Newbie with questions

[4PawMama]

Hello everyone! First of all, thank God for this message board and for all of you! I’ve been skimming a bunch of threads for info and it’s been very helpful!

I apologize in advance for the long post. I haven’t learned the lingo quite yet either so sorry about that too. I’ll work on it. Little bit of backstory:

My baby was diagnosed about a month ago, (perhaps onset from his steriod prescription). He started vetsulin on 3/5. He started with 1unit (once per day) but is now up to 2 (still once per day). He had a BGC done at the vet 3/14. They said he stayed in the 400-500 range while he was there and even went into the 600s. That’s when his dose increased. They suggested that he could’ve been stressed and to try a BGC at home. I did one on 3/22 w/ an alphatrak 2 monitor. That first curve made sense: started the day at 551, then went down after insulin to 193. Then steadily went up for every following check: 218, 298, 359.

Reported this to the vet who suggested to try another curve to pinpoint when he spikes. She didn’t change his dose. So I did another on 3/26. Started at 489, then 447 after shoot, then 166, 179, 290, 329, then the next morning 304. I used two more strips just to make sure and they said 349 and 398. Then 89 after shoot. The backup strip said 86. That could be because he hadn’t eaten in 3-4hrs. Even so, it seemed like a big jump. I tried calling his vet but she wasn’t there that day.

The sudden lower numbers made me really paranoid so I tested the next day before his insulin: 382. It seemed kinda low to start the day. I called the vet again but she was in appointments. She never called back. I checked a couple hours later and it went up in the 400s. So he got his insulin.

I had a rough morning today and wasn’t able to test him right away. I tested him a couple hours after he had his morning medication (1/2 pred dose as vet weans him off) and first meal. It was 190. Backup strip was 198. That seemed too low to shoot.

So my questions are:
1. Is it ok to skip insulin dose for the day?

2. Is it normal for strips taken seconds apart to change numbers?

 

[FrostD]

There must be a full moon coming because I cannot handle anymore vets prescribing once a day dosing

Anyway welcome! I'll drop a canned speech in a few minutes, but few questions:
1. What is his diet?
2. What is current dose?
3. What is pred dose and how often? Why is he on it?
4. You are using an AlphaTrak?

To answer your questions:
1. When you are new we recommend skipping if below 200. I would have called 198 close enough BUT I'm not even sure his current dose is correct/safe, so skip is good
2. Yes. Pet meters are allowed a 15% variance, human meters (which you will find more cost effective, btw, most of us use WalMarts ReliOn brand) are 20%

 

[FrostD]

Now the housekeeping items:

We recommend you start here, getting a spreadsheet and signature set up is the most important part.

We also recommend you put together a hypo kit, discussed here. If you are in the US, here is a food list. If you are elsewhere, just let me know country and I can pull the other lists.

• We define low carb (LC) as under 10%, most of us feed around the 3-7% range. Medium carb (MC) is 10-15%, high carb (HC) is 16%+. You will want some of each type of food in your hypo kit. We recommend writing the % carbs on each can in permanent marker, so when you're in a pinch you don't have to dig. I personally keep very high carb food on hand as well, 23%+.
• You want to feed a low carb wet diet. If he is not currently low carb wet, do not transition food yet. Transitioning food alone can have a drastic effect on BG and be dangerous (life threatening). We will help you through that.
• I'd suggest getting some feeding syringes, as well as a few jars of the Gerber 2nd foods meats or some A/D recovery food. Diabetic cats are prone to all sorts of weird things (pancreatitis, bouts of inappetence, etc) so it's much less stressful if you have some things on hand in case they don't want to eat

Ketones and DKA are a risk for diabetic cats, namely unregulated ones. We define regulated as 50-120 on a human meter. DKA is very serious and life threatening. The recipe for DKA is not enough insulin + inappetence + underlying stress/inflammation. We recommend checking urine daily while unregulated, weekly when regulated. You can just buy regular urine ketone strips from a human pharmacy, like Ketostix. If you think that will be difficult, they make blood ketone meters but strips can be expensive (I have the NovaMax Plus).

Now for Vetsulin specifically, dosing needs to be twice a day. It actually is not a good insulin for cats, the 2018 AAHA Guidelines do not recommend Vetsulin for cats - they recommend ProZinc, Lantus, or Levemir. Semglee is a Lantus biosimilar. Vetsulin does not last long enough in the vast majority of cats, I've seen maybe 2 exceptions in my time here. It is also very harsh and drops them very fast, can be unpredictable and a bit dangerous. Those big/fast drops trigger what we call a bounce - their liver perceives that as a threat and releases stored glycogen and counterregulatory hormones to spike the BG back up. As you can imagine, this is counterproductive.

So...there's no harm in trying Vetsulin as long as you can stay on top of testing, just know that you will likely eventually need to switch. And if he starts throwing ketones I will be pushing you pretty hard (obnoxiously actually ) to change insulins.

