BG curve questions

[kburrall]

Hi all,

We've been managing our cat Chaos's diabetes for many months now. He was initially stabilized and very tightly controlled at 2 units (BG in the 100's all day). His internist left her practice and the next closest one is quite a drive away, and we'll need to do it but poor guy HATES the car. So, in the interim we've been self-managing based on what we learned with the internist.

A couple of months ago we noticed high readings in our spot checks. We figure this has to do with him gaining back a couple of pounds (he had gotten skinny when he first got sick), so we began to increase his dose in half-unit increments. His last few curves are confusing to me, though. He used to have such standard bowl-shaped curves.

On 6/26 he had a standard bowl-shaped curve but with a nadir at +3hrs. (270 pre-food pre-shot, 251 at +3hrs, 291 at +6hrs). That was at 2.5u. Given our internists comments in the past, this all still seemed too high, so we upped him to 3u.

On 6/29 (after about 2 full days of 3 units), he had a mountain-shaped curve (137 pre-food pre-shot, 304 at +3hrs, 283 at +6hrs, 290 at +8hrs, 227 at +12hrs). I didn't put too much thought into this one since our internist had always said to wait 2 weeks to adjust to a new dose before curving, this was more just to make sure he wasn't going hypo.

On 7/12 (today), his curve was quite flat until evening. Pre-food pre-shot he was 229, then 217 at +3hrs, then 278 at +6hrs, then 407 (!!) at +12hrs (before food and shot at night). Again it seems like he may be nadiring early at 3 hrs. My question is: does this seem like insulin resistance? Insufficient insulin? Or insulin metabolism that's too fast? I guess there's even the possibility of a Somogyi type thing going on, though I've never measured him low or seen any hypo symptoms.

I probably need to do a real curve of 12 hrs at 2-hour increments... it's just that he hates getting pricked so much. Thanks for any input!

 

[Kris & Teasel]

What insulin are you using? Are there any other changes in health status? How are his teeth? Is he on other meds?

 

[kburrall]

Good points! Glargine (Lantus). No other changes in health status besides his weight. He seems healthy with a reasonable amount of energy, soft coat, etc. I think his teeth are fine (his vet has never said anything about them). No other meds. We test his sugar with AlphaTrak. Also, the reason we do pre-food pre-shot is because it takes 45 minutes to feed him in increments or else he pukes, so it's a bit difficult to test him post food but pre-shot because it's already been almost an hour since start of feeding.

Also I am a little concerned he'll gain too much weight, although it seems incredible given he's only getting 1 can of wet food at each feeding, twice a day, which is about 50% below the recommended amount for a cat of his size. He started at 17.5 lbs (a bit overweight, though he's just a huge cat), then when he got sick he went down to 13, and now he's back up to 15.2 and seems healthy at this weight. He probably shouldn't gain any more though so hopefully he's stabilizing.

 

[Kris & Teasel]

Actually, in order to assess insulin dose we recommend testing BG before feeding to see where the kitty is without food influence. You can then judge whether the planned dose is safe or not. Lantus is slow in onset so he doesn't need to have a full meal on board before giving his shot. A tablespoon or so should be enough and then he can eat the rest at leisure.

Any number of things can happen that can change a kitty's insulin requirement. UTIs and dental issues are near the top of that list. You were lucky to be able to tightly control him at a single dose level over many months. Many cats vary in the dose they need at least by a little over time - sometimes going up, sometimes going down.

A full curve at the current dose might give helpful information. However, if he's doing something we call bouncing, it might not reveal much if it's done on a day when he's bounced himself up into high numbers. Somogyi is much debated but is usually ascribed to an event of very low BG somewhere in a cycle that triggers an overreaction. We use the term bouncing to describe an overreaction to a variety of triggers: 1. BG dropping to a lower than usual value, even if it isn't very low; 2. BG dropping faster than usual; 3. BG dropping to an actual low value.

