3/31 Penny AMPS 401, insulin goes up and BG goes up

[Robyn and Penny]

Good morning! I'm completely FRUSTRATED. I went back to tight regulation and I cannot get Penny under renal threshold to save my life! She's requiring MUCH more insulin than the last time around. Infections, etc have all been ruled out before putting her back on insulin. She has been active, playful, and her weight loss is going very nicely. She's been jumping back to the top of the cat condos (which she hadn't done for quite some time last year) and is moving around great so I don't feel she's in any pain. Not with as active she has been.

The last dose I had gotten decent numbers at was a fat 1.25u. I increased to get some green nadirs but her BGs have been rising steadily as I've increased. Any thoughts on this?

Her current Levemir pen has been open for just about 50 days, kept in the back of the fridge, and I am seeing numbers going down during the day so I think it's still working at this point. I know I don't have a lot of nighttime data. Been saving those tests for when I NEED them. When I was taking night tests her numbers were higher. She's a social eater so doesn't eat at night while we are sleeping and her numbers tend to be lower during the day, which shows me her pancreas is still working somewhat...

Please help! Thanks in advance!!

 

[Marilyn and Sheldon]

Hi Robyn. I'm really not experienced enough to offer any insight or advice.Perhaps put the question mark in your subject line to get more eyes? Maybe even the "Help" plea.

I can at least bump up your post and send mega vines that Penny starts showing some better numbers.

Marilyn

 

[Phoebe_TiggyGA_NortonGA]

Looks like she has some resistance. Keep going up in dose. Hold a new dose at least 6 cycles (3 days) unless she goes low (below 50) at nadir.

 

[anna and bailey.uk england]

hi robyn. i don't often give advice but ive been at this for well over a yr with a real hard to handle kittycat!this forum knows.believe me!!! he went up to 9.5 u of insulin due to insulin resistance so much so he was tested for infections,high dose conditions u name it! even though really the vet or I didn't really know. but sometimes you just have to keep going with those dose increases.....slowly in .25 units to push past that resistance. were now on 2.75u of insulin. my boys still all over the place but holding those blues/yellows most days.

I don't like saying it but you really need to get more tests in as you don't know whether hes going low in the night. to give you an example. id go to work leaving bailey at around 350 and come home to a preshot of around 200 which was odd. then the same the next day hed be sky high again. on my day off when I tested through the night he gone as low as 70 and I never knew!!! I feel for you cos believe me ive been there. but youll honestly get there. it just takes time and quite abit of testing. you kinda need to know what her numbers are going to do. like knowing the pattern if that makes sense! if you get a min just take a min just take a look a baileys ss. theres times like your today for instance hes gone from 400 at preshot to 270 (like yours at +6) yet has thrown a green inbetween that time.

am I reading ss right that shes throwing up a hairball every day????

 

[Sienne and Gabby (GA)]

Hi, Robyn.

I suspect you're thinking that the highest dose that you gave Penny when she went OTJ will likely be around what she'll need now. That's rarely the case. Kitties who fall out of remission often need more insulin than they did the first time around. You also need to be aggressive about dosing. Fattening the dose vs. increasing by 0.25u isn't getting Penny's numbers where you want them. In fact, it may be contributing to glucose toxicity.

I'd also encourage you to run a couple of curves. With Lev, onset and nadir are later than Lantus -- usually nadir is past +6. I'd just want you to be sure you know where Penny's onset and nadir fall. I also agree with Anna. Getting PM tests that are close to nadir may tell you more or, if you are testing a bit past onset, you'll have a better sense of whether it's going to be an active cycle. Many cats' Lev onset is closer to +4.

Are you giving the gabapentin for Penny's arthritis? Is there any chance she's still in pain? Pain can cause numbers to be elevated.

 

[Robyn and Penny]

hi robyn. i don't often give advice but ive been at this for well over a yr with a real hard to handle kittycat!this forum knows.believe me!!! he went up to 9.5 u of insulin due to insulin resistance so much so he was tested for infections,high dose conditions u name it! even though really the vet or I didn't really know. but sometimes you just have to keep going with those dose increases.....slowly in .25 units to push past that resistance. were now on 2.75u of insulin. my boys still all over the place but holding those blues/yellows most days.

