Evie's Updates

[AliceL]

ORIGINAL THREAD: https://www.felinediabetes.com/FDMB/threads/newbie-member-alice-kitty-evie.277439/#post-3073412

Onsior is only labeled for use for a maximum of three days, with doses given once every 24 hours. I would be careful about giving her that every day indefinitely. It can harm her kidneys. If she’s on NSAIDS daily, regardless of the type, you should get regular kidney bloodwork done. She might be better off on low dose Metacam (Meloxicam) although I can hardly believe I am saying that because I hate Metacam and in the is there is a “black box” warning about Metacam causing kidney failure in cats. — but in Europe and Australia I know that it is used in low doses for pain in cats. I ve had cats with severe stomatitis that needed all teeth removed (well actually they left the canines in) and they did much better and didn’t need any meds. I know you are between a “rock and a hard place” with Evie and her mouth problems/pain and that you are trying to do the best for her.

@Suzanne & Darcy I will chat to my vet about this. The vet put her on a 6-day Onsior test run because she said it's a lot safer to use long term but last thing I want is to have to deal with is kidney issues. Currently she has no kidney problems - they checked when she was diagnosed. I will add her blood results to her spreadsheet.

Before you moved to Portugal, where did you live?

South Africa! Evie is a little African cat. I'm South African/British/Portuguese mix so we had the option of moving to either the UK or Portugal when deciding to emigrate. Hubby really wanted Portugal so here we are, but now with Evie's diagnosis I kinda wish we had gone to the UK, it would have made life a lot easier in terms of food, support, vets etc.

I see you put a pic up of Evie, she is so adorable

@Diane Tyler's Mom She really is! Even though she is really skinny right now, she still makes all the vet techs ooo and ahhh over how cute she is

 

[AliceL]

I'm really perplexed by Evie's BG results the last few sessions. The insulin doesn't seem to be working as well as it did initially and she has higher than before AMPS readings, surely her starting point readings should be declining slowly over time? Her nadir has shortened and the curve doesnt appear to be lasting as long, I read somewhere that the insulin curve eventually flattens out so not sure if this is to be expected....does the body get used to the dose? She is definitely putting on weight, I'm not sure how much but it is noticeable - perhaps her insulin is less effective because basically she is a heavier cat, ie needs more insulin now. I am still unable to get the correct syringes right now but would I be able to increase Evie's dose to from 0.8U to 1.6U safely? This would be the next line in the 100 syringe. Or maybe even experiment with placing the plunger at different points between the lines?

I've also noticed a few other things. She started having a drink of water once in the morning the last 3 days - its not excessive by any means - but since switching to the wet food in April Evie hasn't drunk any water at all so I'm worried if this a sign of increasing diabetic symptoms or not. She also has not had her usual voracious appetite, she is still eating but she doesn't manage to finish her food in one go. Usually she'll lick the bowl clean in 15 minutes but the last few days she takes longer to eat and is leaves around 1/4 of the portion in the bowl to revisit later. A couple days ago we changed her pain med so I'm not sure if this partial loss of food interest means she has more pain or if it's a diabetic symptom. She isn't shaking her head more than usual. I've also noticed her skin at the scruff doesn't pull up so easily as it used to - vet told me that was a sign of dehydration to watch for - but then again she has gained weight so perhaps she is just starting to fill out. I know all of these things are also indications of DKA so I'm really worried trying to figure out what is going on.

It's so frustrating trying to keep track of symptoms with Evie also having stomatitis. Hopefully we can get that surgery done soon.

 

[AliceL]

Ok, scratch that, I think she is drinking much more water today. She just asked my husband for water from the bathroom basin, 5 mins later went back to her water bowl for another drink. That is not usual for Evie.

 

[Shelley & Jess]

I am still unable to get the correct syringes right now but would I be able to increase Evie's dose to from 0.8U to 1.6U safely? This would be the next line in the 100 syringe.

No, that would be too much of an increase/doubling the dose.

