? 14yo Siberian deregulating recently

yacoob

yacoob

Member
Hello there,

We're living together with a soon-to-be 14 yo diabetic Siberian, who's recently has lost his regulation. Vet suggests higher insuline doses, I'm concerned about cat's pre-shot levels. Read on for details.

Muta has been diagnosed with diabetes ~2y ago. We knew it'd happen at some point, as his pancrea is underdeveloped, and he has had related problems as a result (exocrine pancreatic insufficiency, enzyme supplementation for the food). Once diagnosed, we had problems getting his levels stable; we succeed after switching his diet to wet food only (4 pouches of Royal Canin Diabetic per day). He'd still try to steal dry food from two other cats in the household. His "stable" situation was around August last year:
  • 1.5u Prozinc every 12h
  • 2 pouches of Royal Canin Diabetic every 12h
  • pre-shot morning average levels of ~10mmol/L
  • "sensible fructosamine levels" (don't have an actual value here, vet's wording :)
On the way there we've changed the diet couple of time, scored a couple of mild hypo episodes (primarily disorientation, no severe symptoms). Forward to last month. He destabilised *slowly* over time since ~February or so, to arrive at situations where he'd routinely get >25mmol/L blood sugar levels pre-morning shot. The blood test results were seemingly normal, not indicative of any infection that might have contributed. The fructosamine levels were off the chart, which prompted vet to suggest an insuline dose increase. We've increased the dosage to 2.0u, and things improved a bit. Problem is, the pre-shot levels are still fluctuating, sometimes reaching 20 and above. The average hoovers around 11, but there doesn't seem to be a solid baseline. For example, here is a week worth of measurements, mid May (two measurements, morning and evening pre-shot):
  • Monday: 8.9 - 7.8
  • Tuesday: 5.9 - 8.7
  • Wednesday: 16.1 - 5.9
  • Thursday: 15.8 - 5.2
  • Friday: 14.3 - 5.2
  • Saturday: 6.2 - 7.6
  • Sunday: 4.3 - 25
The vet ran a curve, and wasn't happy with the result (pre-shot: 8.7 - 9.3 - 20 - 20.4 - 14.1 - 11.9). They've suggested further dosage increase, up to 2.5. Which makes sense in the light of high values through the day, but the lows are worrying. I'm unsure what causes those. The highs, I'm suspecting it's the dry food he steals from the other cats, every now and then.

As you can expect, there's plenty more medical history to narrate here, but the primary problem I have right now is reconciling the narrative from the vet, who seem to be OK with the low pre-shot results and my own anxiety about hypo episodes. I'm still waiting for the results of fructosamine test done after 3weeks of 2.0 dosage. I don't have any way of providing monitoring through the day, and I'm really anxious about the cat hitting a hypo when there's noone around to help. I have historical records of his blood sugar levels, primarily on paper though, so I can dig up data on demand :D

Opinions and ideas most welcome!
 
Oh, one extra bit: physically he's quite keen for a 14yo. He spends a lot of time sleeping, but in the activity periods he plays with toys, other cats and is otherwise social towards both cats and people. During the deregulation period he got more lethargic, this has improved after switching to 2.0u dose.
 
Hi Yacob-

I have a zillion questions, but first and most important, would you mind getting our spreadsheet set up and enter the data you have from the past couple of weeks? You'll want to follow the directions for the "world" spreadsheet, and make sure you use the one with the correct meter (human or pet meters) Here is the link: http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

Once that is set up, we can take a look and see what it might tell us about dosing. I have a couple of hunches, but want to see the data first.

What country are you in? The diabetic foods are often not the best option for diabetic cats, so if we know what country you're in we can see if anyone knows of foods that might be available there and might work better. You'll want a food that is less than 10% carbs. There's nothing magical about the foods that are marketed for diabetics, and they are often higher than that. I'm not sure on that one though. Do you happen to know?

What other health issues? Different health problems impact numbers in different ways, so knowing what else we're dealing with will help guide dosing.

Any chance of getting all of the cats on low carb food? Even a few biscuits here and there can mess up the BG for a few cycles, so it's really important to stop the dry food theft and the easiest way to do that is to get it out of the house. Cats are incredibly talented thieves! :cat: No matter how vigilant we are, they usually find a way.

Are you (or anyone else) at home during the day? Or are you gone the whole 12 hour cycle? To adjust the dosing, we really need to see data from the mid-cycle. If you're not home during the day, we can talk about alternative plans. The numbers from the vet are helpful, but they are just one cycle, and without data from the cycles before and after that, it's difficult to know what to make of it. Vets often make that mistake of adjusting dosing based on fructosamine, or based on one single isolated cycle.

