? 5/1, Ivy, Dosing review requested, bouncy kitty

Staci & Ivy

Staci & Ivy

Member Since 2022
Updated 5/2/23
*My question is: Because she has different nadirs day/overnight, which is used to determine dosing?

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Hi everyone,
Ivy was diagnosed with diabetes in September 2022. (She also has CKD Stage 2, some anemia and IBD issues. I feed her a novel protein diet of lamb wet food (homemade recipe formulated by veterinarian, 6% carb). No dry food or treats. Single cat household.

Her vet increased her Lantus dose rather quickly from .5 units up to 4 units within one month. (sometimes a .5 unit or whole unit increase within a few days of the last dose). I think we may have possibly blown past a correct dose. We can’t seem to get her regulated.

She’s developed hind legs neuropathy (giving Zobaline for about 1.5 months and recently increased dose to 2x daily, not yet helping)

She had a dental procedure done February 20, 2023. I was hoping that would help with what seemed to be insulin resistance. She had an infected tooth and a few other teeth which were removed.

She was tested and Acromagaly test result was negative.

We had a Libre 2 CGM installed after dental procedure 2/20/23 (and I am now installing new one every 2 weeks a replacement to closely monitor her).

Within 10 days her am numbers began to drop sharply.

On day 11 post operation, March 3, 2023, she had a hypo situation (shown on Libre 2 CGM – not verified with blood test). Hypo was asymptomatic, I was alerted from the Libre.

We then greatly reduced her Lantus dosing and have been trying a dosing restart. Currently giving 2.25 units 2 times daily.

She seems to dip lower in the morning, sometimes after her am Lantus dose, usually drops in the later afternoon (nadir?) and tends to go lower overnight, early am hours.

When she dips lower (for her) she then bounces high up over 400 (high on Libre 2 is over 400).

I’m not sure if we are giving her too much or too little insulin with all of her bouncing.
Could someone please take a look at her trends and give some feedback from her spreadsheet? I appreciate your input!!
Sorry for the long post....many thanks! :)
 
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Hi @Staci & Ivy
Hi Stacy If you can tap on the blue link and give us the information that is asked for that would be great
You can just tap on your name above and then tap on the word signature and add the information that is asked when you tap on the blue link
Here is a link helping us to help you link. If you noticed, our members have some basic information about their cat's in their signature. This helps us to not pester you by asking the same questions (your cat's name, insulin type, date of diagnosis, etc.) repeatedly.
 
Any chance you would be willing to switch to TR? The neuropathy is due to high bg for a long time. You are holding dishes too long even with SLGS since the nadirs are over 150. Even when following SLGS that calls for an increase after 7 days. Way back you cut the dose in half and all that was needed was a .25 reduction. You do know that normal bg on a human meter is 50-100 roughly? Obviously with SLGS your goal is between 100-200 or so.
 
Diane Tyler's Mom said:
Hi @Staci & Ivy
Hi Stacy If you can tap on the blue link and give us the information that is asked for that would be great
You can just tap on your name above and then tap on the word signature and add the information that is asked when you tap on the blue link
Here is a link helping us to help you link. If you noticed, our members have some basic information about their cat's in their signature. This helps us to not pester you by asking the same questions (your cat's name, insulin type, date of diagnosis, etc.) repeatedly.
Click to expand...
Hi
Diane Tyler's Mom said:
Hi @Staci & Ivy
Hi Stacy If you can tap on the blue link and give us the information that is asked for that would be great
You can just tap on your name above and then tap on the word signature and add the information that is asked when you tap on the blue link
Here is a link helping us to help you link. If you noticed, our members have some basic information about their cat's in their signature. This helps us to not pester you by asking the same questions (your cat's name, insulin type, date of diagnosis, etc.) repeatedly.
Click to expand...
I just tried to update signature. I had saved her info in the information tab. (More detailed info there). Please let me know if it’s better now. Thank you.
 
tiffmaxee said:
Any chance you would be willing to switch to TR? The neuropathy is due to high bg for a long time. You are holding dishes too long even with SLGS since the nadirs are over 150. Even when following SLGS that calls for an increase after 7 days. Way back you cut the dose in half and all that was needed was a .25 reduction. You do know that normal bg on a human meter is 50-100 roughly? Obviously with SLGS your goal is between 100-200 or so.
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What would you suggest her dose should be now @tiffmaxee?
I’m very nervous with TR and she seems to try to go low and then bounces so high.
I was told neuropathy was due to being over 240 ( is it 150 then?)
 