I know you were/are on a mission to find U40 syringes. Another option if U40's are unavailable - can you get .3ml or .5ml capacity U100 syringes with half unit markings? If those are available locally that would make it easier to measure using the conversion chart for administering U40 insulin with U100 syringes

 

[Suzanne & Darcy]

The excessive drinking could be the Onsior if that’s the only new medication that she’s been on. I would suspect it. Her BG numbers haven’t gone up enough to make me think that it’s because of that. As for DKA, if any concerns, please test for ketones to make sure. If ketones are present more than a trace, it’s a concern.

 

[AliceL]

I know you were/are on a mission to find U40 syringes. Another option if U40's are unavailable - can you get .3ml or .5ml capacity U100 syringes with half unit markings? If those are available locally that would make it easier to measure using the conversion chart for administering U40 insulin with U100 syringes

I'm close to solving this problem. Today I got 10x u100/0.5ml syringes special order and the pharmacy said I must come back tomorrow to collect 10x u100/0.3ml syringes. If they are ok, they will order a huge box of 200pcs for me to arrive in another day or two. They are not the u40 syringe but at least the measurements between lines will be better!

@Suzanne & Darcy on that note, Evie has done a turnaround today where the insulin seemed to be stalling a bit the last few days but now it seems 'reactivated'. Her nadir was over +6 today and she is at the lowest evening pre shot number we've ever had at 201. Do you think it's ok to give her insulin on this number? She has just eaten a meal. I'm always more worried at night when I can't watch her as closely (I pass out due to my own meds)

 

[Suzanne & Darcy]

Are you still there?

 

[AliceL]

Yes

 

[Suzanne & Darcy]

On May 14, you shot a 207, which is essentially the same number as tonight. Can you retest 30 minutes from the 207 test? Or will she let you? I assume you have not fed her yet because if you have gone ahead and fed her we won't be able to tell.

 

[Suzanne & Darcy]

She has just eaten a meal. I'm always more worried at night when I can't watch her as closely (I pass out due to my own meds)

OH sorry. I see that she's eaten already. No worries

 

[Suzanne & Darcy]

So the question I have is, how late can you stay up with her? How long? If you really cannot monitor her, then maybe it would be best to shoot a reduced dose and let her go a little higher. It does look like she was kind of perhaps bouncing a little and today (six cycles later) she started responding to the insulin a bit better.

 

[AliceL]

I actually did feed her as a reward for the test.
In hindsight I maybe shouldn't have but I'm still not clear on how to proceed exactly when she is close to 200.
I re-tested her 15mins after eating on advice of the Facebook group. Her second test was 280 from 201 so I gave her the shot.
I know this could just be from the meal so I will definitely watch her carefully tonight - I won't take my sleep meds.

What are the exact steps I should do when she is 200 at pre shot time?

 

[Suzanne & Darcy]

When you have a low preshot number, an option is to stall without giving them any food and then to retest in 30 more minutes or so and see if their BG is rising on its own (without food.) That's just for another time if this happens and you want to try it.

 

[Suzanne & Darcy]

You can give her a small treat at test time, like a freeze dried pure bites treat (which has pretty much zero carbs.) I know you've been working on getting her to cooperate at test time so that's okay. I understand. Right now, we do want to keep her happy with pleasant associations at test time.

 

[Suzanne & Darcy]

So you already gave the shot? Okay. Well, I do not want you to worry. Just monitor her like you normally would. I do think she's going to be okay with the shot and that you have nothing to worry about, but if you were going to be asleep, then I would not have felt comfortable if you were not able to get a few tests in before you do go to sleep.

 

[Suzanne & Darcy]

This is a good opportunity to see how she will respond at this dose with the preshot of around 200. Then the next time it happens, you will know if it's okay to just give the full dose or whether you need to give a reduced dose for that cycle.

 

[AliceL]

That's just for another time if this happens and you want to try it.

Ok thanks, I'll definitely do that next time.
It was a bit of a panic situation today because I was out hunting down those syringes and came home right at shot time and didn't want to be too late with the next cycle.
I test, then feed, then shoot insulin...all usually within 20 minutes.
I put down her food and then looked at the number which was 201....by that time she was halfway finished wolfing down her food.
Thanks for your help!

