Yoyo effect, can't get him regulated

Discussion in 'Feline Health - (The Main Forum)' started by DebH, Dec 15, 2012.

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  1. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    I'm new and still trying to get a profile and google docs uploaded. But in looking over the posts, I'm not seeing many that have cats going over 300. Xuxu is 14 yrs old. He was neutered 3 months ago and his blood test at that time showed only a slight increase in liver enzymes, which we later realized was the beginning of pancreatitis and he has been treated. A month later he went DKA comatose, and my incredible vet brought him back. He is yoyoing between >750 and <100. He's on Lantus and we've been trying to get him regulated for over 2 months now. We are force feeing him FancyFeast canned fish. He's been on dry Iams all his life and that's all he'll go for on his own. It seems like his BG settles down for a couple of days on a regular dose, then goes off kilter again. He's crashed 4 times now, and been below 50 when I caught it before symptoms several more times.

    So is this rare? My vet says she's never seen anything like it and we are calling specialists all over the country. But talk with 3 specialists and get 3 different recommended protocols. It's very frustrating.
     
  2. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    You may be giving him too much insulin, his liver compensates for as long as it can, then he crashes.

    Alternatively, comorbid conditions, variable appetite, vomiting, diarrhea etc will make for very difficult to regulate diabetes.

    With the latter situation, you may find that a non-depot insulin such as ProZinc may work better, as there is no carryover between shots. This lets you develop a scale for dosing with experience.
     
  3. Elizabeth and Bertie

    Elizabeth and Bertie Well-Known Member

    Joined:
    Sep 6, 2010

    Hello and welcome to FDMB,

    It sound like you're having a tough time, but hang in there, it will get easier.

    Some cats DO have very high numbers at first. My own cat was mostly in the 400 - 500's for many many months after he was diagnosed; and then his BG would drop like a stone very suddenly and without warning. In his case I never did come to understand the reason for that. It seemed to defy logic. But with time, and a change of insulin, things gradually improved for him.

    I absolutely agree with BJM's advice above. A common cause of high numbers interspersed with low ones is that too much insulin is being given. And digestive problems, infections etc can also make regulation extremely challenging. These things may - or may not - be the cause of your cat's yoyo-ing numbers.

    Are you testing your cat's blood glucose at home? It would be really useful to see what's happening to your cat's BG's during an insulin cycle.
     
  4. squeem3

    squeem3 Well-Known Member

    Joined:
    Dec 28, 2009
    Seafood isn't good to feed to cats all the time. It's low protein and high in phosphorus which can be hard on the kidneys. Will your cat eat anything else? Fancy Feast Classics has many varieties that are low carb for diabetics. If your cat doesn't like Fancy Feast, and there are cats out there who don't, try a different brand of food. Popular brands besides Fancy Feast are Friskies, Wellness, Merrick, Nature's Variety Instinct, and Innova EVO. Some can be bought the supermarket, big box discount store, chain pet store. Other can only be bought at independent non chain pet stores. Here is a list of affordable low carb foods: http://felinediabetes.com/FDMB/viewtopic.php?f=28&t=84512

    A more extensive list of canned foods can be found on these charts/lists:
    http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=84885
    http://www.catinfo.org/docs/Food Chart Public 9-22-12.pdf
    Binky's canned food charts
    Pet Food Nutritional Values list
    Hobo's Guide To Nutritional Values
    Dr. Lynne's Wet Food list
    List of low carb gluten free Fancy Feast

    Look for foods under 10% carbs.

    Keep trying to get your cat to eat canned food. Iams dry food is 30%+ carbs depending on the formula :shock: That's way too many carbs any cats should have. So many supposedly "good" dry foods made by big name companies out there are so high in carbs that it is one reason why many cats end up diabetic in the first place. Dry food keeps blood glucose levels too high in a diabetic cat.

    Here are tips to transition your cat to canned food: http://www.catinfo.org/docs/Tips for Transitioning PDF 1-14-11.pdf

    How much insulin are you giving your cat? Do you test blood glucose levels at home?

    Regulation takes time. Some cats can be regualted pretty quickly, others need months. Here is the basic dosing protocol for Lantus: http://www.uq.edu.au/ccah/docs/diabetesinfo/link4.pdf

    The sreadsheet instructions are here: http://felinediabetes.com/FDMB/viewtopic.php?f=6&t=50130 Download one of the files to your computer, then upload it to Google Drive. The last post in the instruction thread tells you how to upload the file to Google as well as how to get the correct link to share your spreadsheet with others.

    Profile instructions are here: http://felinediabetes.com/FDMB/viewtopic.php?f=6&t=79123
     
  5. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Thanks for the responses. I have been reading all the basic material on the board and using them where it seems appropriate. I learned about the fancy feast from Jan and Binky's food chart and have read many of the papers. I'm on vacation as of Monday and will try to get everything posted. Complicating that is I've just switched from PC to Mac and am still even trying to remember how to copy and paste.

    I am home monitoring, AphaTrak2, and all the state specialists my vet contacted said keep him on Lantus. He has had a respiratory infection and is on Orbax, which definitely makes him feel better. We thought he was over the respiratory and stopped the Orbax for 3 days and you could tell he felt miserable and started sneezing again. His other medications are Tumil K (potassium), famotadine and mirtazapine (also learned of that from this board). He was on Metronidazole for the pancreatitis, but is off it now. He hasn't ever seem to be nauseous, no vomiting at all. The pancreatitis was diagnosed via blood and ultrasound. The radiologist said it was only a small inflammation, and should heal fine. He was not diabetic before that.

