Dosage Advice?

Status
Not open for further replies.
JenCarpenter

JenCarpenter

Member Since 2015
Hi all! I posted some general questions over in the Feline Health forum and was hoping to get some more specific advice on increasing Peppin's dosage to help bring his numbers down.

Here's my story so far:

"Hello all! I'm new to the Feline Diabetes boards (I posted an introduction as well). I'm hoping to get some advice on my current situation - specifically from anyone who has experience working with cats who have diabetes and kidney issues and cats that are hard to regulate.

My 13-year-old cat, Peppin, was diagnosed with diabetes just over a month ago (around 5/20). He had blood work done and the vet found he had pancreatitis as well. He was prescribed Lantus insulin twice per day (6 a.m. and 6 p.m.) with the dosage depending on his blood sugar (for example, if his blood sugar was above 200 and he ate more than 50% of his food, he was given 2 units. If his blood sugar was below 200 or he ate less than 50% of his food, he was given 1 unit. If his blood sugar was below 100 he was not given any insulin). In addition, I have been doing home glucose monitoring with the AlphaTrak2 four times per day (at 6 a.m., 1 p.m., 6 p.m., and 9 p.m.).

About his food: he had always been given a diet of one Fancy Feast can per day and free-fed on dry Purina food. He used to love his canned food, so we tried to get him eating the EVO 95% turkey and chicken canned food. He ate that for a few days and then stopped eating, so I ordered the dry EVO turkey & chicken food, which he loved.

His progress seemed promising for the first couple of weeks. There were a couple of times where his blood sugar dropped too low (below 60), so we briefly tried to administer 1.5 units twice per day - this caused his blood sugar to remain too high so we went back to the previous method. Then his blood sugar started creeping up so we started giving 2 units twice per day - this worked for a week or so and then all of a sudden his blood sugar shot up (500+ at most readings).

At this point I took Peppin back into the vet and he had more blood work done. The vet found that his kidney (BUN?) was high now as well. I started doing sub-q fluids every other day, along with an antibiotic and Pepcid AC (the vet also prescribed a sub-q anti-inflammatory that stings, the name escapes me now, which he absolutely hated getting). He's not a big fan of the fluids, but I'm making it work. She also transitioned him to Hill's Prescription K/D dry food.

I've been giving the fluids, the medication, and the kidney diet for about a week now and his blood sugar readings are still consistently high. My vet's newest theory (she consulted with an internal medicine specialist as well as a human MD with specialty in diabetes patients with kidney problems) is that his liver is not able to process the larger amounts of insulin, so we've been giving him only 1 unit twice per day.

Other weird behaviors I've noticed lately: he's had some balance issues (which I know can come along with the diabetes and high blood sugar), not being able to jump all the way on the couch and falling off when he walks across it. He's also been laying in his litter box the last couple of days, just lounging there a couple times throughout the day. And he hasn't been grooming himself as well either.

I've trusted the vet up until now ... I feel like we've done test after test and all different types of insulin dosage with no positive outcomes. His blood sugar is worse now than it was in the beginning. I've taken him to the vet a handful of times, spent a significant amount of money for all the tests, and am wondering what else I can do to help him out. I'm tempted to give him more insulin (2-3) units this weekend when I can monitor how it will effect him, but I wanted to see if anyone else has experience with cats that have both diabetes and kidney issues? I don't want to give him more insulin if it's going to stress his kidneys, but I'd also like to see his blood sugar numbers come down.

Any advice is truly appreciated - thanks in advance!"
 
a short answer to you rlast comment is no, don't give him more insulin this weekend.

Let me back up and give you some information.

Lantus is a depot insulin - meaning that when you inject, some of it goes to work right away, some of it forms a precipitate in the body and sort-of slow releases. Think of it as being timed-released. That's the depot. The size of that depot is in relation to the size of the dose. So a large dose = a large depot and a small dose = a small depot.