Okay, that's already a lot, so I'll stop for now. Let us know once you get that spreadsheet going, and we can take a look. You don't need to enter all of the data from the past two years, of course! If you could just enter whatever you have from the past two weeks, that will be enough to get started. :)
 
I guess I'll start with the most important information: cat's name is Muta and you can now see him in the profile picture :>

Here's the sheet - I've added data since 1st of April, to show the complete unregulated state in contrast to the current one.
As for his health: he has EPI, as a result of his pancreas not developing properly. We have caught this in 2008 after he has lost 50% of his mass (7->3.5kg), and it took us some time to diagnose it properly. Since that point he's been on pancreatic enzyme to help him digest the food. Diabetes was an expected development once he got older.
Other than that, he's slightly rheumatic and is taking joint support (Yumove, one capsule per meal). In the past the amount of this joint support has made a difference in his blood levels. He has mild gingivitis; about 1.5y ago he had a dental procedure to remove the plaque, and it also helped bringing down his sugar levels. Right now vet says the cat qualifies for another dental, but the anaesthetic risk rules that out.

As for the food: it's kind of hard to find good information about its composition and the exact numbers. It was missing from the popular food list going around on this forum (Royal Canin Diabetic wet). The composition seems to be: Crude ash: 1.2%. Crude fibre: 1.5%. Crude oil fats: 3%. Moisture: 82.5%. Protein: 9%. Popping that into various calculators available online gave us ~14% calories from carbs, which seems bit high. In the past he had some problems with different kinds of food (vomiting, diarrhoea) so once we've established that the diabetic wet RC works for him, we sticked to that - it was better than the dry kibble. It comes up bit expensive, but this was essentially the price of keeping him stable. I don't think I'd be able to keep 2 other cats on the same diet though - that'd be prohibitively expensive. We purchase from zooplus.ie, so I guess we can experiment with whatever's there. We use Sureflap feeders which eliminates stealing, but not entirely. We'll need to improve on that, unless we normalize the diet for all three of them.

We don't have a reliable way of monitoring Muta through the day. We can do it ad-hoc, for 1-2 weeks when needed (and have done so in the past), but in general cats are home alone through the day. I've only now started to check his bloods mid day - but the curve the vet has gotten is probably indicative of general situation (modulo stress caused by the visit). Quite unexpectedly, right now he's the lowest before shot (down to 3.1mmol/L), and quite high during the day. This is quite worrying, and I don't understand what could be the cause here. I'm inclined towards increasing the dosage, but the pre-shot low levels are concerning. Vet is adamant that as long as Muta eats his food, and doesn't have any gastric problems, it'll work just fine. My anxiety remains skeptical :/ I'm pretty sure that me not fully understanding the situation is part of the problem - I cope with the situation better when I have a handle at what mechanisms are at play. Muta's lack of expected blood sugar curve is perplexing to say the least.

Last but not least: since the diagnosis Muta has scored maybe 7 mild hypo episodes. No seizures, no loss of consciousness, just lots of confusion, walking around and bumping into things. Every time we counter it with quick application of honey, and hand feeding of chicken or normal wet food (as he can't feed on his own while confounded). Last episode happened in January, just before destabilisation. Most of the episodes happened due to lack of food (eg. he has thrown up), at least two happened for seemingly no reason at all. Somogyi rebound maybe?

The decision to take right now is to whether to continue upwards with 2.5u dosage. Logically, narrative presented by the vet makes sense. Their reasoning is that out of three risks: general anaesthetic for the dental, doing nothing and potential hypo episode after dosage increase, the last option is the least bad. As much as I agree, the emotional factor of potentially causing a hypo and not being available to sort things out is affecting my rational response. Yay for logic vs emotions :>

Thanks for your help!
 
Oh goodness no! Do NOT increase the dose! This was my hunch, but it's even a bit worse than I expected. Your kitty is being overdosed right now. The inconsistent numbers you're seeing are the result of too much insulin and his poor little body fighting back to try to keep himself safe. Please lower the dose right away. I hope that you skipped the dose on that very low PS number for your evening cycle.

Please read through the stickies at the top of the forum that explain how we approach dosing here. You will quickly see that I'm going to be recommending several changes to what you are doing.

First of all, lower the dose to 1u for your next shot, but only give a shot if he is over 150. If he's below 150, please skip the shot. We're going to need to essentially start over and give Muta some time to recover from the overdose of insulin he's been receiving.