    We've tried the slow approach, moving him from 1U Lantus up to 2.25, but then he started crashing again, so went down to 1.5. I tried moving him up to 2 after almost a week of above 500, but then he went down to 53 @10 hrs, so we started again at 1.5. My vet says higher is better than too low, but she's concerned about his being so high for such a long time.

    I'm starting to get a feel for what his BG is by how he acts, drinking water when he's Hi, wanting to eat more when it's dropping, laying on his side when it's too low. He's a sweetheart in handling this. Doesn't run and hide, sits quietly while I take blood and give shots. We are still force feeding him because we can be assured of how much he's getting. He's already gone from 10.5 pounds to 7, don't want him loosing any more. He hates to stay in the bedroom all the time, so we let him out with the others in the evening, and have to remember to take up the Iams then. He did take a few crunchies of SD DM today, and a few bites of the canned fancy feast. We are giving him the seafood FF because it comes in a case at our local store. The vet said to go for the lowest carb until we can get him stabilized, then we can experiment a bit with food.
     
  6. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    When you make dose increases on small doses of Lantus, only change 0.25 to 0.5 units at a time. Then hold the dose for at least 3 full days, checking the nadir around 6 hours after the shot, before attempting to adjust the dose. In case you and your vet are unfamiliar with it, here is the link for the Tight Regulation protocol

    Discuss with your vet the possibility of using a small (0.25 - 0.5 units) supplemental dose of R for those times when he is popping up very, very high, ie basal Lantus plus, only if over say 400 on the glucometer, the small R dose. You'll need to run a curve the first few times you use it to see how it impacts the overall levels. I did this with Spitzer the last few months when I wasn't able to get the Lantus stabilized due to vomiting and variable appetite and it did help out.

    In addition to trying supplemental R when Spitzer was so erratic (which would tamp down some of the high glucose for roughly 4 hours), I also tried supplemental Humulin N (helped about 6-8 hours), or supplemental Prozinc (helped about 10 hours) because they last longer and would cover more of the time he was high. This is NOT a standard veterinary practice to do this and any trial of combining different insulins should be worked out with your vet with very careful methods for evaluating effectiveness and safety. If it were successful, it would be worth writing up for a veterinary journal.
     
  7. Elizabeth and Bertie

    Elizabeth and Bertie Well-Known Member

    Joined:
    Sep 6, 2010
    Aw, bless him....

    And well done, you, for getting to grips with the hometesting. Your cat is SO lucky to have you being so totally dedicated to caring for him. cat_pet_icon

    I noticed you're using an Alphatrack meter to test your cat's BG. When you get a chance to write a 'signature' for your posts you may want to note there that you're using an Alphatrack; the reason being that they read slightly differently to most other (ie made for humans!) meters, and if you're asking a question about BG numbers, people will allow for that slight difference. It doesn't really matter with the high numbers, but could be important if you have a query about low numbers at any time.
     
  8. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Xuxu went DKA the night before last. My husband caught the symptoms first, disorientation, not making it to the litterbox to pee. He had been at high levels BG for several days while on the 1.5 Lantus, but I was trying to stay the course and give the Lantus a chance to stabilize.. I gave him .5 Regular Humilin, but after an hour BG was still over 750, so I gave 1RH. After another 2 hrs still above 750, he was degenerating fast, so I gave him 2RH, and finally, it started coming down. I knew giving another 2 would make him crash, but I felt I had to get the BG down or he was going to become comatose again. One more night of little sleep since I knew it would probably drop low and I'd have to give him the karo, that happened at 2 am (down to 49), so I did get a couple of hours of sleep. He recovered fairly fast after that, being back to his happy self by the next morning. So I've upped him to 2L twice a day and will see what that does. But I'm not going to let him go that many days above 500 again without increasing the Lantus.
     
  9. squeem3

    squeem3 Well-Known Member

    Joined:
    Dec 28, 2009
    You're giving Humlin R as a booster? I'm not familiar with using that but here is a recent thread about using R insulin with Lantus: http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=84811 Did the vet treat your cat for the most recent episode of DKA? Do you test the urine for ketones?
     
  10. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Yes, I'm using Humilin R as a booster. Only when he is showing signs of DKA. I'm in text contact with my vet most of the time, although I would take him to the Animal ER rather than wake her up in the middle of the night. But my experience with the local animal ER isn't good. They tried to convince me twice to just put him down, when I refused, they didn't really do much for him (going by the detailed invoice of what they did). This time we caught it before he was comatose so I dealt with it myself.

    I think I've got a pretty good emergency kit set up. I'm got a pureed mix of the Iams as emergency food for lows. After seeing his reaction to karo when crashing, it was obvious that I shouldn't give him too much as that would send him back up over 750. So we settled on 1 cc of karo and a high carb food through syringe. That seems to have worked the last time. He has recovered well from this last incidence, and even ate a full meal of Science Diet DM during the night. If he keeps this up, we may be able to stop force feeding him. The mirtazapine is really helping with his appetite. If we let him out of the bedroom, he still makes straight for the dry Iams. I know shape and color of pet foods are copyrighted, but I still wish I could find something that looks and smells like Iams and I think our food issue would be solved. We are still giving him subq fluids to make sure he stay hydrated with dry food. We are still trying to get him to voluntarily eat canned food, but it's just not what he's been use to for 14 yrs.