We do dose changes in in 0.25U increments...I'd hazard a guess your vet is doing whole units. Any time you get a number below 90, or can reasonably infer he went below 90 (I can help with this), you need to reduce the dose by 0.25U. If he went below 68 on an AlphaTrak or 50/60 on a pet meter, I would reduce by 0.5U to be safe (pet meters tend to read higher, hence the difference).

Can you please double check your syringes say U40 somewhere on the barrel? And when you get a chance, can you post a picture of your dose drawn up in the syringe? I'd just like to verify.

It's all overwhelming, I know! We've all been there. I'm one of very few Vetsulin users around, so by all means tag me any time you have a question. If you need immediate advice, post on the Main Forum.

 

[FrostD]

Ah sorry one more thing about testing and feeding:
We withhold food for 2 hrs before the shot. That just gives you a consistent data point to base decisions on (shoot, skip, reduced dose, token dose - I'll explain when you get there lol)

Shots should be 12 hrs apart, give or take 30 minutes. Don't start twice a day yet, I'll look at your spreadsheet first when you get it up and running.

The largest part of the meals should be fed right before shot time. With Vetsulin, we test, feed, then shoot 30 minutes later. It is critical they have food on board since the insulin kicks in hard and fast. Small snacks during the cycle are ok, we just try not to feed after nadir (the lowest point) because the insulin is wearing off. Now, the downside to Vetsulin is that's usually the 3-5 hr mark, and most cats will get ragey without food that long. So any food after that, just try to keep it small amounts.

I would focus your testing on the first 6 hours of the cycle for now. At minimum, you should be testing before each shot, and then once again each cycle (day and night - cats often go lower at night). More testing will be needed if they seem to be on a trajectory to low numbers. I would start with a +2 each cycle if you can, a lot of people opt to shift the shot time to accommodate that.

How's his weight? Ideal? Over/under?

 

[4PawMama]

There must be a full moon coming because I cannot handle anymore vets prescribing once a day dosing

Anyway welcome! I'll drop a canned speech in a few minutes, but few questions:
1. What is his diet?
2. What is current dose?
3. What is pred dose and how often? Why is he on it?
4. You are using an AlphaTrak?

To answer your questions:
1. When you are new we recommend skipping if below 200. I would have called 198 close enough BUT I'm not even sure his current dose is correct/safe, so skip is good
2. Yes. Pet meters are allowed a 15% variance, human meters (which you will find more cost effective, btw, most of us use WalMarts ReliOn brand) are 20%

Hi FrostD,

Sorry for the late reply. I've been swamped. I talked to his vet shortly after posting. We're still finding our footing with him since he's still newly diagnosed.

Answers:
1. He eats dry and wet food. He normally eats wet twice a day and he grazes the kibble whenever he's hungry. My vet hasn't recommended any diet changes yet but we've discussed the possibility of changing it in the future.

2. Up until Tues. he was 2u once daily, but now he's 1u as needed. His BG has been going lower on its own since the steroid has been decreasing.

3. We've been weaning him off his steroid for weeks now, since we suspect that's where the diabetes started. As of Tues., he's officially done with it. He was on it because of his GI issues, but now he's on a new medication for it.

4. Yes, alphatrak2.

Also, we use a U40 syringe.

I followed you all the way to the end. My vet hasn't been specific on feeding time, so I just allow him to eat when he's hungry. I aim to do tests 2 hrs after he's eaten.

 

[FrostD]

I don't really see a significant downward trend that would lead to an "as needed" basis - nor is there a reason to skip doses when he's in the 200s or higher. Remember that non-diabetic numbers are 68-150 on a pet meter, meaning they should be in that range nearly all the time if not diabetic or in remission.

I would continue to give 1U twice a day as long as he's above 200. You don't have quite enough data for me to advise on anything below that, but you will eventually have to shoot numbers under 200.

Suspected IBD/SCL? Moved him to budesonide instead?

I would withhold food for 2 hrs before shot time. That way those are consistent numbers, not affected too much by food.

Removing the dry would be wise regardless of the diabetes, especially if he's got GI problems.

Something to consider - just because the steroid has been removed does not always mean his BG will come back down on its own, the steroid did "damage" over time and everything needs to heal and readjust, which takes time. So usually insulin support is required for some time, and some cats with steroid-induced diabetes stay diabetic forever (more likely if they were pre-diabetic to begin with).

Remember, that higher BG is also causing problems elsewhere within the body. Right now he's above renal threshold almost all the time - this puts additional load on the kidneys, but also increases chances of things like UTI because bacteria thrive on the excess sugar.

So what I'm saying - I would not be too conservative on dosing and shooting. I would give him the insulin he needs to keep him in the target range - for Vetsulin that's 90-150. As his body starts to hopefully heal, you will see BG come down and he will earn the reductions by dropping below 90.