2/15 Sid - Pls take a look at his SS

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Lydia & Sid & Jake(GA)

Lydia & Sid & Jake(GA)

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Sid is following an unconventional protocol. The Prozinc only seems to last about 6-7 hours and then he spikes up to Hi so I give him a unit of R to bring him down. He is getting R about 4 times a day along with 1.25U of Prozinc. Since he has been DKA 3x in the last 6 weeks, the only insulin that consistently brings him down is R. In the last 3 days or so, he has had a change of behavior where he is constantly hungry. I feed him 2 large meals at AMPS and PMPS - lately that has been a can of food at each time. Then at +6 I feed a small meal, which causes him to spike up to HI so I give him a bit of R to bring him down. My vet told me to do this to avoid getting ketones again. I hate all of the spiking and am considering doing a 3x/day Prozinc starting Friday night. Would I space this out to be every 8 hours? If he is only getting 1.25U of Prozinc now, should I increase the dose a bit?



Last condos: http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=63695
 
Hi Lydia
Sorry I haven't been around...internet issues.
Kim would be the best person to answer the TID questions as she has been dosing Kitty that way for a while. I would think that you could shoot three .5u doses 8hours apart, but she may be able to help, especially with respect to feeding and testing times throughout the day.

Is he still handling the IM shots okay?

How is Sid doing as far as ketones lately?
Carl
 
Hi Carl,

Thank you for your advice.
Sid has been accepting the IM shots pretty well. I usually do it while he is eating. His appetite has been so ravenous lately that he doesn't notice what I'm doing. He has tested negative for ketones today and yesterday. And I tested him over the weekend and he was negative. I can tell pretty well by how well he is eating/acting (particularly his breathing) when ketones are in his system. He does not eat well and has a very fast breathing pattern. Thankfully his high numbers have not yet brought on any ketones. I hope that is because I've using the R to bring him down.

Lydia
 
The usual plan is to divide your current dose into thirds and dose every 8 hours, being sure that the number is rising. Dividing the 1.25 into thirds will be tricky. If you increased to 1.5, giving .5 TID would be easy math.

I have no experience supplementing with R, so I don't know how that would be added.

You might pm Nancy and Payne as she has had the most experience with supplementing with R.
 
Sid does seem to get pretty short duration from the pzi, and that may be due to the IM method of shooting. I always thought Bob only got 9-10 hours from his IM shots but I didn't shoot sub-q enough to compare against. Hopefully if you switch to TID you will be able to reduce or eliminate the supplemental R doses. I would pm nancy and kim for their eyes on this thread.

Carl
 
I will PM them to have a look - both did give me advice about TID already. I think dividing up the doses is what I'm concerned about doing. Maybe if I up the dose to 1.5 so that would be 1Ux3 per day? Does that sound right? I can give the shots at 4:30am, 12:30 pm, and 8:30 pm. That could work. Is there anything I need to be aware of the first few times I do this?

I may have to supplement a bit with R and that makes me nervous... Just now at PMPS +6, I went and tested Sid and he was Hi with no food influence at all. So I gave him a small meal and shot 1U of R.

Carl - it's hard for me to judge if the IM method makes the duration shorter because shooting SQ had no effect whatsoever or sometimes it would have an effect and bring him down - sometimes pretty low but more often there was no effect. The vet thought shooting IM would give me more consistency.

It is actually easier to shoot IM (IMO) once I got over the initial squeamishness and worry about doing it. I actually asked a different vet (when my regular vet wasn't available) just to confirm where to shoot exactly because I wanted to make sure I was doing it right and not hitting the sciatic nerve or something, and he refused to tell me because he said shooting IM would make no difference. So obviously he will never see Sid because he would rather see Sid die than try a less conventional approach to his treatment.
 
Hi Lydia,

Marilyn has me up all night again. What did your vet say about the condition of your R? I ran into this tid-bit by accident, and my eyes popped wide open. It doesn't use the word "fizzing"...but it does use "frothing". Sound about right? It's in an article about cloudy insulin, but I can't help but think the same thing could happen to clear insulin???

