Tommy Boy BG Swings

[Chris Findell]

Thank you for the return reply. I'm still new to the forum so still learning how to navigate.

My cat, Tommy Boy, was diagnosed diabetic back in July 2023 and has been on ProZinc since July 1, 2023. He has gone thru a multitude of insulin adjustments throughout this period (per my vet) and has not reached remission as yet, although there have been some nice curves recently. I have attached his CGM readings for the past five days and while not perfect, there were some promising days until last night. As you can see his numbers were doing good throughout the day on Nov. 24 and then he had a very low hypo event at 11:30 pm and lasted until 1:15 am (with a low reading of 40!) and then he went high hyperglycemic the morning of the 25th and has stayed there.

Nothing has changed in his routine this week. His food schedule and insulin delivery has remained constant. His insulin units are currently 2.75.

This is where I get very frustrated. Why did he all of sudden have a significant BG change, from low Hypo to high Hyper and what should I do about his insulin dosage going forward.

Tommy's food consists of 1/2 to 1 ounce of Tiki Cat chicken based wet and 1 to 1.3 ounces of Dr. Elseys dry kibble twice a day. Both foods are high protein, low carb. Caloric intake per feeding is approx. 130 calories (260 per day).
I have tried to feed him prescription DM wet but he will not touch it.

Your advice would be greatly appreciated.

 

[Sienne and Gabby (GA)]

It looks to me like what you're seeing is that Tommy is generally in good numbers but you're not getting great duration from Prozinc. Typically, his numbers are rising into a high range at shot time whereas he's in in the 100s - 200s at nadir. It's likely that his liver and pancreas are getting adjusted to the lower numbers and he may be producing endogenous insulin (i.e., his pancreas is kicking in and boosting the insulin you're injecting). This is what caused the drop into low numbers.

When a at drops into low numbers, drops quickly even if it's not into particularly low numbers, or drops into a range his body isn't used to, the liver and pancreas start to pump out a stored form of glucose along with counterregulatory hormones. These cause blood glucose numbers to spike upward -- hence the jump from the 40s to the 400s. We colloquially call this a "bounce." It generally takes up to 3 days/6 cycles for a bounce to clear.

I'm hoping that you fed Tommy when you caught that 40. We generally do not recommend twice a day feeding. It puts a good deal of strain on a healing pancreas to only feed twice a day. It also means that if your cat drops into low numbers, and a 40 is low, you may not be thinking about intervening with food to bring the numbers back up. Not doing so risks a symptomatic hypoglycemic event. I'd also recommend reducing Tommy's dose by 0.25u. The drop into the 40s (actually below 90) is Tommy telling you that the dose is too high.

 

[Ale & Bobo & Minnie (GA)]

First post for continuity:

https://felinediabetes.com/FDMB/threads/new-member-nov-17-2023.283693/

Thank you for setting up your signature! Are you able to setup a spreadsheet using our template? It will be easier to get members advice on dosing.

Here is a link helping us to help you with instructions for the spreadsheet. We also have a link to our spreadsheet in our signature. We are very numbers driven. The spreadsheet is a record of your cat's progress. By linking it in your signature, we can follow along and provide feedback should you need the help.

 

[Chris Findell]

It looks to me like what you're seeing is that Tommy is generally in good numbers but you're not getting great duration from Prozinc. Typically, his numbers are rising into a high range at shot time whereas he's in in the 100s - 200s at nadir. It's likely that his liver and pancreas are getting adjusted to the lower numbers and he may be producing endogenous insulin (i.e., his pancreas is kicking in and boosting the insulin you're injecting). This is what caused the drop into low numbers.

When a at drops into low numbers, drops quickly even if it's not into particularly low numbers, or drops into a range his body isn't used to, the liver and pancreas start to pump out a stored form of glucose along with counterregulatory hormones. These cause blood glucose numbers to spike upward -- hence the jump from the 40s to the 400s. We colloquially call this a "bounce." It generally takes up to 3 days/6 cycles for a bounce to clear.