Hello and welcome, the signature looks great.

Staci & Ivy said:
She was tested and Acromagaly test result was negative.
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What date was the blood drawn for this test? There is research that shows the test should be done a certain number of days after starting insulin, or you can get false positives. I'm not saying it's a possibility, but just want to make sure the test was valid. Was she also tested for IAA (insulin auto antibodies) at the same time? The blood for that test goes to the same place and is a cheap add on, that can eliminate another source of insulin resistance.

Have said what I did above, I think the dose reset you did in early March was not a correct approach. She did earn a reduction down to 3.75 units if following SLGS, but your notes say that may have been as a result of her dental surgery. Going back to 1.5 units has set her back. It's taking a long time, following SLGS, to get back close to the dose that moved her early March. Plus you did some fat and skinny dosing, when increases should be by 0.25 units. That also slowed down the increases and getting her closer to that dose that some some action before hand. And allowed some glucose toxicity to set it. It sound like something bad, but just means her body is getting used living in higher numbers, the solution to which is more insulin.

Staci & Ivy said:
I’m very nervous with TR and she seems to try to go low and then bounces so high.
Click to expand...
Bounces are a perfectly normal (but annoying to us) thing that happens in cats. Almost all cats bounce in the beginning, some don't stop bouncing. Plus, she isn't going very low at all, just upper blues. People who have been using the Libre find that the the Libre lows do need to be double checked with a hand held meter, as the Libre can read lower than the meter does. Meaning, she might not have earned that reduction if checked by a BG meter. Also, bounces happen regardless of dosing method you follow.

Bottom line, none of the data you have so far shows that her dose is too high. I rather suspect it's still quite a bit lower than it needs to be. 4 units is not a high dose, if that's what she needs. My recommendation is to at least try TR until she gets into better numbers. If that just doesn't work for you, follow SLGS as written, full 0.25 unit increases every 7 days, until her nadirs (plural) are in the 90-149 range.
 
Wendy&Neko said:
Hello and welcome, the signature looks great.


What date was the blood drawn for this test? There is research that shows the test should be done a certain number of days after starting insulin, or you can get false positives. I'm not saying it's a possibility, but just want to make sure the test was valid. Was she also tested for IAA (insulin auto antibodies) at the same time? The blood for that test goes to the same place and is a cheap add on, that can eliminate another source of insulin resistance.

Have said what I did above, I think the dose reset you did in early March was not a correct approach. She did earn a reduction down to 3.75 units if following SLGS, but your notes say that may have been as a result of her dental surgery. Going back to 1.5 units has set her back. It's taking a long time, following SLGS, to get back close to the dose that moved her early March. Plus you did some fat and skinny dosing, when increases should be by 0.25 units. That also slowed down the increases and getting her closer to that dose that some some action before hand. And allowed some glucose toxicity to set it. It sound like something bad, but just means her body is getting used living in higher numbers, the solution to which is more insulin.


Bounces are a perfectly normal (but annoying to us) thing that happens in cats. Almost all cats bounce in the beginning, some don't stop bouncing. Plus, she isn't going very low at all, just upper blues. People who have been using the Libre find that the the Libre lows do need to be double checked with a hand held meter, as the Libre can read lower than the meter does. Meaning, she might not have earned that reduction if checked by a BG meter. Also, bounces happen regardless of dosing method you follow.

Bottom line, none of the data you have so far shows that her dose is too high. I rather suspect it's still quite a bit lower than it needs to be. 4 units is not a high dose, if that's what she needs. My recommendation is to at least try TR until she gets into better numbers. If that just doesn't work for you, follow SLGS as written, full 0.25 unit increases every 7 days, until her nadirs (plural) are in the 90-149 range.
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Thank you @Wendy&Neko and @tiffmaxee
I am willing to try TR with Ivy. Would you suggest I increase her dose to 2.50 units and then increase .25 every 3 or 5 days based on her Nadirs? Am I understanding the method correctly?
I’m still unclear when she hits her nadir as it seems different every day.
Some days she’s in the 200s and some days in 300s later afternoon +6-8 hours
Overnight she drops to from upper 180s-250s late in her cycle.
So I’m unsure what to call her nadir. Can you clarify?

