Steroid-induced diabetes - 2nd day pre-shot lower than expected

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Bedina

Bedina

Member Since 2023
Hello,

I'm Bedina and it's been a tough week.

My 19 year old kitty, Babs, who has previously been very healthy (great six month bloodwork, good kidney function, normal blood glucose, regular acupuncture for arthritis, Wervua wet food diet) was diagnosed via ultrasound in early March with highly suspected GI lymphoma and pancreatitis after several weeks of vomiting, refusing food and water, and constipation (a biopsy was only mentioned after the ultrasound ended or I would have had one). She was put on 5mg prednisolone and weekly B12 shots, which had an almost immediate and positive effect - it was such a relief. By week three, she was clearly not feeling well and so I took in a urine sample. The vet had me come in for a blood test; her blood glucose was 372.

The vet told me her prognosis was poor and that outside of euthanasia, the only option she could think of was to try insulin. I don't want to make her suffer it out until the bitter end, but she's still been engaging and enjoying meals and attention and I wasn't prepared the make that call. We decided to try insulin (Vetsulin is what she had available) and she send me with a bs monitor (Alpha Trak2). This was Thursday afternoon into Friday morning, so it's very new. She put her on 1.5u (after reading this forum, I suspect that may be considered a somewhat higher starting dose).

Kitty is being a trooper about letting me check bs. I've so far checked before meals (still Weruva wet) and at the 6 hour mark (300s still before meals; 262 and 181 at 6 hour marks). Even with those readings, she does seem more comfortable and to be resting better.

I'm tapering the prednisolone and I'm here to try to learn how others have handled steroid-induced diabetes (including finding an alternative steroid). I've also been reading on meal timings as my girl has been getting numerous small meals through the day for years, and getting more than 50-75 calories in her at once is problematic.

Thank you all for what you share here.
 
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Welcome Bedina and Babs (such a cute name)!!!

It’s overwhelming at first but I promise you it gets better once you’re past the learning curve :bighug:

First of all, you can’t diagnose pancreatitis with an ultra sound alone. You need a specific pancreatitis blood test. Did they do that? It could be IBD instead and the ultra sound alone is not definitive. You could ask about budesonide which is a localized steroid that typically doesn’t affect the BG, but I leu if you’re not considering the biopsy.

there’s absolutely no reason to euthanize a cat simply because it’s diabetic. That’s horrifying to hear. They can live healthy lives once the diabetes is regulated. I’m so glad you opted for treatment. Now let’s talk about insulin. Vetsulin is also called caninsulin because it was created for canines who have a much slower metabolism than cats. With Vetsulin, you need to make sure she has food onboard at least 30 minutes before the shot because it’s a harsh insulin that hits fast. It’s also not long lasting so it doesn’t work a full 12 hours and your cat is unprotected after it wears off, so not the best insulin for cats I’m afraid. I’m also very happy you’re home testing that’s so important! Would you be able to set up a spreadsheet and add the numbers you’ve gotten so far?

With a diabetic cat you need

  • A low carb wet diet that is 10% carbs or under. Most of us use around 4-7% carbs
  • A suitable insulin such as Lantus or Prozinc which are long acting, more gentle insulins than the old insulins.
  • We recommend hometesting the blood glucose with a human meter…it is not necessary to use a pet meter which is expensive to run and is no better. It will keep your kitty safe and you will know how the dose is working for your kitty. Only testing every so often will not tell you what is happening in between those times and an awful lot can happen in even a day.
  • HELP US HELP YOU has information about the spreadsheet, signature and hypo box which you will need to be able to look after your beloved kitty properly
We are happy to help you with setting up the spreadsheet, sorting out what food to buy, how to transition safely to a low carb diet, how to learn to home test and much more.

This is an excellent site for diabetic cats…it has been around for more than 25 years and has very experienced people to help you.

Keep asking lots of questions.
 
