Alfred...livin' in the red :(

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KJ & Alfred

KJ & Alfred

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So here we are....just about three weeks in and I am frustrated.

Quick recap - Alfred's diabetes returned presumably due to a pancreatitis flare up. He was treated to two injections of antibiotics and started on ProZinc. As you can see on our spreadsheet, the vet's recommendation after our first BG curve was to increase the does from 1U to 2U which resulted in a 40 that very day. I experimented a bit on smaller increases, but was counseled here and by the vet that I should return to 1U and not get too upset about the high pre-shot numbers and work on getting a feel for how low he going in the mid cycle. Sadly, I haven't been able to get as many mid-cycle tests as I'd like, but wondering if anyone has thoughts on what we've been seeing.

When I asked the vet about the pancreatitis and how to know if we got that "under control" at least for now, she suggested retesting (I can't remember the test, is it FPL?) one month out (so at the end of July). She also said on his initial visit with her, she saw signs of dental disease but he wasn't too keen on letting her really look, so she is unsure of the extent. She recommended I schedule him for a "dental" to see if that may be also having an effect on the diabetes. We have an appointment on the 26th for the dental and test.

Does this seem like a good plan? Is there anything else I should be doing? Other questions I should be asking? Should I request a switch to Lantus since he did so well on it last time? I am not terribly fond of this vet and have an opportunity to travel late next week and take Alfred with me and maybe see another vet? I just am concerned and not sure what to do. It was just so different last time. Many thanks in advance for any suggestions.
 
If it were me I'd want more mid-cycle numbers before adjusting the dose. Can you do that over the weekend?

Do you have U-100 syringes? I have a feeling you may need to make adjustments that are too tricky by guessing with a U-40 syringe. I resisted switching to the U-100's for too long! Look at my crazy numbers for Tuck. He was like Alfred for a while; good mid cycle but high preshots. Several people advised me Lantus might be better. I have multiple cats on Prozinc so I didn't want to switch. Look at Tuck's numbers over the last few weeks, much better. I think it takes some of them a while to get regulated.

I don't have any experience with pancreatitis. A dental is rarely a bad idea.
 
It does take awhile, especially the second time around. The dental could help. I agree with Kristen - there is really no way to know what is happening. Get some nadirs, maybe a complete curve. If he is in the yellows and pinks the entire cycle, increase by 0.25 (those U100 needles are great). Hold for 3 cycles, curve again. If the same, increase again. You may need to be a little more aggressive this time.

But if he dips and has a nice smile curve, then no increase. He's bouncing and you need to wait him out, as long as he doesn't dip under 50.
 
Thanks @AbyResq & @Sue and Oliver (GA). I will go buy some U100 syringes today so I can be prepared for dose adjusting. I will also be able to test more in the next few days so we can get a clearer picture. I can do another curve this weekend as well. Finally, my husband will be home (he's been gone the entire time since Alfred returned to insulin) so it will be nice to have some help with this again.

So, I will go ahead with the dental and keep in mind that this second time is just going to be different. I'll stick with the ProZinc for now, too, I guess. It's hard not to cling to the idea that some easy thing (like switching back to Lantus) could make "all the difference". I'm trying hard to live in the present, with the present reality and not get so hung up on the future and the what if's. Admittedly, that is not my strong suit. ;)
 
Glad your husband is going to be home! I know from experience that just having another person around can help ease the stress. It's not all on you.

I know it's tough, especially since you've been here before! The dental does sound like the first order of business. We've seen kitties suddenly go into much lower numbers after a dental! After that, Sue laid it out pretty well.

We're not saying Lantus is a bad choice. Just that since you have the ProZinc, use it. If we think he needs to switch, trust me, we won't hesitate to suggest it! If it was me, though, I would want to give this a shot first. You can always decide to change later. :)
 
Rachel said:
...If we think he needs to switch, trust me, we won't hesitate to suggest it! If it was me, though, I would want to give this a shot first. You can always decide to change later. :)
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Thanks for that, @Rachel ! Appreciate it and all the wonderful support, advice and just friendly hellos and "you've got this" sentiment from around the board. This place really is great and I told so many people in the years with Alfred was in remission, that I really credit the caring people here (lovingly referred to as the CCP - Crazy Cat People - a tribe, I also happily include myself in!!) as saving Alfred's life.
 
