Advice for bouncing BGs

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Hi all,

I posted a previous thread on the introductions page with some of my cat’s history. Button has been diabetic since 2012, honeymoon from 2013 – Aug. 2016. We are back on PZI and after taking care of a tapeworm which may have been affecting her ability to absorb insulin I am trying to find the right dosage for her. She is underweight (an issue we have been making some progress on) and very tiny, thus a little insulin goes a long way. My vet thinks she is burning through the insulin we give her because her metabolism is so high, and so the insulin does not last the full day. We have been seeing nadirs near 100 during the day and preshot values above 300. We recently reduced her dosage to try to counter the bouncing she has been experiencing. She is also in the early stages of CKD and we are administering fluids and Azodyl for this, but it is possible some of her symptoms could be related to kidney failure as I have seen a lot of parallels there.

Below are some of the ideas I am researching and talking to my vet about. If anyone has had a similar experience and can assist in pointing us in the right direction, please reply to this post.

- A few days ago I switched to an 11/13 shot schedule to try to see if this helps with her PMPS since this one is typically higher than her AMPS. The insulin seems to last longer for her at night. I’m not sure this is going to work as she has had GI issues since the change, but it might be too early to tell yet.
- I would like to see if anyone has recommendations for a decreased dosage when she has preshot values lower than 200. I know the typical recommendation is to not shoot, and I would never give her a new insulin dosage without checking her in the middle of the day, but the high numbers have such an immediate effect on her digestion and therefore her appetite and mood that I don’t like going without any insulin unless she is very close to 100. I have read that some people have had success giving PZI on a sliding scale as opposed to the same amount every time. This might help when we get numbers above 350 as well and I am curious to try this but my vet is not familiar with this technique. I have u-100 needles with half marks indicated so I can adjust as small as 0.1u.
- I have discussed the possibility of switching to Lantus with my vet. Perhaps her body will react differently to Lantus and take more time to absorb it. If anyone reading this has gone from PZI to Lantus, why did you decide to do so? Was it successful?
- Another option I discussed with my vet was giving additional short acting insulin shots two hours before her PZI shot to give her a boost before her next shot. If anyone has tried this, let me know.

Thank you for listening and any advice you can give.
Amanda and Button
 
Welcome Amanda and Button! It sounds like you have multiple issues going on; sometimes it is definitely difficult to isolate them and figure out what is causing what. And you have been doing this a while very successfully, with her doses and levels lowering overall. The encouraging thing is she is in pretty decent numbers - lots of yellow preshots and some blue nadirs. One thing that might help is to do a curve - get levels every 2 hours during a day and see when her lowest point is. Sometimes that will help you see if she drops early and bounces early.

Trying 11/13 looks like a possibility. Often cats have lower numbers at night than during the day. It could be activity levels or it may be the difference in when and how much she eats. What is her feeding schedule during the day and at night? Sometimes you can use food to smooth out the cycle and stop a drop (a curve will help you see if this is a possibility)

If she is under 200, I would stall. Wait 20 minutes with feeding and retest. Both to make sure the number is rising, not falling and to give it time to rise without food - which can artificially raise the number. And you can consider dosing lower than 200. You certainly have lots of data and you are confident testing. You just would want to be confident about bringing up the levels with food in case she would start to drop. We can help with that. Yes, some cats do fine with sliding scales; some want a consistent dose. But that technique would certainly be worth a try. - reducing the dose a smidge when you have a lower preshot than usual and raising it a smidge with a higher preshot. Have you read the sticky on Advanced Techniques on the top of the page? It might be helpful. The beginner's guide and protocol are also helpful. They are in my signature in blue.

I would not discourage you from trying Lantus. It does require a completely different dosing protocol. One thing I would say is that you are getting pretty good numbers at very low doses. Tweaking some things might help quite a bit. If you want to post daily with your levels, we could react to her numbers and help out.
 
Thank you @Sue and Oliver (GA) . I was able to do a curve on Monday, which did show her bouncing. She never got below 100, but since her preshot was high and dropped more than 50% at her nadir it does look like she bounced. Her numbers haven't rebounded since that day yet to get another good check. She has been pretty high for the the last few cycles.

The 11/13 schedule showed some promise for a few days. We began to see more yellow preshots which was encouraging. I may try to stick with that. As for the sliding scale, I did read through the links you mention a few times. That is where I found the idea of the 11/13 schedule. And I have used the stalling technique on multiple occasions, whenever work will allow =) Just not sure how much to adjust with the small amount of insulin we are working with. Since she seems to be bouncing though I think I should hold off to deal with that first. Would you recommend I try to test again to see if the bouncing is consistent, or should I go ahead and reduce her dosage? She has been feeling pretty miserable lately =/ Her updated spreadsheet is below.

I think I will continue with PZI for now as I might try out the raw diet to see if that helps her GI issues, but I will keep the idea of going to Lantus on the back burner. One change at a time =)

Button's SS
 
Lately her numbers seem too high for a dose reduction. She has not been dropping into numbers lately that might cause a bounce. My idea was to give a lower dose when she had a yellow preshot, but stick with a higher dose for the red and pinkpreshots. On 12/12 she did pretty well with the 0.9 on a 340.

It looks like she has been constipated and not interested in eating. What is the vet suggesting for her constipation? Lots of people here swear by Metamucil. Constipation can throw her off her food and cause her levels to rise if the constipation makes her stress. Was she checked out to make sure there was no blockage?

Not eating and high levels are not a good combination. I would definitely suggest getting a ketone test so you can watch carefully for possible DKA.
 
I haven't had her checked for blockages. Most of the time we have troubles with Button having soft stool, not constipation. My vet suggested a diet change a while back, but the normal prescription diets they sell are of course not very helpful for Button's situation. We have her on a general probiotic, Azodyl (For renal disease - also some benefit for digestion) and Mirtazapine (appetite stimulant). She has been having bowel movements twice per day still, but not healthy ones. I want to set up an appointment to get her blood checked again for BUN and Creatnine levels so I will ask about Metamucil and see if we can check for any blockages in her digestive tract. I have been checking at home for Keytones, but I will have the vet check as well in case my test strips have not picked something up. Hopefully addressing this will help her curve even out to where I can tweak her dosages based off of her preshot levels.
 
@Sue and Oliver (GA) , Thank you. I have an appointment today as we had plans to try to go away for a night for the holidays. I will look into this as well. The symptoms look familiar. I believe I may have talked with my doctor about Irritable Bowel Syndrome before when we had persistent UTI's. The Azodyl she is on is supposed to help with this and she has been doing ok for a while. There does seem to be something else going on right now though and I want to rule out any of the more serious reasons. I will post what I find here. Thank you for the help, I am hoping it is just stress over her digestive issues which we can tackle. I am so grateful for the other ideas!
 
I haven't gotten a chance to dig into the details with my vet yet, but Button does have an abnormal fPL reading for her pancreas. Thanks again for the info you provided. I have been pouring over it and it has been very helpful. Glad I went today for the re-check. The symptoms are so much like what we deal with on a regular basis. Hopefully this news will give us another few things to try to see if we can manage together.
 
Sorry that pancreatitis may complicate things, but often it is better to know exactly what you are dealing with. Many kitties here have pancreatitis; it does seem to be fairly common in diabetic cats. There are pain meds that help and foods that are better than others. You might post on Health and ask for advice/tips for members with a cat with pancreatitis. I know people have found lots of things that are helpful.

When she has a flare up with potential pain and digestive upsets, it can cause higher big levels. Learning to identify when she is not feeling well and how to deal with the symptoms can help you both out.
 
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