Mister's Dosing - Pt. 3

MisterBillie

MisterBillie

Member Since 2022
Previous threads: 1, 2.

Currently trying to get his numbers down without any success. No clue what his nadir window is.

This is starting to take a huge toll on my own health, it is currently impossible to get a 4hr uninterrupted sleep cycle in. He refuses to give up being a grazer and demands freshly presented wet food twice between 2am and 7:30am. And then I have to get up and do his AMPS feeding shortly after that. The Cat Mate brand feeder with the ice packs is far too recessed, causing extreme whisker fatigue... and he barely eats any of the food because it pushes to the sides. Terrible design.

Anyways, at what point should I start doing 1u increases? Regarding MPM, I don't understand how only one mid-cycle test is sufficient for knowing where he's at. For example, today I have no clue if I caught his nadir late at +7.5 or if he was much lower earlier in the day.

The good news is I have the BG testing down to a science. He actually enjoys the purrito now.
 
1U increases are only past 10U.

As long as most of the time you can catch something in the +4 to +6 window, that's good enough. Again, we are reasonably inferring data based on patterns over time. The other randomly sprinkled tests youre getting are good too.

As for today, he was likely lower earlier, but probably not by much. The "nice" thing is that he reacts pretty predictably and consistently to ProZinc. If that weren't the case, then yes we'd be talking about a different testing approach. But for now, this is good.

Not much advice on the food unfortunately. In terms of PM+ ?, what time is 2am? I'm wondering if you could just leave him some on a small plate or something on top of an ice pack and save you an extra wake up or two. I use dessert plates on top of a silicone mat, I could easily put an ice pack underneath if I needed to. Your other option is low carb dry overnight, but then you technically couldn't follow MPM as it's written because the dry food affects numbers and trends differently.

FD is unfortunately a balance of life, sleep, safety, cat's best interests, etc. ... you kind of have to figure out what works for you, and get a little creative sometimes
 
Peeked at spreadsheet. Just chiming in to say it's reasonable to assume he's seeing some blues now, likely mid blues, so I would now hold the dose probably 6-8 cycles (I see some premature increases in there). Increase size is up to you...I think 0.5U is good until you get more consistent yellows and blues (minimal pink). But if there's lower blues (or obviously greens) hold the dose 8-10 cycles and consider 0.25U to fine-tune.

Did you get lab work scheduled?
 
FrostD said:
Peeked at spreadsheet. Just chiming in to say it's reasonable to assume he's seeing some blues now, likely mid blues, so I would now hold the dose probably 6-8 cycles (I see some premature increases in there). Increase size is up to you...
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Yeah, I noticed that. I thought when that happens to do 0.25u increases instead of 0.5u increases, that's why I ended up doing a 0.25u increase before seeing this post. Oops. Should I up another 0.25u tonight just to make it an even 6u?

FrostD said:
Did you get lab work scheduled?
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Not yet, my vets aren't booked out at all. I think I am going to time the vet visit to be the same visit needed to rule out Acro/IAA/Cushings in late March.
 
MisterBillie said:
Yeah, I noticed that. I thought when that happens to do 0.25u increases instead of 0.5u increases, that's why I ended up doing a 0.25u increase before seeing this post. Oops. Should I up another 0.25u tonight just to make it an even 6u?
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Up to you. Since you're above 5U, 0.5U is the standard dose change (so even if nadirs are all yellow, still 0.5U....blue nadirs, still 0.5U).
 
Dang it, was finally getting some blue numbers and just did the first furshot ever.

At least now I know what it smells like, here I was paranoid a few other times about it. The smell is so strong there is no mistaking it.

How do I clean it off of him? Is it necessary to give him a bath? I think I'm gonna try two semi-wet warm rags and then finish with a clean one.
 
Yes I've always just used damp rags. If it got in an area he grooms, then I'd probably do bath to be safe.

Hate when that happens!
 
@FrostD @Marje and Gracie His PMPS was 133. Did I finally hit a breakthrough dose?!

I'm gonna go look at MPM guide right now, but does that mean half dose?

Edit: It looks like MPM recommends to skip the dose. This is the first time ever I've had a preshot anywhere close to this low. I have 6u loaded up in the syringe too, dang.

