3/16 Macek AMPS: >27 mmol/L: still high numbers with Lantus

[kilou]

Hi,

I'm new here. My neighbor's cat (Macek) has been diagnosed with diabete in december 2018. He is a 9 years old male, pretty large but still overweight (7.2 kg currently). He was initially started on Caninsulin with 2IU 2x/day. He has been switched to Lantus since mid february, initially at 2IU 2x/day but he was still having large numbers (>20 mmol/L). Since then, the dose has been gradually increased from 2 to 6 IU 2x/day, in increments of 1 IU. However, Macek is still in the high 20 mmol/L and it is as if the insulin was not acting. Acromegaly was "ruled out" because the IGF-1 levels are normal. The vet proposed to increase the dose every 3 days until we see a response. I read on this board that, beside risks of hypoglycemia, too much insulin can also make blood glucose stay high so I'm a bit concerned...

I'm helping my neighbor with home monitoring as I already have experience with that since I had a diabetic cat 10 years ago who went into remission thanks to the PZI tight regulation protocol of Dr. E. Hodgkins. Now with Macek, things look a bit more complicated. We installed a continuous monitoring system (Freestyle Libre) a few days ago so we can follow the blood glucose variations. The system was installed on the evening of March 12 so I attach the blood glucose curves for march 12, 13 and 14. At that time, the cat received 5 IU 2x/day (always at about 7h00 and 19h00). The dose was raised to 6 IU at 19h00 on March 14 and we're supposed to increase the dose every 3 days if the blood glucose doesn't come below 20 mmol/L.

What do you think of these curves? I can't see any action of the insulin for the time being. Is it safe to still increase the dose? Macek is a fairly big cat but 6 IU 2x/day starts to be quite a lot, no? Would be glad to know your impressions. Any advices on this situation? Thanks a lot!

Aziz

EDIT: Just got an update from my neighbor. Her cat was at 18.5 mmol/L at midnight (first time below 20 mmol/L!!) but is now again > 27 mmol/L this morning. He received 6 IU yesterday evening so maybe we're approaching the good dose??

 

[Bron and Sheba (GA)]

Hi Azia and Macek and welcome to FDMB. That is kind of you to be helping your neighbour. You have come to the best place for help and support.
First of all I want to say that 6units of Lantus twice a day in a newly diagnosed cat is way to high a dose. You instincts were correct to be concerned. That is good to know that the IGF-1 level was normal.
Increasing it in 1 unit increments is also too much at once. We recommmend increasing in 0.25 (1/4) unit increments so we don't go past the best dose and it is much safer for kitty.
Is your neighbour testing the blood sugars herself or just relying on the Freestyle libra. Home testing is the best way to keep kitty safe and I would strongly recommmend she looks at trying to do it. It is not hard and won't hurt kitty.
Here is a link to home testing
http://www.felinediabetes.com/FDMB/threads/hometesting-links-and-tips.287/

What type of food is Macek getting? We recommmend canned/wet food with carbs 10% or less. Prescription foods are expensive and not necessary. Here is a link to suitable food charts.
http://www.felinediabetes.com/FDMB/threads/links-to-food-charts.174182/

It is hard to see the graphs you have posted. Do you think you could set up a spreadsheet and put the numbers in that ?
It is a great tool and lets us see exactly what is happening. Here's is the link for you to have a look at
http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

Make sure your neighbour has some higher carb food and some honey in the house in case of a hypo.

Too much insulin can look like not enough. I am going to tag a couple of people who will be able to guide you with the dosing.
@Bobbie And Bubba @Elizabeth and Bertie
If is the middle of the night in parts of the world so it will be a few hours before they come on. In the meantime you may be able to get the SS set up and maybe the signature. We use the signature every time we help a kitty. Then we don't have to bother you with the some questions every time. To get the signature. Go to the top right of this page and click on your user name. Go to signature and tell us yours and kitties name and his owners name, date of diagnoses. Started on caninsulin then changed to Lantus. Type of meter is you are using one, weight, any other health issues, tested negative for IGF-1, country you live in.

Are you testing for ketones? If not I would recommend you buy a bottle of Ketostix from a pharmacy and test the urine daily while the BSLs are high.

Keep asking lots of questions. We are happy to help.
Bron

 

[Bron and Sheba (GA)]

I see you have the signature up Aziz, that's great. Thank you.
I see you live in Switzerland.... I am going to tag @Gill & George as she lives in Spain and she may be able to help you with things available in your neck of the woods.
I can see in your signature that Macek is being fed some dry food. Even diabetic dry food is too high in carbs to feed routinely so I would ditch the dry if I were your neighbour. That could be one of the reasons why the BSLs are still high. HOWEVER when you take the dry out of the food, you need to be testing frequently to see how low the BSLs go...... they can often drop 5 or 6 (100points) and the insulin dose needs to reduced accordingly.
Bron

 

[Sienne and Gabby (GA)]

I agree with all of the information that Bron posted. We tend to be rather dependent on the spreadsheets that you'll see in each of our signatures. It's a great method for tracking trends. Graphs don't seen to provide the same overview.

