2/7 Penny AMPS 370 cannot consistently get good numbers

[Robyn and Penny]

Good morning everybody! Penny was OTJ for 14 months before having to go back on Levemir on 1/3/15. Before I go on, it should be noted that a rare side effect of the medication Penny is on, gabapentin, is fluctuating and/or high blood sugar and I have met someone on another feline diabetes forum whose cat's numbers were off the chart when her cat was on gaba till she put 2 and 2 together and did a taper, and this particular cat is now well regulated on less than a half unit of Levemir each day. Penny is near the end of her gabapentin taper now. About 2-3 more weeks as I've been taking it SUPER SUPER slow to be safe.

That all being said, it seemed when I was following TR that the more insulin she got, the higher her numbers went, so I started back over at 1u and am waiting for her numbers to go flat before increasing b/c when I was doing TR her curve was looking way more like Lantus than Levemir. And instead of increasing by .25u or as TR calls for, I'm going from 1u to a fat 1u to a skinny 1.25u and so on. I am getting flatter numbers now, which is good, and if you look at the last three days it looks like she needs an increase, but last Tuesday (full moon btw) she had blues all day, a green nadir, and her PMPS was low enough that I did a BCS shot. So I'm not sure I have any business increasing yet when I got a green and almost IDEAL numbers on this dose.

Can somebody please offer some opinions on what YOU would do if this were your cat? Besides hitting the wine every night? lol

 

[BJM]

I might finagle with a basal + bolus approach. Keep the Levemir consistent, then on an as needed basis, use a tiny bit of R insulin to drop the erratic highs.

 

[Robyn and Penny]

What insulin would I use for that BJ? I know nothing about how to do that.

 

[Sienne and Gabby (GA)]

Robin;

I think the suggestion of using R is premature. This is your first post. The use of R is not to be taken lightly. It is a VERY fast acting, very potent insulin. If you are not vigilant, it could cause numbers to plummet. There is a process of "curving" the dose of R that you must use in order to establish it's effectiveness and you have to have the flexibility of your schedule to do this along with the help of someone experienced in the use of R to guide you. We generally don't have people fly "solo" with R until they gain experience with it's use.

That said, aside from micro-dosing, have you tried anything else with Penny? On what kind of schedule are you feeding? What are you feeding? When Penny fell out of regulation, did you have her checked by a vet? How are her teeth?

 

[Marje and Gracie]

As someone who uses levemir and R, I would not support the use of R in this situation. First, we have the gabapentin issue. Then we have a cat that might not yet be at a fitting dose and who might stop bouncing on her own once the gab is done and the dose is spot on.

 

[Robyn and Penny]

Robin;

I think the suggestion of using R is premature. This is your first post. The use of R is not to be taken lightly. It is a VERY fast acting, very potent insulin. If you are not vigilant, it could cause numbers to plummet. There is a process of "curving" the dose of R that you must use in order to establish it's effectiveness and you have to have the flexibility of your schedule to do this along with the help of someone experienced in the use of R to guide you. We generally don't have people fly "solo" with R until they gain experience with it's use.

That said, aside from micro-dosing, have you tried anything else with Penny? On what kind of schedule are you feeding? What are you feeding? When Penny fell out of regulation, did you have her checked by a vet? How are her teeth?

Honestly I wasn't comfortable with it anyway. I have to shoot while she eats with her head in a bowl of wet food sprinkled with Forti Flora just to do her insulin now lol. She had seen several vets at 2 different practices prior to making the decision to put her back on insulin. Teeth checked by all vets and are okay, no underlying infections they could find, blood and chem panel came back all normal besides protein in urine, which can be caused by the gabapentin. She free feeds a small amount of Young Again Zero Carb, which she has been eating since her original DX in 2013 and all through remission, and meal feeds FF Classics and a few 9 Lives pates (before the formula change that now contains rice) The concurrent issue is spinal arthritis and I've been doing the gabapentin taper since around Christmas, and just completed 8 weeks of Adequan injections.

 

[Robyn and Penny]

As someone who uses levemir and R, I would not support the use of R in this situation. First, we have the gabapentin issue. Then we have a cat that might not yet be at a fitting dose and who might stop bouncing on her own once the gab is done and the dose is spot on.

