BG Numbers all over the place

Hello everyone,

This is a cross post, I also posted in the Caninsulin / Vetsulin and N / NPH page but am posting here after it was recommended I do so.

This is my first time posting so please correct me if I am not doing this correctly. I have the link to my cats google sheet in my signature. My cat was diagnosed a little over a month ago after I noticed an excess amount of pee in the litter box. My vet started him on two units of vetsulin and we changed his food, he is currently eating the fancy feast pate meals. After a little over 2 weeks on the 2 units she increased him to 2.5. We were originally told to test before the shot and to not give insulin if they are under 180. The 2.5 units of insulin were making it so he was in the 100s after 12 hours. We told our vet this and were told to start testing BG 15-20 after eating instead. His numbers are still showing in the 100s which means we are only giving him insulin once per day. After communicating this with my vet I was told I didn't need to test his BG numbers anymore and could instead just give him 2.5 units of insulin after every meal (twice a day). I do not want to do that and was wondering if someone could look at my sheet and tell me what they think? Should I wait longer than 15-20min to test? Thank you in advance. I am very new to this process but know of the important of testing BG before giving insulin and am feeling upset that my vet wants me to stop and shoot not knowing his numbers.

 

Hi there,

Posting is fine.

If the vet was basing the dose on the curve run just before the increase to 2.5IU Vetsulin then they could have missed that there was a significant possibility that the black readings could have been an upward bounce in BG in response to a safe but unfamiliarly low number in a previous cycle. (Your kitty was already seeing blues and unusually good duration for Vetsulin on the 2IU dose - see curve of 9 August 2020.)

In the early part of treatment you mostly had pink preshot BGs. The intermittent reds may have been influenced by bouncing.

Per the curve of 9 August your kitty has been getting into a good range when the insulin is working at its strongest. The wide range between preshots (pink ones) and the blue nadirs are typical of the insulin you are using.

Very shortly after the increase you very quickly started seeing more blacks at preshot and then 'lopsided' AMPS and PMPS values. When you get a situation where you consistently don't get two 'shootable' preshot BGs it is typically because the dose is too high. If you reduce the dose you should hopefully return to having 'shootable' AMPS and PMPS each day.

A combination of bouncing and lack of insulin in the previous cycle due to the skipped shot may both be contributing to the black preshot BG readings.

This is incorrect advice from the vet. The decision on whether or not it is safe to give a dose of insulin must be based on a FASTING blood glucose reading, not one which is temporarily elevated by food.

If a preshot reading is only slightly under the 'no shoot' limit, it is OK to stall for 20 minutes without feeding to see whether BG levels are rising on their own. If they climb above the 'no shoot' limit after stalling then it should be OK to proceed with the dose because the post-stall BG reading is not food-influenced.

If it had been my cat, and it were not prone to ketones, with preshots that low and with only a few weeks' worth of data I would have skipped too. (If ketone prone, I may have considered giving a very small token dose, but not when preshot BGs were in the very low 100s. I'd have looked to switch to a gentler-acting insulin ASAP instead.)

This is incorrect and dangerous advice, particularly as there was already evidence of low preshot BGs and unusually long duration of Vetsulin in your cat.

Just look at PMPS 5 September and AMPS of 6 September when you gave two consecutive doses of 2.5IU and ended up with a PMPS of 101 (Alphatrak). A BG level of 101 is WAY too low to administer a dose of Vetsulin, even a tiny one. If you had followed your vet's advice and given insulin without testing, your cat's BG could have gone much lower (and with no testing you'd have missed that as well...).

Neither would I.

I suggest that you agree with your vet going back to 2IU [ETA] twice per day for the time being to see whether that will even your kitty out again, getting as many mid-cycle tests as you can fit into your schedule to see what your kitty's doing between doses, running another curve and reviewing the situation.

After that there may be a little room for dose adjustment but, as outlined in the FDMB Caninsulin/Vetsulin Guide, adjusting in 0.25IU increments can help to home in on a suitable, safe dose better than adjusting in larger increments.

My two penn'orth.


