Flat readings - suggestions for dosing?

Kris & Teasel said:
I can't say for sure but I don't see why it should be. Too large an increase in dose is potentially more dangerous. ProZinc isn't a depot insulin although sometimes it can have slightly longer than 12 hour duration. You should see the effect of the dose decrease in a couple of days. We always worry about ketone development when BG runs higher so you might want to do urine ketone testing while you do this experiment.
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Since his BG dropped to 283 this morning I decided to do one more cycle of the 2. I will try to do a ketone urine test today and then try dropping his dose this evening. Thanks.
 
Aside from finding the good dose range, Ramon's two inflammatory health conditions as well as the meds he needs to control them are probably affecting his insulin response. As we often say to others, it's a matter of dosing around them.
 
Kris & Teasel said:
Aside from finding the good dose range, Ramon's two inflammatory health conditions as well as the meds he needs to control them are probably affecting his insulin response. As we often say to others, it's a matter of dosing around them.
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Today I am going to try to drop the dose back to 1.2 and see if his numbers come down. At least when I was staying steady at 1.2 his numbers stayed in the mid 200's instead of the high 200s/low 300s. Plus he seemed to feel better at 1.2 than he does right now. He is definitely not feeling well currently.
 
Kris & Teasel said:
Aside from finding the good dose range, Ramon's two inflammatory health conditions as well as the meds he needs to control them are probably affecting his insulin response. As we often say to others, it's a matter of dosing around them.
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Well the numbers are just as bad but he was acting so much happier all day at this lower dose. I guess I'm committed now to the lowered dose.
 
Please do make sure to keep up the ketone tests! Let's see how this dose goes and then we can go from there.
 
This morning BG is 332. So this is not going well. Weirdly enough his ketone tests have been normal including when he was tested @ 415 while at the vet's (his highest BG). I am assuming that I should give it the 4 cycles before heading back up in dose?
 
You don't need to wait to start increasing the dose. You can move him up now. I wouldn't go all the way back to 2u in one jump though - maybe increase by around 0.4u now and tonight, and then the rest of the way tomorrow.
 
Ramon's mom said:
This morning BG is 332. So this is not going well. Weirdly enough his ketone tests have been normal including when he was tested @ 415 while at the vet's (his highest BG). I am assuming that I should give it the 4 cycles before heading back up in dose?
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If you can monitor you can increase right away. Are you planning on trying 1.4 u then 1.6 u etc. or just bumping him back up to 2 u?

As I said before I think his less than ideal response is due to his two inflammatory conditions and the meds he needs for them. It doesn't mean you won't find a better dose range for him but it likely will mean erratic responses and a rockier road getting him to good BG levels. It will probably be harder to hold him there too. It is what it is and we aim for the best BG level we can sustain in the circumstances. My cat has some level of IBD and a long history of being erratic and hard to predict. My SS is still quite colourful after three years, three insulins and two bouts of DKA. To some my SS would look horrible but to me it looks like Teasel's version of good enough.
 
I gave him 1.2, not knowing I would get advice this quickly. That was 40 minutes ago. Could I give .2 or.4 more at this point? I can monitor except late afternoon (2:30 - 7 pm, which would be +6 to +10ish). Ramon has been erratic since July except for the time on 1.2 where he was flat in the 200's. I had switched from Lantus because of the erraticism. Should I be looking at switching him back? Or is Prozinc just as good?
 
I suggest you wait until this evening for the increase in dose.

Give the ProZinc some time. What was the date of the switch to ProZinc? Maybe include it in your signature. If it turns out that you can't get him to a good BG range you can try Lantus again in the future.
 
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I feel kind of bad because trying this experiment seems to be making my kitty swing up and down in how he feels. He felt better from having the insulin dropped but his higher BG numbers are now making him very grouchy and he's gotten aggressive with my other cats again from it. I bumped him up to 1.6 tonight (his BG at PMPS was 372 which is yet a new high). I guess I'll follow the advice I'm getting here and just keep going up and up on the dose and pray we get a stable place that he will feel better at. For a moment there I almost thought maybe the insulin is actually doing bad things to him and that I should take him off it completely. But all the aggression tells me otherwise.
 
