? Tiger in a Hypo?

Hello,

Over the past two months, we've had a hard time regulating Tiger's blood glucose. He normally receives 1 unit of lantus twice a day. The normal diet is fancy feast pate (Fish, Chicken). Per the vet's rec, we currently have a Libre Freestyle installed and unfortunately, it has led to some paranoia so we scan him often.

On Friday afternoon at around 2PM we scanned him and received a LO reading (below 40), he was showing no signs of low BG. We quickly administered some Karo syrup and some low carb hard food and by 6pm we had his BG around 200. After consulting with our vet a few hours later, we were advised to skip the PM dose. Yesterday he was high (320-375) due to the skipped dose on Friday night.

Today, it is a similar story. We scanned him often and saw a declining score so we administered karo syrup and low carb hard food. He is responding normally and littered normally. We verified the Freestyle score with an AlphaTrax 2 score and they were within 5 of each other.

6:21am - 239
7:34am - 256
8:00am - [AM Injection - 1unit]
8:49am - 245
10:00am - 173
12:08pm - 72
12:13pm - 89
12:48pm - 46 (Gave 1/3 cup of low carb hard food)
12:53pm - 48
12:57pm - 45
1:02pm - 45
1:08pm - 44
1:11pm - 47
1:17pm - 51
1:28pm - 50
1:47pm - LO (Below 40)
1:50pm - LO (Below 40) [Gave 1ml karo syrup & 1ml water mix]
1:52pm - 47
1:59pm - 43
2:05pm - 47
2:10pm - 53 [Gave 1ml karo syrup & 1ml water mix]
2:14pm - 57
2:19pm - 74
---EDITS BELOW---
2:25pm - 85
2:27pm - 102
2:37pm - 142
2:47pm - 174

Obviously we need some high carb soft food so he can metabolize that more quickly. Any other suggestions since it may be difficult to feed him with a full stomach?

 

One suggestion right off....it takes a little time for anything to give to raise the BG to get broken down and into the bloodstream. There's no reason to test (or scan) every 5 minutes.

With simple sugars like Karo/honey/syrup, it's going to take at least 10-15 minutes before you'll know how much it increases the BG.

With food, it will take more time...20-30 minutes.

If you don't give the HC/simple sugars a little time to kick in, you may be scaring yourself more than you need to.

You need to have some HC cat food options too. Most of us use Fancy Feast Gravy Lovers (the beef is 20% carbs). Most of the carbs are in the "gravy", so if you open the can, put the top back down and "squeeze" the gravy into another bowl, you'll get quite a lot. Give a couple of teaspoons of the gravy and test again in about 20 minutes to see if it's bringing him up. If it is coming up, give a little bit of the "meaty" bits just to give him more long-term help. Protein breaks down into glucose too but takes longer to do it.

Be careful not to feed too much because you don't want to "fill him up" in case you need him to eat later.

The 74 is a good number.....just test again in 20-30 and make sure he's not dropping back down again

 

Thanks Chris, those are some great points.

We're starting to see the impact of the food entering his system. The last two scans show positive trajectory. We're going to continue monitoring every 15-20 minutes to ensure the direction continues in the right direction.

This is a touch scary since this has happened twice in three days.

 

What time of day did you shoot this morning? Did you get a scan beforehand, or is that the 173 at 10am?

 

The morning the injection was given at 8am (1 unit). We scanned at 6:21am (239) and 7:34am (256).

I updated my original post so it provide more clarity.

 

Great, thanks!

Around here, we are in all different time zones, so we're in the habit of giving times relative to the shot time. I'm going to condense some of your readings to summarize:

+10.5 (from last night's shot): 256
AMPS: 239
+1: 245
+2: 173
+4: 72-89
+5: 40's, fed dry food
+6: LO, gave karo
+6.25: 50's, gave more karo
+6.5: 85-102
+6.75: 174

 

Next time you shoot, you need to reduce the dose. 1.0U may have been a great dose at first, but it looks like Tiger has decided he doesn't need that much insulin right now!

 

You're right. On Friday, the vet recommended that we skip the PM dose. With the rather steep increase, I'm thinking maybe go down to a .5 unit for the PM injection?