You can try budesonide vice the pred. Budesonide works for IBD and may help with small-cell-intestinal lymphoma. The only real way to to differentiate the two is with a full thickness biopsy of the wall of the small intestine. The usual treatment for small-cell-intestinal lymphoma is pred and chlorambucil. The best dosing of chlorambucil seems to be pulse dosing (one large dose every two weeks) vice a smaller dose every other day or three times a week. Some vet will prescribe chlorambucil for IBD. My Mario did better on the pulse dosing and the oncologist would not prescribe pred. He was DXd with SCIL via full-thickness biopsy.I have used budesonide for several cats with suspected IBD or SCIL and it helped and did not appreciably raise BG/insulin needs.
 
Thank you for the kind welcome (and what a sweet photo!),

Thank you for the information about Vetsulin (and I was able to read here the 30 minute guideline, which I started implementing this am). I will ask about another insulin as well.

In fairness, I believe my doctor was a bit overwhelmed by the addition of diabetes to the mix (I didn't add that she also had surgery what we thought was a cyst removed two weeks ago which turned out to be carcinoma). I think her line of thinking was that it would be difficult for a cat of her age to successfully overcome a GIS mass, suspected pancreatitis (no, the blood-specific test was not run). When I indicated I wanted to try options, she was onboard.

I wish I had been offered the option of a biopsy at the time of the ultrasound. The doctor who performed it said "very likely GI lymphoma, second guess would be small cell, unlikely large cell, and pancreatitis". It's less the money and more of putting her through yet another ultrasound procedure at the moment, but I was also reading about budesonide as a possibility.

Regarding diet, I found Dr. Pierson's page ten years ago and transitioned to a lower-carb, wet diet (currently Weruva Trulux with some of the Weruva pate (one of the lower carbs) mixed in).

A question: if I do want to add in a small third or fourth wet meal to get in sufficient calories (and I think I'll have to), is there a preferred time? And is better to skip that smaller meal after the evening meal-with-insulin? I was considering the 6 hour mid-day mark.

EDIT: Possibly answering my own question by reading this very helpful thread.
https://felinediabetes.com/FDMB/threads/beginners-guide-to-caninsulin-vetsulin.231587/

EDIT 2: Started a spreadsheet. https://docs.google.com/spreadsheets/d/1yOwr0KEh0-Ri6uvMaH7rBkiLfuEhis5aERVymcanlSU/edit?usp=sharing
 
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Larry and Kitties said:
You can try budesonide vice the pred. Budesonide works for IBD and may help with small-cell-intestinal lymphoma. The only real way to to differentiate the two is with a full thickness biopsy of the wall of the small intestine. The usual treatment for small-cell-intestinal lymphoma is pred and chlorambucil. The best dosing of chlorambucil seems to be pulse dosing (one large dose every two weeks) vice a smaller dose every other day or three times a week. Some vet will prescribe chlorambucil for IBD. My Mario did better on the pulse dosing and the oncologist would not prescribe pred. He was DXd with SCIL via full-thickness biopsy.I have used budesonide for several cats with suspected IBD or SCIL and it helped and did not appreciably raise BG/insulin needs.
Click to expand...

Thank you. A friend (also a vet) suggested the budesonide. My primary vet responded "but we don't know what kind of cancer it is". My thought now is that we know the pred is problematic.

Again, a bit frustrated that the idea of a biopsy didn't come up while she was in for the ultrasound, and I didn't know enough at the time to ask for it (we did the ultrasound because I asked for it).
 
I was faced with a similar dilemma with Minnie towards the end and I opted to not do any more intrusive tests and to just treat the symptoms. Budesonide worked well for her for over 2 years and now her brother Bobo is also on it for his IBD.

the timing of the meals doesn’t really matter too much. Most of us feed the larger meals at shot time and then smaller meals or treats throughout the day. It’s important to withhold the food for at least 2 hours prior to the preshot tests so you get a bg that’s not influenced by food since you want to make sure it’s safe to shoot. After that, you can feed at any time since the smaller meals help avoid sugar spikes and are also easier on their pancreas. Minnie would eat at shot time then get a snack at +2 which is when Lantus starts working. Another snack at +6 and +9 then also something before I went to bed after the pm shot at around +2 again. I’d even feed her when I woke up in the middle of the night to go to the bathroom because I didn’t want her too long on an empty stomach because of the IBD
 
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Bedina said:
Thank you. A friend (also a vet) suggested the budesonide. My primary vet responded "but we don't know what kind of cancer it is". My thought now is that we know the pred is problematic.

