Recently Diagnosed, Cautious after Hypo Scare

[Kiki and Sox]

Hello! Sox was recently diagnosed with Diabetes, in November, and in the past 2 months we have had tremendous difficulty caring for him (My boyfriend and I both care for him). Since this is my first post I thought I would give a rundown of his history leading up to now. Sox is 14 yo, and weighs 12 lbs. He has asthma which was treated with steroids for a year leading up to his diagnosis of diabetes. He now has untreated asthma and his asthma attacks often cause him to throw up (as a cat he has always thrown up a lot for many years).

Let me start by saying that the vet we have been taking Sox to has been extremely unhelpful and that we are currently looking for a new vet. When he was first diagnosed he went to the vet all day for 3 days in a row to start his insulin and get blood tests, etc. When he came home he was on 3 units of vetsulin, twice daily. At the time we had no idea we could even test him at home and were totally in the dark about everything. Our vet told us next to nothing other than giving us syringes and insulin, showing us how to administer, and sending him home. (also he was very condescending and would hardly answer our questions) They asked to have him back each week for one BG test and to adjust his dose if necessary. Every time he went back his reading was high, over 400, and the vet suggested increasing the dose by one unit. At the end of the month he was already on 6 units. I should also add that Sox really gets stressed by the vet. So much that when I would pick him up to put him in his crate he would piss himself. At the vet every time they drew blood for tests he would literally **** himself out of fear.

At this point I was skeptical, and sick of dragging him to the vet for torture. After doing a little research realized that we needed an at home testing kit, and that stress really affects their BG. So we got the AlphaTrak2. Even then we didn't know how often to test. We tested once 6 hours after his dose and his BG was 212. We were pretty happy with that since his vet recommended his BG be between 200-250 in that timeframe and thought his dose was fine.

On 12/28 he had been on 6 units of vetsulin twice daily for 3 weeks, and he seemed to be responding well. However we still weren't testing him regularly. That night he started vomiting A LOT. We had already given his insulin, and an hour after the dose his reading was 284.

The next day we made the mistake of not testing him. He had stopped vomiting and was eating again. He got his dose as usual in the morning, but was lethargic all day. Usually he gets up to bother me for food multiple times a day, but he slept all day. I was a little worried, but later that night he got up and ate as usual so we gave him his insulin which was a huge mistake. He receive 6 units as usual at 9:00 pm, and by 11:50 his BG was 44. He was so lethargic he couldn't get up for food, which never happened before. We rubbed some corn syrup on his gums and got him to eat a little before we took him to the emergency vet.

He stabilized at the vet, but couldn't even receive a full exam because he was so aggressive. He had to be muzzled, which I have never seen a vet do for a cat. (at home we can poke him with needles without issue) We brought him home the next day with orders to not give any insulin, and since then we have been testing him regularly. The vet told us to not give him insulin unless his levels rose above 500, and to lower the dose to 3 units. He has been recovering well, but his levels have been pretty high. A couple days ago his BG was at 503, and we decided to give him insulin that night, only 1 unit. This was at night. Two hours after his dose his BG was 292, and in the morning, over 12 hours after his dose, it was 75! This didn't make any sense to me. Obviously I skipped his morning dose, and decided to wait to start insulin again when I was home during the day. I just started his insulin again today with 1 unit, with plans to adjust more gradually. Here's a timeline breakdown with he BG levels:

12/28 10:47 pm 284 6 units at 9:15 pm (vomited several times)

12/29 11:49 pm 44 6 units at 9:00 pm

12/30 9:00 am 134 home from vet, no insulin being given
12/30 1:00 pm 98
12/30 4:00 pm 125
12/30 8:00 pm 238
12/30 12:00 am 386

12/31 12:00 pm 336
12/31 9:30 pm 457

- I'll skip some tests here, for this week his levels ranged from 370 to 500 at various points in the day-

1/7 6:00 pm 503
1/7 8:30 pm (no BG reading) 1 unit of vetsulin given
1/7 10:45 pm 292

1/8 9:25 am 75 no insulin given since last dose the night before!
1/8 12:00 pm 233
1/8 6:00 pm 354

1/9 9:15 am 398 1 unit of vetsulin given after BG reading
1/9 11:30 am 449
1/9 1:30 pm 291

As you can see I've been getting some pretty weird results, he was almost hypoglycemic 12 hours after an injection yesterday morning, and today his BG went up after an injection. Also forgot to add he eats Science Diet canned food, which I realized after some research is way too high in carbohydrates for him so we will have to switch to a lower carb canned food soon.