Mogs
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Thank you so much for your response Mogs! It is very appreciated and made me feel better about the concerns I was having. I have reached out to my vet to discuss going back to 2units

 

Your instincts were spot-on.

Be sure to let us know how you get on with the vet, and shout out for any help you need.


Mogs
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What are you feeding your kitty, BTW?


Mogs
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Pls ignore the above. Reread the opening post.


Mogs
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Hello there!

Mogs has already covered a lot of the issues raised, so I just wanted to mention a couple additional things. If you already know any of this, just ignore, I just don't want to assume you already know everything.

Feeding Times

Vetsulin needs to have food on board BEFORE shooting. Test, feed, wait 20-30 minutes, shoot.
Give multiple small meals throughout the day. It is good to give food at +1 (1 hour after insulin) to slow the drop, and a couple more times in the first half of the cycle. If your kitty is underweight, do not limit feeding (except 2 hours prior to pre-shot test, so we can get a true reading for insulin time).
Do feed throughout the night too, cats drop lower at night.

Testing Times

To help us see where your kitty is going in the cycle, I would get some extra mid-cycles in. A good loose guideline would be getting a +1, +3, +5, and +7, and then the next day maybe alternate to even numbers early in the cycle. Just to fill in the blanks on your spreadsheet.

Do try to get a "before bed" test in, since cats drop lower then.

Alphatrak

The Alphatrak is a good meter, however as I'm sure you're aware, the test strips are very expensive. About $1 each. When you test even the bare minimum with pre-shots, that's $2 a day. Above Mogs mentioned getting more mid-cycle tests, but that's more money spent! Yikes! Vets like to use Alphatraks because they are designed for pets, however human meters have been used in cats and other animals for several decades now, long before the Alphatrak came onto the market, and they work just fine. The human meters run a little lower than pet meters, but we compensate it by just knowing what the acceptable BG range for felines is as read on a human meter (50-120). Again, nothing wrong with using the Alphatrak, but most of us just can't justify the cost so we go with human meters. You are in the US, so if you want to consider a human meter, I'd recommend the ReliOn Prime from Walmart. The meter is $9, strips are $18 for 100. Versus I think the Alphatrak is around $45 with strips $50 for 50.

 

Hi Elizabeth (and Panic!)!

Thank you for that extra information. I knew some of it but not all, this whole experience is new to me so I am trying to learn as much as I can. My vet recommended the AlphaTrak and I am a little nervous to switch things up while I feel that my kitty is so unstable. The $1 per strip is crazy expensive tho, I am not sure how this company is getting away with that but I plan to change once I am not so nervous about his numbers.
I did have one question about the waiting to shoot for 20-30min. My vet specifically said that we could not wait over 20 minutes before shooting so we normally try to do it just after he has eaten a few bites. Why wait 20-30 min? You also said to give food at +1 to slow the drop. Does Vetsulin make their numbers drop super quick? He is a little underweight but has started to regain it since he originally got on the insulin.
Thank you so much for the help!

 

It's perfectly fine to stick with Alphatrak till you're comfortable switching, I did the same thing. Ultimately the cost convinced me to make the plunge.

Where would he get that notion?? Maybe that's protocol for dogs? Vetsulin is a canine insulin after all.

Absolutely wait 20-30 minutes. In cats, Vetsulin hits hard and fast, so food needs to be on board already for when it hits. On gentler insulin such as Prozinc and Lantus (which is what we here on the board AND the American Animal Hospital Association recommends, not Vetsulin) you don't need to wait to feed because the onset (time insulin hits the system) isn't for a couple more hours. It takes about 20-30 minutes for food to hit the system.

Yep! On gentler, longer-acting insulin, the BG will either make a gentle smiley face (Prozinc) or a low, flat line (Lantus). Vetsulin makes sort of a Nike check mark - hard drop, steep climb back up. This is both because it hits fast (hard drop) and typically doesn't last more than 3-5 hours (steep climb up). A cat's metabolism is faster than a dog's, hence why Vetsulin doesn't really work.

In it's defense, cats CAN reach remission on Vetsulin... but not often.