6:21am - 239
7:34am - 256
8:00am - [AM Injection - 1unit]
8:49am - 245
10:00am - 173
12:08pm - 72
12:13pm - 89
12:48pm - 46 (Gave 1/3 cup of low carb hard food)
12:53pm - 48
12:57pm - 45
1:02pm - 45
1:08pm - 44
1:11pm - 47
1:17pm - 51
1:28pm - 50
1:47pm - LO (Below 40)
1:50pm - LO (Below 40) [Gave 1ml karo syrup & 1ml water mix]
1:52pm - 47
1:59pm - 43
2:05pm - 47
2:10pm - 53 [Gave 1ml karo syrup & 1ml water mix]
2:14pm - 57
2:19pm - 74
---EDITS BELOW---
2:25pm - 85
2:27pm - 102
2:37pm - 142
2:47pm - 174
3:30pm - 257

So now that it seems that we’re out of the woods and I have more time to type, I’ll provide some additional background information on TigeyCat:

Tiger, is a 10 year old male diabetic cat. He was diagnosed at 6.5 years old and we’ve be able to 'successfully' control everything with Lantus insulin and diet change. At his peak weight, he was about 16 pounds, free-feeding on dry food (PurinaOne). His litter-mate (Teddy) was about 12 pounds at the time for comparison. At diagnosis, he was in diabetic ketoacidosis (-1 life) and down to 10 pounds. Following the DKA episode he was able to recover. The vet prescribed 1 unit per day, twice a day and a change of diet.

In June 2017, we decided to take him to the vet about 4 weeks ahead of our vacation for a blood glucose curve and the results suggested that we increase his dosage to 2.5 units per injection. While on the vacation, my mother stopped by to administer the injections and out of pure curiosity, she decided to check in on him in the middle of the day. When she found him hiding in our closet, he was having a severe hypoglycemic event (-3 lives?). He had seizures and was rushed to an emergency vet. After two days, he was stabilized and released. The after effects were rough, he seemed confused, may have suffered from some temporary memory loss, and had some minor motor skill issues (circling) but he would go on to make a full recovery. There were two miracle here, (1) my mom decided to check in on him and (2) he survived. The only noticeable difference in his behavior was occasional hind leg twitching. His jumping didn't seem to change post-recovery.

Since July 2017, his dosage has been consistent with twice a year blood glucose curves. When we took him in this April this year, the vet determined that it would be best to increase his dosage to two units per injection. We thought nothing of it since it was doctor’s orders and just continued on like all was normal. Apparently, we didn't learn anything from the first episode. About three weeks after the dose increase we went to feed him one morning and he didn’t appear. We looked around and saw evidence of liquid vomit and feces, so we began to panic. We eventually found him curled up in a dark corner of our family room, conscious but unable to move and in the middle of his second hypoglycemic event (-1 life). We tried testing him, but our AlphaTrax2 monitor failed. We quickly gave him some karo syrup which perked him up and rushed him to our normal vet which was opening right as we arrived. When we brought him to the vet, his BG was too low that it couldn’t be detected so they began hydrating him and intensively elevating his BG. Fortunately, we were able to bring him home same day and took him in the following for an exam. While hypoglycemic events are rough, this one wasn’t nearly as bad as the first or as bad as it could have been, which was a miracle in of itself.

Two weeks after his most recent hypo, we took him in for another BG curve, the vet was perplexed at the reading and suggested reducing the dosage to 1.5 units per day. At this point, we were checking him religiously before each injection and making adjustments to the dosage on the fly at the vet’s recommendation (Below 100: No Dose, 101-150: 1.0 unit, 150 & up: 1.5 units). After this change, there were occasions where the PM score the night prior was above 300, but the AM score the following morning was in the danger zone. After consulting with the vet, we were advised not inject more than 1.0 for the PM injection at any point since he seems to drop more steeply during the night. The vet suggested that maybe the high scores from the in-vet BG curve were induced by stress and that we do a home BG curve.

After doing the home BG curve, the vet was still perplexed by the scores and suggested we try the Libre Freestyle. We ordered one and had it installed on July 28th. In order to establish a baseline, the vet ordered only 1.0u for both morning and evening. Since then, we’ve encountered a few ‘redline’ low situations in both direction. Tiger has been a real champ with the Libre, I think he prefers it to getting poked and prodded in the ears.

Before I realized this forum has a specialized Google Doc format, this is what I’ve been using:

https://docs.google.com/spreadsheets/d/1Z2pVVFAL8LZA7tS5Gbag-MaO0XQ9n7hC1D4sQC8R9Yo/edit?usp=sharing

 

Wow! I think my heart stopped about five times reading Tiger's story! What a lucky kitty to make it through all that...

I have to log off soon, so I will just add a quick comment about dosing: we usually change doses in units of 0.25U at a time, but in Tiger's case? I think I might go down to 0.5U, as you say, and see what he does with that. He's run through a whole lot of lives already, I see nothing wrong with a little extra caution at this point!

