6/2 Max RESULTS OF CURVE Wrong Insulin?

Hello, All,

Please see the spreadsheet. Well, it's not a valley -- more like a ravine, but it's not a checkmark. The nadir is between +6.5 and +7.0. If a checkmark means he's bouncing, this isn't it. Does this mean Max is on the wrong insulin? Even he had had higher dose would he just drop 100 points across the board giving him a nadir of 73, but being at 350 at amps and pmps and above the renal threshold for at least 6 hours a day? That's no good.

UPDATE: Early in the morning on 6/3 at +7 he's at 458!!!

Do we need another curve on to help 6/3 to answer these questions? Do we need more than 2 curves, or do they need to be at particular times?

It tried to attach the graph of the curve here:

Any comments from anyone will be appreciated. Thanks.

So, here's a strange thing: At +7 early this morning his reading was 458 and at +10 it was 379. I guess he did bounce. I'm just at my wit's end.

I think I see something - it seems as though every time he is severely constipated, he doesn't eat as much, and he drops very low. Otherwise, when he is eating normally, he's too high. Do you see that? Does anyone else?

Because the constipation appears to be an intermittent issue, you may do better with PZI or ProZinc, where you can dose what you see, rather than having to wait 3 days and check nadirs. If he isn't eating, you can drop the dose; when he is eating well, you can increase it to cover it. I think it may work better to go with this option rather than continuing with Lantus, which works well when a cat is consistently eating and stable, healthwise.

The other note I have, is shot time consistency. I see that shot times are an issue for you. Lantus is a bit of a pain, because it works best with an exact 12 hour shooting schedules and adjusting times by no more than 30 minutes TOTAL in 1 day. You've been adjusting times by more than 30 minutes in 1 day, and almost every day for some periods. This is going to impair how Lantus works. Its like runing up the down escalator, stopping, running up some more, stepping down on purpose, and running up some more again, instead of climbing to where you want to be, then trudging steadily to stay there. Lantus works best when you do the latter.

Dale: Good for you getting all those tests in yesterday!!! I know it wasn't easy for you, with your one-year-old, etc. :thumbup

This is the part I hate: don't forget that the meters have an accuracy rate of +/- 20% for each reading. The 173 at +6 could really have been a 207. So you don't have to sweat such minor differences in numbers.

And his numbers yesterday could have still been influenced by the high 526 he had on 5/30 as bounces can take 72 hours to clear.

Looking forward to hearing what suggestions people have for you for getting Max regulated and making your life easier! BJM is great at analyzing data, looking at the big picture, and offering suggestions!

Make sure everyone knows about the CRF as well. People may not look all the way at the top of the SS and see that.

Suze

BJM,

Thank you! I hate to admit that I might have to switch insulins just because I can't do this right. That is very hard for me, but if it will help Max. I keep trying and trying to do this right, and I guess I'll give it one more shot because Lantus is supposed to be better for cats. I probably really needed someone to just point that out to me and say, nicely, "You can't do it this way -- accept that and move on." I am going to try one more time to get his shots on time, and look into PZI while I'm doing that.

You are picking up on something about his constipation that is important. It's difficult to get the subcutaneous fluids into him often enough, but if he's dehydrated, I can't hope that the insulin is getting where it needs to go. I'm redoubling my efforts on this front, too.

As far as getting the shots on time, there is this issue:

What jumped out at me about the curve is that at +11.5 he was at 455 which is soooo close to his AMPS. I expected him to go higher by PMPS, and he didn't -- PMPS was 456. I shot at that point exactly 12 hours after the morning shot with the assumption that he would not go higher anyway. Then, take a look at what happened during the early morning hours: I tried to get a test at 12 hours after the daytime nadir. I missed by about 15 to 30 minutes -- and the test was crazy high -- 458! I don't think it was a faulty test because 45 minutes later he was at 379 -- dropping after what should have been nadir. Then, 1/2 hour before shot time, he's at 299. So, I waited to see what would happen next, and one hour later he's at 301. I decided not to wait any longer, and I gave him the shot. So, it's possible that he held the 456 last night 1 full hour (or more) into the next cycle, too. Maybe I'm overdosing him all the time because the nadir is 1/2 to 1 hour late, and the next shot time is too early? I'll keep testing to see if this happens again and again.