You know? That's what I was thinking. I'm reluctant to increase and then when she goes off the gaba completely she will crash. She goes down to 4mg bid starting tomorrow for a week, then 4mg once daily for a week, then I'll do 4mg every other day for a week and see where we are from there. According to Mel, the girl I spoke with, her cat dropped rapidly when they were done the taper completely. These hairballs are compounding the issue, too. When Penny was OTJ, her numbers would shoot up into the high 100s sometimes with a hairball and she'd be at, like 57 the next day when it passed. She keeps pulling her fur out and eating it. Mel said her cat was doing the same when she was on gabapentin.

When Penny had that beautiful day I was thinking "if this is her dose, I'm cutting it in HALF when she's totally done with the gaba to be safe". So I could keep her at a fat unit but I don't like her being over renal threshold all the time, either.

 

[Sienne and Gabby (GA)]

I was actually thinking about what time(s) during the cycle you're feeding. If you're not already providing multiple, small meals, it may be something to consider, as well.

 

[Robyn and Penny]

Gabby...typically her feedings are 8am, 11am, 4pm and 8pm and she eats kibble around 8:30a, 2:30p and before bed. She's pretty consistent and is a social eater and I work from home so it's easy to know when she's eating lol

 

[julie & punkin (ga)]

Hi Robyn,

I've been looking at Penny's spreadsheet and am thinking a couple of things. Just to be sure I have the story - is the Gabapentin for pain for the spinal arthritis? And you are replacing that with adequan? I used gabapentin with punkin (didn't find that it helped) but adequan doesn't have any pain reliever in it. It does help with arthritis, but I'm not sure it's going to be effective enough to be a substitute for a pain reliever.

I saw you tried bupe at one point - is it possible to go back to using that instead of the gabapentin? if she's got bad spinal arthritis, i would think she would still need a pain reliever. Tramadol is another possibility that works for some cats.

One thing to keep in mind with your dosing decisions, and we see this fairly often, is that when you begin to see progress that is not the time to reduce the dose. That was a pretty nice am cycle on Feb 3, but then you reduced the dose in the evening. The way both Lantus & Lev works is that they are most effective when they are dealing with lower numbers. In other words, they can hold the blood sugar flat at 100 very nicely, but they struggle with bringing down 350's. So when you have the chance to give the L insulins a 100 to deal with - it's an ideal opportunity. If the chance comes again and you can monitor the cycle afterwards, go for it and shoot that whole dose into the blue or green number. As long as it's over 50 and you can monitor, do it. I wrote an explanation here for someone about the difference between shooting into a higher number and a lower number, and maybe it will help you to understand the difference too.

Another thought - just because one person had her cat's blood sugar increased from gaba doesn't mean that your cat's blood sugar is increased by gaba. Perhaps there was a sugar component in her meds. I don't think that it's typical for gaba to increase BGs, in fact, often pain drives up blood sugar and an effective pain reliever would in fact, lower blood sugar. I would not decrease Penny's insulin anticipating that her BGs might drop when she goes off of gabapentin. We certainly didn't see that happen when we ended it. If her blood sugar does go down, as long as you are monitoring you'll be able to adjust her dose in response. Since you are tapering the gaba there likely won't be any response in her blood sugar at all. I am just concerned that she have some sort of pain relief when you do take her off the gaba.

We do know from experience that cats that have come out of remission often are more difficult to get back into remission again. The caregiver has to be more aggressive if that's going to happen. I'd encourage you to stick to 0.25u increments in dose increases per the protocol. What happened before is often unrelated to what's happening now a year later. Often with dosing you'll have more success if you "get on top" with the insulin dosing, rather than skootching up in dose.

I'd also encourage you to just get one test in the pm cycle. so very many cats give all their lowest numbers in the pm cycle that we always encourage people to do this. The reason for this is because Dawn Phenomenon increases those am cycle tests. She may be having blood sugar lower than you think in the pm cycle.