 

Yeah - the poor guy has been through quite a lot in the past four years. Most of it could have been avoided with more vigilant testing.

Here are the tests since the last update:
+8.0: 315
+9.0: 373

If this trend continues, I think .5 would be appropriate to keep him at a reasonable level overnight since he drops more during the PM.

The vet was hoping for 3-4 days of data with the LibreView. We're at 5 full days right now.

 

Hey Joe , that poor boy, my heart my heart stopped too after reading about
I agree with the 0.5 units of lantus.
You might want to give the same dose for the AM also
I will tag some very experienced members for you to see what they think

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@Deb & Wink
Hi Deb what do you think about his dose it's a long read but the poor boy had a couple of hypo's already, one was really bad Thanks Deb

 

@Diane Tyler's Mom

I'm working on the spreadsheet now.. The dosing right now is 'Constant' per the vet's rec during the Freestyle metering, but I don't know that I'm comfortable with 1.0u tonight.

BTW, we tested at home for Ketones about two weeks ago and it came up 'No Trace'.

 

Wow that was quick great

 

I understand I would advise giving 0.5 units tonight, I am going to tag some experienced members for you about giving 0.5 units in the AM and PM
When are your shot times

@Deb & Wink

@Chris & China (GA)

@Wendy&Neko

@Bron and Sheba (GA)

Let's wait and see what they say ok

what do you ladies think about his dose it's a long read but the poor boy had a couple of hypo's already, one was really bad Thanks

 

A number of cats become insulin sensitive after a hypo and Tiger has had a number of hypos.

I concur with the 0.5 unit dose to keep Tiger safe. If it turns out that 0.5 units is not enough, it is easier to go up the dosing scale than down.

 

Standing by for additional input.

Here is a graph from LibreView: https://drive.google.com/file/d/1gvtWXbIyXzaOScTIB8S68pbqaSX7W5Cf/view?usp=sharing

 

@JoeAndTiger
Joe one more thing could you add to your signature what you are feeding Tiger just so we don't ask the same questions over and over again

Also if you ever want to switch to a human meter most if us use the Relion Prime from Walmart it's 9 bucks and 17.88 for 100 strips


I used to use the Aloha Trak but the test strips got too expensive, but it's your choice what ever you feel comfortable with

 

Thank you Kel

 

Here is the chart :http://catinfo.org/docs/CatFoodProteinFatCarbPhosphorusChart.pdf

Just in case you ever need higher carbs to bring his BG up

Fancy Feast Gravy Lovers Gourmet Beef Feast in Gravy 20% High Carbs

Fancy Feast Gravy Lovers Gourmet Chicken Feast in Gravy. 15% Med Carbs

Fancy Feast Gravy Lovers Turkey Feast in Gravy. 15% Med Carbs

Fancy Feast Gravy Lovers Chicken and Beef Feast in Gravy 15% Med CarbsCarbs

Like @Chris & China (GA) said you would just give the gravy first ,depending what his BG was and how low it was you would first feed LC , then MC if needed then if needed HC
If Tiger doesn't like to chew and only like pates like my cat if I had to give him any of the Gravy Lovers I would smooch the crap out of it lol with my fingers , and back and forth with a fork add a little water , you wouldn't probably need much any way

Just post if you ever need help

 

Thank you @Diane Tyler's Mom and @Red & Rover (GA) for the suggestions and feedback.

I'm going to wait to see how much he eats right before giving the PM dosage (0.5u). I'm wondering if the BG boosters (Karo Syrup + LowCarb Hard Kibble) I gave him might suppress his PM appetite and if that happens, the abnormally high BG scores I've seen since might drop more dramatically overnight. I don't want a double-whammy while I'm asleep.. But I don't want to wake up with him in the 400s.

 

"Better too high for a day, than too low for a moment."

Lantus has a "depot" or storage area underneath the skin. So when you change the dose, it takes time for that depot area to drain when you decrease the dose. It takes time for the "depot" area to build and to see the full effect of the insulin dose when you increase the dose.

Concur with dropping the dose to 0.5U for now.
Please, ketone test either the blood (special blood ketone meters) or the urine (urine ketone test strips), to make sure that Tiger does not develop ketones and head for another DKA episode.

The Freestyle Libre meter should be thought of as supplementing the Alphatrak meter. It can't totally replace the need to get a BG reading with your hand held meter.

 

@Deb & Wink

Just did a keytone test via urine and the result was no trace. How nice of Tiger to cooperate with a well-timed evacuation! We'll test blood via AlphaTrax2 and compare it to the FreeStyle this evening just prior to the PM feeding/dose. About an hour and ten minutes from now.