 

[Suzanne & Darcy]

You did

Ok thanks, I'll definitely do that next time.
It was a bit of a panic situation today because I was out hunting down those syringes and came home right at shot time and didn't want to be too late with the next cycle.
I test, then feed, then shoot insulin...all usually within 20 minutes.
I put down her food and then looked at the number which was 201....by that time she was halfway finished wolfing down her food.
Thanks for your help![/QUOTE
You did just fine. She is going to be okay.
Which FB group are you on for feline diabetes?

 

[AliceL]

You can give her a small treat at test time, like a freeze dried pure bites treat (which has pretty much zero carbs.) I know you've been working on getting her to cooperate at test time so that's okay. I understand. Right now, we do want to keep her happy with pleasant associations at test time.

I usually do but was running late today and had no more test treats left. I usually do small pieces of plain boiled chicken as treat because getting low carb treats in Portugal is another level of difficulty to overcome.

So you already gave the shot? Okay. Well, I do not want you to worry. Just monitor her like you normally would. I do think she's going to be okay with the shot and that you have nothing to worry about, but if you were going to be asleep, then I would not have felt comfortable if you were not able to get a few tests in before you do go to sleep.

Will 100% monitor her tonight until +6 at the very least, even if I have to set alarms.
I have my own complicated relationship with sleep that I need to figure out how to work around when it comes to Evie's testing. I take sleep aids, if I don't I can get terrible insomnia which further exacerbates generalised anxiety so sleep is important for my mental wellness.
However Evie comes first above my sleep needs obviously. How do other people do this? I'm sure this is going to happen a lot more in future if she heads towards remission.

This is a good opportunity to see how she will respond at this dose with the preshot of around 200. Then the next time it happens, you will know if it's okay to just give the full dose or whether you need to give a reduced dose for that cycle.

She has had an unusual day in terms of BG readings so this will be interesting to see.

I am on the Facebook group for this forum.....apparently? You are making me think twice now.

Thank you so much once again.

 

[AliceL]

this one

 

[Suzanne & Darcy]

I love that photo of her. She's just the cutest little cat!

 

[Suzanne & Darcy]

this one

Yes. That's the one affiliated with this group.

 

[Suzanne & Darcy]

I will check up on her in a few hours or so. It's 3 o'clock in the afternoon here now. I'm interested to see how she does tonight. I'm not anticipating any drama, but I do hope she may see a blue number.

 

[Suzanne & Darcy]

Oh and pieces of boiled chicken for treats are perfect.

 

[AliceL]

Ok, so I just did the +2 test and its 218.
So basically this evening has gone as follows so far:

AMPS = 201, THEN FOOD
WAIT 15 MINS, TEST = 280
WAIT ANOTHER 15 MINS = INSULIN
+2 AFTER INSULIN = 218

Where if anywhere do I record the 280 test?
This was after food but before insulin so a bit misleading maybe.

Just fyi, I also gave her another 1/4 portion of the 4% carb wet food after this last +2 test. Feeling worried about her dropping too much so just letting her snack as she wants to.

 

[Suzanne & Darcy]

Ok, so I just did the +2 test and its 218.
So basically this evening has gone as follows so far:

AMPS = 201, THEN FOOD
WAIT 15 MINS, TEST = 280
WAIT ANOTHER 15 MINS = INSULIN
+2 AFTER INSULIN = 218

Where if anywhere do I record the 280 test?
This was after food but before insulin so a bit misleading maybe.

Just fyi, I also gave her another 1/4 portion of the 4% carb wet food after this last +2 test. Feeling worried about her dropping too much so just letting her snack as she wants to.

I would put the 280 test in the notes/comments section of your spreadsheet. I would just write something like 280 fifteen minutes after food but before giving any insulin. Otherwise there really isn't a good way to put it into the spreadsheet where it will make sense.

