Discussion in 'Prozinc / PZI' started by Melissa-Purna, Oct 7, 2020.
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Welcome to the forum! I am no expert but was just curious and had a peek at your spreadsheet, and it looks a bit different from other folks in here. The bright green column caught my eye, because if that was a Bg meassure it would be a warning that Purn is geeting too low. However, I then saw the column labelled as "units". Are you giving insulin more than twice a day?
How was Purna diagnosed? What were his numbers at the time of dx? Were you feeding dry food before dx? Any steroids given? Any infection treated?
3 units is an awful high starting dose for a newly diagnosed kitty - unless there's a known high dose condition we recommend a starting dose of 0.5 to 1.0 units and increasing slowly so you don't bypass the best dose.
What indicated he was getting visibly sicker when you started out?
Was this through observation only? Do you have any BG readings or vet curves from when you were dosing twice a day that you can share with us?
I'm a little bit scared too but by the combination of things. The amount of the dose, the sliding scale and dosing 3 times a day.
This dosing plan is quite different than the FDMB protocols.
We can help. Are you willing to give us a chance?
It'll take time. Regulation doesn't happen overnight.
Have you read the yellow Prozinc stickys (links inserted below) at the top of the Prozinc ISG?
If you have any questions or concerns or need us to clarify anything please don't hesitate to ask!
Sticky NEW TO THE GROUP: THE PROZINC BASICS. PLEASE START HERE.
Sticky PROZINC DOSING METHODS
Sticky GENERAL INFORMATION AND IMPORTANT LINKS
Sticky INSULIN CARE AND SYRINGE INFO Proper Handling and Drawing
I noticed that purna is a gorgeous large cat (18.3 lbs), perhaps that is why the vet gave the high dose? Not saying is correct or otherwise, just highlighting the fact. It still seems quite high to strat with to me.
Did the vet told you to give prozinc 3X a day? Prozinc from everything I read (I am no expert, mind you) is supposed to be given every 12 hours. It is perhaps better to give it only twice and try to adjust thing with food and dosage?
For what is worth, his numbers don't seem too different from most other cats recently diagnosed in here. Feel free to have a look at hercules spreadsheet in my signature. For reference, Hercules is a largish cat (in "height"), and weights 11lbs. He eats 300 g of low carb can food a day and I weigh him regularly to make sure he is staying on his weight. He doesn't loke to behave like he is supposed too, so this is not a very typical pattern, but you can see we started high, and have gone down a lot, and I think we are getting better numbers as we slowly increase.
At this point it's hard to determine what dose you should reset at - we don't have a clear picture of how the insulin is really working over a 12 hour period. Any test information you have from the very beginning may help with this decision.
Prozinc generally lasts 12 hours in most cats. For this reason I recommend you only dose twice a day. Let's see where the 2.5u you gave him this morning takes him over a 12 hour cycle today. Can you get a couple tests in today please?
I further recommend giving the same dose AM and PM and holding that same dose for a week if following SLGS (Start Low Go Slow Prozinc dosing protocol) - unless, of course, anytime the BG drops below 90 mg/dL, immediately reduce the dose by 0.25u at the next shot and the clock starts over. We base dose changes on the nadir or how low the current insulin dose takes kitty not on preshot numbers.
It may take (quite) a few cycles for Purna to settle in to these changes and again it doesn't usually happen overnight. Patience is a must!
Without data for us to see what really went on with the 2 doses a day (you'll find we're seriously data driven here!) I wonder if you were actually seeing some Bouncing and/or the possibility of some Glucose Toxicity you mention. Does any of this seem like it describes what was going on:
Definition from the General Information Sticky
Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce”. It should be noted that “bouncing” is a term we use in the FDMB and might not be recognized elsewhere.
Bouncing can also be triggered if the blood glucose drops too low and/or too fast. The pancreas, then the liver, release glucagon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles). You cannot avoid all bouncing. It is normal and natural, and frustrating. There are some things to keep in mind that can help though:
Following a bounce, a cat’s BG may stay high and flat for several cycles. Avoid the temptation to increase the dose at this point. If the BG does not return to normal in 6-8 cycles, an increase might be needed based on the method of regulation you are following.
Some vets might have little/no understanding of the bouncing phenomenon. Consequently they will look at a single BG number or a single in-office curve and change the dose without realizing that they could be looking at a bounce number, or a high-flat cycle following a bounce, and increasing the dose will make it worse.
There is also a common misconception, often by vets, that bouncing is caused by chronic Somogyi rebound. Michael Somogyi published one paper based on a very small number of human diabetic subjects on the topic in 1938 in a local St. Louis medical journal. There has been no replication of the research and, in fact, anyone that has attempted to replicate the research with humans failed to find similar results. The research has never been done with cats and, just as importantly, has never been done with cats (or humans) using a long-acting insulin.