In regards to the depot, based on recent trends he tends to spend more time above normal than normal or below. He's been at 1 unit for at least 4-5 days now. It really has us (and the vet) confused.

 

While the numbers on the AlphaTrak and a human glucometer are closer together at the low end, the numbers are further apart at the high end. One meter is calibrated for pet blood, the other for human. Both types of meters are used on this forum. Before the advent of the pet meter, vets used human meters. The Abbot company saw a niche market and developed a meter for it and is making a fortune on very expensive strips.
The two meters are not comparable. There is no magic equation that fits. So many here have tried. It's apples and oranges.
What you need to know is that high is high on any meter. And
Low take action number on an AlphaTrak is 68.
Low take action number on a human glucometer is 50.

I had a look at the graph. What you are seeing are bounces. A bounce can last for a number of cycles. A too low number lasts only briefly.

 

Just tested, fed and injected. He ate about 66% of his meal. That doesn't surprise me considering the mid-day emergency feeding.

AlphaTrax2: 380
FreeStyle: 419

Gave a 0.5u injection.

 

How is Tiger this morning?

 

@Nan & Amber (GA)

The FreeStyle readings were high this morning (380 - 425) and I was unable to obtain a blood sample for AT2 testing. We went with 0.5u to err on the side of caution. He ate his full meal.

AM+2: 358

Hoping to not see a daytime crash today.

I have a Relion Prime monitor & strips and high carb soft food on order.

 

Sounds good!

Not surprised he's in high numbers today. There's a phenomenon called "bouncing" where a cat's body reacts to low numbers by dumping sugar into the blood to try to raise the BG. Bounces can last for a few days, so it's probably why his numbers are still high this morning. There's no way to know how long a particular cat will be bouncing, but hopefully he'll give you a bit of a break today after yesterday's shenanigans!

I'm glad you stuck with the 0.5U dose. Lantus does best with consistent dosing, and it makes it much easier to figure out what is going on, too.

 

Steady as he goes on the insulin dose for now. Good plan.

If you have numbers from the Libre, you could enter those on the SS (spreadsheet) for the pre-shot test times. That would be helpful to see.

 

So it seems like Tiger had a good day today. We went with a 0.5U dose this morning and his BG dropped into the mid 200s for most of the day.

FreeStyle Libre Scan Readings:

AMPS: 443
+1.0: 427
+2.0: 358
+2.5: 328
+4.0: 249
+5.0: 240
+5.5: 255
+6.0: 250
+7.0: 265
+9.0: 270
+10.0: 316

I'm pleased with a fairly level curve today; far better than the V shaped curve I saw yesterday. I'm thinking 0.5U again for tonight?

Something @Red & Rover (GA) said got me thinking based on the Take Action numbers for AT2 & FSL. Is the safe zone different for a human glucometer than the AlphaTrax 2? I checked the FreeStyle Libre instructions I received from the vet, but I didn't see anything.

 

What do you mean by "safe zone?"

 

I was actually wondering the same thing! I think the Libre is designed for humans (someone correct me if I'm wrong on this), and so my guess is that it would have the same "take action" number as the human meters, 50 (vs 68 for the AlphaTrak). You'd also expect to see some divergence between the two numbers if you took readings with both at the same time, generally more so at higher numbers.

We usually estimate that "normal BG" for cats is 50-120 on a human meter (probably including the Libre) and 68-mid/high hundreds for the AT (I've seen different numbers for the upper estimate).

 

My memory is failing me but I've been going by 100-300 is the "safe zone" for diabetic cats.

The PMPS on the FreeStyle scan was 382 and 386 on the AlphaTrax2. Despite these high readings, we went with 0.5U again.

 

Hi Joe,

My vet gave me the normal feline blood glucose reference range as measured on a glucometer calibrated for use with cats (e.g. Alphatrak 2) as:

* 3.9 - 8.3 mmol/L

* 70 - 150 mg/dL

Some sources give 4.4 mmol/L / 80 mg/dL as the lower limit of the reference range for diabetic cats (perhaps factoring in a safety margin cushion for cats on insulin?).

For general safety information, some cats may show symptoms of a hypo slightly above the lower limit of the reference range.

WRT dosing decisions, I always took into consideration the action profile of the insulin, how my Saoirse responded to it and how sure I was that I would be able to test enough to keep her safe should she start running low in a cycle. When she was on Lantus I aimed to set a dose that would keep her in healthy numbers but not too close to the lower reference range limit at nadir. I used the reference range my vet gave me with my Alphatrak 2.


Mogs
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