Worried...PM +6 climbing to 567..has been dealt with

I have not been posting daily condos for awhile. Tuxie had a mild pancreatitis attack on Sunday/Monday which he recovered from with fluids and cerenia within 24 hours. He was on reduced dose for a couple of days because of his poor food intake. Wednesday I put his dose back up since he was eating fine again. Thursday and Friday the numbers were all over the place and today he is hitting the blacks. His +4 and +6 numbers tonite are rising higher and higher. I gave 1.0 units extra at +6 since his numbers are rising too high to wait another 6 hours.

He had full blood work done which came back mostly normal other than glucose and chronic pancreatitis which we were planning on treating with prednisolone. I have done two ketone tests one this morning and one just after his +6 test tonite, both which showed no ketones. I am not looking for dosing advice, just some input into what could be happening.

Thanks

 

Any thoughts on this??

 

Also..Tuxie has been acting fine all day...normal poop, extra drinking and peeing, extra hungry, grooming, purring and playing.

 

Looking at it now. Could be some after-effects of the pancreatitis or it isn't really gone yet. Changing up the times could be part of it, too. A delayed shot acts like a decrease in dose due to less overlap.

Any dehydration (scruff test, gum test per the Secondary Monitoring Tools in my signature)?

 

Thanks BJM

 

He had 200 ml of Sub Q on Monday. The vet said he was only mildly dehydrated, but we opted to give it anyway. His scruff test and gum tests are both good for hydration. No nausea. Good appetite

 

Maybe just the time and appetite changes are doing this.

And when you're up at a 567, that could be +/-20% ie., 453.6 to 680.4 - once you're up that high, the actual number doesn't really mater.

 

I was 2 hours late this morning...slept in...not much sleep this week...and I shot at +11 for the PM shot. His appetite has been back to normal since Tuesday afternoon.

 

It takes depot insulins a while to stabilize and Levemir takes longer than Lantus. It has been about 3.5 cycles; some cats take 10 cycles to stabilize.
Patience pants needed?

 

I have worn out many pairs of patience pants in the last 9 1/2 months. These high numbers at +4 and +6 are very worrying. There was no chance of contraband and (anti-jinx) no sign of DKA, so I am stunned as well as exhausted..

 

Just grabbed another pair of patience pants and will continue monitoring. Thanks for your input BJM>

 

Hang in there!
And the correlation between the AT2 strips and the FS Lite strips is quite good

 

Thanks for the support. Your graph is great..really shows a clear picture of the comparisons.

 

Hi Mary Ann - sorry to hear Tuxie has been having another pancreatitis flair. Now that he's back to eating normally, I wonder if you are at too low a dose. I see when he earned a reduction to 3.75U, but then his appy was off and you reduced more. I'm not sure he's earned reductions down to 3.0U. He did get blue on this dose, so I'd try 3.25U next.

I see you shot an extra dose of insulin at +6. That's not something you should be doing with Levemir or Lantus. I know it's hard to wait for the numbers to come down but that's what is best to do.

 

Mary Ann, when Sheba got a flare up of pancreatitis a few months ago, her blood sugars took much longer than a week to settle down again. You might need to adjust his insulin dose a few times before he settles down again. I think if he is eating and drinking OK and using the LB OK and you are checking for ketones and dehydration..you are covering it all....could he be feeling any pain? That can raise the BSL. His depot probably got a bit depleted after the reduced doses as well. High numbers are horrible I know.

 

I agree he may need more insulin. Possibly a little glucose toxicity happening? One word of caution, though. I wouldn't raise the dose in the morning, as you will still have the second half of the cycle from that extra 1 unit you shot. I'd wait until the PM shot to raise it. Just my two cents' worth...

Oh, btw, you said you were "planning on treating with Prednisolone". I take it that means you haven't started the Pred yet? Because Pred can raise numbers...

 

Thanks for the input. The pancreatitis flare did really throw his numbers off. I was at 3.5 units, then reduced to 2.5 because of low or no food intake. On Sept 1 AM I did a no shot since his levels were at 52-56 for the first half of the morning. That evening I restarted at 2.5 units, since his appetite seemed to be back, but I was still not sure if it would hold. Sept 2 AM I started with 2.5 units then raised the PM dose to 3.0 units since the food intake was totally back to normal. I didn't want to go right back to 3.5 units since that would have been a fairly big increase. I usually hold his dose increase for 4 or 5 days since he foes tend to bounce a lot. So I was getting to the point where I would have increased when he started throwing high rising numbers after the PM shot last night.