Again, a bit frustrated that the idea of a biopsy didn't come up while she was in for the ultrasound, and I didn't know enough at the time to ask for it (we did the ultrasound because I asked for it).
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Did they put her under for the ultrasound? Or were they suggesting a needle cell biopsy extraction that doesn’t require anesthesia?
 
Ale & Minnie (GA) said:
Did they put her under for the ultrasound? Or were they suggesting a needle cell biopsy extraction that doesn’t require anesthesia?
Click to expand...

They did not put her under. I sedated her with gabapentin beforehand.

Now that you ask that, her blood pressure has read low in several recent procedures, including a cardio check prior to the surgery (where it also dropped).

This: I was faced with a similar dilemma with Minnie towards the end and I opted to not do any more intrusive tests and to just treat the symptoms. Budesonide worked well for her for over 2 years and now her brother Bobo is also on it for his IBD. makes good sense to me.

Can I also ask, as someone just starting out, how often to try to grab a bs reading? They're making my nervous but this is forum is making me realize I have to give things time (and today is really the first full day on our own). Her poor little white ears already look bad but she's being a good girl. She's asking for a small meal now. Should I check bs first?

https://docs.google.com/spreadsheets/d/1yOwr0KEh0-Ri6uvMaH7rBkiLfuEhis5aERVymcanlSU/edit?usp=sharing
 
You don’t have to check her bg every time you feed Only before the am and pm shots and those 2 meals. You want to test more than twice a day to try and catch the nadir, lowest point the insulin takes your cat in a 12-hour cycle since we dose by that nadir not the preshot numbers. It makes sense if you think about it. The preshot numbers are the highest but if you don’t know how low the dose is taking your cat you risk a life threatening hypo. It’s better to be high than too low. So we suggest in addition to the preshot tests, to try to get a +4,+5 or +6 but not all on one day. You alternate so maybe today you get a +6 then tomorrow you try for a +5 and overtime you’ll start to get a sense of when her nadir is happening.
 
It’s also good to try to get one more test before bedtime so you know how she’s going to do overnight. So you’re looking at about 4 tests a day on average. Do you need testing tips? We recommend always giving a treat immediately after each test to build positive association. You may also want to warm up the ear to make it easier getting a decent size droplet and alway sim for the sweet spot
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Thank you again. I'm really grateful.

As this was a +4 number, I grabbed it (179). Will update the spreadsheet and give her a small meal when she wakes (she at most got down 60 calories this am).
 
Bedina said:
They did not put her under. I sedated her with gabapentin beforehand.

Now that you ask that, her blood pressure has read low in several recent procedures, including a cardio check prior to the surgery (where it also dropped).

This: I was faced with a similar dilemma with Minnie towards the end and I opted to not do any more intrusive tests and to just treat the symptoms. Budesonide worked well for her for over 2 years and now her brother Bobo is also on it for his IBD. makes good sense to me.

Can I also ask, as someone just starting out, how often to try to grab a bs reading? They're making my nervous but this is forum is making me realize I have to give things time (and today is really the first full day on our own). Her poor little white ears already look bad but she's being a good girl. She's asking for a small meal now. Should I check bs first?

https://docs.google.com/spreadsheets/d/1yOwr0KEh0-Ri6uvMaH7rBkiLfuEhis5aERVymcanlSU/edit?usp=sharing
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And yes time is key. We like to say here that feline diabetes is a marathon not a sprint :bighug:
 
Set up and thank you.