 

[Robyn and Penny]

Hi Robyn,

I've been looking at Penny's spreadsheet and am thinking a couple of things. Just to be sure I have the story - is the Gabapentin for pain for the spinal arthritis? And you are replacing that with adequan? I used gabapentin with punkin (didn't find that it helped) but adequan doesn't have any pain reliever in it. It does help with arthritis, but I'm not sure it's going to be effective enough to be a substitute for a pain reliever.

I saw you tried bupe at one point - is it possible to go back to using that instead of the gabapentin? if she's got bad spinal arthritis, i would think she would still need a pain reliever. Tramadol is another possibility that works for some cats.

One thing to keep in mind with your dosing decisions, and we see this fairly often, is that when you begin to see progress that is not the time to reduce the dose. That was a pretty nice am cycle on Feb 3, but then you reduced the dose in the evening. The way both Lantus & Lev works is that they are most effective when they are dealing with lower numbers. In other words, they can hold the blood sugar flat at 100 very nicely, but they struggle with bringing down 350's. So when you have the chance to give the L insulins a 100 to deal with - it's an ideal opportunity. If the chance comes again and you can monitor the cycle afterwards, go for it and shoot that whole dose into the blue or green number. As long as it's over 50 and you can monitor, do it. I wrote an explanation here for someone about the difference between shooting into a higher number and a lower number, and maybe it will help you to understand the difference too.

Another thought - just because one person had her cat's blood sugar increased from gaba doesn't mean that your cat's blood sugar is increased by gaba. Perhaps there was a sugar component in her meds. I don't think that it's typical for gaba to increase BGs, in fact, often pain drives up blood sugar and an effective pain reliever would in fact, lower blood sugar. I would not decrease Penny's insulin anticipating that her BGs might drop when she goes off of gabapentin. We certainly didn't see that happen when we ended it. If her blood sugar does go down, as long as you are monitoring you'll be able to adjust her dose in response. Since you are tapering the gaba there likely won't be any response in her blood sugar at all. I am just concerned that she have some sort of pain relief when you do take her off the gaba.

We do know from experience that cats that have come out of remission often are more difficult to get back into remission again. The caregiver has to be more aggressive if that's going to happen. I'd encourage you to stick to 0.25u increments in dose increases per the protocol. What happened before is often unrelated to what's happening now a year later. Often with dosing you'll have more success if you "get on top" with the insulin dosing, rather than skootching up in dose.

I'd also encourage you to just get one test in the pm cycle. so very many cats give all their lowest numbers in the pm cycle that we always encourage people to do this. The reason for this is because Dawn Phenomenon increases those am cycle tests. She may be having blood sugar lower than you think in the pm cycle.

Julie, I did not reduce her dose that night. I did a BCS shot that night is because Penny is a social eater and will not eat all night unless she gets one of us up to eat, which usually don't happen till after 4am. If she dropped to 67 on an AMPS of 181 during the day when she's eating, what would she have done that night? Yes, I want her back in remission, but not at her expense, either.

As for the gabapentin, I don't know for sure if that's what took her out of remission. Long story short, we didn't even know she had a problem until she was sleeping on her back one night and woke up howling and rolling around as if she were in a cat fight. Three vets checked her out, rather grainy x rays that didn't confirm, so let's treat pain we are not even sure she is having. I cannot afford bupe + insulin + strips + lancets + her food, etc, even if I got the bupe compounded for cheaper. Plus, she is only 6. A lot of her issue is her weight. I know from being a weight loss coach that weight loss is the NUMBER ONE most effective treatment for arthritis. She has been like a new cat since about 4 weeks after she started Adequan, so it seems to be doing its job. I know Adequan is not a pain reliever. I opted to treat the CAUSE of the pain rather than giving her meds that were making her sicker and sicker. The gaba gave her HORRIBLE diarrhea..to the point that she was rushing to the litter box several times per day and starting to dehydrate. As her dose has been going down, she's gotten much better. That's why I'm putting her BMs in the comments. And she had one of her pain episodes on the gaba, anyway, which is when the vet and I agreed to do her taper.