While manufacturers may label their foods "diabetic," pretty much all of the dry foods are ridiculously high in carbohydrates. Since it sounds like Macek is eating canned food, a low carb canned food is going to be far better for his overall health and diabetes management. If your neighbor is concerned about her kitty having access to food overnight, a timed feeder may be helpful.. Alternatively, freezing watered down canned food and leaving out some cubes can work (providing she doesn't have a cat like mine who would lick at the "catsickle" until it was gone. She liked ice cubes.).

 

[kilou]

Dear @Bron, thanks a lot for all these informations! It is highly appreciated! I have now updated my signature with some details. Things are moving a bit fast now. I just received the curve from yesterday from my neighbor and it seems Macek is now reacting to the insulin (see attached curve). The cat receives 6IU 2x/day since 14 March on the evening so we should certainly not increase the dose further now as there is some reaction. Notice the cat went down to about 15 mmol/L at 21h yesterday but has been going up after that. Today he is still close to 25 mmol/L. The question is should my neighbor still shoot 6IU this evening or should we exert some caution and shoot e.g. 5 IU or even less? We are certainly not at risk of hypoglycemia at the moment but I have some difficulties to get a feeling with how the cat is reacting. With my cat on the PZI, the reaction was much more predictable so I was more confident to shoot according to the measurements. With Macek and the Lantus, it's so much more difficult and sometimes a shot doesn't have any visible effect, sometimes (as yesterday), the blood glucose dropped by as much as 10 mmol/L! I have to check again with my neighbor what she's exactly feeding.

So my immediate question is: would you still give 6IU this evening or should we shoot a lower dose? Or is 6IU with a close monitoring tonight OK? What's your feeling about it?

Thanks for your help!

Aziz

Some more information regarding your questions:

Home testing:
My neighbor does not home test herself as she is a little anxious. I've done the home testing so far with an Accuchek Aviva meter. Since a few days (march 12), the cat is monitored continuously with Abbott's freestyle Libre meter and this gives us continuous curves. This is very convenient and the measurements are in line with what we observed with the Accuchek meter. It would be good if my neighbor tries home testing but I'm not sure I'll be able to motivate her to do so. I'm fine doing the measurements as long as it is not continuous and in periods we really need to check continuously, I guess we can install another Freestyle meter on the cat.

Food:
Currently Macek eats about 100gr of wet food (Almo Nature daily Chicken grain free recipe) + 100gr dry food (Royal Canin diabetic). I'm very well aware that dry food (even diabetic) is not good for diabetic cats. I've had the exact same experience with my own cat and I switched her to only low carb wet food and saw an immediate drastic drop in blood glucose levels. However, for some reasons, vets on this side of the pond do not seem very enthusiastic about switching the cat to wet food. It seems they don't think dry food is a problem in fact. Since Macek is not my own cat, I cannot go against the vet's advices. I've calculated that the dry food he's getting contains 28% dry matter carbohydrates while the wet food he gets contains only 3% dry matter carbohydrates.

Spreadsheet:
I will see if I can put the numbers in a spreadsheet but for now I've not figured out how to export the numbers. The Freestyle Libre application provides blood glucose charts as those posted above. If I can find a way to extract such information as numbers, I'll provide these.

Hypo:
My neighbor is aware of hypo risk. She has some high carb food as well as honey sirup. We're a bit more confident now that the cat is under continuous monitoring because a hypo should be diagnosed pretty quickly. The only "problem" is that it's an outdoor cat so I hope the hypo won't occur when he's outside in the wild.

Ketones:
We're not testing ketones at the moment and have not been instructed to do so. But it is something I'll suggest to my neighbor.

 

[kilou]

I have now created a spreadsheet (see link in my signature) but for now I've only roughly translated the graphs into numbers. I don't have the complete information for today's graph yet though. However, it looks to me that the charts contain much more information than the spreadsheet. The Freestyle meter checks BG every 15 minutes continuously and it is only with that that we can see those peaks downwards on the last graph (see my previous post). I'll try to update the spreadsheet when I get more information.

Just not sure at the moment if shooting 6IU tonight is safe. The shot is due in 3 hours, BG is still high: 22.2 mmol/L but yesterday's reaction was pretty strong...

