AMPS is 327 after yesterday’s roller coaster

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WilbursPerson

WilbursPerson

Member Since 2019
Hey all-
We are 2.5 weeks into treating Wilburs steroid induced diabetes. Any words of wisdom would be appreciated.

We started at 1 unit bid of lantus. We didn’t switch him to low carb food initially because of our other cats (food allergies).

the internal medicine specialist increased him to 4 units bid two days ago and per her recommendation we switched his food. Today was his first day of low carb food.

he had been in the 300 to 400 range but today is in the 50s. We have given him his usual food, some honey, but he is really not coming up.

My husband is out getting a new meter (currently have relion, getting contour next) to see if we get better accuracy.

We are trying not to freak out. It feels like we are torturing him and he is displeased with us. Plus his conjunctivitis is flaring so he really is not having a good weekend.

Ideas or suggestions on getting him up? Or better meters/tools to use?

thanks in advance for any ideas, suggestions, wisdom!
Sarah
 
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Switching to low carb food + steroids wearing off can drop the numbers. Just switching to low carb food can drop the numbers overall by up to 100 points. You do not need a second meter. Return it when you get the chance.

Numbers in the 50s are safe, but you do not want him to drop any lower than 50. Wilbur is safe.

The protocol when seeing low numbers is to feed high carb food and/or a few drops of honey.

Test again in 20 minutes.

If the test number is above 50, do not feed. Test again in 20 minutes.
If the number is rising, test 30 minutes after that. If the numbers are still good, feed low carb.

If Wilbur is dropping, give a small amount of high carb food with a drop or two of honey/karo and test in 20 minutes. Rinse, lather, repeat.

My suspicion is that the dose is now too high, but I'll let other, more experienced people chime in on that.

Here is the Hypo protocol.
 
If you can give us the test numbers and the times of the test numbers, that would be of tremendous help.
For example.
Shot 4 units at ___. Fed _____
+2 ( 2hours after shot) ___. Fed _____
+3.5 (3.5 hours after shot) ____. Fed ____

We are all in different time zones and clock times mean nothing to us.
 
WilbursPerson said:
We are trying not to freak out. It feels like we are torturing him and he is displeased with us. Plus his conjunctivitis is flaring so he really is not having a good weekend.
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It's a stressful situation when they're stubbornly low-- so glad you are testing and could catch this, imagine if you were just dosing blind following the vet's suggestions to increase!

And you aren't torturing him (even if he's a little cranky right now!), most cats settle into the testing routine eventually. Treats are key! Also little post-poke pressure on the poke site and a dab of neosporin/polysporin can go a long way towards preventing bruising/irritation might make him much more agreeable about the whole process. Can't help with the conjunctivitis, though, poor little guy :(.
 
Wow - thanks for the quick replies.
4 units glargine 530am CST, Fed 1 can glycobalance and 1/2 can royal canin select PD
+4 hours glucose 87
+ 5 hours 51, fed 1/2 can royal canin select PD and placed honey on gums
+5.5 hours 57

(I am also going to put a spreadsheet together)

Nan & Amber (GA) said:
imagine if you were just dosing blind following the vet's suggestions to increase!
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That was my first thought too. Our vet basically told me that very few people test and if I can great but not mandatory.
 
OK, great. He's still in safe numbers, but that honey+food only gave him a small boost so I would test again in 30mins to make sure it's holding. I'm glad you're almost at mid-cycle, with luck he'll be starting to come up soon anyway.
 
Couple more questions for you:

1) was the recommendation to go straight from 1U to 4U bid, or were there stages along the way?
2) has Wilbur ever shown signs of ketones or ketoacidosis?
 
Nan & Amber (GA) said:
1) was the recommendation to go straight from 1U to 4U bid, or were there stages along the way?
2) has Wilbur ever shown signs of ketones or ketoacidosis?
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He has never had DKA - no urine ketones on testing twice at the vets. He also never lost his desire to eat or drink.
week 1 - 1 unit bid
week 2 - 2 units bid
week 3 - 3 units bid for 3 days, then increased to 4 units bid by the internal medicine vet specialist (2 days ago)

Red & Rover (GA) said:
My suspicion is that the dose is now too high
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Yes, that is my strong suspicion as well.
 
WilbursPerson said:
My husband is out getting a new meter (currently have relion, getting contour next) to see if we get better accuracy.
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The problem is not the meter. The problem is the vet.
No vet, specialist or otherwise, should increase the dosage and tell the owner to switch to a lower carb food at the same time.

