04/15 Ruarach AMPS 285; PMPS 113 ??? (repeated, got 120) (CLOSED THREAD)

L

LauraZZ

Member Since 2023
I discovered this forum about 2 weeks ago and have been reading and learning. Have a spreadsheet (link in signature). Was going to introduce myself and Ruarach soon. Ruarach is a 17 year old, 10 pound, male neutered cat who was diagnosed with kidney disease over a year ago, and in mid March was diagnosed with diabetes.

I just got a very low PMPS blood glucose reading of 113. I repeated it a few minutes later and got a reading of 120. Repeated 30 min after 1st reading: got 132; had fed him a little about 5 min after first rdg. Those readings were with Relion Classic Premier. (I got out my AlphaTrak2 about 50 min after first reading; it gave a 145.)

This is from a cat who has been in 300s, 400s, and higher; never below 300 until this morning.

Ruarach has been at 3 units of Lantus insulin for 2 weeks (initially diagnosed March 13; have ramped up from 1 unit to 2 unit to 3 units.

The 113 reading made me panic - not sure I should give him 3 units this evening. So, I gave him some food - then read https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/ and realized I probably shouldn't have fed him.

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Stopped panicking as much and read through the SLGS/TR page more carefully, and in particular, this section:

Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.

  • Below 150 mg/dl (8.3 mmol/L), don't give insulin.
So, I guess I will not give insulin tonight. I haven't seen such low numbers before so I don't know how he will respond to insulin, given his current state.
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If anyone reads this later, I'd love feedback about whether this was the best choice. What else could I have done/considered/thought about, etc

Also, what should I do on Sunday? Should I lower his insulin dose if his reading is under 250? Maybe with trying to lower carbs in his diet, the 3 units of Lantus is too much for him.


Background.
You can see from his spreadsheet his blood glucose readings have been very high. I wondered if he was insulin resistant and I had a urine sample taken Tues and the urine culture came back negative for infection.

I have been working toward moving him to a lower carb diet the last few days in particular. Ruarach also has kidney disease, and my vet feels too high of a protein diet would be detrimental to the kidney disease. (I'm a little less concerned, as long as I'm feeding a high quality animal protein, but probably won't go as low carb as I would if he simply had diabetes.) So the diet transition may be part of the reason why his PMPS blood glucose reading was so low.

I also started PhosBind last night but I doubt that has anything to do with his low blood glucose reading (his phosphorus levels have been increasing due to his kidney disease, and last blood work, reached a point where guidelines suggest using a phosphorus binder).

Usually I feed him right before I do the PMPS blood glucose reading and then give him insulin.

Tonight, about 45 min before the blood glucose reading, I fed him some Purina One Grain Free canned food - this was a new food for him, given for the first time. This I believe is very low carbs. But I didn't feed him right before the PMPS blood glucose reading. So he hadn't had any carbs for a while before the blood glucose reading.
 
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Hi and welcome to the forum Lazz and Raurach,
Looks like you are pretty organised which is great. Having the spreadsheet and signature set up help us a lot!
Three units of insulin is a lot of insulin to start a newly diagnosed cat on. The starting dose is 0.5unit or 1 unit depending if you are feeding dry food or wet food.
Also I would recommend you start getting some tests in during the cycles if you can, because Lantus dosing is based on the nadir or lowest point in the cycle, not the preshots. Looking at the SS we have no idea if he is dropping low during the cycles and bouncing back up at the next peshot. This is very possible. I would say that he dropped lower than the 113 during the morning cycle and has come up to the 113 at the PMPS. And it is very possible he has been dropping much lower during the past couple of weeks and you are unaware.
It is fine that you skipped the pm dose providing he had no ketones at diagnosis.
Just a couple of questions:
  • Are you using the solostar to give the insulin or are you using a syringe and drawing it from the cartridge?
  • What is the carb % of the food you are feeding.
With Lantus the routine is test, feed then give the dose of insulin. Don’t feed for the 2 hours before the preshot BG as we don’t want the preshot to be food influenced.
If you have a lower than normal preshot… it is best to stall, dont feed, and test again in 20 minutes to see if the BG is rising.
If you are following SLGS you reduce the dose if it drops under 90.
I would reduce the dose back to 2 units and try and test more often so we can see what is happening during the cycles and work out a better dose for him.
 
