5/16 Mr. Sluggo: AMPS:119, 90@3.0, 58@5.5, 65@6.5, PMPS: 121, 137@3.0, 119@6.0

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Thinking about this last night. Unless cat starts sporting numbers <50, if cat is running 60-120 range human meter with a nice flat curve, why not leave him/her there longer than a week, despite protocol saying you can decrease dose at 7 days. Might it make for a smoother wean later on with more "healing time"?

But I mean, why be niggardly about this? Why not at least give him 2 weeks of euglycemia if his little body will allow before starting dosage wean? If time at 60-120 is the goal, why not just leave him there? How long is long enough to assure maximum benefit? A month? Two?

My only time constraint is I'm having troubles finding a vet that will accept me in the practice while I'm using lantus TR, and my cat does need some ongoing care for bowel issues (e.g., is on maintenance lomustine chemotx I don't want to stop even though it was never clear from biomarkers whether he has ibd or small bowel lymphoma). I could just give that without checking a leukocyte count or just stop it, but those are my choices without a vet. I don't have a handy CBC machine in my house with differential and simply drawing the sample, putting some random patient label on it in a lavender top tube in the OR and submitting it to the lab is a bit sociopathic even for me... ;)

These vets hear, "following lantus TR under xxx protocol" and suddenly both you and your cat are persona non grata. Some sort of "dog/cat whistle" there... I've tried this a couple times. That experiment is repeatable.
 
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you would think it makes sense to hold a dose longer if the cat is in nice numbers, but sometimes that's not the case. If they don't need that much insulin, then they don't need it. Often when a cat is receiving too much insulin, their numbers go higher. The body is fighting what it perceives as excess insulin. The changes can be subtle, like maybe the numbers go from all green to starting to show some blue, then gradually they will show a lot of blue and need an increase to get things started again. For the most part, we have seen that it works best to go ahead and try a reduction once the cat has stabilized in the tight regulation range on a particular dose. Holding a dose too long, whether the dose is too high or too low, can add weeks or months to your treatment time.

Rather than going by a strict 7 days, I tend to look at the cat's spreadsheet. If they have been surfing in healing numbers for a long time, then there may not be a need to wait 7 whole days on each dose before reducing. I didn't always wait that long for Lucy because by the time she finally got to that point, I knew she was heading for remission. If they are new to good numbers, then giving them a little more healing time might be a good idea.
 
Perhaps I should check again in an hour... Might have a number less than 50...
 
I saw your comment in last night's condo about the flat cycles and wanted to share Davidson's spreadsheet with you. He's a kitty that was newly diagnosed, so hadn't come out of remission, but his spreadsheet is a great example of his dose reductions coming most of the time by being 7 days in normal numbers and then Shawna reducing by 0.25u. It took him months to work from 2.75u off of insulin, but he's now been OTJ for more than a year and is still doing well.

The interesting part of his spreadsheet begins in early February 2014. Notice that Shawna began shooting lower numbers then and his cycles just flattened out. Then you can see the dose reductions as they occurred.

Sandy's point (from last night's condo) is a good one - the reason that we see such variety in how cats do is because ultimately, it's all about what's happening in that cat's body. Mr. Sluggo is in charge and your job is to follow his lead.

As far as the vet goes, you may want to not share his spreadsheet or talk about the dosing protocol when you find a new vet.
 
Thank You! Looks like he had his share of <50 BG numbers though also. Sluggo hasn't done that at least yet (except for that single 36 at the beginning where he got overdosed because I was even more aggressive than the protocol ;)). On the whole it's been quite difficult to make him hypoglycemic. It seems to take either deliberate action or stupidity. But I'm only 9 or 10 days in.

Regarding your suggestion... I really hate not being straightforward, or even worse lying. It's not my nature.

But it looks like being honest and straightforward means Mr. Sluggo doesn't get a vet. And with his panoply of issues, that's a problem. I tried approaching two other vets, explaining what I was doing and asked if they'd be willing to see my cat as a patient, and they said, "yes, but not under those conditions (me following this protocol)".

