Unregulated 7+ months with inconsistent numbers - Help!

Hi FDMB! This is my first post, but I've been reading and following along for months.

My cat, Binx, was diagnosed in early May 2024 at a routine vet appointment... we had caught it early! However, I haven't been able to get him regulated since and I'm at a loss for what the numbers/readings are telling me... so I thought I'd try this great community.

Binx started on a combination diet of DM wet and DM dry, for a couple months. We started him on 0.5, using the SLGS method and gradually ended up increasing him to 3.5 units. Around the same time, after reading some posts here, I thought I'd try switching him to an entirely wet food diet. Since then he's been on a combination of DM wet pate and FF assorted pate. Immediately when I switched him to full wet food, we noticed improvements. 3.5 units was much too much. We tried 2 units, that was too much. We tried 1 unit and that was too little. So, eventually we landed on 1.5 units. We held this for a while and after curving him at home (using the AlphaTrak 3), noticed a regression and no signs of stability. We gradually upped him back to 2.5 units and we really saw improvements, but once again hit a road block of excessive bouncing when curving (you'll see this in his spreadsheet). Binx has had 4 rounds of a Libre 2 sensor and the results have been a mixed bag to say the least. Binx's spreadsheet shows the latest two Libre 2 sensor readings (note, it doesn't provide numbers higher than 22.2 mmol/l or 400 mg/dl... but from manual readings I know he hovers in the low 20 mmol/l or high 300 mg/dl when insulin is not effective). I've also input some AlphaTrak 3 data, when I was taking readings before every dose.

Overall, Binx's temperament is great. He plays, he cuddles, he grooms. He is quite hungry, but he doesn't drink in excess (compared to his really bad days). His hind legs have been impacted and they are weak, but when he is doing well on a certain dose, he gains strength back. He has lost about 1 pound since being diagnosed and this is concerning. However, my vet initially gave me the wrong calorie target and I just found out this week. Initially I was told to aim for 270 kcal but now I've been told to aim for 300 kcal, so I've just adjusted.

I don't know how to make sense of any of these numbers and neither does my vet at this point. I'm wondering if anyone in this community can review the numbers and hopefully catch something we're missing?

 

Welcome Briana and Binx
You couldn't have found a better group to join
I'll tag some experienced members for you
@Wendy&Neko
@Sienne and Gabby (GA)
@Bron and Sheba (GA)
@tiffmaxee
@Sienne and Gabby (GA)

@Briana Z
Are you using the U-100 syringes with the half unit markings? We adjust the doses by 0.25 units at a time
If not

found this posted by a member about U-100 syringes with half unit markings from Canada
Check out your local pharmacy for the BD Ultrafine II syringes (purple and yellow box). Those are U100 syringes. If you have a Costco near you, check them out. Or Safeway pharmacy

 

Thank you, Diane!! I'm using the U-100 syringes but my vet has never mentioned adjusting the dose by 0.25, only 0.50. Definitely something I will look at - would you just aim for somewhere in between the 0.5 unit markings?

 

@Briana Z
For example let's say you wanted to give 1.25 units
You would bring the plunger between the 1 unit and the 1.5 units to get 1.25 units

• Full and half-unit syringe scales:

 

Just a suggestion have you ever thought of using the Freestyle Lite Glucose Meter or the Freestyle Freedom Lite as a back up instead of the Alpha Trak, since the Libre is considered a human meter
@Briana Z

 

Hi Briana and Binx and welcome to the forum.
If you are feeding an all wet diet, I would swap to the tight regulation dosing method to see if we can get Binx into better numbers. I see you swapped to 2 units in the am two days ago but were still giving 1.5 units in the pm dose. It is better to give the same dose am and pm so I would change the pm dose to 2 units as well and see how he goes. Start posting every day for guidance and in a few days I will send you over to the Lantus page where you will get more help.

 

TR link
https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/

 

Hello and welcome, waving from the west coast.

For the doses with .25unit changes, we do eyeball between the marks on the syringe. Some people put coloured liquid in a used syringe as a template to show what they used for those in between doses.

When you are doing the testing with a manual blood glucose (BG) meter, it's still a good idea to try to get some tests in the middle of the cycle when you can, and a curve every week. Those night times it's also a good idea to get a "before bed" test, as Binx has shown you he likes to go lower at night. Not uncommon many cats do that. We determine how to change the dose based on how low the dose takes the cat, hence our interest in night time spot checks.

Responding to some of the spreadsheet comments, more smaller meals are better than one large meal. Ideally most of the food should be consumed in the first half of the cycle before nadir, as the insulin effect is wearing off after that and carbs can make the numbers zoom up.

