Cat's numbers falling sharply (instead of gradually)

[MisterBee]

Pigpen was diagnosed two months ago and started on ProZinc. Her numbers have been good and bad (more bad than good, some just awful), but that changed suddenly ten days ago after she came home after being hospitalized for constipation and dental work.

Because of this, I had to switch her over to wet food from Hill's m/d dry (which I'd been resisting doing, even though people here had advised me to do just that). Well, they were right -- since the day after I started her on 4 to 5% carb wet foods (a couple of Fancy Feast pates), the numbers have notably improved -- lots more yellows and blues, even as I've lowered her dosage.

But during these two months, one thing that worries me from time to time are these sudden "plummets" of 100 or more an hour in her number when the number gets close to, or into, double-digits. Here's an example. Two nights ago I gave her the usual 1 unit dose with a shot time reading of 247 (lower than usual). The number fell gradually during hour 3 and 4 to 149 as the ProZinc kicked in and levelled off for about 45 minutes. And then the bottom just seemed to fall out -- from 149 to 81 in the next 40 minutes, 25 of that in the last 15 minutes. Whenever this happens, I always get a bit scared and think the same thing -- how much farther will it go down? 60? 50? 40? How much (or how little) time do I have before this could become an emergency? She'd had a good-sized shot meal and a snack an hour before this happened, but I gave her a snack again and the numbers soon bounced back up, quite a bit.

Tonight, something like that again -- a slow decline, and then suddenly downward by 54 in 25 minutes between hour 6 and 7, from 219 to 165, for no obvious reason. Of course I *want* 100s, but I just don't like her BG getting there so abruptly, you know?

My questions -- (1) Is this a ProZinc thing, or is it typical of insulin in general? (2) Is it something to be concerned about? and (3) When a number sharply falls into the low 80s, is that the time to start trying to bring it back up, or should I wait and see if it gets into the 50s or 60s first?

Thanks for any help!

 

[FrostD]

I'm going to tag @Deb & Wink and @JanetNJ

You have a ton of data, great!

What you're seeing is normal, especially for an in and out insulin like ProZinc. If a cat is sort of grazing, food will keep the BG flatter or slower drops. If he happens to not eat for a bit,you may see a sharper drop. Sometimes it just drops some days.

You're following SLGS, so I'm not sure what the intervention guideline is for that, one of the other ladies can chime in. But those of us following the more aggressive methods generally don't intervene unless we see a steep drop early in the cycle, or numbers in the 50s/60s on a human meter.

What I do want to understand is your notes in the Remarks column that you're delaying shots by several hours for low/falling numbers...nothing in your spreadsheet indicates to me that was necessary. Using today as an example, 221, 217, and 213 are basically the same number when you factor in meter variance. Do you know how to notate tests for delayed shots in the spreadsheet?

Let's use today's AM cycle as an example. Starting at +8, what tests did you take and at what time? What tests did you take while stalling? For example, if you took a test 2 hrs after what should have been shot time, that would be called +14.

 

[Chris & China (GA)]

You can sure tell you have a Libre! While it's perfectly fine to scan every hour, it's not necessary. You must stay glued to Pigpen to scan him that much!

What concerns me is the remarks about stalling. When you stall for 4 hours (like you said you did tonight), that means you'd need to adjust tomorrow morning's shot time by at least 3 1/2 hours. So if (example) your usual shot time is 6am/6pm and you stalled until 10pm, then tomorrow morning's AM shot shouldn't be given earlier than 9:30am.

When you stall, you can work your way back to your chosen shot times by adjusting 15 minutes per cycle or 30 minutes per day. To make up 4 hours would take 8 days before you'd be back to your "chosen" shot time. Remember, the shots need to be 12 hours apart no matter when you give them.

 

[MisterBee]

I'm going to tag @Deb & Wink and @JanetNJ

You have a ton of data, great!

What you're seeing is normal, especially for an in and out insulin like ProZinc. If a cat is sort of grazing, food will keep the BG flatter or slower drops. If he happens to not eat for a bit,you may see a sharper drop. Sometimes it just drops some days.

