7/6 Sam APMS 430 – Need help on dosage and Sam's BG numbers

Katarina

Katarina

Member Since 2022
7/6 Sam APMS 430 – Need help on dosage and understanding Sam’s BG numbers


Hi, my name is Katarina (everyone calls me Kat) – still new to diabetes but determined to help my 5 year old sweet kitty Sam. I am trying to understand what is going on with his BG numbers lately and if I need to adjust his Lantus dosage.

History: My sweet Sam was diagnosed with diabetes and DKA at the end of January 2022 and then subsequently with IBD in Mid-March. He is a complicated case and still not regulated. According to GI test and low folic acid levels, he was also diagnosed with inflammation of the first 1/3 of his small intestine few weeks ago and I am about to start him on Chlorambucil (chemo drug) as increasing Budesonide (steroid) would not be good for his diabetes.

Medications: Sam is on Lantus 1.5 units, 1 mg Budesonide 1x a day, 8mg Cerenia, 200mg Folic Acid, Pure Saccharomyces 10B.
Soon (probably tomorrow) to be introduced to Chlorambucil (6mg 1x in two weeks I believe)

Food: After diagnosis, I started to feed Sam with Primal freeze dry diet but after I've learned to calculate carbs, I saw that was not good either and switched him to RAWZ rabbit pate. Because of his IBD, we are also limited to rabbit, duck, venison, lamb. Since RAWZ had only one type of protein he could have - rabbit and he was not excited by it, I slowly added small batch raw food (rabbit, lamb, duck) 6 sliders a day which became his primary food source. He is doing very well on it.
Most of the time, Sam requests to top his food with sprinkles of Vital Cat treats (duck or rabbit). That is all he has – very strict diet so I would be able to eliminate carbs as an issue for diabetes or the non-novel proteins for IBD.

Current dilemma: These few days, his glucose levels have been concerning - between 93 - 600s!
Sam was on Lantus 2 units until June 30. I wrote on FDMB as I was concerned this is numbers suddenly started to fluctuate. He used to be much better, but it seems I missed sometimes when I could lower his dosage. Still learning…
On the advice, I did lower the dosage to 1.5 units, but BG is still mixed and all over the place after 5 days.

Otherwise, he is doing well - slowly gaining weight (normal weight 12.4 pounds, when he was the worst 7.76 and now 9.6), he is playful, eating, etc. No ketones according to the test from 07/08.

  • Day #1 07/02: Started day well, then it went down the hill. On the top of that, my alarm didn't go off, so I missed few important shots during the night. I was so upset!
  • Day #2 07/03: Day numbers were pretty much horrible but surprisingly, they were wonderful from 7+ to +11 hour (night) after evening shot.
  • Day #3: 07/04: Really bad numbers in the afternoon and evening. There was one strange experience I had... His BG went within 2 hours from 290 to 557! I couldn't believe it, so I took another strip and tested from the other ear within a minute - B was 480! Is that normal there would be such a difference??? I am questioning everything at this point. I did check the expiration date and I always make sure the code for cats matches on the meter and the testing strip container.
  • Day #4: 07/05 - we didn't start well with AMPS 485, +3 525, +6 was 342, +9 571 and then he went down PMPS 376. I did one test at night +8 which was 308
  • Day #5: AMPS was 430.
    C:\Users\Katarina\AppData\Local\Temp\msohtmlclip1\01\clip_image001.png
Just in a case this info could help:
- I am giving him Budesonide 1mg after his dinner ~ 9 PM. He eats usually slowly (7 PM - 9 PM)
- Breakfast 7-9 AM; Lunch 12:30 - 2PM; Dinner 7-9 PM
- Insulin shots 7:30 AM and PM
- Food Small Batch (raw) lamb, rabbit, duck and Vital cat raw treats (duck, rabbit) sprinkle
when he doesn't feel like eating or asks for it. He gets also RAWZ rabbit pate 1/4 of can a day.