I'm hoping that you fed Tommy when you caught that 40. We generally do not recommend twice a day feeding. It puts a good deal of strain on a healing pancreas to only feed twice a day. It also means that if your cat drops into low numbers, and a 40 is low, you may not be thinking about intervening with food to bring the numbers back up. Not doing so risks a symptomatic hypoglycemic event. I'd also recommend reducing Tommy's dose by 0.25u. The drop into the 40s (actually below 90) is Tommy telling you that the dose is too high.

Hello Sienne and Gabby,

Thank you very much for the response.

Unfortunately, I was unable to catch the Hypo event when it happened so I was unable to offer food. I did wake up around 2:30 and he was sleeping on my lap and did not appear to be in distress. I generally turn my phone off at night as the background noise from other apps make it difficult for me to sleep. So the Libre also goes off as well. I don't see Tommy's overnight numbers until the following morning around 6:30 a.m. And Tommy had been doing so well, that I felt fine with having the phone off for now. Kind of figures he would have an event like this when I was unable to address it.

With regards to feeding, Tommy gets his regular meals at 7:30 a.m. and 7:30 p.m. He also gets approx. 1/2- 3/4 ounce of Dr. Elsey's dry kibble (chicken/salmon mix) approx. 6 hours after his morning feeding and when we turn in for the night. 1/2 oz. is approx. 50 kcal. This kibble is a high protein, low carb dry kibble and actually has better numbers than Purina's prescription DM dry kibble. So in addition to his normal feeding he does get supplemental food in between his feedings.

His numbers today (11/25) from 10:30am to 3:30pm were in the 220 to 250 range. From 4pm until now (7:00pm) they hit a low of 312 to a current 376, so they are climbing again this evening prior to his PM feeding.

I will definitely reduce his insulin units tonight to 2.5 and keep him on that for the next 3-6 cycles to see see the effect.

Progress report to follow.

And thank you again for your help with this. Very much appreciated.

 

[Ale & Bobo & Minnie (GA)]

Do you need help setting up your spreadsheet?

I’d add 2 more snakes or small meals a day if I were you. It’s helps slow down drops and avoid big sugar spikes.

 

[Bron and Sheba (GA)]

How are things going? can we help with setting up your spreadsheet Chris?

 

[Chris Findell]

Thank you for checking in!

I have downloaded the template for the FDMB spreadsheet; just need to find some time to begin plugging in numbers. This will take a bit of time as I want to start from the beginning of November so there is some history established. I use a Libre 3 CGM sensor so I have a plethora of data available.

With regards to Tommy's progress sine his low Hypo event and subsequent high Hyper bounce on 11/24-11/25, I reduced his ProZinc insulin units from 2.75 to 2.5. He has not had any more Hypo events, but now his numbers are staying elevated. My understanding is it can take at least 3 cycles to clear the bounce effect, and I am on the 4th cycle as of this morning 11/27.

His numbers look like this right now:
11/25 AMPS "HI" PMPS 358 His Hypo event (with a low of 40) was late evening 11/24. It lasted approx. 2H 45M. His range in this time period was 40 - 57. 3 hours later it was super high (over 400).
11/26 AMPS 356 PMPS 313 Numbers stayed mostly in the 200 range for the majority of the day. Went into the 300's following morning and evening feedings, but back into the 200's between feedings.
11/27 AMPS 348 At midnight BG was 235, rose to 361 at AM feeding/insulin (2.5 units). It is now 11:45am CST and his BG is down to 130. Hoping he's not headed for another Hypo event!

This is where we are for now. Will try to get speadsheet done so Tommy's numbers are easier to see.

Thanks everyone for your help.

 

[Sienne and Gabby (GA)]

It actually takes approximately 3 days/6 cycles for a bounce to clear.

