Dose check

Wally & Stefano

Wally & Stefano

Active Member
Hello,

Wally is a male Russian Blue 8 years old, 4.5kg. His diabete was diagnosed at the end of November when he was hospitalized for about 10 days when he lost a lot of weight from 5.7kg to 4.1kg and stopped eating.

Since then he's back home very hungry, thirsty...and pees quite alot.

We switched almost immediately low carb diet a couple of weeks ago (about 3,5% of carb calories from carbs right now).

He's on Caninsulin 5unit twice a day....seems doesn't make any big effect on him.

See his Christmas curve here:

https://imgur.com/a/7uxFn1B

Any suggestion will be very much appreciated,

We attached our spreadsheet to the signature.....

Wish you all a nice Christmas

https://docs.google.com/spreadsheet...W12A3CvJQeksTzJ55KN_ABknUHg79L_xIJG1R/pubhtml
 
Hi and welcome to FDMB. Sounds like you and Wally have been through a lot over the past few weeks. Was the reason for the hospitalization DKA?
I don't see a signature so can't see your spreadsheet (if you need help setting up the signature just let us know) but looking at the curve done today I presume and you mentioning changing his diet to 3.5% carbs in the last couple of weeks, I'm inclined to think that the dose of insulin is too high. 5 units is a very high dose of insulin for most cats but may have been needed while Wally was in hospital. What was Wally's diet before you changed it?
Most cats, when changed to a low carb diet, require less insulin than when they were eating higher carb foods.
 
Hello MrWorfMen's Mom,

I confirm that he was hospitalized for DKA. When we brought him back to home we were adviced not to give insulin because his levels were back to normal (aroud 90mg/L).... Few days later his glucose levels started to increase so we followed again Vet advice and started using insulin 1Unit twice a day. Since then we increased 1 unit every week..... but without any good result.

Answering your question he was half on dry food and half on humid before... now he's 50% on Purina DM and the remaining 50% on chicken breast from Almo (that is supposed to be 0% carbs).

I hope you can see my signature now!
 
Is the Purina DM the wet food and if so is it the original or the Savory Selects variety? The original is about 9% carbs and the Savory Selects are about 3%. I am not familiar with the Almo cat food but notice there are several varieties of that too.

I can see your spreadsheet now and notice Wally was getting better numbers with no insulin and 1u back in November...almost normal numbers at times. Later his numbers look better on 4u than he is now although still too high. He appears to be bouncing a lot which is a normal phenomenon that occurs when the Blood sugar drops quickly, drops a lot, or drops to levels the cat has become unaccustomed to due to the diabetes. Bouncing is frustrating and complicates dosing decisions to some degree. The other suggestion I would have is to get some syringes with half unit markings so you can adjust doses more finely. Our kitties are small animals and a little adjustment can make a big difference.

Are you testing Wally for ketones? If not I strongly recommend you do so. You should be able to get Ketostix or similar at a local pharmacy that you can use to test Wally's urine. Some folks can stick a designated spoon under kitty's butt to do this while others put plastic food wrap into the litter box to catch a few drops of urine.

I'm still inclined to think the dose may be too high and would try backing him off to 4u after making sure there are no ketones in his urine and keep him there for a couple of days to see what he does. Vetsulin usually starts acting quickly so testing at +2 or +3 after his shot will tell you if he is dropping a lot and if so, you can feed him again to slow him down a bit. It's really important to see how low the insulin is pushing the BG so if you can get a mid cycle test during the day and at least a test before bed at night it will help. The more data you have the easier it becomes to see patterns and make educated guesses as to dosing.

I am very curious as to those low/normal readings at the beginning of your spreadsheet. When exactly was Wally in the hospital?
 