 

[Gill & George]

Hi there, sorry I've not been on the board all day and only just saw the tag fro @Bron and Sheba

Here is a list of foods that are better than than the 'diabetic food' , they are all below 10% carbs whereas especially the dry will be far too high in carbs and may well be what is driving the numbers high.
https://docs.google.com/spreadsheets/d/1J5JpMe6TDXrHq_aTl9hUtHy6Gs9oRBqlz4nPGKxtySA/pubhtml
I can't get any of the food locally so I order on line from zooplus, they have a Swiss site


I would really try to cut out the dry food altogether, but if your neighbour decides to do this be sure that she does it slowly, cutting out the dry can have a dramatic impact on the insulin requirement, so you want to do it slowly so you can attempt to keep up with changing the insulin dose should it become necessary.

The only "problem" is that it's an outdoor cat so I hope the hypo won't occur when he's outside in the wild.

This is quite worrying, especially if you do make any food changes.

The 100g of wet and 100g of dry seems like a lot of food.
George is a similar size and when overweight he was on only 65g of dry hills metabolic before diagnosis, to try and get him to loose weight. I now feed him on an all wet diet, and we have managed to keep him at a good weight and he is also satisfied with his food portions so not always crying for food.

Did you shoot?

 

[Bron and Sheba (GA)]

Well done getting the SS up and running. All valuable information.
With feeding that high carb dry you are going to get high numbers. When does Macek get the wet and when does he get the dry? While you have the continuous meter on, now would be an ideal time to change over to completely wet food. If you are feeding all that dry you have to expect high numbers. It’s like feeding junk food all the time.
Your neighbour does not have to do what the vet says in relation to the food. Typically vets don’t get a lot of education about diet and what they get is from the large food companies that push the prescription diets. Just tell the vet that Macek won’t eat the dry. Or say nothing. A low carb diet is essential if you want to get those numbers down. Otherwise you will be giving large doses of insulin.
Lantus is a slow acting depot insulin. The onset is usually around +2 and the nadir can be anywhere from +4 to up to the next shot. Typically it is +4 to +7 but every cat is different (ECID).. it has a depot and it takes up to 6 cycles to fill the depot and a little of the depot is released each cycle as well as the current shot. It is a great insulin for cats.
Talk to your neighbour about the food. I think you will see results and a reduction in dose if she swaps fully to the low carb.

 

[Gill & George]

However, for some reasons, vets on this side of the pond do not seem very enthusiastic about switching the cat to wet food. It seems they don't think dry food is a problem in fact.

My vet was the same, I just disagreed and fed him LC wet. If I'd fed him the hills diabetic dry that he suggested there is no way he would have gone into remission the first time. Interestingly though, my new vet encourages wet food rather than dry, and prefers a raw/homemade diet. So perhaps it's changing even this side of the pond. I personally feel that the dry prescription diet that George was on to try and get him to loose weight was a large factor in causing his diabetes, when I worked out carb content it was in the high 30's

Of course it's difficult since it's your neighbours cat the decision has to come from her, perhaps supplying her with some of the info I've linked below would encourage her to swap.

Have you come across Catinfo.org,
here is some info for your neighbour to read its written by a respected vet who specialises in feline nutrition, it is quite an eyeopener.
The website is in English but this are links to pdfs in french and italian, (hope that helps)
French Version
Italian Version short
Italian Version

What brand of diabetic food is she feeding?

 

[kilou]

Thanks for all these great info @Gill & George @Bron and Sheba! I'm truly convinced that my neighbor should switch to wet food and she probably is willing to do it. It is just a little bit frightening to do so now that the cat is on such high insulin doses and that we don't get a clear feeling on how Macek reacts to the Lantus. What is still unclear to me is how to do the transition. Macek currently receives 100gr wet food (Almo Nature grain free) + 100gr Royal Canin diabetic dry food per day. Half of the wet food is given at AMPS and the other half is given at PMPS. The dry food is fed during the day whenever the cat asks for food. I'm not used to this strategy though. With my own diabetic cat, I switched her to wet food and was feeding 3 times a day at fixed hours. This allowed (along with the PZI) to see very predictable BG curves and it was easy to shoot according to the numbers.

Regarding Macek, would decreasing the amount of dry food by 10gr a day and replace by 20gr of wet food be a safe option? This would allow to get rid of the dry food over a period of 10 days and the cat would end up getting 3x100gr of wet food in the end. That's probably still far too much for an overweight cat but we could reduce later on. I guess for an overweight cat (7.2 kg), we should aim at roughly 220-250 gr wet food per day. What do you think? Now since it is usually recommended to wait 3 days before adjusting Lantus doses (to stabilize the depot), should we wait at least 3 days before adjusting the food as well? That's kind of scary to change both insulin doses and food at the same time...

