? 10/25 Ming in hospital. What does should I give once he's home?

[Crista & Ming]

Previous thread: http://www.felinediabetes.com/FDMB/threads/10-23-ming-in-hospital.205315/

I'll finally be able to take Ming home tomorrow (hopefully) and do his curves at home. Personally, I'm feeling overwhelmed and burnt out. I have MUCH to learn and I haven't had enough time to sit and peruse the forum so please bear with me. I don't quite understand Lantus yet but I unfortunately don't have the time right now to educate myself. I will have amply time during teh weekend however! I'm SO sorry for the mean time!

I just finished my night shift at the vet hospital and I need to go to sleep but I wanted to give an overall update and ask some questions.

The IM specialist theorized that because Ming is getting a lower dose of pred at night, that his insulin dose needs will be lower vs. in the AM when he gets a larger dose of pred.

I don't have the exact numbers right now and it's NOT on my SS but I will put in the numbers once I get copies of his chart tonight. So the following is by memory:

The night of 10/23, we have him 9 units. He went from 356 at PMPS to 79 at +3 which is a DRAMATIC drop imo. I fed him a bunch of dry food in case he went any lower and managed to get him up around 144 but then went down again at +7 to 101.

At +10, he was at 214 and then suddenly, an hour later at +11, he was back up at 396.

Any ideas why this happened?

His dose was obviously too much. He also did not enjoy his dinner so he actually ate less than ideal.

Then during the day of 10/24, he got 8 units and was HIGH all day. As high as 666!!

Last night, 10/24, the SAME thing happened. Funnily, his PMPS was ~400 and then at +3.5m he went down to 79 and within the hour, was at 68 even. I fed him again a bunch of dry food and wet food. He ate a full dinner though this time. I managed to get him back up in two hours and from there, he just went up and up. His AMPS reading was 488.

Since the specialist suspects his higher dose of red is affecting the insulin, he's getting 9 units during the day of 10/25 (EDIT: he will get 10 units for 10/26 because he didn't really react to 9 units during AM of 10/25. Staying in the low 20s). He will be reduced to 7 units tonight for PM.

Has anyone dealt with this?

I talked to my vet and she said to prepare myself for Ming to be on this type of pred schedule for 1 - 2 months and eventually, we'd go for the lowest possible even dose. She also wonders if Ming is one of those kitties that may need to be given insulin 3 times a day. I asked about Levemir and she doesn't personally have experience with using it with cats but said to try this out and not make any drastic changes right now.

I wanted to ask more (like about getting him testing for insulin resistance) but got really emotional and just couldn't talk anymore. It's been rough.

I'll be sure to input all his numbers ASAP. I'm sorry I'm not able ot update the SS and have to type it all out here. Please let me know if what I wrote was unclear. Happy to explain!

 

[Olive & Paula]

First breathe and get some much needed sleep. You will need it when Ming comes home.I

As far as the numbers go. There are a few things that stick out. King isn't on a dose long enough to see what it can do. Lantus is a depot insulin and the depot takes a few cycles to establish. Changing dose each cycle will not work to its best advantage. The dry food is high in carbs, although I understand why you are giving it, the carbs can take a couple of days to leave their body. Therefore when it does the glucose will drop significantly and with the higher dose insulin your giving you will get those low numbers. So you give more dry, vet gives more insulin, you get low number. It starts all over again and again and again.

When Ming is home and your testing, FDMB will help you make a safe transition to get Ming on track.

 

[Crista & Ming]

Okay.

I’m definitely concerned when I bring him home, he relaxes and I dose him and he goes hypo.

The morning I bring him home, what dose should I ideally give him? Say a unit less than normally given at the vet, etc?

I guess that’s my most immediate question right now. All those other questions, like you said, can be figured out slowly once Ming is home

 

[Tracey&Jones (GA)]

Ming is getting a lower dose of pred at nigh

I have found after some discussion with my vet, with the people here and experimenting with Jones - if you can give the same dose of prednisolone morning and night it works better with the Lantus. According my vet, if the daily dose is 10mg it doesn't matter if you get 5mg BID or 10mg SID. Giving the same dose made things easier to predict.

Any ideas why this happened?