One other comment, what some people call Somogyi is not the same as what we call a bounce. Research has shown that Somogyi is very rare in cats using a good long lasting insulin, starting with a lower dose, and doing safe increase. Binx is just plain bouncy.

 

In addition to the observations that others have made, what I noticed is that I think you're holding doses for too long. Most notably, you've held the 1.5u dose for almost a month. With the dosing methods we use, a dose isn't held for more that a week and with Tight Regulation, not for more than 3 days unless your cat is in normal numbers. If you are sticking with a dose that isn't getting numbers into the range you're looking for, it's possible for glucose toxicity to develop. The name sounds worse than it is. What happens is that your cat's body starts to treat the high blood glucose levels as the new "normal." It makes it harder to get numbers to come down.

 

Not something I had considered until now. I think I read somewhere on the forum that the dosing methods here are based on human meters so that may be my next purchase. I will look into this!

 

Vey helpful! Thank you! Another thing not mentioned by my vet... I'm starting to see a trend with this. Thank you, Diane, for sharing the TR link... I will spend the day educating myself and look to keep the dose the same for AM and PM.

 

More amazing insights here, thank you!! I had been hesitant to do more frequent manual glucose monitoring for fear of pricking his ears too much, but it sounds like that is pretty normal and what I'm seeing a lot of in everyone's SS. I know there's great information about healing and protecting the ears, so I'll give that another read.

Interesting note about bouncing vs. somogyi! My mistake for equating them, thank you for clarifying! A bounce is a sign of a dose being too high though, is that correct? Again, I'll be spending my day combing through the forum for more information too!

 

My mind is blown, Sienne! This whole time I've been under the impression that the goal is to get Binx to one dose that works consistently forever (or rather for a very long time)... but it's sounding like from this (and from reviewing some SS) that dosing is an ongoing change, not just initially but likely for weeks/months/continually to keep Binx stable. Am I understanding that correctly?

I'd never heard the term glucose toxicity and it sounds like it could definitely explain some things. This whole time I've been scratching my head trying to figure out why a dose is good one week and not good the next, but then at the same time why a dose is perfect one week and the next it's too much. Sounds like I really should be listening to the numbers and adjusting accordingly.

 

If you were to think in terms of a human, we test regularly and there are parameters for making changes in the dose. Insulin is a hormone. It's not like an antibiotic where there's a fixed dose that you take for a specified period of time. Your last sentence summed it up beautifully -- you should be listening to what the numbers are telling you.

 

No, a bounce results when their body sees numbers lower than they are used to, or if they do a fast drop. So if a kitty spends a lot of time in high numbers, that's what they are used to. In the beginning, even numbers well above normal blood glucose may still feel low for them. We mostly ignore the bounces, or try to. It should be over in 6 cycles/3 days or less.

 

Hi Bron! Back with a follow-up question. I was at the vet today for a weigh-in and was hoping to discuss all this great info I've been given - including keeping Binx at the same dose both AM and PM but the vet was unavailable and the vet tech (naturally) discouraged me from making any treatment calls without discussing with the vet first. Is there a suggested approach when trying to advocate for your pet's care vs. following the vet's directive? I'm finding it especially difficult because they're only available 3 days a week and that makes any adjustments with their approval slow.

 

Many of us have been in the situation you find yourself. It can be hard to challenge your vet.
However many vets do not know a lot about feline diabetes as they may not come across many or they have not updated their knowledge of it. And they have a lot of other diseases and animals to get their heads around.
Here we deal with feline diabetes and all of us have had to manage it 24/7.
My vet was great but he also acknowledged I knew a lot about FD from experience and he was happy to let me do Sheba’s dosing. That happened over a period of years though. And at times I know he thought I was a bit crazy, especially how often I tested the BG.
Some vets are happy to listen and learn from FDMB members but others feel threatened.
If you don’t want to have a full on discussion with him, and it can be uncomfortable, I would suggest you just smile and nod when he says to do such and such with the dose, and then go home and do what you feel most comfortable with. Remember you are Binx’s advocate and the only one who can stand up and talk for him.

 

I also had that discussion with the vet about doing the same dose both AM and PM. She was much more used to Caninsulin/Vetsulin where that could make sense, and was not so familiar with the depot nature of Lantus. I might have been her first client on Lantus - a locum vet switched us and pointed me here to FDMB. . I let the vet know that I was following a dosing protocol that has been peer reviewed and published in a veterinary journal (Tight Regulation). I gave her a copy of the document. For the first while I would drop off spreadsheets every week. Until she asked me to change to a chart format she was more used to. I think I did that once or twice, then stopped. Too much work. Our conversations changed to her asking "what dose is she on", then that was it.

