Advice please - skeptical of vet

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This? Not a bad food. Estimated 5.3% dry matter carbs :)
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Matthew Brennan said:
Im at a loss. And struggling to find a good vet thats clued up on diabeties near me at all.

Would love for advice on the next steps I should take - dosage wise / 2 or 3 times a day wise.
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If it were me I would probably do 2 units each time three times a day for a while.

You could do the 2 units twice a day, but I think he's going to be spending an awful lot of time in dangerously high numbers.

His numbers will be slightly higher in the middle than those low yellows and blues, but it might settle the bouncing a bit. I've never seen a cat bounce back up as fast as yours... that boy is made of rubber. I'm glad you found a low carb complete food for him to eat that he likes. :)
 
Matthew, please read my post #143. This high number is not at all unexpected. Not welcome and worrisome yes but not unexpected. You were reducing the amount of insulin up till today in the hopes of bringing down those pre-shot numbers but your dosing has been inconsistent and the lower doses have not been held long enough to determine effectiveness and that is making it difficult to figure out the right dose to settle that bouncing down. You gave Timmy a total of 8 units of insulin today with the potential for some mild carry over from shot to shot which is technically a dose increase and it looks like he needs less rather than more insulin.

I still maintain you need to drop the dose down to at least 2u (perhaps even back to 1.5u) if you are going to dose 3 times daily and you need to hold that dose for a period of at least 3 days to really see the results. If during that period, the numbers don't start smoothing out, then a further reduction may be necessary. If you go back to twice daily dosing I would try 2 to 2.5u held for a period of 3 days. It's up to you whether you want to dose twice or three times daily. Right now, to be honest, I think the three times daily is just complicating the situation more.
 
Looking at today's overall numbers, until that last preshot... he was looking much better. he had less total hours in super high black numbers than the previous days. lowering the dose to 2 may even out the numbers a bit more and prevent some bouncing... but I still think 3 shots is working better than two shots for the time being. Ultimately you hold the syringe so you make the decision.
 
You're probably confused because you're getting conflicting advice re TID or BID dosing. However, I think the consensus is that the dose has to come down. You have to decide for yourself whether you want to dose twice or three times a day. Whatever you do, keep it consistent for several cycles. I think your kitty is quite scrambled right now.
 
Figured I would go try to find it and post since Matthew is in UK. Ireland I think? And most of them are probably in bed now :). Except Matthew :p Much better food than plain chicken too :)

I like the idea of dropping the dose as it might give him slightly gentler drops than he's been having. Linda said something in an earlier post, how the big drops activate his body's defenses. Also, I don't think you gave enough time to BID dosing while testing. I know he was diagnosed early last year but we only have data for six days :smuggrin:.
 
MrWorfMen's Mom said:
Matthew, please read my post #143. This high number is not at all unexpected. Not welcome and worrisome yes but not unexpected. You were reducing the amount of insulin up till today in the hopes of bringing down those pre-shot numbers but your dosing has been inconsistent and the lower doses have not been held long enough to determine effectiveness and that is making it difficult to figure out the right dose to settle that bouncing down. You gave Timmy a total of 8 units of insulin today with the potential for some mild carry over from shot to shot which is technically a dose increase and it looks like he needs less rather than more insulin.

I still maintain you need to drop the dose down to at least 2u (perhaps even back to 1.5u) if you are going to dose 3 times daily and you need to hold that dose for a period of at least 3 days to really see the results. If during that period, the numbers don't start smoothing out, then a further reduction may be necessary. If you go back to twice daily dosing I would try 2 to 2.5u held for a period of 3 days. It's up to you whether you want to dose twice or three times daily. Right now, to be honest, I think the three times daily is just complicating the situation more.
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YES YES YES.
Inconsistent dosing and actually a dose increase hasn't helped. Matthew, you need to take a deep breath and be prepared for this to take a little longer. When you start on a new course of action that one of us suggests, stick to it unless there's a really good reason (eg don't shoot a much lower than expected number that your data shows is on the downward curve). I absolutely understand how it's tempting to shoot those pre-shot black with a higher dose, but if you can stick to a plan I think it will make a lot of difference. We may be divided here over whether to shoot two or three times a day... I can see the potential good and bad in both so read over this thread again carefully and make a decision based on what we've been saying. Things WILL get better... but it takes a while.

Good to see Timmy has a new complete food... I haven't heard of that one. If he's enjoying it, great, he will be having better nutrition now and that will help the overall situation once he's down from these high numbers.

