6/24 Henry's ongoing saga AMPS 317 +1.5 308 +2.25 313 +3 336

John & Henry

John & Henry

Member Since 2022
Wasn't sure what to put in the title since we have no AMPS yet. Here's the old thread for anyone following along.

Thank you everyone for all your help. Tagging people so they can find the new thread @Liz & Minnie @Sandy and Black Kitty @Lisa & Oberon @Wendy&Neko @FrostD @tiffmaxee @Bron and Sheba (GA)

I added the "R sheet" from Minnie's SS. We're 20 minutes to AMPS and need to figure out dosing for both R and Lantus. Wendy suggested 1.75U Lantus and .1U if over 300 and .25U if over 350. That sounds reasonable to me, but what do I know?? Love everyone thoughts
 
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This is so weird. According to the Nova the BG is DECREASING! WHAT? It went from 350 to 294 to 287 just now? Could his bodys own insulin be causing this drop? Guess I'm really glad its not going higher. libre is showing 328. so at +11.75 we're at 287 (nova) 328 (libre)
 
Liz & Minnie said:
PS I think the different readings on the nova are within the 20% margin of error? Don't get too hung up on it. I personally think different meters have different levels of accuracy at different ranges of BG
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So I read last night in lab tests on the Nova max was within 9.5%. The FDA allows up to 20%. But yeah, I'm really questioning the accuracy of the meter(s)

edit: and so did my vet in her most recent e-mail this morning. She'd like me to bring in my meter(s) next time I'm in so I can compare them to their lab meters. She was as confused with what happened last night as we are.
 
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See what Elise says, she is so much more experienced...but, if it were me I would stick with Wendy's suggestion 1.75L and, if he's below 300 at shot time, so be it. No R. Try and get a blood ketone reading at shot time too. Then sit tight and monitor til midcycle/nadir, if it's over 300 at that point then top up with R.

John & Henry said:
So I read last night in lab tests the Nova max was within 9.5%. The FDA allows up to 20%. But yeah, I'm really questioning the accuracy of the meter(s)
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I was going crazy with meters. I started with Freestyle lite because I liked the strips and the small drop of blood but was going crazy trying to get good prices on EBay so I finally switched fulltime to Novamax. I noticed that the Freestyle would give scary limes (30s!) and she had no symptoms other than hungry and Novamax would give 60s/70s on same blood drop. Similarly the Novamax would give pinks where the Freestyle give yellows. Also with both meters I can get "off" readings if I don't get enough blood in one go - enough to avoid error codes, but the BG would be weird. Re-check is the answer but all to often I get panicked by the reading (even though that's the first rule, 'don't panic') and forget the extra reading.

So....I feel the monitors are a useful tool but I 'try' to remember it's just that and not get too worked up. So much easier said than done, especially when you don't have months of data on your s/s to look back at!
 
Liz & Minnie said:
See what Elise says, she is so much more experienced...but, if it were me I would stick with Wendy's suggestion 1.75L and, if he's below 300 at shot time, so be it. No R. Try and get a blood ketone reading at shot time too. Then sit tight and monitor til midcycle/nadir, if it's over 300 at that point then top up with R.



I was going crazy with meters. I started with Freestyle lite because I liked the strips and the small drop of blood but was going crazy trying to get good prices on EBay so I finally switched fulltime to Novamax. I noticed that the Freestyle would give scary limes (30s!) and she had no symptoms other than hungry and Novamax would give 60s/70s on same blood drop. Similarly the Novamax would give pinks where the Freestyle give yellows. Also with both meters I can get "off" readings if I don't get enough blood in one go - enough to avoid error codes, but the BG would be weird. Re-check is the answer but all to often I get panicked by the reading (even though that's the first rule, 'don't panic') and forget the extra reading.

So....I feel the monitors are a useful tool but I 'try' to remember it's just that and not get too worked up. So much easier said than done, especially when you don't have months of data on your s/s to look back at!
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That is actually very helpful information! Thank you. I had no idea the blood volume could throw it off, but it makes sense! The only "signs" of hypo I've seen in Henry is he'll occasionally twitch every once in awhile for a few seconds, but only while he's sleeping.
 
