Rooh cant seem to get regulated

[Jmeli]

We started insulin 11/28, PZI at first then switched to Lantus 12/18 as it was my vets first choice to begin with.
We have yet to find a dose that works for him. Every time we increase the dose, it seems to work for a few days and then stops working.

I am a little confused that his BG numbers are higher now than they were before we started insulin or as far as i know it was in the 400's before we started insulin and now it reaches 600 before shots.

A few days ago we increased his dose to 4 units and now it looks like his onset is really delayed plus he isn't going all that low from it.

I am really unfamiliar with diabetes but since his diagnosis have read up on it constantly from all the links on the forum here. Can anyone tell me if what we are going through is not unusual or is it unusual?

Is it still just a matter of finding his right dose?

When he is still on the downswing like tonight am I supposed to give him PM shot? I am pretty sure i read not to do that, but since his numbers are still so high (4oo) , should i give it anyway like I did tonight?

His SS is updated if someone could please take a look. He is eating lowcarb canned FF pates and fish and some dry EVO. He was not an overweight cat before diagnosis and the past 6 years his diet was mostly dry NV instincts which is 12-14% carb. He has had a heart murmur for the past year. I would like to figure out what is the cause of his diabetes but from what I have read it sounds like that could be near impossible to figure out.

EDIT - He started on Prozinc not PZI

 

[tiffmaxee]

Hi Melissa. I just took a quick look at Rooh's ss and see you are increasing in much larger increments than I did. Have you had a chance to look at the stickey that explains the protocol? We increase by .25 of a unit and allow enough time to see what the dose will do. I don't give dosing advice but I think it is quite likely that your cat is getting way too much insulin rather than not enough. Someone with experience will be on to suggest how to correct this if I am right.

 

[Vyktors Mum]

Yikes on the dosing. I think with PZI you may base the dose on the PS number but that's not how it's done with lantus. Starting dose is generally .25 units per kg of cat (or per kg of ideal weight if kitty is a bit chunky) and increases are in .25 increments done in a steady systematic manner so that you don't miss the good dose - I suspect that this has happened in Rooh's case. I think it's going to be a case of start again at the beginning for Rooh but wait and see what others think.

Nice job on the testing, you are testing plenty to do the tight regulation protocol which can be found here have a read and you will be able to see where you have been going wrong. Don't beat yourself up about it though, we will be able to get you and Rooh back on track I would recommend that for a while at least you start posting a regular thread here for Rooh (many post daily) so that we can keep an eye on you and Rooh and your dosing and get him on track.

You were absolutely right to shoot tonight and you're also right that you may never know what caused the diabetes.

 

[Marje and Gracie]

Hi Melissa and Rooh

Welcome to Lantus/levemir Land. We're glad you found us.

Elise's observation that the dose has gone up in too large of increments is correct. PZI is dosed, primarily, on the preshot, but the depot insulins (lantus and levemir) are dosed primarily on the lowest number (nadir). We typically only raise the dose in 0.25u increments unless the nadir is over 300 or numbers are really high and flat....then we might raise by 0.5u.

Raising in larger increments than 0.5u, unless the cat is a high-dose cat, can lead kitty to being overdosed. It's very easy to miss the correct dose when you are raising in increments that are too much (e.g. 0.75u or 1u).

I think most of the increases were ok (although the jump from 1.75 to 2.5 was too much) but the last increase from 3u to 4u was way too much at one time.

The other thing that is very important when using a depot insulin like lantus/levemir, is consistent dosing. It takes a bit of time for changes to the depot to take effect after the dose is changed. Think of it as a cruise ship. The captain can turn the wheel, but the ship doesn't change direction quickly....it does it slowly.

The dry food in the mix further complicates things. Do you have a schedule for taking him off all dry?

You are doing a super job of testing! That helps immensely so we can see what he's been doing.

I really see little response until he is up around 3u but you were back and forth there, a bit, to 3.5u. Overdosed cats can often just be high and flat which looks like they are getting too much insulin.

If he were my cat, I wouldn't start over. You've done enough testing and we've had starting over not be a good thing for cats that actually needed a higher dose. If he were mine, I'd drop his dose to 3.5u and hold that dose for a minumum of six cycles unless he goes lower than 50. After six cycles, let's see if he's got any blue numbers and reevaluate.

We might find that he needs 4u or more but then you won't have so far to take him up. What do you think about that?