Hello MrWorfMen's Mom,

for what I see Purina has sligthly different names in Europe. I am feeding him with this https://www.arcaplanet.it/85x12-g-p...MIyY__z_q83wIVQeh3Ch1zrAtGEAQYAiABEgJ5r_D_BwE

I did my maths on the analytical components and carbs calories should be 5,5% of total calories based on these values

Umidity 77%
Protein 13%
Fat & Fibers 5,5%
Ash 3,2%
Carbs 1,3%

On the other hand Almo in steamed chicken breast that from the label is HFC chicken breasts with no carbs
https://www.zooplus.it/shop/gatti/c...MI1YiH_fu83wIVDud3Ch34FwVWEAQYASABEgLHTvD_BwE

Umidity 77%
Protein 20%
Fat 1%
Ash & Fibers 2,1%
Carbs 0%

I'm mixing them 50/50 because Almo is not complete, while DM it is but still high in carbs values.
I'm waiting for a new shipping of GranataPet Chicken which is complete and 1,6% low in total carbs calories.

We tested for ketones 2 weeks ago and it was Zero!

Last week we did some more blood-testing and the only value that is outside ranges are Fructosamines 535umol/l (normal range 190-365).

Today we are going to monitor +1, +2, +3 to see if nadir goes below 400.

If you see the chart we did a curve yesterday measuring every 2 hours and seemed quite regular movement, but still very high range.

From your experience will bouncing occur even if nadir is on high values? Our last measurement has shown nadir 400 at +6

Wally was on hospital from 14th nov to 24th nov. During that time he has treated with Humulin (dosing from 0,2 to 0,5) Seems like this can't be used at home... (he had ketones 7,9 on 14/11.... but disappeared on 24/11)
 
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I've seen the product spec sheets for Purina Pro Plan DM at my vet's office. Here in Canada, the pate is very close to 6% carbs as fed and the Savory Selects chunks is 10%. The dry version is higher but I'm not sure of the number. It might be different where you are, Stefano.

Stefano said:
Last week we did some more blood-testing and the only value that is outside ranges are Fructosamines 535umol/l (normal range 190-365).
Click to expand...
This test will give a high result even if the high BG range is from bouncing versus inadequate control by the insulin.

Stefano said:
From your experience will bouncing occur even if nadir is on high values? Our last measurement has shown nadir 400 at +6
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Sometimes a cat will bounce up into very high numbers because of chronic overdosing with insulin. They can maintain that high flat pattern for weeks until finally their liver and associated processes can't cope and they crash. It's hard to know whether this is the case with Wally. I find the early pattern of no dose and blues and greens odd. It's possible that the rapid dose increases have caused the high flat numbers the last month.
 
Hello, do you think that 1umit increase per week was too much?

Do you notice any sign on the spreadsheet that tells you that the dose we are giving is too high?
 
Stefano said:
Hello, do you think that 1umit increase per week was too much?

Do you notice any sign on the spreadsheet that tells you that the dose we are giving is too high?
Click to expand...
Yes, that's too large an increase for the way we do things here. We recommend increases of only 0.25 u at a time when the total dose is low (generally below 4 or 5 units). Once the dose is higher we might recommend increases of 0.5 u until there's a good response. That's why we use syringes with half unit marks. Those quarter unit fractions can be "eyeballed" using the half unit marks.

Stefano said:
Do you notice any sign on the spreadsheet that tells you that the dose we are giving is too high?
Click to expand...
I really can't say with certainty but starting off in green, blue and no insulin suggests that his good dose range is lower than what he's getting. As an example, if a cat seems to do well on a lower dose, say 1 u, but needs a bit more our recommended increases would be to 1.25 u, then 1.5 u, then 1.75 u, etc. It's far too easy to jump far past a good dose when increasing by 1 unit at a time. Even 0.5 u is often too much. Cats are small and are very sensitive to small changes in dose.
 
I will discuss about this point of view with my vet.

In case we would follow the idea to decrease which approch would you follow to find che correct dose starting at this point?
 
Stefano said:
I will discuss about this point of view with my vet.