When a dose is increased, the depot has to build to equalize with the larger dose. It can take 6 cycles (3 days) to see what a dose can really do with the blood sugar. When the dose is decreased, that larger depot can take as many as 6 cycles to deplete and equalize with the now smaller dose.

Because of how the depot works, Lantus works best to keep the dose steady for at least 3 days at a time. The way your vet suggested dosing is just right for the older insulins. Lantus just works differently. It's also not dosed based upon the preshot value, but instead upon how LOW the dose can make the cat's blood sugar go. So the most important number is, most of the time, in the middle of the cycle. The low point (nadir) can move around however, and isn't always at +6.

There are a few times when high numbers are not an indicator that the cat needs more insulin. I'm thinking those crazy highs 500+, that you got, where probably from your kitter having gotten into low numbers. Take a look at this link on New Dose Wonkiness, Failed Reductions and Bouncing. I want to point out the NDW and Bouncing parts to you - you probably are seeing those phenomena reflected in his tests.

We are not vets, so all of us depend on data (tests) to be able to help people. Can you get a spreadsheet up and going? It's our best tool! Everyone here uses one. Here is the link to the "New to the Group?" sticky - lots of good info there for you to start with and the part about the spreadsheet is at the beginning.

Dry food can cause a need for much larger doses of insulin. It's also hard on the kidneys because of its lack of moisture, so I'd encourage you to look at Dr. Lisa (a vet who posts on FDMB sometimes) site here. You're interested in the links on kidneys, diabetes, and transitioning a dry food addict to wet food. Low carb canned food or raw food can greatly reduce the burden on the diabetic cat's body.

For the meantime, as far as dose, would you get the spreadsheet up and filled in as best as you can? Just recreate times, doses and tests - your meter will hold some in memory. Include in the comments when he's eaten dry food. Dry food carbs can linger even a day after they've eaten them. We've had members do experiments and found that even 3 little pieces of crunchies can raise a cat's blood sugar hundreds of points. Cats are different in how they respond to carbs, but it's a heads-up for anyone. We can help you figure things out better about where you should go with the dose after seeing numbers in the spreadsheet.

Also put in the name of your spreadsheet your cat's name and AT, for Alpha Trak, if that's the meter you're using. Most of us use human glucometers because the strips are a fraction of the cost (like 1/4), reliable and our documents on FDMB are written for human meters. ATs test higher.

I don't want to overload you so I'll stop there. Take a look at the rest of the yellow stickies, just to get an idea of what's what. Here's a link that can help you find your way around: "Where Can I Find?"
 
JenCarpenter said:
the vet also prescribed a sub-q anti-inflammatory that stings, the name escapes me now, which he absolutely hated getting)
Click to expand...

I almost forgot I meant to ask about this. I'm not aware of any anti-inflammatories that are recommended for cats. What was it being given for? Would you find out what the name is of the drug that was given to him? If it's metacam, there is a black box warning on it for use in cats because it can cause kidney failure. Here's the link to the FDA announcement about that.

METACAM® Solution for Injection is approved for one-time use in cats before surgery to control postoperative pain and inflammation associated with orthopedic surgeries, spays, and neuters. In the United States, the safety and effectiveness of more than one dose of METACAM® Solution for Injection has not been shown in cats for any condition.​
 
JenCarpenter said:
Other weird behaviors I've noticed lately: he's had some balance issues (which I know can come along with the diabetes and high blood sugar), not being able to jump all the way on the couch and falling off when he walks across it.
Click to expand...

This sounds like diabetic neuropathy. One of the best things we use around here is Zobaline for cats. It can take a little while to see improvement, but we've seen it work miracles
 
@julie & punkin (ga) - Thanks for all your insight and the links - I will read them over. The vet and I had considered that the high numbers might be Symogi (sp?) but it has been pretty constant as of late. I did fill out the spreadsheet and linked to it in my signature. Also, the sq injection she had me give was for Cerenia - I stopped it after 3 doses as Peppin hated it.

@Chris & China - Thank you, I will check out Zobaline as well.
 
