Argyle 8/29 - Need help, at a loss

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jackie

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Hi,

I’m really concerned about my cat, Argyle. I’ve been struggling with her dosage since she had two hypo episodes in January and two DKA episodes in February. After the second one, we switched from Lantus to ProZinc (initially with some Humulin to handle ketones). Based on advice from people here (thanks Nancy), we also switched to all low carb wet food. I have been approaching things from the prejudice that she has been getting over-dosed with insulin for a long time (since last summer) and trying to reduce her dose. After reading a lot of posts on FDMB and reading about rebound, liver panic, under-treatment, etc., it just seems so complicated. It’s recently started worrying me that I don’t have any idea what is going on, that I'm only seeing what I wanted to see, etc, and that I need some wiser heads to look at Argyle’s info and let me know what you think.

I don’t have a regular spreadsheet because I’ve been changing the timing of her dosage so it doesn’t fit the 12 hour format. Here are her recent BG curves. Argyle snacks every couple of hours, which might complicate interpreting the numbers somewhat. I test for ketones frequently (generally daily) and haven’t seen anything until a trace reading yesterday (which has cleared up).

8/18/11
Previous shot -17.5 hours earlier
AMPS – 293, shot 0.1U
+2.75 - 156
+4.0 - 191
+7.75 - 229
+17.5 - 235
+24.25 - 260
+28.5 – 238

8/20/11
Previous shot-37.5 hours earlier
AMPS – 296, shot 0.1U
+2.25 - 181
+4.0 - 168
+8.75 - 205
+27.75 - 275

8/24/11
Previous shot -13.5 hours earlier
AMPS – 274, shot 0.3U
+2.0 - 247
+3.0 - 194
+6.25 - 189
+9.5 - 438
+12.0 - 426

I gave her the increased dose because I was worried that I was under-treating her, but this dose really didn’t agree with her. I hadn’t seen a BG in the 400’s in a while. After this dose, she was really, really weak, missing the litter box, stumbling, and hiding under furniture. I went back to giving her 0.1U twice a day after that, but the weakness and hiding persisted over the next few days. Her PSs were in the high-200’s range. Her last shot was 10:00 pm last night. I shot 0.2U because her PS was a little higher. I didn’t give her a shot today because she just seemed so much stronger without it. She has also stopped hiding and has gone back to sitting in her favorite spots.

8/28-29/11
Previous shot -14.25 hours earlier
PMPS – 367, shot 0.2U
+2.75 – 267
+4.25 – 188
+13.25 – 361
+25.75 – 288

I don’t know what to do next. Is she being over-treated or under-treated? Should I try giving her the 0.3U dose again, assuming that she will get used to it and not react as badly next time? Or am I on the right track of trying to wean her off the insulin?

I’d be grateful for any ideas that anyone could give me!

Thanks,
Jackie
 
Hi Jackie,
Posting here in PZI is a great idea. These folks are very familiar with it. My sugarcat Bob was a PZI user, but he's been without insulin since mid-July. I was very fortunate in that he only took about 2 months from diagnosis to OTJ.
I can only offer limited input, but my initial reaction after looking over your numbers is that the dosing schedule is contrary to how PZI works. Most people shoot twice a day, about 12 hours apart. There are a couple people here who have kitties on a 3 times a day schedule. PZI only has about a 12 hour duration. Unlike lantus, which builds a "shed", PZI doesn't really work that way.
I think that's why you are seeing really high 300s and low 400s. Many of those readings are beyond a 12 hour window from his last shot, so I think during those hours, his BG keeps rising because there's no insulin on board to combat the increases he's getting from eating.
Having had two DKA episodes in the past, he'd be more prone to that happening again, especially with high BG levels.
Don't change anything based solely on what I am saying. Like I said, there are people here who have more expertise with PZI than I do. I am sure once they see your post, they'll add their advise and observations. My gut says Argyle needs more insulin, but split into two shots a day, 12 hours apart. Once you see double digit test results, she'll be more ready to be weaned off the insulin. But I think if you try to take her off now, you'll be risking high BG, which could lead to more dka related complications.
Please don't feel discouraged or overwhelmed. You are never alone as long as you post on the board. This place rocks!
Carl in SC
 
Hi Jackie!

First welcome to PZI.

I will have more time to look at your post later, but for clarification...it appears you are dosing on a random schedule and skipping days at a time. Is that correct?

Second, did you catch the hypo events on tests or was the Argyle symptomatic alerting you to the hypo situations?

I am not well versed on small dosing, so that is a little intimidating to me--especially, if those small doses created hypos. What were the doses administered when Argyle did hypo? You were using Lantus....correct?

Was Argyle receiving insulin when the DKA episodes occurred? It appears he was, but was it random dosing or were you dosing on a regular schedule? Lantus?

