product/B0778RHL8C/ref=oh_aui_detailpage_o02_s00?ie=UTF8&psc=1

I will try treats, she really isn't a treat taking cat, but I bought some freeze dried salmon and freeze dried chicken from chewy.com and I will give that a try.

 

There are plenty of good vets out there who just don't have a lot of experience with diabetic cats or are not as familiar with working with longer acting insulins like Lantus. Feeding twice a day was a popular option and somewhat understandable when the insulins being used were In and Out insulins like Novolin which hit hard and fast. With an insulin like Lantus, it is not necessary to get a big meal into the cat before dosing as onset is slower and later leaving lots of time for kitty to eat in relation to the insulin's most active time frame. The important thing is that kitty will eat rather than how much they consume at shot time. While a lot of vets are now prescribing Lantus, many seem to still use the dosing and feeding methods employed with the older types of insulin and that is not optimal or necessary.

Ophelia is a very elegant name but "Kitty Girl" sounds so loving!

 

I purchased a time release feeder with a cold pack in the bottom, for her, hopefully will be delivered thursday. And yes, she is my little fuzzy bunny, she's like cashmere when you pet her, and she looks like an owl in the face, so I can see why they named her Ophelia I certainly hope her brother was adopted by someone who knows about this board, if he was anywhere near as beautiful and kind as she is, I definitely would have wanted them both to foster and probably adopt. I think I am going to pull the trigger on Kitty Girl, she hasn't had one interested person since November 2017, and none since I started fostering her in July. I think she belongs with us. This is her with my little boy I adopted last year, in the background. He is an I-131 kitty, I adopted him at 14 with hyperthyroidism (his family took him to a shelter when he got too old for them, and they wanted a kitten. He broke my heart into 1,000 pieces the minute I laid eyes on him, I call him my puppy cat, he follows me around with my two goldens, all day long. He is a love bug). He got I-131 about a month after I started fostering Kitty Girl, because his T4 was over 24 and methimizole was becoming hepatotoxic and he was wasting away.

 

Kitty Girl is a beauty and little "puppy cat" in the background is just as adorable! Could you do a signature so that the pertinent info is available to us when we read your posts? Here is a link on how to do that: SIGNATURE

 

She is beautiful and does look like she would be as soft as cashmere!

 

Kitty Girl is gorgeous. Kitty Girl and your "puppy cat" look so very content. That picture would make a wonderful avatar! They are extremely lucky kitties and look like they know it. Your compassion for animals is huge. Are you sure you didn't miss your calling? . Me thinks you must be a wonderful physician.

 

Two lovely kitties! I’m so glad you’re considering adopting Kitty Girl. I, too, have a real soft spot for these “special needs” kitties.