Too low glucose almost hypo sos

[kalypso]

Please help! Morning value was 180 on human meter, 1/4 of pill dosage was given, noon value was 48!! Then the cat was given wet food and value is now 45! Gave her some high carb dry, what should one do now? Please help cause vet is on vacation!

 

[Elizabeth and Bertie]

Are you giving glipizide or some other kind of oral med to lower blood glucose?
If so, then to raise blood glucose quickly you need to give syrup, honey, or glucose. This is fastest...

 

[Elizabeth and Bertie]

That 45 is actually probably OK, but you just don't want the kitty dropping lower than that....

 

[Elizabeth and Bertie]

Do you know when you usually see the lowest blood glucose after giving the pill? How many hours after? And how many hours after is it now?

 

[kalypso]

It was 50 now! I don't know the time it gets lowest because I dont have a full curve. she gets glimepiride, got it for a few days, and while the vet is on holidays her values started dropping, so started improvising lowering and skipping dosage. Can she get in remission on the pill? I hope so

 

[kalypso]

Is it better to feed a lot or give just small quantity if this happens again?

 

[kalypso]

Now it is 4,5 hours after the pill

 

[Elizabeth and Bertie]

It was 50 now!

That's better... Would be good to not let it get any lower than this. And if it can come up a bit higher then that would give you some buffer of safety.... The pill will still be working to try to drop the blood glucose...
You may need to test and monitor until you are sure that the blood glucose isn't going to drop further.

Syrup/honey/glucose raises the blood glucose quickest, but also wears off relatively quickly.
High carb food 'may' take longer to work, but stays in the system for much longer. ...I see you've given some high carb dry, and that may be getting into the system now. But you will need to monitor and take any necessary action to raise blood glucose.
Are you home today? Are you OK to do that?

We are not really familiar with oral meds on this forum, as the vast majority use insulin.
If at any time you feel you can't cope with the situation at home DO call an emergency vet for advice.

 

[kalypso]

Sure, how often should glucose be measured now?

 

[Elizabeth and Bertie]

Sure, how often should glucose be measured now?

If this was insulin I'd be suggesting every 15 - 20 minutes at this point, just to be sure that the blood glucose is at least staying up and not dropping again. And then, when the blood glucose rises to a more comfortable level, and definitely isn't dropping, you can space the tests further apart. ...But please be aware that I have no direct experience of the med that you are using. I only have experience of insulin... So, if in doubt DO call a vet.

 

[kalypso]

Thank you so much! What would you consider a comfortable level?

 

[Nan & Amber (GA)]

It was 50 now! I don't know the time it gets lowest because I dont have a full curve. she gets glimepiride, got it for a few days, and while the vet is on holidays her values started dropping, so started improvising lowering and skipping dosage. Can she get in remission on the pill? I hope so

It's not expected that they'd go on remission on these kinds of meds, but our cats do like to surprise us!

 

[Nan & Amber (GA)]

Thank you so much! What would you consider a comfortable level?

Your signature says you are using a "vet inhouse meter"-- does that mean a meter calibrated for cat blood (rather than human)? If so, I think you want to be well above the take-action number of 68, probably at least in the 80's, before easing off (the take-action number for human meters is 50).

 

[Elizabeth and Bertie]

Your signature says you are using a "vet inhouse meter"-- does that mean a meter calibrated for cat blood (rather than human)?

Oh, thanks for spotting that! ...First post said 'human meter', but I never thought to check...

 

[Nan & Amber (GA)]

Oh dear, now I'm confused-- you're right, and now I don't know which one we're talking about. I guess it must be the human meter? @kalypso, can you clarify?

 

[kalypso]

Sory its a human meter, so should I measure every 20 mins until way above 50? Like until it gets above 60?

 

[Nan & Amber (GA)]

Do you give the med once a day? I'm really not familiar with how those meds work, but if it's a once-a-day pill the effects are likely long-lasting.

If it were me, I'd want at least two separate readings above 60, and then I'd probably test an hour later and keep testing just to make sure she's not going down again.

Elizabeth, what do you think?

 

[kalypso]

Thank you so much!Yes it is once a day, every morning. She had skipped it for a few days and this morning she took 1/4 of the pill so also 1/4 of the daily dose initially prescribed.

 

[Nan & Amber (GA)]

What kinds of numbers were you getting that led you to skip her pills? The 180 this morning was definitely too high, but I'm wondering if her pancreas is 'sputtering', working sometimes and sometimes not.