Sorry about all the questions, but I think with some clarificaiton it might help us help Argyle.

The one thing that I feel like I can concur at this point is, Argyle is in diabetic numbers and does need insulin therapy. And, normally insulin should be administered at 12 hour intervals. Even, if you are micro-dosing, he should get his "drop" twice a day! But, obviously this would be based on his 12 hour preshot. Do you test every twelve hours?

Prozinc should create a curve.....with your preshots being higher and then seeing a nadir somewhere between +4 and +8. While we hate to see those bg numbers go back up at 12 hour intervals, that is how prozinc works. Unlike Lantus, where the insulin builds up in a shed and creates a much flatter curve.

There will be some great people along to give you some advice, but I think it would be helpful if we had more information.

Welcome again! And, we will figure Argyle out!

Kim and Kitty
 
jackie said:
I gave her the increased dose because I was worried that I was under-treating her, but this dose really didn’t agree with her. I hadn’t seen a BG in the 400’s in a while. After this dose, she was really, really weak, missing the litter box, stumbling, and hiding under furniture. I went back to giving her 0.1U twice a day after that, but the weakness and hiding persisted over the next few days. Her PSs were in the high-200’s range. Her last shot was 10:00 pm last night. I shot 0.2U because her PS was a little higher. I didn’t give her a shot today because she just seemed so much stronger without it. She has also stopped hiding and has gone back to sitting in her favorite spots. Jackie
Click to expand...

Hi Jackie!

I don't really know enough to give you dosing advice but the thing that pops out at me is the low dose/high BG readings & what sounds like hypo symptoms. I'm at work & reading quickly so I might have missed something but what syringes are you using? I'm wondering if we are on the same page as far as the dose? There is a picture somewhere of what the dose looks like in a syringe but I don't have the time to find it right now.
 
I wanted to add my welcome too. I'll be checking to see some answers to Kim's questions, because they are much needed so we can help you. Like Carl and Kim have already said, PZI is to be dosed at 12 hour intervals. It does not work like Lantus does. Some of us dose more frequently than that, but we have cats with conditions like pancreatitis or other health problems that require a unique approach. Switching to a canned food will help, if you are feeding dry. With as little insuln as your cat seems to be taking, it may very well be that with a change in diet, you may be able to get your cat off insulin entirely at some point.

If you give a dose and your cat isn't acting right, especially the stumbling, etc. please check her blood glucose to ensure she's not gone too low. Higher glucose levels generally won't make them act like that unless there are ketones involved.

Does your cat have any other health issues that may have contributed to the diabetes?
 
Hi And welcome to PZI land.
everyone here is so wonderful and the questions that have already been asked will help us to help you

Shakespeare was on Lantus prior to going to PZI
He did not do well, and as you, I thought he was being overdosed.
We started in PZI and I almost immediately saw a difference.

my feeling is that you might have to keep on a schedule. I know how hard that can be but it is best for Argyle.
I am not usre if there is a reason you are not dosing everyday.

Here is my opinion (which might change after some questions are answered.)

you should start at .1 dose 2 times a day (12 hours apart,)
please keep that dose for at least a week to collect some data.
If you see him acting weird, drunk, stumbling, as Wendy said please take his blood to see if he is hypo..

Low carb meals(no dry food) is important as is the syringe size.
hopefully you can answer some questions for us later and we will do our best to help you

Denise and Shakes
 
I just wanted to understand right that your doses are in the 0.1 and 0.3 zone, am I reading that right? It is almost impossible that you would be overdosing her on those levels IMO, I have seen very very few cats who respond much at all to doses that low. Many cats can tolerate an overdose even by amounts like that and barely even notice it.

If you are not seeing green nadirs and the dose is extremely low, my read would be that you need to increase the dose. A good way to accomplish that as others have mentioned is to give the shots regularly 12/12, rather than necessarily needing to increase your dose per shot.

Rebound is confusing for all of us, but I think we tend to overemphasize it in many cases. I wouldn't worry about it unless you are seeing BG#s under 40-50 or really steep drops. She may react some as she sees better numbers, and that you just turn a blind eye to and try not to let it upset you or throw you off track.

The symptoms of course are of concern. I don't see anything in the numbers that suggests it would cause symptoms from low numbers, I only see things that might lead to symptoms from too little insulin, and the appearance of trace ketones would support that. If she is having a reaction though, that is certainly something to watch out for. Is it possible it is specific to this insulin? Did she react like that on the other insulins you have tried? It's puzzling.

Generally you don't want to wean them off insulin by pulling back and seeing if they will go it alone, you want to keep them in as many low blues and upper greens as you can until they prove to you that they don't need as much insulin. If they start to prove that then you might give a little more leeway, like maybe not shooting insulin under 180 and seeing if they will bring themselves down on their own, but once the numbers start getting over 180-200 they pretty much will need insulin shots to help them down to better numbers.
 