    I'm going to visit my brother over Christmas for a week (taking XuXu with me). I'm taking Xuxu in for a vet check tomorrow before we leave. My brother is a Mac person, so he can help me get everything posted. I think then everyone can see just how hard he has been to regulate.

    BTW,, I love all the cat smilies, especially the one of the smiley petting the cat. Some people are so creative!
     
  11. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    Glad you and your vet are working well together.

    After 3 days at the new dose, you'll want to check the nadirs around +6 hours after the shot to see how low he's doing.

    If his appetite is still pretty erratic and he gets whopping high like that but you can't take the Lantus up because he's too erratic and you'd risk a hypo, you might discuss using an N insulin with a tiny bit more duration (6-8 hours instead of 4ish) and not quite as hard hitting as the R, or perhaps one of the 70/30 mixtures with some R and some N. That would initialy require testing and learning how that worked versus just giving the R, but it might work a bit better than hitting him with the R several times. Its an idea, not a mandate. (Oh, and its an idea that may generate some significant controversy here.)

    For the food - is either Wellness Core or Evo Cat and Kitten an option? The protein content is closer to what cats need and the carbs much lower, although, of course, its still a dry food.

    Here's a recent post on pancreatitis, which often co-occurs with diabetes. Pain meds, hydration, and Vitamin B-12 injections are some of what is recommended for this.It also has a link to another good overview of managing pancreatitis.
     
  12. Denise & Honey

    Denise & Honey Well-Known Member

    Joined:
    Oct 12, 2012
    I have 3 cats - 1 diabetic, 1 hyperthyroid and 1 normal (!)
    When Honey was dx, I moved all onto lc canned food. Honey and Monster (hyper-T) love the wet food, Minkie doesn't - he's a grazer who loved nibbling his dry food during the day.
    I find that when all 3 eat at the same time, Minkie seems to be encouraged to eat his wet food also - its like a herd mentality :smile:
    I also mix cans - he's a fish lover - and put treat sprinkles on top (freeze dried chicken) - he's coming around to liking the wet food.

    Both Honey and Monster lost a lot of weight - Monster is still unregulated and his T4 is very high but he's put on over 1lb on the high protein canned food - I give kitten food once a day but have it up high where Honey can't reach.

    Just wondering if it might help Xuxu if he ate with your other cats rather than having to stay in the bedroom.
     
  13. DKA? I want to make sure we're talking about the same thing here, because the symptoms you are describing (disorientation, comatose?) sound like a hypo episode. Is Xuxu being treated for ketoacidosis? Are you giving sub-q fluids? Testing for ketones? Usually a DKA diagnosis means a stay at the ER, administering fluids, IV insulin, a dextrose drip, and all sorts of emergency measures.

    I'm going to try to find someone with "R" experience that can help you out with that. (Those doses of R sound really high, but I never used it).

    Carl
     
  14. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    I had the same question as Carl. DKA is diabetic ketoacidosis. It's not something you can manage at home if urinary ketones, which you can measure with Ketostix, are more than trace. DKA throws off your cat's electrolytes and can be life threatening. Ketones are more apt to develop if you cat has an uncontrolled infection, isn't eating, and isn't getting enough insulin.

    It sounded like you were describing hypoglycemic numbers and symptoms. I linked information describing hypoglycemia.

    The amount of R that you're using may be compounding the problem of high and low numbers. When a cat's numbers drop into what can even be normal BG range (especially if numbers have been high for a while), your cat's body will react. The pancreas and liver will interpret either the lower numbers or a fast drop as being dangerous and release a stored form of glucose along with counterregulatory hormones. The release of these compounds will cause numbers to spike back up. We refer to this as a "bounce." If you are trying to use a bolus dose of Humulin R (i.e., "R") to bring the numbers down, if you give so much that numbers start to drop quickly, it may set off a bounce. Numbers are then high again and the whole process repeats.
     
  15. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    I can't tell you how much I appreciate all your responses. Just to answer a few inquiries. Yes, he was DKA, BG over 750, he couldn't be hypo, symptoms are often similar. I have so much medical supplies and equip at home now that I was able to handle it. But when I took him in for a check before we were leaving for Christmas yesterday, he was fine when I left home, but was in a Hypo with BG down to 36 by the time I drove the 15 min to the vet. I had given the R at 2 am, but it didn't seem to affect him until over 12 hrs later. We had considered the Somogyi effect before, but that's suppose to take place within 2 hrs of the insulin dose. We got him stable again with a dextrose drip and then reconsidered again. My vet caught an endocrinologist at Virginia Vet Medical College right before closing, but he was grumpy, said he was leaving for Christmas and maybe he'd talk after Jan 1. Real concerned, Bah Humbug. My vet tried IDEXX and stumbled on a internal medicine researcher who loved endo work and she gave us some really good short term advice, but said we needed another ultrasound to see if something else had changed. We were wondering if he still had an infection, or perhaps cancer had been missed the first time and she agreed that was possible. We also decided to add Zithomax to the mix for infection, in addition to Orbax and bump him up to 2.5L.

    So Xuxu was stable when I took him home, and I was told don't give him L until he was over 200. He was 126 an hour later, so I waited. 90 min after that he was up to 504, so I gave the Lantus at midnight. 3 hrs later he was down to 71. I gave him the dextrose emergency injection and 30 min later he was back up to 91 so I felt I could sleep for a couple of hours. He was ravenous and snacked on both dry SD DM and Fancy Feast canned salmon. He was back up to 451 at 11 hrs after the last show, so I gave another L shot, trying to get him back on a 12 hr schedule. 2.5 hrs later, he was back down to 390.