I would love to hear from the experienced members their opinion and what could I do better, any changes, etc. I want to help my baby so much! It is overwhelming to go through all info but I’ve been educating myself but I am not at the point to know what to do in this kind of situation just yet. Thank you so much for understanding.
Please, check Sam's spreadsheet for all the details.
Thank you so much, Kat & Sam
 
Diane Tyler's Mom said:
Here’s the dosing sticky.
https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/

Please choose one :cat:
Click to expand...
I am not sure what to do as it says: "THE USE OF PET-SPECIFIC METERS IS DISCOURAGED BECAUSE THE DOSING METHODS USED ON THE FDMB WERE CREATED WITH METERS CALIBRATED FOR HUMANS. ALL REFERENCED NUMBERS CORRESPOND WITH METERS FOR HUMANS, NOT PET METERS."
It seems the number there will not help me as I am not using human meter but Alphatrak2. I believe the BG numbers mentioned in instructions would be different :-(
 
Why budesonide? Why Renal K? Does he have IBD, small cell lymphoma, or kidney disease? While most here use human meters there are plenty that use pet meters. Pet meters read higher than human meters so anything bg under 68 calls for a dose reduction. How are you determining your dose? Have you looked at the ones we use? Neither would have had you reduce to 1.5 but we would have suggested stalling without food to see if the bg came up without food or if not possible shooting a token dose or skipping insulin that cycle. The bg went up quickly so you were probably safe to shoot a full dose if able to monitor. What you saw after that was a bounce from having a bg your cat was not used to and the reduction was not needed.
 
tiffmaxee said:
Why budesonide? Why Renal K? Does he have IBD, small cell lymphoma, or kidney disease? While most here use human meters there are plenty that use pet meters. Pet meters read higher than human meters so anything bg under 68 calls for a dose reduction. How are you determining your dose? Have you looked at the ones we use? Neither would have had you reduce to 1.5 but we would have suggested stalling without food to see if the bg came up without food or if not possible shooting a token dose or skipping insulin that cycle. The bg went up quickly so you were probably safe to shoot a full dose if able to monitor. What you saw after that was a bounce from having a bg your cat was not used to and the reduction was not needed.
Click to expand...
Hi Elise,
Thank you very much for your feedback.
  1. Why Budesonide? - As I mentioned, Sam was diagnosed with IBD in March and therefore he needs steroid. When he started to lose weight, my vet did ultrasound and said she was suspecting IBD as his intestines were thickened. Once he was in emergency they did another ultrasound, and they couldn't see anything and dismissed any IBD even when I was telling them there is something else. He kept losing weight, his stool got horrible and smelly and after 5 weeks a critical doctor transferred him under an internal specialist who finally listen to me and my vet. They did endoscopy/biopsy and he was diagnosed mid-March for IBD. No small lymphoma.
  2. Why Renal K? - His potassium was very bad when he came to emergency 2.8 or something like that. They got it up to 3.7 and then it started to slowly drop again. Now he is fine at 4.0
  3. Kidney disease? Sam was DKA in January when it all went down. His kidney values improved but not 100%
  4. How I determine a dose? Sam used to have FreeLibra for the first 4 weeks. I was recording everything - BG, food amount, weight, behavior... Then we used to go for checkup and glucose curve to the Internal doctor in the hospital but I found it useless. I found this forum and started to learn. I had phobia of needles and blood (experience from my childhood) so I was not sure how we would function. Doctor in the hospital didn't care about me testing Sam, but my vet encouraged it and showed me how to do it. I've been keeping my spreadsheet since then. But I just checked with my vet and Internal doctor about dosing. I see I need more help from this forum as we are not getting anywhere this way. Hospital orders, if he is 200 or less do not give insulin. So, you may see some crazy things when I gave 0.5 unit less etc. but I do not think I ever went 1.5! Internal doctor told me to go down 1 whole unit and saw on this forum you just don't do such thing because of a bounce. I know more now, but definitely not enough to make decisions. I always saw if 68 then you reduce BUT he was never 68. Now I know that was in Human meter not pet meter and I could go down if his BG was something more I just do not know how to convert. I see discrepancies in info. I saw somewhere that Human meter reads 30-40% lower and Human meter/0.65 = pet meter estimate (using midpoint 35%). According to that I could have reduced a dose when Sam was ~105 on my meter. Ugh :-( I missed some opportunities. If that calculation is correct, I could re-calculate the instructions posted to my meter and follow that?
Note: Sam will start Chlorambucil (chemo drug) most likely tomorrow as he was diagnosed with inflammation of the first part of his intestine (blood test - his folic acid went down from 17.x to 10). My vet doesn't want to increase Budesonide and impact his diabetes even more.
 