I suspected the gaba was the culprit well before I met Mel online last week. If you go back into her 2014 SS, you will clearly see how her numbers JUMPED as soon as I increased her original gaba dose. Both compounds she was on with the gaba were sugar free formulations. And if you look up gabapentin on RX List or Web MD, high blood sugar IS listed as a rare side effect. So it IS possible. She has lost just shy of 2lb since all this started and just completed 8 weeks of Adequan and I do have some bupe on hand if she has an episode, so I'm watching that closely. What dose of gaba was your cat on?

The problem is, I was following TR and her BGs were just going up and up. Do you see that? More insulin, higher BGs. Her curves looked like Lantus curves but she is on Levemir. I spoke with quite a few people who have been using Levemir the past couple of years and they found with their cats that TR didn't work the same with Lev as it did with Lantus. They needed to hold doses longer and inch up the dose. I'm just really reluctant to go shooting right up to 1.25 when she got a 67 on 1u. I don't want to send her liver into a tailspin, either..

 

[Robyn and Penny]

Julie...also...I will shoot a green during the day when I'm awake to monitor and I know she's eating all day. Night is a different ballgame. I read through what you wrote about shooting low numbers, but you did mention that shooting low numbers is for people who know how their cats respond to the insulin. That's the problem this time around. Her liver does what it wants and she has been unpredictable until I finally got her to flat numbers by going slower than TR. That's where my frustration is. I understand TR but with her being so erratic, not sure I can take that chance at night unless I'm off the next day so I can stay up all night and monitor.

 

[Robyn and Penny]

So I copied and saved your explanation. It makes sense. My reasoning was that if she dropped to 67 on an AMPS of 181, would she drop even lower if she won't eat at night? Even if we get up, she won't eat if we try because she's just not used to eating at night bc of her whole social eater thing. I'm sure if she dropped below 50 and I gave her gravy food she'd be all over it though! lol

But do you think an increase to 1.25 is a good idea when I did have that one day of good numbers. Or should I hold a few more days to see if that happens again and not get so chicken $hitty if I get those numbers again? lol There is a hairball factor this week. If you see the comments, she's been passing hairballs and coughing all week. Possibly another side effect of the gaba that she's ripping out her hair and eating it. She's done it before but NEVER as much as she has been recently. When she was OTJ, a hairball would shoot her up to close to 200 and after it passed she'd throw me a number in the 50s. So they can and do jack up her numbers, as well.

 

[Wendy&Neko]

The problem is, I was following TR and her BGs were just going up and up. Do you see that? More insulin, higher BGs. Her curves looked like Lantus curves but she is on Levemir. I spoke with quite a few people who have been using Levemir the past couple of years and they found with their cats that TR didn't work the same with Lev as it did with Lantus. They needed to hold doses longer and inch up the dose. I'm just really reluctant to go shooting right up to 1.25 when she got a 67 on 1u. I don't want to send her liver into a tailspin, either..

A couple comments from another Levemir user. First, I see that the majority of your mid cycles tests are at +6. Typically with Levemir, the nadir is a little later than with Lantus, so I'd mix up those tests a bit. Try getting some +7, +8 or +9 tests instead. I'd especially have gotten a test an hour after that 67 you got at +6 on Feb 3rd. Night tests are also very important as many cats go lower at night. Neko loves to go low at night then do a mini bounce during the day. Getting a before bed test, or even an up in the morning test if it's a couple of hours before shot time would be really helpful in filling out the picture. If I didn't test Neko at night, I'd often think she needed an increase, when in fact she needed a decrease. Before deciding on an increase or decrease, I'd get a few spot checks at different times.

By the way, TR works just fine with Levemir. Jacquie Rand of University of Queensland (one of the authors of TR) has tested it with both Lantus and Lev. If you look at the end of the Tight Regulation Protocol Sticky here, there is an article attached called "Management of Diabetic Cats". In there is the protocol for glargine/determir, with no differences between the two insulins. From personal experiences with Neko on both insulins, I find I need to increase the same amounts and time frames now on Lev as I did when Neko was on Lantus. The only time I'll "inch up the dose", is if she's seeing a bit of green already and I want to fine tune it. I did the same on Lantus.