I don't like saying it but you really need to get more tests in as you don't know whether hes going low in the night. to give you an example. id go to work leaving bailey at around 350 and come home to a preshot of around 200 which was odd. then the same the next day hed be sky high again. on my day off when I tested through the night he gone as low as 70 and I never knew!!! I feel for you cos believe me ive been there. but youll honestly get there. it just takes time and quite abit of testing. you kinda need to know what her numbers are going to do. like knowing the pattern if that makes sense! if you get a min just take a min just take a look a baileys ss. theres times like your today for instance hes gone from 400 at preshot to 270 (like yours at +6) yet has thrown a green inbetween that time.

am I reading ss right that shes throwing up a hairball every day????

No the hairballs are in her poop lol. She was OTJ for 14 months but when she was flirting with a hairball she would jump to the low 100s from her usual 70ish reading, so I got in the habit of tracking her hairballs. Plus she has a bit of I suspect IBD so I track the consistency.

 

[Robyn and Penny]

Hi, Robyn.

I suspect you're thinking that the highest dose that you gave Penny when she went OTJ will likely be around what she'll need now. That's rarely the case. Kitties who fall out of remission often need more insulin than they did the first time around. You also need to be aggressive about dosing. Fattening the dose vs. increasing by 0.25u isn't getting Penny's numbers where you want them. In fact, it may be contributing to glucose toxicity.

I'd also encourage you to run a couple of curves. With Lev, onset and nadir are later than Lantus -- usually nadir is past +6. I'd just want you to be sure you know where Penny's onset and nadir fall. I also agree with Anna. Getting PM tests that are close to nadir may tell you more or, if you are testing a bit past onset, you'll have a better sense of whether it's going to be an active cycle. Many cats' Lev onset is closer to +4.

Are you giving the gabapentin for Penny's arthritis? Is there any chance she's still in pain? Pain can cause numbers to be elevated.

Penny's highest dose the first time around, On Levemir, was .5u before she went OTJ. This is MUCH higher. I'm guessing by the numbers I've already gotten that her onset is just around +3 and nadir around +6. It looked like it was going later with the higher dose but when you look at the trends, it's back to +6. No way is she hitting a nadir at +10 and then shooting back up to 300s by PMPS. That's not Lev's nature.

I was doing 2am tests but it's frustrating to see a high number overnight and then take an hour to fall back asleep. I was reserving that for when her numbers are lower b/c it takes me forever to fall back asleep and I work lol

 

[Robyn and Penny]

Hi, Robyn.

I suspect you're thinking that the highest dose that you gave Penny when she went OTJ will likely be around what she'll need now. That's rarely the case. Kitties who fall out of remission often need more insulin than they did the first time around. You also need to be aggressive about dosing. Fattening the dose vs. increasing by 0.25u isn't getting Penny's numbers where you want them. In fact, it may be contributing to glucose toxicity.

I'd also encourage you to run a couple of curves. With Lev, onset and nadir are later than Lantus -- usually nadir is past +6. I'd just want you to be sure you know where Penny's onset and nadir fall. I also agree with Anna. Getting PM tests that are close to nadir may tell you more or, if you are testing a bit past onset, you'll have a better sense of whether it's going to be an active cycle. Many cats' Lev onset is closer to +4.

Are you giving the gabapentin for Penny's arthritis? Is there any chance she's still in pain? Pain can cause numbers to be elevated.

Oh and no more gabapentin. It did nothing for her pain and I believe caused her loss of remission. If you go back in 2014 you can see her numbers were slightly elevated in the 100s when she started gabapentin and when the vet raised her dose to 60+mg per day she shot up into 200-300s. She's running up and down the steps, not stiff when she's getting up and now for the first time since we adopted her in 2012, she's chasing and playing with her sister at night whenn she's not down the basement on "bug patrol". Shes been jumping to the top of her 5' cat condos for the first time in about a year so she's awfully active for a cat in pain if she is. She's lost almost 3lbs with her "exercise program" and is on Adequan, which I believe worked WONDERS on her spinal arthritis. The weight loss alone is more effective than any painkiller. But judging by her behavior, acting like a kitten for the first time since I met her, I don't believe she is in pain.

 

[anna and bailey.uk england]

i do think its LITERALLY case of not enough insulin if everything else seems fine

I know the feeling of a zombie walking! haha but sometimes you have gotta do what you gotta do! I couldn't sleep anyway with the worry of such high numbers and had my suspicions so im glad I did get up. good luck robyn.