For reference:
RC glycobalance is 14% carbs (which is at the high end of medium carbs).
RC Selected Protein Duck 16%
RC Selected Protein Rabbit 15%
RC Selection Protein Venison 24%

These foods are considered the high end of medium carb and low end of high carb. The venison is definitely high carb.

Why was Wilbur taking steroids? Was it for IBD?
 
Wilbur has idiopathic hypercalcemia so he was on steroids to manage that. He remains on alendronate (no plans to bring this down) weekly for management of the calcium. The hope is the alendronate will keep the calcium stable.

regarding the foods, that is actually fascinating. If the RC duck protein is 16% carbs and the RC glycobalance is 14% carbs, then overall we did not really switch his diet up that much. That means the lower glucoses today are more the increased dose of Lantus and coming off the steroids rather than what we have been feeding him. I need to go find the nutrition info on the Royal Canin site. the carb content does not appear to be on my cans.

his recheck is 62 so definitely going in the right direction.
 
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Please test tonight and post for advice on dosing before giving Wilbur his shot.

It is fantastic that you are hometesting. It is the only way to keep a cat safe.

It would help tremendously if you could set up a spreadsheet. We are fairly data driven here. If you have problems setting up a spreadsheet, there are a few spreadsheet gurus here who can do it in minutes.

I have to leave the house. Nan should be around if you run into any problems.
 
thank you guys for all your generous suggestions and replies! I've got the spreadsheet set up (or at least I think I have it set up/linked correctly in my signature). I'll update this evening!!
 
DO NOT SWITCH TO A LOWER CARB FOOD right now. The dose needs to be lowered first. Once a proper dose on the current food has been established, then it will be time to move to lower carbs. You do not want another dramatic day like today.
 
Red & Rover (GA) said:
DO NOT SWITCH TO A LOWER CARB FOOD right now. The dose needs to be lowered first. Once a proper dose on the current food has been established, then it will be time to move to lower carbs. You do not want another dramatic day like today.
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We are going back to the RC PD tonight for certain. although based on the data above, the RC PD does not seem all that different from the Glycobalance. It must be coming off steroids and breaking through the glucose toxicity.

Nan & Amber (GA) said:
Can't help with the conjunctivitis, though, poor little guy
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I'm just grateful I had the forethought last week to order a new batch of antiviral eye drops: he hasn't needed them in months but I figured with the stress he might need the drops again.
 
Red & Rover (GA) said:
DO NOT SWITCH TO A LOWER CARB FOOD right now. The dose needs to be lowered first. Once a proper dose on the current food has been established, then it will be time to move to lower carbs. You do not want another dramatic day like today.
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I agree. As much testing as you've done so far (and again, thank goodness you were doing that!!!), I don't think you have enough data to properly assess Wilbur's dose yet.

We usually recommend pre-shot testing, every shot, at a minimum. Then, for Lantus, we try to assess dose effectiveness based on the nadir (which can be a moving target, somewhere in the middle of the cycle). So far, before today, Wilbur has been quite high mid-cycle on all the previous doses, but here's where it gets tricky: when a cat hits a low number it isn't used to, often the body responds by dumping sugar into the blood to compensate, and BG skyrockets. We call this "bouncing" and it can last a long time, up to three days in some cats. That makes it hard to look at Wilbur's spreadsheet, even with all the high numbers, and say for sure that his previous doses were too low and needed to be raised. It's possible that the couple of curves you did just happened to fall on bounce days-- hard to say without consistent data every day.

I see from the notes on your spreadsheet that you are already looking through some of the info on the Lantus forum and deciding between TR and SLGS dosing methods. Both are excellent options for making future dose changes (note in particular that we usually move in 0.25U increments, not the 1U used by your vet :eek: ). Aside from that, I do think you'll probably want to go back at least to the 3U dose tonight, maybe even 2U, depending on where he is at shot time. I see the +8 62 on the spreadsheet-- he's really determined to hang out in greens today (which is normally a great thing, we just want to make sure he gets there via a safe dose and isn't planning on going any lower than that!).
 
I’m glad you and Wilbur found us. Great job doing the SS. A quick admin note while I’m looking things over to comment. If you could please read this post (click on dark blue), it will tell you how best we can help you and it also gives the list of things that should be in the signature block (location is not one of them). So if you don’t mind updating that and putting Wilbur’s SS on the very bottom line by itself so we don’t have to look for it, that would be fantastic. Thanks so very much. BTW, we don’t include the dose in the signature block because it changes :)

My first question is, to diagnose idiopathic hypercalcemia, did they test his ionized calcium or did a vet dx that condition based on the typical serum calcium you see on labs? When was he dx and how long has he been on the Alendronate (Fosamax)? I do see that a recent ionized calcium showed it to be in normal numbers and that’s great. I am assuming he does not have chronic kidney disease and thus the dx of idiopathic, non PTH mediated hypercalcemia? Did the vet that gave him 5 mg prednisolone give a sustained release and do you know how long it was supposed to last?

