Cross post from Health - Mom's cat Francis needs dose advice

I'm posting for my mom who has an uninformed vet: "give 3.5 units, don't test and call me in 3 weeks" and Mom has no internet access and lives in a different state than me.

I've gotten some help before from FDMB for her and Francis. He is about 14-15 years old and on PZI. He is also hyperthyroid and on meds for that. Looks like the insulin is finally working; it took her a while to get him on the right dose. She's switched to wet food but still has a 13% carb dry food out because she's got 3 other cats and can't switch to all wet for many reasons.

My question is about PZI. I know nothing about it and it seems his numbers are bizarre and he may be ready for a dosecrease. Is it the same as Lantus, if his BG hits <50, go down by .25? Here are his numbers:

Saturday:
AMPS=447, +2=465, +4=292, +6=74 (she gave syrup cuz he's never been that low), +6.75=103, +9=226, PMPS=330

Sunday:
AMPS=362, +6=62

I told her to watch him and test to see where he goes from here. The thing is that she will be working tomorrw and will not be able to get a +6. Any thoughts on course of action?

 

Also - are there general dosing guidelines for PZI that I can give Mom so that she can see them? I want her to ask her vet what protocol she follows, but I'm guessing she doesn't have one! Crazy!

 

It seems to me the only scale I have ever seen is the old one of Dr. Hodgkins, which you can find on the internet. Personally, it seems to me, that you have to take into account the nadir as well, which Francis looks like, IMO, a dose reduction would make sense. He seems to get great duration! Pearl always got truly wonky numbers with even a late cycle drop on it. Any thought about getting your mom's cat on Lantus or Levemir since she tests? I'm thinking with such great duration on PZI (it seems like most people get nadirs earlier than Francis does) he might really do well on them.

 

Francis's +7.25 number is 75 without being fed. He's doing well!

Hi Karen-
I'd LOVE it if Francis got on Lantus. It's a matter of her vet giving her a hard time and me having to make continuous suggestions. It's kind of exhausting. THe next time I speak to Mom (probably soon, lol) I'll mention her asking her vet to switch to Lantus, if for no other reason, it's what I'm using and she'll have some support and the knowledge that I have from this board.

 

Wow. An recalcitrant vet. Who'd a thunk. What's weird is while lev is definitely "new" Lantus is pretty common now.

 

From what I understand, Lantus generally gives you a much flatter curve than PZI. These #s look reasonable (i.e. not bizarro) to me for PZI - onset is usually in the +2 - +3 zone, nadir around +5.5 - +7.5 (though some cats nadir later), and poopout around +10 or later. Unfortunately I don't know of any nice tidy protocol for PZI. If there is one, I'd LOVE to see it!!!! I generally suggest a modified version of Start Low, Go Slow.

With dry food in the picture, the drop is likely to continue monster-big like that on PZI, which in and of itself can make a cat feel pretty rotten, even if it doesn't cause rebound. Hard to know if rebound might be in the picture or not - I wouldn't worry about it too much, but it's good to be aware of. If she starts seeing really high PSs and nadirs like the ones he's getting now, it's not a great pattern any way you look at it. But the dry food is going to cause high #s at the start and end of the cycles, most likely.

Personally, I would try reducing the dose by 0.5u and seeing if there is still a reasonably good nadir. If the nadir is a lot higher in the 1st cycle or 2 on a reduced dose, I'd go back to this dose, and start looking at Lantus (assuming the dry food can't be removed - preaching to the choir here but that of course would be the best thing to reduce the high #s). This is just such a huge drop, I can't imagine that feels good for Francis. From what I've seen PZI works really well when you can get a pattern going of a PS around 150-200 (unrealistic with dry food), and a nadir like Francis is getting. The cats with consistently higher PSs have for the most part I think switched over to L or L to get a flatter curve.