Hi everybody,

Thanks for all your responses. I feel like Argyle is in good hands already.

Sorry it has taken so long to get back with more info. I spent a couple of hours writing a post last night and then when I went to post it, I lost it because I wasn’t logged on. So then I logged on and spent another hour writing another post and the same thing happened - guess I must have timed out or something (sigh).

Argyle was first diagnosed in April 2009. She was originally on Lantus and switched to ProZinc after her second DKA hospitalization in February 2011. When she was on Lantus, it was either once a day or twice a day (every 12 hours). The ProZinc was originally also every 12 hours, but I did a BG curve in May and it looked like the ProZinc didn’t last the whole 12 hours. I started giving it every 8-10 hours, although sometimes it would slide to 11 or 12 hours. The really wonky dosing schedule really only started over the last month as I lost my mind and started trying different things to see if it would help her.

This is Argyle’s recent history: Her dose had worked its way up to 3U Lantus twice a day by the beginning of this year. In mid-January I smelled ketones on her breath so we went to the vet. She had a UTI that was treated with antibiotics. A few days after ending the antibiotics, I increased her dose to 3.5U twice a day. After 4 days of that (on 2/2/11), I noticed her staggering and measured her BG at 30. I treated this with Karyo and food and reduced her dosage, but she had another hypo episode on 2/6/11 (BG=24). After that, she was definitely not feeling well and the ketones came back. I first just spoke with the vet on the phone, but finally took her in on 2/15/11. They found ketones in her urine, so she went into the hospital (first DKA event). She had another hypo episode in the hospital after getting Lantus (don’t know the dose), so when she was released on 2/17/11, she came home on 0.5U twice a day. She didn’t do really well and the ketones didn’t go away. I was monitoring her urine at home, and when I got a “moderate” reading on 2/22/11, it was back to the hospital (second DKA event, although probably just a continuation of the first). This time she was released on 2/26/11 on a Lantus dose of 1.5U twice a day. She was also getting clindamycin (just in case, not because they found an infection) and mirtazipine because she wasn’t eating well. Both of these had bad side effects for her so I discontinued them quickly. I was also giving her subQ fluids.

Her BGs stayed mostly high, so the Lantus dose crept up, but she didn’t do very well at all (weakness, vomiting, ketones). She also had really bad soft poop. The vet thought maybe the Lantus doses were carrying over, so we switched to ProZinc on 3/18/11, starting at 1U twice a day. Again her BGs stayed generally high and the ketones didn’t really go away, and she wasn’t really feeling well so we went back to the vet on 3/21/11. I couldn’t afford another hospitalization for her, so the vet gave me some Humulin insulin so that I could treat the ketones at home. I managed to get rid of the ketones by the end of April, but her BGs stayed generally “HI” and she was clearly not feeling well over this time.

I first contacted the FDMB in March or April and got the advice to switch to low carbohydrate wet food, so she has been eating only Friskies since then. I also got the advice to get her off the Humulin because this type of insulin was hard on their system, so she has been on ProZinc only since the beginning of May. I’m giving her the really small doses of ProZinc using U-100 syringes and the conversion chart that I found on this site. The ketones have been mostly gone since then until they briefly showed up a couple of days ago.

As I mentioned, I was giving her the ProZinc every 8-10 hours. She started at a dose of 0.4U to 0.6U, but her BGs stayed mostly “HI” at the PS, dipping down to ~300 at +3 or +4. She would sometimes have the shakiness or staggering or desperate eating that I associated with a hypo event and had the bad soft poop. My interpretation, which could have been completely wrong, was that the dose was too high, so I went to 0.1U or 0.3U, which didn’t seem to help much. I went back up to 0.6U and the bad soft poop came back. I went back to 0.4U, and it seemed like the PS numbers did come down a little (mid 400s). Then I went down to the 0.1U or 0.2U and the PS came down a little more.

I switch from the AlphaTrak to a TrueResult meter in mid-July, but her numbers after that were lower than would be expected just because of the change in the meter. Toward the end of July, I started getting PS number that were really close to 200 and she was still having the soft poop, so I started getting the idea that I could stretch out the time between the doses. I was also experimenting with the doses (short-0.1U, 0.15 U). I got the BG curve on 8/17/11 that was sort of “U”-shaped, so I thought maybe she was getting too much insulin so I really started stretching out the time between doses (usually 0.2U). Then I panicked and decided that I was misinterpreting everything and under-treating her, so I gave her the 0.3U dose on 8/24/11. She reacted really badly to that. She had the shakiness and stumbling that you would expect from a hypo event, even though I measured her BG at 194 while it was happening. She was really weak afterward, and it took her several days to recover.