So keep at it, be patient and try not to be disheartened... you're actually doing a phenomenal job. Hard work and persistence will pay off!
 
Yong said:
I know he was diagnosed early last year but we only have data for six days :smuggrin:.
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I think this is really key. I know it feels really urgent right now when you are seeing these high numbers-- it feels awful to see your little guy up in the reds and blacks and to have, basically, what seems like a quantitative measure of how yucky he's feeling. You want to fix it as soon as possible so he can feel better. But he didn't get to these numbers overnight, and you aren't going to be able to get him into better numbers overnight, either. Soon, we all hope, but not instantly.

You really are doing a great job in a difficult situation!
 
Wow still dipped down to the low 200's at +4 even on only 2 units. I'm curious to see the rest of the day and if the swings are as dramatic as yesterday.
 
Honestly I havent noticed a change much in his general behaviour since starting testing him.

Around injection time and especially for a few hours after he is very vocal, hungry.
Around mid cycle of insulin he is very content, mainly sleeping.
Then as it comes round to injection time very vocal.

He was very vocal before injection time this morning. Now he is sleeping away happy. He is not a very active cat at the best of times in his older age.

Ive found a good indicator is how far away he sleeps from his water bowl. When he is high, he will sleep next to it. When he is below the 300's, he will sleep in other rooms of the house.
 
Matthew, how often and when in each cycle do you feed Timmy? Sometimes switching up feeding times a bit can help to smooth out those dramatic curves a bit. Timmy may be very vocal early in the cycle because he is feeling hungry due to sudden drop in BG. If you are not doing so already, might be an idea to offer him a small snack between +2 and +3 to see if that helps slow the drop a bit.
 
Others will have to weigh in on "how much" in quantitative terms (if that's possible to generalize at all), but it will definitely help to have food on-board early in the cycle for the insulin to work on. That's why (esp. with the fast-acting insulins) you want to have a meal before the insulin starts working-- otherwise, you can get a really severe crash. Since Timmy is currently dropping hundreds of points in the first few hours of every cycle, it really can't hurt to give him some more mini-meals during that time to try to help slow him down. Just getting him to drop 200pts rather than 300 might help reduce the bouncing that comes right afterwards, which will help on the next cycle.

[Edit: just noticed I started off saying others would have to be specific, then went and put numbers in anyway! Just to be clear, this wasn't meant to be a prediction or an average result from adding more food, it was just for illustration of an ideal result.]
 
MrWorfMen's Mom said:
Matthew, please read my post #143. This high number is not at all unexpected. Not welcome and worrisome yes but not unexpected. You were reducing the amount of insulin up till today in the hopes of bringing down those pre-shot numbers but your dosing has been inconsistent and the lower doses have not been held long enough to determine effectiveness and that is making it difficult to figure out the right dose to settle that bouncing down. You gave Timmy a total of 8 units of insulin today with the potential for some mild carry over from shot to shot which is technically a dose increase and it looks like he needs less rather than more insulin.

I still maintain you need to drop the dose down to at least 2u (perhaps even back to 1.5u) if you are going to dose 3 times daily and you need to hold that dose for a period of at least 3 days to really see the results. If during that period, the numbers don't start smoothing out, then a further reduction may be necessary. If you go back to twice daily dosing I would try 2 to 2.5u held for a period of 3 days. It's up to you whether you want to dose twice or three times daily. Right now, to be honest, I think the three times daily is just complicating the situation more.
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I really do agree with Linda here!
 
Despite another black pre-shot, I think todays' cycle was encouraging. I'd stay the course with 2u right now. It often takes 2 or 3 days for bouncing to settle down but the lack of an extreme drop today was exactly what we were trying to accomplish so give 2u a chance. Making dose changes while kitty is bouncing will just confound the puzzle. Takes a lot of patience to deal with these furry kids but slow and steady wins this race.:)
 
MrWorfMen's Mom said:
Despite another black pre-shot, I think todays' cycle was encouraging. I'd stay the course with 2u right now. It often takes 2 or 3 days for bouncing to settle down but the lack of an extreme drop today was exactly what we were trying to accomplish so give 2u a chance. Making dose changes while kitty is bouncing will just confound the puzzle. Takes a lot of patience to deal with these furry kids but slow and steady wins this race.:)
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Agreed.... Nuts how he can drop 200 in an hour!

Keep it going a few more days.
 
Yes... still a bit of a bounce going on so it may be a matter of lowering the dose a little but def keep at 2u for another day or two... all the tests are important info.
Well done Matthew.
 