If I were worried about low #s, instead of Karo I would just feed a little of the dry food he is already getting (although assuming she is using a human meter, I wouldn't worry unless the # got below 60). If she has another cat she can get a resting BG on, that's a nice way to get some reassurance on what # is safe with her meter. With my human meter, one of my civvies was at 65, and at 80 on my cat meter, so I use those #s as a baseline for what a "perfect" nadir is with each meter.

If you do look up the Dr. Hodgkins scale, keep in mind that is for a different approach than what your mom is doing now, and it is not meant to be used with dry food in the picture (I tried that... doesn't work well!). Given what you've said before about her schedule, I think sticking with BID and a steady dose (not sliding scale) is probably what she would prefer (as she is doing now). [ETA: that said, I would mention to her though that it's a good idea to reduce the dose a bit if the PS is a lot lower - e.g. if she saw a 250 PS vs. 450, it's not a bad idea to reduce the dose a bit, especially if she won't be home to get a +6. In PZI we work to some extent with the % drop - PS to nadir - ideally you want a drop of no more than 50 - 60 %. From what I've been told, steeper than that can make the cat feel ill, and also risks causing rebound.]

Caveat: all of this is based on my own experience, what I've been told by others on the board, and observation of cats on the board, as well as reading the generic reference docs on the board. I do not mean to give medical advice, my intention is to share my own experiences and observations in the hope that they may be of help. Always check with your vet! :RAHCAT

 

+9=82

He's not eating now, probably because he doesn't feel too good. I'm ready to jump off a cliff because I'm in the middle of a clueless vet and a clueless mother. Thank you all so much for this information, incredible, actually.

I just spoke to her and his +9 is 82 (probably from not eating) I just don't see how she'll be able to give him insulin safely tonight after all this and I DON'T know what to tell her, you know??? Her vet is unavailable. Not even an emergency beeper or anything.

I suggested Lantus and she said her vet uses only PZI and she gets it from the vet too, not a pharmacy. Is this right???

More info: he was diagnosed about 4 months ago and they started him at 2 PZI units BID and no home testing. Since I was home testing she started doing it too and found out that his BG's were through the roof. 500+. In the month of December they raised him to 3 units. His bgs were still too high, so up to 3.5. Now it's kicking in. She says they think PZI is the best insulin and that's what they've had the most luck with. She needs a new vet.

Lastly, she's going to call me with her +12 so I can help her decide what to shoot if anything. :YMSIGH: I feel so helpless and frustrated but it's not my cat and it's a ton of extra work to worry about her cat AND mine!!! Sorry...venting.

Thanks for all help, it's a godsend!

 

I am not really comfortable giving any kind of dosing advice because there are factors in play here that I know nothing about, namely hyper-T and the effect of dry food on #s. By that I simply mean that I have never factored dry food into dosing calculations, so although I know dry keeps #s higher, I don't know how much higher or how long the food spike lasts, etc.

That being said, the only thing I can say with any certainty is that Francis is getting some SERIOUS drop from his current insulin dose. The 74 and 62 are actually great #s, and the PMPS from Saturday could certainly be due to the syrup being given. As Joanna mentioned, that drop is possibly making Francis feel like poop. Since your mom won't be home and able to keep an eye on him, I would agree with Joanna's advice to reduce the dose by 0.5u. Without a +6 test, it will be hard to know what it did for him, but if his PS #s go down after a couple of cycles at that dose, then it's fairly certain that rebound was an issue.

I don't know of any protocol for PZI either, unfortunately. I've dealt with it pretty much by trial and error and the advice of folks here. Not the best way for your mom to have to approach it, I know. You are such a good daughter (and bean-sibling to Francis!) for doing all you can to help her.

Please let us know if we can do anything else for you. It does sound as if Lantus would be an excellent choice for Francis, both because you are using it and because it might help even out the roller coaster. I was planning on switching to Lantus for the same reason: Buzz's #s were all over the place, all the time. Someone here (Terri and Lucy) advised me to stick with PZI because she felt Buzz was close to remission, and so I did. Luckily, she was right. However, I would have definitely switched otherwise just to get rid of the high highs and low lows. I was really happy with the way Buzz did on PZI, though.