I just tagged you on a post where a new member from Spain said that U-40 syringes can be shipped to Portugal. She put links in there when I told her about your problem finding the U-40 syringes. Nice.

 

[Suzanne & Darcy]

Oh, and as for the snacks... that's just fine... all low carb and the snacking is good for her and for the cycle. She's going to do fine. I hope that in a little bit you will be able to take meds and go to sleep.

 

[AliceL]

I just tagged you on a post where a new member from Spain said that U-40 syringes can be shipped to Portugal. She put links in there when I told her about your problem finding the U-40 syringes. Nice.

I saw this, thank you. I'll respond tomorrow when I'm less tired.

+4 test is 216 btw.

Evie is not sleepy at all and having a fat bath from head to tail while mom is sitting here bleary eyed

 

[Suzanne & Darcy]

I hope you went to bed and slept well after you saw she was flat in yellow.

 

[AliceL]

@Suzanne & Darcy We had a vet visit today and Evie didn't gain as much weight as I thought, it's only 100g but I'll take any small victory at this point.
Vet agreed insulin needs to be increased. She suggested increasing Evie's dose from 0.8 to 1. What is the suggested amount?

Thanks for your help locating those 40u syringes on Amazon but I really do not want to rely on importing something so important into Portugal.
I live in central Portugal which is quite rural and the first time I ordered something on Amazon it took 3 weeks to arrive due to custom hold ups and issues with delivery.

I have now found a good local source of the 0.3ml syringes, so if possible I would like to try increased dosage on this one. What are your thoughts? One of the admins on the Facebook group mentioned it was possible so I'm really hoping this will work. I'll send a picture of the syringe in a moment.

Just FYI, I'd like to start increased dosage tomorrow daytime shot so I can watch her closely.

 

[Shelley & Jess]

0.2 unit increase sounds good - just shy of the 0.25 unit increases FDMB protocols recommend.

 

[Suzanne & Darcy]

0.2 unit increase sounds good - just shy of the 0.25 unit increases FDMB protocols recommend.

Perfect, Shelley!

 

[AliceL]

It's the first time I've ever managed to catch a blue in both of Evie's daytime & night time cycles. It's silly but I feel so happy about it.
She seemed so good today, was very active and playful.

Overall we are both getting more comfortable with this new way of life.
The daily insulin injections don't feel as dramatic as they first did
Evie is taking better to the frequent ear tests and I am managing to get more tests done by myself without having to call my husband to help.
I worry about her ears getting a little raggedy and sore even though I have been alternating them. Is it better to perhaps stray from that recommended sweet spot every now and again to prevent over traumatising the ear edge?

She has also been off the pain meds for the last few days and doesnt seem to be in distress.
Her stomatitis is looking better visually, I think maybe it's because her glucose levels are better overall - we all know sugar feeds inflammation.
I am still looking into some natural options to try help the inflammation in the meantime, while we wait for her surgery which could be later in June or July.
I thought I would include a new picture of her looking very chilled, she is such a sweetie.

I've been reading up more about the dosing methods.
It's a lot of information and I'm still taking it all in but I guess I'm already kinda doing a long version of SLGS. I'm not sure which protocol is the best for Evie?
I worry about TR and the increased testing requirements. Still figuring it all out.

If I decide to stick with SLGS in a few days I would do a 12hr curve at 2hr intervals and then increase her dose by 0.25 if the nadir is not yet dropping below 150.
Is that correct?

 

[Suzanne & Darcy]

It’s totally NOT silly to be happy about it! I am thrilled to see the blues and I am really happy to hear about your progress with the testing and that she’s been playful. These are all good signs. I’m sitting here smiling!

them. Is it better to perhaps stray from that recommended sweet spot every now and again to prevent over traumatising the ear edge?

You can go up and down the edge of the ear a bit. Definitely alternate the ears. It kind of depends on which spots bleed better. Usually cats have one ear that bleeds better than the other as well.