Thanks @Sue and Oliver (GA) for asking....

I got some....not as much as I'd hoped. He's still in the red (and even black on preshot) and not dropping as much as I thought. The vet called last night and advised me to up the dose to 1.5U. I started that last night. He has started throwing up fairly frequently, however. I saw some very liquid-y, nearly clear vomit a few times this weekend but wasn't sure which cat it was. Then today, I saw him do it 3 times in 30 minutes. Called the vet, was told she'd call me "right back". It has been 4 hours and still no call.

But through all this, he is still eating and still acting okay - cuddly, not hiding, playful, etc.
 
He started throwing up before you upped the dose? I don't know that upping it would have anything to do with the throwing up. Have you started a new food or anything lately? Is he throwing up right after eating or is it just random times?
 
Any chance of a hairball?

I am glad he is feeling better. I'd just watch carefully with the 1.5. Definitely the nadir looked like an increase was a good idea. He drops but probably not enough for a bounce, more insulin looks like a plan. Hope you can catch a few nadirs with the new dose.
 
The vomiting was definitely not a hairball and not after eating meals. It was mostly clear-ish and went on for several days. And no new food.

Last night the vet called finally and thought maybe Somogyi effect and recommended I bring him in this morning to see if there was anything else they had missed and to get some anti-nausea meds to help with the vomiting. When I went, she was very surprised to see him looking as good as he does (he gained a pound! and is well hydrated). There's glucose in the urine but no ketones. She decided to increase dose to 2U.

So I'm monitoring closely today. Just got a 291 at +3, but will watch for further dips.
Thanks, as always, for your replies @Rachel and @Sue and Oliver (GA)
 
So far, so good on the nausea....I haven't seen him vomit since day before yesterday. He also hasn't had the super drop after the 2U like he experienced when we tried 2 weeks ago. I'm watching closely though, just in case.
 
Glad he is feeling better. Yesterday's cycle was pretty nice. Today could be a little of a delayed bounce. I'd hold the dose awhile and see how he looks. Those were pretty big increases pretty fast.
 
Are you getting cerenia - since he's had pancreatitis, many vets prescribe cerenia of varying strengths (my cat gets 4mg a day for 5 days, skip a day, then repeat) Cerenia is an anti-emetic and also anti inflammatory. My cat used to vomit and get pancreatitis bouts frequently - and cerenia has made a huge difference in decreasing vomiting. I would absolutely ask your vet about cerenia
 
I'm not an expert... but high preshots, with those green numbers, makes me think reduce the dosage. Those high preshots could be bounces. We are going through that with Shorty right now. But looking at last night, a PMPS of 292, gave 2 units, and at +3 is at 69..... that's too much insulin in my mind. Alfred is dropping too much, too fast, which means his liver is releasing extra glucose to cover, creating a bounce.

@Sue and Oliver (GA) , what do you think?
 
Thanks so much for the continued advice here. I'm sorry I missed a few of these posts in the past two days....I was sick and had company.
He goes for his dental tomorrow. I am going to share his spreadsheet with the vet today and ask again about the dose and the bouncing, like you guys mentioned. I will also ask about the cerenia (thanks, @Carol & Murphy).

Based on where he's at today, should I go down to 1.5U? I think I should have likely done that last night (or really just 1U) but feeling sick I was really doubted my ability to monitor him closely enough in the night so when I saw the 199 last night, I went with no shot.
 
I'd wait and look at a dose adjustment after the dental. 2 units does looks like too much; it may work for the really high preshots but is too much for the pinks. What did they advise you to do about his dose before the dental?
 
