Rain - Old/Returning Member, Flirting with Remission, Need Some Guidance

[Wulfwin]

Hello everyone!

I've been on FDMB a couple times before, once with Jason (GA) and with Rain back in 2016. I'm back again with Rain and looking for some guidance on what to do with her.

Quick rundown on Rain: 15 year old female gray DSH (her pic is my avatar). She's a steroid-induced diabetic. 1st bout was in 2016 following a steroid shot for asthma. She was treated with ProZinc and went OTJ after 1 month, plus diet change to LC wet food and pancreatitis treatment. She was OTJ until 1/14/23 when she was hospitalized for DKA (she had been started on Budesonide, a steroid, for suspected IBD August 2022; I was checking BG and fructosamine initially but I got complacent and didn't continue checking). She had a very difficult 7-10 days (in addition to the DKA hospitalization, she required a blood transfusion for severe anemia and then had a severe asthma flare up also requiring hospitalization). However, she's been doing really well and stable since mid-February.

We initially started her on Lantus 1 unit BID, but that was dropped to 1/2 unit BID in mid-February. I have primarily used a FreeStyle Libre 2 sensor for the first month and a half due to the severe anemia and also because Rain's ears are fairly sensitive due to allergies.

Rain was having some dental symptoms and had her first dental last week (5/3/23), in which she had 9 extractions and an inflammatory mass removed. She struggled some after and did have to have extended pain medication. I had a new FreeStyle Libre put on the day after the dental since I know dental disease can impact her glucose. She does still need 2 more teeth removed (I opted to only do one side of her mouth at a time).

Here's where I need some guidance. Rain's flirting with going OTJ as far as I can tell, and I've had to skip insulin a number of times since the dental (a few times due to her not eating, but mostly due to her numbers). I had been giving her 1/2 unit so long as her pre-shot number was above 100. I've reduced the dose the last 2 times I gave it to about 1/4 unit, as best I could eyeball it.

Should I do a OTJ trial? Try to reduce the dose further?

I'm mostly using the raw data of the FreeStyle Libre (which is what's in the spreadsheet) instead of the scans since those seem to be more inaccurate the lower her numbers are. I also picked up a ReliOn Premier Classic to confirm numbers as needed. Rain is running higher than the last time she went OTJ but she is on an oral steroid still (Budesonide) so that doesn't seem surprising. In the raw data she's mostly between 50-120, with occasional 130s (typically 4-5 hours after she gets her Budesonide dose in the AM).

Hopefully most of that made sense. Thanks to anyone who has any recommendations/insights.

 

[tiffmaxee]

She’s seeing too many bg readings over 100. As a long term diabetic a reduction is earned by dropping under 40 or a week all green. I’m not sure why you have skipped when under 100. That’s safe to shoot. You could try shooting 0.10 rather than skipping. I’ll link a few things for you to read.

 

[tiffmaxee]

 

[tiffmaxee]

https://www.felinediabetes.com/FDMB...ng-reductions-and-starting-otj-trials.150160/

 

[Wulfwin]

She’s seeing too many bg readings over 100. As a long term diabetic a reduction is earned by dropping under 40 or a week all green. I’m not sure why you have skipped when under 100. That’s safe to shoot. You could try shooting 0.10 rather than skipping. I’ll link a few things for you to read.

Is she considered a long term diabetic? I guess I misunderstood - I thought since she started back on insulin in January this year (and was only on insulin for a month previously in 2016) she would be considered more of a newly diagnosed cat.

I've admittedly probably been more gun shy since her dental than necessary. We had a couple days where she was struggling and the FreeStyle Libre scans seem to err on the side of going low with drops. I've only in the last few days really taken a dive into the difference between the scanned number and the raw data numbers. The spreadsheet I filled in over the last few days with the raw data numbers, but before that I was going off the scanned numbers which can be a bit off from the raw number. The reader also has a low glucose alarm but the lowest number you can set it to is 60, so I've been getting quite a few alarms and last night it scanned at 43 at PMPS+7 (the closest raw data point was 56). So I'm sure the sheer number of alarms I've been getting has made me nervous as well.

I also haven't had a lot of flexibility in my schedule lately and today my foster cat who was declining (took him to the emergency vet just about right after I posted, and only got home a little bit ago), so I've been more hesitant about things when I wouldn't be able to monitor or delay a shot.

Basically, I've probably been nervous and gun shy with her since the dental. Sorry for the rambling word salad, I'm rather tired after the emergency vet visit.

Thanks for the link and the 0.1 unit image, that's extremely helpful!

 

[Sienne and Gabby (GA)]

One other consideration is that anesthesia can lower BG numbers. Given the number of extractions, I'm guessing that Rain was anesthetized for a while. The drugs should be out of her system by now but it can take some cats a couple of days to work the meds out of their system.

In general, with Lantus you can shoot low numbers. There are considerations (e.g., are you going to be home to monitor) but it's not unusual to give a shot as long as pre-shot numbers are over 50. If you've not shot low, Elise's suggestion of dropping the dose to 0.1u is worth considering.

One other thought... I'm wondering whether you give a snack around the time you're giving the budesonide? Since you're thinking it's the steroid which is bumping up the numbers, I wonder if a bit of food may help to stimulate Rain's pancreas which would help to lower the numbers. It may be worth experimenting to see if that works.

 

[tiffmaxee]

My bad. She’s long term because she was first diagnosed in 2016. Once a diabetic, always a diabetic. She was a diet controlled diabetic until she came out of remission.

 

[Wulfwin]

One other consideration is that anesthesia can lower BG numbers. Given the number of extractions, I'm guessing that Rain was anesthetized for a while. The drugs should be out of her system by now but it can take some cats a couple of days to work the meds out of their system.

In general, with Lantus you can shoot low numbers. There are considerations (e.g., are you going to be home to monitor) but it's not unusual to give a shot as long as pre-shot numbers are over 50. If you've not shot low, Elise's suggestion of dropping the dose to 0.1u is worth considering.

One other thought... I'm wondering whether you give a snack around the time you're giving the budesonide? Since you're thinking it's the steroid which is bumping up the numbers, I wonder if a bit of food may help to stimulate Rain's pancreas which would help to lower the numbers. It may be worth experimenting to see if that works.

I'm probably having a hard time adjusting to shooting low numbers, especially if I'm not home to monitor her. The last time she was on ProZinc.

She gets the Budesonide at the same time as her AM insulin so she's fed at that time. She's more of a grazer, but she typically gets fed/fresh food four times a day (AM shot time, early afternoon, PM shot time, and before I go to bed). There just seems to be a fairly consistent pattern of her numbers rising about 4-5 hours after she gets the Budesonide, and it's only given in the AM.

 

[Wulfwin]

My bad. She’s long term because she was first diagnosed in 2016. Once a diabetic, always a diabetic. She was a diet controlled diabetic until she came out of remission.

Ah, that makes sense! Thanks for the clarification!