Xuxu 1/12/13 AMPS 690

Thank heavens I waited to switch Xuxu to Levemir until today so I had the whole day to monitor him. All H... broke loose and I thought I was going to lose him. After reading a lot of posts, and internet articles, it seemed ok to keep his same dose as Lantus (2.25), since it seems probably a higher dose of Levemir than Lantus is usual. But Xuxu can't do anything boring. He crashed so fast I'm glad I didn't go grocery shopping as planned. I had to give him glucose 3 times and force feed him AD before his BG started trending upward. He even went into hypo symptoms, fast breathing and heart rate, shaky and stumbling, and doing that peculiar cry that says he doesn't feel well. It was a good 10 hours before he started acting like he felt better.

I had given him his every 3 day dose of mirtazapine with the Levemir shot, and boy did that kick in once his BG started going back up. He lived up to his name, Xoom Xoom. He was racing around looking for anything to eat, actually looking wild-eyed. We had opened a can of AD, and he kept running up, jump on my lap (where I was keeping it away from the other cats), chomp down a couple of bites, then jump down and run over to the water bowl. He did this about every 10 minutes. He ate nearly a whole can in an hour.

At the 11 hr mark, his BG was back up to 750, and at 12 hrs I just gave him 1.5 of Lv. His BG hasn't really come down much. I'm haven't "diluted" it, so I'm not sure if it's the same situation where it's sitting under the skin for a while. He now seems to have calmed down, although he is very grouchy in getting his pm meds and his subq fluids. I guess I don't blame him, he's been through the ringer today. I don't know how long to stick with the 1.5. My vet said she didn't want him going more than 24 hrs at a straight 750 because it would affect his brain.
(on his sheet, there are a couple of double numbers in cells where I checked both ears to make sure it was accurate).

 

Wow, that is all really scary. Yes, it is good that you didn't leave home yesterday and that Xuxu is ok now.

I am rather mystified over his treatment protocol though as well as those numbers in the 600s and 700s. (that is just my initial reaction) What is his normal diet? I ask because those numbers are really unusually high. Also, I guess the AlphaTrak meter reads up to a lot higher than most meters we use. 600 seems to be the top number and after that it just reads "HI".

Anyway, I have just never seem really high numbers like and I will be honest in that I am suspect of them. Has your meter been double checked by you or the vet to make sure it is reading correctly? I check mine by testing myself and I realize the AT may read a bit off on a human, but it shouldn't be that far off. Another cause of high numbers is rebound, which I think is going on, but it usually doesn't spike numbers higher than the 500s - given that the cat is eating a low carb wet food diet. Do you still put down the IAMS dry at all? (that food caused Beau's diabetes and he was tough to switch to wet food also).

Are you still using R insulin? And by "sodium Chloride" you mean basic IV solution, right? I have not seen that technique - shooting fluids into the injections site. Many people here give their cat subQ fludis for various reasons to prevent dehydration, ketones or to help with kidney function. Doing that tends to increase the action of the insulin by some mechanism. It may be that proper hydration does allow the insulin to precipitate into the blood stream faster or more thoroughly. It's just something to be aware of and note how it effects your particular cat's dosing. Do you still give him fluids regularly? That will help with both pancreatitis and ketones and should be continued until he is at least well regulated.

The main thing that jumps out at me is the swing from 750 to 20s and back. That is indicating that the insulin is super effective if it can bring him down that far in 6 hrs or less. Swinging back to 600-700s is rebound. The only way to stop that is to reduce the dose. If he wasn't prone to DKA I would say "start over" at 1u (or even .5u), but because of that I would say stay at 1.5u for several days. His body needs time to rid itself of all the hormones that are released during rebound. It can take up to 3 days for that to happen. The switching dose on lev from lantus should be at most 70% of the lantus dose, which would be 1.5u. I just think that lantus dose was too much as well. It might be that what is needed is a hold at 1.5u and then slowly reducing from there, while using a very small amount of R when he is "bouncing' up really high. I have not used R, but I think you want to be using .5u or 1u and not 2u of it. And I would not shoot fluids into or near the injection site. Give him subQ fluids on a regular basis, but makes sure the insulin is injected away from the area you give fluids - and if you can keep the time separated by several hours as well.

You might also think about getting a Bayer Contour meter and doing dual testing (same drop) for a while to see what you get. The Alpha Trak is so expensive and I don't think it is really that much more accurate. All meters will have a 20% variability to them (any number can be 20% higher/lower than actual) so the numbers are more of a guide to what is happening than factual - they show trends. This is also why you get different numbers on each ear at the same time, so you can save him the poke on that second ear.

And - we want to see a picture of him. He must be gorgeous!