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Ramon's mom said:
I feel kind of bad because trying this experiment seems to be making my kitty swing up and down in how he feels. He felt better from having the insulin dropped but his higher BG numbers are now making him very grouchy and he's gotten aggressive with my other cats again from it. I bumped him up to 1.6 tonight (his BG at PMPS was 372 which is yet a new high). I guess I'll follow the advice I'm getting here and just keep going up and up on the dose and pray we get a stable place that he will feel better at. For a moment there I almost thought maybe the insulin is actually doing bad things to him and that I should take him off it completely. But all the aggression tells me otherwise.
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You'll get there. It's very possible that you might want to try Lantus again at some point. It's less likely to cause big ups and downs and you might have success if you follow the Lantus dosing guidelines more closely. For now let's see what ProZinc can do. :)

Another member posted this link to a FB video of a research vet at Britain's Royal Veterinary College. He's discussing a research trial they conducted comparing remission rates in cats treated with Lantus versus ProZinc. He also makes a lot of good points about other issues:
https://www.facebook.com/watch/?v=10154849470681010
 
Kris & Teasel said:
You'll get there. It's very possible that you might want to try Lantus again at some point. It's less likely to cause big ups and downs and you might have success if you follow the Lantus dosing guidelines more closely. For now let's see what ProZinc can do. :)

Another member posted this link to a FB video of a research vet at Britain's Royal Veterinary College. He's discussing a research trial they conducted comparing remission rates in cats treated with Lantus versus ProZinc. He also makes a lot of good points about other issues:
https://www.facebook.com/watch/?v=10154849470681010
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Thanks for the link. I will try to view it this weekend. At this point he has received the 2 units 3 times (we're just starting the 3rd cycle after going down to 1.2 and then back to 1.6 and now 2 units). Tonight I caught him eating @ +11.5 so I quickly took his blood sugar on his second mouthful and it was the lowest its been in almost 3 weeks (211). @ PMPS I retook the BG (after he had eaten) and it read 286. I gave him the 2 units again and plan to monitor. Assuming he doesn't bounce too low over night but continues to read @ 200 (or even lower) in the AMPS, should I still give the 2 units? I just don't know what to do next. Thanks!
 
The general approach is to keep a dose for 3 to 4 cycles. If the nadir numbers don't drop to at least blues, increase by 0.2 u (because you use U100 syringes) and repeat. Ignore the pinks, etc. and focus on the middle range numbers. If he bounces, so be it. Your goal is to lower the middle numbers in the +4 to +7 range. That's where you'll see the progress if you're getting to the good dose range. If you have a much lower than usual PS you can stall without feeding for a half hour, retest and if he's rising give the usual dose.
 
Kris & Teasel said:
The general approach is to keep a dose for 3 to 4 cycles. If the nadir numbers don't drop to at least blues, increase by 0.2 u (because you use U100 syringes) and repeat. Ignore the pinks, etc. and focus on the middle range numbers. If he bounces, so be it. Your goal is to lower the middle numbers in the +4 to +7 range. That's where you'll see the progress if you're getting to the good dose range. If you have a much lower than usual PS you can stall without feeding for a half hour, retest and if he's rising give the usual dose.
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I've followed your advice. And now in his 2nd cycle at 2.2 units he dropped 135 points from a PMPS of 322 to a +4 reading of 187! I plan to set my alarm and test again @ +6 to see if he drops another 135 ! I hope not. I hope this is just getting to his good dose range. Any thoughts to encourage me? @Djamila ? @Rachel ? @Kris & Teasel ?
 
Sorry! I was fast asleep last night when you posted this. :) It looks like he stayed nice and safe last night though. I'm hoping this will help lead to a nice AMPS!
 
I'm so happy to see those blues! :cool: The 135 is a very nice but safe number. Keep the 2.2 u today and we'll see how he does with it in the daytime. They often run lower at night.
 
AMPS 234! But PMPS 373. No blues today. This brings me to another dilemma. I'm also going to be boarding him for 5 days while I go out of town. The cat sitter will give him his meds, test BG and give insulin but I was planning on prefilling syringes for her and instructing her to only inject if the BG is above say 225? Given this, should I continue increasing the next 2 days or stop and resume when I get back?
 