I'll just throw this out there: what if your cat's insulin need has actually gone down and the 2 unit dose became too much and the increases since have exacerbated the problem? Maybe he's now giving erratic BG numbers because of the bouncing phenomenon?

 

[kburrall]

Thanks so much! Glad to hear we are actually testing at the right time doing pre-food pre-shot. We usually end up dosing him somewhere in the middle of his feeding to make sure he has enough food in his system and isn't going to throw up. That's good to know that we could even dose him sooner. (Though we don't test him every time pre-food)

What dental issues should we look for? I know what to look for with a UTI and I'm pretty sure he's fine.

Regarding your last point, after reviewing old curves, that seems possible as we had some erratic (high) readings in the past when otherwise he seemed tightly controlled (though these curves were reviewed by his internist and she didn't seem to suspect bouncing back then). If we think he may be bouncing / overdosed, should we try dropping his dose to 1.5 units directly? Is there any worry with dropping a dose too fast? We always increase slowly, of course, but not sure if there are any worries with dropping the dose.

 

[Kris & Teasel]

Though we don't test him every time pre-food)

If you read more on FDMB you'll see that we're very data-driven and strongly recommend testing pre food pre shot every day both AM and PM. Many/most vets won't suggest this for any number of reasons but we rely on BG data here to help anyone who comes here for advice.

What dental issues should we look for?

Any plaque/tartar buildup will be visible a thick yellowish layer on the molars especially. If you see a line of brighter red at the top of the gum line that can indicate gingivitis, again, more evident on molars.

If we think he may be bouncing / overdosed, should we try dropping his dose to 1.5 units directly?

I believe he's at 3 u currently, correct? Does he have any history of ketones in his urine? If not, this is an experiment you could try. I strongly recommend that you post for more advice on the Lantus forum which is a very large group that has some highly experienced people on it.

If you're not ready to do that, at least go read the info sticky on using Lantus and you'll see these recommendations:

• dose changes should be only 0.25 u at a time, especially at low dose levels (where you are)
• there are two dosing protocols under the acronyms TR (Tight Regulation) and SLGS (Start Low Go Slow) and you choose based on your needs, what you feed your kitty, etc.

Stepping back from the details: it's always a huge leap of faith in deciding to try the advice offered here, especially when you've been working closely with a vet internist or even your regular vet. Authority and credentials count to all of us. I think almost everyone who comes to FDMB has done so because they can't afford repeated trips to the vet for curves, etc. or they were given bad advice by their vet and put their kitty at risk or they've tried doing things their vet's way and got nowhere.

Does any of this help?

 

[kburrall]

Yes, that's very helpful, thanks! He's at 3 units. He does not have history of ketones though he's only been checked for those at the vet, not at home. I'll look into home testing. I'll also condense this whole story and put it on the Lantus forum today, thanks for the tip. Wow, so much good stuff to read on the Lantus forum! I'll get myself educated on there.

Interestingly, some of the recs are different than those from Chaos's internist (eg she always raised us by 0.5u). I am more comfortable with 1/4 unit though especially if I'm not regularly talking to the internist. That said, that's for increasing a dose - I read on many places that if a Somogyi rebound effect is suspected, a dose drop of 50% or back to 1 unit is recommended. (eg: https://asgvets.com/feline-diabetes-insulin-overdose/ - this cat was taken from 7u back to 1u, http://www.vetsulin.com/vet/Cats_Monitoring_Somogyi.aspx recommends going to 50% of current dose or 1u, whichever is lower).

IF Chaos was overdosed at 2 units, I wouldn't expect any resolution of his weird sugar numbers by dropping him to 2 3/4, 2.5... etc. until we got below 2. So, my plan would be to drop him back to either the last known safe dose (where he wasn't alternating high / low) which is 1.5 units, or the 1 unit recommended above. (Despite the 2u curves being evaluated by the internist). As an example, here's his 2 unit curve that gave me pause but didn't seem to concern the internist at the time: PFPS 123, +2hrs 220, +4hrs 84, +6hrs 63, +8hrs 97, +10hrs 120, +12hrs (PFPS) 384 (!!!). What's up with the 384 in what otherwise looks like a tightly regulated curve?

