New member needs dosing advice

Hello! Nacho was first diagnosed July 17, 2020 and went into remission Aug 18, 2020. He is back on insulin since Jan 9, 2021. I would like to know if I am doing things correctly. My vet told me recently not to give insulin if reading is under 12mmol/L, another told me less than 10mmol/L. While others have told me not to skip a dose. I need some clarification Thank you so much!

 

We usually tell new people not to shoot under 11 until they have more data. The exception being if the cat has any history of ketones.

 

Hello,

I'm putting a link to your post in the Vetsulin forum here, the Vetsulin forum is better to give advice. Exception being an emergency situation, I'd post here in Main Health since more people are looking at it.

In the meantime, there's some info that would really help. Can you read through this and complete the steps when you get a chance? Most importantly the signature information. Right now we don't have enough information to give any dosing advice.

Edit: Janet and I were replying at same time, and I saw she commented in Vetsulin forum post lol I'd keep everything here for consistency then

 

I don't think my cat has history of ketones.

 

thanks, I posted on both initially- I'm new at this haha. I updated my spreadsheet. He was at 11.4 an hour before PMPS (I couldn't take it at the exact hour I usually do) but I didn't shoot because my vet said not to at less than 12mmol...and then 2 hours later, I checked glucose without the insulin he was at 7.4mmol. Does that mean the pancreas is working on its own without insulin?

 

That's great! Could be!

 

Well now that is interesting. What time(s) did he eat? If you fed him at the +11 or later, it would appear that yes the pancreas is still functioning on some level.

It's usually better to have consistent dosing, vs a shot then all these skipped ones. So for example, tonight I personally would have shot a reduced or token dose (token is usually 10-30% of a normal dose, reduced is say something like 50% but really depends on the cat and the data you have).

As you get more comfortable, I'd recommend trying that. I do wonder if a dose reduction would be better, but his mid-cycle numbers aren't quite dropping low enough for that (at least with the data we have).

 

Today I had to feed him an hour earlier and take his reading because I had to pick up a family member from a medical appointment. Therefore, yes I fed him at the 11+ (he was also hungry at that time too- if that helps to know). The first time he was diagnosed, he went from 1unit to 1/2 unit at a reduced dose but his numbers were way better! Should I give it another week and call the vet? I am at work all day, so it's hard to check his numbers at the +5/+6 hour.

 

My guess is pancreas might be firing up for.you!

So... I think 1U as a consistent dose is too much for him, based on the data you do have. You could go another week, but I think you've been at 1U for long enough. I personally prefer 0.25U increases and reductions, so you might try 0.75U for a few days and try to do a curve on a day off of work. Worst that happens is numbers go up and you return to 1U, just be sure to give him a few days at any new dose.

Back when we were regulated on Vetsulin (see early last year on my SS...don't ask what happened in July, I still have no idea and it drives me nuts), I had a sort of sliding scale. If he was above 200, full dose. If he was 150-199, I usually did a reduced (half dose). 100-149, I did token dose (about 10-20% of usual dose). Ideally I would have tested much more mid-cycle, but like you I wasn't able to.

 

Thanks. If the reading is under 11mmol, I could also skip it as well, no? Or is giving reduced better? I don't think he has a history of ketones. I've never been told that, and he hasn't been sick or hospitalized before.

 

You can do whatever you're comfortable with. But I prefer some insulin over none for consistency. And I would think skipping does increase chances for ketones. @JanetNJ , thoughts here?

Just because he doesn't have a history doesn't mean it won't/can't happen though. Good idea to test every so often.

 

For instance, his AMPS today was 11.8. So I ended up shooting 0.5 of Caninsulin. I'll be able to do a reading around 1pm (+7 mark). I'm just confused cause my vet said no shooting less than 12. But I think maybe I should follow reducing the amount for now. However, I also want to know if the pancreas is working on its own by seeing if numbers go down without insulin.

 

Oh, by the way, I was also curious, what are member credentials on the FDMB group? I always wonder how everyone is so knowledgeable

 

Lots of experience. Lol.

 

Hi Marinachi,

Did your vet do any blood/urine tests or check Nacho's teeth and gums to see whether there might be any infection or inflammation driving up numbers? Did the vet prescribe any other treatments besides recommencement of insulin treatment?

I ask because I am wondering what the trigger might have been to throw Nacho out of remission and whether whatever it was might be getting better - because his numbers are showing improvement.