I'd stick with increases until it's time to go out of town. When are you leaving? Are you boarding him at the vet or having someone come over to your house?
 
How long is it before you leave on your trip? We can suggest a safe dosing routine according to the BG data you accumulate between now and then.

I suggest you increase to 2.4 u this AM.
 
I agree with Kris and Rachel about continuing the increases for now. Leaving town is always hard, but we can help figure that out when the time comes.
 
I leave in two days (7:30 am CST). I am boarding him with a pet sitter who tells me she has experience with a diabetic cat. I can't leave him at home because he'd hide from a pet sitter there (plus he bullies 2 of my other cats). And the vet charges $80 a day. Anyway, please do suggest a safe dosing routine for him! I'll go ahead with 2.4 today. 2.2 has worsened things again. 352 this morning.
 
Ramon's mom said:
I leave in two days (7:30 am CST). I am boarding him with a pet sitter who tells me she has experience with a diabetic cat. I can't leave him at home because he'd hide from a pet sitter there (plus he bullies 2 of my other cats). And the vet charges $80 a day. Anyway, please do suggest a safe dosing routine for him! I'll go ahead with 2.4 today. 2.2 has worsened things again. 352 this morning.
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Actually, until you get his BG down more you're very likely to see these ups and downs. You might see a glimpse of better numbers then he'll go back to higher values. It's quite normal. After you're back home you can resume the dose increases. Easier said than done but try not to focus on individual ups and downs. Scan your SS from a distance and see the overall pattern. That's a better way to assess the dosing regimen.
 
@Kris & Teasel Since there is often a delay in getting responses here, can you suggest the dosage to me sometime on Wednesday (in the next 30 hours) so I can get his meds prepped for the cat sitter? I will be leaving early on Thursday before I typically get responses here. Thanks tons for all this help! I assume I will be giving her instructions to skip doses at certain levels (or if he resists her too much she may end up having to skip!).
 
Ramon's mom said:
@Kris & Teasel Since there is often a delay in getting responses here, can you suggest the dosage to me sometime on Wednesday (in the next 30 hours) so I can get his meds prepped for the cat sitter? I will be leaving early on Thursday before I typically get responses here. Thanks tons for all this help! I assume I will be giving her instructions to skip doses at certain levels (or if he resists her too much she may end up having to skip!).
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I would give at least 2 u. His AMPS will be useful in making a final decision. He can probably handle a full dose if he's at 200 or higher and a slightly reduced dose (1.6 u or 1.8 u?) if he's 150 to 200. I'm guessing on this though. @Djamila ?
 
Assuming he stays in his typical yellows/high blues after this dose today and tonight, I might be inclined to have the sitter go with 2.2 if she can test and knows he's 200 or higher, and maybe 2u if she can't test. He isn't showing any indication that he needs a lower dose, even when being cautious. And I would not have her skip. If he's low, I would instruct her to stall if she's able to, and give the dose late. If she can't stall, and is low, I agree with Kris about the 1.6-1.8. Skipping when he's in these numbers and with the added stress of not having mama there, could be risky for him.
 
@Kris & Teasel @Djamila @Rachel Today's numbers kind of look like a bounce. 250 AMPS then 219 @ +2ish and 151 @ +5ish and 294 @ +7 (though he did eat after the +5). But now the question is - what do I do tonight and with my pet sitter starting tomorrow? I believe that she will test at AMPS and PMPS but probably not inbetween. Thanks for your advice!
 
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Ramon's mom said:
@Kris & Teasel @Djamila @Rachel Today's numbers are much better again. 250 AMPS then 219 @ +2ish and now 151 @ +5ish I plan to check again in 2 hours. But now the question is - what do I do tonight and with my pet sitter starting tomorrow? I believe that she will test at AMPS and PMPS but probably not inbetween. Thanks for your advice!
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I think Djamila's advice in post #78 above still applies. You could drop back to 2.2 u tonight if you're more comfortable with that.
 
Hi all. I am back home with Ramon and I just filled in his readings from when I was gone (the pet sitter was great about testing and following the dosing instructions per Djamila's advice. Wonderfully enough he settled into yellows and blues! I am thinking I should check the nadirs for a few days and stop increasing for a while? Does this sounds right? @Kris & Teasel @Djamila @Rachel
 
Welcome back! I think I would hold the 2.2u tomorrow, and see how he does. Cats often respond differently when mama is out of town because they might not eat as much, or might have some anxiety. So let's see where he goes now that you're back and then decide if you need to adjust again. Hopefully he'll keep on like he is because it's nice to see him staying out of the pinks for a few days!
 