I know giving the extra 1 unit was an unorthodox approach, but with rising numbers I didn't want to wait another 6 hours and chance his numbers continuing to rise and face the possibility of another pancreatic attack or DKA developing. If I had some R insulin I would most likely have given him a small dose, but I didn't have any and it was too late to find a pharmacy that would be open. I was able to continue monitoring him through the night and at least this time it did seem to even out his numbers. I know this is not the best approach and not something I would normally consider using but seeing his numbers go from PMPS of 472 to 437 then rising to 567 was very unnerving especially after his problems a few days earlier.

For the AM shot I gave 3.0 units since it was +12 from his original 3.0 unit shot and +6 since the additional 1 unit so I am considering this a 3.5 unit shot with the remaining overlap from the extra shot. I will be looking at an increase to 3.5 for his PM shot unless he throws some really low numbers.

 

Thanks for looking in Bron. I just replied to Wendy with an explanationof my "reasoning" and I will be giving an increased dose then holding for 4 or 5 days to see where it goes.

EDITED TO ADD:

I don't think he was in any pain. He was purring, playing and grooming at the time his numbers were going up. Just based on my own observations of a kitty whose every action I have been watching like a hawk for almost 10 months I do not think that was a factor in the rising numbers.

 

Thanks for your input. I think I was posting at the same time you did. I did not increase the dose this morning because of the extra depot from the extra shot 6 hours ago.

We have not started the prednisolone and I will be holding off on starting until Tuxie's numbers settle down a bit. I am aware of the problems with incresed glucose levels with steroids, which is why I gave not tried this approach so far. I am actually having another U/S done on Friday to assess the inflammation of the pancreas, liver and adrenals before I start to make sure there is no triaditis involved as well. Tuxie had an U/S done in January so this is a follow up to see how much worse the inflammation of these organs is.

 

Sounds like you've got it covered, MaryAnn. So I'll just send some healing vines and safe sliding vines and we'll hope Tuxie sorts himself out soon!

 

Thank you Tricia. Your help and vines are greatly appreciated.

 

Are you giving any pain meds? I know you know that pancreatitis is painful. I wouldn't assume because a cat is purring and grooming that the kitty is not in pain. These can also be self-soothing behaviors. If you have bupe on hand, I'd try a couple of doses over a few days and see if there's an improvement in numbers.

 

I would also say that you should be monitoring very closely the next couple of cycles as the effects of the extra 1 unit doesn't always show itself in the cycle you shoot it, normally it doesw show anything until the following couple of cycles, which is another reason, even with rising numbers,, its not a good idea to shoot midcyle like that.....it really won't do anything for that particular cycle usually

 

No pain meds for this episode or last one in early February. In Feb. Tuxie had 200ml sub q and a .1 mg shot of Cerenia and was back eating within 6 hours and back to normal within 12 hours. This time he got 200ml sub q and .5 mg shot of Cerenia. He was eating within 12 hours and back to normal within 24 hours. I know cats will still purr when in pain, but Tuxie was also playing and social with his sister.

With the weird dosing I did last night Tuxie's numbers are now quite low, His AM +5 is 88, so I don't think pain was a part of the problem.

I believe with the reduced doses when he was not eating and the skipped dose Sept 1 AM when he was too low to shoot, then the restart and increase all in a short period, what BJM said may just be the problem....:
"It takes depot insulins a while to stabilize and Levemir takes longer than Lantus. It has been about 3.5 cycles; some cats take 10 cycles to stabilize.
Patience pants needed?"


I will continue monitoring and most likely hold his dose for 5-7 days, until I have the other U/S done and I possibly start the prednisolone treatment, in which case I will have to adjust the doses. I stopped following the TR protocol in July and started using the GS (SLGS) protocol.

 

I am monitoring closely and have caught the big drop atAM +5. I already stated my reasoning for shooting the extra 1 unit at mid-cycle and I was aware of the possible consequences. I would not suggest or revisit this approach.

 

I don't think the depot information about Levemir taking longer to stabilize than Lantus is correct. Levemir's onset and nadir are typically later in the cycle than Lantus but this doesn't have anything to do with the depot. It's certainly possible that this is the case for some cats but it would be an ECID thing vs. a general truism.

 

Sorry...I should have clarified that the part of the comment I agreed with was the length of time it can take for Tuxie to adjust to dose increases. Because of the wonky dosing with the pnacreatitis episode with the reduced doses because of lack of food, no shot because numbers were too low and then restarting and increasing, the fact that Tuxie had only had 3 1/2 cycles to make the dose adjustment could very well have been a part of the rising high numbers. In the past Tuxie has taken up to 8-10 cycles to "settle in" on a dose increase.

 

Absolutely -- all of that factors in especially so since you know Tuxie well enough to know it takes her longer to settle in to a dose. Thanks for clarifying!