Anyway, the reason vets often suggest lower doses at night is so you can sleep. Which makes sense with in and out insulins. The problem is that with the depot nature of Lantus, the dose you shoot in the AM often influences the night time cycle too. See how the lower dose at PM means Binx is higher during the day?

My vet worked 4 afternoons a week and I found the same as you - it took a while to get feedback. The vet often returned my calls end of her day, after 8PM, which was too late for the dose that night. I took the leap of faith and relied on here. Neko needed quite a bit higher dose, it would have taken even longer to get her regulated if I'd waited.

 

Thank you, Bron + Wendy!! It's very validating hearing both of your stories about interactions with your vets... the number of times I've felt like the crazy cat lady with all the emails and calls I make to them, just to get some medium answer.

I appreciate that my vet is incredibly busy and overwhelmed with care for other pets but I may also be at the point you reached, Wendy, where it's time to take a leap of faith and rely on the wealth of knowledge here. It's given me confidence that I can make sense of what's best for Binx with the many resources available and even more so that there are experienced members like yourself ready to support.

Spending the weekend putting together a thorough email for the vet on how I'd like to move forward (based on the TR protocol). I'll have a conversation with them at the very least but if they cannot support, smiling and nodding it will be.

 

I got the Freestyle Lite this weekend! I figured especially since the dosing methods refer to numbers based on human meters this would be the best call when starting the TR protocol. For the first few measurements, I've been using both the AlphaTrak and the Freestyle, just to get comfortable with the difference in numbers (I've now read several threads about this, since I was initially so surprised). However, I got one weird reading...
PMPS: AT 17.7, FS Lite 12.6 (expected)
+7: AT 18.7, FS Lite 11.9... an increase with the AT was a decrease with the FS Lite

Is this just a result of the meters inherent accuracy range?

 

@Wendy&Neko
@Sienne and Gabby (GA)
@Bron and Sheba (GA)
@tiffmaxee

 

Depending on country, but the meters can be out by what we call manufactures variance, and it can be up to 20%. Which is a more significant amount in higher numbers. Did you use the same blood drop for both?

 

Noted, thanks! And yes, same blood drop for both.
I’ve continued to use both meters today at each reading and it hasn’t recreated the same issue so must’ve been due to the variance.

 

Hi all! I wanted to provide an update as Binx is now 9 cycles into the TR protocol and we've just done his first increase of 0.25 units tonight. I'll be monitoring closely to see what happens.

My biggest question is about his bouncing - PMPS number is usually low (the lowest but maybe not his true nadir, as I've fed him at these shots). I know he usually trends up shortly after this (November data with these lows shows a nadir at +13/+14 [but again, he did get food at this time, just no insulin] and a quick shot up for the rest of the cycle) and he also has a late nadir at night, so I have been giving him the full 2 units (even with a reading of 137... perhaps this was too risky too soon). At night, it's harder to collect data so I've only been able to get readings during the first half of the cycle (except last night when I set a 4am alarm and saw his BG had shot UP). I likely need more time and data to see how this charts out and I'll be doing a full curve every Friday moving forward... probably so more early morning alarms too.

@Sienne and Gabby (GA) I saw a comment of yours on a somogyi/bounce thread that noted for humans the recommendation is to decrease and for cats, it just results in high numbers... which is one of the reasons I've moved forward with the increased dose tonight. If you have any more advice here, that would be great!
@Wendy&Neko I saw a comment of yours on another thread about lantus dosing and how Neko didn't have a "normal nadir" often at +9 or +12. I'm wondering if you have any advice on dealing with this or is it just about knowing the numbers/data and knowing your cat? I also saw "BCS" in Neko's SS - is this in reference to reducing the dose for that one shot?

Thanks all!

 

BCS = Big Chicken Shot, or a one time reduced dose. Neko had a higher dose than a lot of cats, so that higher depot was also a force to be reckoned with. Also, she had a pituitary tumour causing her diabetes and after I had it treated it could mean some rather rapid drops is dose needed. Hence the BCS to reduce the depot.

Neko was on Levemir for a lot of her time, and Lev tends to have a later typical nadir. Neko had both a later onset and later nadir on both Lantus and Levemir that most kitties. If a cat is breaking a bounce, that can also lead to a later nadir. A lot of the first blues (then greens) I saw for preshot were immediately followed by yet another bounce. You are right that gathering data on your cat is the way to deal with it. If you haven't been over the Lantus/Levemir forum yet, I recommend you read the Sticky Notes there, including this one:
Tight Regulation: Becoming Data Ready to Shoot / Handle Lower Pre-shot Numbers