You may have missed his nadir this morning so that 499 could be him starting to rise again and we don't know how low he may have gone on last night's cycle. I'd still hold the dose for today. I agree with Diana that he's still bouncing albeit not quite as much. I'd start getting a reading around +3 to see if he is dropping by then on the next couple of cycles. If he doesn't smooth out by tomorrow, perhaps dropping him down to 1.5u should be considered. You've obviously got a very bouncy kitty and they can be a tough nut to crack. Hang in there!
 
Not great... Very hard to say, and data can vary hugely from day to day anyway.
Just one possibility though - could you by any chance have given a fur shot this morning (what we call it when there's some doubt about over whether the dose was given to the kitty... everyone messes up sometimes)?
 
Diana&Tom said:
could you by any chance have given a fur shot this morning
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Good point Diana! Didn't occur to me but certainly something to consider.

My concern (pure speculation) right now is that if he really is reaching nadir around +5, is it possible he's having some hold over of the dose until the next cycle acting like a dose increase for each succeeding cycle. Both night cycles on the TID dosing have shown huge drops by +2 and we have no idea how low he is going by +5 over night. If he is going into the blues overnight by chance, the bouncing is just being perpetuated and the dose needs to be lowered. Thoughts?
 
MrWorfMen's Mom said:
Good point Diana! Didn't occur to me but certainly something to consider.

My concern (pure speculation) right now is that if he really is reaching nadir around +5, is it possible he's having some hold over of the dose until the next cycle acting like a dose increase for each succeeding cycle. Both night cycles on the TID dosing have shown huge drops by +2 and we have no idea how low he is going by +5 over night. If he is going into the blues overnight by chance, the bouncing is just being perpetuated and the dose needs to be lowered. Thoughts?
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Yes that sort of thought was going through my mind too, Linda. This is where the TID dosing may not be so good. It would seem worth a go at lowering the dose (maybe in another day or two if no better with 2u) but the risk in that case of course is that it might not do enough initially to bring the black pre-shot numbers down for very long. TBH I don't really know what else to say except to advise Matthew to stick to the 2u a little longer as we've suggested... test as often as possible, and we can look in as often as we can and comment as appropriate.
 
Yes-- this is where it would be nice to have some more data on 2U BID, where there would be little or no holdover, to compare nadirs. He dove pretty early and pretty hard at BID, but then he was getting a lot more insulin per dose as well.
 
Dunno-- I'm not a fan of TID in general, especially in the long term, but there's something to be said for holding steady (with maybe a dose decrease) for a few more days. It just takes some time to understand the results of a dose, and though we have some guesses here, right now that's all they are.

Let's see what others say about this.
 
I think TID dosing is the way to go when it appears the BID dosing is not lasting long enough and the sign of that is often kitty nadir being early in the cycle )(anywhere from +2 to +4). I don't know that the insulin is lasting a full 12 hours for Timmy but he doesn't seem to be gulping it down quickly either so even if he is getting 8 to 10 hours of effect, TID dosing would be causing a slight dose increase at the early part of each cycle. As Diana pointed out, the problem is what dose is going to bring down those black pre-shots. If Timmy has no history of ketones or DKA then I'd be inclined to go back to BID dosing at a dose of 2u to see what he does for a couple of days. I would however also make sure I was checking for ketones with those high pre-shot numbers because you don't want to cause any additional problems cropping up while searching for the right dose.
 
There are arguments for and against both BID and TID dosing, I think we agree. I think we need to keep to the current dose for today though and see what tomorrow's AMPS is... that would be after a full day's dosing of a total of 6u which is still higher than average so there is every possibility that Timmy is still bouncing on current doses. If he is still in the blacks tomorrow morning, maybe try 1.5u - I still wouldn't think that's enough to bring him down much from the very high numbers but you could try a day of TID dosing at 1.5u if only to collect data from that.

Or... still on TID, I'm wondering about a slightly reduced dose for one of the three shots, maybe the middle one... that would reduce the overall daily dose/overlap and hopefully the extent of the bounce, yet still keep some insulin going until the next shot.

Another option is to try 2u BID - that could go either way, ie not last 12 hours and send Timmy rocketing up again, or maybe helping to reduce the bounce.

It's trial and error, pure and simple.
 