"If you shake or drop the insulin, you can cause frothing, which will denature (physically damage) the fragile insulin molecules, and weaken the insulin, again leading to unpredictable insulin action."

http://petdiabetes.wikia.com/wiki/Rolling_insulin

Deb
 
Hi Lydia,
I am sorry I dont have any experience with R
I am curiuos though why you arent increasing the prozinc if Sid is going so high..
I dont know all your circumstances, but I am curiuos
 
If your dose is 1.25u bid, you would give 1u tid. If it's a total of 1.25/day in bid, you would give .5 tid.
 
Deb thanks for the link. I never dropped or shook the bottle but frothing sounds right. I have not yet taken the bottle to my vet. He didn't have time on Tuesday to see it. I still have it and will take it in soon. I've been using the new bottle and getting better response when drawing into the syringe.

I am planning to increase the dose a bit when I start the TID, but the Prozinc does not start to work until about +3 and when he is high, I need to bring him down a little faster to avoid ketones.

I wonder, is he getting too much R in a day? I know it is out of the system quickly, but how do I know if it is too much?
 
Hi Lydia,

Denise might have a point...in the form of a question...but I see where she's heading. Is there a reason you’re not increasing the dose first on BID? I am totally new to ProZinc...I am not an expert on any insulin, and I am terrible at analyzing other folks spreadsheets. Now that I've built-up your confidence in me :shock:...Marilyn had worked her way down to 0.75u Lantus...on her way to 0.5u...and right now she is at 1.6u ProZinc (I need to update her SS). It looks like Sid started ProZinc two days before Marilyn, and although they are completely different cases (ECID), 1u & 1.2u ProZinc just weren't doing the trick for her either.

I don't know where she'll end up when she settles-in, but for now, she's getting better duration with a higher ProZinc dose. 1.0u ProZinc wasn’t even close to cutting it, as far as duration, and food spikes. So I bumped her up rather quickly (due to ketones), every couple cycles, until I saw some action. This AM, I had to wait for a rising number to shoot. Even her insane food spikes are getting a little better. I know you realize that if you increase the ProZinc, you'll have to cut way back on his R accordingly, but there's nothing wrong with that if you're getting better numbers.

Remember when I said next time I might be brave enough to try a full 0.1u of R? Well, I did...I was out of ketone strips...had a high pre-shot...and knew an ugly food spike was around the bend. I ended up having to test her every 15 minutes for 8 hours. Even though the R was long gone, it didn't give her ProZinc nadir any room to move. It was a horrible day that I won't forget anytime soon. The problem started when she dropped 104 points, in 15 minutes, between PM+2 & PM+2.25. Don't get me wrong, she never went too low, but it wasn't from lack of trying. I fed throughout the cycle. In fact, her lowest number was a 122 @ PM+5.5, but it's not a day I want to repeat. It looks like kind of the same thing happened when Sid's R, and his ProZinc, crossed paths on 2/14/12 @ PM+5. The R may not have been in his system, but it had him low enough, that when the ProZinc was peaking, there wasn't a lot of room to move. This kind of thing will get you in trouble on a higher dose of ProZinc, so you will really have to rethink his R dosage when increasing the PZ dosage.

I'm guessing it would be even more complicated with TID dosing. If you're planning on increasing the total daily dosage (now with 3 nadirs), without knowing what that daily dosage did on a BID basis...then you're adding R into the mix...I myself, am scared sh*tless...but that's just me.

It seems like too much R, and not enough ProZinc on a BID basis...but I really think you need more eyes on this...more experienced eyes. Hang in there.

Deb
 
Hi Lydia,

I can't see the SS, I am work-- I will look at it later, but here are some early thoughts.....

I must express my concerns over one thing you have stated. You said you wanted to up the dose when you started tid--- that is actually opposite of what I would recommend. If you want to increase the dose, you should do that with bid dosing first. When dosing tid, you want to take the total units you are giving bid--which looks like 1.25 twice a day= 2.5 daily total and divide by 3 for your tid dose...so, that would be .83 (good luck seeing that!), but you get the idea. Truly, when you start tid it is normally advisable to cut your dose back a little, to protect against any overlap.