FYI the wet food we intend to feed is the following:

Almo Nature Daily Chicken flavour (grain free):
- Protein 10%
- Fiber 0.4%
- Fat 5%
- Ash 2%
- Moisture 82%
83.7 kcal/100gr

This means there is roughly 0.6% carbs (wet matter). So I guess in dry matter basis, this translates into 0.6x100/(100-82)=3.3% which is pretty good.

 

[Bron and Sheba (GA)]

Did you reduce the dose down to 5 units last night. You mentioned you thought you would. Can you update the SS please ?
Regarding the timing of the food. Feeding before the insulin is correct. Then you can either feed more at say +3 and +5 or you could do +2 and +4.. others free feed during the cycle but take the food up for the 2 hours before the next shot so that the BSL is not food influenced.
If you want to take 10 days to swap over you can or you could do a week. Whatever suits you both.
With the insulin dose, when you are changing over to a low carb diet and the insulin needs are changing, you reduce the dose whenever it is warranted. Just keep doing the change over to low carb, you have the continuous testing at the moment so ideal to start soon, and we will help you with reducing the dose. You are doing it slowly so it shouldn’t be dramatic. But do make sure your neighbour has some honey and higher carb food in the house in case it is needed.
We aren’t changing the dose and the food over at the same time. You are just changing the food over to low carb ..... and adjusting the dose if the BSL drops low enough to warrant it. People do it all the time here. It is quite safe if you are home testing.
So I would:
*Start the change over soon (as you have suggested)
*test frequently (should be easy with the continuous meter)
*post daily for help and suggestions.
*Keep the SS up to date all the time if possible
*if something changes and you need help, change the subject line to HELP.. if it is urgent, there is a 911 at the beginning of the subject line.
Keep asking questions. You are a great neighbour.

 

[Wendy&Neko]

It’s great if you to help your neighbour. In addition to dry food, there are a couple of other conditions besides acromegaly that we call “high dose” conditions. I used quotes because not all cats with these conditions have high doses, though usually cats with high doses have one of those conditions. I presume the IGF-1 test was done at the Royal Veterinary Clinic? Do you know what the IGf-1 number was? Just asking cause we’ve had a couple vets use the wrong scale and called a cat non acromegalic when it was.

The strategy outlined above of gradually replacing the dry food is a good one to start with.

 

[kilou]

We finally gave only 5IU yesterday to remain on the safe side. This was probably overcautious because BG was again very high during the night and this morning. This morning Macek got 6IU. SS updated.

I will discuss food change today with my neighbor. We'll see if we can switch the cat gently to wet food. I think from the cat's perspective there will be no problem as he seems to like the (non-diabetic!) wet food. The presence of the continuous BG meter is reassuring since my neighbor does not home test herself. However the current device will probably not hold for too long anymore (5th day in place). Whenever it falls off we may place a new one but I'm not sure how good this is for the skin (the cat's neck is enrolled in a band to keep the device in place).

IGF-1 was measured by the vet in Switzerland. I don't know where the analysis took place but it took a few days to get the results. Probably still in a lab in Switzerland though. IGF-1 levels were between 100-200 (don't know the unit) but acromegaly is suspected when levels are >1000 according to the vet.

Thanks for all your help!

 

[Bron and Sheba (GA)]

Thanks for updating the SS.
I see you commented in the SS that you don’t understand how Lantus works. There are yellow stickies at the top of the Lantus page which explain how Lantus works. Have a read of those.
PZI and Lantus are both long acting insulins. Lantus is different in that it has a depot. The onset of the insulin for Lantus is usually around +2 and the nadir can be anywhere from +4 to up to the next shot but usually around +6 or 7.. only collecting data will tell you. It is a great insulin for cats.

 

[Wendy&Neko]

IGF-1 was measured by the vet in Switzerland. I don't know where the analysis took place but it took a few days to get the results. Probably still in a lab in Switzerland though. IGF-1 levels were between 100-200 (don't know the unit) but acromegaly is suspected when levels are >1000 according to the vet.

Good to know the test was done in Europe. It probably was sent to RVC because very few places do the actual test. In the European measuring system 100-200 is normal, in North America with a different measure, it would be considered positive for acromegaly.

One comment on the dosing, unlike PZI or Caninsulin, we don't determine how to change the dose based on the preshot numbers. Rather, we look at the nadirs, or how low the dose is taking the kitty. We try to give the same dose for at least six cycles, for the depot to build. Unless kitty earns a reduction of course. After those six cycles we evaluate what next to do with the dose.

Another question, how is your neighbour administering the insulin? Is she using pens or syringes? I also want to make sure she is using the U-100 syringes, which are different than the ones used for either Caninsulin or PZI, which use U-40 syringes. The U-100 syringes (BD Microfine) can be obtained with 1/2 unit markings, making it easier to make smaller changes than 1 unit at a time.