 

[Jmeli]

Thank you everyone for your input. I did read about increasing at .25 units but my vet is very involved with calling the dose, we talk once a week on the phone. When i went to 3 units, she wanted him at 3.5 that week but I saw results at 3 and left it there but when the results fizzled out she wanted to go to 4. Are there any medical journals that reference this protocol that I could share with her?

I did try to take him off of dry and that worked for about 3 days. He lost so much weight the month before diagnosis i just want him to eat and he does eat 75% wet but every few days demands some dry. I also give freeze dried chicken but that doesn't satisfy him when he wants the dry.

He hasn't been tested but I am pretty sure he has frequent pancreatitis attacks. He vomits about every 3 days and sometimes doesn't want to eat.

 

[Ann & Tess GA]

Here is the link to the Roomp/Rand Study from the University of Queensland. It is the protocol that many of us follow here.

 

[Jmeli]

Thank you Ann! btw I just tested him 2.5 hrs after PM shot he is at 171

 

[julie & punkin (ga)]

Welcome to both of you.

There is a great section on transitioning a dry food addict to canned/raw on www.catinfo.org.

 

[tiffmaxee]

My Max has had chronic pancreatitis for five years. I empathize with you. How do you treat it? Max becomes inappetent so he gets ondan twice a day when it happens. That is usually enough to help him. My vet had me take him off dry food when he was first diagnosed and I was told to feed small amounts several times a day. Some give bupe for pain and sub-q fluids. It took some time to find canned food Max liked. He wasn't diabetic then so I had lots of choices. I hope you can find a canned food Rooh likes.

 

[Sienne and Gabby (GA)]

Welcome to Lantus & Lev Land!

Marje summarized my thoughts. What I would suggest is that you share the information from the Roomp & Rand study with your vet. Ann provided the "cheat" sheet on the study. I'm including a pdf of the actual journal article. Since your vet is invested in Rooh's care, she may prefer to have a reprint of the published article. This is a 2009 article that is in one of the top vet journals and hopefully, it will get your vet on the same page regarding dosing. Most vets are most familiar with the non-depot types of insulin or they use the same dosing strategy with Lantus/Lev as they do with insulin like PZI or Humulin N. It doesn't work as well as using the Tight Regulation Protocol

If Rooh is absolutely insisting on dry, perhaps something like Young Again Zero Carb or one of the other dry foods that are low in carbs would be an alternative. Sometimes, you can transition by sprinkling some crushed dry on top of the low carb canned food.

 

[Jmeli]

My Max has had chronic pancreatitis for five years. I empathize with you. How do you treat it?

Tiff, I give him a few ml's of dandelion tea and catnip for pain. I follow it with crushed and liquefied b12 orally a few hours later and lots of love. He usually snaps out of it within 4-6 hours and starts eating again. If that doesn't work then I give 2.5mg pepcid ac which always works but he hates taking it.

 

[tiffmaxee]

Pepcid is another VERY bitter pill. I can't recommend gel capsules highly enough as the cats don't have to taste the bad tasting medicines. Pepcid works for stomach acid and that type of nausea but isn't enough forpancreatitis nausea and while I have read that catnip might help with pain I don't think it would be strong enough for full blown pancreatitis pain. For nausea most use cerenia or ondansetron. I like ondnasetron and Max starts eating with it. Just some things to consider if you find what you are doing isn't helping enough.

Another food you might consider to replace the dry is Stella & Chewy's freeze dried. It comes in chicken, turkey, duck, and salmon and the company has told me it is less than 1% carbs. Right now I haven't used it alone but sprinkle it on the canned food.

How is Rooh now?

 

[Jmeli]

Welcome to Lantus & Lev Land!

I'm including a pdf of the actual journal article.

If Rooh is absolutely insisting on dry, perhaps something like Young Again Zero Carb or one of the other dry foods that are low in carbs would be an alternative. Sometimes, you can transition by sprinkling some crushed dry on top of the low carb canned food.

Thank you so much. I do love our vet. She is one of the few around here who understands and believes in alternative medicine.
Honestly Rooh really is transitioned. He eats mostly wet food. But he has his days that he insists on some dry crunchy food and only eats about 1 tablespoon then. I tried baking wet into dry and that was just nasty, my cats looked at it and called me crazy. EVO states on their website that this is 8.41% carb. I did get a sample of Zero carb from Young again he was okay with it, so I think I will order a bag and give it a try.

 

[Sienne and Gabby (GA)]

If Rooh likes the Evo, I hope it's the cat and kitten variety that you're using.

If you go with the Young Again, from what I understand, there's a fair amount of moisture in it. Since you're feeding so little, You may want to freeze what you're not using. Dry food can go rancid very quickly.