 

[kalypso]

Last 4 days (with no pill) it was120 to 150 in the morning and in the 80s early afternoon

 

[Elizabeth and Bertie]

Do you give the med once a day? I'm really not familiar with how those meds work, but if it's a once-a-day pill the effects are likely long-lasting.
If it were me, I'd want at least two separate readings above 60, and then I'd probably test an hour later and keep testing just to make sure she's not going down again.
Elizabeth, what do you think?

Sounds good to me...

 

[Elizabeth and Bertie]

Last 4 days (with no pill) it was120 to 150 in the morning and in the 80s early afternoon

Those are pretty good numbers without the meds...
What are you feeding your kitty at the moment....?

 

[Nan & Amber (GA)]

Last 4 days (with no pill) it was120 to 150 in the morning and in the 80s early afternoon

Hmmm.... numbers going down post-meal does sound like pancreas action. However, it could also be the tail end of the meds activity (my understanding is that what they do is to basically supercharge whatever pancreas activity is there naturally, and I don't know how long that action lasts).

Those are pretty good numbers without the meds...
What are you feeding your kitty at the moment....?

Yes, that's the other critical piece here.

 

[Elizabeth and Bertie]

but if it's a once-a-day pill the effects are likely long-lasting.

Yes it is once a day, every morning.

This is concerning me a bit... We don't know when this med reaches its peak activity, and kitty may need to be monitored longer....?

 

[Critter Mom]

Hi there! (Not sure what your name is from your signature. )

Great job catching the low number.

Like Nan and Eliz above, I've no experience of using tablet meds to treat diabetes, I've only used insulin so any suggestions I make here have this strong caveat attached and are only based on general principles.

Last 4 days (with no pill) it was120 to 150 in the morning and in the 80s early afternoon

All but the 150 are numbers in the normal BG range as measured on a human meter (50-120mg/dL).

Is she currently eating a completely wet low carb diet, or is she getting a mix of wet and dry? If it's a mix, then if you were to ease out the rest of the dry, higher carb food, it's possible that your cat might stay in normal numbers without the meds. (Safety Note: continue to feed dry high carb food as and when needed today to make sure your kitty stays in safe numbers! )

In the meantime I'd advise seeking veterinary advice ASAP, as I'd worry that the tablet meds might be too high a dose for your cat, and she may be close to not needing them at all. I see your own vet is on holiday. Is there anyone covering for him while he's away that you could phone for advice?


Mogs
.

 

[kalypso]

Thank you all so much! The cat is on bozita wet food, it is low carb. These values were on 4 days in the row with no pill, so I don't think there was any tail end effect of pills... I guess she will be on no more pill at least until her vet returns on Monday.. So this cannot be considered remission because of the over 120 values?

 

[Critter Mom]

numbers going down post-meal does sound like pancreas action.

In principle, I agree, but need to confirm that the drops are definitely postprandial, not something influenced by activity level or circadian rhythms of the body.

Need to do a food response mini curve when kitty is clear of today's med dose:

1. Withhold food for 2 hours.

2. Test fasting BG then feed.

3. Test +1 hour and +2 hours after feed to see if postprandial BG is lower than fasting BG.

4. Feed as normal after the test.

@kalypso - when you got the 180mg/dL this morning, how many hours before that test did your kitty last eat? What did you feed them at that time - low/high carb, wet/dry?


Mogs
.

 

[kalypso]

Before the 180 this morning, she had last eaten yesterday evening bozita. She justs eats bozita, only gave her dry today after the low value.
So she had bozita around midnight and 180 measurement was around 9 am, so around 9 hours later.

 

[Critter Mom]

Thank you all so much! The cat is on bozita wet food, it is low carb. These values were on 4 days in the row with no pill, so I don't think there was any tail end effect of pills... I guess she will be on no more pill at least until her vet returns on Monday.. So this cannot be considered remission because of the over 120 values?

She may not be far off it. I've seen some Bozita low carb tetra pack foods positively impact BG levels (ETA: compared to other foods with equivalent carb levels). Unfortunately my Saoirse would not eat them.

Please refer to the instructions for the food 'mini curve' in my previous post. If you could do a couple of those over the next few days when you're skipping the glimepiride (a drug of the sulfonylurea class, so drugs.com informs me) it would throw some light on whether the pancreas is producing enough insulin at mealtimes.

Again on days when your kitty has not been given any glimepiride, if you could do some tests after your kitty has not eaten for several hours (e.g. 3-4 hours) it may give some pointers as to whether the pancreas is secreting enough insulin between meals (the basal 'trickle').