Also, I note that Nacho went into remission very quickly last year. Did you and your vet ever identify something that might have tipped him into a diabetic state (e.g. steroid treatment for another condition, infection, other)?

With the readings you're getting at the moment I would suggest a very conservative and cautious approach to dosing of insulin. I agree with the suggestion above to monitor daily for urine ketones, especially if your vet has yet to determine what tipped Nacho out of remission.


Mogs
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Sorry for delay. my vet checked Nacho's teeth and gums and wasn't concerned about it, just mentioned I should look into a cleaning in the near future.
No blood nor urine tests done recently. He had some tests done in June, I will look for the results or ask for a copy and post it. No other treatment recommended, only change of diet. (they recommended DM- but I decided to do Fancy Feast pates)
I have two cats, so I changed both of their diets. The other cat also loves dry food . They both eat the Fancy Feasts pates but I also started giving my other cat Dr. Elsey's clean protein and I know my diabetic cat started eating some of it too. I wonder if that's what triggered the spike. He hasn't really eatten much of the Dr. Elsey's recently. I just updated my spreadsheet, I haven't given him any insulin since this readings were below 11 these past few days. Is that ok?

 

Over 150 I would give some insulin. You've been skipping shots but he will need some insulin support if you want him back in remission. Even over 120 I'd give a token tiny dose.

 

I saw a post here recently about a cat that had been eating the low carb Dr. Elsey's food. It's numbers apparently improved a great deal when the dry low carb was removed from the diet so maybe that's something you could try easily to see whether it might make a difference for Nacho.

WRT teeth that need a clean, sometimes that can cause gingivitis and the inflammation may adversely affect BG regulation.

Maybe the dietary tweak might help, maybe not. I would suggest not leaving it too long to go back to the vet to try to get to the bottom of what tipped Nacho out of remission. UTIs and tooth/gum issues are common things to check for (though not the only things that might cause deterioration in BG regulation).


Mogs
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What numbers are exactly the most important to look at? The pre-shot ones or the ones at +5/+6...if still on insulin (thinking of just doing 1/2 dose if the reading is 9 or 10mmol). How can you tell it's working and at what moment exactly do you know, you just don't need insulin anymore? I know it's at least two weeks of low numbers but is that with insulin or without insulin.

 

Huh?


Mogs
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Oops wrong thread. I had a couple windows open on my phone. Lolol

 

Oh, that's better. I got very confused there (doesn't take much).


Mogs
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So in a sense it's all of them combined that are important:
- Preshots: help you to know if it's safe to shoot, and perhaps whether to stall, or give reduced dose. And that decision is based on prior ->
- Mid-cycle tests:

• Caninsulin onsets around +2 for most cats
• The nadir, which is how we determine dose, is usually around +4. I haven't seen it mentioned on this board, but my vet mentioned if the nadir is too early it can indicate too high of a dose
• The later tests, +7 to +11 or so, indicate duration. Some cats just don't get a good duration from Caninsulin and it may be better to switch insulins

The other insulin support groups here do an "off the juice" (OTJ) trial with specific guidelines and parameters, but I haven't come across the guidelines for something similar for Vetsulin. Perhaps someone else can chime in there...my goal was always first and foremost regulation (this link here explains regulation) and remission was a possible bonus.

 

Is your standard dose 1U right now? The 0.5U does appear to be safe to shoot at 9-10mmol range, but keep in mind every day might be different.

When you have a day you can stick around to monitor, I think it would be worth trying token doses in the 8-9mmol range (so 0.1-0.25U). He doesn't appear to come low enough when you skip a shot, but it's a bit hard to say without more data.

 

A bit of a clarification: Caninsulin/Vetsulin dose onset is typically earlier than +2 - round about the +1-ish mark - but drop in BG typically lags behind a little. Some cats can hit nadir by +3. Here's a helpful illustration of what a (non-bouncy) cycle might look like for a feline diabetic with an 'ideal' response to Caninsulin/Vetsulin:





(By way of general info, in cats that metabolise insulin particularly quickly, onset for Caninsulin/Vetsulin may occur earlier than +1, and nadir sooner than +3.)


Mogs
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That's a very helpful diagram. For instance, today AM he was at 8.6 but I decided not to give him any and then he rose to 10.6 (+7) and PM was at 11.6. Does that mean I should have given him some insulin in the AM? I have been doing 0.5 units, even though my vet said not to give him any if it's lower than 12

 

Do you have ketone strips?

Has Nacho any history of testing positive for ketones or episodes of diabetic ketoacidosis?