In case we would follow the idea to decrease which approch would you follow to find che correct dose starting at this point?
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Vets can have a different perspective on insulin dosing. See what your vet says. Usually a cat is started on 1 unit of insulin every 12 hours. A vet often wants a full BG curve done 7 to 10 days after starting at that dose. Based on the curve results the vet might want the dose to be adjusted. Often these adjustment are in larger fractions than we would recommend. We also recommend testing at key times every day including before each shot and at least once in the +4 to +6 range. If you wait to do a curve and it happens on a day when the cat is high and flat from bouncing that can lead to an unnecessary dose increase.
 
thank you Kris.... so in your opinion we don't have any way to understand if the posted curve is high from bouncing.... do you think that reducing half a unit and then monitor the curve after a week could be useful?

Could also the chart be a sign of insulin resistence?
 
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Linda in her post #4 above also said she thought the dose might be too high. She suggested dropping the dose back to 4 u for a couple of days to see what happens. She also stressed the importance of getting BG tests in the middle of the cycle to see how low the dose takes the BG. I think that's worth trying.

Stefano said:
we don't have any way to understand if the posted curve is high from bouncing
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It can be hard to know this. That's why we recommend a reasonable starting dose and using very small increases with each held for a couple of days. It's less likely that the good dose will be passed over.

Stefano said:
do you think that reducing half a unit and then monitor the curve after a week could be useful?
Click to expand...
I don't think a half unit would be enough. Try a full unit at least. It's also better to get test data daily instead of doing a weekly curve. Here's the basic testing routine we recommend:
  1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
  2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
  3. do extra tests on days off to fill in the response picture
  4. if indicated by consistently high numbers on your spreadsheet, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose.
Stefano said:
Could also the chart be a sign of insulin resistence?
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Insulin resistance can happen for a number of reasons. They can include: a disease like acromegaly, ongoing infection or inflammation (eg. dental disease, urinary tract infection), development of anti insulin antbodies, chronic rebound state from overly high insulin dose. Regardless, anything that puts BG into high numbers for a long period of time can create insulin resistance because the body cells lose their responsiveness to insulin.
 
This morning he was again on "HI" of my meter.... I dropped to 4 UI.

I will also monitor +2 and +6...and keep him a couple of days at these levels ...then we'll see what else to do.
 
I know it's soon to be happy but our PMPS registered the lowest value since 1 week.

I spoke with my vet about the choice to lower to 4U... he said that we should switch to Lantus and start over from 1UI....

I'm very scared to make it wrong again...
 
Stefano said:
I know it's soon to be happy but our PMPS registered the lowest value since 1 week.

I spoke with my vet about the choice to lower to 4U... he said that we should switch to Lantus and start over from 1UI....

I'm very scared to make it wrong again...
Click to expand...
Lantus is a very good insulin for cats. The usual starting dose is 1 unit every 12 hours. It's much gentler in action than Caninsulin - slower onset, longer duration. That can help very volatile, reactive cats to have calmer responses. I recommend that you post on the Lantus forum to introduce yourself and explain what you've been through. Say that you need dose advice for the switch in the title of your thread. It's a large and very busy forum but the level of expertise is very high. Go read the yellow information stickies on that forum to get an idea of how Lantus works and how dosing is determined.

I think you'll be pleased with how Lantus works. It won't get Wally regulated immediately but it should calm down his responses fairly soon.
 
Hello my friends,

I'm feeling better because Wally's spreadsheet numbers are now more pink than black.

It appears that lowering to 4UI of caninsulin had beneficial effects on him. THANK YOU ALL!

Still high though, but i am proud of how Wally is reacting.

He seems in shape in my eyes, keeping his body weight at 4.5 - it seems to me that he's drinking and peeing less than usual.

Now the question is.... what to do next??? Please suggest the next step

- Keep him at 4U Caninsulin and see if it goes more down than this
- Lower insulin (he didn't see 300's since a lot)
- Follow my vet advice as follows

My vet has prescribed switch to Lantun a few days ago (which i already have in my fridge)... but I don't want to waste the positive trend i'm seeing

Please advice!!!