A couple of more things….I would stick with the ReliOn meter. If you chop and change the meter with a pet meter, you will get very confused with the numbers. Our dosing methods are based on the human meters.
If you are using a human meter we recommend new diabetic caregivers don’t shot under 200 to start with until they gather some data. This is where you would stall, don’t feed and see if the BG is rising.
As you lower the carb content of the food, it will affect the amount of insulin you are giving so you need to be extra vigilant when transitioning the food to lower carb. Another reason to get those tests in during the cycles:)

With the kidney disease, they don’t need low protein until it is very advanced so a low carb diet is fine for a diabetic cat with kidney disease. We have quite a few here with kidney issues. What is better is to look for lower phosphorus foods. Weruva has a new line out which is very low phosphorus and low carb. Lookup their website.
Also you can look for low carb, lower phosphorus foods in this FOOD CHART
Look for foods that have under 250 or under 200mg phosphorus per100kcals.
Or you can use a phosphorus binder. But do give 10% or under carb content.
Keep asking lots of questions.:)
 
Thank you Bron. I appreciate the advice.
I will reduce the dose to 2 units tomorrow morning. I was planning on doing a glucose curve tomorrow; will watch him carefully. I will also start getting some blood glucose readings during the cycles - I had realized others were doing this and had been planning on doing that more (this week was difficult and I did not expect his numbers to drop like this.)

I will post back tomorrow, and post his readings.

I'm using the pen as a vial; drawing the insulin with a syringe.

I'm feeding him a variety of foods so difficult to give you an exact carb amount. He had a crisis mid-March (severe constipation) and only wanted Fancy Feast Medleys for a while. FF is bad for kidney disease because of high phosphorus (in all varieties), plus is fairly high carb. The last few days I've been giving him a mix of Weruva WX Phos Focused which is a very low carb food (and low phosphorus); some Fancy Feast pates (lower carbs than medleys) and about 1/3 of a Fancy Feast Medley, because he is not too interested without the FF Medley added in. (Usually 3 different foods mixed together in about equal proportions.) Today was the first day I tried the Purina One Grain Free - he ate maybe 1 ounce of that about 45 min before PM blood glucose reading. He had had the mix of the other 3 varieties a few hours earlier.

He is a grazer. He doesn't get free fed because I have another cat, but he comes to me and wants food, or I give him food. He won't eat all that much at once, and to keep his weight up (kidney cats tend to lose weight), I have to feed him more than 2-3 times a day. But, I will be sure to not feed him for the 2 hours before the preshot BG.

His meds / supplements (most are based on recommendations and practices for kidney disease; felinecrf.org has provided a lot of guidance)

Fortiflora – as needed, sprinkled on food; has some vitamins plus one probiotic strain
Renal K+ (powder as of Apr 10 2023; wasn’t fond of gel) – potassium supplement

Swanson’s Activated B-complex – 1/10 of capsule. Swanson Ultra Activated B-Complex High Bioavailability (started early Apr 2023)
Vitacost Methyl B12 capsules – for possible diabetic neuropathy, and anemia. Tanyacrf mentions people have reported it helps with constipation. (started early Apr 2023)
Weekly: ½ ml of cyanocobalimin (B12) injected into port of SubQ fluids. 1+ year
Miralax - about 1/4 - 3/8 tsp total, spread out across 2-3 meals per day (1+ year)

PhosBind: started Apr 14 2023

Ondansetron: 1 4-mg tablet every 14-18 hours (anti-nausea) since mid March
Cisapride: 0.25 ml (compounded liquid) every 14-18 hours (colonic motility; as needed to prevent constipation) since mid March
Lactulose: 2 ml every 8-16 hours, as needed (constipation) since mid March

Elura: 0.4 ml every 24 hours (as needed); appetite stimulant (since mid March; Didn’t give him this Apr 14 or 15 2023)

Lantus insulin: currently 3 units twice daily (since Mar 13 2023)

Lactated ringers solution (SubQ fluids) about 120 ml daily


Food: Mixing Weruva RX with some Fancy Feast varieties, aiming toward lower carb content. Know FF is high in phosphorus but it’s what he’ll eat. Apr 15: first try of Purine One Grain free
 
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Thanks for the 2nd note Bron.

I just pulled out the AlphaTrak 2 because I wanted to be sure the Relion was giving accurate numbers.

I will follow the guideline to not give insulin if BG is under 200, at least until I get more experienced.

I know phosphorus is the biggest issue with kidney disease, and he had been on fairly low phosphorus foods until his mid-March crisis. After that, he wasn't interested in those foods - all I could get him to eat for days was the Fancy Feast. And eating was more important than phosphorus content at that point. Up until his March bloodwork, his phosphorus numbers had still been low enough to not require the phosphorus binder. But with the phosphorus level from mid-March bloodwork confirmed by mid-April bloodwork, I've just started adding PhosBind to his food.

