04/08 Soldier PMPS 466 1 month on Lantus no change : guidance needed

[Lisa & Solgy]

Hi there. First time posting here. My sweet boy Soldier was diagnosed with diabetes for the third time on 10th March 2022. First two times we suspect his DX was linked to pancreatitis, and he went into remission both times in under 2 weeks on Lantus. This time is VERY different. We suspect it may be due to steroids (budesonide) he has been taking for his IBD since January. He has been on 1mg/day.

Our spreadsheet is a bit messy. I started him on 2units (he is 16lbs and 2 units was the starting dose last time) but when we didn't see any changes for ~10 days we dropped down to 1 to make sure we weren't overshooting and have since been sticking to the TR protocol every 3 days and we are now up to 3 again. We have had a few readings within range but mostly we're up in the reds. After upping to 3 units we got our first 2 readings in the blues (yay) right before our highest reading yet at almost 600 (oh no!!). I am so confused and frustrated and worried. It's been a month now and his BG is still so high and is basically unflinching. I don't know if I need to go up again or maybe we overshot from the get go and he has been bouncing ever since?? We could sure use some help over here. We saw our vet a month ago and I've emailed my vet twice and sent him the spreadsheet to try to get guidance on dosing but no reply. It's hard to get follow up care...

Thank you.

(a bunch of preshot readings are missing..we weren't taking for a while because we knew the BG was very high anyway (no risk of giving too much insuline) and were trying to minimize stress + strip usage but I've been trying to take it more regularly now)

 

[tiffmaxee]

Welcome. We usually ask you to start with an intro on main/health but you are all set up. While he was diet controlled did you ever test his bg? I suspect he’s been high fir awhile and needs to get used to normal bg. It also could be the budesonide. Some cats are harder to regulate on it although it’s usually better than prednisolone for tge bg. Pancreatitis definitely can effect the bg. My boy had chronic pancreatitis fur a few years which I think eventually caused him to become diabetic. That’s why he goes from blue back to pink and red. I know you said you skipped preshots because you felt he was not in danger of going low but we see cats go from a high bg at night to green by morning. Max’s first green amps was after I went to bed with him a lot higher. Some cats drop a few hundred pounds. So please get a test before each shot. Be safe. It also lets us know if he’s bouncing.

Looking at your spreadsheet he’s not at a good dose yet. I’d increase to 2.25.

 

[Sienne and Gabby (GA)]

One other observation is that those high numbers are a result of a bounce. When Soldier is dropping into lower ranges, his pancreas is overreacting and driving the numbers back up as a result of the liver and pancreas releasing a stored form of glucose along with counterregulatory hormones. These cause the numbers to spike. It can take up to three days for the numbers to drop back down. The bounces are an annoying but normal phenomenon. As Soldier gets more accustomed to being in lower numbers, it will happen less often.

 

[Lisa & Solgy]

Welcome. We usually ask you to start with an intro on main/health but you are all set up. While he was diet controlled did you ever test his bg? I suspect he’s been high fir awhile and needs to get used to normal bg. It also could be the budesonide. Some cats are harder to regulate on it although it’s usually better than prednisolone for tge bg. Pancreatitis definitely can effect the bg. My boy had chronic pancreatitis fur a few years which I think eventually caused him to become diabetic. That’s why he goes from blue back to pink and red. I know you said you skipped preshots because you felt he was not in danger of going low but we see cats go from a high bg at night to green by morning. Max’s first green amps was after I went to bed with him a lot higher. Some cats drop a few hundred pounds. So please get a test before each shot. Be safe. It also lets us know if he’s bouncing.

Looking at your spreadsheet he’s not at a good dose yet. I’d increase to 2.25.