I will put this out for open eyes to view, to be sure I am not out of line with these comments......I actually had a hard time understanding why I was going to reduce my Kitty's dose for tid, when the reason I went to tid dosing was because the insulin was only lasting 8 hours. So, I really felt like I knew there was no danger in overlap-- thus why did I need to reduce the dose? Like you, the reason for tid dosing with Kitty was due to short duration--- so, if the insulin is gone in 8 hours, why should I reduce? But, I still did decrease for safety purposes. When I started tid, I was dosing anywhere between 4 and 5 units big-- intitially with tid, I began with 3 units. Within a few weeks, I was dosing 4 units tid. Now that Kitty has settled in to tid, I dose 3 to 3.25 units tid. When we first started tid, the curves were very shallow. So few people dose tid, that I never got good feedback on the shallow curve, but my thoughts were-- that since I was shooting every 8 hours, the insulin was more consistent in Kitty, thus creating the shallow curves. I related it to gas in a car--- We always had half a tank---never empty and never full--the needle didn't move much! As time has gone on, she does curve a little more on the insulin- but the curve is still a little flat compared to most Prozinc curves.

Also, you always want to be sure you are shooting into a rising number. Early in tid, I tested Kitty at +6 and +8 (preshot) to be sure that she was heading up. You never want to shoot into a falling number.

Before TID, Kitty was in terrible numbers. And, even now, at times when I am an hour late giving a shot-- she will be in the 400s. But, if I shoot in the 8 hour range, she is "normally" in the mid to low 200s. TID has been Great for Kitty and I would recommend it to anyone that has the flexibility to shoot every 8 hours and is dealing with high numbers. I think anyone that was around with Kitty and I last spring, would admit that Kitty was extremely complex. Also, I think it would be agreed upon, that she would be the last Cat in the forum that anyon expected to be regulated.

Prozinc is very flexible and is a very good insulin for complex cats!

Good Luck, I am more than willing to help you in anyway that I can!
 
I apologize for my math error, and lisa got it right. If you are shooting 1.25 bid now, that is 2.5 per day. Divide by three and you get .8 per shot tid. So if you wanted to switch to tid and increase a little, you could go with 1.0u tid
Thanks Lisa!
Carl
 
I stated in my post, but I want to be sure it doesn't get hidden.....I would not recommend increasing the total insulin daily intake when starting tid. It is normally advisable to decrease a little when starting tid, to protect against any overlap. If you are interested in increasing your prozinc dose, I would increase with bid dosing first.

Yes, I agree your numbers are probably high enough to support an increase with bid or tid-- I just think it is not advisable to increase with tid initially.

Just my thoughts!
 
I think I screwed up the math too. (Teach me to post late at night.) My ultimate dose may be okay if you want to lower - .5 TID -but I got there incorrectly.

I appreciate your quandry looking at the suggestions. Try a higher dose BID and see if it works, staying with the R as needed. Or go to TID which is definitely going to be more difficult with your complex kitty, but has potential.
 
Kim and Sue are right. Increase with BID first, see how that works. If you go up to 1.5 and keep seeing short duration, then look at going TID.
Carl
 
Thanks everyone. I get the point about not increasing the dose for TID. I shoot prozinc with a U100 syringe which will make it easier to shoot. 83 using a conversion chart. The reason I have hesitated to increase the dose of prozinc is that at the hospital the doctor tried to crease to 2.5 and Sid had abed hypo episode. He was nonresponsive and they had to put him on a glucose IV to get him back up. They finally did but it took hours.

However I wasthinking about that and I think Sid wenttoo low because they were not feeding him more than twice per day and not testing more than every 2 hours. If Sid had been home I probably could have prevented that.

I thin I will try that first and increase to 1.5 units. And see how he does. Then try TID if it doesnt work.
 
Hi Lydia,

It sounds like Kim knows her "TID Stuff". It's good to know that initial TID dosing calls for a daily decrease. So you have two good options...increase BID, or decrease TID. I'm kind of relieved that you’re trying the BID increase...since R is involved.