Her test for acromegaly was done late January 2023, 3-4 months after diagnosis. Unfortunately they didn’t do the antibody test at the same time. Do you think that was too soon for the test to be done?
 
tiffmaxee said:
Hold the dose for at least 6 cycles. If you get blue or green nadirs then hold 10 cycles and see the nadirs.
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What would I then increase her dose to after 6 cycles/3 days?
I’m still unclear when she hits her nadir as it seems different every day.
Some days she’s in the 200s and some days in 300s later afternoon +6-8 hours
Overnight she drops to from upper 180s-250s late in her cycle.
I’m unsure what to call her nadir. Can you clarify? @tiffmaxee
 
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Actually increase to 2.5.
Increasing the dose:
  • 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.
 
Staci & Ivy said:
Her test for acromegaly was done late January 2023, 3-4 months after diagnosis. Unfortunately they didn’t do the antibody test at the same time. Do you think that was too soon for the test to be done?
Click to expand...
You should be good on the acro test, you want to wait at least 73 days after starting insulin before doing the test. So the test time was fine.

I agree with Elise (tiffmaxee), I'd increase to 2.5 units now.
Staci & Ivy said:
I’m unsure what to call her nadir. Can you clarify?
Click to expand...
Nadir is the lowest point of the cycle. It can change around, not all cats nadir at the same time every cycle. If breaking a bounce, the nadir can be later. As the dose gets closer to a good one, it'll be easier to spot Ivy's typical nadir time.
 
Wendy&Neko said:
You should be good on the acro test, you want to wait at least 73 days after starting insulin before doing the test. So the test time was fine.

I agree with Elise (tiffmaxee), I'd increase to 2.5 units now.

Nadir is the lowest point of the cycle. It can change around, not all cats nadir at the same time every cycle. If breaking a bounce, the nadir can be later. As the dose gets closer to a good one, it'll be easier to spot Ivy's typical nadir time.
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Ok, so we will go to 2.5 units.
If she is under 200 overnight, do we use that low as her nadir? she tends to drop lower overnight. Please advise. @tiffmaxee @Wendy&Neko
 
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Staci & Ivy said:
Hi

I just tried to update signature. I had saved her info in the information tab. (More detailed info there). Please let me know if it’s better now. Thank you.
Click to expand...
Hi Stacy looks good, if you can put
phosphorus binder 2x daily that would be good.
A lot of members don't look at the information tab that's why we ask you to put it in your signature . If you are switching to TR you can add that to your signature also and on your spreadsheet where you have SLGS just put TR as of then the date
If you can put a blank line above the date you intend to start TR just type Switched to TR and highlight that line so members are aware of it :cat:
@Staci & Ivy
 
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Diane Tyler's Mom said:
Hi Stacy looks good, if you can put
phosphorus binder 2x daily that would be good.
A lot of members don't look at the information tab that's why we ask you to put it in your signature . If you are switching to TR you can add that to your signature also and on your spreadsheet where you have SLGS just put TR as of then the date
If you can put a blank line above the date you intend to start TR just type Switched to TR and highlight that line so members are aware of it :cat:
@Staci & Ivy
Click to expand...
Ok sounds good, thanks @Diane Tyler's Mom
 
@Staci & Ivy
Hi Stacy this is just a suggestion , I see you use the Alpha Trak 2 as a back up.
Would you consider using the Relion Premier Classic human meter from Walmart?
Our numbers are based on human meters anyway.
I know how expensive the strips for the Alpha Trak is
You can pick everything up from Walmart The Relion Premier Classic meter and test strips or even order on line

https://www.walmart.com/ip/ReliOn-Premier-CLASSIC-Blood-Glucose-Monitoring-System/552134103. 9 dollars

https://www.walmart.com/ip/ReliOn-Premier-Blood-Glucose-Test-Strips-100-Count/575088197. 17.88 for 100
 
tiffmaxee said:
On this forum we ask you to start a new thread each day you post. The nadir is the lowest point in each cycle. We look for trends. It doesn’t matter if it’s 200 or 250. Same range. Meter variance is 20% as well.
https://felinediabetes.com/FDMB/threads/posting-guidelines-please-read.231511/
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Yes, I understand the nadir is the low.
*My question is: Because she has different nadirs day/overnight, which is used to determine dosing?

If in the overnight cycle her nadir is in the higher 100s, is that her nadir which I base dosing around?
(Afternoon values tend to be higher than overnight for her)
Sorry, I think I am hung up on technicalities, but I want to be as prepared as possible.

(I tried the Relion Premier Classic and always got errors (think it required much more blood than AT2). I bought a Contour Next and will use that. (Will add to my spreadsheet.)
 