 

Thank you for looking over his chart. He does seem to be an exceptional case, for my vet and several of the specialists we have called. The link in my signature for "health discussions" outlines the first 4 months after Dx of trying to figure out what insulin to use and how to treat him.
To answer your questions -
Yes the 750's are true figures, both in comparing to 2 other AlphaTrak2 monitors at the vet's and to her IDEXX machine for blood work.
He is on Science Diet DM dry food and Fancy Feast canned Classic Ocean Varieties. He was raised on Iams and still prefers that. I take it up when I let him out of the bedroom but he still seems to find a couple of stray kibbles the other cats have spread around every time. He will go for Iams over anything else. He'll eat the DM and FF when confined. We gave him the AD yesterday to get his BG up.
Yes, the NaCL is IV Solution. We ended up having to develop that technique of "diluting" the Lantus or it would just sit there for up to 2 days under the skin then be released all at once (read health discussion). The NaCl is pH 4.4, very close to Lantus. The technique worked in that the Lantus started showing a more normal release. We are not having to dilute the Levemir so far, the different reservoir characteristic seems to be better for Xuxu.
Yes, he is being hydrated, 100 cc Ringer's Subq every night. He drinks well during day, but seems to do a lot better when he gets the extra fluids. He's also on Denemarin for his liver infection, Mirtazapine, Orbax, Tumil K and a OTC antioxident supplement.
No, I've not used N for several weeks when he was 750+ for several days and showing signs of DKA. Once I started "diluting" the Lantus, he didn't need the N.

It really seems like he eats up insulin. I've seen very few days where it looked like the dose lasted even 12 hrs, let alone any overlap. He's a pretty laid back inactive, but very underweight kitty. I'm wondering if he would be better on 3 (8 hr) doses, but my work schedule would not allow that 2 days a week. I'll see how the Levemir does for a couple of weeks.

 

Deb, how old is Xuxu? Has he been tested for hyperthyroid and/or thyroid tumor? If his metabolism is that fast maybe there is something going on there. HyperT also causes PU/PD, weight loss and possible increased needs for fluids.

I hear you on the Iams addiction. Beau was so in love with dry food I called him Mr. Crunchy Man. He took a long time to transition to wet food. I did it by slowly decreasing the dry food. Some days he would not touch the wet so I stuck 6-8 kibbles into it so they just barely protruded above the surface and he could smell them. He had to eat the wet to get at the dry. I switched all three of my cats at the same time and the other two did much better. I am assuming you have tried the standard of crushing dry and sprinkling it over the wet? You can also try crushing freeze dried chicken over the wet food (Halo, Pure Bites, etc.) or sprinkling FortaFlora over it.

 

Xuxu is 14 years old. All of this only came up when he was neutered in late summer and pancreatitis started. He had been a breeding male and show cat.

I'll have to check on the thyroid, I think so on his first blood test in Aug. He's had two ultrasound but I don't think they did his throat. I'll check on it.

The last ultrasound showed a liver infection probably from the high glucose in the preceding months. The pancreas had healed significantly but there was scar tissue. He has had very high
wbc, the only time it was low was Nov 26 test, (been doing cbc @2 wks). We were looking at what had changed and the only thing with medication is he was still on metronidazole at that time. The dose ended and we felt his pancreatitis was over so stopped it. I'm thinking of starting it again and seeing if that made a difference. Perhaps his pancreastitis has flared up again.

 

Could there have been some complication with the neutering - an infection or something? It's strange that it would have caused the pancreatitis and diabetes.

I wish Pamela were posting regularly because her cat, Tigger, had severe liver issues and she turned it around with meds and supplements. I'll try to get her to chime in here. I think she uses Denamarin as well as feeding him a raw diet. he is doing very well now and his liver issues cleared up years ago.

Another thing to look into is triaditis, and I apologize if this was brought up before. It is intestinal inflammation, pancreatitis, and liver involvement (w/wo the gallbladder involved).

Metronidizole can cause lowing of WBC count. If the ptitis is flaring again he may need a different anti-inflammatory drug. Steroids are common for ptitis, but somewhat contraindicated with a diabetic. You would want a low dose oral med over a long acting shot (depo-medrol).

Beau had pancreatitis on and off from the time he was 3 until about 4 years ago. (he is 14-1/2 now) He had steroids (oral) for many years because when we tried to ween him the first two times the ptitis flared up. I am sure that the diet change to low carb and then the insulin change to lev helped rid him of it (knock wood). He has not had any flares for a long time. I now add enzymes to his food because he had some symptoms of IBD and lost weight for no real reason about 3 years ago. This was also right after he went OTJ and a year after he was dx with hyperT. His blood work and physical exams kept being normal so I stopped subjecting him to them. The enzymes and slightly better quality of food seems to be helping a bit. He also has cardiomyopathy (HCM - dx at age 3). It's a balancing act and a miracle he is still here. His prognosis after the HCM dx was 2-5 years.

 

previous post, Lantus being diluted...
viewtopic.php?f=32&t=86578&hilit=+water

If you were diluting the Lantus but not diluting Levemir, I think you would have problems in your dosing.