Help please - Lev cat

Hi
I am triple posting to health, Lev and Lantus. Akane's numbers seem to get worse and I need help. It has been 4 months since the switch. He was better regulated on PZI and he was better at the beginning on Lev, it seems. I am very worried.. Which way is the right direction? Decrease? Increase? He is eating well, poop, play, preen, purr all good. Peeing and drinking increased but he seems OK at the moment. Ketone negative. Our vet said that as he has pancreatitis (spec fpl is 6) and a little kidney insufficiency, perhaps he was getting gradually difficult to be regulated and she did not give any instruction about dosing. I do not agree with her view but also do not know what to do.. I just want to get him better, steady numbers. I am not hoping remission. Appreciate your thoughts. Thanks..

mami

I have a couple questions.

What syringes are you using with the Lev? You need to be using u100 syringes.
What is that dose you are putting on your ss? That 0.3 or 0.4 is not something I recognize. If you could record the dose in numbers better understood (are you using u40 and converting the dose value?) more people will be able to help you with dose ideas.

How are you treating the pancreatitis as it is quite painful. You will need to give pain meds and also giving 1/4 tab of pepcid AC 10mg should help your cat. I also give subQ fluids at home when my cats have pancreatitis.
You mentioned that you disagree with your vet, I hope it's not regarding the pancreatitis because the normal range for that fPLI test is 0- 3.5 so the 6 may be mild but positive.

After a day of low numbers, the next day could be partly a bounce. Also, pancreatitis is a condition that may cause higher BG.

Hi Mami~and welcome to you and Arcane!! Here on the Lantus forum, there are many kitties on Levemir too! As a matter of fact, my two have been using Lev since the switch from Vetsulin.
This is a very active forum here and we post daily. It's like a big family! A good place to star would be with reading the stickies at the top of the page. I know you read the Tilly Protocol and that is a good thing. We use that as our guide here. There are specific instructions for changing the dose. We usually increase/decrease in increments of .25u.
A good place to start is "New to the Group" viewtopic.php?f=9&t=18139

So Arcane was dx in 2007? You were on PZI...any other insulin?

Glad you are using the half unit syringes. And good job on the SS! Others will hopefully stop by and talk to you about the dose. And yes, you are right with what you said about the different doses. Levemir and Lantus like consistency. So we shoot the same dose both AM/PM and only raise or lower the amount according to the protocol It has worked for many kitties and we have a very long list of kitties who have gone into remission. the Protocol works!

Please read the stickies and then come back and post any questions you may have. We post a new condo (thread) each day and link the previous days condo to the first post of each day. You are welcome to visit others and see what is going on in the neighborhood! :lol:

Can you tell us what type of meter you are using?

We suggest having karo syrup and a supply of canned gravy foods on hand. You should have high carb >18% on hand at all times to bring the numbers up if needed. There is info on the Hypo kit in the stickies.

I hope you will be able to post here each day so that we can watch Arcane's progress! Again, Welcome to the group! :mrgreen:

First, please read the sticky note at the top of the board regarding the Tight Regulation Protocol. This is the method we use to guide dosing decisions. There are links in the note to the formal version of the protocol. The protocol has been published in top tier veterinary journals and is geared to be used at home.

I'm not sure I understand how you've been dosing. You also made notes early on that you were diluting your Lev. Lantus and Lev should not be diluted. Sliding scale dosing is not recommended for Lev -- it is more appropriate to PZI or other, shorter acting insulin. Lantus and Lev both require consistency in dosing. These are depot-type drugs and are very different in their pharmacological action. It takes a very different mind set than using PZI.

What were the interferon and acyclovir for?

You've noted that there's bouncing. I see that too. I also suspect that your cat may not be getting enough insulin.

Gayle: The link to Health indicates Mami is using U100 syringes. I'm assuming the dose is an approximation.

Hi Mami..

I responded on Lev...

"Hi Mami,

please remind us, how are you treating the pancreatitis?

That can be a very painful problem and kitty needs some pain meds. Pain can make BG's go higher.

I would be concerned about giving more insulin than the .4u ( 4 tenths of one unit) b/c he has gone so low at least twice recently on that dose.

When my PK had pancreatitis I gave buprenex ( pain killer) and fed the lowest fat wet food watered down- I had to synringe feed as his tummy hurt too much for him to eat on his own.

I also gave sub Q fluids- lactated ringers- all this as per vet and the FDMB message board.

Please tell us what treatment you are giving for the pancreatitis and how long ago that was diagnosed.

I do also wonder if there is some need to lower that dose more- that the high BG's might be bounce, but I tend to lean more toward this being a result of the pancreatitis...will wait your response before commenting further.

I know there is a bit of a language translation issue, so if you want me to clarify something, please tell me.

hang in there!"

Thank you for your replies, Gail, Pat, Sienne and Melissa.I am using BD 1/3cc for U100 with half unit markings 30G. And I am dosing him less than 0.5u. Struggling how I can dose him precisely.. even though I spent lots of time practicing and being more than careful when drawing insulin. He had been on BCP-PZI 40U only until last Nov. He is a low dose cat from the dx. Started home-testing and low carb diet in Dec 2009 after he survived DKA. I am using Free style freedom.