Okay, so now I get your "ProZinc fear"...but you're not near the 2.5u that the hospital gave...at least not yet (by the way, was that 2.5u BID, or daily, at the hospital???). Also, I think you called it right, regarding your attentiveness vs. the hospital's. It doesn't look like you sleep much (I know the feeling), so hopefully you will catch any "about to be" hypo. My fear is with the R. I wasn't able to hold onto a rising number, that wasn't food induced, until Marilyn's PM+6.25. By PM+7, I was certain she couldn't get into trouble, but then her AMPS was way too high...because she had gone too low, too fast. The R yanked her down too fast, and kept her numbers low, just long enough, for it to interfere with her ProZinc nadir. I understand your painful DKA balancing act, but I'm thinking you have to be really careful with the R, until you know where your ProZinc BID increase is taking him.

So you're using u100 syringes? And 0.2u ProZinc = 0.5u increments on the u100 syringe. So is your current dose of 1.25u BID, actually 1.2u BID, or are you trying to eyeball the 1.25u? This is just me, since my vision isn't good, but I stick with the 0.2u increments of ProZinc, which line up perfectly with the half unit, and full unit, markings on the u100 syringe. That way I know precisely that my dose is consistent...not fat, or skinny, or just plain wrong. So if Sid is on 1.2u BID, that would increase your next dose to either 1.4u BID, or 1.6u BID....basically, either side of the 1.5u BID that you are thinking about. This would mean that 1.4u ProZinc will line up exactly with the 3.5 unit mark on the u100 syringe...or 1.6u ProZinc will line up exactly with the 4.0 unit mark on the u100 syringe.

I hope I'm not driving you crazy...maybe your vision is better than mine...but I hope this helps. :-D

Deb
 
Sorry that was a typo - the hospital tried to increase to 1.5 units and he had a bad hypo episode.
I've been giving him 3 units of Prozinc on the U100 syringe which equals about 1.2 U40. I am testing him tonight to see what happens with no R. :-D
 
Lydia & Sid & Jake(GA) said:
Sorry that was a typo - the hospital tried to increase to 1.5 units and he had a bad hypo episode.
I've been giving him 3 units of Prozinc on the U100 syringe which equals about 1.2 U40. I am testing him tonight to see what happens with no R. :-D
Click to expand...

Hi Lydia,
Someone asked if I would take a look at your R use as it was a bit high.
So I come over and looked at Sid's ss.

You mentioned that the PZI is not lasting longer than 8 or 9hrs, then there were some words about going to TID, and giving IM shots(which hurt if muscle is not completely relaxed), and using R to pull down the high numbers...

My biggest question is why are you sticking with an insulin that is so obviously that is not working for Sid?? Have you tried Lantus or Levemir? They will certainly last much longer, be more gentle, and you will have ZERO need for the harsh R insulin.....Nobody gives almost equal amounts of basal and bolus insulins, nobody. If you are needing to give 1.25u of PZI and 1u of R, there is something majorly wrong.

You have tried your best, but I think it's time to give Sid a break and move over to a much gentler insulin; those high 400s and 500s are just killer numbers on the body. Despite his history with DKA, there is no way those numbers are good for him.

Quite often, it's been seen that people are compounding their problems by using R in hopes that it will make up for the lacking in the basal insulin level. Even people whose cats are getting high doses over 30u BID are not giving more than 1u or 2u of R.

I hope that you can speak with your vet and try Lantus or Levemir for Sid; you won't be sorry as they are both excellent long lasting and smooth insulins. Once you are giving Sid a basal insulin that lasts the entire cycle, you can then focus on using a bit of R, but only when needed.
 
Gayle,

Lydia had Sid on Lantus since 2011, according to her previous posts. He went through 3 DKA episodes. She just started on ProZinc less than a week ago, looking for the flexibility it offers. If I were her, I would want to try several of the different dosing options available with ProZinc to see what might work.
 