If the BG level stays low or drops after meals but rises higher after longer fasts then that could point to what's called impaired fasting blood glucose control. If this were to be the case then your kitty's pancreas might benefit from a little extra support and then go into diabetic remission. The information you've provided thus far points to such a possibility.

If your cat were to need additional support I'd very much recommend you talk with your vet about a short course of a long-acting insulin like Lantus (insulin glargine). Such insulins work well in cats, don't typically produce big drops in BG levels and, with sufficient testing, it is possible to give very, very small doses of insulin safely to cats who are running most of the time in the upper end of the normal BG range but where suitable treatment is needed just that little bit longer to allow the pancreas to rest and heal. That extra rest period may increase the chance of your cat achieving remission. We can help you with more information about all this, so please post with any questions you have.


Mogs
.

 

[Critter Mom]

Before the 180 this morning, she had last eaten yesterday evening bozita. She justs eats bozita, only gave her dry today after the low value.
So she had bozita around midnight and 180 measurement was around 9 am, so around 9 hours later.

Really helpful info. That's the sort of longer fasting period I'm interested in you getting more data on.


Mogs
.

 

[kalypso]

She is actually on bozita tins, because tetrapacks also contain sauce etc.
So we will try the mini curve and get back to you!!
Thank you so much

 

[Critter Mom]

This is concerning me a bit... We don't know when this med reaches its peak activity, and kitty may need to be monitored longer....?

Agree. I'd monitor longer.

According to info from drugs.com and Wikipedia, in humans glimepiride reaches peak effect 2-3 hours after dose administration and duration is 24 hours. I can't find anything at all online about treatment of FD with glimeripide, never mind such specific info as peak activity and duration.

If it were my cat I would continue to test regularly throughout the 24-hour period till I was sure the dose had worn off. During this period I'd be careful to check whether BG drops after feeding, because if the pancreas is pulsing a significant amount of insuiln in response to food then in the current situation that could potentially increase the risk of a hypo, so it might be necessary to steer numbers with food till she's completely clear of the glimeripide. (Saoirse did that. Put the heart crossways in Mel and myself on a couple of occasions. )

As mentioned in my earlier post, all suggestions are based on general principles of blood glucose regulation in felines. I haven't a scooby of how the glimeripide metabolises in cats, I'd just automatically choose to err on the side of safety.


Mogs
.

 

[Critter Mom]

She is actually on bozita tins, because tetrapacks also contain sauce etc.
So we will try the mini curve and get back to you!!
Thank you so much

Some of the tetrapaks are low carb (some of the ones in jelly rather than sauce, and also some of their 'feline function' range).

The ingredient type I was trying to remember was beta-glucan.

I like the Bozita range because they don't muck about with the ingredients. They just put what the cat's body needs into their foods, not ingredients designed to make the products sound appealing to potential human customers.

Will look out for your test results. I'm not sure from your signature what name to call you and what to call your kitty.


Mogs
.

 

[kalypso]

Thanks!
I know it is confusing and I just wanted to keep focus on the cat low glucose so I didn't explain from the beginning. I am Sophia, Kalypso was my late cat, but I am writing about Lisa, the siamese cat of my friend Dionysia who is not fluent in English!
Here is Lisa

 

[Nan & Amber (GA)]

How long has Lisa been on the meds? I was assuming (from your join date) that it had been a while, but perhaps this is a recent diagnosis?

Has Lisa ever had some kind of steroid medication for the asthma?

 

[Critter Mom]

the meds activity (my understanding is that what they do is to basically supercharge whatever pancreas activity is there naturally, and I don't know how long that action lasts).

Yep. They stimulate functioning beta cells to release more insulin (putting the cells under greater strain, hence their lower position in the normal pecking order of FD treatments).

Also, according to Wikipedia:

There is some evidence that sulfonylureas also sensitize β-cells to glucose, that they limit glucose production in the liver, that they decrease lipolysis (breakdown and release of fatty acids by adipose tissue) and decrease clearance of insulin by the liver.

[Note: No citation provided in Wikipedia for the above excerpt.]​

It is going to be really interesting to follow along and see how το μικρό ελληνικό γατάκι gets on.



Fingers and paws well and truly crossed in the Shire...



Mogs
.

 

[kalypso]

Yes Lisa had taken steroids for asthma which most probably was the cause of her diabetes. After she finally switched to low carb wet food, her glucose levels were in the 300s. She started taking this pill a few weeks ago. Around 10 weeks. Sory that was 6 not 10 weeks!!