    We were able to get the radiologist in this morning. This is a retired vet who set up a mobile ultrasound and goes around to other vets. We were lucky he was willing to come in on Sat. He was fantastic. He looked at all the data I had accumulated, then rechecked all Xuxu's organs. There is some mild scarring on his kidneys, and one slightly large, the other slightly small, but no real difference from a month ago. But since he is still peeing well with no blood, this wasn't a concern. His pancreas looked good, but his liver was slightly enlarged. There were no tumors or possible cancers.

    So, what is going on. This radiologist feels it's an absorption problem. (BTW, he is also a diabetic). He says that sometimes when a cat is slightly dehydrated, or not active, the insulin can sort of sit under the skin at the injection site, even the R. Then when the area is warmed, is given fluid, or is moved about, that insulin is suddenly released. This can also happen when the R is not diluted. This would account for the insulin not seeming to have any effect, yet hours later there in an immediate effect in a short period seeming like there is too much insulin. He also said that we might be dealing with a resistant microbe, accounting for the infection starting in the liver, enlarging it. Or it might be a result of the high BG for so long, a microbe feeding on the sugar in the liver which is complicating the situation. In any case, he thought starting the Zithro was a good move.

    So his suggestion is when it seems like the insulin is not working, to give him a massage around the injection site, or warm the area up to get the blood moving. He also said it was ok to dilute the L immediately before injection with a sterile diluent 1:3, so there was plenty of flush getting the insulin out of the injection site. He said this shouldn't affect the PH enough to change the chemical effectiveness if immediately injected. We talked quite a long time about other aspects such as potassium, which I need to increase as he is dropping over his regular L dose. We also talked about adding antioxidants to Xuxu's diet. He thought there was some available that is mixed in the food but I will have to look online to see if I can find it (unless someone here already knows about it?)

    So that's the story for now. Needless to say, we cancelled our Christmas trip, deciding it might be too much stress for Xuxu. I've tried to post on my goggle doc account that I haven't used in a while and it won't let me in. Trying to figure that out. I have all his info in excel files which I could attach, or switch to pdf and attach if this site allows it. I have no idea when I'm going to be able to get all this stuff up in your usual system.
     
  16. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    The makers of Lantus specifically state it is not to be diluted. I wrote them and asked them that when I started using it in 2010. Also, they were uninterested in making either a pH-specific diluent or a lower concentration for children (animals).

    If dehydration is a concern, then perhaps regular subcutaneous fluids would work better, with the Lantus injected in a different location. We have had repots of wonky Lantus effects when given in the same location.

    It is possible Lantus is not the right insulin for him. And maybe a non-depot insulin such as ProZinc or BCCP PZI would let you more flexibly adjust the dose, as they can be used with a sliding scale approach.
     
  17. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Yes, all info on Lantus says not to dilute and this radiologist agreed with that in terms of not diluting and storing like is often done with R. As I mentioned, he is diabetic himself, and has used Lantus. He is now on a continuous monitor to control his own BG. What he suggested is diluting with sterile water which won't change the pH and less than a second later injecting. He said to draw up the water, don't shake the syringe and keep it tilted needle up, so In effect, the insulin is still in the head of the syringe and the water is the first out, no mixing. I know there will be discussion on whether this is correct protocol or not. And I'll be logging Xuxu's reaction religiously and letting you all know.

    All I can say is that in the two injections I've done that way, Xuxu's BG is staying between 240 and 400 for 18 hrs@ 2.5L, which is nothing short of miraculous for him. :RAHCAT He's eating on his own, staying hydrated and pretty much a happy cat. cat_pet_icon After 3 months of 20 to 750+, I was ready to try anything even against protocol. If he stays in that range for several days, I'll do a curve, and possibly move him up to 3U to see if we can lower it a bit more.

    I'm in research professionally, and what the radiologist suggest is what we call an elegant solution. It's a theory that is simple, and everything fits to explain the data. I desperately hope it holds true. We have Xuxu scheduled for a recheck next Friday. If his WBC is down again, then we can assume the Zithro is working on his liver and respiratory infections. The radiologist said if we can solve the infection, he saw nothing in the ultrasound that would indicate Xuxu couldn't go into remission. Please keep your fingers crossed for him. :YMPEACE:
     
  18. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    Sterile water should have a pH of 7, which is neutral (for any pH novices, <7 is acidic w/ more hydrogen ions, 7 is neutral w/ even number of hydrogen and hydroxide ions, >7 is basic w/ more hydroxide ions).

    I don't know what the pH of Lantus is, although I believe it is acidic based or reports here that large doses sting because they are acidic and the volume is large enough that it becomes noticeable to the cat.

    And when you mix 2 different pH solutions, it DOES change the resulting pH of the solution - it will wind up averaging out the concentration of hydrogen ions, just like mixing 2 different amounts of shades of pink would get you a shade in between the 2 starting shades, leaning towards the one with the higher concentration of pigment.

    But if it works, it works - empirical (observational data-based) results of success are how a lot of antibiotics are selected, for example.

    And my brain is enough of a sieve right now that I'll have to look up the normal pH of humans (sigh - took physiology last year and already lost the info from my brain!)
     