My vote is to Keep doing what you are doing for at least another 3 days. I think changing again is not letting us see a clear picture. his numbers didn't come down as far today and that's ok. we don't want him dropping 70% each time. I think just give it a little more time and then re-evaluate. I think if you switch back to 2 units twice a day your cat is going to be spending 8 or more hours a day in black numbers.

if it were my cat I'd keep with the 2 units three times a day for a few more days and see what happens as it seems the bouncing is lessening. it's doing exactly what we intended with that drop from 2.5 units to 2, which was to lessen the drop from preshot so the curve isn't so sever. Now of course we want to see that preshot come down. The fact is his cat has probably been in VERY high numbers for a VERY long time and his body is used to being in those high numbers. he has to get used to being lower and that's going to take a while.

Be very sure he's not getting any food for at LEAST 2 hours prior to preshot tests. we don't want those preshots influenced by food at all.
 
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Matthew, do you have or can you get, any records of curves done at the vet's office before you joined FDMB or was the vet using fructosamine tests to determine the degree of regulation? Just thinking that a peak at what the vet was seeing on a curve, even though it was no doubt elevated by vet stress, might provide a bit more data to see how Timmy has been utilizing the insulin back when the vet suggested he was doing fine.
 
MrWorfMen's Mom said:
Matthew, do you have or can you get, any records of curves done at the vet's office before you joined FDMB or was the vet using fructosamine tests to determine the degree of regulation? Just thinking that a peak at what the vet was seeing on a curve, even though it was no doubt elevated by vet stress, might provide a bit more data to see how Timmy has been utilizing the insulin back when the vet suggested he was doing fine.
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It may well be a good idea to check a few things with the vet... I would be really interested to see his/her comments on Timmy's numbers as per his up-to-date spreadsheet. If a vet says this is "fine" then they are sadly misinformed (that's the polite version of what I would really like to say).

Having said that, it's always possible that Timmy's numbers have been better and this recent data is caused by something else... Matthew, you said that Timmy had a cold... that could well affect BGs and he may need treatment for it. He may even have other underlying conditions that are producing these numbers... we on FDMB are aware of these but only a vet can examine and diagnose.

Other thoughts... go back to basics. Is the insulin stored upright in the fridge, are you rolling it between your palms before use, is it still within the maximum recommended useage time from when it was first opened? All these things could affect the results you're getting.

I would be inclined to ring the vet about Linda's comments (records of past data) and ask for a discussion of your spreadsheet (some people email the link to their vet). The vet may not be experienced in FD but there is no denying what is there in black and white, and as a professional animal healthcare person it is their responsibility to at least say something constructive. Try it - you have nothing to lose.
 
There was no curve done, it was a simple 5 minute test - so im not sure how useful that data would be?

Do you guys think the vet will be able to add anything valuable over what is available here? Surely this will just recommend a dosage to try?

Question, if we stop the bouncing and it holds steady between 400-600. Then when we start to increase the dosage to get his levels down wont he start bouncing again?
 
Sounds as if the vet just did a spot check which could have been at any point in the cycle and as such, worthless.

I just think that the vet - who is, after all, primarily responsible for Timmy's health while on insulin - should be aware that he is not "fine" and that in fact his blood glucose is all over the place. He/she will probably dispute why the 4u is not being given, so you would have to say that you have sought advice elsewhere and the consensus is that the dose was too high. So no, the vet won't add anything on dosing as such but as I said, with numbers like these that may have been going on for a long time, it could be that there is an underlying issue that needs to be checked out. It may be that Timmy is just a very bouncy kitty and we need to find the right dose, but if it were me I would soon be looking for a complete check-up.

If we're able to stop the bouncing, it should mean that pre-shot numbers will be lower and the curve should be gentler and somewhat more predictable, allowing you to determine a "usual" dose. We don't know what that dose is yet, we're still collecting data. On the correct dose to bring BGs down without panicking his body into producing more insulin, he shouldn't bounce.
 
Sounds like the vet did either a quick glucose or possibly a fructosamine test. Either way, it wouldn't add anything useful to the picture. While fructosamine can confirm the diagnosis, it can also give one a false picture of regulation. I had the vet tell me my girl was doing well based on a fructosamine test but I was home testing and had copious amounts of data to prove otherwise. The fructosamine was NOT reliable for determining regulation in my world.

I think Diana's idea of talking to the vet about the numbers you are seeing is worthwhile. Whether the vet can offer any useful suggestions or not, it could be an opportunity to educate the vet about their current practices. I agree it's possible Timmy was better regulated in the past but right now, he is running high and it would be worth having the vet give Timmy the once over to ensure there isn't an underlying condition contributing to his BG levels. You mentioned a cold and dental issues can sometimes cause symptoms similar to a cold. When was the last time the vet checked Timmy's teeth? Dental issues are often found to be the cause of elevated BGs with our sweet furkids.
 