For when you start using R - sorry my R tab is so complicated, I tend to overwork spreadsheets! The R scale is over on the right. columns S - U.
column 1 - BG range
column 2 - R dose at shot time
column 3 - R dose at midcycle

You'll want to put different numbers in for Henry based on Wendy's suggestion, so
>350 0.25u
300-349 0.1u
<300 0u

I'd probably start with the same doses for the midcycle. As you learn how he responds, you'll make new tables. I used black kitty's as a template.

We are looking for the right R dose that brings a BG drop of around 100.

You want to give R when you can be around to monitor for 4 hours afterwards (or perhaps even longer when you're first learning how Henry responds, especially given last night's shenanigans). This is how my R tab ended up so complicated, I wanted to track how she responded at different L dose, R dose, BG and ketones and hopefully find a pattern though as I said before, my conclusion was that it's R roulette. Could not find a pattern!

Eagerly awaiting his ( ? ) AMPS reading!
 
tiffmaxee said:
Did you get another test? I too think 1.75 should be safe. I should put should be in quotes.
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Just did one. 376 on the libre. 317 on the nova max and .4 ketones. 1.75 sounds good to me. we're over 300. should I try .1U R too?

edit: the libre number was off A LOT, just correct it from 2 something to 376
 
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John & Henry said:
Just did one. 242 on the libre. 317 on the nova max and .4 ketones. 1.75 sounds good to me. we're over 300. should I try .1U R too?
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Time to pick a meter and stick with it. The other meter can be a double-check.

If it were me, I would go with the guidance (hardest thing to do, not second guess!) - 0.1u R and make sure you're monitoring at least every hour. i.e. follow the Novamax. You can still read the Libre but base your dosing on the Novamax.
 
Liz & Minnie said:
Time to pick a meter and stick with it. The other meter can be a double-check.

If it were me, I would go with the guidance (hardest thing to do, not second guess!) - 0.1u R and make sure you're monitoring at least every hour.
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I've been using the Nova max as my main guide and the libre as a backup. I agree with the .1U R.. so scared of the ketones. OK, time to put my .1U measuring abilities to the test. (I've been practicing a lot last night with Gatorade)
 
Looks like you are in good hands here with Liz. She’s an experienced R user. I found that I didn’t always get a consistent response to the same R dose (Liz’s R Roulette). Hopefully Henry’s tiny dose will help and he will be consistent.
 
John & Henry said:
So I read last night in lab tests on the Nova max was within 9.5%. The FDA allows up to 20%. But yeah, I'm really questioning the accuracy of the meter(s)
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Meters can be confusing, especially in the early days when you’re short on data and putting so much stock into each reading. And with what you’ve been through already? Shaking head.

I did a couple of things to give me a “reality check.” First, I tested one of my non-diabetic cats just to verify that the meter was likely working properly (a non-diabetic should be in “normal” range, right?). I also had a backup meter(s) just in case I needed a second (or third) “opinion.” It’s not the exact value that matters, just a general feel for how the BG is trending and what constitutes “low” on your meter. Some meters run higher/lower than others. And yes, I’ve seen wonky readings with too much/too little blood, so if in doubt, re-test. I also ran double tests whenever switching batches of test strips (last strip from old vial vs a strip from the new vial).

The other thing to know is that anemia can cause glucometer readings to be “off” although I don’t see that as one of Henry’s issues so I won’t go into the weeds on that.

I was following along last night and am very glad you got Henry up out of those lower numbers. “R” is a powerful and potentially dangerous insulin (I used it on two of my three diabetics) so I’m very glad you were testing and on top of keeping him safe. I’m not thrilled with the vet giving a whopping 0.5u of R without previous data and then discharging Henry. I don’t get the sense the vet understood what risk that might present.

When do you expect the results from TAMU on the fPLI/fTLI/folate/cobalamin? That might be helpful information.