I'm pulling my hair out with frustration at this point, and none of this is making sense even though I've been researching more. Sorry for the extremely lengthy post but I wanted to be as thorough as possible. I really hope I can get some advice because this has been such a struggle. I'm starting my second semester of grad school in a few weeks and with my boyfriend working full time I really hope to find a better balance by then!

 

[Kris & Teasel]

Welcome! We can help. Let's get started:

He now has untreated asthma and his asthma attacks often cause him to throw up (as a cat he has always thrown up a lot for many years).

There are other owners of asthmatic and diabetic cats here. It's possible to treat both although if steroids are needed for asthma you might have to dose insulin around that. I have no experience with it so I suggest you post a separate thread about how to treat asthma in a diabetic cat.

Every time he went back his reading was high, over 400, and the vet suggested increasing the dose by one unit.

Common occurrence - vet stress raises BG and vet increases insulin dose by too large an increment. Dosing according to a stress-raised BG is a recipe for a hypo. Also, we recommend increasing by only 0.25 u at a time so you don't zoom past a good dose.

At the end of the month he was already on 6 units.

Very likely overdosed because of inflated BG when the vet checked him.

After doing a little research realized that we needed an at home testing kit,

Hurray for you! It's the single best tool to keep your kitty safe. The AlphaTrak is a great meter and will give BG results similar to what your vet measures. However, its test strips are very expensive. We recommend a fair bit of testing here and many people buy a human meter because the strips are much cheaper. Walmart's ReliOn brand meters are popular. The Micro and Confirm models use only a tiny blood drop. You could use a human meter day to day and use the AT meter if your vet wants data.

That night he started vomiting A LOT. We had already given his insulin, and an hour after the dose his reading was 284.

I'm not sure what caused the vomiting. It's possible that the insulin dose, being likely too high, was making him feel ill. It's also possible his BG had taken a nose dive earlier and he was reacting to that. Without BG tests you won't know.

I just started his insulin again today with 1 unit, with plans to adjust more gradually.

Good move. Based on your data for today it looks like 1 unit is a little low. I wouldn't change it yet. Is your kitty eating only low carb wet food? That's best for diabetic cats. If he eats higher carb food and you change to a low carb wet diet it can have a significant impact on BG levels. Any diet change should happen before a dose increase, along with a regular BG testing routine.

Here's the basic BG testing routine we recommend:

1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
3. do extra tests on days off to fill in the response picture
4. if indicated by consistently high numbers on your SS, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
5. post here for advice whenever you're confused or unsure of what to do.

Bouncing might be why the BGs have been so high:

Here's how it works:

1. BG goes low OR lower than usual OR drops too quickly.
2. Kitty's body panics and thinks there's danger (OMG! My BG is too low!).
3. Complex physiologic processes take glycogen stored in the liver (I think of it as "bounce fuel"), convert it to glucose and dump it into the bloodstream to counteract the perceived dangerously low BG.
4. These processes go into overdrive in kitties who are bounce prone and keep the BG propped up varying lengths of time (AKA bouncing).
5. Bounce prone kitty repeats this until his body learns that healthy low numbers are safe. Some kitties are slow learners.
6. Too high a dose of insulin can keep them bouncing over and over until the " bounce fuel" runs out and they crash - ie., have a hypo episode. That's why we worry so much about kitties that have had too high a starting dose prescribed by the vet and the owner isn't home testing.

Link to the spreadsheet we use here:

http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

 

[Kiki and Sox]

Thank you for your thorough reply! You've given me a lot to consider. I think getting a second meter would be really helpful financially, I wasn't aware that human meters could be used for cats. It's good to know about bouncing, and in hindsight that seems very likely in his case! (although like you said hard to know for sure since we weren't home testing at the time)

I will definitely implement the BG testing routine, and have already been testing more often since the hypo incident! I will also familiarize myself with the spreadsheet and start filling that out, such a helpful tool!

