Can't get this cat regulated - need advice on dosing

[Melissa and Rascal]

Hi. If someone can please take a look at Rascal's spreadsheet and give us some advice, we'd appreciate it. We were having weird responses to her old vial of Lantus and had a hypo event a week and a half ago, but often it wasn't working at all. She's been around 150-350 for the last several weeks. I think it was the old Lantus. We started over with a new vial a few days ago and have all her data since then. I was scared to start higher than 0.5 units after the hypo recently and that dose worked well the first day (see spreadsheet). Now I can't get her down much and am wondering if I should raise the dose.
She has been more lethargic the last couple days for sure. May be just the high numbers, but I just went out briefly and came home to find her lying in her litter box. She NEVER does this. She seems week. She is still eating and drinking though. No vomiting or diarrhea either. Just acting more tired and weird. I just went out and bough ketostix and am waiting for her to pee to test her. I'm so scared something is wrong. I just gave her an extra token dose 0.25. I don't even know why. I'm panicking. Maybe I should have started with a higher dose, but I'm also wondering if she is bouncing. Now I'm wondering if I should take her in to the animal hospital, but maybe I'm overreacting.
Thank you for any help!

 

[Chris & China (GA)]

Generally, a cat that's still eating isn't dealing with DKA.....not eating, not enough insulin and infection/inflammation is the "recipe" for DKA

You might try smelling her breath while you're waiting for the ketone test...cats with ketones will have their breath smell like nail polish remover

If the old insulin was bad, it's possible she just needs more time to build the depot back up, but PLEASE watch her carefully today!! We don't ever give an extra "token" dose in response to high numbers. That's only for short acting insulins under the supervision of a vet or someone who's had a lot of experience with short acting insulins. We don't use Lantus like that

I don't see any indication of bouncing....I think she may just need a higher dose, like .75

How low did she go when she had her "hypo event" and what kind of symptoms were you seeing? What was the dose then?

Of course if you're concerned, it can never hurt to have her looked over by your vet

 

[Melissa and Rascal]

Thanks! I feel a bit better now. Yes, I was thinking 0.75 might be better. That is her total for the day so far, but I will keep in mind that it now complicates the timing of the cycle. I will be in and out and test often today.
Her breath smells normal, I think. I don't know why I freaked out so much. I just never see her lying in her box and she seems extra tired today. I guess we had it too easy the first time around and got her into remission without too much trouble at all. It's been a lot more complicated this time around. Because it was smooth sailing before I didn't plan well for relapse and read up on certain topics like I should have. Ketones were one of them. Not knowing exactly what that was, it was the first thing that popped into my head. I've never even tested for them before! I think I got to Walgreens and back in 5 mins with those stupid sticks today, but I just missed her last trip to the box.
With the old Lantus we pushed it too far. Beyond the 6 months but it seemed to be working. But sometimes when it did it worked too well. Other times it did nothing at all. SO weird. I was working up to 0.75 and 1 unit when she had the hypo scare. She got 1 unit that day and quickly plummeted from 264 to 60 in 2:45. Thankfully I was home and monitoring constantly. She had definitely clinical signs. Totally disoriented, wobbly, staggering and pacing. We halted the free fall at 60 with Karo syrup. The part that is so odd is that she got the same dose or similar (I know now I shouldn't have been changing doses back and forth like I was but always between 0.5 and 1.0) before and it helped a little or not much at all. Someone here said the insulin might have had precipitates in it or something so that some doses actually had a lot more hormone in it and others not much. I may never explain it.
So you don't think she's bouncing? What do you make of the fact that the first day her numbers dropped well and since then not nearly as well at all then?

 

[Melissa and Rascal]

Also, what makes this difficult is that Rascal is 17, has IBD and takes budesonide for that (a steroid - not as bad as pred for sugar, but still a steroid), and she was just recently treated for a UTI. We are assuming it's cleared up after 6 weeks on antibiotics. A lot going on.

 

[Chris & China (GA)]

What do you make of the fact that the first day her numbers dropped well and since then not nearly as well at all then?

She's a cat

Without seeing a lot more data, it's just not possible to have a better answer than that, but bounces are caused by 1. dropping too low 2. dropping too much, too fast and 3. dropping into numbers their body isn't used to being at (or any mix of all 3)

I don't see any "too low" numbers, I don't see any fast, deep drops and I don't see any numbers in the last cycle or two that look like they're much lower than her body is "used to" being at, so I don't see any reason for bouncing right now

 

[Melissa and Rascal]

So the last few days after the first wouldn't be a bounce then or the temporary elevation they talk about that people see in cats sometimes when first starting out or raising a dose or whatever?
Yes, she's a cat! I love her with all my heart, but she is killing me with worry. She and I are both going to end up in the hospital soon if we don't get this figured out. LOL! It was not this difficult at all with the first remission. Everything was much more consistent and predictable.
I changed the title of the thread. I think there's no emergency here now. It turns out she may have gotten tired hanging out around the litter box and just decided to lie down in it because she couldn't poop! I chased her there twice with the ketostix to get urine. She seemed to be straining and finally the second time had a good bowel movement. Unbelievable! I nearly had a heart attack because she's constipated.
Seriously though, I do need as much help as I can get going forward with figuring out doses. I will keep updating the spreadsheet. The little extra dose did lower things to around 200 but she should be reaching the nadir from her morning 0.5 dose so i'm not too worried about hypo. I will keep checking though and she keeps eating. Depending on her numbers today if anyone has advice on what to give tonight and starting tomorrow, that would be wonderful. Thank you so much for your help!!! I don't know what I'd do without you guys.