Oh, and you have a very powerful tool in your dog. She might be your early warning system going forward. (What’s her name?)
 
JL and Chip said:
Meters can be confusing, especially in the early days when you’re short on data and putting so much stock into each reading. And with what you’ve been through already? Shaking head.

I did a couple of things to give me a “reality check.” First, I tested one of my non-diabetic cats just to verify that the meter was likely working properly (a non-diabetic should be in “normal” range, right?). I also had a backup meter(s) just in case I needed a second (or third) “opinion.” It’s not the exact value that matters, just a general feel for how the BG is trending and what constitutes “low” on your meter. Some meters run higher/lower than others. And yes, I’ve seen wonky readings with too much/too little blood, so if in doubt, re-test. I also ran double tests whenever switching batches of test strips (last strip from old vial vs a strip from the new vial).

The other thing to know is that anemia can cause glucometer readings to be “off” although I don’t see that as one of Henry’s issues so I won’t go into the weeds on that.

I was following along last night and am very glad you got Henry up out of those lower numbers. “R” is a powerful and potentially dangerous insulin (I used it on two of my three diabetics) so I’m very glad you were testing and on top of keeping him safe. I’m not thrilled with the vet giving a whopping 0.5u of R without previous data and then discharging Henry. I don’t get the sense the vet understood what risk that might present.

When do you expect the results from TAMU on the fPLI/fTLI/folate/cobalamin? That might be helpful information.

Oh, and you have a very powerful tool in your dog. She might be your early warning system going forward. (What’s her name?)
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This is so helpful. No he isn't anemic luckily. Vet did send me some results this morning but I don't think they included the fPLI/fTLI/folate/cobalamin. I'll post what she sent when I get my laptop back up. My GSDs name is Penny and she hasn't been doing the excessive sniffing that she had been when he had ketones so yeah, I think it's a very helpful metric. Thank you JL
 
Oh, something else I picked up - I mark in the s/s when I dose R (so in the cell where you have 317 I also would write 0.1 R, then manually change the color of the cell). As I said, I am a bit overkill with my s/s so I also put a lime green border around the cell to make it easy to spot. You don't have to do it, could just put it in the remarks and I know you're already tracking in the other R tab - I just found it easier to have the R's in the main s/s itself.

Crossing paws for the first reading! If you see he is dropping a lot in the first hour (say 100) I would give some higher carb food. You want to slow that drop and don't want him dropping more than 100 in the 4 hours. That's not just an R thing, others can probably chime in with tips on that too, but after last night you're already a pro.
 
I always did, too, write the R dose in the same cell indicating the hour that it was given. Sometimes it was at pre-shot, sometimes mid-cycle, as long as I was around to monitor for the next several hours. It's just too difficult to slide the SS all the way to the right and try to figure out when the R was given and at what BG level it was when it was given, etc. Also, I added a column specifically for ketones.
 
Henry is famous, I went to check his spreadsheet and there's anonymous dingo, goose, otter, crow and wolverine looking too :p. Too early to tell how well the R is working but it's in the right direction at least and confirms the R was the right decision! I'm sure you're doing this already, but I'd make sure there's plenty of water mixed in with his food. Minnie only drinks water when her BG is high for a while, but she always takes whatever I mix in with her food.

I have to run out to do some errands - will have my phone but not checking here as frequently. But, you are in many many good hands. There's nothing special for you to do about the R now, just wait and monitor. Crossing paws for you!
 
Finally got my other laptop dusted off and updated. Now I gotta get used to it again. I can't move as quickly with this keyboard, scroll speed, etc...
So we're at AMPS +1 we're reading 308 (nova) and 397 (libre) (I'm following the nova as my "guide")

Suzanne & Darcy said:
So for today, I would write 1.75 L and .10 R into the cell. Good idea Liz has for the border color.
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Done, but the boarder isn't easy to see, even when bolded unfortunately.