Depending on how long that steroid was supposed to last, you might be seeing the effects of that wearing off plus too large of an increase. I don’t mean to disparage your specialist but raising the dose that much while dropping the carbs was irresponsible especially with a steroid shot in the mix that would be waning.

Are you home much and able to test? As others have said, you need to be sure you get a preshot test every single time before you give insulin. The other tests that help us figure out what is going on is a +2 every cycle if you can do it. Let us know if a work schedule interferes with that during the day cycle. The +2 test can give us alot of information. If it is similar to or less than the PS, you should be prepared for an active cycle.

It then helps if you can get random tests during the cycles, if possible. If you are home during the day, you can mix it up and do a +2, +5, +9 one day, and then a +2, +6, +10 another (unless numbers are dropping, of course). At night, a +2 and before bed really help. If you are up an hour or two before his morning shot, that’s a good time to get a test as well at least until we figure this all out.

I actually wouldn’t drop the dose back much. If you can get some tests in, I wouldn’t drop it back more than to 3.5u because he didn’t go that low today and he came up quickly. But, as the steroids continue to wear off, he might continue to need a decrease. Once he’s more stable after the steroids are worn off, then we can slowly work towards reducing the carbs.
 
Nan & Amber (GA) said:
I see the +8 62 on the spreadsheet-- he's really determined to hang out in greens today (which is normally a great thing, we just want to make sure he gets there via a safe dose and isn't planning on going any lower than that!).
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We are at +10 and glucose is 63 now. I'll recheck pre insulin but I have to say I'm worried about insulin tonight.

Marje and Gracie said:
My first question is, to diagnose idiopathic hypercalcemia, did they test his ionized calcium or did a vet dx that condition based on the typical serum calcium you see on labs? When was he dx and how long has he been on the Alendronate (Fosamax)? I do see that a recent ionized calcium showed it to be in normal numbers and that’s great. I am assuming he does not have chronic kidney disease and thus the dx of idiopathic, non PTH mediated hypercalcemia? Did the vet that gave him 5 mg prednisolone give a sustained release and do you know how long it was supposed to last?
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I updated my signature - thanks! The hypercalcemia was diagnosed based on several years of elevated total calciums and ionized calcium levels. His PTH and PTHrP were both low and he has normal renal function. He has been on the alendronate since spring 2018 and had been on prednisolone from spring 2018 through essentially now (had been 5 mg qd but after the diabetes diagnosis we changed to 5 mg qod for 1 week, then 2.5 mg qod for 1 week, then 2.5 mg twice over the course of 1 week, and then off). He had just finished his final dose of prednisolone when the events of two days ago occurred - our local vet drew blood and the total calcium was 13.7 (ionized is send out in their office). This is when they gave him 5 mg as a one time oral dose: it was not an IM dose. He then sent us emergently to a veterinary referral center where they rechecked the ionized calcium in-house and it was high normal. Our family vet thought we would need to be admitted for fluids and such over the weekend but given the ionized that was not necessary.

Neither our "family" vet or the specialist had advised us to check before each injection but we certainly can do this. Going forward, work may get in the way of us testing a ton during the day but there are 3 days per week when I am not at work where I can do frequent testing.

Thanks a ton everyone!
 
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WilbursPerson said:
We are at +10 and glucose is 63 now. I'll recheck pre insulin but I have to say I'm worried about insulin tonight.
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It’s ok to give him a LC snack now to see if that number will come up a bit. While we don’t usually feed within two hours prior to a shot (unless numbers are 40s or below on a human meter), as long as you give him LC now (even if it’s still 1.5 hours until his shot), it’s ok. We want to try and nip that duration a bit without causing a spike that you give insulin into. If you do not have any LC food under 10%, then don’t feed. Let’s see what he does. We have ways to deal with this and this post (which you can read quickly) will give you some ideas.

If he’s below 150 at his PMPS test, please do not feed or shoot him but post and ask for help. Be sure your subject line indicates you are stalling and need help. I also see you decided on SLGS so here is some info on lower PSs with SLGS (sorry, I don’t usually like to cut and paste but I’m in the middle of something and I want you to be “prepared”).

