10/18 Keiko's new insulin - not working?

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KeikosHuman

KeikosHuman

Member Since 2014
I wasn't sure where to post this question. I started Keiko on a new vial of insulin yesterday (5 units). I spot checked him and his BG did not vary much - I tested him 4 times and he remained between Alphatrack 513 at +4 (AM)- and 483 at +9 (AM) (384 and 362 human) . Evening +4 was 485 (364).

Today I went back to the old insulin (5 units). He started at AMPS 493 (370) and at +5 he was 413 (309). I will check again in a little while. This insulin seems to getting more of a response. He has been difficult to regulate making it more complicated. Am I crazy? Any ideas?

Thank you.
Maria
 
Hi maria!

i don't think you can tell anything from one day on a new pen - although if there was a huge difference in effectiveness with a new pen you might, ie, if the old pen was really toast. Can you put it on your ss when you start a new pen - that can be valuable information. If this was your original pen and it's 4 months old, it might be time for a new one. Some people can get 6 months out of a pen, some get less than that.

It'd be helpful if you list every date on your ss from now on, even if you don't test. That way when we look at the ss, we can see easily when there are skipped dates and aren't thinking these BGs are all from consecutive days. I would always encourage you to get one test before every shot and one other test in every cycle, so 4 tests per day, just to see what the dose is doing. It's much cheaper to go with a human meter, even considering the cost of buying a new meter. That's why most people switch to the human glucometer.

I'd encourage you to stick to increasing per the protocol. It looks like you are thinking 5.0u is a maximum dose, and it's important to just give a kitty what they need. Punkin got up to 15.5u per shot. Some cats go to even more than that. Often a cat will not respond much to the insulin, even if you're increasing the dose, until you seem to hit the "sweet spot" and suddenly things will fall into place and the BGs will shift into a lower range.

The protocol guidelines are used by evaluating the nadirs (how low the cat goes in each cycle) over the past 3 days or so, and comparing it to the guidelines here on the Tight Regulation Protocol. Remember that the blood sugar numbers given here are for a human meter, so using an Alpha Trak, you would multiply the AT number by about .75 to get an approximate human meter equivalent.
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.
After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
Click to expand...

Keiko's getting nadirs of about 400ish on the AT. 400x .75 = 300 on a human meter, approximately. Comparing to the protocol guidelines above, I'd increase his dose by 0.5u. Go 6 consecutive cycles at that dose, getting a mid-cycle test in each cycle (doesn't have to be at exactly +6, sprinkle your tests around from +3-+8 or so), then repeat the evaluation process.

If he's still consistently having most of his nadirs over 300, repeat the process and increase by another 0.5u.

These are pretty high numbers and not good for his body. It would be good for him to be getting into lower ranges. I'd keep plugging and re-evaluating every 6 cycles until you're getting his blood sugar into normal ranges, which on an AT is roughly 68-160ish. Don't get stuck on thinking he "ought" to be able to get there on a particular dose. He will just need as much as he needs. Sticking with it he WILL get there - you just have to be persistent.

It can be very discouraging to feel like your cat isn't responding, but he will. Keep posting and we'll help you figure out how to move ahead! One foot in front of the other gets you to your destination. :YMHUG:
 
Thanks Julie.
This was a new vial from Canada.
I was unable to get the pens with the discount card - pharmacy said it would not accept because it was an animal.
He's due for another increase next week. I just hate to be using bad insulin (if it is bad). The pharmacist said there was no way to know with a new vial (?!!) Seems like there should be some way. He said the dose may need to be adjusted.

Thanks again.
M
 
was this only your second vial? what i'm asking is, was your last insulin 4 months old? If so, I'd probably stick with the new insulin.

How are you deciding that he's due for an increase next week? When you stay too long on a dose that's not getting a cat into normal numbers, it just increases the glucose toxicity, and then it takes even more insulin to move him. Increasing him more quickly will mean that the overall process of finding the "right" dose will happen a lot faster and he'll get into normal numbers sooner. The speed of the protocol's suggested increases is safe to go by and it helps prevent glucose toxicity.
 