Liz & Minnie said:
Oh, something else I picked up - I mark in the s/s when I dose R (so in the cell where you have 317 I also would write 0.1 R, then manually change the color of the cell). As I said, I am a bit overkill with my s/s so I also put a lime green border around the cell to make it easy to spot. You don't have to do it, could just put it in the remarks and I know you're already tracking in the other R tab - I just found it easier to have the R's in the main s/s itself.
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Good idea, just did that. Thank you

Suzanne & Darcy said:
How is he eating now/this afternoon? I'm happy the last ketone test was .3 -- any more since then?
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Last ketone test was .4 at AMPS, I'll add it to the SS

Suzanne & Darcy said:
How is he eating now/this afternoon? I'm happy the last ketone test was .3 -- any more since then?
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He downed a whole can of FF about 3 hours ago, and he's always begging for more. I find that if I don't leave food out for him all the time, he's more likely to eat everything I give him.
 
Liz & Minnie said:
Henry is famous, I went to check his spreadsheet and there's anonymous dingo, goose, otter, crow and wolverine looking too :p. Too early to tell how well the R is working but it's in the right direction at least and confirms the R was the right decision! I'm sure you're doing this already, but I'd make sure there's plenty of water mixed in with his food. Minnie only drinks water when her BG is high for a while, but she always takes whatever I mix in with her food.
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Ha!, I've been watching those little animals constantly. Henry's got his own exotic zoo! He hasn't been drinking much. The high BG/ketones definately make him want to drink constantly. We got some subQ fluids on deck for tonight tho. I'll try mixing in the water with the food and see how that goes.

Liz & Minnie said:
I have to run out to do some errands - will have my phone but not checking here as frequently. But, you are in many many good hands. There's nothing special for you to do about the R now, just wait and monitor. Crossing paws for you!
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Thank you Liz, really appreciate all your help!

Suzanne & Darcy said:
Not too much movement in the first hour. I never did get much in the first hour (but my cat was unique) either. Waiting now for +2.... (cue Jeopardy music).
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Glad to hear that. I was hoping for a bigger move. Next check isn't too far away for fingers crossed.
 
Suzanne & Darcy said:
Still very little movement in BG. Grrr. Frustrating. I'm sure you will start to see some downward movement soon.
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Yes, was just coming to comment that. +2.25 313 (nova) 370 (libra) ... Looks like we should have given a bit more R. Henry just finished his second can of fancy feast (in about 5 minutes). His belly feels so full. I just wish he could migrated some of that to his bones. Hope we see some movement soon and the ketones are minimal being just over the 300 mark. +3 check in 30 minutes. Hopefully we see the Lantus work its magic. I gotta close my eyes for a minute. I'm not sure I even fell asleep last night, maybe got an hour or two. Got my alarm set for 30 minutes!
 
John & Henry said:
Yes, was just coming to comment that. +2.25 313 (nova) 370 (libra) ... Looks like we should have given a bit more R. Henry just finished his second can of fancy feast (in about 5 minutes). His belly feels so full. I just wish he could migrated some of that to his bones. Hope we see some movement soon and the ketones are minimal being just over the 300 mark. +3 check in 30 minutes. Hopefully we see the Lantus work its magic. I gotta close my eyes for a minute. I'm not sure I even fell asleep last night, maybe got an hour or two. Got my alarm set for 30 minutes!
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Oh I hope you wake up with your alarm. I wish there was a way we could prod you awake if we don’t hear from you :woot:
 
Suzanne & Darcy said:
Oh I hope you wake up with your alarm. I wish there was a way we could prod you awake if we don’t hear from you :woot:
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I just envisioned some sort of system where you can shock me over the internet lol.

So not looking good. Nova is 336 @ +3 and libre is reading HI. so too high to be read :( So we're not getting any help from the Lantus. This is like what happened right before he went in the hospital when 2U of Lantus did almost nothing. Frustrating. When can we use more R? Not til +6? I can feel the ketones building. I'd much rather deal with hypo which can be fixed with some corn syrup.
 