I’ve been home testing since Argyle was first diagnosed in 2009, but not as intensively as would be desirable. Looking back at my records in light of things that I read on this site, it seems to me like she was being overdosed almost since the beginning. Her Lantus dose started at 1U twice a day and then went up to 2U twice a day, and she went off insulin for a while and then back on. She was getting 1U or 2U once a day, and in February 2010, the vet said her fructosamine show that she had long-term hypoglycemia, so her insulin was discontinued. Her next fructosamine in March 2010 showed poor control, so it was back onto insulin. In May 2010, she was on ~1U twice a day and the vet again found long-term hypoglycemia. She had a tooth removed at the end of May 2010, and restarted on 0.5U Lantus twice a day after that. Her BG wasn’t really well controlled, so the dose gradually crept up. I wasn’t doing enough testing through this whole time, but it seems to me, in retrospect, that her dose was too high almost from the beginning.

I’ve read somewhere that long-term overdosing can really do a number on a cat’s system. Argyle hasn’t really been doing well for quite a while. She is 19 years old, but is in really good health except for the diabetes. When she was in the hospital in February, she had lots of blood work, an X-ray, and an ultrasound, and the only thing they found which wasn’t diabetes-related was a heart murmur. The whole diabetes thing kicked off in 2009 with some pancreatitis, but that hasn’t reappeared. She’s never had any thyroid problems. I just have the feeling that her system is really messed up because of being overdosed for so long. She had such a bad reaction to the 0.3U dose, I don’t really know if I could treat her enough to get her into the green numbers, especially since she was showing the hypo symptoms when her BG was 194. I don’t really know whether she could take that again.

Sorry for the really long post. I tried to answer all the questions, but now it seems like TMI. I just don’t know what to do next. It seems like whatever I’ve been doing for the past year has just made things worse for her. I’m very grateful that so many people are trying to help Argyle. Any ideas for what to do next, or even what is going on, would be really appreciated.

Jackie
 
I am not an expert here, but I am very intersted in helping you and Argyle. I have not digested your recent post, but I wanted to respond so you would not think the post had been overlooked.

My Cat, Kitty is also receiving tid dosing and has had DKA, so I can relate to many of your issues.

Hopefully, others will respond later also.

As soon as I get a chance to reread your post, I will respond with the things that stand out to me. Hang in there!

Get back with you soon!

Kim
 
Awwwwwwwwww :YMHUG:

One thought I have is that the picture can be really different on dry food vs. on LC canned. My cat needed over 4u on dry (and I still couldn't get him regulated), compared to more like 1.5 on canned. So I agree with your assessment to try some lower doses - if she hypo'd on 3.5u when on dry food, she may well be a low dose kitty on LC.

Another thought is that Lantus is quite a bit different than PZI. Lantus hypos from what I have read (I have not used Lantus, and haven't read a huge amount on it) can be really extended. The good news with PZI is that the insulin wears off pretty fast, so even if you saw a low number, there is only a concern for a few hours after that (assuming it is before or at peak - if it is after peak, there is even less time needed to be worried about it). Vs. Lantus where the hypo can continue even past +12, which is virtually unheard of with PZI unless perhaps they were given some monster dose like 20u or something, that I don't know about.

On the question of her reaction to the 0.3, and the general question of her reaction to doses where her numbers aren't low, I would post on Health if you haven't already about that. It's possible she is super-sensitive to any drops, or it's possible she has a response to the insulin itself - there are rare cases of allergies & such, though I think they would be more like an anaphylactic shock reaction or something, and more breathing problems or such. I have never heard of insulin causing poop problems, but maybe on Health you will find that others have?

If I were in your shoes, I think I would make my goal simply to avoid hypos and DKA if possible, and try to keep her in a moderate place and hopefully feeling reasonably well. If she dropped from HI to 300 on a dose of only 0.4, then she appears to be pretty sensitive to the insulin. You might try something like 0.2, and try going back to shooting more often than +12, and see if that gives her steadier numbers. It's just a stab in the dark, but I'm wondering if maybe she is just so sensitive to the drops from a higher PS that that's what's making her feel sick - i.e. not the higher dose per se or any low numbers, just the drop. I have read it can make you feel woozy. Shooting more often, like 8-10 hours like you were doing, is a good way to keep the insulin in her system more steadily on a lower dose and hopefully head off higher numbers at the same time.

It's also possible that her reaction is coincidental, or has to do with the higher numbers in themselves. We had one person recently who was convinced her cat was having a reaction to the insulin, but then with some encouragement to raise the dose, it turned out it wasn't really that at all, if I remember correctly. It's hard to say really, I mean if she is staggering, I can see why you wouldn't want to give her that dose again. But on the face of it, few cats respond much to a dose like 0.3, and it's almost inconceivable they could actually hypo on that kind of dose, unless perhaps they weren't eating and were really sick and their body just not working well.
 
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