The food situation sounds like it's probably fine as far as the food he's getting. A little high, but that might be what has been keeping him from having a symptomatic hypo, so don't change food until we sort out the insulin situation. We only change one thing at a time around here, and right now we need to change the insulin dose.

Will you be around this weekend to do some extra testing? I would love to see how he's doing mid-cycle at home.
 
I must say that I'm confused; how would an overdose result in high blood sugar numbers? Surely they'd flatten out and got very low, if the dose would be too high?
For what it's worth, he's been doing really well in the past on 1.5u. Past February, the numbers went all the way up, and adjusting to 2.0 brought them down at least a bit. The pre-shot values are not the reason I'm concerned; it's the fact that he has lost weight recently, plus the few spot checks mid-day we've done were all high and higher than the morning value.

Yesterday evening he was 9.1 PMPS, so I gave him the usual dose of 2.0. Today 5.6 AMPS - he ate, and most likely throw up a little bit (maybe ~1/15 of the total). Skipped the shot as per your advice, will test during the day, but I expect to see sky-high numbers without the insulin.

Lastly: there's a decent time lag between us, so my answer to your questions could be bit futile. Yeah, I'm able to stay at home this weekend and see how things play out. It's also already weekend. :> The evening shot will arrive before you'll have a chance to look at my answer. I'd appreciate if you'd lay out the plan you have in mind a bit further ahead so I can understand it better and get as much information as possible from this.
 
Hi Yacoob - yes, I expected that would sound strange. Have you read through all of the stickies now? Those will be your guide when no one is around to respond. While we often vary from those directions, they are written and designed to keep a cat safe, so they are good directions to follow if you can't get timely in-person responses. This forum is small, so even if you were in the same time zone, there is often a lag between asking a question and anyone being online to respond. The stickies are an important resource, so as you've read them, please ask any questions you have. There are a few places where they get a little confusing.

Here is a short explanation of what I believe is happening for Muta:
1. BG goes low OR lower than usual OR drops too quickly. Anything in the lime green colors is "too low". Not necessarily a symptomatic hypo, but too low to be safe and needs to be brought higher. A normal healthy non-diabetic cat will be between 3.8-8.3 (68-150).

2. Kitty's body panics and thinks there's danger (OMG! My BG is too low!).

3. Complex physiologic processes take glycogen stored in the liver (I think of it as "bounce fuel"), convert it to glucose and dump it into the bloodstream to counteract the perceived dangerously low BG, and the BG rises. Sometimes dramatically.

4. These processes go into overdrive in kitties who are bounce prone and keep the BG propped up varying lengths of time (AKA bouncing).

5. Too high a dose of insulin can keep them bouncing over and over until the " bounce fuel" runs out and they crash - ie., have a hypo episode. That's why we worry so much about kitties that have had too high a starting dose prescribed by the vet.

6. Many vets have little/no understanding of the bouncing phenomenon. And quite honestly, many vets have very little understanding of how the insulin actually works, or of feline diabetes in general. They often treat it like diabetes in dogs which is quite different, or they'll read about one insulin, and plan treatment around that knowledge, not understanding that different insulin types can be quite different from each other.

This is the process that is causing the inverted cycles that you're seeing - where he is higher in the middle and lower towards the ends. His body is fighting back against the insulin.

Now it's quite possible that Muta will run higher today. If so, that will give us important information about what's going on. It's also possible that he'll run nicely for a couple of cycles and then start to rise. It's also possible his BG might be rather inconsistent for a little bit. It's okay. We just need to give him some time to recover from what's happening right now and then we can work on finding his new "right" dose range. As for his history - needs change over time, and sometimes rather quickly. Cats are incredibly resilient and they are also incredibly fragile. So their needs can go up and down. In addition, your cat has a couple of conditions that can cause increased and inconsistent numbers, so those could be in play here too. We'll need to work around such things as we sort this out. It's going to take some time and patience here. Since insulin is given every 12 hours, the process of sorting out and adjusting is rather slow, and because the body is so complex, it can often feel like we are chasing a moving target. Patience is going to be essential, and you may always deal with some inconsistency in numbers, but we can hopefully at least get rid of the inverted cycles and keep Muta safe.
 
Thanks a lot for the narrative, it helps a lot in paint a picture of what's happening. I've read about this "emergency sugar dump" that can be induced by different things. I've always thought that this is a one-off thing - eg. that those are transient situations, happen once and that's it. I've never considered a chronic, permanent situation like that. I've found a description of matching situation here:
https://www.aaha.org/guidelines/diabetes_guidelines/interpreting_glucose_curves.aspx
with the main difference being there's an initial drop *after* the injection. In Muta's case, if this hypothesis is true, it looks like the bounce is prompted by the tail end of the cycle (eg. low number just before the shot) which is bit weird, as by that time the insulin should be done...