I agree about sugar being very inflammatory. I’m happy the stomatitis seems improved. I would encourage you to explore natural helps for the stomatitis. Funny you mention Lactoferrin. I use it in my FIV cats with skin problems. I use Jarrow and they eat it mixed in with their food and don’t seem to notice it.

 

[Suzanne & Darcy]

I love that picture! She’s so pretty!

 

[Shelley & Jess]

What a fantastic update to hear about both of you! Love the new pic!

I worry about TR and the increased testing requirements.

You currently test more than enough to follow MPM (Modified Prozinc Method). MPM works well when a caregiver can monitor closely as it allows for faster dose changes. Evie's numbers aren't terrible, but, it does appear she needs another increase.

If I decide to stick with SLGS in a few days I would do a 12hr curve at 2hr intervals and then increase her dose by 0.25 if the nadir is not yet dropping below 150.
Is that correct?

If you stick with SLGS and maintain the current amount of testing a 12 hour curve is not necessary. A curve once a week is recommended for caregivers that can't test like you are - both mid cycles every day. And yes, if you don't see anything under 150 after a week at the current dose, then a 0.25u, or in your case (using U100 syringes with U40 insulin) a 0.2 unit increase is recommended.

 

[Suzanne & Darcy]

I totally agree with Shelley. If you don’t see nadirs below 150 after 14 cycles then you can increase by .25 units.

What I would say about the curve is that it would be good if you could fill in a few of the cells on the SS that are normally blank — like +2 and +4 and +8 This will be better than doing a curve — just filling in blank areas on the spreadsheet, if that makes sense. I meant to write this last night, but passed out about midnight. So just keep up the good work! We are going to see better numbers soon! I’m optimistic!

 

[AliceL]

Good morning! This night time shot is really doing my head in.
I need to move her shot time so I can have better management of the second cycle.

There have been 3 occasions in the last week where she got morning numbers in the 300s.
These are all mornings after I accidentally fall asleep waiting to feed or test her and wake up in a panic around 1am (around +6) which results in a later than usual night time snack. This happened again last night - at least I managed to get a +6 test in, but now she has a high number this morning. This is so frustrating.

How quickly can I move her shot time safely? I have been moving it by 10 mins a day, trying to get from 7am/7pm to 5am/5pm.
We are currently at 6:30 (am/pm) - could I shoot her at 6pm this evening or is 30 mins jump too much?

What I would say about the curve is that it would be good if you could fill in a few of the cells on the SS that are normally blank — like +2 and +4 and +8 This will be better than doing a curve — just filling in blank areas on the spreadsheet, if that makes sense.

I'm not clear on what you mean in terms of the frequency of doing more blank cell tests. On one day before dose increase or more sporadically over time?

You currently test more than enough to follow MPM (Modified Prozinc Method). MPM works well when a caregiver can monitor closely as it allows for faster dose changes. Evie's numbers aren't terrible, but, it does appear she needs another increase.

From what I read on the MPM page I need to do better at monitoring the night time nadir before I can do MPM. I'm going to move the shoot time and try to get a few more days of results in before I start this protocol.

Interesting side note, yesterday I met another foreign diabetic cat mom in my town!
That doesn't sound like much except when you consider we live in tiniest rural town in the middle of Portugal it's absolutely amazing to meet someone who understands the unique pains of dealing with a diabetic cat in Portugal!
She is American and actually had to fly home to get u40 syringes when her cat was on Prozinc - she confirmed it really is impossible to get those u40 syringes in Portugal!
Her cat is now on u100 insulin so she uses u100 syringes and she wants to donate 3x boxes of the u40 syringes to me.
It's a limited supply so I'm not sure how I will use them exactly. I'm thinking if a certain dose is hard to achieve an exact measurement on my u100/0.3ml syringe maybe I could use a u40 syringe as a back up, only for certain dosages. What do you think?

 

[Suzanne & Darcy]

Really quickly (and I will be back with more answers in a bit) but you can move shot time by 30 minutes a day (either 15 minutes at each shot time or 30 minutes all at once.)