I think I'll probably roll the bones, give him his maintenance chemo in 3 weeks without checking a neutrophil count even though it's lousy medicine and address the issue in 9 weeks when he's next due. It would probably be ok, since his neutrophils were only low during induction therapy, vet relations will be risky while he's on the protocol and his blood sugars go phase 2 booster in the ionosphere at the vets office every time. I could also be honest if I can finish in 9 weeks and it would likely be better in getting a lasting relationship with a vet who'll be there for him when the going gets tough. Right now things aren't tough anymore; sluggo is surfing in good numbers and the waves are tiny. I hate doing it this way, but it is what it is and those are my alternatives. At least in human medicine "honesty is the best policy". If you don't tell your anesthesiologist you've eaten the morning of surgery or tell him about the crack you smoked the night before last it could be the last mistake you ever make.
 
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We ask members in this forum to please link the previous day's thread (condo) so it's easy to get to quickly. With so many members, you can imagine the time it takes to look up past posts if we want to review them. With the link in the condo, we can do it quickly :):):)

Here's the link to Mr. Sluggo's 5/15 Condo

One way you can help him keep his BG in euglycemic numbers longer and thus give his pancreas more healing time, is to manage the curve so he doesn't earn a reduction. Some kitties will go up and down around a dose (mine being one of them) and when the CG reduces, the numbers go up. If you can use his regular food to manage his curve (anticipate when he might drop and feed before it), then you can potentially keep him above 50 longer and perhaps he'll earn his reductions by staying in mostly green numbers for a week instead of by going below 40. I'm not sure what his feeding schedule is but you can experiment with it and see how it goes.
 
I have a wonderful vet, but I use this forum for diabetes management. She does know that I test at home; when I had Lulu in to see her last week, she commented that I'm doing a wonderful job managing Lulu's diabetes, and that she hadn't seen Lulu looking so good and chipper in a long time. I don't share that I'm following the TR protocol, and don't feel as though I'm lying (of course, that could be considered by some as lying by omission). But this forum works well for Lulu and me, members have stayed up half the night coaching me. I wouldn't expect my vet would be willing to be on call 24/7.

Anyway...just my .02. EBID (every bean is different ;))
 
Sandman said:
I think I'll probably roll the bones, give him his maintenance chemo in 3 weeks without checking a neutrophil count even though it's lousy medicine and address the issue in 9 weeks when he's next due. It would probably be ok, since his neutrophils were only low during induction therapy, vet relations will be risky while he's on the protocol and his blood sugars go phase 2 booster in the ionosphere at the vets office every time. It would set him back. I hate doing that, but it is what it is.
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Do you have an oncologist for him? If you do, you might not have to broach the subject of the TR protocol because an oncologist is not going to deal with that anyway. Do I remember correctly that you are in McAllen? If so, here's the yelp listing of McAllen Vets. Don't know if that helps any.

I had to take Gracie into an internal medicine specialist for mildly elevated ALT values. He wanted to discuss her insulin therapy. I told him I wasn't there for that and I'd like to keep the discussion focused on her liver values. I said it very respectfully and he was professional enough to proceed as I asked.
 
No, not an oncologist. Gary Norsworthy up in San Antonio is a cat specialist of some reknown, who diagnosed sluggo and prescribed his ibd/bowel lymphoma therapy. He knows I manage his diabetes and TR is not his thing (ultra-loose management with a 26% remission rate, so I don't like the way he does it.), but he has so far seemed to tolerate me. And he appears in most other respects a smart super-dedicated doc I feel lucky to have on my side (if he still is... the clinic owner that fired me was apparently a colleague of his at Texas A&M and cc'd him on the email!). And San Antonio is 250 miles away; not a day-trip. He seems a bit smarter than the typical vet I've run into. And one other complication is I did look at the spreadsheet, the insulin consumption, and control about a week ago, decided prozinc wouldn't get me where I needed to go and changed both the insulin and the protocol.

So this looks to be a problem...