  19. Hi Deb,
    Thank you for all that amazing information! I will need to read it a couple more times to wrap my head around most of it. I'm not anything close to a scientist but I do totally understand your willingness to try anything "outside the box". My vet sent me home as her first "case" of attempting to shoot insulin (pzi) IM instead of sub-q, while administering a couple of sub-q fluid treatments a day for a recovering DKA cat (Bob), who was at death's doorstep when I brought him to her. After he went into remission, and I asked her "how did you know this would work?" she told me "I didn't. I just thought it was his only chance, and I thought you were determined enough to try it".
    I know two injections isn't conclusive, but those numbers sure are encouraging compared to what has been going on.

    My fingers will be crossed while waiting for your updates.
    Carl
     
  20. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    And found it - normal pH of the human body is 7.35 - 7.45, which is slightly basic.
    Probably similar to cats - I'll go search for that next.

    So X amount acidic + Y amount neutral + entire body slightly basic, even with differing concentrations of the 1st 2, would probably wind up still shifting towards the basic side because there's simply more of it. Lantus is supposed to make little precipitates when that happens (depot), so while there might be a small change in the speed of that, it would still occur.

    Hmmn. Maybe do a partial early curve with hourly tests over the 1st 4 hours to see how fast it kicks in.
     
  21. squeem3

    squeem3 Well-Known Member

    Joined:
    Dec 28, 2009
    The ph of Lantus is 4:

    Pharmacodynamics

    Insulin glargine is a human insulin analog that has been designed to have low aqueous solubility at neutral pH. At pH 4, as in the LANTUS injection solution, insulin glargine is completely soluble. After injection into the subcutaneous tissue, the acidic solution is neutralized, leading to formation of microprecipitates from which small amounts of insulin glargine are slowly released, resulting in a relatively constant concentration/time profile over 24 hours with no pronounced peak. This profile allows once-daily dosing as a basal insulin.
    http://products.sanofi.us/lantus/lantus.html
     
  22. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    Lantus pH of 4 vs water pH of 7 could result in faster precipitation with both in the same location.
    You wouldn't want the mix to sit in the syringe as it could precipitate in the syringe, possibly clogging the needle.
     
  23. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Hi All,
    Xuxu is doing much better. Here is his full record, the chart sheets at the bottom of the worksheet are various ways I've tried to graph it. I'll attach the fdmb file on the next message.
     

    Attached Files:

  24. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    Well darn. I can't download it to my phone because the file type is unsupported.

    Could you create a free account on Google Docs/Drive and upload/import the file there, publish/share it to the web, and share the link?
     
  25. Blue

    Blue Well-Known Member

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    Dec 28, 2009
    Discussion about diluting insulins should include some sort of disclaimer.... a "don't try this at home" one liner because we do not want others who may think it's OK to try on their own, then end up causing harm.

    Diluting R pretty much defeats the purpose of using it, and diluting Lantus is not recommended so why do it? If you are not having the results you like from Lantus, why would you not try Levemir before messing with the Lantus insulin?

    It may be an idea for this dilution discussion to be moved over to TT.
     
  26. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    If you want more help with Xuxu's numbers, it will be infinitely more helpful to use the format for a spreadsheet that we use here. I read a lot of spreadsheets and looking at the way you have the Excel document formatted will take far too much time to decipher. I have no idea what some of the columns mean. Here's the link to the spreadsheet template we use. Open anyone's spreadsheet and you'll see what it looks like.

    I've seen some cat's here have the kind of response to Lantus that Xuxu has had. One theory, if your cat in underweight, is that there is minimal adipose tissues (fat tissue) for the Lantus to bind to. Lantus binds to fat molecules and is slowly released from the subcutaneous depot. If your cat has no fat stores, there's nothing, or almost nothing, for the insulin to bind to. In addition, adding water to the Lantus is neutralizing it and/or causing it to form a precipitant prematurely. There is no way to predict the long term effect of using the insulin in a manner that's not pharmacologically sound.

    If your cat is underweight and you want to use a long-acting insulin, you may want to consider Levemir. Levemir binds to albumin. As long as your cat's albumin levels are normal, this may be an option. This is an article on the differences between Lantus and Lev.

    While I've not had experience with this directly, I know of one member who was giving intramuscular injections of Lev. She has an elderly cat who is/was quite thin (6 lbs). Between age-related changes in drug metabolism and lack of fat stores, her vet suggested IM injections. Ultimately, I believe she switched to PZI which doesn't rely on an insulin depot. Carl can tell you more about PZI. I've not used it and can't gauge whether this would be a better option for you.

    You may want to consider a shorter acting insulin like Humulin N. It's not necessarily considered to be the best insulin for cats but it may give you better control.

    However, I am not entirely convinced that this is an issue of insulin absorption or your cat's ability or inability to metabolize the insulin. For Lantus or Lev to be effective, dosing needs to be consistent. Your dosing is not consistent. The only cats that I'm aware of that are getting the kind of dose of R that you're giving Xuxu are cats with acromegaly and very few of those acro cats who's spreadsheets I'm familiar with get up to 3u of R. To my eyes, what you're seeing could easily be bounces. At the very least, this possibility needs to be ruled out.
     
  27. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Here is Xuxu FDMB file.

    I did an hourly chart (bottom of Xuxu insulin Dec.xls) I just realized I posted the first one in Mac, so will repost as pc.

    I thought of another way to dilute the Lantus, pull the Lantus into the syringe, then pull an air bubble, then pull in the sterile water. If done gently, the air bubble should keep the two liquids separate. Just keep the syringe tilted in the same direction so the bubble doesn't move. Or you can inject the lantus, leave the needle in skin, pull out the plunger, put in water, then inject with plunger.