Then there are the events that happened after: rising sugar levels at the same 2 unit dose (could be any reason, eg his weight gain) BUT after raising to 2.5 and then 3 units (over time with lots of curves, as per internist's former instructions), we saw very little change / reduction in his sugar levels.

New information: we decided to curve him overnight to see if it looked any different than the daytime. It does, though it's still confusing. He still got 3 units. (Hey, what better way to prepare for the baby coming in Dec than to wake up every 2 hours and poke a pissed off cat? Haha)
pre-food pre-shot pm: 407 (as mentioned previously)
+2hrs: 234
+4hrs: 138
+5hrs: 163 (extra check here due to the precipitous drops)
+6hrs: 164
Pre-food pre shot am: 130

I wonder if the precipitous drop from >400 to low 100's would have been enough to give him a rebound effect at some point (though clearly it didn't happen right away). It's certainly not a clear-cut case of rebounding. I guess is it possible that he's able to 'rebound' just enough to stay in the 100s and not go any lower?

In any case, I'm sufficiently confused that I got him in with a new internist today, so hopefully she'll be able to help us out. Sincere thanks again for all the tips! I'll post any new stuff I learn later.

 

[Kris & Teasel]

Here's my take for what it's worth:

Re the 2 u curve data:
AMPS 123 - lovely number
+2 220 - maybe breakfast food spike
+4 84 - insulin in effect
+6 63 - beautiful nadir value of 50% of AMPS
+8 97 - insulin effect waning
+10 120 - insulin poop out/back to level of AMPS
+12 384 - either lack of duration of AM dose or bouncing from the day's lows.

Re the recent overnight curve:
PMPS 407 - high/ maybe a bounce number (is he usually higher at PMPS?)
+2 234 BIG drop for this early in the cycle - a warning of more activity to come
+4 to PMPS - essentially holding in decent but not low numbers.

This recent curve - on the face of it - shows that a 3 u dose is having very good duration but not getting him as low as your earlier 2 u dose did. From what you say, his response has changed. The problem with having only sporadic curves done and insufficient routine BG testing is that you're trying to figure out what's happening without a frame of reference. That's why we're such big proponents of daily BG testing and spreadsheet logging of data. It's like having a thick, detailed textbook on your kitty to consult. The jigsaw puzzle is complete and you're not in the dark.

We often tell people to worry less about individual numbers and focus on spreadsheet trends over time. That tells the story. You can see with clarity how your kitty's response waxes and wanes, how the dose drifts up and down and you have a heads up that an issue has arisen when the array of colours changes. Most of us learn that FD is a dynamic, not a static, condition so fluctuations in insulin response and dosing levels go with the territory.

 

[Kris & Teasel]

Addendum: another reason for the descent from a high of 407 to a low of 130 at the end of the cycle is from a bounce "clearing" as we describe it. That is, the elevated BG caused by a dumping of glucose into the bloodstream in reaction to a lower than normal BG gradually declines to an appropriate level.

 

[kburrall]

Very interesting. Thanks again for taking the time to provide your knowledge and experience!

Brief summary from our visit to the new internist: his response at 2 units may have been a Somogyi effect due to dose being too high (can't even be sure 63 was the lowest value he attained since we aren't continuous testing). If she had seen that curve, she would have had us reduce the dose. This is a different opinion than his last internist who believed he was just tightly regulated at 2 units. If that were true, we could be seeing all the high readings as a result of near-constant rebounding, and if he was overregulated 2 units, he certainly is at 3 units. That's possibility number 1, which you called out in your first post.

Possibility number 2 is that he may be becoming slightly insulin resistant, hence his response to increasing doses not having the desired effect of lowering his overall BG curve. Possible causes of this would be various conditions (counterregulatory hormones such as a hyperthyroid condition, serious dental infection, or UTI, as you mentioned, as well as a few other rare conditions), so he's getting some testing to rule that out.

