? Getting low numbers even while reducing the amount of insulin

Dagmar Usta

Dagmar Usta

Member Since 2019
Coco was diagnosed last December with diabetes. Since then we have been working to get some control and to help him feel better. Before being diagnosed he went into a ketoacidosis and when he came out of the emergency clinic they started him on 2 units every 12 hours.

Coco is fed raw food as he does not like eating other types of food, at the moment we needed him to gain weight and get as healthy as possible so we gave him the food he will eat. We have noticed that his body is reacting to the insulin as we have been reducing his units periodically. His first reduction was from 2 units to 1.50 for almost 2 weeks, then we started on 1 unit for an even shorter period as his morning levels were too low for us to feel comfortable injecting him and not being at home in case something happened.

Today his amps were 11.5 and his pmps were 22.3 we proceeded to give him 0.5 units just to see if that amount will help us reach control, and be able to inject him twice a day as recommended by the veterinarians. He started acting restless and running like crazy, we took a BG test and noticed that at +4H his levels where at 5.9. When we did his curve at +4 hours his BG was at 9.8 with the possibility of going down without causing any problems for him until the lowest point and then back up. He reached 5.9 too soon in comparison with his past measurements noted on his chart.

I don't know what to do considering that his numbers are still a bit high but his body reacts to well to the insulin and they drop down to fast. has this happened to anyone else? Is this common? how have people handled this type of situations? Any advice is useful.

Thank you
 
Hi there Coco and Dagmar,

here is your last post in the feline health board
http://www.felinediabetes.com/FDMB/threads/diagnosed-a-month-ago-working-to-get-control.210061/

I have to go out to the pharmaccy in just a moment, so I will get back to you.
But have you got another test after that +4?

It's important to know that cats will not always have their nadir (low point) at the same time. George has nadired as early as +2 and as late as +13.

Since Coco has dropped so much although still in a nice numbers, it's important to see if he will drop any further, if you haven't already, it would be a good idea to give Coco a little snack of his regular raw food.

Another thing that is very important with a cat that has recovered from DKA is not to take the dose down too quickly, because this can, in some cat's trigger another bout of DKA, we will need to try to help you figure out a dose that you can shoot every 12hrs, skipping doses in a DKA cat is not advisable, but at the same time we don't want Coco to go too low.

What is your availability to monitor coco on a day to day basis? Is he alone for large periods of time? Do you have an auto feeder?

One other thing I would be grateful for you to do is to update your signature and put DKA and the date Coco had it on your signature, as it is an important factor do consider when anyone is offering advise and might be over looked by someone new visiting your thread.
If you have a chance, and haven't already, please try and read through the stickies, the yellow highlighted posts at the top of the board, particularly the one about the dosing methods, though with DKA in the picture we need to adapt those more specifically for Coco, but reading through them will start to give you an idea of how to get best results with lantus.

Where are you in the world? just for an idea of time zones, I'm in Spain? Are you in Europe too?

I have to go get ready and then dash out to the pharmacy. But I will stop by a little later.
 
Hello Gill,

The fact that coco can go into a second bout of DKA is what worries me the most. I am very concerned about that and will like to find the correct amount of insulin to give him and avoid going through a hypo episode.

Yesterday I gave him a little bit of his raw food when he became restless. Unfortunately I am unable to stay with him from 9:30 am to 5:30 pm, I have a camera at home to see if anything happens and if I can do anything for him but I don't have an automatic feeder. I am very frustrated and don't know what to do. This first month has been very overwhelming.

I am in Canada by the way. Hope I can get some help.
Thank you
 
Hi there,
I thought you had to be europe or canada.
What time zone are you in, it helps us know when you're shooting with members from all over the world, it helps us work out when to look out for you.
Dagmar Usta said:
Unfortunately I am unable to stay with him from 9:30 am to 5:30 pm,
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What time do you shoot?
If I had to leave him at 9.30am, what I would do is shot on a 6am 6pm schedule. That would allow me to feed and shoot at 6am, then I could get a +2 and +3 before I left, if he was dropping at that point it would give me an idea of whether I need to leave some extra food out for him or if indeed if he was dropping fast whether I might need to give him some food with extra carbs to boost his numbers to try and keep him safe while I am away.

Dagmar Usta said:
but I don't have an automatic feeder.
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I invested in one of these, my boy guzzles any food I leave out so it worked really well and was/is a lifesaver for when I have to go out, or for when I go to bed. Some come with little icepacks to keep the food fresh.
Will your boy graze? have you noticed if he gets particularly hungry when his BG is dropping? You mentioned he was running around, was he trying to get your attention for you to feed him?

My boy get's real hungry when his BG drops suddenly/quickly or when he gets too low, he comes and finds me and makes a fuss, so he lets me know something is up. Not all cats do this but if they do it's handy.