Mogs
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It might be worth trying a dose of 0.25IU for a few cycles to see how Nacho does. It might help to give you two 'shootable' preshots each day and therefore make dosing more consistent. If you decrease the dose - and also because you've been needing to skip several doses - it's a wise general safety precaution to test daily for urine ketones. (Test strips can be obtained at a pharmacy.)

Tips for collecting urine samples

If at all possible, for safety I'd strongly recommend you get a before bed test each night - even if it's a PM+2 - in addition to your daily AM mid-cycle checks.

A favour: when you get a moment, it would be really helpful if you could add that you're using an Alphatrak meter to your signature.


Mogs
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I'm using the Elimedical U-40, 1 mL, 28G x 1/2", So it's hard for me to adjust the dosages by 0.25. I can do 0.5 or 1unit no problem. Is there another type of syringe you recommend? Today I had to do 1 unit as his number went up to 12.6mmol AMPS. Not sure as to why it was high again.

I will look into the ketones strip although it's gonna be tough to do. I don't recall the vet ever saying he had ketones. He's had many urinary tract infections before though and one bladder infection in the past.

 

Yes.... Instead of a 1 ml syringe you want one that says u-40, 3/10 ml (it will go up to only 12 units on the barrel) with half unit markings.

 

You can get U40 syringes with 1/2 unit markings like there
https://www.adwdiabetes.com/product/16363/carepoint-vet-u-40-syringe-29g-half-unit

 

Like this https://www.adwdiabetes.com/product/18553/ulticare-u40-pet-29g-3-10cc-1-2in-half-unit

 

ha ha we were
both doing the same thing at the same time

 

Also, you can use human U100 syringe use this conversion chart.
http://www.felinediabetes.com/insulin-conversions.htm
If you use 1/2 unit-marking U100 syringes each 1/2 unit mark is 0.2 units of a U40 insulin

 

Hi Everyone! Based on my new spreadsheet date, should I still be giving insulin?
I feel so horrible, I think Nacho is starting to get fed up with me with all this ear pricking. Poor thing!

 

He's doing well! Technically you earned a 0.25U reduction yesterday since he went under 5 mmol, so I'd be giving 0.25U. Unfortunately the poor guy will just have to get used to the ear pricking

We really need to see what's happening at night though. Cats usually go lower at night. When your "before bed" test shows a significant drop (in your case, more than 2.6 mmol-ish) from the PMPS, it's a good idea to set an alarm for a little before nadir time.

Trouble is, I can't quite pinpoint where Nacho's nadir is based on the data you have. Using tonight as an example, he dropped quite a bit at your +2 test. I'd check him again at +4.

As long as he's not going below about 4.4 to 5mmol during the cycle, I'd call it a pretty good dose. But if he starts to go below that, we probably want to reduce to something like 0.1U or a "drop dose".

Would you be able to do a glucose curve this weekend? Where you test every 2 hrs for 12 hrs? There's also an option to test every 3 hrs for 18 hrs, but with Nacho I'm afraid 3 hrs is too wide a gap to catch nadir.

Edit: I know you expressed concern with measuring 0.25U on your syringes. I'd do the best you can to "eyeball" it...it's better than keeping him at precisely 0.5U because it seems that dose may be a bit too high.

 

At one point, do I just stop giving him insulin? I can prob do a curve on Sunday to see.

 

Ideally, yes! He went into remission before, hopefully can do it again!

It's usually best to slowly remove the insulin over time, so do drop doses for awhile, and then do an "off the juice" trial - 2 weeks without insulin. But there's guidelines for that, such as PS and nadirs being in a certain range for a certain amount of time.

@Critter Mom @JanetNJ is there an OTJ trial equivalent for Vetsulin? I know the ProZinc forum intentionally doesn't post one, wondering if it's the same here.

 

I inserted pics as I don't know exactly measurements. The first one I believe would be maybe 0.25 and the second pic would be a drop dose (about at the top line) ?

The 0.5 I've been giving is between the very first line and the second line.

Edit: I can't seem to add a picture.
I've been using the u-40 elimedical syringes

 

I've inserted it. This morning I gave him the 0.25 one as seen in the pic, so it's a little bit less than the 0.5 i've been giving him. Let me know what you think. I will be taking his glucose at +6 because I am coming home for lunch from work at that time.

 

The 0.25U looks as close as you can get! Drop dose always hard to tell, but also looks ok.