The pattern seems fairly siniliar the past 3 days (TID 2u). Are we sure he is bouncing, and its not just that the insulin is wearing off too quick, letting him drift up to the 600's?

Are we absolutely certain that less and less insulin is correct and not that he doesnt actually need more?
 
Matthew Brennan said:
The pattern seems fairly siniliar the past 3 days (TID 2u). Are we sure he is bouncing, and its not just that the insulin is wearing off too quick, letting him drift up to the 600's?

Are we absolutely certain that less and less insulin is correct and not that he doesnt actually need more?
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No we're not certain, Matthew. Certain conditions can mean that cats require very high doses of insulin, or metabolise it inconsistently, and that's one reason a good vet's opinion and advice would be good. We can suggest one course of action here based on what we have heard, ie insulin dose probably raised too quickly, but without any early data we cannot be sure. That's why Linda asked if you had any curve results from the vet.
If you can't find a good vet very locally to you, you may have to look a little further afield. I'm sorry to keep on about it - finding a vet who knows what they're talking about - but if Timmy has been in these numbers for a long time they are doing him no good at all. A vet could also take blood tests or diagnose an infection and prescribe antibiotics... we on FDMB can do none of those things, we can simply talk you through the theory.
 
Matthew Brennan said:
Any recommendations of what to look out for when searching for a decent vet?
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Ring some practices and ask if any of their vets have a special interest in cats, specifically with experience of treating diabetes in cats. More and more cats are being dx with diabetes, caused at least in part by a dry food diet, so the whole area of FD is one that more vets should be paying attention to. I have found that it is the vets a few years out of vet college who realise things like this and take it upon themselves to study more (ie as opposed to vets with a long career during which time they may not have treated many cases of FD, let alone wised up about it).
 
Matthew, no one can tell you 100% that Timmy isn't going to need more insulin. That remains to be seen. And whether the insulin is lasting long enough is another question but my read on the data we have is that we can put that hypothesis to rest because Timmy doesn't seem to be metabolizing the insulin overly quickly i.e in the early part of the cycle between +1.5 to +3 . From your testing it looks like he is not reaching peak action until somewhere between +4 and +5 hours post shot so with TID dosing he should be getting reasonable insulin concentrations for the full 24 hours.

What is clear is that when he drops, he drops a lot, often by 50% or more of his pre-shot reading and that is a recipe for bouncing. While his mid cycle numbers are not quite as low as they were, his pre-shot numbers appear to possibly be gradually coming down albeit slowly. His body has become used to high numbers and over reacts to those big drops in BG and his perception of a big drop is out of kilter and needs time to recalibrate. Some cats are very prone to bouncing while others bounce and then smooth out quickly. Getting the major bouncing out of the picture will allow you to slowly adjust the dose to find the optimal dose whether that dose is ultimately more or less than what he's getting now.

Given we don't have historical data, this may very well explain why your vet may have wrongly assumed Timmy was doing fine. He may have always been bouncing into these high numbers. If the vet took readings like the 205 on the 26th at +5, 201 at +5 on the 30th or the 149 at +4 on the 30th in the 2nd cycle of the day, the vet could very well assume Timmy was attaining acceptable if not optimal BG. Some vets prefer to have their feline patients running higher than optimal simply because they are on insulin. Your vet's error in declaring Timmy's numbers as OK may have come from not seeing the whole picture as opposed to misinterpreting what they did see.

Now that you have data throughout the cycles, your vet may very well have a different take on how well Timmy is regulated. I think it's worth checking in with the vet or getting a 2nd opinon if you prefer.
 
Thanks again everyone for the super comments and useful information given - always appreciated.

The vets test was always at 11-12, so would have been +2/+3 from the shot. My worry with that vet is that they never suggested home testing, curve, or anything like that. Been ringing round a few vets, for a second opinion, if anything a fresh pair of eyes wont hurt.
 
Many vets don't suggest home testing, because they are afraid owners won't want to make the commitment to their pet and will choose to euthanize if told they should do hometesting. Some don't suggest curves because they are expensive, and, again, many owners won't do it. Not saying that's what is going on with your vet, just giving you a possible alternate explanation for the hands-off approach.

I do think a second opinion would also be valuable, and it's always a good idea to rule out additional health issues when trying to sort out insulin dosing.
 
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