You're following SLGS, so I'm not sure what the intervention guideline is for that, one of the other ladies can chime in. But those of us following the more aggressive methods generally don't intervene unless we see a steep drop early in the cycle, or numbers in the 50s/60s on a human meter.

What I do want to understand is your notes in the Remarks column that you're delaying shots by several hours for low/falling numbers...nothing in your spreadsheet indicates to me that was necessary. Using today as an example, 221, 217, and 213 are basically the same number when you factor in meter variance. Do you know how to notate tests for delayed shots in the spreadsheet?

Let's use today's AM cycle as an example. Starting at +8, what tests did you take and at what time? What tests did you take while stalling? For example, if you took a test 2 hrs after what should have been shot time, that would be called +14.

Thanks for the comment! (1) I was going by the FAQ here (specifically Q4.4) on when to shoot or not to, plus my own vet's advice and my experience, specifically with shooting into a falling number and shooting below 250. I didn't have room to completely explain the other circumstance in the four-hour delay -- when I first postponed the shot I fed her anyway (hard to resist a begging cat), and when I felt ready to give the shot, she looked at her supplemental meal and said, "No thanks." So it took a while longer.

No, I didn't know how to notate tests for delayed shots, thanks for the info.

 

[MisterBee]

You can sure tell you have a Libre! While it's perfectly fine to scan every hour, it's not necessary. You must stay glued to Pigpen to scan him that much!

What concerns me is the remarks about stalling. When you stall for 4 hours (like you said you did tonight), that means you'd need to adjust tomorrow morning's shot time by at least 3 1/2 hours. So if (example) your usual shot time is 6am/6pm and you stalled until 10pm, then tomorrow morning's AM shot shouldn't be given earlier than 9:30am.

When you stall, you can work your way back to your chosen shot times by adjusting 15 minutes per cycle or 30 minutes per day. To make up 4 hours would take 8 days before you'd be back to your "chosen" shot time. Remember, the shots need to be 12 hours apart no matter when you give them.

Actually, much of the FreeStyle data on my spreadsheet comes from the readings taken automatically every 15 minutes by the sensor, which I access via Tidepool. I only scan occasionally except when I'm monitoring a steep drop or when it gets close to double-digits. (And she likes to sleep on a box next to my computer table, so when I'm seated here I literally just have to stick out my arm to get a number!)

Yes, I keep the shots 12 hours apart, but it seems also like stalling a shot tends to make the insulin less effective over the next one or two cycles. Thus, I'm mulling whether to maybe just try to stick to a strict 12-hour schedule and give a reduced dose if the pre-shot number doesn't come up high enough.

 

[Deb & Wink]

What pre- shot number are you using for your decision point BG number?

Looking at the SS, I’m not seeing any pre-shot tests that indicate you should have stalled. You have a ton of data. Any BG > 200 is shootable. Even a BG of >150 is likely shootable, considering the wealth of data you have.

Prozinc is a bit more forgiving on the shot times, as compared to the depot type insulin’s. So a 1 hour delay can still be fine for shooting the insulin at your regular shot time the next cycle.

 

[MisterBee]

What pre- shot number are you using for your decision point BG number?

Looking at the SS, I’m not seeing any pre-shot tests that indicate you should have stalled. You have a ton of data. Any BG > 200 is shootable. Even a BG of >150 is likely shootable, considering the wealth of data you have.

Prozinc is a bit more forgiving on the shot times, as compared to the depot type insulin’s. So a 1 hour delay can still be fine for shooting the insulin at your regular shot time the next cycle.

My rule of thumb has been to shoot at a minimum of about 250 with clear indications that the number is rising. (I shot once into a falling number that was still pretty high (355), went to bed and set my alarm, checked on the cat five hours later, and she was at 59.)

But then on Thursday PM the number at her normal shot time was 187. An hour later it was 198. An hour after that it was 193. Following the advice in Q4.4 of the FAQ, I opted to wait. Finally, three and a half hours after the normal shot time, I shot at 247 with the number rising. And by hour 5 the number was at 81 after falling sharply over a 45-minute period, as I explained in the initial post.