Katarina said:
Hi Elise,
Thank you very much for your feedback.
  1. Why Budesonide? - As I mentioned, Sam was diagnosed with IBD in March and therefore he needs steroid. When he started to lose weight, my vet did ultrasound and said she was suspecting IBD as his intestines were thickened. Once he was in emergency they did another ultrasound, and they couldn't see anything and dismissed any IBD even when I was telling them there is something else. He kept losing weight, his stool got horrible and smelly and after 5 weeks a critical doctor transferred him under an internal specialist who finally listen to me and my vet. They did endoscopy/biopsy and he was diagnosed mid-March for IBD. No small lymphoma.
  2. Why Renal K? - His potassium was very bad when he came to emergency 2.8 or something like that. They got it up to 3.7 and then it started to slowly drop again. Now he is fine at 4.0
  3. Kidney disease? Sam was DKA in January when it all went down. His kidney values improved but not 100%
  4. How I determine a dose? Sam used to have FreeLibra for the first 4 weeks. I was recording everything - BG, food amount, weight, behavior... Then we used to go for checkup and glucose curve to the Internal doctor in the hospital but I found it useless. I found this forum and started to learn. I had phobia of needles and blood (experience from my childhood) so I was not sure how we would function. Doctor in the hospital didn't care about me testing Sam, but my vet encouraged it and showed me how to do it. I've been keeping my spreadsheet since then. But I just checked with my vet and Internal doctor about dosing. I see I need more help from this forum as we are not getting anywhere this way. Hospital orders, if he is 200 or less do not give insulin. So, you may see some crazy things when I gave 0.5 unit less etc. but I do not think I ever went 1.5! Internal doctor told me to go down 1 whole unit and saw on this forum you just don't do such thing because of a bounce. I know more now, but definitely not enough to make decisions. I always saw if 68 then you reduce BUT he was never 68. Now I know that was in Human meter not pet meter and I could go down if his BG was something more I just do not know how to convert. I see discrepancies in info. I saw somewhere that Human meter reads 30-40% lower and Human meter/0.65 = pet meter estimate (using midpoint 35%). According to that I could have reduced a dose when Sam was ~105 on my meter. Ugh :-( I missed some opportunities. If that calculation is correct, I could re-calculate the instructions posted to my meter and follow that?
Note: Sam will start Chlorambucil (chemo drug) most likely tomorrow as he was diagnosed with inflammation of the first part of his intestine (blood test - his folic acid went down from 17.x to 10). My vet doesn't want to increase Budesonide and impact his diabetes even more.
Click to expand...