 

[julie & punkin (ga)]

Are you familiar with Glucose Toxicity? When you stay at a dose that isn't getting a cat into normal numbers (50-120 human glucometer) the cat's body accepts those high numbers as normal. Then you have to give even more insulin to break through that barrier and bring the range down. I think she's got that going on. I think part of the reason for it is because you're skootching your dose instead of using 025u or 0.5u increments. Sometimes it takes a bigger increment to move BGs unless you are really just fine tuning. I wouldn't go to fattening doses unless you're really basically there on a good dose and having consistent green nadirs. Until that point, I'd use the full amount suggested in the TR guidelines - either the 0.25u or 0.5u increment, based upon the nadirs you're getting. You did that with this last increase and I think that was a smart move.

Looking at the dosing guidelines, I think you're mostly falling in the part I bolded/colored below. As long as your seeing nadirs over 200, I'd hold the dose for 6 cycles only, and during that time get one mid-cycle test in each cycle, including the night, so that you can confidently & safely increase and know that there are no hidden low numbers that might be causing bouncing high numbers.

Whenever a situation is hard to figure out, I always go back to the basics - which includes a night cycle test. I'd also vary up the time you do test during the day cycle instead of always getting it at +6. If you think of the spreadsheet like a jigsaw puzzle, a sprinkle of pieces throughout the whole puzzle will make it so you can tell pretty clearly what the picture is. If you only have edge pieces and one stripe down the middle, it's much harder to ferret out the picture. If you only have pieces in one side of your puzzle, you don't have any idea what the whole picture is. Right now you're confused by the puzzle that is Penny's spreadsheet - these little hints will help you uncover missing parts and let you see the whole picture. It'll be a relief to be certain what's going on!

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.

One trick that might help you with the night cycle (I wouldn't want to get up at 2am AACK either) is to adjust your shot time to accommodate getting night tests. I have no idea when you get up in the morning, but could you shoot earlier or later so that the nadirs might fall at a better time for you sleep-wise? There are people who shoot at noon and midnight - doesn't sound ideal to me, but with Lev, it really works for them.

 

[Robyn and Penny]

If you notice on her SS, I did go back to .25u increases since she was on 1.75u. Did anybody see at all that she had a few days in the blues at a fat1.25u? And she hasn't been under renal threshold since I increased from that dose? Does anybody feel that her liver is working against us here?

 

[Tina & Sammy]

Hi Robyn, This is the first time I have visited your condo. I don't typically give dosing advice, but I did take a look at Penny's spreadsheet and it looks to me like you did everything right on the increases. You were even doing increases more slowly by including fat and skinny doses as well. I am not one to quote the protocol or tell you what you are doing wrong, I just try to possibly open your eyes to things you can look at to see if they might be the problem.

Sammy is back from remission after 5 years, and and he required almost double the dose the second time than he did the first time. I see the first time Penny was on insulin she was only on for a short time and didn't require much. I can also tell you that Sammy's cycle is totally different the second time around than it was the first time. So the best advice I can give you is try not to compare them. I know it is hard, I still do it now and then. They might have some similarities, but don't expect everything to be the same. You need to do a few curves to really determine what Penny is doing now.

Also, have you ruled out allergies? You said you have ruled out infection, so I am assuming that includes any infection that might have to do with bad teeth. I have found with Sammy when he has a particular type of food his numbers skyrocket, but when I remove that food the numbers come down even without increasing the dose. I know others have experienced similar issues with their cat also, @Chris & China. Maybe you need to do some food experiments with Penny to see if that could be a problem. Both the first time Sammy was on insulin and this time around the MOMENT I implemented MiniMeals Sammy's numbers normalized and he has gone down the dose scale. He is currently nearing remission again. I am not saying that food or MiniMeals will help, but if it were me I would try absolutely everything to figure out what works.

Having looked at Penny's spreadsheet and seeing the results you were getting as you continued to increase, I probably would have done the same and gone back to a dose that I knew worked. I don't know if it will work, but my motto is that unless I try I will never know. I hope it works for you, but if nothing else you will just head back up the dose scale again.

Good Luck to you, hopefully you will be seeing better numbers one way or the other. Also remember that Penny currently has a much larger depot of insulin, so it might take a few cycles before you see the numbers going down if that is what is going to happen.