Look at the second biography from the bottom here:

http://www.prozinc.us/prozinc.html

I imagine Dr. Norsworthy would look at that spreadsheet managed with prozinc and think the only problem was that I had the spreadsheet and was collecting BG numbers at all. No problem with the prozinc... The cat doesn't have symptoms. I kid you not. Probably the same deal with his buddy. So I guess we shoot blind and go sailing into the hurricane or leave our cats at the vet for glucose curves and fructosamine tests. Then shoot blind. Any takers?

This and sluggo's problems have me up nights. I seldom sleep more than 4 hours now. And my appetite is gone. I'm a big guy, like sluggo, so that is definitely not normal.

Religion kills, I'm afraid. It certainly kills people and maybe cats too!

And the toughest thing, in anesthesiology at least, is realizing when things have gone off the rails and a paradigm shift is necessary. It's the last thing you learn. Some never do. Too bad that paradigm shift appears to have alienated me from every vet on the face of god's green earth.
 
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It's possible that their discomfort is because they are well versed in prozinc/old PZI and not lantus/levemir. I did have a conversation with a different IM specialist than the one referenced above and he asked me why I didn't have Gracie on prozinc or compounded PZI.
 
Marje and Gracie said:
he asked me why I didn't have Gracie on prozinc or compounded PZI.
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I don't know about PZI, but can comment on prozinc as its what I used to get sluggo otj the first time. But that was a diabetic at first diagnosis and it was steroid induced. Look anywhere on the web. Those are relatively easy to get into remission. I have seen some comments that a 2nd remission is very unusual. I guess they haven't been to this board. How many relapsed cats get better with prozinc or PZI?

If you want to see what happens if you try using prozinc on a cat who has relapsed, take a good look at my spreadsheet up until May 5th or so (my personal AHA moment). Rising doses and regulation, mediocre on a good day. Then look at the 10 days since. I mean, this is what you'd call a crossover study. It could be that I suddenly and instantly became more adept at managing with lantus than I was with 2 1/2 months using prozinc (1 month with initial remission), 1 1/2 month screwing around with it this time, i.e., "operator skill". But I wouldn't bet on it.

There's a paper I found when I was tooling around on pubmed yesterday or today comparing remission rates for newly diagnosed diabetic felines by type of insulin. It's not directly applicable to my case, but let me look.

Here is the short & sweet answer to that internist. Glargine (lantus) cats got better. The others didn't. :smuggrin:

Send to:


J Feline Med Surg. 2009 Aug;11(8):683-91. doi: 10.1016/j.jfms.2009.05.016. Epub 2009 Jun 18.
Treatment of newly diagnosed diabetic cats with glargine insulin improves glycaemic control and results in higher probability of remission than protamine zinc and lente insulins.
Marshall RD1, Rand JS, Morton JM.
Author information
Abstract
Glycaemic control and remission probabilities were compared in 24 newly diagnosed diabetic cats treated twice daily with either glargine, protamine zinc (PZI) or lente insulin and fed a low carbohydrate diet. After day 17, the probability of remission was substantially higher for cats with lower mean 12h blood glucose concentrations on day 17, irrespective of insulin type. Glargine-treated cats had lower mean 12h blood glucose concentrations on day 17 than PZI- or lente-treated cats, and all eight glargine-treated cats achieved remission compared to three PZI- and two lente-treated cats. The probability of remission was greater for cats treated with glargine than cats treated with PZI or lente insulin. In newly diagnosed diabetic cats, twice daily treatment with glargine provides better glycaemic control and higher probability of remission compared to twice daily treatment with PZI or lente insulin. Good glycaemic control soon after diagnosis is associated with increased probability of remission and should be the goal of insulin therapy.
 
Not quite sure what happened with PM shot. Didn't seem like a fur shot, but number looks like it. So much for the 7 days of normal numbers... Nothing unusual with diet, etc. Oh well...
 
The doc you linked is on here somewhere. There are many cats that go OTJ on Prozinc as well as Lantus. We've seen lots of good results with Levemir too. It does seem like longer duration is very important, and the L insulins last longer than Prozinc. Even among all Lantus users there are some cats that only get 8 hrs from it.

You do have to get to the right dose with any insulin. I haven't used Prozinc since learning about home testing in the beginning, but I can't help but think one reason for your success with switching to Lantus is because the dose was much greater than the Prozinc dose.
 