I had his spec fpl tested at the end of Dec. I was very glad with the result because it was much much better compared to 21mg/dl when he was suffering from severe vomiting and inappetence 2 years ago before DKA. And I know a cat who's spec fpl result was worsened but the cat seems to be much better with supplements so I was not worried about the result. But it could be the reason for his high numbers..I see.. I sometimes give him famotidine (the same ingredient as Pepcid AC) when he sounds unhappy and eats grasses a lot but now he does not seem in pain.. Our vet dose not give him sub q fluids yet.. I need to find another vet who can allow sub q fluids at home for future when he needs it for kidney. Here not many vets permit it, unfortunately.

Interferon and acyclovir were for his sneezing. He did not have fever and the vet suspected a mild herpes virus infection. I only gave him acyclovir two times and gave him l-lysine later when I got it.

I am aware of dilution and sliding scale.. Appreciate your advice.

Thanks, Melissa, for posting here too.

I agree with Melissa that more insulin is not the way to go. Getting to 80 and 62 on that dose indicates that it is not too little insulin. It is possible that he dropped lower later last night. He did drop to 25 on the .3u dose a month ago. The 300s/400s are probably rebound/bounce.

However, did he suddenly start acting like he is getting a pancreatitis flare in the past few days? With Beau that was always a decrease in appetite, but other kitties will act like they are sick or in pain by withdrawing, "meat-loafing", or being grumpy (growling when touched, hissing when picked up, etc.). It seems like his last flp test was 6 weeks ago? A lot can change in that amount of time. If he is acting ok, as you indicated, it doesn't sound like a p-titis flare to me. Also, when Beau flared, his BG actually dropped and he needed less insulin because he wasn't eating as much. But pain can raise BGs. So, every cat is different.

I would suggest watching him very closely for signs of feeling ill (loss of appetitie, etc.), test for ketones every day and hold the dose so it can settle out of the rebound. The 62 and 80 are beautiful numbers (although they were arrived at rather quickly in 3 hours from the preshot), but he isn't used to them yet so they are causing a bounce.

Please try for some later numbers after he goes to 60-90 before +6, even if you have to set an alarm and get up to test. He may be dropping even lower than 60. That would explain staying in the high numbers today. If he is dropping lower, you may need to back off on the dose. It would depend on how low he is going.

Thanks, Sheila. I replied on Lev..

About dosing. Those highs are a bounce from 60, yes, I expected one or two cycles of highs though not as severe as he actually did for the first cycle.. but he read 306 AMPS on the 2nd cycle so I was hoping he would continue to come down during the day a bit because he usually does but he went up again. And again.. Is it a consequence of dropping to 60? Would "decrease" be the direction? If I decrease the dose, he may come down but I noticed that it was just temporary when I tried it.. Sorry I am confused - he did not stayed high like this even when he was given .5 before and if thinking various things, I do not know how to interpret..

Mami, welcome to LL!

A couple of thoughts....several members here have commented about the BD syringes being very inconsistent for dosing. Since you are microdosing, those small variations are much more significant. I would suggest going back to Monoject syringes.

How old is your insulin? Is it cloudy or does it have floaties in it?

Bouncing is a very common problem, the best way to respond to bouncing is to hold the dose. It's part of LTS (liver training school).....you need to keep showing him those lower numbers until his liver learns that those numbers are ok. Reducing the dose is not a good solution because you will end up with higher numbers overall. The lows you are seeing are in the normal range and don't require a decrease in insulin dose.

You mentioned herpes virus...does he have any URI symptoms?

What is his feeding schedule?

welcome to Lantus Land!

I have a one word answer to your questions: data.

Ok, I pretty much never say anything in just one word :lol:, but I do think data will be the key to finding the information you need. We can speculate all we want, but there is an easy way to find out what is going on. You do a good job of testing during the day, but we suggest a before bed test every night. Lots of cats have more action at night than they do during the day, so without that test you are missing half of the picture. As you can see, on the one night you did get a +3, Akane had dropped almost 200 points!

My first impulse in looking at your spreadsheet was "too little insulin." But there are a few hints here and there that that might not be the case. More night data will help fill in the picture. You don't have to stay up all night every night, but do grab tests whenever you can. If you see a big drop like on 2/6, don't go to bed without another test to see if the drop has stopped. Even one more test that night probably would have given us the information we need - did he continue to drop after that 62 to a very low number? Or did he surf there all night until the bounce started? I see on his spreadsheet some times when he did drop low quickly and surf, but I see other days where he nadired later. My guess is that he dropped lower and he is still bouncing from that (these counterregulatory hormones can stay around for up to 72 hours). We make dosing suggestions based on data, not guessing, so if you get the data then the dosing will be easy.