He dropped dramatically over a short time period. I understand using the dry food to get his numbers up but his body may have already been in crisis prevention mode. This does not mean that Ming was hypo or having a low BG event...more like his body natural reaction to the falling blood sugars and then the liver panics and throws out some to keep things staple. So with the dry high carb food there is also the natural body reaction. We call that a bounce. It will clear the system in 3-6 cycles usually. The dry just adds some extra spring to the bounce. A wet high carb food doesn't seem to last as long which is why it is suggested here to use a higher carb wet food with gravy.

The other thing is vet stress. Being in the hospital is stressful for kitties. Numbers can fluctuate a whole 100 points or more just from a check up.

Then there is pain management. Pancreatitis is very painful, especially in the midst of a bad flare. Is Ming receiving any pain medication? Pain will drive up the BG numbers as well.

The very first thought that has come to mind is that you need to keep the dose consistent. Lantus craves consistency.

Since the specialist suspects his higher dose of pred is affecting the insulin

Ming is on 3.75mg a day or BID? Jones gets 10mg a day - 5 mg BID. He is on .75 units of Lantus right now and without the dry food he is on now (a discussion for another day and not recommended by me unless a it is a hail Mary). Before the introduction of the dry food he was on 0.1 units or less.

Has anyone dealt with this?

There are lots of people here that have dealt with using a steroid and dealing with FD.

Are you testing for keytones at home? With DKA in Ming's history, that complicates things a little bit more.

I believe that Wendy gave some basic information on high dose conditions to have the IM test for as well. Was that discussed with the IM?


I can't help with a dose suggestion but tagging Wendy for you. @Wendy&Neko

 

[Kris & Teasel]

I recommend that you post asking specifically about what dose of Lantus to try once he's home. Put the blue question mark icon at the front end of your title. He was bumped very quickly from a "normal high-ish" dose to a very high dose so the usual advice probably won't suffice. Usually a small reduction (maybe 0.5 u) is recommended as you transition from ProZinc to Lantus. Lantus has to slowly build up in his system before you see the full effect of a dose. That "filling up" is called the depot. The higher the dose, the bigger the depot and it requires dosing experience to work with a large depot that can have an effect over quite a few cycles. You also have the steroid in the picture and that makes it trickier.

When you can find a little time I suggest you read these stickies on Lantus' depot and the two methods of dosing that are used here on FDMB. The SLGS method might give you more breathing room at the start.

http://www.felinediabetes.com/FDMB/threads/what-is-the-insulin-depot.150/

http://www.felinediabetes.com/FDMB/threads/start-low-go-slow-method-slgs.129446/

http://www.felinediabetes.com/FDMB/threads/tight-regulation-protocol-tr.1581/

 

[Crista & Ming]

I’m on my phone right now so it will be difficult to quote specific replies. But I’ll try to answer the questions asked.

Ming is getting 3.75 mg in total once a day. 2.5 mg in the AM and 1.75 mg in the PM.

I did ask if he just gets the entire dose in the morning if we’ll see the same trend of him going lower at night and higher in the AM. Vets seem to think so.

But are you saying it is better to just give 3.75 mg at once in the AM?

He is getting oral bupe twice a day I believe. He should also be given cerenia as well. It’s in the plan but he hasn’t gotten it.

And yes, we’re testing his ketones every urine output. At home, I may need to set up a different litter box with less litter but I can test ketones at home as well.

And no, I haven’t spoken to the IM about insulin resistance yet. Just another thing I forgot to ask but will.

I’ll be posting another post then if that’s okay to ask the specific question of what dose to give Ming when he comes home tomorrow.

 

[Wendy&Neko]

Usually a small reduction (maybe 0.5 u) is recommended as you transition from ProZinc to Lantus.

Not true, we take the current dose into consideration, and what sort of numbers you are getting with that dose. Sometimes there is no reduction at all. If Ming needs a larger dose of Lantus (some do) I wouldn't want to go backwards in dose needlessly which will slow down his progress.

When possible, could you put a blank line in the spreadsheet after the day of last Prozinc shot and before the Lantus was started. Whenever you can get the latest data from the hospital in there, that will greatly help us figure out where to go with dose. With Lantus, we determine the dose based on the nadir or low point, with very minor consideration given to the preshots. Lantus is a depot insulin, and with the dosing methods we use here, we find it best to stick to the same dose, unless they earn a reduction, or need an increase in dose. That 68 (if on a pet meter), means that dose is likely too high, at the moment. Jumping around in doses each shot makes it hard to figure out where to go next. Let us know when you have the data in, and we'll be able to give some thoughts on what to dose at home.