 

[Suzanne & Darcy]

It’s recommended to try SLGS for 30 days prior to switching, but let’s take a look at things and think through everything. One other note is that no dry food can be given if following MPM.

 

[Suzanne & Darcy]

On one day before dose increase or more sporadically over time?

More sporadically on different days. I'm just saying that those are the hours where we don't have a lot of data, so it would help us to fill in a more complete picture if we could see a couple of tests at the hours where we don't usually see what's going on. This would be in lieu of doing a curve.

 

[Suzanne & Darcy]

We are currently at 6:30 (am/pm) - could I shoot her at 6pm this evening or is 30 mins jump too much?

I answered this before, but just want to make sure you see it. I would be fine to shoot 30 minutes early tonight.

 

[Suzanne & Darcy]

It's a limited supply so I'm not sure how I will use them exactly. I'm thinking if a certain dose is hard to achieve an exact measurement on my u100/0.3ml syringe maybe I could use a u40 syringe as a back up, only for certain dosages. What do you think?

I think this sounds a little confusing, but if you are really savvy with the conversion chart and know exactly how much insulin you want to shoot, then it might be okay. I am a little nervous about this though (switching back and forth between syringe types) because it would seem like there's more possibility of error and either over- or under-dosing Evie.

 

[Suzanne & Darcy]

Okay... I think/hope I've answered all of your questions. Let me know if there's anything I missed.

 

[AliceL]

So tonight's shot is cycle 14 at 1U so I'd like to increase her dose to 1.2U starting tomorrow.
In my 0.3 syringe that will be at the 3 mark with conversion, is that correct? I think so but just wanted to double check.

 

[Suzanne & Darcy]

Yes. That is correct. Draw the insulin to the 3 unit mark in the U-100 syringe in order to give her the 1.2 units of ProZinc. Good luck with the increase. She is making progress, but you do have some wiggle room for the increase still.

 

[AliceL]

Just wanted to share good news - Record low for Evie today at 161
I also caught more blue numbers this evening! I hope this means a lower number at AMPS
I still need to break up my days to get some +2/4/8 readings, will start that tomorrow.

 

[Suzanne & Darcy]

I’m loving those blues on the spreadsheet both during the day and the evening! Congratulations!

Are you using an Alpha Trak meter? I saw AT on your spreadsheet and was wondering because that is not your usual meter.

 

[AliceL]

Are you using an Alpha Trak meter? I saw AT on your spreadsheet and was wondering because that is not your usual meter.

Nope, it literally means 'at' as in @
But I can see how that may be misleading so I've changed it on the spreadsheet.

Side note on the Alpha Trak:
My husband emailed the US head office asking where we can get this monitor in Portugal.
They told us they are only releasing the Alpha Trak 3 in Portugal in August. They also apologised for the inconvenience and sent us a free Alpha Trak 2 starter kit to try out.
I know the pet monitor strips are generally more expensive than the human monitors so I'll wait to see if it's worth switching.
I am finding the human monitor strips pretty expensive here in Portugal at about €‎14 for 50.
If she were a human with a prescription the strips would cost only ‎‎€‎2 for 50 as Portugal has subsidised national healthcare.

 

[Suzanne & Darcy]

They told us they are only releasing the Alpha Track 3 in Portugal in August.

Here in the U.S. they're changing over everything to the AT 3 also.

I am finding the human monitor strips pretty expensive here in Portugal at about €‎14 for 50.

That does seem kind of expensive.
I'm not a fan of the Alpha Trak, but I can deal with it. Here the strips are more expensive. Also, they tend to read higher than the human meters, so that confuses things. All of our dosing protocols are written for human meters. Again, can deal with it, but have to make the mental conversion. Also, it will be somewhat confusing on the spreadsheet if tests are taken using AT sometimes and at other times using a human meter. But people using both the Libre and then a human meter as backup (which is necessary to have some kind of a back up meter) have to also note which are Libre and which are meter. The Libre sensors, in my experience, read quite a bit lower when in lower numbers -- which can really give you a scare and when you get a low reading on the Libre you really need to check it on a handheld meter.