    The hourly chart shows that the Lantus was working when I did it by the last technique above, and his low was between 6-7 hrs. Yesterday, I didn't do hourly, but just gently pulling the water in after Lantus worked. However, today, it didn't work, and when I drew it in, I saw a few bubble in the syringe. I think I pulled too hard and there was some mixing. I gave him a massage as the radiologist suggested and will retest him in 2 hrs. So I'm going to try the air bubble technique tonight. I think I just need to test him at 2 hrs to make sure it is going down.

    There has to be some mixing of body fluid with the Lantus once injected, I don't know what a cat's subq fluid pH is, but I'm assuming that the Lantus doesn't precipitate once injected.
     

    Attached Files:

  28. Blue

    Blue Well-Known Member

    Joined:
    Dec 28, 2009
    Your dosing on the Lantus is jumping all over the place, so it's no wonder you have BG numbers all over the place.
    I don't see where you have the R dosing marked on the ss. Even acro cats don't usually need that much R, so are you giving your watered down R or is it full strength? Do you use a sliding scale for the R, and what sort of protocol are you following with the dose determination for Lantus?
     
  29. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Your comment about the adipose tissue might be a part of the problem. He is very thin. But it doesn't seem to explain the whole problem. Yes, we've had a hard time going on a strict 12 hr schedule. Sometime, his BG is too low to chance giving him anything more, even the Lantus, sometimes it's been too high for too long and we had to do something or watch him go into a coma. Sometime our work schedule just doesn't allow us to get home in time. But I don't think that's the whole problem either. His is obviously a complicated case, and I'm hoping for a simple solution.

    Here is the fdmb template in pc format.

    My vet has more experience with PZI, but there was something about it not being available anymore. Every specialist we've talk to (count is up to 8) has insisted we keep him on the Lantus. I'm not familiar with the other Levemir, but I'll check what his albumin level is and ask my vet about it. We used the NPH at first, but it doesn't last long enough for hubby and I to go to work and leave him. I have used the R. I'm puzzled that someone said I shouldn't dilute the R, but from what I can tell, it's done all the time. My vet diluted it before giving me a small bottle, and I've seen references to diluting it to make it easier to draw up the right amount. Anyway, if the dilute R gets into his system, it does work in Xuxu's case.

    I can appreciate the comment about a disclaimer that one should not dilute the Lantus on their own. I'm talking with my vet, the radiologist, and listening in on calls to specialist. I didn't take the action of diluting it on my own. I did try the technique of drawing up the Lantus, then a large air bubble, then the sterile water. There was no mixing of fluid, the air bubble definitely kept the fluids apart. I'm going to try that for a couple of days and will let all know how it goes.

    Xuxu has finally resigned to eating the canned fancy feast on his own when confined to the bedroom. But if we let him out in the house, he immediately wanders around looking for the Iams. We take it up and the rest of the cats just have to wait to get their dinner until Xuxu goes back in the bedroom. It's tough on the others since I've always free fed. Xuxu seems to be staying hydrated well, and he's talking to us a lot, that's a sure sign that he's feeling better.

    It is funny, Xuxu seems to know when he needs his shot. He is generally under the bed, but at shot time he comes out on his own, meows to me and jumps up on the bed, in correct position to have his ears pricked. He sits there quietly until he has his shot (if he gets one then). Then he jumps down and eats something. Can he possibly be equating actually feeling his BG rise and getting stuck and petted making him feel better? Don't know, but he does it nearly every time he needs an injection.

    When I went to the pharmacy looking for ketone strips, I found a tube of glucose for diabetics. I had read that pure glucose was better than using the karl syrup (fructose). I used it the last time he went too low, and it worked great, both getting it into him and how fast it worked. It's not cheap, but it didn't take much.
     

    Attached Files:

  30. Compounded PZI seems to be getting harder to find. And Prozinc (rDNA) insulin experienced a severe shortage earlier this year. But from what I've read, and from the number of cats that have showed up here in the past couple of months prescribed Prozinc, I believe the shortage is over.

    I've read a lot of people note the same thing with their kitties, and I saw that with Bob too. It's like they realize that poking with a lancet or a syringe equates to feeling better soon afterwards. They also associate the pokes with getting fed or being given treats. Bob still comes running if I get the meter out, but I'm quite sure that has more to do with the expected treat than the need to "feel better". He only gets tested once a month or so nowadays.

    Carl
     
  31. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    Darn. Neither Microsoft format, .xlsx nor .xls, is supported on my phone. Try doing a File, Save As and save it as an ods file type, or as html, then maybe my phone can read it.

    I'm a bit concerned about injecting the air bubble under the skin; air isn't supposed to be there and I'm not sure what consequences might occur.
     
  32. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    R is a suspension. The insulin crystals are mixed with a clear liquid. The instructions with R indicate that if you are diluting it, you need to dilute it with a specific and suitable dilutant. Water is not the dilutant.

    Lantus is a solution. If you mix anything with it, you end up causing a change in the pH which causes the insulin to drop out of solution.

    BJ -- the files are in Excel and open on my computer. The issue may be that there are multiple tabs and you need the tab with the raw data and not the graphs. The one in the 2:22 PM post is still an Excel file but follows the template we use.
     
  33. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    I'm using my phone to read the board & do not have any Microsoft software on it, so it won't let me download the file to even open it. *sigh*
     
  34. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    Hi Deb,

    Somebody asked me to stop in and look at your numbers. I've studied a lot of Lantus spreadsheets (as has Sienne) so I wanted to see if I can help see what is going on with Xuxu.