 

[Jill & Alex (GA)]

Did anybody see at all that she had a few days in the blues at a fat1.25u?

Yes, but that was then and this is now. Has glucose toxicity set in in the mean time? I'd say it's very likely. We've seen glucose toxicity set in in a matter of days and that was about a month ago. Julie left you a link to some awesome info she put together on glucose toxicity.

Having said that, I can make a suggestion based on what I'm seeing on your spreadsheet. Penny's ss both confuses and intrigues me at the same time...
I'd want to know where those reds are coming from. It looks like some kind of bouncing action to me, but who knows? I wouldn't be surprised if she's bouncing from seeing 100s. There's only one way to find out and that's to fill in the blanks on Penny's spreadsheet. If I were in your shoes, I'd stagger the tests. It's always much easier to address issues (especially dosing issues) when you *know* what you're dealing with. IMHO, there's currently not enough evidence to draw a hard conclusion that onset is at +3, a consistent nadir of +6 (as you know *generally* levemir has an onset of +4 and a nadir of +8 - +10), and far too many blanks in the recent data (sorry --- PM cycles can offer a lot of info when you're seeing red at AMPS).

Penny's highest dose the first time around, On Levemir, was .5u before she went OTJ. This is MUCH higher.

It's not unusual for a kitty to require a higher dose than ever before after falling out of remission. In fact, I'll take this one step further. In all the time I've been a member of the FDMB, I can't recall a single cat who came back from the Falls whose insulin needs were not much greater than the first or even second time around. Heck, Alex was a low dose kitty the first time around. The second and third times she went on insulin her dose got up to around 2.5 units... and I was much more aggressive than most caregivers (didn't let glucose toxicity set in). Sure it's hard to swallow the increase in insulin requirements, but you know what? I came to the conclusion we just have to give our kitties what they need. Our cats fall out of remission for a reason. It only stands to reason health issues (which require higher doses of insulin to overcome) can make regulation and/or remission more difficult to achieve.

Like the others, I strongly suspect Penny simply hasn't arrived at a good dose yet. If I were in your shoes I would become as aggressive as I could safely do so. It's much harder to bring a cat back into remission a second or third time. The longer it takes, the less likely it will happen if it was meant to happen at all.

Just my thoughts and observations...

 

[Robyn and Penny]

Okay...I'm just learning about glucose toxicity. Should I follow increasing every 6 - 8 cycles till I get to a good dose? Then how do I know when to drop? And how far?

 

[Robyn and Penny]

Hi Robyn, This is the first time I have visited your condo. I don't typically give dosing advice, but I did take a look at Penny's spreadsheet and it looks to me like you did everything right on the increases. You were even doing increases more slowly by including fat and skinny doses as well. I am not one to quote the protocol or tell you what you are doing wrong, I just try to possibly open your eyes to things you can look at to see if they might be the problem.

Sammy is back from remission after 5 years, and and he required almost double the dose the second time than he did the first time. I see the first time Penny was on insulin she was only on for a short time and didn't require much. I can also tell you that Sammy's cycle is totally different the second time around than it was the first time. So the best advice I can give you is try not to compare them. I know it is hard, I still do it now and then. They might have some similarities, but don't expect everything to be the same. You need to do a few curves to really determine what Penny is doing now.

Also, have you ruled out allergies? You said you have ruled out infection, so I am assuming that includes any infection that might have to do with bad teeth. I have found with Sammy when he has a particular type of food his numbers skyrocket, but when I remove that food the numbers come down even without increasing the dose. I know others have experienced similar issues with their cat also, @Chris & China. Maybe you need to do some food experiments with Penny to see if that could be a problem. Both the first time Sammy was on insulin and this time around the MOMENT I implemented MiniMeals Sammy's numbers normalized and he has gone down the dose scale. He is currently nearing remission again. I am not saying that food or MiniMeals will help, but if it were me I would try absolutely everything to figure out what works.

Having looked at Penny's spreadsheet and seeing the results you were getting as you continued to increase, I probably would have done the same and gone back to a dose that I knew worked. I don't know if it will work, but my motto is that unless I try I will never know. I hope it works for you, but if nothing else you will just head back up the dose scale again.

Good Luck to you, hopefully you will be seeing better numbers one way or the other. Also remember that Penny currently has a much larger depot of insulin, so it might take a few cycles before you see the numbers going down if that is what is going to happen.