While I thought 1 u seemed low as well, I'm now concerned because even on 1 u his BG has been dropping really low at times. Of course I'm not going to raise it anytime soon but it seems really odd and I don't know why that is happening. Two days ago we gave him 1 u for the first time since his hypo episode. This is what happened:

1/7 6:00 pm 503
1/7 8:30 pm (no BG reading) 1 unit of vetsulin given
1/7 10:45 pm 292

1/8 9:25 am 75 no insulin given since last dose the night before!

Of course on the morning of the 8th his BG was too low to give insulin, and I was worried about starting the next dose at night when we can't test him often with that low of a reading. So this morning I gave him 1 u again, and his BG is at its lowest point 8 hours after injection! This doesn't make any sense to me because most places I've read the lowest reading should be 4-5 hours after injection, and then should rise after that.

1/9 9:15 am 398 1 unit of vetsulin given after BG reading (he ate about an hour before)
1/9 11:30 am 449
1/9 1:30 pm 291 (fed him again)
1/9 5:00 pm 123

So basically I'm really confused at this point. I'm going to test him again in a couple hours to see where his BG is at, and hopefully it doesn't drop even more. If it does I won't be able to give him insulin tonight!

Overall, I'm going to keep him on 1 u for now, while testing regularly, and I'm going to switch his food as well. He is on Science Diet canned food which, upon researching, is really high in carbohydrates and has grains in it (yuck). I had no idea until looking it up on this list:

http://catinfo.org/docs/CatFoodProteinFatCarbPhosphorusChart.pdf

Hoping for some clarity!

 

[Critter Mom]

Hi Kiki, and welcome to you and Sox.

Overall, I'm going to keep him on 1 u for now, while testing regularly, and I'm going to switch his food as well. He is on Science Diet canned food which, upon researching, is really high in carbohydrates and has grains in it (yuck).

Please be v-e-r-y careful with the timing of the diet change! I'd suggest holding off on it for the moment until you get a better handle on what's happening with Sox's BG on the lower dose of insulin. Normally you'd expect to see the nadir BG (lowest value) in a cycle anywhere between +3 and +6 hours after dose admin on Vetsulin. That 1/8 morning reading of 75 - THIRTEEN hours after the previous dose was given!!! - would be a warning flag to me to be extremely careful and monitor closely to better determine what's happening and to make sure Sox is safe. (Great job with the testing, BTW! )

While Sox is getting unexpected lows like this then he could potentially go dangerously low if you were to change the carb load in his diet (and 75 on a pet meter is right down at the bottom of the normal BG reference range as it is).

Whenever you do go for the diet switch it's best to start the transition when you definitely have a couple of days where you can monitor Sox right the way through each cycle to make sure he doesn't go too low

Here's vet Dr. Lisa Pierson on how to safely transition a diabetic to a low carb diet:

catinfo.org - Feline Diabetes Page

He now has untreated asthma and his asthma attacks often cause him to throw up ...

On the asthma/FD side of things, it's not a black 'n' white, either/or situation treatment-wise; a kitty needs what a kitty needs.

I know that some members whose cats have both FD and asthma have used Aerokat inhalers with the appropriate meds. I definitely know of one cat here who was asthmatic who achieved remission after a few months of insulin treatment. If you create a thread on the Feline Health board asking members for suggestions about what treatments they've used for asthma alongside their kitties' diabetes you should hopefully get some specific advice on that (notably which steroids may have less of a negative effect on BG levels). In the meantime, here's a link to a recent thread on asthma/FD which may give you some pointers:

http://www.felinediabetes.com/FDMB/threads/advice-for-asthmatic-diabetic-kitty.189118/


Mogs
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[Kiki and Sox]

Hello Mogs!

Considering your advice I think I will hold off on switching his food until we get a better idea of how he is reacting to his insulin. I"m sure the link you provided will be a great guide when we get around to making the switch!

I'm also really concerned that his BG dropped so low so long after his last insulin dose. I'm still monitoring him closely and testing every few hours considering how low it has been dropping.

I agree, I don't think it should be a matter of choosing which one to treat, however the vet we were taking him to seemed to dismiss the severity of his asthma, told us to stop his steroids, and the med he switched him to gave him horrible diarrhea. Since we are in the midst of finding a new vet due to the previous vet's incompetence and unwillingness to work with us we haven't been able to start a new treatment for his asthma.