How to handle a lower than normal preshot number:

Until you collect enough data to know how your cat will react, we suggest following the guidelines in the FDMB's FAQ Q4.4:
Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.
  • Below 150 mg/dl (8.3 mmol/L), don't give insulin.
  • Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
    • a.) give nothing
    • b.) give a token dose (10-25% of the usual dose)
    • c.) feed as usual, test in a couple of hours, and make a decision based on that value
  • Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
  • In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
  • Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.
Keep in mind these are general guidelines, and they should be personalized to your own cat's response to insulin. If your experience is that your cat does not became hypoglycemic with a dose which is close to her usual, then personal experience should be your guide.

With experience, you may find that lowering these thresholds may work well for your cat. When you have reached that stage, the following guidelines are suggested for Lantus, Basaglar, and Levemir users following the Start Low Go Slow approach:

If the preshot number is far below usual preshot numbers:
  • Do you need to stay on schedule? Then skip the shot.
  • Do you have some flexibility with your schedule? Then stalling to wait for the number to rise might be a good option. Don't feed, retest after 30-60 minutes, and decide if the number is shootable.
  • Repeat until the cat either reaches a number at which you are comfortable shooting, or enough time has passed that skipping the shot is necessary.
If the preshot number is near kitty's usual preshot numbers:

Look at your data to see what numbers you have shot in the past and decide what would be a safe, shootable number for your cat. Don't feed. Stall until kitty reaches the preshot number you've decided on and then shoot.
We usually don't suggest or recommend shooting a preshot number less than 90 mg/dL when following the SLGS Method. Remember that with SLGS, generally speaking, your goal is to achieve flat numbers that are greater than 90 mg/dL. However, let experience, data collected, knowledge of your cat, and availability to monitor help in making the best decisions for your cat.
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WilbursPerson said:
I updated my signature - thanks! The hypercalcemia was diagnosed based on several years of elevated total calciums and ionized calcium levels. His PTH and PTHrP were both low and he has normal renal function. He has been on the alendronate since spring 2018 and had been on prednisolone from spring 2018 through essentially now (had been 5 mg qd but after the diabetes diagnosis we changed to 5 mg qod for 1 week, then 2.5 mg qod for 1 week, then 2.5 mg twice over the course of 1 week, and then off). He had just finished his final dose of prednisolone when the events of two days ago occurred - our local vet drew blood and the total calcium was 13.7 (ionized is send out in their office). This is when they gave him 5 mg as a one time oral dose: it was not an IM dose. He then sent us emergently to a veterinary referral center where they rechecked the ionized calcium in-house and it was high normal. Our family vet thought we would need to be admitted for fluids and such over the weekend but given the ionized that was not necessary.
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Thank you for this information and for updating the signature block.
 
No insulin at such low as 57.

Definitely a dose reduction.


You use glargine which is the same as Lantus. And it depots under the skin and releases itself a little by little into the body system. The problem with Lantus/glargine then is that it stays longer in the body and if dosed too high can give some serious hypos which requires a lot of fast dextrose and then keep feeding with some high carb dry food to avert a very long hypo incident.


I have always been very cautious with Simba and the Lantus after the sudden and first hypo he got even if home testing. In Simba's case it proved that every 2 1/2 day on a steady same dose of a dose above 1,5 U BID, the Lantus throws him into a hypo.
 
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Eeep!

OK, let's try a 30-minute stall. Don't shoot, don't feed, and test again in 30mins. He's going to come up (possibly way up) eventually, but I'm not comfortable advising you to shoot until we actually see clear indications that he's on his way. There are a lot of variables at play with him.

In the meantime, couple more questions:

1) If you had to, would you be able to stay up late tonight (possibly very late), testing and giving carbs when needed?
2) How off-schedule can you get in shot times? Could you shoot an hour or more later for a couple days if you shot late tonight?

We don't like to skip shots if we don't have to, and I'm a bit worried that Wilbur is also under the weather a bit, but given that his appetite is still good and he has no history of ketones, it may end up being the best option. But let's see where he is in a half hour.
 
Ann & Scatcats said:
No insulin at such low as 57.
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That’s what I was assuming/ planning on but so new to this reassurance is helpful!

@Nan & Amber (GA)
We can totally recheck in 30 minutes - I’m not thinking though he will come up since he has been cruising here all day. He is also starting to lose patience with us and I can’t say I blame him.

time wise we are very flexible tonight but tomorrow am we are less flexible. So there is a limit to how long we can delay tonight.

thanks!!!
 
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We are up to 81 so definitely an improvement over earlier but I am still super hesitant to give him any insulin tonight.

again many many thanks!!
 
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Ann & Scatcats said:
It's his first day on low carb food. And giving such low bg numbers then. Which is to be expected.
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So I’m not convinced his diet today is all that different based on information from @Red & Rover (GA) above. He had been on the RC Select protein duck which is 16% and this morning we tried a mix of that plus RC glycobalance which is 14%. I gave him a can of the latter and 1/2 can of the former.