 

[Jmeli]

Pepcid is another VERY bitter pill.

Another food you might consider to replace the dry is Stella & Chewy's freeze dried. It comes in chicken, turkey, duck, and salmon and the company has told me it is less than 1% carbs. Right now I haven't used it alone but sprinkle it on the canned food.

How is Rooh now?

This is so helpful !!! Thank you. I had not thought of using a gelcap and I have been wondering what I will do if what currently works stops working. My other cats eat Primal freeze dried but Rooh will not touch it. He insists on hard and crunchy when he wants it. I do think he is transitioning himself to wet because he is eating the dry less and less often. Maybe he is loosing interest since it doesn't have the amount of carbs it used to have.

He has been waking me up like clockwork every morning the past two weeks at 5 am wanting food even though i feed him and leave wet food out when i go to bed which is usually between 11-1 am.

This morning his number was 406 before eating at 5am. It was 169 at 1am. and it is 600+ now at 9am pre AM shot. Its like his PM shot are not even working or maybe he is bouncing?

 

[Jmeli]

If Rooh likes the Evo, I hope it's the cat and kitten variety that you're using.

If you go with the Young Again, from what I understand, there's a fair amount of moisture in it. Since you're feeding so little, You may want to freeze what you're not using. Dry food can go rancid very quickly.

Yes it is the cat and kitten.

 

[tiffmaxee]

I give Max freeze dried chicken as a treat after ear pokes and sometimes sprinkle some on his canned food. I buy large human cans now from honeyville.com because it is way cheaper than pet fd. I get 1.5 pounds for $53.

 

[Sienne and Gabby (GA)]

When you have a chance, can you add the numbers from last night to your spreadsheet/

I think Rooh is bouncing. The drop from 406 to 169 is substantial and into a range that Rooh hasn't spent that much time in. When drops are fast, large, into low numbers, or into numbers the kitty is unaccustomed to there's a good chance that a bounce will follow. The more time Rooh spends in normal numbers, the less bouncing should occur -- or at least that's the theory.

 

[julie & punkin (ga)]

This morning his number was 406 before eating at 5am. It was 169 at 1am. and it is 600+ now at 9am pre AM shot. Its like his PM shot are not even working or maybe he is bouncing?

I agree that these high numbers are coming from bouncing. Here is a longer explanation of bouncing and New Dose Wonkiness that might be helpful. NDW is when a cat has higher blood sugar in the next day or two after increasing a dose. Some of the higher numbers might come from the dry food, too, although what you have sounds relatively low carb. With regular dry food we've seen even 3 pieces of crunchies raise the blood sugar for as much as 24 hours.

I want to encourage you to not increase the dose at this point because of the higher numbers. That 169 last night tells us that 4.0u can get her at least into the 100's. I'd hold this dose for a minimum of 3 days (6 consecutive doses of 4.0u including the 5 shots you've already had at 4.0u) to see if it can get her there again.

One other thing I'd encourage - when you begin to see progress, ie, when the preshot number begins to come down, don't back away from the dose and reduce it. Everyone does it at the beginning - i'm not criticizing, just letting you know - but the path to getting regulated includes shooting the full dose into everything over 150 as a new member, and everything over 50 as you get a little more experience. As long as your cat is eating - I know you're having some issues with pancreatitis, but if she's eating, go for everything over 150 for now. I'm looking at the reduction to 3.0u with a pmps of 201 on 1/15. Lantus doesn't work as well in high numbers, but when you give it lower numbers to work on it does fantastically at keeping a cat's blood sugar flat throughout an entire cycle. That's the goal.

From the Tight Regulation Protocol:

Increasing the dose:

• Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
  • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
  • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.

• After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.

• After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

 

[Jmeli]

I give Max freeze dried chicken as a treat after ear pokes and sometimes sprinkle some on his canned food. I buy large human cans now from honeyville.com because it is way cheaper than pet fd. I get 1.5 pounds for $53.

I buy the FD chicken in 10# cans as well. I buy Thrive brand because it is the lowest in sodium that I have found.

 

[Jmeli]

I agree that these high numbers are coming from bouncing. ....

One other thing I'd encourage - when you begin to see progress, ie, when the preshot number begins to come down, don't back away from the dose and reduce it. Everyone does it at the beginning - i'm not criticizing, just letting you know -

Thanks Julie. Yes i was nervous about giving him a full dose in the PM since he was on a downswing, I appreciate the encouragement that it will be okay. As for the 600's that only started 1 week after starting insulin. He was initially in the 400's.