Hi and thank you so much for your reply! Sorry for missing the health intro. Asides from whats in the signature, the reason we decided to get an ultrasound to start with was that he was having intermittent vomiting episodes. These vomiting episodes were spread a few months to several months apart, but when they happened they are always very intense, like throwing up every half an hour to an hour for a whole day, tapering off and finally getting better in about a week. I'm pretty sure these are pancreatitis flares and we have all the meds now to help him through these. Knock on wood he hasn't had an episode like this for 5 months now so maybe the budesonide is helping, it's hard to tell so it's somewhat of a waiting game. Anyway, the ultrasounds showed thickening of his intestines and to rule of lymphoma we went ahead with the biopsy, which lead to the IBD diagnosis and prescription of budesonide. And now diabetes. He had a bad reaction to the general anesthesia from the biopsy and lost his coordination for about 3 weeks but he is better now. Who knows what his health would look like if we hadn't gone ahead with the ultrasound but sometimes I can't help but feel like things have been worse since and it's like a game of whack-a-mole where we try to address one thing and something else crops up. I'm tempted to taper him off the budesonide because it's like, which disease is worse?? but I'm trying not to rush into things.

To answer your questions, we did occasionally check his BG while he was diet controlled and it was always in range and good. He also had so many blood test done between the ultrasound and after the biopsy and they were always in range. So it would seem the longest he could have had undiagnosed diabetes in about 2 months, I don't know if that is a long time on not. We will definitely try to be more diligent with preshots. It's hard in the morning, with his diabetes + steroids his appetite has been ravenous and wake ups have been anytime between 4:30 and 5:30. It's hard at that time to be coordinated enough to do the test + insulin injection + breakfast. I know we all have to deal with these challenges but I can't pretend it hasn't affected my sleep quality.

You said 2.25 but I suspect you mean 3.25 as he has been on 3 now for about 5 days. we have u100s that only have 1 unit increments so that's tricky so maybe I'll try to go just above the 3 level.

 

[Lisa & Solgy]

One other observation is that those high numbers are a result of a bounce. When Soldier is dropping into lower ranges, his pancreas is overreacting and driving the numbers back up as a result of the liver and pancreas releasing a stored form of glucose along with counterregulatory hormones. These cause the numbers to spike. It can take up to three days for the numbers to drop back down. The bounces are an annoying but normal phenomenon. As Soldier gets more accustomed to being in lower numbers, it will happen less often.

Thank you so much for your reply. I have been reading about bouncing and kind of hoping that that is what we have been seeing, and that we will see the numbers fall down after holding steady on the dose. But as of yet after 5-6 days on dose 3 his numbers are still so high. I have a suspicion his metabolism is pretty slow (he is a big boy even though he didn't use to eat much pre-diabetes) so maybe it's taking him longer. I guess one of my main worries is that if there's a possibility he bounces for an extended period of time, could the high numbers at lower doses have also been bounces? I don't want to up his dose and make the problem worse. It is interesting that after the 1st dose of insulin we gave him after his diagnosis (2 units) we had a reading of 124 and then after that it's been pretty consistently high.

 

[tiffmaxee]

Yes. 3.25/ Sorry about the typo. Measuring .25 doses can be tricky. I used digital calipers as tge syringes have lines that can be off by a lot for a cat. I’ll give you a link. Meanwhile do your syringes have half unit markings ?

I would not stop the budesonide since it seems to be working. I had a cat with intestinal lymphoma and I think she likely started with IBD and it morphed. I know the jury is out as to whether that’s possible.

https://www.felinediabetes.com/FDMB/threads/dosing-with-calipers-updated-w-videos.79851/#post-862835

Bounces can take 4-6 cycles to clear. They can also happen if the bg drops too fast. What’s your feeding schedule? I found small amounts the first half of the cycle worked fur both pancreatitis and fd.

 

[Lisa & Solgy]

Yes. 3.25/ Sorry about the typo. Measuring .25 doses can be tricky. I used digital calipers as tge syringes have lines that can be off by a lot for a cat. I’ll give you a link. Meanwhile do your syringes have half unit markings ?

I would not stop the budesonide since it seems to be working. I had a cat with intestinal lymphoma and I think she likely started with IBD and it morphed. I know the jury is out as to whether that’s possible.

https://www.felinediabetes.com/FDMB/threads/dosing-with-calipers-updated-w-videos.79851/#post-862835

Bounces can take 4-6 cycles to clear. They can also happen if the bg drops too fast. What’s your feed8ng schedule? I found small amounts the first half of the cycle worked fur both pancreatitis and fd.

Thank you for your advice. I do have digital calipers, but using a good magnifying glass is a good idea! Yes, my internal med vet who did his biopsy said that IBD-lymphoma is more of a spectrum than a discrete thing. He almost made it sound like it was inevitable...