Hi Elise
@tiffmaxee

@Katarina
Have you looked at the 2 dosing methods they will let you know when an increase or decrease is needed
https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/
It looks like you are giving doses based on the pre shots
They are based on how low the BG is dropping
I'm sure Elise can explain it better than me
 
Diane Tyler's Mom said:
Hi Elise
@tiffmaxee

@Katarina
Have you looked at the 2 dosing methods they will let you know when an increase or decrease is needed
https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/
It looks like you are giving doses based on the pre shots
They are based on how low the BG is dropping
I'm sure Elise can explain it better than me
Click to expand...
Hi Diane,
I've been reading for hours and I understand better how that works now. I am just having problem to determine what my numbers are to increase, decrease as I am using pet monitor Alphatrak 2 and instructions are for human meter. I saw a formula to go by difference Human meter shows values 35% less and then also 20% which could be a huge difference. So, far, I just followed what the Internal doctor in the hospital but we do not see him often. I need to take the charge of this situation and not sure where to start. I am trying to create a table for me to check against if I would go with Tight Regulation (TR).
I need to find out what are the values that are mentioned in the instructions for a pet meter, otherwise it could be a dangerous game.
I am now on 5th day after I decreased dosage by 0.5 and the lowest nadir was 93 and highest BG 687. I should have decreased only by 0.25 but it is too late now. I just need to make a decision now on what to do and then follow one of the methods.
If I go with 35% difference in the meters of his nadir 93 could be 74.4 in human meter or if 20% it would be 60.45. So, I need some advice here otherwise, I am stuck on what to do :-( Increase, decrease, stay?
Sam's BG got much worse than what it used to be. and I am so worried when he is in 500 and 600s. But I know it could be also due to bouncing.
 
I’m a little confused. You said he has done much better on Small Batch. Does the vet now suspect small cell? You are starting a cancer Med which is why I ask. How long has he been on budesonide? Other than weight loss any symptoms?

You can’t really compare readings with human and animal meters like you are. Many have tried and failed to find that reliable including one of our moderators. You need to choose one. With TR and a human meter reductions are under 50. With vet meters it’s 68. With SLGS regardless of the meter you reduce any time there’s a drop under 90.
 
Katarina said:
He kept losing weight, his stool got horrible and smelly and after 5 weeks a critical doctor transferred him under an internal specialist who finally listen to me and my vet.
Click to expand...
It sounds like Sam has a lot in common with my Henry. Henry had DKA 3 times, extreme weight loss, smelly stools, suspected IBD/SCL. Reason for this post is tho: What do his stools look like? Anything out of the normal? Color? Ever have diarrhea? if so how frequently and what color is it? Is he still losing weight? How is his appetite?
 
I echo Elise (tiffmaxee), why start a chemo drug if you aren't dealing with small cell lymphoma? On my third cat now with SCL, and if I didn't have to, I'd drop chlorambucil in a heart beat. You will see potentially quite strong nausea (ondansetron is essential), and it is carcinogenic by itself so that as a possible concern. Plus a large number of vets aren't up to date with a proper dosing method for cholorambucil.

As for dosing, I rather suspect the suggestion to go back down to 1.5 units was ill advised. With either of our dosing methods, that 93 would not have had you reduce the dose. Start Low Go Slow method says to reduce if below 90, which Sam did not do. How about 1.75 units next? More properly I'd try 2.0 again, but if you want to go conservative you can go to 1.75 units.
 
tiffmaxee said:
I’m a little confused. You said he has done much better on Small Batch. Does the vet now suspect small cell? You are starting a cancer Med which is why I ask. How long has he been on budesonide? Other than weight loss any symptoms?