John & Henry said:
I just envisioned some sort of system where you can shock me over the internet lol.

So not looking good. Nova is 336 @ +3 and libre is reading HI. so too high to be read :( So we're not getting any help from the Lantus. This is like what happened right before he went in the hospital when 2U of Lantus did almost nothing. Frustrating. When can we use more R? Not til +6? I can feel the ketones building. I'd much rather deal with hypo which can be fixed with some corn syrup.
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Right. Can’t do any more R yet. Sorry about the numbers. See you in an hour?
 
So interesting thing here. First test I did with the nova read 266 but the libre was still reading HI. So I opened a now box of strips and the second reading from the nova was 342! Quite the difference! stupid meter! So we're still getting outta control. The dog has sniffed his mouth atleast 3 times in the past few hours. My K9 ketone meter is lighting up. I feel we gotta do something soon!

edit: He's also not acting as "bright" as he has been since he's been back just in the last few hours. I wouldn't saw lethargic, maybe he's just being a typical cat (he went and got in my bed around 8am this morning, like "Enough with the pokes papa, its bed time already!"
 
Just caught up. I am in no way experienced with R besides what I've read here and picked up from spreadsheets. Just a few comments -

I trust Wendy and Liz's advice re:R Insulin. Better to start a little conservative because we've seen some drastic reactions and karo isn't always the safety net we like it to be (not to completely scare you, but we had a cat seizing on and off for 9+ hours and stuck in the 30s/40s despite constant karo administration).

I'm not sure how quickly R scales can be adjusted but I would imagine you do have leeway up to 0.25U. Like everyone else mentioned, the corner is overlapping nadirs. On a normal cycle, his L nadir appears to be +6 to +8...but it is a bit muddied with the hospitalizations, etc. On a bounce breaking cycle, that nadir is often much later, often +8 to +12 - sometimes later. And they get extra downward momentum on the break - hence not giving R to add fuel to that fire.

He is absolutely bouncing, you can only fight the liver dump and counterregulatory hormones so much. I suspect the R may be helping keep him from higher numbers even though it seems like nothing.

Also about the meters... I'm a fairly vocal critic of the Libre. I think it is a fantastic tool in the chest in this exact situation, and in situations we need to at least have an idea what's happening. But the trouble is what you're seeing - anecdotally it tends to read artificially lower below about 70, and artificially HI on the upper end. It has messed quite a few people up in terms of dosing strategy, intervening with food when they didn't need to, etc. But it's one of the many tools we have, I always say use a handheld as your primary meter, use the Libre to help fill in the gaps.

Don't drive yourself crazy with the meters ...hard not to, I know. Everything you listed is pretty much within variance. Pick a meter and stick with it. If it's on the threshold of R vs no R vs different R dose...take 3 readings and do an average.
 
It can’t hurt to give fluids. I never noticed a huge change in ketones with sub-q fluids. But I gave them anyway - I just didn’t see a lot of change in the numbers. I logged it all on my spreadsheet. Did you say they said to give 60 mL?
 
JL and Chip said:
Did you say subQ fluids were on deck for tonight? Hydration is key and fluids can sometimes help lower BG a bit in some cats, so I might be looking at doing them sooner rather than later…
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Yeah, I've been thinking about that. My only concern is it may interfere if we were to give more R, but I really have no idea. I suppose the R could be given somewhere other than the shoulders. She prescribed 60ml of subQ fluids. Is that a standard amount?
 
I would feel very uncomfortable giving any more R before +6, and then still only .10 units at this point. And even this would be dependent upon a ketone meter test. I hope that, since @Wendy&Neko is in your time zone, she will be able to stop by and give us her recommendation.
 
She probably based that on his weight. Since you said he is down to 7 pounds some ounces? It’s normally based on the cat’s weight as you don’t want to overhydrate because it can be dangerous for the heart. I do not think 60 mL is too much right now.
 