If you give your cat some low carb food and then re-test in 30 min you can see if his numbers are flattening out. If his numbers keep dropping, give him a teaspoon or two of higher carb food to prevent him from dropping too fast or too far.

 

[Chris Findell]

Tommy’s number bottomed out at 104 two hours later (1:45pm cst) and have been steadily rising throughout the afternoon. BG is now 220 at 4:00pm cst. No food intervention was necessary.

 

[Chris Findell]

I’ve attached some Libre 3 BG curves for Tommy Boy for the last ten days and am looking for some feedback as I feel kind of lost right now as to what I need to do to get him back on track. Somehow these uploaded in the wrong order so you’ll have to look at the dates. He was doing pretty good but then had a very low Hypo event the late night of 11/25 with a low of 40. He’s gone into 50’s in the past, but never in the 40’s. His ProZinc insulin units were 2.75 up to that point. I then adjusted it down to 2.5 after that event and held that for 7 cycles and his numbers have stayed in the higher end range. So, I adjusted his insulin back to 2.75 after this morning’s feeding. His feeding/insulin times are 7:30 am/pm. His food offering never changes (high protein, low carb). I haven’t been able to get the FDMB spreadsheet started yet, but I think these graphs tell a good story in the meantime.

Thanks all for your feedback.

 

[sullim4]

Hey Chris,

This was all new to me a few weeks ago as well . I thought it might be helpful for you to see the Libre results we're getting for Sally to compare Lantus to Prozinc. She is on Lantus and getting a half unit twice daily. She was just diagnosed about a month ago, and started on a dose that was much higher than it should have been (2.0 units). It's since been adjusted down to the half unit with the help of the folks here.

I wasn't quite sure what everyone meant by "flat curve" until I saw the data from the last few days. Sally's general trend is to peak right after breakfast and her AM shot, then a steady path down, almost "flat" at points in time, until her lowest which is usually around 8 hours after her AM shot. She gets a snack between 10am and noon, and then gets fed again at around 7pm (along with her shot). She dips to her lowest point around 10pm-midnight (she gets a snack in the auto feeder at this point), then stays pretty steady throughout the night.

When I fill out the spreadsheet, I tend to take an average from the min and max for a given hour. Yeah, it's not exactly precise... but it's good enough to see the trend.

She had a "bump" on Monday morning but seems to have cleared it. I am happy she is on Lantus - precisely because of the "flat" curve!

 

[Sienne and Gabby (GA)]

Chris -

Most of us are wed to the spreadsheet we use here. If you want feedback on your cat's progress or help with dosing, can you please input the Libre information onto our spreadsheet?

 

[Chris Findell]

Hey Chris,

This was all new to me a few weeks ago as well . I thought it might be helpful for you to see the Libre results we're getting for Sally to compare Lantus to Prozinc. She is on Lantus and getting a half unit twice daily. She was just diagnosed about a month ago, and started on a dose that was much higher than it should have been (2.0 units). It's since been adjusted down to the half unit with the help of the folks here.

I wasn't quite sure what everyone meant by "flat curve" until I saw the data from the last few days. Sally's general trend is to peak right after breakfast and her AM shot, then a steady path down, almost "flat" at points in time, until her lowest which is usually around 8 hours after her AM shot. She gets a snack between 10am and noon, and then gets fed again at around 7pm (along with her shot). She dips to her lowest point around 10pm-midnight (she gets a snack in the auto feeder at this point), then stays pretty steady throughout the night.

When I fill out the spreadsheet, I tend to take an average from the min and max for a given hour. Yeah, it's not exactly precise... but it's good enough to see the trend.

She had a "bump" on Monday morning but seems to have cleared it. I am happy she is on Lantus - precisely because of the "flat" curve!