On the pragmatic side: with no insulin in the morning, Muta's sugar mid cycle is high as expected (25.7), and he's going to be high in the evening. Sure enough, I can give him 1.0u. The question is, what to expect later on? I've found this post - I'm fully expecting him to fall into the "high and flat" bucket :D I'm bit low on the testing strips, just ordered two more boxes. I can stay up late to check his nadir mid-night - and with some creative scheduling I've managed to make sure we'll have ability to monitor him through the entire week this time.

Last but not least: What are your expectations for his blood sugar levels if it was really an overdose? Are there any other situations other than overdose that might look like this?
 
yacoob said:
What are your expectations for his blood sugar levels if it was really an overdose? Are there any other situations other than overdose that might look like this?
Click to expand...

If it really was an overdose, I would expect that his BG will start to come down from that 25.7 as his body clears out the extra glucose. If that does not happen, then it's possible that he's not getting too much insulin, and instead is hitting nadir at the end of the cycle instead of in the middle of the cycle. That would be very unusual on Prozinc, but not impossible. Typically, cats will hit nadir sometime between +4 and +7 on Prozinc, with a few cats earlier or later than that. Doing a full curve - testing every two hours - can help to figure out when a cat is reaching the lowest point in the cycle.

This is going to be a bit of a guessing game with Muta to try to sort out what exactly is going on. How many hours until your PMPS?
 
Gotcha. Well, we'll see. Too bad I haven't recorded the numbers back at the beginning of April when he was on 1.5 and (supposedly) all time high. 2h till PMPS.
 
Well shoot. It should have come down more than that. If he's still high in the morning, go back up to 1.5u and we'll start exploring the "late nadir" theory instead. I don't want him sitting in those high numbers, and overdosing should have started to show some self-correcting already.
 
Well shoot. Okay. 1.5 in the morning, and then keep increasing over the next few cycles to get back to 2u. Looks like he just has a super late nadir. I've never seen a cat do that on Prozinc in the time I've been here, but I've read an old thread where there was a cat that did it. You have a unique little fur baby :cat:
 
AMPS 15.7 (why?!), gave 1.5. AMPS+5 20.9. Sure, lower than no shot, but higher than AMPS? :(

I'm starting to get an impression that the kibbles he manages to steal from two other cats are a factor here. Staying at home I could *hear* the theft process happening every now and then. He had cosmic blood sugar numbers back at the beginning when he was still on the dry. How much <10 kibbles a day would make a difference? I think this is about as much as he manages to sneak.

I can try eliminating kibble completely from everyone's food for a few days and see if the numbers stabilize. Not sure whether I should try it with 1.5 or 2.0u dose though.

If this experiment is successful, I'll need to think about a replacement food, as royal canine for 3 cats is not a sustainable prospect. Someone suggested this food in one of the stickies.

Thoughts?
 
yacoob said:
AMPS 15.7 (why?!)
Click to expand...

I think a full curve would be really really helpful when you get enough test strips. If Muta hits nadir at the PS time, that will help you as you consider dosing going forward.

As for the food, you might want to post out on the Main forum and see if there are more folks out there who might be familiar with that food and could chime in.

Kibble - yes, even just one or two pieces can impact BG numbers. Kibble tends to be 20-30% carbs which is much too high for a sugar cat.

Also, when are you feeding? Do they get snacks during the day or free feed? Or do they just get two meals? If it's possible to spread the food out with some snacks/smaller meals, that can sometimes be helpful.
 
I feed the whole clowder twice per day, synchronised to Muta's shots (8AM/PM). Muta scarfs down most of his food in one go, leaving maybe 10% for later. Two other cats eat both wet+dry, so they usually eat wet first, and leave dry for later. And that's when Muta has a chance to play grand theft kibble.

Starting with wet food alone tonight, that is in 2.5h.
 
yacoob said:
And that's when Muta has a chance to play grand theft kibble.
Click to expand...
Lol! :smuggrin:

How is Muta's weight? Is he underweight, overweight, or just right? If he's not chubby, it might also be worth trying some mid-day snacks for a few days to see how that impacts things. My cat's BG goes up if he gets hungry, so snacks helped him stay in better numbers. If he is chubby, you might try breaking up his food into a few mini-meals so he isn't getting more calories, but is still getting to spread out the impact of the food. Sometimes it helps, sometimes it doesn't. o_O
 
After a no-kibble night AMPS was 7.3, with just 1.5u given at PMPS the day before. This is most welcome. Sadly, AMPS+5 was 17 - so it's still a hike, as opposed to a drop. I'll keep no kibble going for couple of days to see how it plays out.