    I always look at the spreadsheet first, before reading all the text in the threads. I do that because I want to see the numbers and patterns without being influenced by anyone else's opinions. I did read through this thread quickly though.

    First, a couple of questions... 1) when was the last time you gave R? On the spreadsheet it looks like 12/20 in the PM cycle, was that the last time? and 2) if you are diluting the Lantus, are you 1000000% sure you are giving the same dose each time? Others are right, it is not recommended to dilute Lantus and I honestly don't understand why you are doing that, I'm not recommending or condoning that, but for now I'm just trying to find out how consistent the Lantus dose is.

    What I see on the spreadsheet is actually not an atypical pattern at all. If your vet is more familiar with PZI, that might explain his/her confusion, but those of us who follow a lot of Lantus cats recognize these patterns right away.

    Sienne said:

    These counterregulatory hormones tend to stick around for a while, in some cats for a few hours and in some cats for 3-4 days. Then they will clear out on their own, resulting in the cat's numbers dropping quickly.

    Looking at this week as one example (I'm assuming no R use, since it isn't notated on the spreadsheet):

    12/22:
    PM+5 ~ 48. Body thought "oh no, that's too low!" released those counterregulatory hormones.
    +12 ~ 581 <<<<< BOUNCE

    12/23
    AMPS ~ 581
    +2 ~ 371 <<<< bounce is already starting to clear. Normally +2 is about the same as preshot, so the fact that it is lower indicates that the counterregulatory hormones are already starting to clear.
    +9 ~ 382 <<<< about the same as +2

    +12/PMPS ~ 200 (no shot) <<<<< wow that's a big drop at the end of the cycle, the bounce is clearing FAST now, lots of downward momentum, watch out for even lower numbers.
    +8 ~ 157 <<<<< no data to know if or how much he kept dropping after the 200. My "crystal ball" thinks there were some low numbers, based on the fact that he had a lot of momentum at the 200, and based on the fact that what comes next looks like it could be a big bounce.

    12/24 (the cycle repeats)
    AMPS (+11) ~ 720 <<<<<< this is a probably a combination of two factors: 1) possibly a bounce off of the fast drop and possible low numbers last night, and 2) skipping the shot last night emptied his insulin depot somewhat and left his AMPS higher than usual.
    +2 ~ 609 <<<< hmmmm, already dropped over 100 points at a time in the cycle when the insulin usually isn't showing action yet. Watch for numbers to keep dropping rapidly.
    +5 ~ 283 <<<<< he has been dropping over 100 points per hour (without R, correct?). This fast a drop can create a bounce all on its own, but again we have the fast momentum as he continues to drop.
    +9 ~ he does bump upward a little at the end of the cycle, so momentum might be slowing down.

    PMPS ~ 323 (did you give insulin at +9, or do you just mean that the number is the same as it was at +9?).
    +1 ~ 192 <<<< holy kittens! A 100+ point drop at +1 is a lot, I'm REALLY glad you got a +2.
    +2 ~ 39 <<<<<< yep, the bounce is gone, this is too low.

    Then he bounced high again this morning. Looking back at your spreadsheet, I see a lot of cycles where you caught a very low green number, then he was very high again by the next preshot. It seems logical that some or many of those cycles where you didn't check in the middle of the cycle, but just saw two very high preshot readings, could be the same. It only takes him a couple of hours to get from 50s to 500s so it's easy to see where you could be missing the low numbers.

    Based on your data, assuming that you have not used R since 12/20 and assuming that your insulin dose is consistent, I would say that your Lantus dose of 2.50u is too high. You want to consider how low the dose is taking him, ignoring the highs because they are just bounces and will clear out on their own. I see that you reduced to 2u today and I think that is a very good idea. I would also ask that you consider NOT using R next time he goes high, to see what happens. As you can see, it sure looks like he is able to bring those highs down quickly on his own, without R. Adding a large dose of R to the mix can make him drop even faster, setting him up for even more bouncing. R is useful when ketones are developing, but it can also compound the problem if it is used when it's not really needed. 2u of R is also a pretty big dose for a cat that isn't hospitalized.

    I hope this helps.
     
  35. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    Here is your spreadsheet in Open Document Format (.ods)



    When I get on a wifi connection, I'll see if my phone will let me download it now!

    And my phone won't. *grump*
     

    Attached Files:

  36. BJ
    There are a couple of free android apps like Documents to Go, and Kingsoft Office, that will let you view MS Office 2010 formats like xlsx or docx...

    Carl
     
  37. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Lucy,
    Thanks for the evaulation of Xuxu's BG Curve. Your description of how he is bouncing was really helpful. You are right, I hadn't given him the R since 12/20. I've only been using it when he's been Hi for several days and was showing signs of DKA. I have stayed with the 2.0 but am thinking that 2.25 is really the better number, but I'll have to change needles to be sure of an accurate draw up if we do that. I was going to do a daily curve on New Year's day to see how it's going.

    On the topic of diluting Lantus. I was using sterile water at first, but that apparently stings. So we switched to sodium chloride solution (medical grade in a drip bag). That doesn't appear to sting. I've settled on a method of injecting the insulin, leaving the needle in the skin and pulling out the plunger. Then shoot some of the sodium chloride solution in the syringe, and put the plunger back in. I was hoping that allowed a few seconds for the insulin to mix with body fluids before the extra solution hits would avoid any problem with the pH of the Lantus. Also, the sodium chloride is pH 4.4, much closer to the 4.0 pH of the Lantus. I've been doing nadirs occasionally, and it appears to be working. I haven't seen any incidents where his BG just sat at HI for hours. It does appear to be dropping, although not as low as I'd like to see. But he's definitely feeling better, other than when it does go HI.

