WARNING: *** LONG POST ***
He started eating Fancy Feast in the beginning of May right before he started insulin.
That's what I needed to know, Kim. I'm glad to hear that Minet is starting to regain weight; my Saoirse has chronic pancreatitis so I can really relate to how worrying it is when our little ones won't eat enough.
OK, looking at Minet's data, if he were my cat I would be pleased with the significant downward trend in his BG levels, and I would work on the principle that his pancreas may be showing signs of recovering some beta cell function and starting to help out - especially with the now-reduced carb load in his diet since he was switched to Fancy Feast. Both the diet change and the support from injected insulin are allowing Minet's pancreas to rest and, all going well, recover some beta cell function so that he might start producing enough of his own insulin to cope with the lower carb food.
Minet's PM BG numbers are pretty consistently lower than his AM BG numbers and that is
not usual for a cat on Vetsulin; normally the curve is cup-shaped because the dose tends to start pooping out anywhere from +6 after injection time. Taking into account the way that Vetsulin works, Minet may have gone even lower than his PM BG numbers while the dose was still at full force. You were right to skip the doses when you did.
With the huge improvement in Minet's numbers over the past 36 hours and how he kept low without
any insulin overnight it is suggestive of his pancreas doing some work. That Minet's BG is registering in the 90s
after eating a little food is another reason to suspect that his pancreas may be showing signs of activity (although after 30 minutes the full food rise might not be obvious). If a cat's pancreas is starting to sputter back into action one needs to be extra cautious about insulin administration. I know the testing is tough going for all of you at the moment but no matter how tough it may be, a period of brief stress for a test is far, far better than a hypo. For Minet's safety I would urge you to get pre-feeding AM and PM tests PLUS at least
one mid-cycle test any time you give insulin to Minet so that you'll have at least
some idea of how low the Vetsulin is taking him (around the +3 mark - might not be quite at nadir but it will alert you earlier if Minet is getting too low for comfort and you'll be better placed to intervene with extra carbs should they be needed). With a possibly sputtering pancreas the best thing you can do to keep Minet safe during this unpredictable period is to grit your teeth and go through the discomfort of getting these tests.
You need to lift food 2 hours prior to test time and you need to test BEFORE giving Minet his food. If he eats beforehand you'll be making dosing decisions on a food-influenced number and that could result in giving a dose when it's not safe to do so. In an ideal situation one should test, feed, then then wait 20-30 minutes before administering Vetsulin (assuming it is safe to give the dose).
I suggest talking with your vet about when to give a token dose and when to withhold insulin. Personally I kept to a high no-shoot number (>200mg/dL on an Alphatrak) for Saoirse when she was being treated with Caninsulin (UK brand name for Vetsulin). After her transition to low carb wet food even a dose of 0.2 IU produced too steep a drop in BG level. I started skipping doses left, right and centre and eventually stopped giving her the Caninsulin on safety grounds even though she was not in remission. Thankfully I was able to secure a Lantus Rx for her and the gentler action of the Lantus allowed me to continue her insulin treatment until she went OTJ. My decisions served Saoirse well and kept her safe.
Going forward I suggest the following strategy for you to discuss with your vet:
1. Do not give a dose of 1IU Vetsulin again; I really think it's too high (doubly so because of Minet's eating pattern and the fact he's not eating as much as he needs right now).
2. Agree with your vet a reasonable no-shoot number (with such little data, Minet's recent BGs and the way that Vetsulin works I suggest sticking to 200mg/dL).
3. Agree with your vet a reduced dose. If it were my cat in these circumstances I would be reluctant to dose more than 0.25IU (if the preshot test was high enough) and I would make sure I got a mid-cycle check to see how low the dose was taking the blood glucose level.
4. If Minet were my cat and his preshot test BG levels remained under 120 without any insulin I would consider running an OTJ trial to see whether he is going into remission. If his numbers were to trend upwards I would keep in close contact with my vet, look at microdosing Vetsulin (when safe to give a dose) for a short period - say, a week to 10 days - to see whether that might nudge him into remission. I would get preshot and
at least one mid-cycle test each time I gave insulin (even if the AM test was a +2 it would possibly give warning that the dose might take Minet uncomfortably low and alert you to the need to stay with him; and I would strongly advocate getting a before bed test if you give a PM dose). If that didn't prove successful I would look to switch him to a longer-acting, gentler insulin where there would be greater and safer control of BG levels because the drops would not be as steep.
With regard to Minet not eating enough, it might be worth your discussing with your vet the use of an appetite stimulant. Cyproheptadine is fairly gentle in action and usually a very small dose (1/8 of a 4mg tablet or less for a 10lb cat) can provide just enough support to get a cat more interested in food and also to eat a bigger portion at a sitting. The appetite stimulating effect typically lasts about 8-12 hours, possibly a bit longer. You can dose 3x per day so you can fine tune the med support to the cat's needs. Things to check with the vet are liver function and also blood pressure (it's an antihistamine so may have a vasoconstricting effect). The other appetite stimulant commonly used in cats is mirtazapine. An antidepressant med, it can have an excessively strong appetite stimulating effect, even a small dose can make a cat crazed with hunger (not pretty) and the appetite stimulating effect typically lasts for 2-3 days so it's less controllable. Mirtazapine also carries the risk of inducing serotonin syndrome which can be potentially life-threatening (antidote is cyproheptadine, BTW). The risk of serotonin syndrome may be increased by interactions with other drugs, especially anything that affects serotonin levels. It can interact with buprenorphine (bad case on here a few months ago).
Another thing to ask your vet about is whether supplementation of Minet's diet with L-carnitine might be a valid treatment option; an amino-acid, it can help with building lean muscle mass.
Here are some useful links relating to appetite issues:
Tanya's Site - Persuading cat to eat
Tanya's Site - Nausea and appetite problems and treatments (has info on appetite stimulants)
FDMB FAQs Sticky - Tips for encouraging cat to eat
(NB: If the Tanya's Site links don't work first go, keep trying; sometimes it's a bit tricky to get onto the site. When you do get onto the site print out the pages for future reference.)
Hope some of the above is helpful to you. Note that I am not a vet, Minet is your cat, and you need to discuss all of this with your vet. Please be cautious and do as best you can with the home testing, including mid-cycle tests if you give any insulin; with these conditions it is much more necessary for Minet's safety than if he were in higher numbers.
Mogs
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