As to dose, looking at the data you have on the SS, it seems like the 1.5u was too much, as that got you into light green. So reducing the insulin was probably a safe choice. However, cats are reallly sensitive to small dosing changes, we usually make changes in dose in 0.25u steps, so it would have been better to have taken him down to 1.25u.
As for taking him down to 0.5u my feeling is that is not enough insulin, you might find that a strange comment given the large drop he had last night, but because lantus is a depot insulin, and beause of the dose changes/ skipped shots you've had in the prior few cycles, the depot is having to adjust and that is leading to some 'wonky' numbers, so it makes it hard to judge what might be a correct dose.
When you were dosing the 1u, he was dropping into blue and bouncing back up into black, the bounces into high numbers, may have been a result of him dropping too low, or dropping fast, or just lower than his body is currently used too. DKA kitties do seem to like to bounce.
Unfortunately you don't have much midcycle data, do you think you could regularly start getting a couple of tests in the am and pm cycle?

If you could shoot in the morning at a time that would allow you to at least get a +2, that would be extremely useful, if you get home early and can grab a +11, that would be excellent too, and then in the evening if you could get a +2 and a before bed test then you would be well on your way to gathering the data you will need to be able to make a good dosing decisions in order to keep Coco safe.

One other suggestion, you are using a pet specific meter, the strips are much more expensive than the human glucometers, moreover, the dosing methods we use have been developed using human meters and it is advisable that you use a human meter for this purpose, folk have tried to make comparisons with human and the AT" unfortunately it isn't possible to convert one number reliably to the other.

Some reading that I would suggest (sorry for the homework),

This explains the insulin Depot
http://www.felinediabetes.com/FDMB/threads/what-is-the-insulin-depot.150/
Tight Regulation with a full time job
http://www.felinediabetes.com/FDMB/...ion-possible-with-a-full-time-job-yes.129378/
Read post number 10 for for an explanation why we encourage the use of human meters for the dosing protocols
http://www.felinediabetes.com/FDMB/threads/pardon-our-dust.210108/

As for dose...
I have asked some other experienced members to look in on you. But I do think 0.5u may well be too low, and with the DKA that can be a problem since not enough insulin can trigger another DKA bout, particulary if he is not getting enough food or if he stressed and or develops and infection. I'm thinking that you should go back to trying to shoot 1u twice a day, as that was the last dose that he was at where it seems as he was getting below the renal threshold and where you didn't catch any lime green numbers, with the proviso that you can at least get those extra midcycle tests in that I have tested, if you can get more tests daily then even better at this stage the more data the better, but you will also need to figure out a way of leaving food out for him while you are out if the numbers suggest that you need to in order to keep him safe.
I should emphasize, that with DKA, you want to avoid skipping shots, so it's going to be important to try and get some good data in as soon as possible so we can
1) get enough food and insulin into him to keep DKA at bay
2) keep him safe from hypos.
 
Hi Gill, I live in British Columbia so Pacific Standard time. I feed him at 6:00 am and give him insulin at 7:00 both am and pm. this gives me a little bit of room to test before I leave. Coco does get particularly hungry when his BG goes down and runs around trying to get attention looks into the sink when there are dishes lying around and approaches his food dish to see if there is food.

I will get another test before I leave for work today and it will be up on the chart. I reduced the amount to 0.25 before reading you second post because I was trying to be careful giving him a shot and not risking a hypo episode. I don't know if maybe his depot has a good "reserve" and that is why his body is acting this way. If that is the case then reducing and going back up depending on his measurements will be a good way to find balance?

I have been reading most of the information on the forum and following the advice. In case he is a bit lower that what I feel is normal I will leave some food for him if he needs. We don't have an automatic feeder but we have one of those dishes that will only open only for him as we have another cat at home. I will try my best to get as much readings as possible and get a hold of his cycle so he can be happy.
 
Welcome from Alberta :)

I'm not sure what your strips are costing you, but Superstore and it's affiliates have Freestyle Lite strips for $75/100. And you ask for the meter free when you buy 100 strips, and they will fill out a card on their end so you get the meter free. I have a One Touch Ultra 2 Mini and it's strips are $20 more, and it takes 3x the sample that the freestyle and alphatrak do.
Any meter with a small sample size and decent priced strips is good though.

Do you have urine strips to test for ketones? You can get ketostix or ketodiastix(measure glucose too) from any pharmacy.
 
Dagmar Usta said:
We don't have an automatic feeder but we have one of those dishes that will only open only for him as we have another cat at home. I
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That's good, if he is not a guzzler and will graze and look for food, then that will work quite well for him.
Usually because lantus is slow acting we test feed all in about 10 minutes, so if you are up and feeding him at 6am, I would suggest testing him before you feed, then put his food down and give him his shot, I shoot George while he has his head in the bowl, usually he won't even look up, and it beats standing around waiting for him to finish LOL, some folk do wait for their kitty to finish.