Hi Maria, I have looked back through your post, and I have not seen anything suggesting that you are testing for ketones. With a kitty in consistantly higher numbers(over 250), it is a good idea to get a ketone test when possible. You can pick up the strips at any pharmacy usually. Just a FYI. :smile:
 
The increase protocol is with my vet. We increase. .5 units every 7days. She's concerned about symogi. At the start 5 months ago we were increasing by 1 unit per week. Then the dental cleaning around 6 units which I was told might help his response. After the dental the vet wanted to start over at a low dose and here we are. I don't think the dental did much for him looking back. Other cats may benefit.
M
 
Maria:

The dosing strategy that your vet is using may be way too aggressive for Lantus. I'm attaching a copy of the veterinary journal article that describes the Tight Regulation Protocol and the research to support it.

The maximum increase for a cat who's numbers are above 300 is 0.5u. The problem with increasing in too large increments is that you can miss what would be an effective dose. Unfortunately, too little insulin and too much insulin can look pretty much the same.

As for Somogyi, there have been a number of discussions on the topic over the years. The difficulty with the idea of Somogyi is that there is no definitive research to support its existence. The original research was done in 1938 and has never been replicated in humans, let alone in cats. Further, there's been no research into it with newer insulin, such as Lantus.I've copied a portion of what I posted to Marje/Gracie back in December of 2010 when Somogyi was being discussed.
The topic of Somogyi came up some time before you joined the Board. Both Jill and I did a lot of lit searching. I have access to both a medical and veterinary library system. For a theory that has so many people convinced that it is a factor in human as well as in feline diabetes, there is an amazingly small amount of research on the topic. The earliest paper by Michael Somogyi, is from the 1930s and was not published in a widely recognized medical journal (i.e., it was in the Weekly Bulletin of the St. Louis Medical Society). Note that this was a report based on 5 human subjects and urine glucose, not blood glucose was measured. More recent reports note that Somogyi's observations have not been reliably reproduced under controlled conditions.

Gale said:
Although some patients had a very rapid fluctuation from hypoglycaemia to hyperglycaemia, we found no evidence that changes in counterregulatory hormone levels were responsible.The preceding interval of hypoglycemia was often prolonged, which implied defective homeostasis, and the difference between the patients with apparent rebound and those without could not be explained in terms of circulating levels of cortisol, growth hormone, or glucagon. Other workers have noted very variable changes in growth-hormone and cortisol levels after acute hypoglycsemia in unstable diabetics. We did not measure catecholamines and cannot rule out the possibility that they were partly responsible for the difference between our groups. However, the evidence presented here suggests that free insulin is the major factor involved.
Click to expand...
The bold is mine. It points out that there is no evidence for what the vet is suggesting about "stress" hormones (i.e., cortisol).

In addition to the dearth of empirical research, there is even less that pertains to cats and none that addresses Somogyi phenomenon in the use of Lantus. Given that the presence of Somogyi is believed to be associated with doses that are raised in too large of an increment, it is surprising that this IM vet would not be an enthusiastic supporter of the Queensland/Rand tight regulation protocol. (FYI - there is another TR protocol and the vet may have assumed this was the one you were referring to.)

This is a link to info on Chronic Somogyi Rebound on Wiki. I would draw your attention to the section on Controversy:
Although this theory is well known among clinicians and individuals with diabetes, there is little scientific evidence to support it. Clinical studies indicate that a high fasting glucose in the morning is more likely because the insulin given on the previous evening fails to last long enough.[5] Recent studies using continuous glucose monitoring show that a high glucose in the morning is not preceded by a low glucose during the night.[6] Furthermore, many individuals with hypoglycemic episodes during the night fail to wake due to a failure of release of epinephrine during nocturnal hypoglycemia.[7] Thus, Somogyi's theory is not assured and may be refuted.
Click to expand...
Click to expand...
This information pertains to humans, not cats. However, the phenomenon was based on humans and extrapolated to felines so I'm going to presume the issues with the paucity as well as quality of the research are the same.
 

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Sienne,
I'm confused. We are increasing in .5 increments. Isn't that what is recommended? I'll read more closely and look at the article and share with my veterinarian.