Ah, I'm glad it wasn't metacam. Cerenia is typically used for nausea, vomiting, although I think someone else did mention recently that it has some anti-inflammatory properties. It's safe for cats. You can give it orally as well.

Great job getting the spreadsheet up and going! That's really helpful.

Is he getting dry food regularly? If so, I think I'd put my energies towards getting him weaned off of it and onto canned low carb - I think those ugly blacks would disappear. He's got some weeks on the spreadsheet when he's in better numbers, even under 50. Was he eating dry food the entire time, or was he eating only low carb some of that time?
 
He was eating Fancy Feast the first few days I was giving insulin, then I switched to the EVO canned food, which he ate for a few days and then stopped, which I why I went back to the dry after that. I tried giving him the EVO canned again tonight, he had a few bites and then walked away. I think it may help if I try a different type of low-carb wet food.
 
One of the tricks on catinfo.org is to pulverize the dry food and sprinkle it over the canned food. That can entice many cats and doesn't take too much dry food.

It's more important that he keep eating than it is that it's low carb. So if it has to be dry, then it has to be dry. Then he'll just need enough insulin to work around the dry. It can take weeks to move a hard core dry addict to wet, but it's worth it.
 
If he likes the Fancy Feast, I'd switch him back to that! The "Classics" are low carb and if you add a little warm water to it to make a little "gravy" it'll add even more water...which is great for the kidneys!

The K/D is 27% carbs and all the Fancy Feasts are under 10% so it should make a big difference in his numbers to get him back on the low carb canned.

Just make sure you test when you lower the carbs....we've seen the diet change drop their numbers 200 points pretty quickly
 
I think I might still actually have some Fancy Feast from before, I'll have to see if it's the "Classics" type.

I'm curious based on his recent dosing and blood sugar levels, if I start the TR Protocol, should I start him at 1.25 units or 2.25 units? I'll have the luxury of working from home tomorrow and Friday afternoon, so it'd be a good time to test out a higher dosage, but then next week I'll be at work full days most days.
 
Since you're not starting new, we'd look at what he's got going on with his current dose and food and we could suggest something for you. The food has a huge impact on his blood sugar. If you think you can get him 100% on canned food, then I think I'd get that done first. Test a lot while you make that change so that if he drops low you know it.

The point you're looking for is 68 - you need to intervene at 68AT with high carb food. You don't have to intervene before that, but have the 68 in your mind.
 
So the Fancy Feast I have is the Gravy Lovers, not as low carb as the Classics but lower than the K/D Dry. I can go pickup some of the Classics can tomorrow and get him eating that while I can monitor him. Once he is back on the canned food, what would you start his dosage at? I was thinking keep it at 2, switch back to the canned and see what happens?
 
How much does Peppin weigh? The dose is 0.25 units per kilogram of lean weight.
What is Peppin's current weight?
What is Peppin's ideal weight?
Take the lower.
Convert pounds to kilos (pounds / 2.2)
Multiply by 0.25
Round down to the nearest quarter unit

Using 9.5 pounds, I get 1 unit.
 
That's kind of what I'm thinking too @BJM

Since she's still early in the dance, I think it might be helpful to start over on the correct dose by weight and see how it goes but I can make a pretty good argument for starting a little higher too

As long as you're going to lower the carbs, I think I'd probably start over. It'd be safer for Peppin, but let's see what others have to say
 
Hello and welcome from me too.

I'd actually avoid the Fancy Feast if you can find something else he'll eat. They are all pretty high in phosphorus, so not good options for kitties with kidney issues. Ann/Tess keeps a list of low carb/low phos food options in Tess's SS, although the Friskies special diet are being phased out. Neko is also watching her phosphorus now. I've also switched high carb food to something more phosphorus friendly. Weruva Grandma's Chicken Soup is what's I'm currently using, There are other options - check out the food list on Dr. Lisa's site that Julie pointed too. Or you can just add a drop of karo, syrup or honey to regular low carb food to turn it into something higher carb.
 