It's been 8 days since what looked to be his big bounce, so 16 cycles? It hasn't gone up to 600 again but has settle around the 350-450 range again, which is still much too high. Every dose we have tried seems to produce the same result. We have upped to 3.5 units and his numbers are still just under 400. I am worried that we have missed the optimum dose and he is just bouncing constantly, but I guess it would also be the effects of the budesonide.

He eats RAWZ rabbit pate and since he is a grazer he eats smaller portions often. I guess he has a slightly larger potion at the time of his shots (so around 5:30am & pm), he'll then eat mini meals every hour or so for a few hours, and then probably not much food between 1pm-5pm and 12am-5am (nap times).

 

[tiffmaxee]

You are doing everything right so kudos to you. I don’t think it’s inevitable the IBD will morph. I sure hope not. Good that you increased today. Now see what happens in 6 cycles unless there is a drop under 68 with the AT.

 

[Chris & China (GA)]

Hi Lisa! Saw your post on the Feline Diabetes group on Facebook and glad to see you posting here. The best idea is to post here daily (or at least every other day) so you get eyes on your spreadsheet as often as possible. Start a new thread once a day.

A few things...Please always get the AMPS and PMPS tests, even if you think they're always going to be high. Cats can (and do) surprise us all the time so it's really important. I totally understand not wanting to use many strips though, especially since you're using the Alpha Trak. The strips are insanely expensive. I'd strongly urge you to switch to a human meter where the strips are more affordable.

You can get a Relion Premier Classic at WalMart for $9 and the strips are only $17.88/100. All our dosing methods were developed using human meters so we're very comfortable using them. The only big difference is the "time to act" point. On the Alpha Trak it's below 68...on a human meter it's below 50 (so they're actually fairly close at low numbers which are the most important for safety!) As the numbers get higher, there's more of a difference, but it really doesn't matter if kitty is at 380 or 500..."too high" is too high!

You say you're doing Tight Regulation. On TR, you increase by .25 every 6 cycles if you're not getting the results you want (nadir's at least in the mid-low 100's). Once you start to get better nadirs, you might want to hold the dose a few cycles more, but again, if you post here, we'll be able to tell you when you should hold the dose and when you should go up. A cat needs however much they need so don't get too concerned about the 3.25 dose. If he goes above 6U twice a day, we will suggest getting him tested for acromegaly and IAA but that's something to deal with when (IF) we get there.

I understand your syringes only have whole unit marks. Again, Walmart is your friend here! You can get their Relion 3/10ml, 30 or 31 gauge insulin syringes and they have half unit marks (no matter what they might tell you). ALL their 3/10ml (or 0.3cc) syringes come with half unit marks. To do the .25 and .75 you have to eyeball it (getting a pair of reading glasses that magnify can really help) or you can learn to use calipers.

You went from 3U to 3.5 and I understand why you might have done that, but he really should have only gone to 3.25. He was getting nadir's that were under 300, so increases should be in .25 increments.

If you want to stick with the 3.5 for now, that's fine but please get both AMPS and PMPS and at least 1 mid-cycle on the AM cycle and at least a "before bed" test on the PM cycle. If you're in a position where you can get more tests, that's even better! The more data you have, the more pieces you'll fill into the puzzle known as Soldier.

Hold that dose for 6 cycles (unless he should happen to drop below 68 at any time..50 if you change to a human meter) and then let's re-access.

Hang in there! He is a bouncing baby boy but the more time we can get him into better numbers, the sooner his body may get used to them and stop overreacting so much! The bounces will not go as high and won't last as long.

Any questions?

 

[Lisa & Solgy]

Hi Lisa! Saw your post on the Feline Diabetes group on Facebook and glad to see you posting here. The best idea is to post here daily (or at least every other day) so you get eyes on your spreadsheet as often as possible.

A few things...Please always get the AMPS and PMPS tests, even if you think they're always going to be high. Cats can (and do) surprise us all the time so it's really important. I totally understand not wanting to use many strips though, especially since you're using the Alpha Trak. The strips are insanely expensive. I'd strongly urge you to switch to a human meter where the strips are more affordable.