FrostD said:
Just caught up. I am in no way experienced with R besides what I've read here and picked up from spreadsheets. Just a few comments -

I trust Wendy and Liz's advice re:R Insulin. Better to start a little conservative because we've seen some drastic reactions and karo isn't always the safety net we like it to be (not to completely scare you, but we had a cat seizing on and off for 9+ hours and stuck in the 30s/40s despite constant karo administration).

I'm not sure how quickly R scales can be adjusted but I would imagine you do have leeway up to 0.25U. Like everyone else mentioned, the corner is overlapping nadirs. On a normal cycle, his L nadir appears to be +6 to +8...but it is a bit muddied with the hospitalizations, etc. On a bounce breaking cycle, that nadir is often much later, often +8 to +12 - sometimes later. And they get extra downward momentum on the break - hence not giving R to add fuel to that fire.

He is absolutely bouncing, you can only fight the liver dump and counterregulatory hormones so much. I suspect the R may be helping keep him from higher numbers even though it seems like nothing.

Also about the meters... I'm a fairly vocal critic of the Libre. I think it is a fantastic tool in the chest in this exact situation, and in situations we need to at least have an idea what's happening. But the trouble is what you're seeing - anecdotally it tends to read artificially lower below about 70, and artificially HI on the upper end. It has messed quite a few people up in terms of dosing strategy, intervening with food when they didn't need to, etc. But it's one of the many tools we have, I always say use a handheld as your primary meter, use the Libre to help fill in the gaps.

Don't drive yourself crazy with the meters ...hard not to, I know. Everything you listed is pretty much within variance. Pick a meter and stick with it. If it's on the threshold of R vs no R vs different R dose...take 3 readings and do an average.
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Thank you, that's very helpful. I'm thinking of the pre-hospitalization numbers where he was in the 400s but the 2U of Lantus didn't touch it. Are you saying with the counter regulatory hormones I could give him a huge dose of R and it still wouldn't bring it down? I thought in the hospital they could always bring it down (granted they're using those continuous infusion IV pumps they can dial up and down as needed... maybe I should price those out... feel like I'm at my wits end here). It sounds awful to have seizures for 9 hours, but in such a situation I'm only 5 minutes from an ER that could set him up on dextrose. His ketones build quickly, and he was half way to DKA and very lethargic this last hospitalization in under 24 hours in the 400s. I just can't afford these repeated hospitalizations, I'm probably down over $15k at this point. If we get to the point of another hospitalization, I'm probably going to have to make a very hard decision I really don't want to make. I'm going to check ketones on next check. Praying they're not through the roof :(

Theres so many "what ifs" and I'm already seeing him acting tired. I feel like I gotta do something.
 
John & Henry said:
Yeah, I've been thinking about that. My only concern is it may interfere if we were to give more R, but I really have no idea. I suppose the R could be given somewhere other than the shoulders. She prescribed 60ml of subQ fluids. Is that a standard amount?
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I have always done subQ in the flank. I think 60mL is fine
 
John & Henry said:
Thank you, that's very helpful. I'm thinking of the pre-hospitalization numbers where he was in the 400s but the 2U of Lantus didn't touch it. Are you saying with the counter regulatory hormones I could give him a huge dose of R and it still wouldn't bring it down? I thought in the hospital they could always bring it down (granted they're using those continuous infusion IV pumps they can dial up and down as needed... maybe I should price those out... feel like I'm at my wits end here). It sounds awful to have seizures for 9 hours, but in such a situation I'm only 5 minutes from an ER that could set him up on dextrose. His ketones build quickly, and he was half way to DKA and very lethargic this last hospitalization in under 24 hours in the 400s. I just can't afford these repeated hospitalizations, I'm probably down over $15k at this point. If we get to the point of another hospitalization, I'm probably going to have to make a very hard decision I really don't want to make. I'm going to check ketones on next check. Praying they're not through the roof :(

Theres so many "what ifs" and I'm already seeing him acting tired. I feel like I gotta do something.
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Deep breaths…

a few questions-
Is there an underlying infection/inflammation?
Has he lost weight?
 
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