I did go with my gut and went back down and no improvement yet although her pre shots are lower. I'm a creature of habit so I realize I have to fill in the blanks on mid cycle tests. That +6 test happens after I work out everyday and Penny hangs out with me expecting her chicken snack, which is what she gets after a test lol. I actually run her up and down the steps to get her chicken (hence the steps x 18 on my SS) to help her lose weight. And I know I need to discipline myself to get up for some tests overnight b/c it takes me FOREVER to fall back asleep but if I want to help her, I need to do it, right?
I'm gonna hold her at f1.25u for a couple more days to see if I see improvement and probably move into a new pen while I'm at a lower dose before I really start to aggressively treat glucose toxicity.

I'll have to look p MiniMeals. Is that raw food?

 

[Robyn and Penny]

Nevermind...I just googled mini meals and Penny eats q4h plus snacks on Young Again kibble three times per day in between. Plus her test treat of raw chicken twice per day while I'm running her up and down the steps. She eats all day, like i do lol

 

[Tina & Sammy]

I did go with my gut and went back down and no improvement yet although her pre shots are lower. I'm a creature of habit so I realize I have to fill in the blanks on mid cycle tests. That +6 test happens after I work out everyday and Penny hangs out with me expecting her chicken snack, which is what she gets after a test lol. I actually run her up and down the steps to get her chicken (hence the steps x 18 on my SS) to help her lose weight. And I know I need to discipline myself to get up for some tests overnight b/c it takes me FOREVER to fall back asleep but if I want to help her, I need to do it, right?
I'm gonna hold her at f1.25u for a couple more days to see if I see improvement and probably move into a new pen while I'm at a lower dose before I really start to aggressively treat glucose toxicity.

I'll have to look p MiniMeals. Is that raw food?

Mini Meals are just smaller meals of whatever your cat's current diet is. I started Sammy on hourly mini meals of about a teaspoon or two of food. Then I slowly increased to about 1 oz of food every two hours. It seems to be working for us.

 

[Wendy&Neko]

This is MUCH higher. I'm guessing by the numbers I've already gotten that her onset is just around +3 and nadir around +6. It looked like it was going later with the higher dose but when you look at the trends, it's back to +6. No way is she hitting a nadir at +10 and then shooting back up to 300s by PMPS. That's not Lev's nature.

Each cat can look quite different on Levemir too. Not all cats are flat, and some can zoom up from a late green nadir to a pink preshot. Check out Toby's SS and Milo's SS. Both cats could easily zoom a couple hundred points in a few hours. On a more dramatic scale, Jack did a 53 at +8 on March 19th and was over 500 4 hours later at preshot! And nadirs can move around on Lev cats. Neko's nadir is most often between +9 and +12, but it's also been as early at +5 and as late as +15.

I echo the rest, Penny needs more juice and moving around test times can really help fill in the picture. Getting random night tests will really help fill in the picture what is happening on a dose.

 

[Robyn and Penny]

Each cat can look quite different on Levemir too. Not all cats are flat, and some can zoom up from a late green nadir to a pink preshot. Check out Toby's SS and Milo's SS. Both cats could easily zoom a couple hundred points in a few hours. On a more dramatic scale, Jack did a 53 at +8 on March 19th and was over 500 4 hours later at preshot! And nadirs can move around on Lev cats. Neko's nadir is most often between +9 and +12, but it's also been as early at +5 and as late as +15.

I echo the rest, Penny needs more juice and moving around test times can really help fill in the picture. Getting random night tests will really help fill in the picture what is happening on a dose.

Thanks Wendy. I'm guessing Jack is newly diagnosed? Penny wasn't really on insulin long enough for me to really know what I'm doing yet...as you can tell lol. How many diabetic cats do you have?

 

[Wendy&Neko]

Jack is returning back from being in remission a number of years ago, and so is Milo.

I just have one diabetic cat - dealing with acromegaly and diabetes in one is enough for me.

 

[Robyn and Penny]

Lol I hear ya! That's why I work hard to make sure Weeny gets enough play time and stays thin so I don't have TWO on my hands! Penny just came out of remission after 14 months. Which is why I'm still so inexperienced with dosing and regulating. The first time she went into remission within 6 weeks and within 2 weeks of switching from Lantus to Levemir. It was very easy. This time? Not so much lol