You may be seeing some New Dose Wonkiness, too, with the dose increase. In any case, with Keiko at this point, I'd be following the Tilly's Diabetes Page version that has the option of increasing every 2-3 days. The Tilly page is based upon the same Rand/Roomp Tight Regulation Protocol that we follow on FDMB, but it has a few variations that can be helpful for some cats here. On the FDMB guidelines, we suggest every 3 days or 6 cycles. I'd probably opt for the 2 days/4 cycles until he gets into some better numbers.
To convert your AT tests to the human glucometer numbers below, multiply your AT test by 0.75u - it gets you somewhere close to the right number.
http://www.tillydiabetes.net/en_6_protocol2.htm
Phase 2: Increasing the dose
Most cats need to have their dose increased. Do it in 0.25 IU or 0.5 IU steps (0.25 IU if the cat is getting a low dose and/or relatively low BGs, 0.5 IU if the cat is getting a higher dose and/or relatively high BGs). Hold each dose for 5-7 days. However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU. Alternatively, if the cat is continuously producing moderately elevated BGs (nadir always >=200 mg/dl), increase the dose every 2-3 days by 0.25 IU ( if the cat is getting a low dose) or 0.5 IU (if the cat is getting a higher dose). From this point onward test for ketones once per week, or more often if the nadirs are still >=200 mg/dl.
Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations.
Have you ever looked at Toby's ss? You can learn a lot from reading other condos, and Toby is another high dose cat that's undiagnosed as to the cause of the high dose need. He began having his dose increased every 4 cycles or so in September - it might be helpful for you to look at the progression after that point.
I went back and read your last couple of posts, just to double-check on what's already been said. I'd second what Wendy said on 11/20:
Your vet is not there when you fill the syringe - you get to make those changes when you think it's time. Keiko is now on a higher dose of insulin, greater than 6 units. When that times comes, it's likely that there is an underlying high dose condition. You might want to get Keiko tested for them. Neko has two high dose conditions, IAA and acromegaly. The chances that your vet has experience with either of those is highly unlikely. With both those conditions, there is a type of insulin resistance. In order to beat the resistance, it's important to keep increasing as per the protocol so Keiko can get out of those high numbers. There is probably a lot more high dose experience on this forum than your vet has. Other high dose kitties whose SS you can look at are Cobb/Suzanne, Polly/Marilyn, Toby/Peg, Punkin/Julie. There are others, but those are the most active posters around now. I saw some reference to research that says acromegaly is the cause of 25% of hard to regulate cats. Vets used to be taught that it is vary rare.
On how to approach the vet, just tell her that you think there's a possibility of a high dose condition. The current method of waiting 5 days isn't changing Keiko's numbers much. The protocol you gave her allows changes every three days, and you are going to try that to see if it can make a difference. My vet didn't think Neko had a high dose condition but humored me by ordering the tests. She was more surprised than I was by the results. She sees how much I test, she trusts me to do the right thing.
Your vet's advice is right on for MOST kitties. Typically, with a depot insulin you want to make sure you're allowing enough time in between dose increases so that you can see what the dose is really going to do. It also works for people who aren't hometesting. Some people want the vet to do a curve every week or so, and then they adjust the dose based upon that. But you're testing at home and you can see exactly what's happening with each dose.
The concern about waiting too long is that when you've got a cat with a dose that's not even getting them below renal threshold, the cat's body is being constantly subjected to glucose floating about in the body. It is especially hard on the kidneys. Here is some information on
Glucose Toxicity.
With a high dose kitty you have to be more aggressive with the dose. We know Keiko's got something going on because otherwise he'd be on a dose that is something less than 3 or so units. We don't know how much insulin would be optimum for Keiko, but he clearly needs more than the average cat. Remember your vet works for you!!! Keiko's health is the first priority.
I'm not trying to pressure you. You hold the syringe. But I do want to empower you and give you some confidence in what you are doing! Your vet is no doubt not experienced with high dose cats. Most vets aren't - I'd guess most never see even one cat with iaa, acromegaly or cushing's unless they are at a university veterinary school. But we know that as long as a person is hometesting and methodically increasing the dose by small increments (0.25-0.5u), allowing at least 4 cycles on each dose, you can be confident that you aren't going to overshoot the "right" dose for the cat. That's the beauty of the protocol - it lays out a path for you to follow. With high dose kitties we don't follow it exactly, but it's a great roadmap to begin with.
I hope that helps you a little bit to feel more confident about the dose you're giving Keiko. It's hard having a diabetic cat - it's even harder for those of us with high dose kitties that don't respond like they are "supposed" to. Been there, done that - and that's why I stay around even though Punkin is gone. I know how hard it is. The good news is that you aren't alone, Maria. There are many of us who have been in your shoes and are happy to help you and Keiko navigate ahead. :YMHUG:
Have a wonderful Thanksgiving! Enjoy some cuddles with your sweet boy!