Once we've ruled out the obvious causes of possibility 2, we'd test possibility 1 by dropping his dose to 1 or 1.5 units to see if he's still regulated at the lower dose or whether he actually needs 3 or more units (in which case we go on a new search for rarer potential causes of his insulin resistance)

We may also need to start curving him at night since his numbers at night look so different than his numbers during the day. She said she has some patients who have to have a different dose at night versus morning.

Regarding the twice daily testing: we have thought about this. It is a difficult decision to make, though, because of two things. 1) initially in Chaos's treatment, we were testing and adjusting dose frequently (like the TR protocol), but our doctor believed we were over-testing and micro-changing his dose too much based on the results, not allowing him to adjust to any particular dose (she recommended 2 weeks per new dose, not 3 days). So there may be a legitimate concern about over-managing. 2) It is absolute torture for him. If my ultimate goal is to optimize his health and well being, I then have to figure out the balance between managing his diabetes as well as possible via data versus torturing him on a daily basis with ear pricks. It seems that many cats get used to this and so the torture piece is a non-issue, but at this point I can tell I am very much stressing him out to do even as much testing as we are currently doing (which is not as sporadic as the posts may have indicated - we do nadir and PFPS checks every few days and fuller curves about every 2-4 weeks). I will continue to re-evaluate this tradeoff, of course, looking at both our need for data and his changing response to testing.

 

[Yong & Maury GA]

Possibility number 2 is that he may be becoming slightly insulin resistant, hence his response to increasing doses not having the desired effect of lowering his overall BG curve. Possible causes of this would be various conditions (counterregulatory hormones such as a hyperthyroid condition, serious dental infection, or UTI, as you mentioned, as well as a few other rare conditions), so he's getting some testing to rule that out.

Definitely a good idea

he actually needs 3 or more units (in which case we go on a new search for rarer potential causes of his insulin resistance)

Usually when a kitty gets to 6.0U twice a day, it's recommended to think about testing for insulin resistant conditions.

We may also need to start curving him at night since his numbers at night look so different than his numbers during the day. She said she has some patients who have to have a different dose at night versus morning.

Many kitties tend to run lower at night and there's no official explanation . With that, are those other patients using Lantus? Since it's a depot insulin, it usually prefers consistent dosing (same AM and PM dose).

If my ultimate goal is to optimize his health and well being, I then have to figure out the balance between managing his diabetes as well as possible via data versus torturing him on a daily basis with ear pricks.

Data is collected via home testing. Out of sincere curiosity what is your alternative method?

It seems that many cats get used to this and so the torture piece is a non-issue, but at this point I can tell I am very much stressing him out to do even as much testing as we are currently doing (which is not as sporadic as the posts may have indicated

Yes they do, even members who have started with semi-feral or skittish kitties . It really isn't torture. Once again, I mean no offense with this statement but you may be stressing him out because you have yourself worked up. Kitties are little sponges that can pick up and feed off our emotions. [/quote]

- we do nadir and PFPS checks every few days and fuller curves about every 2-4 weeks).
I will continue to re-evaluate this tradeoff, of course, looking at both our need for data and his changing response to testing.

Your PFPS, which we call AMPS and PMPS are the most important tests to do because you want to know if he is safe enough to receive insulin. If he was a human baby, would you still have the same hesitation? These are just our fur babies instead . We really do care about each other's kitty's and their beans. If I have upset you, I am sorry and it was very much not my intention.

Wishing you the best!