Dose was certainly greater with lantus than prozinc, however, I remember hearing some place (maybe the protocol) lantus is less potent than prozinc/pzi on a unit-for-unit basis. In other words prozinc 1u > lantus 1u in glucose lowering potency. But lantus has significantly greater duration. The problem I was having with prozinc has been lack of duration. I was even using a sliding scale with it and dosing every 6=8 hrs (Hodgkins' in the beginning and my attempt at refinement when it was resulting in a single big dose per day for a 200+ in the morning and nothing after) and was still having problems with a 70 on one test and a 200+ on the next. You can't use a sliding scale with lantus. Very different drug. Changing the dose is like turning an aircraft carrier.

Lantus has no discernible peak. it just goes up & hangs around a very long time >24 hrs. That's why you can get in trouble dosing on the 12 hr if you go too fast. It's also how I knew with that hypo on a dose of 2.0 units I was very close to "correct". It came after 6 doses given on the half-time. That's when such a dosing scheme reaches equilibrium. Backing off the 0.25 u was all I needed (AFTER treating the clinically insignificant horrifying number).

Nevertheless, the science is the science. Did you see the article I left out on remission versus insulin type?

Gary is on here somewhere? What we do would just be like acid in his mouth, I think.
 
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Adding onto Julie's example of Davidson, one of the current kitties on here, Jack, was originally on Humulin 3 years ago, fell out of remission and is now on Levemir and down to 0.1U, with a lot of his reductions because he's been a week in normal numbers. Here is Jack's SS.
 
No longer relevant to me. Sluggo popped a 137 tonight... I don't know why. I don't think I did a fur shot, but who knows.

So, I think my day count for normal glucoses resets, right? Or maybe he'll pop a 200+ by morning and I'll be looking at going the other way (an increase?!)..

This is much more tedious than the first time I got him in remission. That one was a romp.
 
Back to normal if only barely to end the day. The spike to 137 was interesting. Wonder what tomorrow will bring.

Certainly a marathon, this. Not a sprint.

Good night all!
 
Thanks, Wendy!

My sluggo had an abscessed tooth, the vet had me putzing around with antibiotics for a week with no plan to address it surgically. This produced my first run-in with the veterinary establishment when I noticed 330+ blood glucoses in my cat formerly in remission, I was shooting large doses of prozinc and it was like shooting water and I couldn't reach my usual vet and when she did call back said she couldn't see him for a couple days. Can you say DKA?

A trip up the road, they got him in to surgery the following day, but fired me as a client when I told them I was trying to personally manage the aftermath to get a second remission using TR. So now my cat with multiple medical issues doesn't have a vet and I have no realistic prospect of getting one, short of lying through my teeth about what I'm doing. Wonderful. Simply wonderful.

Oh well. Anybody know a good vet who'll let you do the best thing you can for your cat's diabetes? Do I have to go to Cornell and take up residence in NY or what?!
 
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One number above normal does not negate the ability to reduce after seven days. You just want the majority of the numbers to be below 100. Who knows...he could have gotten a food spike if you had fed him recently.

Thanks for the info and links. We've seen these before but there are a lot of new members who have likely not.
 
One thing I did differently today... I did blend his fancy feast with fortiflora in a nutribullet (he's had some vomiting lately --- IBD vs small cell lymphoma of bowel). You'll note I did ask in other forums about carb content of the fortiflora. Bunch of different answers, not consistency. Sluggo won't eat food with fortiflora on top of it. And I guess it's possible breaking up the fiber might increase the glycemic index. Also, he really chowed down on that versus just leaving it out on a plate.

Sluggo does need to lose some weight, but I did notice with my daily weight he was down a few ozs. Thought I'd try and get on top of that one. Perhaps I mini-spiked his sugars in the process... I'm pretty sure he didn't get into anything. I do feed my other two some evo a couple times a day because they are sugar junkies and even that 8% dry matter carb is too much for poor sluggo. I'm always careful to keep poor sluggo away from that though! Tomorrow is another day.
 