@Staci & Ivy
This is from the TR Method
Increasing the dose:
  • 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.
Reducing the dose:

The TR Protocol is an aggressive method in itself. The modified version of the protocol is slightly more aggressive. Let's keep all our kitties in the Lantus, Levemir, & Biosimilars ISG safe by taking reductions when appropriate.
  • If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 units

Your kitty is still considered newly diagnosed since Ivy was diagnosed on 9/21-2022 . After a year they are considered a long term diabetic

Any time Ivy would drop under 50 at any time of the cycle you would reduce by 0.25 unit

Going to tag Elise to be sure I gave you the correct information
@tiffmaxee
 
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You would use whichever is the lower nadir. Cats often drop lower at night. So far the nadirs are all within range of each other, between 251-296. If that continues you would increase by .25 whether the lowest nadir is anywhere between 200-300.
 
Saw you're adding Zobaline; B12 (methylcobalmin form) can help with the neuropathy, as I'm sure you're aware.

I'm using the Vitacost methylcobalamin capsules that are listed on http://felinecrf.org/vitamin_b.htm#methylcobalamin (product is https://www.vitacost.com/vitacost-vitamin-b-12-methylcobalamin-500-mcg-300-capsules ).

I peaked at your cat's labs, and it looks like the phosphorus is getting too high. The "normal" range on lab tests includes the normal range for kittens, which is too high for adult cats.

Edit to add: Saw on the information page you are giving a phosphorus binder. Usually phosphorus issues don't show up until later stages of kidney disease; I'm surprised they're showing up so early. From your cat's creatinine levels, it seems to be in stage 1 (=normal creatinine), based on your lab's normal range, and the IRIS guidelines. High phosphorus can be caused by problems other than kidney disease.​

The IRIS guidelines (http://www.iris-kidney.com/pdf/IRIS_Pocket_Guide_to_CKD.pdf) for stage 1 & 2 kidney disease say "Keep phosphorus <4.6 mg/dL (<1.5 mmol/L)". See also https://www.felinecrf.org/phosphorus.htm​

Low potassium, which is a problem with kidney cats, or high phosphorus, can also create symptoms that look somewhat like diabetic neuropathy. From your cat's past labs, the potassium looks ok, but you don't have a recent lab result for potassium posted. If you get lab results that show low potassium, powdered Renal K+ is an options for a supplement (also discussed on the felinecrf.org web site).

Also saw your cat has anemia per your Signature (although from the lab results, it looks like it's in the very low end of normal). The felinecrf.org site has good information on anemia, potassium, and phosphorus relative to kidney disease.
 
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LauraZZ said:
Saw you're adding Zobaline; B12 (methylcobalmin form) can help with the neuropathy, as I'm sure you're aware.

I'm using the Vitacost methylcobalamin capsules that are listed on http://felinecrf.org/vitamin_b.htm#methylcobalamin (product is https://www.vitacost.com/vitacost-vitamin-b-12-methylcobalamin-500-mcg-300-capsules ).

I peaked at your cat's labs, and it looks like the phosphorus is getting too high. The "normal" range on lab tests includes the normal range for kittens, which is too high for adult cats.

Edit to add: Saw on the information page you are giving a phosphorus binder. Usually phosphorus issues don't show up until later stages of kidney disease; I'm surprised they're showing up so early. From your cat's creatinine levels, it seems to be in stage 1 (=normal creatinine), based on your lab's normal range, and the IRIS guidelines. High phosphorus can be caused by problems other than kidney disease.​

The IRIS guidelines (http://www.iris-kidney.com/pdf/IRIS_Pocket_Guide_to_CKD.pdf) for stage 1 & 2 kidney disease say "Keep phosphorus <4.6 mg/dL (<1.5 mmol/L)". See also https://www.felinecrf.org/phosphorus.htm​

Low potassium, which is a problem with kidney cats, or high phosphorus, can also create symptoms that look somewhat like diabetic neuropathy. From your cat's past labs, the potassium looks ok, but you don't have a recent lab result for potassium posted. If you get lab results that show low potassium, powdered Renal K+ is an options for a supplement (also discussed on the felinecrf.org web site).

Also saw your cat has anemia per your Signature (although from the lab results, it looks like it's in the very low end of normal). The felinecrf.org site has good information on anemia, potassium, and phosphorus relative to kidney disease.
Click to expand...