View attachment 68138

Thank you so much for sharing. These numbers are very impressive. Would love to get Tommy in this range. He’s six months in to his diabetic journey and we just don’t seem to be able to get him to a stable point yet. I am in discussion with my vet about switching him over to Lantus but it won’t be for a couple of months as I just renewed his ProZinc prescription ($133 expense). Can I ask how much you are paying for Lantus and where you purchase it. My understanding is this is very expensive, but is probably worth it if it will stabilize his numbers.

 

[sullim4]

Thank you so much for sharing. These numbers are very impressive. Would love to get Tommy in this range. He’s six months in to his diabetic journey and we just don’t seem to be able to get him to a stable point yet. I am in discussion with my vet about switching him over to Lantus but it won’t be for a couple of months as I just renewed his ProZinc prescription ($133 expense). Can I ask how much you are paying for Lantus and where you purchase it. My understanding is this is very expensive, but is probably worth it if it will stabilize his numbers.

We're paying $35 per vial (or per box of 5 pens) through the GoodRx deal. We get the script filled at Costco. We had no issues with using it for Sally... GoodRx explicitly allows their card to be used for pet medications.

More info here: https://www.goodrx.com/lantus

 

[Bron and Sheba (GA)]

@Chris Findell
I’m going to ask @Bandit's Mom to help you set up a spreadsheet for Tommy. You will get much more feedback with a spreadsheet.

 

[Bandit's Mom]

I have downloaded the template for the FDMB spreadsheet; just need to find some time to begin plugging in numbers. This will take a bit of time as I want to start from the beginning of November so there is some history established. I use a Libre 3 CGM sensor so I have a plethora of data available.

Chris, a cat's insulin needs go up and down and more than 2 weeks back is ancient history as far as feline diabetes is concerned. You want to start with the latest data (last week) and then work back when you have the time. At least that way, we will have some info in the SS to be able to help you with dosing. Also, dosing is based on nadirs, so you don't need to record every data point in the SS. You could start with preshots and a couple of reads per cycle (including the nadir). I'm going to tag @Staci & Ivy who also uses a Libre.

Let me know if you'd like me to set up a spreadsheet for you. Will only take me a minute

 

[Chris Findell]

Chris -

Most of us are wed to the spreadsheet we use here. If you want feedback on your cat's progress or help with dosing, can you please input the Libre information onto our spreadsheet?

Working on it. While I am retired, I have lots of irons in the fire and I need to find the time to get in a routine on the spreadsheet. I’ll get there.

I should note that Tommy is not the only cat in our household, but is the only diabetic cat. Over the years we have rescued many cats due to cats being dumped in our neighborhood and showing up at our doorstep. Shelters are always full in our city so my wife and I took it upon ourselves to become cat caregivers. We didn’t sign up for it, but it is what it is. At present, we have 14 completely indoor cats. 7 live in the main house and the other 7 live in a 700 sq. ft. cat room that I built onto the house. It is air conditioned and heated for their comfort. We have another 5 outdoor cats that are semi-feral, but well cared for. For them we have five cat shelters that are insulated and weather tight with small heaters for the winter months. Also weather proofed a 6’x8’ greenhouse. It also has a heater and cat beds and blankets that they can shelter in when it’s cold. Fresh food and water is replenished daily. Needless to say, we are maxed out with cats and there is no more room in home or budget to take in any more felines. Occasionally I find time to play golf.

 

[Chris Findell]

@Chris Findell
I’m going to ask @Bandit's Mom to help you set up a spreadsheet for Tommy. You will get much more feedback with a spreadsheet.

Oh my, thank you so much! How nice. If you’ll read my recent reply to Sienne and Gabby you’ll get a better idea of our limited time schedule.

 

[Sienne and Gabby (GA)]

Chris -
I hope the retirement activities are as rewarding as they sound! While you may be covered in cat hair, I also suspect you get a lot of love for what you're doing.

 

[Chris Findell]

We're paying $35 per vial (or per box of 5 pens) through the GoodRx deal. We get the script filled at Costco. We had no issues with using it for Sally... GoodRx explicitly allows their card to be used for pet medications.