It can't be coincidence that this happened after yesterday's furshot... Maybe intentionally missing a shot, or shooting a reduced shot, is like jumpstarting his body's natural ability to balance glucose?
 
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Skipping was the right thing to do. I probably would have tried something like 1U if I could stay up to monitor. You can see he bounced pretty quickly.

You can see some insulin from your fur shot went in because he did come down. But no it didn't "jump start" anything, he's been slowly seeing more blues lately - you're hitting the breakthrough where his body is getting more used to the lower numbers.

Now this is where you'll need to be more careful. I wonder how low he went given the 133... probably saw safe green. It looks like he's nadiring a bit later now too, +7/+8. So now that you're breaking through he might get some quick reductions, hard to say. I would try to get a +4 and +7 every cycle now to keep a close eye.

Fur shots do reset the cycle count. I'm assuming he saw green, so you'll want to hold this dose for 10 cycles (and of course reduce if he goes below 50 - reduction would be 0.5U while dose is above 5U, under that it's 0.25U)
 
Wow, that low PMPS two days ago was just random it looks like? Looks like he's back to his normal 300s or mid/high 200s at best.
 
It might just be because of the skip, he's trying to work his way back down. But it can also be a sign of IAA, and if it's anything underlying let's hope that's what it is.
 
So I remember you saying it is fine if he eats prior to midcycle tests.

I still don't understand why that can be, especially with my cat being a grazer. Today was a great example of my concern here: After the AMPS, he slept and didn't have a meal until +5, which is very rare. Usually he wants to eat every 2-3 hours. During this +5 fast, he tested 156, which is way lower than most every other day.

The overall concern here can be distilled to this example: Let's say my cat wasn't a grazer, like so many other cats, and he has windows where he fasts for 5hrs. His blood glucose numbers would be widely lower looking back. For example, his ideal dose could have been way lower, like 2.5u, and for all we know we overshot it.

I am also beginning to think the magic "don't eat 2hrs before the preshot" isn't accurate. Why 2hrs and not 2.5hrs or 1.5hrs? In reality, it probably varies from cat to cat, I bet my cat it's more like 3 or 4 hours. Which would be painful, because even that 2hr wait before the preshot he has natural ravenous hunger tied to dust and dawn hours.
 
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Remember insulin has to be worked around the cat. We don't want to intentionally restrict food just to see lower numbers. The goal is a relatively gentle/flat curve, like you would see in a non diabetic. It's actually lucky he's a grazer because it's saves you extra work/stress trying to get him to snack to prevent dives.

It's the same as human diabetics - they don't starve themselves or fast to lower their BG, they just work the insulin around their needs.

Now the cats that aren't grazers, we often have to force snacks to slow down dives, because those dives then cause a bounce back up. Kaia is a good example of this, we've been trying to mess with meal schedule to stop it from happening. Because the swings often make them feel worse than just high and flat.

You did not overshoot the dose. If you did, you'd have caught very low numbers many times, you'd have seen very high bounces, and in all likelihood at this dose he would be dead.

The 2 hr thing comes from data collected here over time, and is twofold. (1) The effect of wet food is worn off after 2 hrs; dry food is more unpredictable but we stick to 2 hrs because --> (2) It gives you a consistent data point to base your shot decisions from.
 
Interesting, that is good to know.

6u just might be the breakthrough dose then? He likely dipped below 100 at some point today.

What if he tests below 200 for the PMPS tonight? Should I halve it or go to 1u?
 
Could be. I would still do the labs though, it's an unusually high breakthrough dose, and it's still reading like an IAA spreadsheet to me (but I very well could be wrong!). Just the way you see a hint of good numbers, then they disappear, repeat...kind of chasing the dose up a bit so to speak.

Sorry I wasn't around, what to do below 200 isn't a straightforward answer. If it happens, stall without feeding for 20 minutes, and I'd post on the main forum and ask for help, more traffic there
 
MisterBillie said:
Ok, good to know. So if it is IAA, then what is to come? Does the IAA recede at some point, at which point the preshot numbers will come down or...?