That bothers me. I'm a worry-wart about such things. When I see a double-digit number that's been falling sharply, I get scared. Scared to the point where I get a lot more cautious than I probably should. But then when I read things about how "hypos can kill!", I just want to avoid anything close to that whole territory, you know? I don't want to feel like I'm playing Russian roulette when I'm preparing her insulin.

So I guess maybe I'm aiming for a looser regulation, with the nadirs between low or mid-100s, rising to no more than about 300.

This might have gotten a bit complicated by two things -- (1) ProZinc seems to be less predictable if you don't shoot the same dose on a consistent 12-hour schedule, and (2) since Pigpen went on a wet food diet, the ProZinc seems to linger a bit longer, sometimes beyond hour 12, into hours 13 or 14, which makes it harder to shoot on a 12-hour schedule.

(Postscript -- Early Sunday morning I tried something else suggested in Q4.4 of the FAQ -- when the number just before shot time came up a bit lower than I felt good about and not rising (227), I decided to give a half-dose (one-half unit), thinking I'd probably just end up with 300s and 200s during the cycle. (The "262" AMPS on the spreadsheet was very likely tainted, from what I've read here, by the fact that I fed her part of her shot meal a half-hour before the shot -- because she was hungry and raising the roof about it). To my surprise, I got good results for much of the cycle, albeit with a big bounce at the end, up to 417 for the PMPS. This is more like what I'd like to try and accomplish, except of course for the big bounce.)

Sorry to drone on like this, but this is what's behind the questions I asked in the initial post.

 

[FarmKitty]

It is great that Pigpen is trending down after the dental work! Love those yellow preshots!! I found the same thing happened with Dixie (wish she had the dental done sooner!)

But during these two months, one thing that worries me from time to time are these sudden "plummets" of 100 or more an hour in her number when the number gets close to, or into, double-digits. Here's an example. Two nights ago I gave her the usual 1 unit dose with a shot time reading of 247 (lower than usual). The number fell gradually during hour 3 and 4 to 149 as the ProZinc kicked in and levelled off for about 45 minutes. And then the bottom just seemed to fall out -- from 149 to 81 in the next 40 minutes, 25 of that in the last 15 minutes. Whenever this happens, I always get a bit scared and think the same thing -- how much farther will it go down? 60? 50? 40? How much (or how little) time do I have before this could become an emergency? She'd had a good-sized shot meal and a snack an hour before this happened, but I gave her a snack again and the numbers soon bounced back up, quite a bit.

Not sure if this helps or not, but when I had Dixie on ProZinc, she would drop down a lot, even going 190 -> 65 in 2 hours. Like you, I was also concerned thinking that she would continue that trend and keep dropping, but it seems like as the numbers get lower, they drop a lot less. So once she hit those greens, she would just sorta stay there. If her pre-shot was higher, then she would drop more, but if it was lower (in the greens) then she would drop less (both on the same dose).

When a number sharply falls into the low 80s, is that the time to start trying to bring it back up, or should I wait and see if it gets into the 50s or 60s first?

Each cat will react differently to this, so the only way you can try this out is just by gradually shooting him with lower pre-shots and being awake and checking on Pigpen during his nadir time, but don't intervene unless he gets into that 40-60 range, where you can then follow the hypo emergency guidelines. Make sure you have medium carb and high carb food on hand, as well as some corn syrup. But even then, this does not mean he is immediately having a hypo as soon as he hits 60. I have had Dixie below 50 quite a few times with no symptoms, and it wasn't the end of the world. But I get that it can feel very scary and intense the first few times it happens! You will need to figure out what is right for your cat. If he does get below 90, just follow the SLGS protocol and reduce his next dose.

Early Sunday morning I tried something else suggested in Q4.4 of the FAQ -- when the number just before shot time came up a bit lower than I felt good about and not rising (227), I decided to give a half-dose (one-half unit), thinking I'd probably just end up with 300s and 200s during the cycle.