You can’t really compare readings with human and animal meters like you are. Many have tried and failed to find that reliable including one of our moderators. You need to choose one. With TR and a human meter reductions are under 50. With vet meters it’s 68. With SLGS regardless of the meter you reduce any time there’s a drop under 90.
Click to expand...
Hi Elise (Tiffmaxee),
How did we get to chemo drug chlorambucil?
The critical care doctor was claiming Sam would keep losing weight until diabetes is not controlled but he was going down the hill and she didn't take in any of my concerns - my vet saw thickening of his intestines via ultrasound and his stool was getting worse every day. He was vomiting too. Finally, she transferred him under care of Internal doctor and he listed to me. He performed endoscopy and biopsy. Sam was officially diagnosed with IBD on March 14th - no cancer! Since then, he is on Budesonide (Steroid).
GI blood test that was done by my vet on 6/9 (pancreas efficiency, etc.) and it showed that his Folate went down drastically down from 17.1 to 10.
More info on: Folate Information - Gastrointestinal Laboratory (tamu.edu)
Folate is a vitamin absorbed in the upper 1/3 of the small intestine closest to the stomach. So, this result means we do not have a good control over the inflammation in that area. I am giving Sam now Folic Acid but that is just treating of a symptom not the root cause. My vet doesn't want to increase Budesonide to treat the inflammation as that would mess up his diabetes even more and that is when chlorambucil comes into the picture.

Glucose meters:
If I cannot compare, I am not sure how can I follow the numbers in the instructions that cannot be translated to a pet/vet monitor as I am using Alphatrak 2:( Thank you for the info for the reduction numbers - that was very helpful!!! I immediately wrote it down. I would also need to know when to increase dosage, but all instructions are in human monitor numbers. Right now, I am thinking I may need to increase tomorrow morning by 0.25 if no changes over night.
 
Wendy&Neko said:
I echo Elise (tiffmaxee), why start a chemo drug if you aren't dealing with small cell lymphoma? On my third cat now with SCL, and if I didn't have to, I'd drop chlorambucil in a heart beat. You will see potentially quite strong nausea (ondansetron is essential), and it is carcinogenic by itself so that as a possible concern. Plus a large number of vets aren't up to date with a proper dosing method for cholorambucil.

As for dosing, I rather suspect the suggestion to go back down to 1.5 units was ill advised. With either of our dosing methods, that 93 would not have had you reduce the dose. Start Low Go Slow method says to reduce if below 90, which Sam did not do. How about 1.75 units next? More properly I'd try 2.0 again, but if you want to go conservative you can go to 1.75 units.
Click to expand...

Hi Wendy,
I cannot thank you enough! I already have the chlorambucil in my fridge but still holding off. Something was telling me to wait. I will listen and talk to my vet. Oh my Goodness, you have 3rd cat on it? I'll be honest I had a good cry when I have learned about putting mine on it and was asking 10,000 questions, doing research. Wishing you all the best! Sending a big hug.
That is exactly what I was thinking to go up to 1.75 tomorrow stay there for some days as prescribed and see if any changes. I will go slower as I do not want him to start bouncing. THANK YOU!
 
I think a switch to prednisolone from budesonide might help you better. So many downsides to chlorambucil. Yes, pred will make his BG numbers worse, but that just means you have to up the dose to compensate. We've seen some nicely regulated diabetic kitties taking prednisolone. Pred's action is more even than that of budesonide. My girl Neko was on budesonide instead of prednisolone, but that's because her heart could not handle prednisolone, which has a more systemic action. The other two were on pred. I did monitor the blood sugars, because I could, and it didn't impact it much. It would more so in a diabetic.

Are you giving a probiotic? Visbiome is specifically formulated for IBD.

We had dozens (maybe more?) people use the Alphatrak 2 and follow our dosing methods. The only change is that if they are using the AT and following the Tight Regulation protocol, the reduction point moves to 68 on the AT instead of 50 on the human meter. All other considerations in the dosing methods, such as increases, use the numbers at face value. For example SLGS reductions at 90 regardless of meter type. Human meter strips are a lot cheaper which means people tend to not be as conservative on testing.

Do not worry about bouncing. Really. It's pretty much a necessary evil for all recently diagnosed cats (and even some longer term), who aren't used to normal blood sugar numbers yet.
 