As you mentioned before in your post here, I plan on doing the labs and the test for Cushings, IAA, and Acro on March 27th as you recommended: https://www.felinediabetes.com/FDMB/threads/misters-dosing.258048/#post-2912421
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If it is IAA, it usually resolves in it's own within a year. But it helps to know, because we are usually more liberal with reductions when IAA cats start to see low numbers/it looks like the IAA might be resolving. There's no treatment but to wait, and to stay on top of increases/decreases as needed. It can be frustrating, because you'll hit a breakthrough, come down, then the antibodies take over, dose goes back up.

Its best to keep IAA cats as regulated possible, as once the numbers creep up again it seems to run away again (which is why we say stay on top of increases as needed).

If it is IAA, it's not like it just keeps going up and up and up. At some point there's a dose that overwhelms the antibodies he can make against the insulin, and that's the breakthrough.
 
So 6u appears to have broken through some kind of threshold. I am now able to get him in the low 100s, perhaps even lower if I'm not catching nadir...

So it looks like I am due for a 0.25u increase soon? Should I do it?
 
Great!

Dosing sticky: https://www.felinediabetes.com/FDMB/threads/prozinc-dosing-methods.225629/

At this point it's your call if you want to do 0.25U or 0.5U increases/decreases because it's borderline around 5U. Remember with MPM we want nadir 50-99. With that 110 I'm leaning 0.25U, and you can do that whenever is next convenient for you (tonight if you wanted).

Once you're seeing green you'll want to hold for 4-5 days at least.

Excerpt:
If nadirs are 100-200, increase the dose by 0.25 unit.
hold the new dose for 3-6 cycles unless the BG drops below 50. If the BG drops below 50, decrease the dose by 0.25u on the next cycle.
if your cat is new to nadirs under 200, you may notice that she/he feels a little sluggish and sleepy when first getting into healthier numbers. This is normal and will get better in time.
If nadirs are more than 200, increase the dose by 0.5u. Dose increases should be made every 3-6 cycles and should continue to increase until nadir numbers begin to come down.

If nadirs are 50-100, hold the dose for additional cycles.
If the nadirs start to rise, then increase the dose by 0.25u.
If nadirs stay in green numbers (50-99), continue to hold the dose.
If nadirs are under 50 on a human meter or under 68 on a pet meter, decrease by 0.25U
 
Okay, sounds good. But isn't 50 on the edge of hypo? How do you even manage that, it's such a fine line. + or - 50 is random, you'd have to test him every hour to be sure he's not say 20 vs. 50
 
MisterBillie said:
Okay, sounds good. But isn't 50 on the edge of hypo? How do you even manage that, it's such a fine line. + or - 50 is random, you'd have to test him every hour to be sure he's not say 20 vs. 50
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The idea is "close to" 50. This is why I'm leaning 0.25U increases. He's a little unpredictable with how low he goes, so smaller increases should prevent going too far below 50. Once they get regulated (blues and greens) it's usually much more predictable and safer to get closer to 50. But yes, we don't want them in 30s or 40s long at all, we throw high carb and sometimes karo at them (and reduce dose obviously).

If you can get his nadirs around 65-70 that will be perfect, hopefully give him time to come down overall.
 
I got a fresh bottle of ProZinc today.

He tested at 78 today at 1:30am... less than 2hrs after a feeding, so I freaked out and gave him like 4 kibbles of dry food. Without that feeding, he certainly would have went lower than 70.

It's good that I'm finally seeing a green number for the first time ever, but how on earth do I make sure he doesn't go hypo? If he decides to sleep and not eat for 5hrs, wouldn't he go hypo?

I just don't see how it's possible to micromanage keeping him at 50-70 and not have him dip lower than 50. If he decides to skip a meal, isn't that guaranteeing he'd go hypo?
 
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So a 78 that late in the cycle isn't too concerning, since it's close to/past nadir. If it were earlier then yes you'd want to intervene with medium or high carb food.

Now, the question is, how low was he before or slightly after that? Hard to say, but I don't think under 50. So, you have a decision to make - you can hold this dose for a few more cycles to get more data, or you can reduce back to 6U if that's more comfortable.

Generally they know they need to eat. As long as there's food left out, they can feel the drop or lower numbers and will seek food out. Is he a good eater in general? Does he come bother you if he gets hungry? If so I'm not too worried. I'm not saying reply on that as a safety measure, still need the usual spot checks. There are some anorexic or picky cats that make things more tricky.
 