 

[Robyn and Penny]

A couple comments from another Levemir user. First, I see that the majority of your mid cycles tests are at +6. Typically with Levemir, the nadir is a little later than with Lantus, so I'd mix up those tests a bit. Try getting some +7, +8 or +9 tests instead. I'd especially have gotten a test an hour after that 67 you got at +6 on Feb 3rd. Night tests are also very important as many cats go lower at night. Neko loves to go low at night then do a mini bounce during the day. Getting a before bed test, or even an up in the morning test if it's a couple of hours before shot time would be really helpful in filling out the picture. If I didn't test Neko at night, I'd often think she needed an increase, when in fact she needed a decrease. Before deciding on an increase or decrease, I'd get a few spot checks at different times.

By the way, TR works just fine with Levemir. Jacquie Rand of University of Queensland (one of the authors of TR) has tested it with both Lantus and Lev. If you look at the end of the Tight Regulation Protocol Sticky here, there is an article attached called "Management of Diabetic Cats". In there is the protocol for glargine/determir, with no differences between the two insulins. From personal experiences with Neko on both insulins, I find I need to increase the same amounts and time frames now on Lev as I did when Neko was on Lantus. The only time I'll "inch up the dose", is if she's seeing a bit of green already and I want to fine tune it. I did the same on Lantus.

Hey Wendy...that was one of my concerns. This time around, her nadir is +6. Levemir is definitely acting more Lantus-y. I have been getting a lot of before bed tests. those are the +3s and +4s you see after PM shot. They get fed as soon as I get up, and I have to feed her to shoot her b/c there's no way I'm getting that needle in her unless her head is in a bowl full of wet food sprinkled with Forti Flora. She usually gets somebody up to eat around 4-6am, and it's usually Mom, so I will tell Mom to get me up so I can poke her in the wee hours. I had gotten some +6 tests overnight. Then it takes me over an hour to fall back asleep lol.

I know TR was done with Lev, too, and it usually works. I've read TR so much I probably know it verbatim by now. My question is....when I was increasing .25u every 6-8 cycles, her numbers were just going up and up as the insulin dose was going up and up. Do you see that in her first month? And a whole lot of reds and a more Lantus-y curve than Levemir-y curve. I did manage to flatten her out by following Mel's advice, which is what we want with Levemir, right? So it I go back to TR this time, won't I get more of the same of smiley faced curves and angry reds and big drops in the same cycle? I know TR works for most cats, but since it her need was increasing with the more insulin she got, should I keep trying to do the same thing (TR) and expect a different result?

 

[Wendy&Neko]

Sorry, I've looked at Penny's SS and I can't see how you've figured out her nadir is +6 now. Some cats can have variable nadirs. I'd still recommend mixing up the mid cycle tests a bit. I've seen Neko nadir from +5 to +15 on Lev, although it's most often between +9 and +12. But I've also seen other Levemir kitties that have earlier onsets and nadirs that mean the smiley faced curves. It's not unusual.

If you are looking at TR, or even SLGS, try to ignore the highs when you are looking at dosing. Focus instead on the nadirs or how low the dose is getting Penny. The highs are just bounces and we don't consider them when dosing. I don't see Penny's numbers going up and up with her dose, in fact I see the opposite. When you started at .5 units, she was only getting as low as mid 200's. At .75U she got a high blue. At 1 unit she got more mid level blues and 1.25 units got even more blues and into lowish blue territory. She's only gotten one green and that was at f1.o. If you want to get her back into remission again, you have to get her into a dose where she's seeing a lot more green.

 

[Robyn and Penny]

Wendy...I know I keep looking at those preshots and getting frustrated and thanks for the reminder to focus more on the nadir than the preshots. But did you notice when I took her back DOWN to the f1u that's when I got my first green, yet I wasn't getting a green with 1.5u? Her nadirs were no lower on 1.5u than 1.25u. Then I bring her down to 1u and a fat 1u and I get a 67?? I know I wanna see more greens, but when I'm getting a green with less insulin and not with more, then do I really wanna rush her up again? That's where I'm confused. She got a desirable nadir at f1u and then been high and flat since..