Thanks for your helpful comments, @LauraZZ we have a follow up appointment with the internal med department later this month and we will be checking those phosphorus (and more) levels. We were aware they were elevated in February, when her dental was done. We will check all values later this month to see what's going on.
She's been watched for kidney issues for about 5 years, discovered when she had a prior dental done. Been on phos binders for many years.
So much to consider :(
 
Staci & Ivy said:
Thanks for your helpful comments, @LauraZZ we have a follow up appointment with the internal med department later this month and we will be checking those phosphorus (and more) levels. We were aware they were elevated in February, when her dental was done. We will check all values later this month to see what's going on.
She's been watched for kidney issues for about 5 years, discovered when she had a prior dental done. Been on phos binders for many years.
So much to consider :(
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Glad you're going to get labs done the end of the month, if the HCT is still low ask them what are they going to do for the anemia
 
If Ivy has neuropathy this is what I gave Tyler
It's a capsule just open it and sprinkle it on her food
Vitacost. 14.49 for 100 capsules
Just sprinkle it on the wet food always add water to the wet food
One per day

https://www.vitacost.com/vitacost-vitamin-b-12-methylcobalamin-5000-mcg-100-capsules-6


The Zobaline is crazy expensive for 60 tablets it's also 3000 MCG
Even though the Vitacost is 5000 mcg they will pee the rest out , it's water soluble
 
Diane Tyler's Mom said:
If Ivy has neuropathy this is what I gave Tyler
It's a capsule just open it and sprinkle it on her food
Vitacost. 14.49 for 100 capsules
Just sprinkle it on the wet food always add water to the wet food
One per day

https://www.vitacost.com/vitacost-vitamin-b-12-methylcobalamin-5000-mcg-100-capsules-6


The Zobaline is crazy expensive for 60 tablets it's also 3000 MCG
Even though the Vitacost is 5000 mcg they will pee the rest out , it's water soluble
Click to expand...
I know the cost is crazy for Zobaline @Diane Tyler's Mom My nutritionist suggested using it so I followed her recommendation. But something to consider using the Vitacost product. So far it’s not helped her. We need to bring her bg down
 
Staci & Ivy said:
I know the cost is crazy for Zobaline @Diane Tyler's Mom My nutritionist suggested using it so I followed her recommendation. But something to consider using the Vitacost product. So far it’s not helped her. We need to bring her bg down
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Yes exactly once you get her regulated it will help.
Tyler had it and I saw an improvement I would say every 2 weeks or less.
Around a month and a half he was jumping and running again .
A lot of members here use the Vitacost brand.
That's great your nutritionist knew about it :cat:
By the way Ivy is adorable, she looks so nice and fluffy
 
Diane Tyler's Mom said:
Yes exactly once you get her regulated it will help.
Tyler had it and I saw an improvement I would say every 2 weeks or less.
Around a month and a half he was jumping and running again .
A lot of members here use the Vitacost brand.
That's great your nutritionist knew about it :cat:
By the way Ivy is adorable, she looks so nice and fluffy
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I’m so glad it helped Tyler so quickly @Diane Tyler's Mom
I really hope we can get Ivy regulated already and that the Zobaline will help as well with the neuropathy. It’s heartbreaking watching them struggle to walk.
The thing with Vitacost was that my nutritionist felt it was too high a dose, so why over medicate (and didn’t have the folate in it as Zobaline does). So she felt it best to just use Zobaline.
We shall see what happens. I just hope it helps in time and we reduce her numbers safely.
Ivy is so sweet and fluffy. She’s a real beauty, thank you
I really appreciate all the support of you and this group.
 
Hi @Staci & Ivy It is heartbreaking watching them struggle to walk, I know.
I was using the Zobaline in the beginning until a member here told me about the Vitacost brand. So what I did was by folate tablets 400 mcg and cut then in half so they would equal 200 mcg the same amount that was in the Zobaline and crush them up and add them to the food also.
Some members didn't even add the folate and it still helped.
After awhile I stopped adding the folate also.
I only switched because of the price.
You just have to be patient , believe me if I didn't take the advice from the experienced members here giving me advice Tyler wouldn't be in remission today since 1-24-21.
 
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Diane Tyler's Mom said:
Hi @Staci & Ivy It is heartbreaking watching them struggle to walk, I know.
I was using the Zobaline in the beginning until a member here told me about the Vitacost brand. So what I did was by folate tablets 400 mcg and cut then in half so they would equal 200 mcg the same amount that was in the Zobaline and crush them up and add them to the food also.
Some members didn't even add the folate and it still helped.
After awhile I stopped adding the folate also.
I only switched because of the price.
You just have to be patient , believe me if I didn't take the advice from the experienced members here giving me advice Tyler wouldn't be in remission today since 1-24-21.
Click to expand...
Great ideas and advice
Best endorsement ever for this group of kind, caring, giving cat lovers
 
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