    Someone commented that by diluting the Lantus, I didn't know how much I was putting in. I just want to make clear, the insulin is measured out first, and only diluted with each shot. We aren't talking about diluting the bottle of Lantus. I know exactly how much insulin I'm giving him.

    My sister-in-law is a a diabetic nurse specialist. I asked her about diluting the Lantus. She said that the company had done such a hard campaign on not diluting it primarily because people on a budget are always trying to make expensive medication go farther by diluting or cutting it. Can you imagine the cost of a human on 10U of Lantus a day! She suspected that making the pH so specific was part of the plan in making it ineffective if diluted. She said that may be a cynical attitude, but she's seen a lot of hijinks with pharma companies in her career. She thought my method described above was workable. Unfortunately, she isn't willing to give advice on diabetic cats, just human.

    He's been talking a lot more when he's feeling good and moving around, mostly when he wants out of the bedroom. It's a rapid talkitive chatter. But the other night, I heard him crying to me about 4 am. It was just a one note pleading cry. He didn't look well, so I did a test, and sure enough he was HI. It was 90 minutes early for his shot and I didn't know quite what to do. I waited, but I'm not sure that was the best plan. I felt like I was depriving him of feeling better, but I really need to keep him on a 5:30 shot schedule to allow for when I have to depart and get back from work. Could I have given him a small shot, say .5, to start his BG coming down? and then reduced his regular dosage on the schedule? or would that have screwed everything up?
    Deb and Xuxu
     
  38. If you're talking about doing that with Lantus, then no, you don't want to do that. If you shoot just a small dose, and then another dose a couple hours later to make up the difference, then you end up with two cycles running "out of phase" with each other. It would most likely mess up the onset time, and the nadir timing. You might have the first dose peaking right when the next dose is starting to onset.... best off waiting like you did.

    Carl
     
  39. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Thanks Carl,
    So for another question. Sometimes Xuxu has been between 100 and 200 when it's time for the next shot. I don't know whether to give it to him on schedule or not. I guess I got too freaked out by the crashes. I know that's in the normal range, what we've been shooting for, but it seems like it would be so easy to slip on down to a low reading before it starts back up. I haven't seen any mention of this quandry in the protocols.

    Deb and Xuxu (Zoozoo)
     
  40. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    At this point, I'm wondering if TID (every 8 hours) dosing might give you better coverage.
     
  41. BJM

    BJM Well-Known Member

    Joined:
    Oct 6, 2010
    They call that split dosing and it is vehemently discouraged. There is someone on the board who found a way to do it because of her work schedule.
     
  42. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    if you want to come over to the Lantus board and introduce yourself, then next time that happens someone can walk you through the decision. Try to get your Google spreadsheet together in the meantime because that will really help.

    If you're on a good dose, then we routinely shoot over 150 and most of us will learn to shoot lower than that, once we have the data to do so. If you think about it, Lantus usually takes 2-3 hours to start working so you can give insulin at slightly lower numbers than some of the insulins that are faster acting. This is where your data can really help you, because you will be able to see whether Xuxu usually still keeps rising after +12, how many hours it takes for the Lantus to kick in, how much of a spike in numbers he gets from his normal meals, etc. We can help you learn to interpret that data.

    Here is the link to the Lantus forum: http://www.felinediabetes.com/FDMB/viewforum.php?f=9

    Take a look through the stickies on that forum too. Lots of good information there.
     
  43. d0zivyhoo

    d0zivyhoo Member

    Joined:
    Nov 21, 2012
    Just wanted to chime in here to remind all of you wonderful experts that an AlphaTrak2 is being used here. So, please do keep that in mind on the BG numbers, since they will be higher than the human meters by default.

    Otherwise, I'm am just amazed at the responses and effort some of you are providing here!

    DZ and Sarah
     
  44. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Thanks Carl, That explanation was really helpful.
    Yes, I will move over to the Lantus board. Thank you to everyone that has looked at Xuxu's case and given such helpful and supportive responses.

    I'm not sure I'll be able to get things up on Goggle. It refuses to send me my password, but won't let me open a new account on my email. I'm guessing it's going to take a while to clear it up. I'll continue to post the 12 hr FDMB excel every once in a while.

    Deb and Xuxu
     
  45. Thanks Deb, but give credit to Libby for that great explanation, and the invite to the Lantus forum. ;-)

    Thank you very much for pointing that out, DZ. I'd forgotten that detail.

    Deb -
    You should go into your "control panel", click on the "profile" tab.... then click on the left on "edit signature". You'll see a big blank box that you can put any info you would like to in. To DZ's point, it would be a great idea if in your signature you put a comment like "Using AlphaTrak meter". That way, when people look at your data, they'll keep in mind that the meter makes a difference when they give you any advice.

    Carl
     
  46. DebH

    DebH Member

    Joined:
    Dec 1, 2012
    Yeah :RAHCAT I just got my Goggle account fixed and a signature set up. Now I'm trying to figure out how to get his spreadsheet posted through a link instead of an upload.
     
  47. On googledocs, when you click on "file" and "publish to the web", you should see a box containing the hyperlink to your spreadsheet. That's what you copy/paste into your signature box. Oh, make sure the box that says "republish when updated" or something like that is "checked" too.

    Carl
     
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