Did you shoot 0.5 or or 0.25 in the end? it says 0.5 on the ss.
Dagmar Usta said:
If that is the case then reducing and going back up depending on his measurements will be a good way to find balance?
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The best way to figure out the dose is to shoot consistently, going up and down makes it trickier, we need to find a dose that you can feel safe shooting consistently.

Dagmar Usta said:
I will get another test before I leave for work today and it will be up on the chart.
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Excellent. look forward to it.
majandra said:
Do you have urine strips to test for ketones? You can get ketostix or ketodiastix(measure glucose too) from any pharmacy.
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Excellent point, testing for ketones is very important, especially if BG are consistently high or if Kitty has had DKA or prone to ketones, I used ketostix to test Georges urine(never had DKA), but most folk who have a kitty that has had DKA invest in a blood ketone meter. It will give you an early warning if things are going wrong and help you manage the situation more effectively, because you can take preventative measures before he ends up in a critical situation that will require intensive vet care.
 
Discovering your cat is diabetic due to a case of DKA is unfortunately like initiation by fire; along with learning about feline diabetes in general there are some very important things to know specific to avoiding a DKA recurrence.

First line of defense is daily testing for the presence of ketones, either with test strips for testing urine or a meter that checks the blood.

You see the way DKA works is that when there is not enough energy from food making it into the cells, the body will breakdown it’s own fat and protein to try and fulfill the need for more metabolic energy. The excessive breakdown of these stored reserves creates a toxic by-product - ketones. As ketones build up in the blood stream, the resulting pH and electrolyte imbalances can very quickly develop to life threatening levels , a state of DKA.

The factors that contribute to formation of ketones are : not enough insulin + not enough calories + infection/inflammation or some other systemic stress.

In general when recovering from DKA, feeding at least 1.5 times the calories required for maintaining ideal weight is recommended, along with as much insulin as you can safely shoot consistently, so that the energy from the food can make it into the cells. Lastly any infection or inflammation must be addressed otherwise energy will be diverted to fighting the stressors with little left for restoring health.

Recovery does require intensive care. Many here have successfully navigated the balancing act required to fully recover from DKA, myself included. Hang in there and hang in here. :cool:

 
I couldn't agree with Sandy more. Testing for ketones is the single best way of preventing a costly hospitalization for DKA. My kitty was diagnosed with DKA at the time she was diagnosed with diabetes. It was a harrowing experience that I never wanted to repeat. Just like you're testing his blood glucose levels, it's important to test for ketones.

One FYI - you do not need to wait an hour after you feed Coco to give a shot. With a long-acting insulin like Lantus, most of us test, feed, and shoot all within a few minutes. It takes approximately 2 hours for Lantus onset to begin. With shorter acting types of insulin, you must have food on board prior to giving a shot.

With the dosing strategies we use here, we adjust the dose in 0.25u amounts. Depending on which dosing method you're using, doses are reduced with readings at either below 90 or below 50. (See the Dosing Methods sticky.) So from the standpoint of the methods we use, Coco did not truly "earn" all of the reductions you've been providing. Particularly with a kitty that's been through a recent bout of DKA, we are particularly careful about not reducing the dose too quickly and we are especially careful to not suggest that doses be skipped if at all possible. As Sandy noted, not enough insulin can be a factor in ketoacidosis recurring. It is sometimes better to err on the side of giving a higher carb food to offset the effect of insulin so you can give your kitty a shot.

Since Coco likes raw food, what do you use to increase the carb content if you need to?

 
Yes Unfortunately the vets took too long to confirm that he was diabetic because his test weren't conclusive. The day he started his crisis they were about to teach us how to inject him and use the insulin.

Gill & George said:
The best way to figure out the dose is to shoot consistently, going up and down makes it trickier, we need to find a dose that you can feel safe shooting consistently.
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What I meant is that while we get a handle of what should be his consistent quantity I will have to figure out if I should increase that 0.25, which I think is too low. He is not a fat cat he was weighing 5.9 kilos before everything happened, he is not back to it yet but getting there.

majandra said:
Do you have urine strips to test for ketones? You can get ketostix or ketodiastix(measure glucose too) from any pharmacy.
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I am going to be buying the ketosticks and test for those when I have the change. Not sure how to do it but will try at least. I measured his BG at 2+ he was on 13.6.