Thank you
 
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Hi Stephano! This is good news! I think a switch to Lantus is best for these reasons:
  1. you already have it
  2. you're probably seeing what the 4 u dose can do and trying a lower dose *might* help but might also just extend the time Wally is in high numbers
  3. there are very clear dosing guidleines on the Lantus forum (this is extremely useful!)
  4. there are many very experienced Lantus users there to help you
  5. it's generally a better insulin for cats - smoother action, longer duration, etc.
  6. you'll get a good trend going with Lantus sooner than you think
  7. the thing we know always seems safer/better than the thing we don't know - we understand this! ;)
 
Thank you for your advice...

What about this evening shot?

I know it's better to switch at AM to the new insulin... what you think?
 
Stefano said:
Thank you for your advice...

What about this evening shot?

I know it's better to switch at AM to the new insulin... what you think?
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I would wait until morning. Are you home to test through the day tomorrow? You're in Italy and many/most of us are in North America so time difference is an issue if you need advice. However, the Lantus forum is large and busy so there should be someone available to help much of the time.
 
Kris & Teasel said:
I would wait until morning. Are you home to test through the day tomorrow? You're in Italy and many/most of us are in North America so time difference is an issue if you need advice. However, the Lantus forum is large and busy so there should be someone available to help much of the time.
Click to expand...

Yes I will be home so i can monitor my baby every 2 hours!
 
While the numbers look a little better in the last day or so, I'm still inclined to think the dose is too high. I am really perplexed by those normal numbers right after Wally's hospitalization despite no insulin being given. Have you managed to check Wally for ketones recently?
If ketones are negative, I think I'd start out with a lower dose of Lantus and only make dose changes in 0.25u increments. It's also important to keep testing for ketones on a daily basis until his numbers start coming down a fair bit.
I think the Lantus will help to smooth out any bouncing and last longer through the cycle which should bring those high pre-shot BGs down.
 
Thank you very much for your feedback MrWorfMen's Mom... Wally numbers are better since I received your precious advice.

Not ready for ketone test yet :( I am waiting my measurement device (should arrivate tomorrow or the 2nd of jan ....).

What surprise me is that his numbers are going down on +8 since today's AM dose. ... usually nadir was on +6

Considering I can't test ketones yet what would you do until then?

I understand you would start with a lower dose of 2 U Lantus. How much depends on ketons?
 
Sounds like you ordered a meter that will test for ketones? That is a great idea but in the meantime if you can get strips and test his urine, it would definitely be a good idea. You don't want to have to deal with ketones again and catching it early makes it easier to deal with quickly to prevent the need for another hospitalization. If Wally is shy or protests against plastic wrap in his LB, perhaps some fish tank gravel in a litter box would make it easier to catch a sample.
2u twice a day sounds like a reasonable dose to start. The problem is that with the history of DKA, you don't want to go too low dose wise but also not too high. It's a fine balancing act which is why I'd really like to know whether he has any ketones now as that would definitely need to be considered when determining dose.
 
We are waiting for a blood meter... I'm having issue with urine testing inside his "litter robot" that is also used by his sister, this is why I opted for the meter.

We did a blood test a few days ago for fructosamine (around 500) and few other parameters... i wonder why the vet didn't test ketons in that occasion.

Given I wont be able to test for ketones.... I feel a big responsability in switching insuline type now.... should I do anyway?
 
The important thing is to make sure that Wally is eating well, getting insulin and staying well hydrated. As long as he is eating, hydrated and otherwise seems well, I see no reason not to change insulin. It's not the type of insulin but rather that he gets the insulin he needs that will work to getting him regulated and keep ketones out of the picture. It is interesting that his nadir appears to be later today which again suggests to me that the dose may still be too high but that is just a guess because nadir can change.
I'd go ahead with the insulin change tomorrow AM as planned.
 
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