What if he really is bouncing this much on a tiny dose? There are a few options. Reducing the dose is one thing you can try. Usually we find that the bouncy kitties just get even more bouncy when the insulin dose is reduced (because they are not getting enough insulin to overcome the higher numbers). For many of the cats with patterns that look like this, what is working very well is to alter their feeding schedule slightly to help slow down those fast drops. Over time, that will allow the insulin dose to be safely kept a little bit higher so it can help bring down the high numbers, without letting the cat get too low on the other end. Each cat is different, but getting some data will help us help you figure out a good way to manage Akane's numbers.

It is important to keep in mind that Lev requires patience and improvements don't happen overnight. Breathe, and let us help you! I would hang onto the current dose for a few more days and work on collecting as much data as possible, then we can see what the numbers tell us to do.

Re: Help please - Lev cat / reducing

Great comments... (Hi, Libby!)

In my opinion, Akane's chart reflects a lot of messing around with the dose, popularly known as "dose hopping" (a practice that has to do with the bean more than the cat) and which has consequences of the sort where the metabolism is effected and therefore the data for long term insulin need is corrupted and misleading. I think Akane's chart is a textbook case -- at least the Lev part. For that reason I am not in the lower-the-dose camp, as some of my Levemir mates are.

High numbers are often blamed on rebound... sure .. but I think there is reason to believe that lows in response to a reduced dose are also a form of rebound. As Mami points out, Akane comes back up, and alarmingly so. If that rebound is then interpreted as still too much insulin (whereas it is a response to too little!!), it's a disaster because we are taking a cat on a relatively low dose and figuring out how to undermine its systems.

I am suggesting that low numbers in response to reduction can be an "inverse rebound": caused by the pancreas responding to a reduction by calling on reserve capability and delivering an amount of insulin to handle the sudden shortfall. The bean cuts the dose in half? to a quarter of what it was? Fine, you may see lower bg but it is a mirage: the cat is diabetic and can't be operating in emergency mode all the time. Pretty soon the dose is reluctantly returned to higher levels. Poor cat.

I would say the idea that reducing the dose is a possible solution, is not goofy. What is goofy, and possibly destructive, is falling into the belief that it works in more than a minority of cats. Of course it works from time to time -- in those cases where there is the exact set of complications, such as metabolism issues, that present diabetic symptoms.

But exactly what percentage of cats is that? The disease is diabetes, and the last time I peeked, the cause of this disease was not a surfeit of insulin.

My tuppence, centimes, eurocents, whatever.

So nice to see the familiar names. Best regards to all..

Ilkka

Thanks Laurie. I noticed inconsistency in BD syringes, too, so I preferred Monoject but my order from US has been stopped at the customs so I am using BD without choice at the moment. I am trying to pick a good one checking zero line. I sent necessary documents by mail yesterday to a relevant office so hopefully I get them, soon. The insulin is quite new. I bought it the end of January. He is not showing any symptoms right now. He sneezed and there was a noise around upper bronchus when I took him to the vet. He gets food when he asks but he will not get too much. He usually eats small portion of low carb wet or raw at one time.

Thank you for your insights, Libby and Ilkka. I will try testing before bed when I can and fill in the picture. Thanks for the good explanation. It helped me to understand our situation clearer.

Hi Mami! Thanks for the answers, it helps to rule out some common problems.

Sorry to hear about the syringes being stopped at customs, I hope you can get that cleared up! It can be difficult when importing the supplies you need. I guess we are spoiled here in the US with so many different syringe suppliers to choose from. I'm glad you are aware of the problem with the BD syringes, it sounds like you are doing what you can to ensure consistent dosing.

I have a herpes virus cat also, he struggled with a chronic URI for months....so that caught my attention. I'm glad to hear that he is not showing symptoms.

I'm happy to see that his numbers came down somewhat. nobody likes those high numbers! I agree with what Libby said, holding the dose and collecting more data will help us to get a clearer picture.

Small frequent meals are good. I was thinking the same thing as Libby when I asked about the feeding schedule, sometimes more feedings just before and during the most active part of the cycle can help slow the drops and eliminate some of the bouncing. Bouncing can come from a fast drop, even if the cat doesn't go very low. It would be helpful if you could make a note of when/what you are feeding on the SS so we can see the effect of food.

Re: Help please - Lev cat / small correction, & etc.

dosgatos said:

Thank you for your insights, Libby and Ilkka. I will try testing before bed when I can and fill in the picture. Thanks for the good explanation. It helped me to understand our situation clearer.

Click to expand...

yw Mami

I made an error -- I should not describe the dose-reduction-induced low bg numbers as inverse "rebound," but as an inverse bounce.

The cat bounces down because of less insulin, and if at that point the owner misinterprets the low dose as a success, it's made worse. The bg level going lower is thus not false data, but it is a false indicator; all of this is counterintuitive until you realize that the injection is only part of the insulin delivery. The cat is continually responding to dose, and it does adjust its systems accordingly; so the actual dose (i.e., actual insulin in), is the injected amount + what the cat provides -- and what the cat provides is variable. Adrenaline is a response to a threat, insulin is the response to a shortage -- if the cat has capacity to respond. What that means is that however precise we are in our dosing, we should not confuse that with the actual insulin levels in the blood day to day, because we are not metering the cat's input part of it.