You don't need to start a new post for the day, just change the subject line and modify the subject prefix to add the ? icon. There are enough people posting here a day that it's easier to keep track of the action if it's all in one thread.

As for the prednisolone, you may have to see how Ming handles it and what works for you. Some people have seen a delay in it's blood sugar raising effect. One member used to give pred in the AM, because she knew it would lift the numbers enough that her cat would be safe during the day while she was gone. If there is less chance of you being able to monitor because of night shifts, you may want to mix that up. If that's how Ming reacts to pred.

 

[Crista & Ming]

Oh oops. I won’t update that thread and edit the post to redirect everyone here. So sorry!

And after I finish my duties for the night I’ll input the numbers.

They’re attempting 7 units tonight and 10 tomorrow. And I’ll hopefully be able to take him home during PM tomorrow so that gives all of us time to look at his numbers. And for me to sit and educate myself about lantus.

 

[Crista & Ming]

Oh darn it. Of course I edit the wrong thread. I’m so so so sorry everyone. I’m a mess! Currently fixing the situation though.

Edit: Okay fixed.

I spoke to my vet about Levemir (not the specialist). She personally does not have experience with using it with cats and only have seen it used with 2 dogs personally. One did not work out the other is a success. She mirrored what you guys have told me: not to make any changes just yet and let Lantus do its job.

 

[Crista & Ming]

I think you need to get all the info first. I certainly would not give 9 units if the 8 dropped his glucose like that. And probably wouldn't give the 8 units.

Regulation doesn't happen in a few days. Most cats go lower overnight and not during the day. If Ming is bouncing from a night time low number, he will be higher in the morning and possibly all day. It something you have to wait out.

It sounds like the vet is using Lantus the way Regular or N insulin is used. Lantus is totally different and will not work the way vet is thinking.

That concerns me. I'm afraid this will all catch up to him and he'll go super hypo (is that possible? lol). But once I get all the info for everyone to see, then we can make a better informed decision. I'm going to assume that I'll be giving a lower dose at home.

He's getting 7 units tonight at PM and then 10 units during the AM. Which yes, concerning, but.. at this point, I'm not educated enough to advise against anything. He'll come home after they monitor him during the AM and it will give us time to look over Ming's numbers and myself to do much needed reading and education.

 

[Wendy&Neko]

Too bad on the 10 units tomorrow AM, 7 would be better to help stabilize the depot. The problem with the depot based insulins is that what you give at one shot can influence later ones, so that 10 units may keep you hopping tomorrow night. Make sure you have a good suppy of high carb food, corn syrup/honey and test strips on hand. Once you get him home we'll help you get him to a better point with dosing.

 

[JeffJ]

In these higher pressure situations, just remember that you are doing a great job for your kitteh. Sometimes they get in these tough situations and we need to put in a little more time. I can see from all the testing and meds that you are doing a great job.

Leo gets pred daily. Since pilling is challenging, we do it once in the morning. It raises his BG for the AM, and I compensate with a larger dose. Currently 3.0 in AM and 2.0 in PM. Part of the dosing is particular to Leo. He eats a lot less at night as well. So the lower PM insulin dose is a small compensation and keeps him safe.

Sure, this is not per the forum guidelines, but it mostly works for Leo. Most of his diabetic life, he has been pretty bouncy anyhow. His body really likes Levemir the best (after trying Lantus and Prozinc). And pre-SRT he was up to 18 units/dose of Levemir, and his body seemed to like it best.

As discussed in the last few days, if you can, I would get the IAA and Acro test done. But only if you plan to do some treatment.

 

[Wendy&Neko]

Personally, I would get the high dose tests done, regardless of whether or not you are planning on treatment. First, with knowledge comes power. It gives you a plan and may impact dosing decisions. Second, there are some clinical symptoms that can come with acromegaly, some of which are not obvious, perhaps until too late. My Neko had a tooth saved because her dental vet knew she had acromegaly. What first looked like a bad tooth turned out to be a soft tissue growth causing her canine to rub against the gum. Instead of removing a tooth, the canine was shaved back. We've had more than one acrocat here have heart issues. With an acro, if there is a heart murmur, I would strongly suggest an echocardiogram. If nothing else, for a baseline. Heart issues can be treated if caught in early stages.

 

[Olive & Paula]

Oh no not 10 units. Can you talk them out of that? You do have the right to say no. Maybe if you tell them "let's give him time to settle" his doses are all over the place.

Hope you will be home tomorrow to monitor.