As for the shed, I see an issue with it. It seems that when I miss a dose or I give a shot way too late, a few days later we have a good day, even some days too low to shoot. It's almost as if letting shed empty some is resulting in some lower numbers. Could this bolster the idea that I'm overdosing him? Only running curve after curve will tell me, but it is curious. I don't think I've ever had a number too low to shoot without having messed up on the timing of the dose a few days earlier. This would play into the possibility that the nadir is late and there is overlap which means I have two shots working at the same time until the first shot wears off. Too early to tell.

max&emmasmommie said:

...You are picking up on something about his constipation that is important. It's difficult to get the subcutaneous fluids into him often enough, but if he's dehydrated, I can't hope that the insulin is getting where it needs to go. I'm redoubling my efforts on this front, too.

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Ask the vet if you can give subQ everyday. Or better yet just give him 100cc once a day as part of the routine. I don't see how you can give a dehydrated uncontrolled diabetic too much fluids. And up the miralax if he keeps getting constipated. Up to a tsp in each can of food and add as much water to it as you can get away with. Reduce the miralax if it gets too soft. But too soft is better than another enema. Don't give more fluids if it's pooling around his legs or belly or he has trouble peeing.

Don't give Hills MD to a constipated or diabetic cat. It has corn starch and sawdust (cellulose) which turns into cement. To help with the constipation a grain and veggie free diet can help with intolerance and ibd as well as being good for CKD and diabetes. In other words a meat diet. The Wellness probably has too much veggie filler for ibd. Try Merricks BG canned food. The BG 95% beef and BG 95% turkey work for low carb and CKD. BG 95% Turkey is good for all three including ibd. The turkey ls a better choice if Max will eat it. I believe the BG chicken has too much phosphorous for CKD.

It's most important that he keeps eating. But if you can fix these things while he is still healthy and eating the prognosis can be quite good.

MammaDale, Max is very lucky you are so determined to figure this all out, but if you can it's sure worth it. I agree the ProZinc might be more flexible for the circumstances if you can't make more progress with Lantus.

Hmm, well, that's too bad because he likes Wellness. Maybe he'll like Merrick, too. Corn Starch and Sawdust in cat food?! Good grief!

I'm not sure about the fluids everyday. I read that you have to be careful not to give too much because it will make the kidneys work too hard. Have you seen that concern? I also read something about hypertension and sodium/potassium levels being affected by giving too much especially when the cat has CRF. There was some limit -- maybe it was 100cc per day.

Thank you for your help!

max&emmasmommie said:

... I hate to admit that I might have to switch insulins just because I can't do this right. That is very hard for me, but if it will help Max. I keep trying and trying to do this right, and I guess I'll give it one more shot because Lantus is supposed to be better for cats. I probably really needed someone to just point that out to me and say, nicely, "You can't do it this way -- accept that and move on." I am going to try one more time to get his shots on time, and look into PZI while I'm doing that.

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You have to find what works for you and Max - although we have standard protocols, we also say Each Cat Is Different (ECID). This means sometimes you find a solution which differs from some protocols.

max&emmasmommie said:

... You are picking up on something about his constipation that is important. It's difficult to get the subcutaneous fluids into him often enough, but if he's dehydrated, I can't hope that the insulin is getting where it needs to go. I'm redoubling my efforts on this front, too.

Click to expand...

That variability may be an element in the irregular glucose levels you've observed too; it may affect absorption and distribution. Lantus really, really likes consistency. I never had that with Spitzer due to issues with inflammatory bowel disease and pancreatitis - appetite up -> glucose up; vomiting or appetite down -> glucose down.