More info here: https://www.goodrx.com/lantus

Thank you for this information. I saw this on GoodRx and asked our local Costco if they would honor it for a pet prescription from my vet. They informed me they could only accept from a medical doctor prescription. I think I’ll have my vet write a script anyway and just go to my Costco and present it and the goodrx coupon and they see if they’ll fill while I’m there. I read good things about Lantus so this would be the way to go. Fingers crossed.

 

[Staci & Ivy]

Chris, a cat's insulin needs go up and down and more than 2 weeks back is ancient history as far as feline diabetes is concerned. You want to start with the latest data (last week) and then work back when you have the time. At least that way, we will have some info in the SS to be able to help you with dosing. Also, dosing is based on nadirs, so you don't need to record every data point in the SS. You could start with preshots and a couple of reads per cycle (including the nadir). I'm going to tag @Staci & Ivy who also uses a Libre.

Let me know if you'd like me to set up a spreadsheet for you. Will only take me a minute

Hi Chris, I see Bhooma tagged me and I am happy to assist about the Libre, which I do use with Ivy. If you have any questions, I am happy to answer.

 

[Chris Findell]

Hi Chris, I see Bhooma tagged me and I am happy to assist about the Libre, which I do use with Ivy. If you have any questions, I am happy to answer.

Thank you so much for your offer. I looked over your spreadsheet and was very impressed by the detail. It appears your curves are very similar to the curves I have been experiencing with Tommy, a roller coaster. Since its a gloomy day here in south Texas, I'm going to carve out some time today and start filling in my spreadsheet. Hopefully can get November numbers in. My vet is also going to write a script for Lantus Solopens which I'm going to take to Costco with my GoodRx coupon and see if they'll fill it (5 pens for $35). If successful, I'll probably switch him over at the beginning of 2024 as I refilled my ProZinc a couple of weeks ago.

 

[Staci & Ivy]

Thank you so much for your offer. I looked over your spreadsheet and was very impressed by the detail. It appears your curves are very similar to the curves I have been experiencing with Tommy, a roller coaster. Since its a gloomy day here in south Texas, I'm going to carve out some time today and start filling in my spreadsheet. Hopefully can get November numbers in. My vet is also going to write a script for Lantus Solopens which I'm going to take to Costco with my GoodRx coupon and see if they'll fill it (5 pens for $35). If successful, I'll probably switch him over at the beginning of 2024 as I refilled my ProZinc a couple of weeks ago.

Glad you were able to make sense of my SS! My girl is a major diver and bouncer. Still trying to figure how to get her regulated. But the Libre at least warns me when she's diving very low and I spring into action.
For me, my local pharmacies would not honor the Good RX coupon as it said for humans only. Maybe in TX, it's different? Can't hurt to try!
I filled my Lantus script at a CVS and paid $35 (with a coupon I found on the actual Lantus site for Sanofi) for 5 pens in a box. Will last many many months.

Keep us posted and ask lots of questions! Talk to you soon and best of luck with Tommy!

 

[Chris Findell]

We're paying $35 per vial (or per box of 5 pens) through the GoodRx deal. We get the script filled at Costco. We had no issues with using it for Sally... GoodRx explicitly allows their card to be used for pet medications.

More info here: https://www.goodrx.com/lantus

I was unsuccessful using the GoodRx coupon for the box of five Lantus pens. Something to do with the number of units in five pens greatly exceeds the number of units the cat uses within a particular period of time. If Tommy is getting 4 units per 24 hour period then five pens would theoretically last 375 days. Was told by the pharmacist they can’t fill a prescription that lasts this long. Am I missing something? How did you get your prescription filled? I tried explaining that five pens would really only last 5 months as once you open a pen it has to be replaced in 28 days, regardless of how many units remain. No luck.