Glad to see these lower numbers. Be sure to let us know how the labs come back, I know there's still some time (plus waiting for results to come back)
 
Dang. I left the house for an on-site interview for a few hours. When I came back he was sleeping where I've never seen him sleep and he tested 40 on the glucometer, the lowest number yet.

He had been fed 3.5hr prior to testing.

These random low numbers are just disconcerting as the high numbers.
 
Wow. I'd ask if you tested again, but the 84 tells me it was close to right. Well, a reduction at least?

We usually say give a new insulin 2 months to work then consider switching if not coming down overall. Mister is a bit of a special case because he's a high dose cat...At this point I would use up the vial you have, then consider switching to a depot insulin. Hopefully by then labs will be back, and if it is an underlying issue the depot insulins tend to be much better at managing them. Maybe with some extra time at these doses/with these lower nadirs he may start to come down, but he's not budged much
 
FrostD said:
Wow. I'd ask if you tested again, but the 84 tells me it was close to right. Well, a reduction at least?

We usually say give a new insulin 2 months to work then consider switching if not coming down overall. Mister is a bit of a special case because he's a high dose cat...At this point I would use up the vial you have, then consider switching to a depot insulin. Hopefully by then labs will be back, and if it is an underlying issue the depot insulins tend to be much better at managing them. Maybe with some extra time at these doses/with these lower nadirs he may start to come down, but he's not budged much
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Okay, next week I'm gonna make an appointment for these tests. Is there a thread on here that details the process, and what I should tell/ask the vet?
 
In your part 2 thread (you linked back to it in the very first post of this thread), towards the tail end I put in the links and catalog numbers. There's a few different options. IAA is only done at University of Michigan, but the IGF-1 (acro) usually has more options. It's really up to you and your vet, I sent both to U of M.

Has he had thyroid labs done recently? Any symptoms of Cushing's?
 
FrostD said:
In your part 2 thread (you linked back to it in the very first post of this thread), towards the tail end I put in the links and catalog numbers. There's a few different options. IAA is only done at University of Michigan, but the IGF-1 (acro) usually has more options. It's really up to you and your vet, I sent both to U of M.

Has he had thyroid labs done recently? Any symptoms of Cushing's?
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https://vdl.msu.edu/Bin/Catalog/Catalog.exe
Catalog # 20031 is the IAA
Catalog # 20005 is IGF-1 (acro)

I plan on sending the IAA and Acro tests to MSU. So that is just one blood test where they'll draw the blood and then my local vet handles sending off the samples? Regarding the freezing before shipment, I wonder if my vet will even do this. Also, would they be able to satisfy this requirement I wonder, is this something I have to bring my vet?: "We recommend using the MSU VDL Insulated Mailer with UPS (99220 - Single, 99221 - 3 pack or 99222 - 6 pack)."

Regarding Cushing's, your link says "Diagnosis of hyperadrenocorticism is not always straightforward and usually requires multiple blood tests, urine tests and diagnostic imaging (X-rays and/or ultrasound).". Do I ask for all these tests straight away? Or should I just ask my vet to test for Cushing's.
 
I called my vet ahead of time to let him know the tests I wanted done, and they took care of it. I believe it's pretty standard practice to freeze before sending out to other labs.

(And yes sorry, Michigan State, no clue why I said U of M)

I would not test for Cushing's if he doesn't have the other symptoms like the patches of hair/skin falling off, curled ears, potbelly. It's a less likely diagnosis, so I'd start with the easy ones of IAA and acro before putting him through the other stuff. But since they're already drawing blood, might be a good idea to check basic thyroid labs
 
FrostD said:
I called my vet ahead of time to let him know the tests I wanted done, and they took care of it. I believe it's pretty standard practice to freeze before sending out to other labs.

(And yes sorry, Michigan State, no clue why I said U of M)

I would not test for Cushing's if he doesn't have the other symptoms like the patches of hair/skin falling off, curled ears, potbelly. It's a less likely diagnosis, so I'd start with the easy ones of IAA and acro before putting him through the other stuff. But since they're already drawing blood, might be a good idea to check basic thyroid labs
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His ears are normal, sometimes he purposely curls them in when I am about to lance his ear, but he eventually relaxes the ear. My cat is always shedding, I've never seen skin fall off. The potbelly thing is hard to tell, not sure how to tell that apart from the primordial pouch.
 