When it’s not a bounce: in general, during a cycle, the blood glucose should decrease for a few hours, and then begin to increase again. If you plot the numbers on a graph, they should look like a smile. This rise in BG towards the end of the cycle is normal. It is not bouncing. As a cat gets better regulated, the cycle will get a little flatter and the PS numbers will decrease, but in the beginning, it can feel like that rise at the end is a bounce. It often isn’t. It’s just the insulin losing duration. As you slowly reach a better dose for your cat, the insulin will last longer and the numbers will look better.
How we deal with Glucose Toxicity:
From the New to the Group, the Prozinc Basics, Sticky, excerpt from subsection INSULIN RESISTANCE/ GLUCOSE TOXICITY: Worth knowing about:
"This is how we use this concept on the forum: If your cat has been on PZ for quite a while, remaining in “high and flat” BG numbers throughout his/ her 12-hour cycles at the current dose, the dose may need to be increased every 6 cycles by a small amount, until you reach what we call a “breakthrough” dose."
I've never seen a cat on Prozinc needing insulin dosed 3 times a day. I've only seen the 3 times a day dosing with the NPH insulins and in 1 (one) case with a member using Vetsulin for their cat and she tried dosing every 8 hours with the Vetsulin (aka Caninsulin).
It's really rough on the caregiver to dose and test their cat 3 times a day, every 8 hours.
Yes, Google Sheets and Google Drive help people that are only using a phone to setup and use our standardized SS.
There is a version of the SS for dosing 3 times a day. But we'd all like to see you try 2 times a day dosing and adjusting the dose per our well tried out dosing protocols. Used by thousands of cats over the years.
Food can make a big difference in the BG levels. So would you please tell us what Purna is eating now?
You can include notes on the SS, in the Remarks column over to the far right on the food.
Since Prozinc is an in-and-out insulin, rarely lasting beyond the 12 hour dosing cycle, making changes in the timing of the dose are easier than if you are using one of the depot type insulins (lantus or levemir).
You could select the best times for you to give the insulin on a 12 hour basis going forward.
Then skip the latest shot for the day, the evening before.
Think of it as having done a "fur shot" where you did not get all to some of the insulin into your cat.
Start up the next morning at your new selected times.
So if 7 am and 7 pm work best for you, try that. If 6 am and 6 pm work best for you, try those times instead. Pick which times would work best for you.
I'm not even sure what dose to suggest at this point. I would not suggest that you reset the dose back to 1U or even 2U. Somewhere between 2.5U and 3.5U would be a likely good dose for now. But I don't know where within that range would be good for Purna. It's going to take some trial and error to find a good dose. It may be safer to start Purna at the lower range and try to avoid a hypoglycemic episode. But it's your choice on how to proceed.
Your cat did not get diabetes from one day to the next. Signs of feline diabetes can be subtle and overlooked, even by vets. It will take time to get your diabetic cat Purna better. This is a marathon not a sprint. Patience will be required.
SLGS (Start Low, Go Slow) is the most common method used here. Using that method, would have you hold the dose for a week, to see if Purna settles down. I'd like to see at least 6 cycles on a steady dose at a minimum before you make a change. Of course, if Purna drops too low and "earns" a dose reduction, then you take that reduction.
Do you test for ketones by any chance? Either using urine test strips (ketodiastix is one kind) or a ketone blood meter that uses special strips.
Ok on your 2 day dose transition plan, from 3 times a day dosing to 2 times a day. It's kind of similar to doing a slow food transition, when you are trying to change your cat from a high carb dry food diet to a low carb wet food diet. Slower food transitions can mean less digestive upset to the cat.
I'm guessing the same sort of effect for switching from 3 times a day dosing to 2 times a day. But it's only a wild guess. But you could just switch overnight if that works for you. There are always options. Lots and lots of options on how to manage your diabetic cat. We suggest ideas and you choose what works for you.
With your 3 times a day dosing, 6 cycles is indeed 2 days. With 2 times a day dosing, 6 cycles would be 3 days.
The re-evaluation might need to be stretched out a bit more. When you would be reducing to the 3U dose is up to you.
But I see that you already dropped the dose to 3.25U. So the 3U dose may not be far behind.
It's really difficult to see what is going on with 3 times a day dosing. Once you switch to dosing twice a day, there are more people that have experience with that and can help you.
We also don't base dose changes on the pre-shots. Or mostly we don't. We adjust based on the nadirs, or lows. The "mostly we don't" comment is because if the pre-shot test is lower than expected, there are options like stalling, token dose, skipping that come into play. You can read more about these in the
Sticky PROZINC DOSING METHODS
If you print out that document, you can mark it up, write notes in the margins that are helpful to you, and have it to refer to when you don't get a response and need to make a decision on how to proceed. My copy is so crammed full of notes, it's like I've done a "brain dump" of all the many different things I've learned over the years about feline diabetes and some sections have more notes than made in many textbooks. I find it invaluable. Hope you do too.
If his nadirs fall below a certain level, then the dose needs to be reduced and the cycle count starts over again.
You are using a human glucometer, so that reduction number is 90 mg/dL.
Reductions are done by 0.25U per our dosing protocols we use here.