Hopefully we can find a better course of treatment with a new vet. I'm also wondering if maybe vetsulin just isn't a good fit for him, or if something else internally is going on to cause such an extreme reaction to a low dose.

Just today for example his BG was 398 before insulin at 9:15, after which he got 1 u. At 5:00 pm it was at 123, and it has gone up to 199 by 7:30 pm. I'm worried his levels won't even be high enough tonight for insulin, especially considering how 2 days ago before insulin it was 503, and thirteen hours later it was 75. With these levels I can't believe he was ever on 6 u!

 

[Critter Mom]

With these levels I can't believe he was ever on 6 u!

Unfortunately we see kitties here who have the dose increased too fast ending up in similar situations to yourself and Sox. Too much insulin can result in BG levels that look like a cat is not getting enough. The body will try to compensate by releasing stored sugars into the bloodstream - sometimes far too much - and then the body's protection mechanisms get overwhelmed and all of a sudden the kitty can go dangerously low. It's great that you're home testing, and your instincts are very good.

2 days ago before insulin it was 503, and thirteen hours later it was 75.

Part of the problem with Vetsulin is that it can drop BG levels very hard and very fast after dose admin and the body's protection mechanisms may then go into overdrive, releasing a lot of stored glucose and then one can end up with very high preshot BGs. Indeed, Vetsulin is very good at yanking down high BGs - even unusually high preshots - back to a much lower BG when the insulin is exerting its most powerful effect but they tend to jump right back up at the end of the cycle - usually.

All going well, with your regular home testing you'll get a much better picture of what's happening with Sox and you'll be better able to determine his true insulin requirements. Should it prove that Vetsulin is not a good fit, there are other insulins with 'gentler' action profiles which might suit Sox better. Time and testing will tell.

I don't think it should be a matter of choosing which one to treat, however the vet we were taking him to seemed to dismiss the severity of his asthma, told us to stop his steroids,

There can be incredible differences between vets in terms of treatment approach. I've had some that firmly believe that no cat can safely be given an insulin dose unless fasting (preshot) BG is over 200mg/dL on a pet meter (not true if you're home testing sufficiently and using one of the insulins with a 'gentler' action profile). I've had some vets who, like your current one, consider it unthinkable to give any steroid medication to a diabetic cat (and this, IMO, is wrong-headed if the cat has an issue where steroids are make or break for another concurrent condition since insulin dose can be worked around the treatment needs for other more pressing medical issues).

Wishing you success with your vet shopping.


Mogs
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[penni]

I had a similar hypo experience with my girl soon after her diagnosis 2 months ago! She would definitely be dead right now if I hadn't have been working from home that day (planning to leave for our swiftly cancelled Thanksgiving trip!). It was so terrifying. I'm so glad you guys made it through that and are here now, where there are so many resources to improve treatment for your little guy!

I'm too new to offer any advice on the FD, but Akila has had asthma for almost 10 years now, I think, and I really recommend looking into using a human inhaler with the Aerokat. We use fluticasone/Flohale (which I order from a Canadian pharmacy at 1/4-1/3 the price of American pharmacies). 10 years ago, my vet tested Akila with oral steroids to see if she responded (on a cheaper med) and once she did she immediately switched her to the inhaler for long-term, specifically because oral steroids can cause so much ancillary damage. She didn't mention FD specifically at the time, but talked about how it could harm various organ functions. So I'm really concerned that your vet never suggested even trying to move away from oral steroids for the asthma once you all knew it would be a long-term treatment. Is that the same vet that's treating you like poo with the treatment for the FD? #ByeFelicia

I also have an "emergency inhaler" which I think is albuteral/ventolin, although I rarely have to use it with Akila (and not sure how much value it has when I do try to use it). But her maintenance dose of Flohale keeps her asthma pretty well under control, and on the occasions when she has a mild attack, I try to sit with her and comfort her till it passes. I also have this air filter: https://www.amazon.com/GermGuardian-AC4825-Sanitizer-Allergens-Guardian/dp/B004VGIGVY/ref=sr_1_4?s=home-garden&ie=UTF8&qid=1515559696&sr=1-4&keywords=hepa air filter which I think does help reduce her incidence of attacks as well. I keep it in the living room, where she spends most of her time. Before I purchased one, I think I posted on Facebook or something, can't remember, but a friend had an air filter they weren't using, so I got to try it out for a while before I invested. Maybe you could ask around or look on craigslist or some freecycle sites to see if you can try one out without spending a lot at first.