I am going to fire off an email to my vet to inquire about the IAA and Acro tests. I've been too chicken to ramp up past 6u after the numbers I saw on 03/18/22 where he surely woulda went hypo had I not been there. I've been dealing with orientation for new job so I haven't been home to test him during the day most days. But in two weeks, I will be fully working from home.

Should I look to proceed to 6.25u and beyond? Or do the tests first, then reassess?

He seems to be nadir'ing very late. What do other people do when their pets are like this? I'm thinking of switching to a 11am/11pm preshot schedule to accommodate this.
 
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I'm not quite sure when nadir is...the night you caught that late blue was a bounce break it looks to me (given that PMPS was higher than usual, often indicates a bounce). When they break a bounce, the nadir is often later.

Good idea to ask the vet. I want to say they only run the one test on Wednesdays or something, so it can sometimes take 1-2 weeks for results.

Even with that 130, I think an increase to 6.25U is ok
 
FrostD said:
Still no results?
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I've been busy lately at work, will definitely try to get him in early next week for those tests.

edit: I just made the appointment for early next week for a re-check and the blood draw to be sent to MSU for Acro and IAA.
 
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@FrostD

My cat is in the vet right now for the recheck and the blood sample draw for the acro and IAA tests.

I'm getting pushback from my vet regarding the acro test. He's saying that Acro being an underlying illness for diabetes is exceedingly rare.

I remember finding a study somewhere that said literally the opposite (that Acro was the leading most common underlying illness for diabetic cats experiencing insulin resistance other than IAA itself) . Let me know if you have an gem links with studies about this, I will try to find the study I came across.
 
MisterBillie said:
@FrostD

My cat is in the vet right now for the recheck and the blood sample draw for the acro and IAA tests.

I'm getting pushback from my vet regarding the acro test. He's saying that Acro being an underlying illness for diabetes is exceedingly rare.

I remember finding a study somewhere that said literally the opposite (that Acro was the leading most common underlying illness for diabetic cats experiencing insulin resistance other than IAA itself) . Let me know if you have an gem links with studies about this, I will try to find the study I came across.
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I will dig later but you are correct, recent studies say as many as 1 in 4 diabetic cats have acro as the underlying cause
 
Here's one post I found, linking it here for later:

https://felinediabetes.com/FDMB/threads/acromegaly.157204/#post-1675691

Somehow the vet robbed me of $240 just to draw blood. Wow. And he wanted to sell me on a fructosamine test, which is over $200, to which I declined. How much is a simple blood draw and shipping to MSU suppose to cost normally?

He's lost 3.5lbs since January. The vet said 6.5u is alarmingly high dosage and seemed to hint at not going any higher. He says that the best numbers many diabetic cat owners will see is in the 150 to 200 range. And like I said above, he recommended not testing for acro and he claimed acro is exceedingly rare. So basically everything he said is provably false, it sounds like many of his patients will go undiagnosed for acro and IAA.

I also asked him if switching to a depot insulin would be a next good option, but he didn't seem to know much about that and wanted to wait for the results.
 
MisterBillie said:
Here's one post I found, linking it here for later:

https://felinediabetes.com/FDMB/threads/acromegaly.157204/#post-1675691

Somehow the vet robbed me of $240 just to draw blood. Wow. And he wanted to sell me on a fructosamine test, which is over $200, to which I declined. How much is a simple blood draw and shipping to MSU suppose to cost normally?

He's lost 3.5lbs since January. The vet said 6.5u is alarmingly high dosage and seemed to hint at not going any higher. He says that the best numbers many diabetic cat owners will see is in the 150 to 200 range. And like I said above, he recommended not testing for acro and he claimed acro is exceedingly rare. So basically everything he said is provably false, it sounds like many of his patients will go undiagnosed for acro and IAA.

I also asked him if switching to a depot insulin would be a next good option, but he didn't seem to know much about that and wanted to wait for the results.
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I think they have prices listed on their website, I think I maybe paid somewhere around $150 for both? That said my vet tends to do a lot for me near cost, because spent quite a bit with him over the years....