 

[kburrall]

Hi Yong! Thanks for weighing in. I don't immediately see how to do that segmented reply thing, so I'll just go one by one

- Definitely hoping he's not insulin resistant, but we should know relatively soon.
- The day/night thing is interesting; I'd never really thought about it, but of course all hormone production is drastically different day vs night, so it makes sense, as they're all on interconnected pathways. I'm not sure what her other patients were using, but if she were to recommend a different day/night dose I would definitely ask her about whether it's better to have constant dosing vs evening out day/night numbers
- I wish I had an alternative method - I don't, I just test him less frequently than before every feeding/dose. I have yet to convince myself that this level of testing is really necessary to properly manage his condition, especially since I've already had one internist tell me I was over-testing early on (at that point, I was doing the checks before most feed/doses). We've been super clear with his doctors that we're willing to do whatever is required to do the best job we can with him, but they still don't seem to recommend testing this frequently. Out of curiosity, I'll ask his new doc next time I talk to her why they don't recommend it.
- I'm very happy for those kitties who get used to it! I wish it was a question of managing my own stress, and you're probably right that that was true at first, but now I have zero stress about it but every time I get out the Alpha Trak, he sees it and runs and hides. Smart guy. I then have to coax him out, and the whole time he's giving me these sad eyes like "why are you doing this to me?", and if only I could explain to a cat that it's for his own good. It's hard to relate over the internet, but I know him and I can tell when he's upset just like any cat-parent can, and testing legitimately upsets him. To answer your hypothetical human baby question, absolutely: I would continue to test at the level at which I believe is necessary/optimal, but no more, in order to not cause unnecessary discomfort. I do treat these kitties like my babies, short of carting them around town in a stroller, because they would hate that.
- Don't worry about upsetting me, it doesn't at all, I genuinely want to hear opinions on what others believe is in my cat's best interest. But at the end of the day, I have to make the decision based on all the information available to me, whether that's from forums, articles, or from his internist. So far, I just haven't been convinced that testing twice a day is necessary, and since it upsets him, I don't. If the situation changes and it becomes necessary, I'd do it in a second.

My other cat just jumped on my keyboard and tried to type her own response. Ha.
Best to you and your kitty(ies) as well!

 

[Yong & Maury GA]

For the testing, do you always do something positive after the test? Treat, cuddles, grooming, catnip, anything like that? When you poke, are you aiming for the marginal vein? (If yes, don't hit the vein as it can be more painful) Are you warming the ear before poking? Is he more likely to let you try testing his paw pad?

- Don't worry about upsetting me, it doesn't at all, I genuinely want to hear opinions on what others believe is in my cat's best interest.

I always take it into consideration, I know emotions can run high here . It takes a lot of energy for me to write my tactful responses. I can be very blunt but at least I'm aware of it! So I try my best to soften my responses

But at the end of the day, I have to make the decision based on all the information available to me, whether that's from forums, articles, or from his internist. So far, I just haven't been convinced that testing twice a day is necessary, and since it upsets him, I don't. If the situation changes and it becomes necessary, I'd do it in a second.

Yes this is very true, the decision will always come down to being yours but I'd like to try and convince you of at least the 2 PS tests. However, that greatly depends on figuring out what's going on in Chaos's mind. Obviously, I do not want to upset him more but will try to see if there is a reason .

Could you share the story of how you and Chaos got together?

 

[kburrall]

For the testing, do you always do something positive after the test? Treat, cuddles, grooming, catnip, anything like that? When you poke, are you aiming for the marginal vein? (If yes, don't hit the vein as it can be more painful) Are you warming the ear before poking? Is he more likely to let you try testing his paw pad?

Yes, absolutely! All of the above. Warming the ear, going next to the marginal vein so we only get a small drop and it hurts less, etc. Tons of pets and cuddles. He will even jump on my lap to get his insulin shot because he loves the petting. However, it's not enough to get him to tolerate the BG testing. Maybe we need to try treats too, but weren't sure if those will mess up his sugar. I could try his paw pad again but early on, he hated that even more.

Yes this is very true, the decision will always come down to being yours but I'd like to try and convince you of at least the 2 PS tests. However, that greatly depends on figuring out what's going on in Chaos's mind. Obviously, I do not want to upset him more but will try to see if there is a reason .

