2/21 Minnie AMPS 397/+2 535 - dosing advice/reassurance again please

https://www.felinediabetes.com/FDMB...ce-ketones-advice-please.243283/#post-2743076

Hi again,

Still adjusting Minnie's dose and looking for confirmation of my approach or other advice. She is on day3 @3.5 Levemir BID and still mostly in the red/blacks so I'm planning to increase to 4u tomorrow morning.

She gets 2 meals plus 6ish snacks per earlier advice - trying various lower carb wet food as snacks, DM Selects at 10% carb for meals. Do I need to limit the snacks? I am desperate to avoid another DKA so wonder if I might be overfeeding now, though she is hungry a lot and eats it all. Added back Ondansetron in a pill pocket to avoid nausea/inappetance.

Also I haven't seen a poop from her in over day. Is this known effect of Levemir? Recommendations? Apart from that, she seems fine and normal behavior.

Thanks again. I'm not posting daily but wanted to check in again to make sure I'm on track...or not!

Elizabeth

Below are instructions from the internal med vet, basically increase by 1/2 unit after 2 days if nadir not around 150-200. I think this is almost the TR approach - is that correct?

• Start Levemir on 1/2 unit, if BG doesn't get below 280 in 2 days increase to 1 unit.
• Similarly, if not below 280 in 2 days increase to 1.5 unit.
• If doing a 12 hour window her BGs do not fall between the 150-250 range AT ALL, then I would increase by 0.5 units and then give her 2 days to adjust to the new dose. Like I've said before I don't want her to drop below 80-90 but ideally, she should have her lowest point around 150-200 during a 12-hour window of time.
• Increase to 3 units given the readings and her change in water consumption/urination. Should her values after two days not improve at all, then I would recommend that we increase to 3.5 units.

 

The instructions for using Lev are the same as Lantus. If yo9u are following TR, which it sort of sounds like your vet is suggesting, you hold the dose for 3 days. Unfortunately, it sounds like your vet decreased Minnie all the way back to a dose of 0.5u rather than starting at 2.5u which is what's recommended when switching from Lantus to Lev. (You start at about 70% of your Lantus dose.) If the majority of nadirs are over 300, you would increase by 0.5u. Your vet has been doing what we would call "fast tracking" the dose given that the 0.5u was way less than what Minnie needs.

I think increasing to 4.0u is fine for tomorrow.

Is there a reason there is such a gap between when you feed and shoot for the PM cycle? It's fine to test, feed, and shoot all within a few minutes of each other. Lantus and Lev onset takes about 2 hours so you do not need to feed your cat way in advance of a shot the way you have to with shorter acting types of insulin. It also looks like there's not 12 hours between shots -- although this has improved a great deal recently.

 

Thanks! Yes, I'm very frustrated the vet started Lev at such a low dose leading to the DKA and such stress for me but on the plus side it prompted me to seek out you wonderful people.

You got me my timing has improved now I'm tracking on the spreadsheet. My PM issue/dilemma is they are begging for dinner 5/530 but shot time is not til 730. I'm giving her the big meal at 530 to keep her going the full 2 hours, then giving a snack with the PM shot. I have started tracking snack times in the s/s.

I'm looking for guidance on snacks - in practice right now, if she wants food I give it to her except for the 2hr window and when I'm asleep. OK to continue with this till we start getting better numbers? I guess at that point her appetite should decrease anyway.

Also when should I start worrying about constipation? She's not straining to go, she just hasn't gone in >day.

 

PS Gabby was a beautiful girl, what a lovely tribute

 

The snack timings would be more useful to us if you referred to them in + times instead of time of day. As for feeding a large meal at 5/5:30 (I presume that's +10?), I wouldn't do it. Give her a small lower carb meal/snack then. In general, you want to feed the majority of food before nadir. Which on Levemir is typically around +8, though later on with my girl. If you feed after nadir, the insulin effect is wearing off, and adding extra carbs, especially the DM at 10%, will shorten duration and cause her number so shoot up to preshot. So ideally, shrink those late cycle meals and try to do some thing in the less than 5% carb range, like the Weruva's of BFF's. And you can add more snacks from the +4 (typical Levemir onset) ot +8 time.

As for constipation, it's not uncommon for every other day BM's. Are you watering down her food? Diabetics, when unregulated and peeing a lot, could use more water.

 

Elizabeth, your Minnie is gorgeous. You're getting lots of good advice here. Big hugs to you. You're going to get those numbers down. Are you testing to keep an eye on the ketones? Didn't I read somewhere where you ordered the Nova Max meter that tests for ketones? That's the one I use for my Darcy. We have finally gotten his ketones down into a normal range, even though his numbers aren't still that good.

 

Thanks to you both! The advice and knowledge is incredible and I'm amazed how less overwhelmed I'm feeling now after only a week. [HMM...it's 2 weeks. Lockdown + cat nursing = no sense of time]

When you explain the logic behind timing of the snacks, it seems completely obvious now. If I make main meal time coincide with the shot, that simplifies things including my s/s since I won't need separate columns for food and shot times. Gotcha on the +times, you can see I had to put a translator row on there for myself (and the vet). Can't wait til we find a consistent nadir...

I have been watering down the food. Constipation is new for her since the switch to Levemir though she is also not as ravenous and thirsty since coming out of hospital.