Sue and Oliver (GA) said:
Gayle,

Lydia had Sid on Lantus since 2011, according to her previous posts. He went through 3 DKA episodes. She just started on ProZinc less than a week ago, looking for the flexibility it offers. If I were her, I would want to try several of the different dosing options available with ProZinc to see what might work.
Click to expand...

I cannot comment on the reasons for DKA while on Lantus but blaming the insulin is not the way to go. Lantus does not result in DKA
Causes for DKA should be known and they include insufficient insulin, insufficient foods, underlying health problems.
Without seeing the Lantus ss, I cannot see how the dosing was done, but looking at the current ss, it is one massive ugly mess. Nobody should have to dose equal amounts of basal and bolus insulins. If the current basal is not lasting 12hrs, forcing the use of too much R and the consideration of needing to dose TID, I think it's time to accept that the trial has not succeeded.
 
Yes, his SS is very ugly and it is causing me an extreme amount of stress. I feel like I am trying to do the best I can for Sid but I am in a race against time. He cannot be allowed to be Hi for any length of time or he develops ketones.

I am working on cutting back on the R and increasing the amount of Prozinc he receives, preferably to go to a TID dosing with the Prozinc. I don't feel he has been on Prozinc long enough or received a high enough dose of it yet to make the assumption that it isn't working.

I didn't find lantus to be all that "gentle" for Sid when he was on it. Probably because of the underlying conditions he has (IBD, small cell lymphoma, pylenonephritis (resolved) and pancreatitis (probably), which is why the internal specialist who is treating Sid referred to lantus as too potent for him. When he was on lantus, he received a miniscule amount and it would cause him to drop to near hypo numbers and then spike. In fact he had a pretty serious hypo episode the second week he was on lantus and he had many other times that he dipped pretty low requiring 2 visits to the emergency hospital. To me, levemir would be similar and I am too scared to switch him to an insulin that builds a shed. That makes it even harder to gauge what might happen.
 
I'm not blaming the lantus for the DKA - he had DKA 3 times due to what the vets believe to be pylenonephritis which he was on baytril and clavamox for 3 rounds (1 month), diagnosed with IBD and small cell lymphoma, and maybe pancreatitis but the specialist doubts this is a contributing factor - his fspecl level was 1.5 well within normal range.
 
Hi Lydia
You already know where you are trying to get, and that is reduce or eliminate the R, and find an effective dosing strategy for prozinc, whether that is BID or TID, whatever it takes to get Sid's numbers down overall, and trying to avoid the very low numbers you've seen on every insulin. As long as you post here, the people here will do whatever we can to help. There isn't a person on the board who has come to "meet" you and Sid who doesn't want what is best for you and him. All of the friends you have made in FDMB are relly pulling for you. The obstacles that you have faced are so many and so huge, and yet you and Sid just keep on fighting, which is an inspiration to all of us.
Nobody knows for sure which insulin is best for each cat. None of us are vets. Kitties have gone OTJ on lantus, lev, prozinc, pzi, even humulin since I joined the board. All any of us can do is try to help, and to be here when you need us, no matter what you try to do.
Hugs,
Carl
 
Lydia & Sid & Jake(GA) said:
I'm not blaming the lantus for the DKA - he had DKA 3 times due to what the vets believe to be pylenonephritis which he was on baytril and clavamox for 3 rounds (1 month), diagnosed with IBD and small cell lymphoma, and maybe pancreatitis but the specialist doubts this is a contributing factor - his fspecl level was 1.5 well within normal range.
Click to expand...

Ah OK, at least we have eliminated the pancreatitis from this mix of issues Sid is having.... that's a relief!
Let's see what some others have to say to give you some help.
 
Hi Lydia,
I read your post and it reminds me so much of what I went through with Harley 2 years ago. He also had DKA 3 times very expensive) and has been on almost every insulin there was. Lantus (1u), NPH (12u), Regular 3-4u 3x/day, and then back to Lantus. They also considered levemir. He ended up being diagnosed with IAA, IBD, Pancreatitis. I have never used PZI, so I cannot give advice there but if there is anything I can help with, let me know.

Pattie
 
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