I posted more in the spreadsheet for the last few days. I gave him new insulin one day then old the next. I may be wrong but don't think the new insulin is not moving his BG. The old stuff brought him down into the 300s. With the new he stays in a narrow range in the 400s (I know its not a full curve). I'm inclined to buy another expensive vial -ugh- after spending $$ for this vial. I know its too much to ask whether anyone agrees with me -that it seems not to be working. I have a call in to the place where I bought it but they likely won't replace (we don't let you return things) and I'm not sure I trust them.
I could also be wrong and it's Keiko's body.
This is the craziest situation I've ever seen.
M
 
Julie,
The vet has me check him with a full curve every 7 days then we increase his dose by .5 depending on the results. I'll look at the article mentiioned. My main concern right now is whether this new insulin is doing anything for him. (see post above).
Thank you.
 
Hi Maria,
I hope Keiko will begin to respond to the insulin. I know that this is frustrating for you. I'm confused by the gaps in your spreadsheet. Did you give insulin on the days that are not listed? Or did you simply not test? I am also confused by the fact that you never seem to test at PMPS. The pre-shot tests are important indicators of how a cycle will progress.
It is possible (probable) that by increasing the dose by a whole unit during the early days of Keiko's FD adventure he may have missed his good dose and got stuck in high numbers. I am reminded of my experience with my previous diabetic cat, Stu. His vet increased him by many units over a short time with no effect on his numbers--until he crashed. We almost lost him, and would have if I hadn't found this board.
Please study the protocol and ask your vet to read the professional article Sienne cited.

Don't give up hope. Perhaps you can find a pharmacy that will sell you a single pen. A hospital pharmacy is a good place to inquire. That way you will be able to have another pen to compare with the vial you suspect is bad. I must confess that I don't see any appreciable difference in the numbers between the tests done with the old vial and those done with the new.

Hang in there!

Ella & Rusty
 
Ella & Rusty,

The gaps mean he had insulin but I did not test. I was told originally to do a curve once a week. I have done some spot checks too but have stuck to the 1 curve a week situation for the most part. Expense is one barrier to more testing but I'm looking at a human meter.
 
Just a stray thought, but there is a phenomenon we call New Dose Wonkiness (NDW), where upon raising a dose the numbers can actually go up for a few cycles until the shed re-balances. Using a new vial of fresh insulin could have the effect of a dose increase if the old one was loosing strength. I'd give the new on a chance for up to 6 cycles. Every time I raise Tess's dose she goes up for 5 cycles and magically comes down on the 6th.

Re new pen: Several members have had luck getting a single pen at Target and have had the discount card accepted for a pet there too.
 
Maria:

What about a compromise to get a better handle on what's going on? Before deciding there's a problem with the insulin or anything else for that matter, I think you need a lot more data. With a curve only once a week followed by an increase, you have a single snap shot of 7 days x 24 hours of potential data. With the way you're testing, you're missing a lot of information. What I would suggest is to take a look at a lot of our spreadsheets so you have an idea of how people test. People test differently. I test a fair amount because Gabby has a history of taking nose dives early in the cycle. However, with Tight Regulation, you want to test at pre-shot times plus at least once during each cycle. If you want to test more, that would be great!

I think by testing several times a day over a few weeks, you'll have a better idea whether Keiko is stuck in high numbers or whether what you're catching when you do a curve is a day when there's some bouncing from lower to higher numbers going on. When a kitty goes into a lower range and their body isn't used to being in lower numbers, there's a rebound into a higher range. The numbers can stay there for up to 3 days.

The other advantage of getting more data is that I know I would feel better knowing that you've got some spot checks to insure that Keiko's numbers are in a safe range.

In response to your question, if the nadir is generally above 300, the protocol advises that you increase by 0.5u. However, the assumption with tight regulation is that you are testing more than once a week.Basing a dose-related decision on one data point can be misleading. Just as an example, early on, Gabby would do things like have her AMPS in the 400s, drop into the 40s by nadir, and be back in the 400s by PMPS. If all the test data I had was her pre-shot values, I would have increased her dose. Knowing that her nadir was in the 40s meant that I needed to decrease the dose.
 
Thanks Sienne. I'm working on getting this right.
I'm not sure I'm seeing people's spreadsheet links in their messages. I'll get out of this message and take a look.
 
sounds like you're really frustrated. I don't blame you. it's really tough when your cat isn't responding to the insulin the way you think they ought to be, and the way you see other people's cats responding. Punkin had acromegaly - and I had plenty of frustration with that.

Sienne's suggestion about getting more data in so you have a better picture of what's going on is excellent. Data doesn't lie. You don't know quite what's going on because you don't have enough information yet.