You can get a Relion Premier Classic at WalMart for $9 and the strips are only $17.88/100. All our dosing methods were developed using human meters so we're very comfortable using them. The only big difference is the "time to act" point. On the Alpha Trak it's below 68...on a human meter it's below 50 (so they're actually fairly close at low numbers which are the most important for safety!) As the numbers get higher, there's more of a difference, but it really doesn't matter if kitty is at 380 or 500..."too high" is too high!

You say you're doing Tight Regulation. On TR, you increase by .25 every 6 cycles if you're not getting the results you want (nadir's at least in the mid-low 100's). Once you start to get better nadirs, you might want to hold the dose a few cycles more, but again, if you post here, we'll be able to tell you when you should hold the dose and when you should go up. A cat needs however much they need so don't get too concerned about the 3.25 dose. If he goes above 6U twice a day, we will suggest getting him tested for acromegaly and IAA but that's something to deal with when (IF) we get there.

I understand your syringes only have whole unit marks. Again, Walmart is your friend here! You can get their Relion 3/10ml, 30 or 31 gauge insulin syringes and they have half unit marks (no matter what they might tell you). ALL their 3/10ml (or 0.3cc) syringes come with half unit marks. To do the .25 and .75 you have to eyeball it (getting a pair of reading glasses that magnify can really help) or you can learn to use calipers.

You went from 3U to 3.5 and I understand why you might have done that, but he really should have only gone to 3.25. He was getting nadir's that were under 300, so increases should be in .25 increments.

If you want to stick with the 3.5 for now, that's fine but please get both AMPS and PMPS and at least 1 mid-cycle on the AM cycle and at least a "before bed" test on the PM cycle. If you're in a position where you can get more tests, that's even better! The more data you have, the more pieces you'll fill into the puzzle known as Soldier.

Hold that dose for 6 cycles (unless he should happen to drop below 68 at any time..50 if you change to a human meter) and then let's re-access.

Hang in there! He is a bouncing baby boy but the more time we can get him into better numbers, the sooner his body may get used to them and stop overreacting so much! The bounces will not go as high and won't last as long.

Any questions?

Hi and thank you SO much for taking so much time to help me. You have no idea how grateful I am given my high anxiety levels over this! I just hate not knowing what I'm doing or what the plan is. You wrote quite a bit so I'll try to answer in the same order.

Yes, I understand that the AMPS and PMPS readings are important. I will definitely be getting all the PMPS readings and as much AMPS as possible (sometimes my husband has to do the morning shots and he's just not as comfortable taking the blood samples as I am). Agreed the alphatrak strips are super pricey and we do actually have a human meter (it's the true metrix 60 - CVS health) which I got during an emergency but switched to alphatrak cause I thought it was more accurate. I will plan to switch over to this one (unless you think the relion premier classic is the preferred one?) so that we don't have to be stingy on the strips due to cost. You make a good point that a high reading is a high reading so it's kind of not that informative to know exactly what the value is.

I thought it was ok to go up by 0.5units under TR if the BG readings are above 300 or 350. To be honest we are probably closer to 3.25 but as it's quite impossible to be that accurate with syringes with only 1 unit increment I just put down 3.5. I will plan a trip to walmart to get those syringes you recommended. And I will try to stick to 0.25 increases every 3-4 days and hope that we never reach 6 units.

I will aim to post more regularly here with updates. Thank you so so much!! I feel much better having a bit of a plan in place.

 

[Lisa & Solgy]

You are doing everything right so kudos to you. I don’t think it’s inevitable the IBD will morph. I sure hope not. Good that you increased today. Now see what happens in 6 cycles unless there is a drop under 68 with the AT.

Thank you thank you! I am so grateful for the support!

 

[Lisa & Solgy]

Hi Lisa! Saw your post on the Feline Diabetes group on Facebook and glad to see you posting here. The best idea is to post here daily (or at least every other day) so you get eyes on your spreadsheet as often as possible.

A few things...Please always get the AMPS and PMPS tests, even if you think they're always going to be high. Cats can (and do) surprise us all the time so it's really important. I totally understand not wanting to use many strips though, especially since you're using the Alpha Trak. The strips are insanely expensive. I'd strongly urge you to switch to a human meter where the strips are more affordable.