I'm nervous over the pending drop, both possibly from the small meal she just had (35 calories) as the vet's strong advice of just two meals a day. Although I do feel better knowing how many people don't agree what that guidance.

Plan to inquire about Lantus when the vet opens next week.
 
Welcome to FDMB!

A couple of points for your consideration. Vetsulin is not a particularly good insulin for treating feline diabetes. It was developed for dogs. The American Animal Hospital Assn no longer recommends it for treating cat given its fast onset, harsh nature, and that it doesn't last the full 12-hours resulting in wide swings in numbers. Either Lantus (glargine) or Prozinc are recommended. The vet likely keeps it in stock because it is an insulin for animals.

It can be difficult to differentiate IBD from lymphoma based on an ultrasound. This is why a biopsy is the only way to get a definitive diagnosis. There are differences in the treatment of the two conditions. This link may be helpful. With IBD, you would want to be feeding Babs novel proteins.

If your cat does have pancreatitis, it needs to be diagnosed by a blood test -- either a Snap or Spec fPL. The Snap can be done in the vets office. It looks like a pregnancy test with either + or - results. The Spec is sent out to a lab. The issue with pancreatitis is that it's painful! You would want to get pain meds, such as buprenorphine, to help your cat be more comfortable. An ultrasound may indicate if there's inflammation but it's not definitive.

Especially with Vetsulin, I would not rely on 2 meals per day. Vetsulin can drop numbers hard and fast which is why you want to have food on board before you give a shot. I would likely want to feed my cat at +2 to buffer the impact of the insulin. Depending on how Babs responds to insulin, you may want to add another snack before nadir. As an example, I was a Lantus user and my cat had an early onset and nadir -- typically around +3. (Nadir with Lantus is typically around +6.) I fed her at pre-shot, +1, and +2 and depending on where her numbers were, +3. You can use food to steer the numbers.
 
I don’t think you’ll see a drop at all to be honest but let’s see what happens. There’s a lot of trial and error involved in treating feline diabetes and every cat is different (ECID) the more you test, the more knowledgeable you’ll become about Babs and how she reacts.

fyi, Lantus tends to be expensive here in the us so a lot of members buy the generic version and there are pharmacy coupons you can use to make it more affordable. Others like me, ordered it from Canada because it’s 1/3 of the cost there. Just some options for you so you’re not scared or discouraged by the price tag
 
Sienne and Gabby (GA) said:
Welcome to FDMB!

Especially with Vetsulin, I would not rely on 2 meals per day. Vetsulin can drop numbers hard and fast which is why you want to have food on board before you give a shot. I would likely want to feed my cat at +2 to buffer the impact of the insulin. Depending on how Babs responds to insulin, you may want to add another snack before nadir. As an example, I was a Lantus user and my cat had an early onset and nadir -- typically around +3. (Nadir with Lantus is typically around +6.) I fed her at pre-shot, +1, and +2 and depending on where her numbers were, +3. You can use food to steer the numbers.
Click to expand...

Thank you so much for the welcome and the information.

As of right now, she had breakfast (9:15) followed by a shot at 9:45 (late as yesterday's shot was at the vet at 10:10am; I'm trying to nudge the times up to accommodate work), a bs check at +4, and a small snack just after. I was considering a second small snack, primary to get in sufficient calories, at around 5 pm, then another bs check at 9/meal at 9:15/shot at 9:45. Do you think it's better with Vetsulin (which we're on at least through the weekend) to steer snacks earlier in the dosage, or am I overthinking too early?
 
I would probably lean toward snacks earlier in the cycle. Usually, you don't want to feed your cat all that much past nadir (i.e., the lowest point in the cycle). After nadir is when the effect of insulin starts wearing off. If you are feeding your cat past nadir, it's likely the food will cause numbers to rise.
 
It's about three hours until insulin. I can tell she's not feeling great; I think it's wearing off.

I hate this for her. I also hate that it's Tuesday until my vet is in the office.