Ketones - yes, Nova Max due to arrive tomorrow but I'm dreading the blood sample size required. I'm getting better but the 3 microliter and having the AT strip take blood on the side are major bonuses for me. In the meantime I'm using the urine strips (Relion strips are the easiest to read) - she pees so much there are nice big puddles so it's very easy. I also smelled the ketones on her breath before anything showed up on the strip, so I'm happy she has meaty breath right now.

Mr Darcy, what a wonderful name. Love it. Is he dark and handsome and brooding and a bit snooty?

 

The Nova Max really doesn't require much blood. The strips are really good at "sipping" up the blood and then the meter beeps to let you know that it's got enough blood and then will shortly give you a reading. What size lancets do you use? I use the 33 gauge thin lancets from Wal-Mart (ReliOn) and I still can get enough blood. Does Minnie hold still for you? Sometimes Darcy gets too excited about his food or snack that he KNOWS is coming... so he tend to jerk his head a little at the wrong time. If I use a small glass water bottle and heat it up, I invariably can get quite a bit of blood. If not, I'll just skip the ketone reading until the next test and wait until the next test time and see if I get more blood and then do the ketone check then (you know how sometimes you get more blood than others.)

 

Oh, and Darcy is big and handsome... not very snooty (except he doesn't like my calico Ginger). I think he only broods when his glucose gets too high! He's a favorite at the vet, so I think he's very tolerant. My vet says he never likes to make a fuss... so I think he's quite stoic.

 

Good to know. I'm using the ReliOn 26 gauge. Have the 33s but they're not working for me yet. She does hold still but flicks her ears around, she doesn't like it and sometimes growls but overall is very patient. No fears of her scratching me - she is such a good girl - but I feel awful, her ears are so light I can not just see the vein but all the bruises from my stabbing. I still can't get the blood first stab but absolutely sometimes get a pinprick and sometimes a big blob. I tried all the heating things but it really wasn't helping, just more things to juggle so I've abandoned that for now at least.

Thanks for the encouragement on the Nova Max. I'll take all the encouragement I can get, she's back in black again after her PM dose Still, tomorrow is another day. Up the dose and I will be more methodical and precise about the snacks.

 

Elizabeth, do you hold the ear with some pressure on it after you get your blood? This helps a lot with the bruising. I don't know if she will let you do this. I usually keep small squares of paper towel in the basket that holds my meters (regular and ketone) and other supplies. If I'm on the ball, I will use the little paper towel square and hold Darcy's ear for a minute... otherwise, I just pinch it off with my fingers.

 

I've got a stash of cotton wool squares which I have behind her ear while sticking and then apply pressure afterwards, she mostly sits tight. I think the bruises are obviouse because her fur is so light and ears so pink and she's been such a pincushion the last couple of weeks as well. I don't understand everyone saying they don't feel it though, she definitely feels it so either she's extra sensitive or I'm extra clumsy. I do need to get a little container to fill with hot water, though I have tried with a warm cloth and the rice sock and she just doesn't like anything touching her ear.

Thanks for all your tips! My next project is try to transition from Alphatrak strips to Petmate and see how that goes, though that also needs blood in the middle of the strip. I love how it's on the sides of the AT strips

 

Sounds good. You’ve got this! It’s Minnie’s white ears.

 

I've heard some not so good things about the Petmate. Any reason you aren't using a human meter?

 

First thing, I made a mistake. I meant Petsure strips.

I am still having a really hard time getting samples, it really seems harder now than when I started so I need to stick with something that takes 0.3microliter. I'm waiting for the ketone monitor to arrive which only needs 0.3 for BG so that might work.

I have tried both Relion Prime and TrueMetrix (which already broke, replacement in the mail) but neither worked great. Not only do they need more blood but you have to get it in the center of the strip - the best thing about the AT the tiny little bits that stick out on the side to suck up the blood. The Petsure strips are in the middle too so not really working for me.

I've read all the tips and really don't know why none of them are working for me. Rice sock, warm damp cloth, pill bottle full of hot water, massage the ear, vet-suggested press down on the vein to get the blood to pool up, vaseline. 26 gauge lancets. I stab her, she flinches and most of the time no blood comes out.

Not having a great day of it...increased the dose, feeding her slightly lower carb food (Weruva Double Dip 8% vs DM 10%) and her numbers went UP @ +3 and +5. Poor ears have been stabbed half a dozen times in my attempts to get the next reading. In the meantime (for right or wrong) have been reading about acro and perhaps prematurely panicking.

 

I feel your pain. I was in tears initially trying to get blood out of Darcy. Occasionally, I still have a bad time poking. And I will tell you, although sometimes... and I wonder if he's not being a drama queen at those times... he makes a little cry (very low) when I poke his ear. I try to go in at about a 45 degree angle, but sometimes I do pierce his ear... the lancet goes all the way through and I can feel it touch my finger. I've done this many times and he's no worse for wear, but I hate doing it. Sometimes he bleeds slowly. I prick a very tiny bit and then have to wait a while and sometimes have to "milk" the ear a bit to get a tiny speck of blood... just enough to use. I'm sorry! Hang in there.

 

Thanks. I wouldn't feel so bad about it if the numbers were going down! I was reading some of Darcy's story...you've been through the wringer (and still are). Another great thing about this is to have a community of other people who understand how stressful this all is AND full of knowledge and advice.

 

YES. At times it seemed very hopeless. I have hope now though that I've joined this group. I feel like I'm on the right track... but it's a very long road for us. Talk to you later. Take care.