Our vet has implied the glycobalance had way less carbs than the select protein but that doesn’t seem to be the case.

again thanks!!!
 
Hmmm.... I'm glad to see him coming up some, but I also wish he'd come up more. You do have the option of trying for one more test to see if he gives you a number you're more comfortable with, but it does get to be diminishing returns on stalling-- you just can't hold back dinner for much longer without hunger-anxiety also affecting numbers!

Just fyi, the reason we hesitate to recommend skipping or large dose reductions with "new" cats who come in with high-ish doses is because of the risk of ketoacidosis. Having something like the conjunctivitis going on at the same time as insulin is reduced adds a risk factor. Wilbur eating and drinking well, and not having had ketones prior to this, are two big factors in the other direction, though, so that's very good.
 
@Nan & Amber (GA) - I think we’re just going to skip his dose tonight. He had been 500+ without ketones so even though there is the DKA risk I’m more worried about lows. He hasn’t been in this range since his diagnosis (and presumably had high numbers for awhile before) and I don’t think he’s used to normal anymore.

I’ll recheck pre bedtime tonight to get that as a data point (and my own reassurance) and reassess in the morning.

again a million thanks for all the advice and support!!
 
How much past your scheduled shot time can you shoot in the morning?
With Lantus, to get back to your regular shot time, you shoot
1. 15 minutes early per cycle equaling 30 minutes per 24-hour day, or
2. 30 minutes one cycle only per 24-hour day

Edit: if you do not shoot tonight, you can shoot at your regularly scheduled time in the morning.
 
Nan & Amber (GA) said:
Sounds like you have a very good handle on things!
Great idea!
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Thanks - it doesn’t totally feel like I have a good handle on things. I’m just terrified of him having a severe low so I do have a greater tolerance for highs. I just feel bad for the little guy too - he doesn’t understand what’s going on but he doesn’t seem too upset.
 
Yeah, I think we're all familiar with The Look: "Mom/Dad, what the heck are you doing with my ears again? I was trying to sleep!"

Lows are definitely much scarier than highs in general. Hopefully you'll be able to get a good night's sleep tonight with no worries (assuming he doesn't have any more tricks up his sleeve in that before-bed test!).
 
Red & Rover (GA) said:
Will someone be home during the day tomorrow to test? Tonight's no-shoot will drain the depot somewhat but not completely. Depending on the number, that may be a factor.
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I will post in the morning but no one will be home during the day tomorrow unfortunately. Normally I’d be able to run home at lunch but given most of Friday got eaten up by a trip to the emergency vet/referral vet I suspect I’ll be tied up during lunch.
 
I am concerned that the dose was raised too quickly.
Doses should be raised by no more than 0.25 unit increments so that you do not go right past the proper dose. With steroids working their way out of the system, it makes no sense to increase so rapidly and by so much.
 
Marje and Gracie said:
I actually wouldn’t drop the dose back much. If you can get some tests in, I wouldn’t drop it back more than to 3.5u because he didn’t go that low today and he came up quickly. But, as the steroids continue to wear off, he might continue to need a decrease. Once he’s more stable after the steroids are worn off, then we can slowly work towards reducing the carbs.
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I'm wondering if the reduction should be greater given that 3 units was given for only 4 cycles before increasing to 4 units.
 
Red & Rover (GA) said:
I'm wondering if the reduction should be greater given that 3 units was given for only 4 cycles before increasing to 4 units.
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I just checked him and he’s at 101 (shot should have been 4 hours ago so kind of at +4 now). I’m going to bed and will see where he is in the morning. I’m torn though about what dose to use in the morning - I’m leaning towards 2.5 if he is around 150-200, 3 if just over 200, and 3.5 if really high.

In retrospect I should have questioned going from 3 units bid to 4 units bid so quickly.

again thanks!!
 
Morning all - AMPS is 327. He feels fine: I can tell because he is asking for food. Any input on dosing him this morning?? Thanks!
 
I'm sorry no one got back to you about the am dose.
I see looking at the SS that you have increased the dose from 3 units this am to 3.5 this pm.
Glargine works best if you stick to the one dose. Chopping and changing will give wonky numbers.
I know you got bad advise from the vet and you are trying to fix it, but you need to choose a dose and stick to it unless your kitty drops too low.
Try and get some inbetween tests in during the evening please as it is the lowest BG in the cycle that determines the dose, not the preshot.
A +2 and a before bed test are good tests to get. It they are the same or lower than the preshot, that can mean an active cycle and you may need to test further to keep Wilbur safe.
 
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