 

[Staci & Ivy]

I was unsuccessful using the GoodRx coupon for the box of five Lantus pens. Something to do with the number of units in five pens greatly exceeds the number of units the cat uses within a particular period of time. If Tommy is getting 4 units per 24 hour period then five pens would theoretically last 375 days. Was told by the pharmacist they can’t fill a prescription that lasts this long. Am I missing something? How did you get your prescription filled? I tried explaining that five pens would really only last 5 months as once you open a pen it has to be replaced in 28 days, regardless of how many units remain. No luck.

I followed this prescription info exactly and it worked perfectly. Hope this helps!
Then go to the Lantus site to generate the coupon as in second image.

 

[Staci & Ivy]

Also, use the pens till the last drop. Vials also are good for more than 28 days. Ignore that info from the pharmacy. You will refrigerate the insulin always to keep it ok. Others here will confirm this information for you!

 

[Snickers and Chrissy]

What Staci and Ivy said is right. The pens are good for much longer than the 28 days. That number is for people who carry the pens around with them everywhere, like at work, in the car, in their purse, etc. As long as they're refrigerated then one pen is good for months. Some folks here use every little drop, even if it takes a year.

 

[Chris Findell]

Update to my Lantus/GoodRx saga. I tried having the Lantus prescription filled with the GoodRx coupon at Walmart, Costco, CVS and Walgreens. Same story at each place; none of them could honor the coupon. I then called GoodRx and they confirmed the coupon would only be honored if the prescription comes from a medical doctor, not a veterinarian. They did however give me information to give to the pharmacist for filling a prescription for the generic version of Lantus, which is Insulin Glargine-xfgn. Five pens could be filled at Walgreens for $82.30, which is still a good price. I also called Costco to see if they could fill the generic version and to my surprise, they could. Member price is $75 for a box of 5 pens. So even better. Looks like this will be the route I go once I have used up my ProZinc this month.

 

[Larry and Kitties]

I then called GoodRx and they confirmed the coupon would only be honored if the prescription comes from a medical doctor, not a veterinarian.

DId you then ask GoodRx why they did not have a "Pet" restriction" included in the "Restriction apply" popup? In the past for Lantus one restriction listed was that it can't be used for a pet.

 

[Chris Findell]

DId you then ask GoodRx why they did not have a "Pet" restriction" included in the "Restriction apply" popup? In the past for Lantus one restriction listed was that it can't be used for a pet.

I did not ask.

 

[sullim4]

I did not ask.

Another option - Amazon's pharmacy claims that the pens/vial of Lantus is $35 "if eligible". Info here: https://pharmacy.amazon.com/Lantus-..._1_1&s=amazon-pharmacy&keywords=lantus&sr=1-1

There's nothing in the list of eligibility requirements that says pets are ineligible... but I haven't tried to actually fill the script from them. I think they use the Sanofi coupon that @Staci & Ivy mentioned upthread.

 

[Staci & Ivy]

Another option - Amazon's pharmacy claims that the pens/vial of Lantus is $35 "if eligible". Info here: https://pharmacy.amazon.com/Lantus-..._1_1&s=amazon-pharmacy&keywords=lantus&sr=1-1

There's nothing in the list of eligibility requirements that says pets are ineligible... but I haven't tried to actually fill the script from them. I think they use the Sanofi coupon that @Staci & Ivy mentioned upthread.

I paid $35 at a local CVS for a box of 5 pens. They just followed the Sanofi coupon. And I made sure to have the script follow the specs precisely of the info I posted above.

 

[Larry and Kitties]

Update to my Lantus/GoodRx saga. I tried having the Lantus prescription filled with the GoodRx coupon at Walmart, Costco, CVS and Walgreens. Same story at each place; none of them could honor the coupon.

My guess is that the pharmacies wanted an NPI (National Provider Identifier) number which veterinarians can't get. Most veterinarians do have a DEA number but that is only supposed to be provided for controlled drugs.