I agree. Let's hold the dose for now and see what happens. I know my cats for example don't eat as much when I'm not home. That can make the numbers a little lower so waiting to see if Ramon's behavior changes now that you're home and seeing how that affects BG is a good plan.
 
As mentioned above, cats will often eat less while mama is away which can make their numbers a little lower. They are also stressed (even if they like the pet sitter), so while most cats go higher when they are stressed, there are some cats (mine included) who will run a little lower than normal.
 
Since he did not go down, I went up to 2.4 this morning and now he has gone further up. I will give the 2.4 tonight and tomorrow morning as per previous suggestions from you folks but once again I kind of regret changing his dose. I do want him to go down into the blues but I can't seem to make that happen (at least not at home. His pet sitter did however...) He also has been off his food today and had a case of diarrhea too. Can't tell if it is the insulin increase or something to do with his IBD? I have been holding off contacting his vet because I have been changing his insulin dose against her orders, and assume she will just blame any problems on that.
 
Please advise me - I stayed on the new higher dose of 2.4 for an extra day because the numbers seemed to be going down. Now they are zooming way up again. Based on your earlier advice I should be raising it again? I'm sorry I am so needy for advice and/or encouragement/assurance. I really hate this roller coaster. @Djamila @Kris & Teasel @Rachel
 
Hi -- Do you think that today's pinks may be a long bounce from having gone into the blues (which his little body thinks are low) overnight? That's the only thing that makes sense to me if you are sure that you did not have a partial fur shot this AM. In either case, I might hold it one more day, either to see if he clears the long bounce or to be sure you got all the insulin into him.
 
I am sure it was not a fur shot. (I always rub around the area afterwards to feel for moisture. And I could see the needle going in plus it s very short 6mm needle). But it could be a big bounce. Since July I have not been able to get him to stay stable on any particular dose, so to me it just looks like the same old out-of-control situation. Djamila and Kris have been advising me that he probably has glucose toxicity and/or insulin resistance, and have been advising regular increases in an attempt to find a stable dose for him. I guess I'll take your advice and try another day at the 2.4. I'm really losing hope of ever getting this under control. But thanks for your response.
 
Good morning! Sorry I didn't get your tag...I was asleep early. I've been sick all weekend.

It definitely could be a bounce. Remember bounces don't mean the cat got too low...just lower than they are USED to. It's not a bad once if it is a bounce though, which is good.

If he doesn't get into lower numbers this morning, I'd go ahead and increase again. If he does have a bit of glucose toxicity, which is likely, you want to got on top of it if he finally starts to dip a bit lower. And it does look like he was going down last night when you got that test in, showing that he wasn't staying high and flat like a bounce cycle...so hopefully if it was a bounce, he'll have cleared it!
 
I'm so sorry this has been such a struggle. You do want to keep increasing - I know it's hard, but some cats need quite large doses for a while, and especially when you're dosing around budesonide. While for some cats it raises BG less than other steroids, it looks like Ramon is in the group of cats that are impacted by it, so your dosing isn't going to be "normal". I know I would struggle too if it felt like the insulin wasn't doing anything. It's going to be a matter of adjusting your expectations for what Ramon's spreadsheet might look like. As long as he needs to be on the steroid, you're going to see that impact in his numbers and his dose.

I want to assume your vet walked you through all of your options before starting the steroid, but given the variations in vet quality we run into around here, it may be worth double checking....

If I remember correctly, Ramon already takes a probiotic daily, correct? Have you already tried removing any foods with carrageenan (this causes IBD and skin allergies in many cats)? Have you tried a diet completely free of fish (checking the ingredient list very carefully since it often hides)? Have you tried a novel protein diet for at least a month (rabbit, kangaroo, or venison are usually the easiest to find - making sure there are no added chicken, turkey, or fish sneaking into the ingredient lists)? Have you tried a raw food diet?