Yes for some reason a lot of vets think it's very rare, and just haven't treated it. My vet originally said they usually wait til a dose of 2U/kg, but he humored me and did it anyway. He did tell me he was the first acro cat hes treated, and was happy to refer me to an IM vet or endocrinologist if needed

But yes, you can see here if you're willing/able to put in the time and effort, can do much better than 150-200, it just may need an insulin change. I would use up your ProZinc first, then consider a switch. If the results come back acro and/or IAA, I'd consider a switch to Levemir - Lantus starts to sting around the 9-10U mark. No guarantee you'd get that high, but it would stink to buy it and only use it for like a month. A lot of us with high dose cats prefer Levemir, it's also flatter than Lantus
 
Oof, up to 7u now...

Vet should have results on the MSU tests on Friday regarding Acro or IAA.

Scheduling a dental exam and cleaning soon.
 
MisterBillie said:
Oof, up to 7u now...

Vet should have results on the MSU tests on Friday regarding Acro or IAA.

Scheduling a dental exam and cleaning soon.
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Ok, good. Remember, he needs whatever amount of insulin he needs.

A day or so before the dental let us know, we usually have to adjust dose. I don't have enough experience with that so will have to ask some others.
 
FrostD said:
Ok, good. Remember, he needs whatever amount of insulin he needs.

A day or so before the dental let us know, we usually have to adjust dose. I don't have enough experience with that so will have to ask some others.
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Okay, any advice would be appreciated. That is so crazy that dental would have absolutely ANYTHING whatsoever to do with insulin. I never would have guessed. I absolutely need to rule this out, my cat has never had a cleaning and he has a few small black spots on his gums when he yawns.
 
MisterBillie said:
Okay, any advice would be appreciated. That is so crazy that dental would have absolutely ANYTHING whatsoever to do with insulin. I never would have guessed. I absolutely need to rule this out, my cat has never had a cleaning and he has a few small black spots on his gums when he yawns.
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It's a combination sort of thing as I understand it - since they have to fast for a certain amount of time beforehand that affects insult needs, but also dental health in general has a decent effect on BG. Things like infections and bad teeth especially. I wouldn't say that's the case for his current insulin needs, but you may see some movement in BG after a dental
 
My cat barely ate anything last night and won't eat this morning before his AMPS. His AMPS was 354.

So should I skip this shot then? There was white foamy clear vomit in a couple spots in the house from last night. He also has excessive dander out of the blue.

edit: I was able to give him some PureBites Salmon (his favorite treat) which stimulated his hunger and he ate a little bit of his normal food too, so I ended up giving him his shot. I am going to 7.5u tonight then, I will test a couple times today.
 
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MisterBillie said:
My cat barely ate anything last night and won't eat this morning before his AMPS. His AMPS was 354.

So should I skip this shot then? There was white foamy clear vomit in a couple spots in the house from last night. He also has excessive dander out of the blue.

edit: I was able to give him some PureBites Salmon (his favorite treat) which stimulated his hunger and he ate a little bit of his normal food too, so I ended up giving him his shot. I am going to 7.5u tonight then, I will test a couple times today.
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Yes with ProZinc it's a good idea to reduce slightly if you can't get them to eat, but his numbers are high enough I think you'll be ok, especially if you can keep an eye on him.

Have you checked ketones lately?

When I hear inappetence in a diabetic cat I usually go straight to pancreatitis or ketones/DKA risk.

I can't be around a lot today with the holiday, but just keep trying to get him to eat small amounts and push fluids. It's more important that he eats, do not worry about carbs if all hell eat is higher carb.

If he will not eat on his own you will need to assist feed as best you can, I know with Easter many places are probably closed. Dropping some links below for you.

If he gets lethargic, breath smells like pennies or acetone, or you get ketones higher than trace take him in.

https://www.felinediabetes.com/FDMB/threads/suggestions-on-how-to-stimulate-kittys-appetite.130770/

http://www.felinediabetes.com/FDMB/threads/syringe-assisted-feeding-video-and-tips.144367/

http://www.felinediabetes.com/FDMB/threads/a-primer-on-pancreatitis.83108/
 
Also if you need urgent advice please do post on main forum. Not sure how many will be around today, but a fair amount of people here have experience with pancreatitis, inappetence, etc
 
Results for Acro and IAA test are in. I'm devastated...

IGF-1: 327 (12-92 is normal range)
IAA: 64 (20 or less is normal range)

So he has Acro then...? Now what.
 
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