Here are a few possibilities:

- Keiko could be Bouncing on your curve days. Bounces can last up to 3 days, and if the curves happen to be during a bounce, you may be thinking he's always high, when in fact he might just be high on that day.

- Keiko could be having New Dose Wonkiness - which Ann mentioned and is described in that same link as bouncing above. Although if you're doing the curve after a week at a dose, it would be resolved by then. NDW shows up after you increase a dose, not several days later.

- Keiko might not be getting enough insulin yet - he just might not be at a good dose yet.

- Keiko could be overdosed. Looking at his spreadsheet though, the only yellow on there is when he was at 6.0u - my gut feeling looking at that is that he isn't overdose, but likely underdosed.

- the insulin could be bad. I'm not feeling that one, though - because his numbers on the last pen are basically the same as the 2 days you've had on the new insulin pen.

What we've found to be most helpful in getting a good picture of what the insulin is doing in a cat's body is for a sprinkling of tests throughout the 24 hrs. That actually gives us more of a picture than doing a curve every 2 hours once a week. Think about a jigsaw puzzle - it's a great metaphor for the spreadsheet. Let's say your puzzle is 24 pieces across from side to side. When you have three horizontal stripes across a jigsaw puzzle, even if you have every piece in that strip, you still might not have a good idea what that puzzle picture is. On the contrary, if you took those 24 pieces x 3 stripes and traded them in for the 72 pieces that were scattered across the puzzle, you'd have a great idea of what the picture looks like.

That's what a sprinkling of tests does for us - we can make educated guesses about what's in between the tests, based upon what is there. The best tests to get are always a preshot test to make certain it's safe to shoot, and one other test in the next 11 hours - move that test around from cycle to cycle so we get an idea of what else is going on. Four tests a day is enough to get a pretty good picture. The data tells us what's going on and can help us help you figure out the dose.

The cost of the AT strips is the reason that most everyone switches to a human glucometer. A human glucometer strip will cost you as little as 10 cents. I haven't bought them in a long time, but people here are masters at stretching $$ to take care of their diabetic cats. Everyone is in the same boat on the costs of taking care of a diabetic cat. Many people buy one of the walmart meters - a Relion Confirm or micro - Some of the models are new since punkin passed away, so i can't speak to the "best." But I used a confirm and then bought strips through American Diabetes Wholesale - I was getting 250 strips (buy 4 boxes of 50, get 1 free) for about $60, or 24cents per strip. There is also an Arkray generic meter available from ADW that is inexpensive and has generic strips - that's likely the best bet. It's the cost of the strips that keep people from testing - the AT strips cost about $1 each.

The cost of doing a 7 test curve using an AT in one day/week would be $7 if they are $1 each.
Using a human meter, 4 strips a day at 24 cents is $1 per day, or $7 per week.
So the end cost to you would be the same, but you would have so much more information for your money!

These Terumo Syringes are about the least expensive around, but the markings were also the most accurate in a comparison test that Marje did. Many people like them and they may save you a little money.

You can register at http://www.mrrebates.com and get rebates on what you buy at ADW, or you can use the "shop" button at the top of this forum to purchase at ADW and this site gets a small commission. When I started they didn't have that relationship, so i went through mrrebates and i have gotten many $30 checks back on what i spent at ADW.

I hope some of that helps you. I think a little more information will really help make it clear what direction to go with Keiko. Hang in there, maria - it gets easier when you have more information and the decisions are a little more obvious!
 
I have ordered a human meter.

K's BG is in the mid 400s (Alphatrak) still with one check today. I guess doubting the insulin has come up because I bought it from a Canadian pharmacy. Doesn't mean its bad but its somewhat of an unknown and the dose increase and seemingly flat numbers ... nailbite_smile I'm surprised you see them as the same. I don't have as much experience here.

Thanks so much for your support!! Keiko says thank you too cat_pet_icon
 
you're welcome! it's difficult enough to understand FD with people teaching you - i don't know how anyone can understand it without coaching. that's why so many of us check the board every day to teach new people.

We usually start a new thread every day - that keeps the information manageable. When you're ready to post again, go ahead and start a new thread (condo).

I think you'll be happy with a new human glucometer.

Have a great week, maria!
 
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