I agree that some high quality protein - around 35% , is ok for kidney cats (he's stage 3, mid to high end of stage 3). But I'm a little more concerned about getting him to 40 - 45% protein; I've read some of the scientific literature on feline diabetes, and it seems that level of protein could be more problematic. On the other hand, carbs are definitely problematic for diabetes. So I'm stuck trying to juggle 2 diseases with contradictory dietary needs. I am trying to get him to eat higher quality animal proteins (and not plant proteins) - I think that (higher quality animal proteins) might alleviate some of the concerns of a very high protein diet for kidney cats. I'm going to try adding in some YoungAgain Zero LID (once I get it) based on a recommendation I got from someone. I'm trying to walk a fine line here ... I've read the veterinary scientific literature and know people have argued against both protein and phosphorus. My take (from the literature) has been that phosphorus is the much bigger concern. But, adequate research is lacking (as is always the case in the veterinary world, esp. with cats).

Up until his midMarch crisis, I had been feeding him some Hills KD, but mainly lower phosphorus varieties of canned Science Diet. Those were helping to keep his phosphorus down. But, I've since learned (now that I'm also concerned about diabetes), those foods are pretty high carb - higher than Fancy Feast! So just as well he's not interested in Science Diet.
 
We also don’t go up and down in 1 unit increments. Unless the nadirs are greater than 300, we go up in 1/4 unit increments (0.25 unit).
That is why I was asking you about whether you use a syringe or the pen to give the dose.
 
Hi Bron,
Thanks again for your replies and advice; I feel a lot better about tonight's decision, and dropping his insulin dose.

His nadirs in his first 2 glucose curves were greater than 300, but I'll keep in mind the point about increments relative to the nadir. At the time, I was following my vet's advice who is knowledgeable but not a diabetes expert. As I've read more, I've started realizing fine-tuning insulin is important. My vet sold me full unit (not half unit) syringes, so I need to order half unit syringes.

My vet also has advised that for diet, I should focus on the kidney disease, but I clearly don't fully agree with that (he sees 2 vets at the same clinic; they work cooperatively with each other). I'm definitely less concerned about protein than I think my vet is. I've been looking for lower carb foods with lower phosphorus (those are hard to find - there's one list out there that I've seen, but it's very out of date, and about half the foods on the list are no longer available). There are some journal articles that say to focus more on kidney disease dietary needs, while others say the opposite. I'm trying to find that golden middle where I find the perfect balance.

I was blind-sided by this diabetes diagnosis (didn't even know what a 'nadir' is initially), plus at the same time was dealing with the cat's constipation crisis (4 vet or tech visits in a week), so initially, just did what the vet told me to do. But fairly quickly started doing my own research.
 
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These are the insulin syringes you need to get U100, 3/10ml, 30 or 31 gauge, 6 or 8 mm insulin syringes with 1/2 unit markings.
BD is a good brand and you can get ReliOn ones at Walmart but make sure they give you the 1/2 unit markings ones.
The link to the food chart I gave you should be good.
Have you thought about joining this site for CRD information https://www.felinecrf.org/
 
@LauraZZ
Have you tried these if he likes pates, the
I know that Petco sells single cans for sure , maybe PetSmart so you can try them out and see if he likes them

As for wet food for cat that are diabetic and who have kidney disease you can try these
You can check these out from Weruva BFF like

One of our members put it together
BFF play chicken Checkmate
Protein 31%
Carbs 5%
Phosphorus 129%
BFF play chicken & turkey topsy turvy
Protein 32%
Carbs 5%
Phosphorus 129%
BFF play chicken cherish
Protein 31%
Carbs 5%
Phosphorus 135%
BFF chicken & turkey tiptoe
Protein 31%
Carbs 5%
Phosphorus 136%
BFF chicken duck & turkey take a chance
Protein 32%
Carbs 5%
Phosphorus 149%
BFF play chicken & lamb laugh out loud
Protein 31%
Carbs 5%
Phosphorus 154%
BFF play chicken & duck destiny
Protein 32%
Carbs 5%
Phosphorus 165%
BFF play chicken & beef best buds
Protein 33%
Carbs 5%
Phosphorus 171%
With weruva foods
You want the metabolizable energy profile percentage of carbs to be less than 10%, and the phosphorus which Weruva lists in Minerals to be less than 250 mg per 100 cals. So you have to look at two different places in the Weruva charts.
https://weruva.com




When you go to the weruva site and click on one of the pics of the food , click on Detailed Nutrition information that is under guaranteed analysis to the left
YOU WANT CARBS UNDER 10% AND PHOSPHORUS IDEALLY LOW 200's OR LESS
 
Just wanted to let you know that the new line Weruva came out with called WX Phos Focused Foods are not a complete and balanced diet
I copied this right from the Weruva site
This food is not complete and balanced and should not be fed as the only meal to cats on an everyday basis.
 
Thanks Diane. I discovered the Weruva WX Phos Focused foods about a week ago. Mentioned above I've been mixing them in. Thanks for the other suggestions and detail about reading the Weruva charts for phosphorus content.

Thanks Bron. I agree the felinecrf site is excellent; I've been using it for 20 years (had a kidney cat back then). In last year, have read it thoroughly again, since dx of my current kidney cat.
 
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