Can you tell me why he hit blue numbers at doses of 1, 1.50 & 3 but cant seem maintain them? Did we just not give those doses enough time? It seems to be pattern that he hits blue then the dose does not work anymore and he migrates back up to 500 & 600's.

 

[Sienne and Gabby (GA)]

The most likely explanation is that there is a certain amount of glucose toxicity that's occurred. We have no idea how long Rooh was developing FD. As a result, her body began to acclimate to the higher numbers and treat those higher ranges as the new "normal." This is likely why the bouncing occurs and why it can be so frustrating to get any cat out of those initially higher ranges. There may be other reasons but at this stage of the process, I suspect this is the most likely explanation

 

[julie & punkin (ga)]

Could be a few different possibilities.

There are 3 conditions that can cause a need for a high dose. The most common of these is acromegaly - where the cat has a benign tumor in its pituitary gland that puts out a growth hormone. Think teenage boys. Huge appetite and body actually grows, even though it's already grown. That's what punkin had. The most concrete example I can use is to think of every cell as having a lock. Insulin is key-shaped and must pass through the lock. The tumor output mimics the key and "clogs" it so that the insulin can't get in. Every bit of energy we have comes from the glucose going through the lock into the cell so it can do its thing and nourish us. That output prevents the glucose from being used. The dose for a cat with acromegaly can go up and down as the output from the tumor waxes and wanes. Crystal has acromegaly but hasn't been tested for iaa.

The second most common high dose condition we see is insulin auto-antibodies (iaa.) The body forms antibodies against the insulin and it's basically "binding" it up so it can't be used. IAA is a self-limiting condition, usually resolving in a year or so. Our most famous iaa kitty is Sandy's BK. He ultimately went off of insulin and is living a very happy life, tearing up paper towels into confetti in his free time. LOL but true. Neko and Polly have both acro & iaa. Cobb has iaa but hasn't been tested for acro.

We have some other high dose kitties who haven't been tested to see what's going on. Toby is one of them.

The third condition is fairly uncommon - Cushing's disease. I've only seen 2-3 Cushing's kitties in the 4 years I've been here. Its hallmark is high dose & fragile skin. Nuggie, who just began posting as well, has Cushing's.

All of those need more insulin than the average diabetic cat. The amount varies hugely - we just give the kitty what they need.

We don't usually even suggest that a cat get tested for a high dose condition, though, until they pass 6u per dose.

Seeing a cat initially respond to a dose that then "goes stale" as Wendy says, can mean that the cat has developed antibodies to it. At first the dose works, then it just seems to stop working.

I do wonder about the dry food. I think it would be helpful if you marked in the ss comments when he gets dry food. I know that the companies advertise them as low carb, but i'm a skeptic, and since we have seen that dry food can significantly increase BGs for even another day, that gives me a big question mark about even the low carb dry foods.

ah, I see Sienne just posted to you about Glucose Toxicity. That can be another factor. But since I've already been working on answering you for 15 minutes, i'm going to go ahead and post all of this anyway.

The beauty of following the Tight Regulation Protocol is that if you do that, you can have some confidence that your cat isn't overdosed and it gives you guidelines for just plowing ahead. You don't have to know why it's happening, you can just adjust the dose as needed to get on top of the blood sugar. Even though I've mentioned these high dose conditions, it is too soon for you to worry about them. It could be as simple as glucose toxicity + dry food. Let's go one step at a time and try not to worry about "what if's" at this point.

 

[Jmeli]

We have no idea how long Rooh was developing FD.

I do know he has not been diabetic more than 6 months. He had bloodwork done May 2014 and his glucose was fine. He started loosing weight and going downhill in late October and bloodwork in November showed high glucose, extremely high triglyercides (991 with 160 being normal) high liver values, high cholesterol, decreased T4 from his normal and low neutrophils. We reran his bloodwork last week and everything has gone back to normal except the high glucose and his BUN is now slightly elevated.

Agree I shouldn't jump the gun, but I just cant help myself.

 

[Sienne and Gabby (GA)]

The one thing that a diabetic cat that's on Lantus will teach you is patience. Take a deep breath and try to relax. Rooh is the one leading this dance. All any of us can do is follow along.

 

[julie & punkin (ga)]

diabetic cats are often dehydrated from the excessive peeing. Dehydration can elevate the BUN, so it's pretty common in bloodwork to see that. As he gets more regulated and isn't peeing as much, that will hopefully improve.