If you've already walked through all of those for several weeks (typically 4-6 week trials) and he's still showing the IBD symptoms, then the steroid is likely simply necessary and you'll just need to dose around it. If your vet didn't tell you about one of those steps, or you're not sure you tried it long enough and want to give it another go, for many cats their IBD can be managed without an ongoing steroid through consistent probiotic use and careful diet choices. And if that's an option, it will likely help with the BG numbers. Again though, if the steroid is needed, then it's needed. And knowing that may help your heart as you can adjust your expectations of his numbers and find some peace in knowing his numbers are just going to look different.

Please ask if you have any questions about any of that, and again, if you've already tried them, no need to type out the whole history of the trials and fails along the way. I just wanted to make sure you knew about them in case your vet hadn't been thorough. My assumption is that he/she was though, so we'll just keep dosing about the budesonide and get to the best numbers we can for Ramon. :bighug::bighug::bighug:
 
Djamila said:
I'm so sorry this has been such a struggle. You do want to keep increasing - I know it's hard, but some cats need quite large doses for a while, and especially when you're dosing around budesonide. While for some cats it raises BG less than other steroids, it looks like Ramon is in the group of cats that are impacted by it, so your dosing isn't going to be "normal". I know I would struggle too if it felt like the insulin wasn't doing anything. It's going to be a matter of adjusting your expectations for what Ramon's spreadsheet might look like. As long as he needs to be on the steroid, you're going to see that impact in his numbers and his dose.

I want to assume your vet walked you through all of your options before starting the steroid, but given the variations in vet quality we run into around here, it may be worth double checking....

If I remember correctly, Ramon already takes a probiotic daily, correct? Have you already tried removing any foods with carrageenan (this causes IBD and skin allergies in many cats)? Have you tried a diet completely free of fish (checking the ingredient list very carefully since it often hides)? Have you tried a novel protein diet for at least a month (rabbit, kangaroo, or venison are usually the easiest to find - making sure there are no added chicken, turkey, or fish sneaking into the ingredient lists)? Have you tried a raw food diet?

If you've already walked through all of those for several weeks (typically 4-6 week trials) and he's still showing the IBD symptoms, then the steroid is likely simply necessary and you'll just need to dose around it. If your vet didn't tell you about one of those steps, or you're not sure you tried it long enough and want to give it another go, for many cats their IBD can be managed without an ongoing steroid through consistent probiotic use and careful diet choices. And if that's an option, it will likely help with the BG numbers. Again though, if the steroid is needed, then it's needed. And knowing that may help your heart as you can adjust your expectations of his numbers and find some peace in knowing his numbers are just going to look different.

Please ask if you have any questions about any of that, and again, if you've already tried them, no need to type out the whole history of the trials and fails along the way. I just wanted to make sure you knew about them in case your vet hadn't been thorough. My assumption is that he/she was though, so we'll just keep dosing about the budesonide and get to the best numbers we can for Ramon. :bighug::bighug::bighug:
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Hi Djamila - He was diagnosed with IBD with some symptoms but also with an ultrasound that showed thinkening intestine walls. They (both my regular vet and the internal medecine specialist) told me that its either IBD or Lymphoma. They can't know which without an endoscopy but I was holding off from doing that. All that was offered to me was the budesonide. However I have done elimination diets on him previously for the pemphigus. At this point he is on a limited diet of raw and homemade with organic supplements. He's only been on the budesonide since mid January. I went ahead and increased his dose this morning to 2.6
 
Can I have some feedback on the current situation with Ramon's readings? I'm up to 2.8 and the first day he had great readings but today it has gone back high (maybe because I gave a low dose last night because of a low BG reading). Do I stay at 2.8 a little longer? Or do I go on up to 3 units? @Djamila @Kris & Teasel @Rachel Thanks for your thoughts!
 
Yes, I think the reduced dose is the cause. I would stay at 2.8 today, and then increase again tomorrow (unless he gives you a low PS like that again).
 
I'd been up to doses of 3 units since Saturday and thought I'd reached his good dose range becasue of getting blue numbers, but since he repeatedly has now been getting pinks (300's) I upped his dose again today. Can anyone give me more specifics about how to tell if it is time to stop raising his dose? @Djamila ? @Kris & Teasel ? @Rachel ?
 
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