Wendy&Neko said:
I think a switch to prednisolone from budesonide might help you better. So many downsides to chlorambucil. Yes, pred will make his BG numbers worse, but that just means you have to up the dose to compensate. We've seen some nicely regulated diabetic kitties taking prednisolone. Pred's action is more even than that of budesonide. My girl Neko was on budesonide instead of prednisolone, but that's because her heart could not handle prednisolone, which has a more systemic action. The other two were on pred. I did monitor the blood sugars, because I could, and it didn't impact it much. It would more so in a diabetic.

Are you giving a probiotic? Visbiome is specifically formulated for IBD.

We had dozens (maybe more?) people use the Alphatrak 2 and follow our dosing methods. The only change is that if they are using the AT and following the Tight Regulation protocol, the reduction point moves to 68 on the AT instead of 50 on the human meter. All other considerations in the dosing methods, such as increases, use the numbers at face value. For example SLGS reductions at 90 regardless of meter type. Human meter strips are a lot cheaper which means people tend to not be as conservative on testing.

Do not worry about bouncing. Really. It's pretty much a necessary evil for all recently diagnosed cats (and even some longer term), who aren't used to normal blood sugar numbers yet.
Click to expand...

Hi Wendy,
As far as prednisolone, it may not be a good choice for Sam. Here is why... My vet and I were suspecting IBD but we were still waiting for some tests. As he was getting worse, I told my vet let's just go ahead with Prednisolone. I gave him the first doze of it and in the morning, he was in emergency in a very bad condition diagnosed with diabetes. I will always blame myself that I gave it to him. Also, there was one evening when I forgot to give Sam Budesonide and his BG was better next day. Many cats are not impacted by it at all, but he seems to be. I will talk to my vet next week and tell her I am having second thoughts about chlorambucil.

Sam is on Probiotics, I've been through few and changed as they contain some ingredients that could affect BG. Right now, he is on Pure Saccharomyces 10B. He was also on AnimalBiome (gut restore and maintenance that helped a lot.
I will check Visbiome.

So, I made a decision and started Sam on the previous doze of Insulin 2 units yesterday morning and we will follow SLGS protocol. His numbers have definitely improved:
Yesterday: 321, 403, 483
Today: 184, 381, 451
We had a week prior with multiple 500 - 600. I think this is a good start. So far, I was just collecting data, making sure he is not low and I was very concerned about the high values.
From now on, I will be following instructions for SLGS.
So, you are saying that I can just follow the values that are specified there (90, 150, etc.)? It says it is for human meters.

Hold the dose for at least a week:
  • Unless your cat won’t eat or you suspect hypoglycemia
  • Unless your kitty falls below 90 mg/dL (5 mmol/L). If kitty falls below 90 mg/dL (5 mmol/L) decrease the dose by 0.25 unit immediately.
After 1 week at a given dose perform a 12 hour curve, testing every 2 hours OR perform an 18 hour curve, testing every 3 hours. Note: Random spot checks are often helpful to "fill in the blanks" on kitty's spreadsheet. The goal is to learn how low the current dose is dropping kitty prior to making dose adjustments.
  • If nadirs are more than 150 mg/dl (8.3 mmol/L), increase the dose by 0.25 unit
  • If nadirs are between 90 (5 mmol/L) and 149 mg/dl (8.2 mmol/L), maintain the same dose
  • If nadirs are below 90 mg/dl (5mmol/L), decrease the dose by 0.25 unit
A stupid question about nadirs. Apologies, I am still learning :-).
Do I just look for 1 nadir and act on it to increase a dose by 0.25 (at the end of the week after a curve) or nadir needs to be > then 150 every day in order to increase a dose?
I want to make sure I am doing it right, so I do not miss any opportunities to make Sam's diabetes better.
THANK YOU!
 
No stupid questions here. You are looking for trends.with fd. If green at shot time, stall and drop my feed. If on the way up in 20-30 minutes you shoot unless still under under 150 until you have data to see how he does. Some people base dosing on the curve only but that is not a really good way to do it. It’s best to catch a a few nadirs in both cycles if scheduling allows.
 
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