 

well, it could poop out by +10 and shooting time be fine. You just have to wait. If it isn't can she just wait until it is a comfortable level to shoot? I bet you will see poop out and an upshot sometime in the next 2 hours.

 

I agree with Karen that your mom will probably see a zoom in the next couple of hours. PZI usually does start to crap out around +10. However, it's great that he's still at 82 at +9.

I don't know what your mom's "no-shoot" number is, but with a steep dose of 3.5u and Francis' huge drops, I hope it's pretty high. Personally, with the combination of large drops & her not being able to check him, I would be awfully nervous about giving that same dose. Of course some of that depends on what his PMPS is, or what it looks like it's going to be based on his +10.

FWIW, when giving dry food as a hypo preventative, remember that dry food takes longer to kick in than wet food. Dry will raise the BGs higher, that's for sure, but it's not an immediate thing. So if you are dealing with really low #s and you need immediate higher #s, don't count on dry to do that for you.

Also, I think I understand your question about getting the PZI, and if I do, then the answer is yes. Vets sell PZI because it is an animal-only medication, unlike Lantus which is a human medication as well. I have always gotten my PZI from my vet, although you can get it online too (Drs. Foster and Smith had it even a month ago; don't know if they still do). You will not be able to get it at Walgreens, though.

 

Many of us on PZI have a "no-shoot" #. If the PS is lower than that, we wait and retest until we get a higher #, and then give insulin. PZI, as others have mentioned, does "poop-out", and then you may see zoom pretty fast. Often people start with 200 as their no-shoot, until they have more data.

As for retesting, if he is too low to shoot at +12 but the # is well over 100, I'd probably test again in 1/2 hour. If he's still 80 or something, I might wait an hour. I probably wouldn't skip the shot, unless he is not eating at all and something is clearly wrong on that front. If he's eating, but not as much as usual, she might want to lower the dose some, maybe cut it in half or so. That is just ballpark, I don't know if there is an actual formula for it. The more data she can get on how he responds in different situations, the easier it will get to make decisions on stuff like that. With PZI there is a fair amount of trial and error.

When in doubt, in the absense of ketones, the best compromise I know of is a reduced dose and/or late shot if needed. PZI is more flexible than Lantus in that you don't have to stay with a 12/12 schedule. The general concept with PZI is to get a nice overlap between shots - the next one is kicking in (onset around +2), as the last one is pooping out. Some cats need shots 3x/day on PZI, some, like Bix, got good duration til around +14, so didn't always need a shot even at +12. You want to catch them once the PS has risen some, so you know zoom is coming, but before the zoom has really started in earnest. That's where the no-shoot comes in, and takes some of the stress out of trying to figure out the perfect timing.

[edited: got the Start Low Go Slow link from Janet & Binky! http://binkyspage.tripod.com/SLGS.html]

 

Help!
His +12.5 =121 and she gave him 3 units!!!!!!!
OMG. He won't eat on command either. She has syrup and HCW but she'd have to force feed him. I basically told her she'd have to stay up and get his numbers and she has to get up for work at some INSANE time like 5AM.
She doesn't have fat syringes for force feeding.
I think he's going to hypo for sure. What do you think???
Any thoughts on how she can prepare for this?

 

Posted a plea for help on Community... Hang in there!

I would think she will need to test every 15 minutes and if too low (don't know what that is with PZI) rub the Karo on then back off to testing every 30 minutes once the BG comes up...

ETA: I am inexperienced with PZI... after reading some responses on Health, I see that the onset will be slower than I initially thought. It's been recommended to test in one hour, then spoon feed small bits.

 

Please see thread on Health for more posts. I flagged the Mod on that one, and also posted on Community.

 

Thanks for your help. She'll be calling me to tell me his +2 number soon. She knows to get him to eat. He's an older guy and he gets a bit annoyed with her constantly trying to feed him, but oh, well. Update coming soon!