 

[Critter Mom]

I know it is confusing and I just wanted to keep focus on the cat low glucose so I didn't explain from the beginning. I am Sophia, Kalypso was my late cat, but I am writing about Lisa, the siamese cat of my friend Dionysia who is not fluent in English!
Here is Lisa

Hi Sophia,

I'm so sorry to hear that Kalypso is no longer in this realm.

It's great that Dionysia has you to assist her. She couldn't wish for a better helper! The focus, clarity and speed of your communications here today have been top notch, and very much appreciated at this end because we can only go on the information we're given.

Thank you, Sophia. Please say 'hello!' to Dionysia and give some scritches to little Lisa for me. She has a gorgeous little face!


Mogs
.

 

[jt and trouble (GA)]

Sophia for being a good kitty cat friend!

 

[kalypso]

Thank you Mogs and jt and trouble for your help and kind words.
Dionysia will be on holidays herself for a week starting tomorrow, during which Lisa will be off the pill, so we will get back after that with the mini curves results.
Best regards from all!

 

[Critter Mom]

Sophia,

If you wouldn't mind and you have the time, I'd be grateful if you could post any further test results you get during today's 24-hour period while the glimeripide is active. If you're able to, it would help if you could give the time elapsed since the glimeripide dose was administered alongside the BG reading (same system as used in FDMB spreadsheets), e.g:

Pre-dose test - 180 (human meter)

HH:MM - time dose was administered.

+2.00 hrs - ???
+?.?? hrs - ???
+?.?? hrs - ???
+?.?? hrs - ???
+?.?? hrs - ???
.
.
.
+24.00 hrs - ???

It would help us to learn a little and it might also help another kitty some day.

Shout out if yourself and Dionysia need help with anything in the meantime.


Mogs
.

 

[Critter Mom]

Dionysia will be on holidays herself for a week starting tomorrow, during which Lisa will be off the pill,

Just as a precaution, it might be a good idea to check Lisa's ketones during the time she's not getting the tablets in case numbers go back up. Not ideal for a holiday activity, granted, but it's a little belt 'n' braces measure to keep Lisa safe. Here are some helpful resources:

Testing Your Cat for Ketones

Tips for Collecting Urine Samples (you only need a small amount of urine, enough to dip the ketone test strip into).

καλό ταξίδι!


Mogs
.

 

[kalypso]

she took 1/4 pill
+3:48 - 48
+4 - 45
+4:18 - 50
+5:55 - 78

 

[jt and trouble (GA)]

All this info gathering might give us insight to how glimeripide works no?

 

[kalypso]

I don't know if today's values are helpful enough though, as Lisa had some extra carbs in the meantime to avoid a hypo. But I hope they are helpful!

 

[Critter Mom]

Thank you for the data and the info on what you fed, Sophia. It's very helpful indeed. The feeding info gives an idea of how you kept Lisa's numbers up successfully.

If you do any more tests later today, it would be great if you could add them too (if you have time! ).


Mogs
.

 

[Critter Mom]

All this info gathering might give us insight to how glimeripide works no?

That's the hope, Jeanne. A little snapshot is much better than not having any clue at all.


Mogs
.

 

[jt and trouble (GA)]

That's the hope, Jeanne. A little snapshot is much better than not having any clue at all.


Mogs
.

Agree at least something to go by even if ECID.

 

[Red & Rover (GA)]

@Critter Mom
@Elizabeth and Bertie
@Nan & Amber (GA)

From: Plumb's Veterinary Drug Handbook (6th ed., 2008)
I apologize for the weird look. I did clean it up somewhat. It was copied and pasted from a pdf.
Bold emphasis mine.

GLIMEPIRIDE (glye-meh-per-ide) Amaryl® SuLfONyLuReA ANTIDIAbeTIc AGeNT
​

prescriber Highlights
Oral, once-daily, anti-hyperglycemic agent; could be useful in the adjunctive treatment of non-insulin dependent diabetes mellitus (NIDDM) in cats
Very limited experience in cats
Contraindicated: Patients hypersensitive to it or with diabetic ketoacidosis
Hypoglycemia may occur
Potentially, significant drug interactions
Do not confuse glipizide, glimepiride & glyburide

uses/indications
Glimepiride may potentially be a useful adjunct in the treatment of non-insulin dependent diabetes mellitus (NIDDM) in cats. Its duration of action in humans allows it to be dosed once daily, which could be of benefit in cats. It may also have fewer side effects than glipizide in cats.