 

[Critter Mom]

Hi Kiki,

Saw a very positive recommendation for this site on another thread:

Feline Asthma with Fritz the Brave

If you have a dig around you might find something helpful there.


Mogs
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[monty_dweezil (GA)]

I know nothing about Vetsulin but my Dweezil (who is on Lantus) also has puzzling sudden drops way beyond his next dose time. Like 16 hours. And I know Lantus is long acting, but come on!!!

I am wondering if maybe Sox's pancreas was sort of jolted into partially working after that first hypo episode and being on such a high dose.

In 2015, Dweezil went from 2 units to 3 to 4 and then briefly to 5 before having a hypo (meaning needing IV glucose) on 4. Came down to 3 units. Then several months later he had a hypo on that and came down to 2 units. Ever since then he's hovered between 1 and 2 units but has also had a hypo on 2 units and has shown those extremely late and prolonged nadirs.

I wonder if maybe both Sox and Dweezil's pancreases are sputtering out their own insulin once the Vetsulin / Lantus is leaving their bodies, thus causing these low late numbers, and that some previous overdoses of insulin have prodded the panceas into action. Maybe.

If this is true, great, but really NOT great because it's dangerous and not helpful! lol

 

[Critter Mom]

some previous overdoses of insulin have prodded the panceas into action. Maybe.

The body can become much more sensitive to insulin after a hypo (not sure whether this holds true for both biochemical and symptomatic hypos, or just symptomatic hypos).


Mogs
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[Kiki and Sox]

There can be incredible differences between vets in terms of treatment approach.

So true! We had a wonderful vet that really listened to us and was open to different treatments before we moved (and before FD Dx), but have yet to find a good fit here!

Also, thank you for the reference site Mogs! Will definitely do some research for the asthma there as well!

She would definitely be dead right now if I hadn't have been working from home

So sorry to hear this! At least you were home! A VERY similar timeline with us as well. It can be so scary when they go hypo! Glad to hear that she made it through! Thank you for sharing your asthma tips as well! When we were at the emergency vet they actually suggested an inhaler too, but its good to know the difference between the types, i.e. the Flohale vs. the emergency albuteral. Also getting an air filter would be a great idea! I hadn't actually thought of that yet. I have asthma too so that would probably just help both of us out

So I'm really concerned that your vet never suggested even trying to move away from oral steroids for the asthma once you all knew it would be a long-term treatment. Is that the same vet that's treating you like poo with the treatment for the FD? #ByeFelicia

Our previous vet prescribed the steroids, and he was on a very low dose, which helped to control his asthma almost entirely. The current vet had us stop the steroids, which I understand could have complications with the FD treatment, but didn't really give us many alternative options after that. The one medication he switched him to gave him horrible diarrhea, and with the other ways they were unhelpful (not giving us any information about tests they did, resisted working with us on home testing, raising his insulin dose 1 u/week) we decided to dump them!

this, IMO, is wrong-headed if the cat has an issue where steroids are make or break

I do wonder about this, because his dose was so low for the steroids, if it wasn't possible to continue them. At the same time I am probably going to consider other treatments before resorting back to the steroids. Our vet told us they could have contributed to his development of FD.

I know nothing about Vetsulin but my Dweezil (who is on Lantus) also has puzzling sudden drops way beyond his next dose time. Like 16 hours. And I know Lantus is long acting, but come on!!!

From what I know, which isn't much, vetsulin is supposed to drop BG fairly quickly and gradually wear off up to 12 hours. I didn't think it was supposed to be especially long lasting which is why its so bizarre! It is good to know we aren't the only ones experiencing this, yet still so troubling since I worry about the risk of him becoming hypo again. This is why I have been testing more regularly!

The body can become much more sensitive to insulin after a hypo

This would make sense, maybe that's why his BG is low so long after his last dose? Or maybe his body is metabolizing much slower now?