Sue and Oliver (GA) said:
I'd wait and look at a dose adjustment after the dental. 2 units does looks like too much; it may work for the really high preshots but is too much for the pinks. What did they advise you to do about his dose before the dental?
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The vet advised me to increase to the 2U. When I dropped him off this morning I asked her about the possible bouncing and whether she thought 2U was too high. She didn't think so, but that either I should 2U in the morning and 1U at night, or possibly go to 1 dose/day. That seems to go against most of what I've learned here. I also asked about switching to Lantus since we had good results with it last time. She suggested we work with the ProZinc a bit longer and see if the dental helps get him more regulated.

Thoughts? I hope to get a chance to talk to her again this afternoon when I pick him up.
 
Hi KJ, why would she suggest to go so drastically from 2 to 1 or the other way around?
From the numbers I see in Alfreds sheet it seems to me that he is a little bit on the high end with the insulin.
This because he has shown you some nice mid-cycle numbers so maybe the dose is to high.
I would not recommend going to 1U but maybe you can try 1,5U every 12 hours for a couple of cycles (6 or so) and see how that works out.
What does he eat? Low carb food? (sorry if you’ve already mentioned it but I don’t know.)
 
I wouldn't advise going to 1 dose per day. You need to find the dose you can successfully give 2x/day. Prozinc is supposed to last 10-14 hours, not 24.

I think he's bouncing. If you're using the u 40 syringes you might get more consistent results if you switch to the u 100's and do the conversion. If he were mine I'd aim for around 1.6 units for several cycles then re-evaluate. Look at Tuck's sheet, he looked a lot like Alfred. Red preshots with decent numbers mid-cycle. He's 1 week into an OTJ trial. I think you can get Alfred regulated or back into remission without going back to Lantus.

Did he have teeth extracted? If so he might be off his food so you'll definitely want to monitor his blood sugar. I had a hard time getting Tuck regulated after his dental. I think I was overreacting to his high prehosts and giving him too much.
 
Well, I think two units is definitely too high. That dose took him from 551 down 400 points ( a huge drop) and gave you an unshootable pmps. I think trying 1.25/1.5 and maybe varying that - 1.25 on a pink or yellow preshot and 1.5 on a red/black one could work

My experience is that once daily shooting doesn't work. It means they may be in decent numbers for 12 hours and then high the other 12 - like being on a roller coaster. PRoZinc is sold as a twice daily insulin.

If he were mine, I'd lower the dose, get those midcycle numbers whenever you can and post here for dosing advice.
 
I'm not sure why she recommended bumping from 1U to 2U (she suggested it twice). The second time, I had tried bumping him to 1.5 first. I agree with you all that shooting once/day didn't seem right. Makes me nervous to follow her advice on anything, to be honest.

I don't know if Alfred will have any extractions today (I'll know this afternoon when I pick him up - it's only 11am here).

I think I will switch to the U100s, use the conversion and try with Sue's advice above.

THANKS all!
 
I think we are all on one line here. Lowering the dose. Hope this will get Alfred regulated soon so he goes out of those nasty reds!
 
Ruby&Baco said:
What does he eat? Low carb food? (sorry if you’ve already mentioned it but I don’t know.)
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*snip*
Appreciate your thoughts @Ruby&Baco and forgot to answer this part earlier.... he eats only low carb (FF or Friskies or Stella/Chewy's). We made the big diet change after the first DB diagnosis three years ago and he's continued on the same diet since.
 
No Problem KJ! ;) Oh thanks for telling me, I was wondering if maybe Alfred's higher numbers came from the food he gets, but FF is something that I've seen a lot of people on here give that as well.
 
So, Alfred did great with his dental. No extractions needed and they said after they got the tarter off his teeth, they looked really good. They also will run another FPL (?) to see how the pancreatitis is doing. He's doing fine at home and eating, etc.

I didn't get to speak to the vet but her written recommendation for me was 2U in the AM and 1U in the PM....but I think I will try the 1.25 or 1.5 and see if we can find a happy medium. At least she seemed to have changed her mind on the once a day thing, Makes me really wonder about the things she says, cuz that felt like stabs in the dark to find something to tell me this morning.
 
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