I think it is great that you decided to go for that half-dose. I was doing the same thing and it gave me a lot more courage to lower my pre-shot BG decision point. I also prefer this method much more instead of stalling, because it keeps you on schedule and builds up confidence in shooting the insulin. When I started this journey, I never ever thought I would be giving insulin shots when seeing a green pre-shot value, but now I get to do that most days (fingers-crossed!)

The "262" AMPS on the spreadsheet was very likely tainted, from what I've read here, by the fact that I fed her part of her shot meal a half-hour before the shot -- because she was hungry and raising the roof about it

You are right that the food can/will raise their BG levels, so when you are still in the process of figuring things out (and especially with new food) you want to remove food 2 hours before the PS test. Don't give into the cat! Although, I definitely know how hungry an unregulated diabetic cat can be... but just remember, the best cure for their hunger is regulating their diabetes!

Is this a ProZinc thing, or is it typical of insulin in general

I had Dixie on ProZinc for about 10 months and have recently switched to Lantus. I found that my preshot values were higher with the ProZinc, but then it would drop her down very well throughout the day. I couldn't really increase her dose because the ProZinc was so effective at lowering her BG levels. With all the data that I had gathered, I made the decision to switch to Lantus which gives a smaller drop. Now, I can shoot her when her preshots values are lower. All the data you are gathering now will help you in the future decide if ProZinc is working, or if another insulin would work better. But you are in the information gathering stage!

So I guess maybe I'm aiming for a looser regulation, with the nadirs between low or mid-100s, rising to no more than about 300.

Just curious why you are aiming for such loose regulation? Is it because you are unable to be around to monitor him? When Dixie was in the 200-300 range she was consistently peeing out glucose, so she was over the renal threshold. Not a place I want her to be! If PigPen is ok with you sticking a test strip under his butt when he pees, then you can also check this yourself at home. Otherwise, you will probably get this test result if you do a urinalysis at the vet.

PS. If it makes you feel any better, lots of people do not daily test like us and their cats are fine. I find that sometimes all this extra data we get can create more fear. Try to think of the BG data as more of a way to enhance PigPen's recovery! You will never feel 100% comfortable when seeing these lower values for the first time... you basically just gotta balance your feelings and the knowledge you get from the site (very hard.. I know )

 

[Deb & Wink]

The section 4.4 of the FAQ’s you are quoting, is outdated. Please refer to the Prozinc Dosing Methods sticky thread document in the Prozinc ISG group. That document was updated in February 2020 and is much more current than the FAQ’s document you refer to.

You still dose on a 12 hour schedule, even if you think the dose is lasting longer than 12 hours. Not seeing that happening the longer duration,, at least not according to your SS.

Test, feed, shoot cycle should all be done within about 15 minutes or less. No need to wait 30 minutes between the preshot test and giving the insulin.

 

[Sienne and Gabby (GA)]

An observation:

But then on Thursday PM the number at her normal shot time was 187. An hour later it was 198. An hour after that it was 193.

Those really aren't dropping numbers. There's a 20% variance in any test number due to the inherent "error" in a meter, strip, etc. Those tests are actually pretty much the same number and didn't warrant stalling.

Also, it may help to keep in mind that normal blood glucose (BG) range is 50 - 120. Most people crave those low blue and green numbers. In fact, you want to see them in order to be able to reduce the dose of insulin. However, it takes a bit of getting used to lower numbers and developing your confidence in steering the cycle with higher carb food (if necessary). Ultimately, you will want to be able to shoot lower numbers. With many of the longer duration insulins, shooting in the lower range means a flatter cycle. It's totally counterintuitive but it happens. It may be helpful to look at spreadsheets. You'll find Prozinc spreadsheets on the Prozinc board. (There are a lot of Prozinc users that post here on Health.. It's just easier to identify them on the specific insulin group.)

 

[Diane Tyler's Mom GA]

Might be a good idea to set up your signature, it's at the end of everyone's post in gray

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