For the drop dose, you just push the plunger all the way up kind of forcefully to get rid of air, insert in vial, then let go. Should result in about one drop

 

Thanks! He's at 7.3mmol at +3 after the 0.25units

 

Looks good! +6 should hopefully be right where it needs to be.

 

I couldn't do +6 (got held up!) but I did closer to +7 and he's at 7.9mmol. What would that mean?

 

It means he hit nadir between +4 and +6, which is pretty typical for Caninsulin (my guess is more towards the +4/+5 mark). So he went lower after you did the +3, and was coming back up by +7.

Without the tests it's hard to say for sure, but I doubt he went much below 5.5 mmol. I'd hold this dose for a few shots and see what happens, but definitely try to get tests in the +3, +4, and +5 ranges.

With Caninsulin, you ideally want nadir to be around 5 mmol for most cats. It would be nice if his preshots came down a bit more too, but there's nothing you can do about those. They often come down over time.

 

Hi, his +12 is at 12.0mmol. Should I give 0.50units? Or 0. 25?

 

Sorry I'm not usually on this time because of dinner. Looks like you gave 0.25U? That would have been my suggestion, just hold it for a few more shots as long as it's safe to give. I'd say preshots above 8.3 mmol you can shoot, but it's up to what you're comfortable with.

Again, would be super helpful if you could get +3, +4, and +5 tonight. At minimum, +4.

 

ok Done!

 

Nice! He didn't go quite as low as I'd hoped, but it's still not bad.

Nadir seems to be about +3, but that can move around. I will say that probably doesn't bode well for duration (how long the insulin is actually lasting in his body), but it might not matter. Thats just the nature of Caninsulin, hits many cats hard and fast and doesn't last as long as some other insulins. Getting some +8 to +11 tests would give you a better idea, but no rush on that.

Is he free fed at all times? If not, when does he usually eat?

Like I said earlier, hold this dose for a few days, as long as it's safe to give. As many +3 to +5 tests as you can get would be helpful, so we can see how low he goes.

 

I had to change my other cat's diet to make it easier and as preventative measures. I feed them both around 5:30-6am/pm daily. He usually has left over wet food from the morning which I notice he finishes it off around 9am. Then I have two automatic feeders that comes on around 1pm (I do see most of it is eaten when I come home)- I have two cats, but it's most likely Nacho who is eating it as he tends to have a bigger appetite. If i'm at home, they both will eat around 1pm. I also leave another bowl with 1 can out in case the automatic feeder doesn't work and he gets hungry between 9am-1pm or after. Then I think they just go to the bowls whenever they like (it's hard to control during the day) but I always make sure there is wet food out for him. My other cat mostly eats on schedule. Then I see him eating around 10pm or 12am if there was left over food.

 

Ok thanks! I was just trying to get an idea how food might be influencing the cycle

 

Hi, should I give insulin at 9.2mmol (PMPS)? Yesterday night he did not allow me to give insulin he kept running away and was just not having it, and AMPS was at 10.7. Not bad! I did give him 0.25units this morning (quite the challenge). What do you think I should do. It might want to attack me again today.

 

By the way, he has never been that way. He's always such a good, calm boy and let's me do everything to him. He cried out the night before (not sure why) and since then, he's been scared.

 

I would give 0.25U, provided you can test +2 and +3 to see where he's at/where he's heading. If you can't, I'd suggest 0.1U.

Sometimes the insulin can sting, but that doesn't usually happen until around 5U of Vetsulin. Perhaps the usual area is sore? Maybe you're going too far and hitting muscle? I'd try a different site altogether if you're comfortable with that.

 

OK, yeah unfortunately I can't do another injection site on him. I think it might be soreness. Thanks.

 

I retested and he is at 7.4. I will not be giving him insulin tonight.

 

Understandable!

Just be sure to test for ketones soon, he's been reduced on insulin pretty quickly

 

Keep an eye on that avoidance behaviour associated with the insulin. It might be Nacho's way of telling you that the Vetsulin is making him feel bad (he's in fairly good numbers - potentially his body might be fighting the dose?).

I know that you've skipped tonight but is there any chance you could get a +2 or +3 test tonight to see whether Nacho's BG might have gone lower after his evening feed?

It might be worth considering dropping the dose down to 0.1IU for a few cycles to see how Nacho gets on, but don't lower your current 'no shoot' limit.


Mogs
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Hi, today I did a glucose curve. Please let me know what you think! Thank you!!!

 

Thanks, I just saw this It seems like Nacho is letting me inject him now no problem.