Sienne and Gabby (GA) said:
Since Coco likes raw food, what do you use to increase the carb content if you need to?
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That is what I am trying to figure out, I feel like everything that has happened relates to the quantity of carbohydrates the food has. Is there a link you guys can provide that explains something about adding carbs to his diet without putting him in danger?
I think his diet is good for a diabetic cat but will like to know if he will benefit from a little bit more carbs to give the insulin and body something more to work with. maybe having too little carbohydrates makes lantus too effective to the point that it goes really low?
 
Unfortunately, adding carbs isn't a uniform process. A great deal depends on how carb sensitive your cat is and this differs among cats. One member here could feed her kitty a piece of chicken and her numbers would increase by 30 points. Her cat was very carb sensitive. Other cats, you could give a teaspoon of gravy to and there's no response whatsoever. In addition, the effect of carbs may depend on when in the cycle the carbs are needed. In the earlier parts of the cycle (before nadir), insulin has it's greatest effect so you may need more carbs than later in the cycle when the effect of insulin is waning in order to get the same result.

You are also correct -- some cats do better when they have more carbs in their diet. They may do better, for example, on 8% carb vs 4% carb food. The only way to figure this out is trial and error. One of the common expressions here is "every cat is different" (ECID). The other concern you've noted re. a cat going "too low" is one that we all have to deal with. First, what's "too low." Many cats can be in low numbers for a brief time and do not exhibit signs of hypoglycemia. You don't want to ignore the numbers. Rather, because you're testing, you know to intervene and give something high in carbs to raise the numbers. If Coco's pancreas starts to heal, there will no doubt be times when you're giving the same amount of insulin you gave the day before and Coco's pancreas pumps out some of it's own insulin. Coco's numbers will drop. It's a matter of you're being mentally prepared to give some HC food (or syrup) to bring numbers back into a safe range. As strange as it may sound now, it really does become second nature.

You want to add carbs when numbers are getting low -- certainly if they are falling below 50. If numbers are dropping fast, feeding some of your usual food and seeing if that helps to put the breaks on dropping numbers is a good first strategy. If numbers continue to plummet, adding higher carb food may help to slam on the breaks. It becomes a balancing act between giving enough carbs to keep your kitty in safe numbers vs giving so much high carb food that your cat's numbers bounce to the moon. There's a sticky on Handling Low Numbers that describes the process of testing, feeding and re-testing shortly after as a means of helping to steer numbers. There are usually people here who can help you learn how to manage those numbers.
 
I notice that your SS doesn't have any comments. It would be helpful to you and those helping you if you add in some comments, for example, what you feed, how much, and when. Then you can look back later and see how Coco responded in those situations.
What do you currently feed? You could add the regular meal food to your sig if you'd like
 
Hello from another BC'er. I don't know which raw food you are feeding, but Red Dog/Blue Kat products are from 3-5% carbs and are primarily what I fed. When my girl got CKD I had to remove the poultry ones from the line up because of the ground bone.

Also, depending where you live, you can get test strips from ADW sent to US post boxes in Point Roberts or Blaine, which is what I did. The link point to the ones I got. Even with the exchange there was quite a cost savings. And those ones just need a small amount of blood. I'd order several hundred at once. That meter is a human meter, but that's what our dosing methods use.
 
Hey there and welcome to L, B, & L I am sorry that your boy and you went through the DKA event.

I agree with Gill to get as much data as you can in the way of testing to find a good dose for Coco. I think that 1u could be a good starting place.

As far as raw feeding, I raw feed Bubba also. His numbers can raise as much as 15-20 just from eating a small 1 oz raw meal. Getting some +1 test in might be helpful to you to know what a meal does to his BG's.

Giving him extra water in his food will help to flush any ketones that could be forming. I got a blood ketone meter when Bubba had ketones, because finding him in the litter box was not happening and if I did find him in the box, he would jump out.
 
Hi just checking up on you, I hate to bump an old post, but I was wondering how you were doing?
Have you managed to get something to check for ketones?
How is his eating?
Looks like he dropped down into blue again.
Perhaps you could start a new post.
 
Gill & George said:
Hi just checking up on you, I hate to bump an old post, but I was wondering how you were doing?
Have you managed to get something to check for ketones?
How is his eating?
Looks like he dropped down into blue again.
Perhaps you could start a new post.
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Hi,

We are doing as much as we can to regulate coco, we have been increasing his food since he was wanting to eat more. That required some adjusting to his insulin but we are doing as much as we can to control his BG. We noticed that he was having spikes during the evening and decided to do a new curve to see where he was and adjust accordingly. We are going to give his body some days to get use to the new quantity.

Now, just today (March 4) we noticed that he was not putting pressure on his left front paw, he does not limp and does not react aggressively when we hold it but he tries not to put weight on it. It also does not feel any different from the other leg and is not inflamed. Has this happened to any of you? I know about diabetes affecting the back legs but not the front ones. Any information that you could provide is great.

Thank you for checkin on us! Much appreciated.
 
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