Sandman said:
There's a paper I found when I was tooling around on pubmed yesterday or today comparing remission rates for newly diagnosed diabetic felines by type of insulin. It's not directly applicable to my case, but let me look.

Here is the short & sweet answer to that internist. Glargine (lantus) cats got better. The others didn't. :smuggrin:

Send to:


J Feline Med Surg. 2009 Aug;11(8):683-91. doi: 10.1016/j.jfms.2009.05.016. Epub 2009 Jun 18.
Treatment of newly diagnosed diabetic cats with glargine insulin improves glycaemic control and results in higher probability of remission than protamine zinc and lente insulins.
Marshall RD1, Rand JS, Morton JM.
Author information
Abstract
Glycaemic control and remission probabilities were compared in 24 newly diagnosed diabetic cats treated twice daily with either glargine, protamine zinc (PZI) or lente insulin and fed a low carbohydrate diet. After day 17, the probability of remission was substantially higher for cats with lower mean 12h blood glucose concentrations on day 17, irrespective of insulin type. Glargine-treated cats had lower mean 12h blood glucose concentrations on day 17 than PZI- or lente-treated cats, and all eight glargine-treated cats achieved remission compared to three PZI- and two lente-treated cats. The probability of remission was greater for cats treated with glargine than cats treated with PZI or lente insulin. In newly diagnosed diabetic cats, twice daily treatment with glargine provides better glycaemic control and higher probability of remission compared to twice daily treatment with PZI or lente insulin. Good glycaemic control soon after diagnosis is associated with increased probability of remission and should be the goal of insulin therapy.
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Just wanted to remind our veterans and make it clear to new members that while this study was published in 2009, the study actually took place earlier. Without taking a whole lot of time to find the original date, I believe it was in the early 2000s, like 2005 or 2006. I only mention it because the study was done with PZI not Prozinc. PZI is no longer available and hasn't been for a few years now. Prozinc is a new and different insulin so we can't use the study cited above when comparing Lantus to the newer Prozinc insulin.
 
As I've said before, I think using Prozinc in my cat after he fell out of remission was a mistake possibly a critical one, since the clock was ticking and pancreatic beta cells were dying. So many lost! I did it because it was what I knew and it worked the first time. But a cat that's fallen out of remission is a tougher nut to crack than one freshly diagnosed, particularly when steroids have been involved with the latter. Different patient. Different prognosis.

PZI was a bovine insulin as opposed to prozinc which is human recombinant. PZI is a better match for feline insulin (many fewer amino acid differences in the peptide).

It's quite possible (there's even a rationale for believing it) that PZI would work BETTER than prozinc. Just a thought.
 
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Sandman said:
But wasn't PZI a bovine insulin as opposed to the prozinc which is human recombinant? At least theoretically that one was a much better match for feline insulin.
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Yep. The insulin used in that study was PZI... the bovine insulin you're referring to.
Prozinc is a human recombinant which wasn't even around when that study was done.

Theoretically better? Maybe.

I came to the conclusion several years ago that "the best" insulin is the one that works for YOUR cat! :D
 
Sandman said:
Regarding your suggestion... I really hate not being straightforward, or even worse lying. It's not my nature.
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I'm with Julie.
Back when we were in the thick of it, vets would freak out at the amount of Lantus I used and the R on top would blow their minds. I had found a nice vet but it got to the point where she told me she would not refill BKs Lantus Rx ( she thought changing to PZI was best). Soon after he turned the corner and his vet calmed down. When he started flying down the dosing ladder she saw things differently. When he went into remission all she could say was "he's amazing".

Find a vet that is familiar with Lantus and can care for Sluggos other conditions. Smile, nod, get your Lantus Rx and go about your business.
When CBC times come around and Sluggos BG is looking excellent the vet will smile back. :cool:

 
I have prescriptive authority (as a human physician with license and DEA#) and the local supermarket will fill my meds for my cat and in my cat's name. I was surprised at that. Did this for the lantus at my neighborhood HEB.

Want to talk about a vet freak-out?!

Vets like docile clients... I think they must put "The Stepford Wives" on auto-loop at home.

Maybe it's time to install a CBC machine in the garage...
 
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