 

[Chris & China (GA)]

You might want to consider adding a little Miralax to help her out if she has problems with constipation fairly frequently, or a little plain pumpkin (not pumpkin pie filling!) or baby food squash can help keep her more comfortable too.

Miralax is a tasteless powder that a lot of people here use to keep things "moving" so to speak. It acts by drawing extra water out of the intestinal tract and adding that water to the stool to help keep it soft

As for your bouncing question, I just don't see the numbers she got on that first day as being THAT low, although the drop from 313 to 134 was fairly steep, it didn't happen TOO fast...usually when we're looking for quick, deep drops, we're thinking along the lines of dropping a lot more faster than that, but even if that WAS a little fast for her, bounces usually show up in the next cycle or two and she only went up into flat yellow after that. If she'd gone from blue to pink or red the next cycle, then yes, I'd think it was a bounce, but in her case, she spent quite a bit of time in yellow before going to pink, then came back down to yellow, and back up to pink....that says "not enough insulin" to me instead of "bounce"

 

[Melissa and Rascal]

That makes sense. I have pumpkin on hand with her IBD issues so I did give her a little with some food. I like where her numbers are going now! Is it too soon to make a permanent increase from 0.5 to 0.75? I know they say to hold the original dose for a week and then reassess, but then I also probably started rather low. But then if I had started at 0.75 I'm a little concerned about how much lower she might have gone that first day.

 

[Chris & China (GA)]

Is it too soon to make a permanent increase from 0.5 to 0.75?

Gotta giggle....there's no such thing as a "permanent increase"...LOL

We'd like to see her numbers at nadir lower...like high green....when the BG is in normal numbers (50-120) the pancreas can heal and hopefully heal enough to start working again, so I'd go ahead and increase to .75 tonight and let's see how she does.

As for holding the dose for a week, do you know which protocol you're following? You test enough to be doing Tight Regulation, and with TR, the only time you hold the dose for 5-7 days is when you first start....when you're "building the depot"....unless your old vial of Lantus was TOTALLY dead, I'd think she would have been getting some good out of it, so it's not like you're completely starting over

After those first days, on TR we hold the dose for 3 days (6 cycles) unless they drop below 50 and then re-evaluate to see if we should increase again

From the TR Sticky:

"General" Guidelines:

• Hold the initial starting dose for 5 - 7 days (10 - 14 consecutive cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 consecutive cycles).

• Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction (See: Reducing the dose...).

• Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.

Increasing the dose:

• Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
  • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
  • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.

• After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.

• After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

 

[Melissa and Rascal]

I was just looking at general guidelines posted in a sticky in the Lantus/Levemir forum called "Start Low, Go Slow." We did TR or pretty close to it last time around. Lots of fine turning. I will have to read what you just posted above. It's probably dangerous, but last time we got down to using very small doses at the end and I was dosing more on intuition and my familiarity with her very consistent responses. I didn't follow specific guidelines.

 

[BJM]

Since you mentioned it, you might find the following web site helpful:
Feline Constipation

 

[Melissa and Rascal]

Thanks, BJM! Yeah, we're old pros with all things GI since Rascal has IBD. I gave her a little pumpkin yesterday and today. She seems better, and her BGs are getting a little better too.

 

[Melissa and Rascal]

BJM, that looks like a great website! I know some of those tricks but should familiarize myself with some of the other info. I will have to share that with the IBD group too. They already have all their typical protocols and recommended treatments but are always willing to check out something new.

I think what happened with Rascal is 1) being older (17) things just don't move like they used to and 2) I had been giving her some Primal frozen raw rabbit cat food, which is one of the few things she can tolerate with her protein sensitivities besides her stupid prescription Royal Canin cans. I'm not thrilled with the Royal Canin for a number of reasons, but especially because of the higher carb content (pea flour). I don't think it's terrible, not compared to some or especially to dry kibble, but I know Rascal would be better off with even lower carbs.

As for the Primal raw, it has ground bone as its calcium source and, I believe, a mineral balance overall that might not be ideal for Rascal. I was told in the past on the IBDKitties forum that I should probably limit that one as it can be constipating for some cats. Something with eggshell for calcium might be better, I was told, but again there are SO few foods she can tolerate. She is enjoying a little of the Primal lately but that may be what stopped her up, so I have to back off as constipation can set off all sorts of nastiness and sometimes precedes a full blown IBD flare up with her. I may have to bite the bullet eventually and make homemade. That will be a big transition though, and if I do that we will have to go slow and really watch the BGs.