Something you might try to help with hydration is using distilled water. Put it down for drinking and also mix some into the food. Why? Because the kidneys need a certain ratio of the stuff to be excreted (solute) to water. Water with minerals already in it, can't carry out as much of the solute to be excreted (urea, some excess minerals, etc).

max&emmasmommie said:

...As far as getting the shots on time, there is this issue:

What jumped out at me about the curve is that at +11.5 he was at 455 which is soooo close to his AMPS. I expected him to go higher by PMPS, and he didn't -- PMPS was 456. I shot at that point exactly 12 hours after the morning shot with the assumption that he would not go higher anyway. Then, take a look at what happened during the early morning hours: I tried to get a test at 12 hours after the daytime nadir. I missed by about 15 to 30 minutes -- and the test was crazy high -- 458! I don't think it was a faulty test because 45 minutes later he was at 379 -- dropping after what should have been nadir. Then, 1/2 hour before shot time, he's at 299. So, I waited to see what would happen next, and one hour later he's at 301. I decided not to wait any longer, and I gave him the shot. So, it's possible that he held the 456 last night 1 full hour (or more) into the next cycle, too. Maybe I'm overdosing him all the time because the nadir is 1/2 to 1 hour late, and the next shot time is too early? I'll keep testing to see if this happens again and again.

As for the shed, I see an issue with it. It seems that when I miss a dose or I give a shot way too late, a few days later we have a good day, even some days too low to shoot. It's almost as if letting shed empty some is resulting in some lower numbers. Could this bolster the idea that I'm overdosing him? Only running curve after curve will tell me, but it is curious. I don't think I've ever had a number too low to shoot without having messed up on the timing of the dose a few days earlier. This would play into the possibility that the nadir is late and there is overlap which means I have two shots working at the same time until the first shot wears off. Too early to tell.

Click to expand...

What I though I saw was that those lows happened when he wasn't eating well due to the constipation. Less food in with same amount of insulin resulting in a low. Then he feels better, eats and zoom, up he goes.

Remember that the shed is somewhat like a rolling average - the effect of the sum of roughly 6 insulin shots divided by the number of hours, which should be 72. Shoot late and the rolling 3 day average drops a bit because more hours are being covered. Shoot early and the rolling 3 day average rises a bit because you have fewer hours being covered. (Sorry - math person here!)

Another way to visualize it is this sewing analogy - if you were gathering fabric in sewing, its like you are pulling it together on the thread in clumps, rather than smooth, even gathers. The result will have funky clumps of gathers with other sections that are barely wavey.

Maybe take a 2nd line for each day and note when you give fluids and when you feed. This may help clarify the relationship between fluids, eating, and glucose levels.

max&emmasmommie said:

Hmm, well, that's too bad because he likes Wellness. Maybe he'll like Merrick, too. Corn Starch and Sawdust in cat food?! Good grief!

I'm not sure about the fluids everyday. I read that you have to be careful not to give too much because it will make the kidneys work too hard. Have you seen that concern? I also read something about hypertension and sodium/potassium levels being affected by giving too much especially when the cat has CRF. There was some limit -- maybe it was 100cc per day.

Click to expand...

Are those lactated ringers? If so that is balanced electrolytes and not usually a problem as long as they aren't retaining fluids. With hypertension and heart disease you break it into smaller doses more often like 50cc twice a day instead of 100cc once. 100 cc is not much for a cat that size.

ALL ABOUT SUBCUTANEOUS FLUIDS (SUB-Qs)

But ask the vet just to be sure.

Every cc of filtered or distilled water (no minerals) you can add to the food is less needed from subQ. You never want him dehydrated. Miralax, CKD and uncontrolled diabetes can burn through a lot of water. Constipation can become a dire emergency so you want to stay ahead of it.

And I've seen the *concrete* produced from Hills products with cellulose (sawdust) added. Hard as a rock.

First and foremost you want him to keep eating so keep him on wellness (and add more miralax and water) if he doesn't like Merrricks but get a couple of cans at petco and try it.