The more I read and talk to his internist, I think I am understanding when the 2 PS tests would be required. Basically, if there is any chance of him being too low to get his shot. She suggested if we ever get a reading below 100 on a curve at a given dose, we need to be doing PS tests the whole time he is on that dose. Makes sense, because there is a chance we shouldn't dose him at all. However, if he's never been observed to go under 100 at a given dose, even with relatively frequent full curves, less frequent testing like we had been doing is fine.

Could you share the story of how you and Chaos got together?

We adopted Chaos and his sister from a shelter in NYC in 2011 as 4-week-old kittens. We since moved to the west coast, and he enjoyed several years of carefree non-diabetic existence. He always had a hearty appetite, and about a year ago he was slightly overweight but not much. (He's also just a huge cat. He's a healthy weight at 15 lbs! Which he is now) At the time we were feeding them their favorite, Merrick wet food, which had been on a 'good' list given to us by the shelter as far as carb content. (Later we found out they reformulated and added a ton of carbs! Agh!) A little less than a year ago he began to lose his appetite, and weight, and we got worried. That's when he was diagnosed and we began treatment (and switched their food, of course). His symptoms have drastically improved on treatment and he is back to his normal jovial self. Some strange curves of late had us worried, but he is still playful and seems like he feels fine. We were told it's likely the cause of his diabetes is genetic, so we are closely watching his sister for any symptoms (as well as feeding her the same low-carb stuff we feed him), but so far she's fine. They are wonderful cats.

 

[Yong & Maury GA]

Yes, absolutely! All of the above. Warming the ear, going next to the marginal vein so we only get a small drop and it hurts less, etc. Tons of pets and cuddles. He will even jump on my lap to get his insulin shot because he loves the petting. However, it's not enough to get him to tolerate the BG testing. Maybe we need to try treats too, but weren't sure if those will mess up his sugar. I could try his paw pad again but early on, he hated that even more.

There are low carb treat options available. I use PureBites freeze dried treats.

The more I read and talk to his internist, I think I am understanding when the 2 PS tests would be required. Makes sense, because there is a chance we shouldn't dose him at all.

Yes this is why PS tests are the most important. The extra tests in between just help see the bigger picture .

We adopted Chaos and his sister from a shelter in NYC in 2011 as 4-week-old kittens. We since moved to the west coast, and he enjoyed several years of carefree non-diabetic existence. He always had a hearty appetite, and about a year ago he was slightly overweight but not much. (He's also just a huge cat. He's a healthy weight at 15 lbs! Which he is now) At the time we were feeding them their favorite, Merrick wet food, which had been on a 'good' list given to us by the shelter as far as carb content. (Later we found out they reformulated and added a ton of carbs! Agh!) A little less than a year ago he began to lose his appetite, and weight, and we got worried. That's when he was diagnosed and we began treatment (and switched their food, of course). His symptoms have drastically improved on treatment and he is back to his normal jovial self. Some strange curves of late had us worried, but he is still playful and seems like he feels fine. We were told it's likely the cause of his diabetes is genetic, so we are closely watching his sister for any symptoms (as well as feeding her the same low-carb stuff we feed him), but so far she's fine. They are wonderful cats.

Ohh does that mean they were bottle babies? With him jumping on your lap for shot because he likes the attention, might make the BG testing more tolerable. Meaning desensitizing his ears could work beautifully .

I'm going to give you the links I try to give all new members to the forum now .
Setting up your Signature with information about Chaos will be helpful as you continue to post. Many members, myself included, check on a lot of kitties every day so the signature info helps refresh our memory :
http://www.felinediabetes.com/FDMB/threads/editing-your-signature-profile-and-preferences.130340/

Since you have had some home testing numbers, it would be nice to see them on a Spreadsheet. Just need a Google account and if you need help setting one up, just ask: http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/
Here's how to understand the SS too: http://www.felinediabetes.com/FDMB/threads/understanding-the-spreadsheet-grid.156606/

Lastly, I like to give this so you can read ahead of time because it's better to be prepared, but I hope you never need it. http://www.felinediabetes.com/FDMB/threads/how-to-treat-hypos-they-can-kill-print-this-out.15887/