Two thing I wondered that I haven't been able to find in the form:

1. If Vetsulin isn't long lasting, does anyone give it more frequently than twice a day? (I would assume the better option is a different insulin)
2. I'm going to ask about Lantus. As she will have been on Vetsulin four+ days by the time I can do that, is there a transition period, or because it leaves the system quickly, can I just start fresh so to speak?
 
I would be very reticent to give Vetsulin more than twice a day.

There's no transition period between Lantus and Vetsulin. The brand name Lantus is quite expensive in the US. It's now available as a generic or biosimilar (Semglee and Basaglar). The prices are much more reasonable. You can purchase it at Costco (you don't need to be a member to use their pharmacy) at a fraction of the cost.
 
This was unexpected.

I checked and it was 167. I rechecked (I was concerned I inadvertently contaminated the strip so I used a fresh strip but the same blood drop, as it was really welling up and I didn't want to poke her again) and got 196. Was that a screw up on my part?

I'm on the phone with a friend (who is diabetic) who suggested going ahead and feeding her, which I did. And now I'm kicking myself for doing that without asking here first what to do. The vet had advised dropping to 1/2 a unit if between 150-200, but that seems concerning - I don't want it to drop further and I see that 200 is the "no shoot" mark.

Is anyone still around who can give some guidance?

EDIT: I just re-checked (she's still eating) as I though I surely must have messed up. Fresh prick and I got a reading of 156. Knowing from my minimal records so far that it has dropped under 200 post shoot at least twice now, I am going to follow the "no shoot" guidance.
 
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I think that’s best especially overnight with Vetsulin. Typically the guidance here is to stall for 20 minutes and not feed but retest then. If numbers are higher then shoot but if not don’t. Let’s see where she is in the morning. Probably higher since you skipped but better high than too low. In the future if you need immediate dose or shoot advice, start a new thread titled something like shoot or not and list the bg value you got
 
Thank you again.

I have a question that possibly should be a new thread about timing.

I've been working my shot timing up in half hour increments (per the vet) to accommodate my work schedule. I wondered whether I can make a bigger shift in that after a skipped dosage (Sunday morning should be a test at 8:30/food 8:30-9, shot at 9 day.)

(I think it probably is a new thread, although I'll return here to report on her morning readings).
 
I went ahead and tested early.

OK, she was 337 this morning (I tested at 7:45) and she's eating now.

The doctor let me know that she gave her best estimate of at starting dosage at 1.5u. I'm trying to determine if I stay there or shoot somewhere between 1 and 1.5.

My known data is that she was at 377 yesterday morning, 179 at +4 and 156 BS check last night.

I know this may be bettering the Vetsulin forum but as following up here first.

EDIT: I dosed approximately 1.25, although the syringe made it difficult to see that. I'm slightly paranoid I got a fur shot although it wasn't wet so it may be paranoia. I'll check BS again (+1 or +2?) to verify.
 
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I apologize for the constant updates.

I clearly did not do a fur shot. 337 at morning; 179 at +2. I gave her a snack. I suspect from what I'm reading that 1.5U was too high a starting dose for Vetsulin. And you all warned me it would drop quickly.
 
You can move the time of the shots by 15 minute increments not more than that is recommended. 30 minutes is too much. Can you try 15 minutes at a time? But as Bron mentioned on the other thread, except after you skip a shot.

I think we need to see a few more days of data to be able to advise on the dose. The normal range you’re looking for is 80-120 so the fact you’re getting all those blues is a good thing right now. If she had been dropping under 90, I’d say you should reduce the dose but that’s not quite happening yet. I know it’s nerve wrecking seeing the big drops with Vetsulin so I think you’ll have a lot more peace of mind with Lantus.
 
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Thank you. I'm sorry if I'm updating in too many threads - I'm in a bit of panic right now and I'm kicking myself as my diabetic friend said to go lower on the dose and I was scared to.

Will continue with the other thread and update the subject unless you tell me too stay here.
 
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