You can get a Relion Premier Classic at WalMart for $9 and the strips are only $17.88/100. All our dosing methods were developed using human meters so we're very comfortable using them. The only big difference is the "time to act" point. On the Alpha Trak it's below 68...on a human meter it's below 50 (so they're actually fairly close at low numbers which are the most important for safety!) As the numbers get higher, there's more of a difference, but it really doesn't matter if kitty is at 380 or 500..."too high" is too high!

You say you're doing Tight Regulation. On TR, you increase by .25 every 6 cycles if you're not getting the results you want (nadir's at least in the mid-low 100's). Once you start to get better nadirs, you might want to hold the dose a few cycles more, but again, if you post here, we'll be able to tell you when you should hold the dose and when you should go up. A cat needs however much they need so don't get too concerned about the 3.25 dose. If he goes above 6U twice a day, we will suggest getting him tested for acromegaly and IAA but that's something to deal with when (IF) we get there.

I understand your syringes only have whole unit marks. Again, Walmart is your friend here! You can get their Relion 3/10ml, 30 or 31 gauge insulin syringes and they have half unit marks (no matter what they might tell you). ALL their 3/10ml (or 0.3cc) syringes come with half unit marks. To do the .25 and .75 you have to eyeball it (getting a pair of reading glasses that magnify can really help) or you can learn to use calipers.

You went from 3U to 3.5 and I understand why you might have done that, but he really should have only gone to 3.25. He was getting nadir's that were under 300, so increases should be in .25 increments.

If you want to stick with the 3.5 for now, that's fine but please get both AMPS and PMPS and at least 1 mid-cycle on the AM cycle and at least a "before bed" test on the PM cycle. If you're in a position where you can get more tests, that's even better! The more data you have, the more pieces you'll fill into the puzzle known as Soldier.

Hold that dose for 6 cycles (unless he should happen to drop below 68 at any time..50 if you change to a human meter) and then let's re-access.

Hang in there! He is a bouncing baby boy but the more time we can get him into better numbers, the sooner his body may get used to them and stop overreacting so much! The bounces will not go as high and won't last as long.

Any questions?

Second reply here (there's a longer one above). I've just been staring at his spreadsheet some more. We got some good readings at 2.5 units. But for some reason the AM mid cycles are better than the PM mid cycles, which were still high. So we went up to 3, which is when he had his big bounce. I'm wondering if actually 2.75 could have been a sweet spot..if I get my hands on some better syringes do you think it's worth dropping down to 2.75 for a while and then working our way back up?
Also, do walmart sell syringes without a precription?

 

[Chris & China (GA)]

I will plan to switch over to this one (unless you think the relion premier classic is the preferred one?)

check the price of the strips for the meter you have. No reason to buy a new meter if the strips for the one you have are affordable! "Affordable" varies from person to person so I was thrilled to only have to pay $17.88 for 100 of the Relion strips. I don't know how much the strips for the CVS one are.

I thought it was ok to go up by 0.5units under TR if the BG readings are above 300 or 350.

Increases are based on the LOWEST reading (the nadir) not the Pre-Shots.

Increasing the dose: (from the TR protocol...red highlights are mine)

• Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
  • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
  • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
• Increase by 0.25 unit after 3 days (6 consecutive cycles) if nadirs are greater than 200, but less than 300.
• Increase by 0.5 unit after 3 days (6 consecutive cycles) if nadirs are greater than 300.

.if I get my hands on some better syringes do you think it's worth dropping down to 2.75 for a while and then working our way back up?

No...If the 3.5 dose is too high and you are getting tests at different points in the cycle for those 3 days, we'd catch it if he was dropping low and bouncing back high. For now, I'd just stay the course.

Also, do walmart sell syringes without a precription?

Depends on where you live. Different states have different laws regarding syringes. Just so you make sure to get the right ones, they will be in one of these 2 boxes (Walmart employee's are notorious for giving people the wrong syringes even if they ask for the right ones)

This link has the laws regarding syringes. I think you're in CA where a script is not required, but some pharmacies will have their own policy (and it can vary depending on who the pharmacist is that day)

They should have a purple stripe no matter which color the box is.