Muta is currently ~7kg. Siberians are large. Previously he was stable at 7.5kg, and that's not a weight that'd be considered overweight for him. During last vet visit on 21st of May they've clocked him at 6.7, which is concerning. My scale is not the most correct one, so I'm more likely to trust their result than mine to be honest. But yeah, slight downward trend, which is indicative of lack of regulation :( Spreading the food through the day is next to impossible due to lack of personel :D We've tried an automated feeding machine, but sadly Muta is not the smartest tool in the shed and he'd consistently ignore the fact that a new food portion has arrived. Plus, with two other cats in the house, open bowl would mean a free game for everyone. The sureflap feeder at least remain locked until the correct cat approaches it...
 
yacoob said:
We've tried an automated feeding machine, but sadly Muta is not the smartest tool in the shed and he'd consistently ignore the fact that a new food portion has arrived.
Click to expand...

Lol! Poor Muta! :joyful::smuggrin:;)

To be honest, I'm finding this fascinating. Muta is like a unicorn. A rare kitty, indeed! I can't wait until you're able to do a curve at home and we can see the full cycle. I think Muta is just going to need his own special dosing protocol. I'd say go back up to 1.75u now. The 7.3 is nice, but still not what we need.

I wonder how it would work for Muta (and the others) if you left out a couple of foodsicles for them? You would take the low carb wet food, mix in a couple of tablespoons of extra water, and freeze them into ice cubes. Then when the last person is leaving for work in the morning, you leave out a couple of ice cubes. Over the next couple of hours they melt, making them accessible a little later in the day, and preventing anyone from really scarfing it all down.

Sam does great with them. My other cat tries to just eat them frozen. Of course it doesn't work, but it's pretty funny watching him try!

I'm sorry to hear about the weight loss. You are correct about that possibly indicating the shift in regulation. Anytime you can give him extra food, go for it to try to prevent further losses.
 
PMPS+5 at 25.0. And no kibbles in any of the bowls. One more day to check for the baseline, and we're going forward with 1.75 or 2.0 :|
 
We got some more strips, and are. back in business. I've back-filled the spreadsheet as much as it was possible. Without measuring, I've sticked to the old food and 1.5u dose. After the strip came back, I've confirmed that he's still following high-veryhigh-high pattern. Looks like the kibbles weren't a major factor. We've switched to Felix As Good As It Looks food, and the results are... inconclusive. He's persistently high AMPS and PMPS, not super high, but high enough (~19). There don't seem to be any drop mid cycle. We've tested a higher insuline dose (2.0u) - the only effect is that the level seems to be roughly flat now. We could go even further to 2.5 or so, but I don't think pre-shot level at 19 is good.

It seems like we have following options:
  • go back to old food (for Muta), go towards 2.5 (as he wasn't seeing any drops mid-cycle on 2.0)
  • try another food for everyone
  • stick to Felix, increase insuline dose.
Any suggestions welcome at this point :/
 
I don't know the carb levels on those foods, so it's hard to comment on that part. I would stick with whatever is lowest in carbs and has the highest moisture - two important things for cat health, regardless of diabetes.

And yes, I'd say go forward with the increases and keep monitoring. Whenever you can (days off, holidays...), move the test times around a little so you can get the fullest picture of Muta's responses. Nadir times can move, and some cats respond early or late (as it looks like Muta responds quite late, but you'll want to scatter those other tests around to be sure that stays true).

I'm glad you posted again, I've been wondering how you and Muta were doing!
 
Ran the medical history and recent blood results by another vet, only to receive a solid ¯\_(ツ)_/¯. We've asked for a referral, and are now waiting for a consult with an endocrinologist at a veterinary hospital. Meanwhile, Feringa and Bozita food arrived; we've started with Feringa first, half of the evening meal was Feringa. Enthusiastic approach on all three feline accounts, although it's down to bloods and gastro reception afterwards...
 
Muta is getting really good results on Feringa. Granted, the pattern is not always visible, but for the first time in a looong time there have been cycles with a drop, even if a nominal one. Overall, I haven't seen a result >11mmol/L, which is very promising.
 
Ah, those numbers are looking lovely! That food must agree with him! Great job getting the mid-cycle tests. Not all cats hit nadir at +6, so when possible, you might try grabbing a test a little earlier or later instead to fill out a more complete picture. Love seeing all the greens and blues!
 
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