pharmacology/actions
Glimepiride increases pancreatic release of insulin from function- ing beta cells and, with continued use, may also increase peripheral tissue sensitivity to insulin. The exact mechanism for these effects is not well understood.

pharmacokinetics
No pharmacokinetic data for cats was located. In humans, glimepiride is completely absorbed from the GI tract. Peak levels occur in 2–3 hours; food delays the peak somewhat and lowers AUC by about 9%. Volume of distribution is 0.11 L/kg; the drug is greater than 99% bound to plasma proteins. Glimepiride is hepatically metabolized to at least two major metabolites. One of these, M1, has activity at about N that of the parent compound; clearance is 48 mL/min and elimination half-life about 9 hours. Approximately 60% of the drug (as metabolites) are excreted into the urine and the remainder in the feces. The drug has a 24-hour duration of activity in humans.

contraindications/precautions/Warnings
Glimepiride is contraindicated in patients hypersensitive to it or with diabetic ketoacidosis.

adverse effects
Hypoglycemia has been reported in about 1% of human patients taking the drug. Dizziness and asthenia have been reported; rarely, liver function impairment, dermatologic reactions, or hematologic reactions have been reported in humans.

Reproductive/nursing Safety
In humans, the FDA categorizes glimepiride as a category C drug for use during pregnancy (Animal studies have shown an adverse effect on the fetus, but there are no adequate studies in humans; or there are no animal reproduction studies and no adequate studies in humans). In rabbits and rats, glimepiride did not cause teratogenic effects when given at high dosages. There were some intrauterine deaths when maternal hypoglycemia was induced by the drug.

Some glimepiride is excreted into maternal milk of rats. The manufacturer states to discontinue the drug in nursing, human mothers.

overdosage/acute toxicity
Overdoses may result in hypoglycemia, ranging from mild to severe. Treatment consists of glucose administration and intensive monitoring. Because of the drug’s long duration of activity, patients may need to be supported with glucose for a least 48 hours post-ingestion, even after apparent recovery.

Drug interactions
The following drug interactions have either been reported or are theoretical in humans or animals receiving glimepiride and may be of significance in veterinary patients:
antiFungalS, azole (ketoconazole, itraconazole, fluconazole): May increase plasma levels of glimepiride
beta-blocKeRS: May potentiate hypoglycemic effect
cHloRampHenicol: May displace glimepiride from plasma proteins
coRticoSteRoiDS: May reduce efficacy
DiuReticS, tHiaziDe: May reduce hypoglycemic efficacy
iSoniaziD: May reduce hypoglycemic efficacy
niacin: May reduce hypoglycemic efficacy
pHenotHiazineS: May reduce hypoglycemic efficacy
pHenytoin: May reduce hypoglycemic efficacy
SulFonamiDeS: May displace glimepiride from plasma proteins
SympatHomimetic agentS: May reduce hypoglycemic efficacy
WaRFaRin: May displace glimepiride from plasma proteins

laboratory considerations
No specific laboratory interactions or considerations were noted.

Doses
catS: For treatment of NIDDM:
a) 2 mg (total dose) per cat once daily (Bruyette 2004)
b) 1 – 2 mg (total dose per cat) PO once daily (Scherk 2005c)

monitoring
Efficacy: Standard methods of monitoring efficacy for diabetes treatment should be followed (e.g., fasting blood glucose, appetite, attitude, body condition, PU/PD resolution and, perhaps, serum fructosamine and/or glycosylated hemoglobin levels)

Adverse effects

client information
Clients should understand the “investigational” nature of using this drug in cats and report any untoward effects to the veterinarian.

chemistry/Synonyms
A sulfonylurea antidiabetic agent, glimepiride occurs as a white to yellowish-white, crystalline, odorless to practically odorless powder. It is practically insoluble in water.
Glimepiride may also be known as: HOE-490, Amarel®, Amaryl®, Amarylle®, Euglim®, Glimepil®, Solosa®, and Roname®.

Storage/Stability/compatibility
Glimepiride tablets should be stored between 15 – 30°C (59 – 86°F) in well closed containers.

Dosage Forms/Regulatory Status
VeteRinaRy-labeleD pRoDuctS: None
Human-labeleD pRoDuctS: Glimepiride Tablets: 1 mg, 2 mg, & 4 mg; Amaryl® (Aventis); generic; (Rx)

 

[kalypso]

Lisa was prescribed the 1mg pill (one daily)