Hello and welcome to the group! Chris asked me to pop in to suggest a dose for tomorrow.

If you're switching Peppin to a low carb wet food immediately (stopping dry cold-turkey)... starting over at 1u BID is probably a good idea.

However, if it'll take time to transition him, I'd be inclined to shoot 1.75 units BID if you're available to monitor him carefully. My reasoning is it took 2u BID to drop him into double digits... so it just makes sense to give a little lower dose because of the impending switch to low carb food. His insulin requirements may drop quickly as he's switched over to low carb wet food so testing will become more important than ever.

Just my thoughts...
hope to see you posting often!


Edited to add:
Peppin can always be fast-tracked up the dosing scale if necessary. If you post often, experienced members will be able to help you with that.
 
As usual, Jill has an excellent suggestion on dosing. The only thing I would add is that it's important to test regularly for ketones when dropping the dose, especially since Peppin's numbers have been fairly high.

Good luck with the food transition. We've seen some cats make dramatic improvements once they've switched.
 
In case no one has mentioned how to test for ketones, you can purchase Ketostix at any pharmacy. You dip the end with the paper into your kitty's urine and then follow the instructions re. how long to wait. Then compare the color on the paper to the guide on the container. You want to see trace or less.

As you're reading through the sticky notes at the top of the board, please let us know if you have questions.
 
Changing the food to low carb canned or raw has dropped some cats glucose level anywhere from 100 to 300 mg/dL, depending on the amount of carbohydrate in the diet and the cat's sensitivity to it. This also has resulted in doseage drops from 1 - 2 units less. These numbers are based on various individual reports here.
 
Thank you everyone for your input, I really appreciate it! I gave Peppin 2 units last night and this morning and fed him the Fancy Feast Gravy Lovers so he would actually eat. I am headed to the pet store this afternoon to pickup some lower carb canned food and will start him on that tonight along with a dose of 1 (unless he has issues eating the canned food, then I will try the 1.75 dose and try mixing the dry and canned foods). I'll also get some ketone sticks asap. I'll post updates once I see how he does - thanks again!
 
One more question - would you guys recommend that I continue giving the sub-q fluids every other day? I know it helps to keep him hydrated, but he really doesn't enjoy it.
 
Fluids every day is best for them. If you are using the usual needles the vet provides (green cap, 18g), getting a smaller one will help him tolerate it better. We get 19 or 20g Terumos. I know they were phasing out their ultra thin wall which were the best, but I still see them as an option on Thriving Pets http://www.thrivingpets.com/index.php/terumo-needles-box-of-100.html It goes a little slower, but they are way more comfortable for the cat. Our Taz was insane when we first started and needed both of us to do it, sometimes we took her to the vet's for the techs to get it done. Now she purrs and eats treats and I often do them by myself.

Make sure you are getting Lactacted Ringers vs Normosol. With the shortage of Lactacted Ringers my vet tried switching Taz to the Normosol and we noticed the difference in her comfort level immediately. I suspect a few vets may be trying that switch tactic. Normosol is known to sting and only needed in cats with calcium problems too.

Are you using a phosphorus binder? With the diabetes and the need to keep the carbs down, I'd get a binder. That way you don't have to worry as much about that part of the balancing act.

Watering down the pate foods might encourage Peppin to eat it thinking he is getting gravy and it will help with the fluid intake for the CKD.

eta: If your vet wants you to give Cerenia again, there is no reason to give a painful injection. Ask for the pill, you give 1/4 tablet per dose and its got to be cheaper too. Cerenia will probably be something you give on occasion with CKD since it does come with bouts of nausea and vomiting and you really want to make sure they keep eating.
 
Last edited:
Hi Jen! Just checking to see how Peppin's doing today? How's the food transitioning going? I'm stalking his spreadsheet ;) and just wondering if he's out of those black numbers yet today.

We gave punkin subq fluids every other day and gave them while he was eating, 3 hours after his shot. He would tolerate them ok as long as the food lasted, so we watered it down a lot to make it last longer.

Hope today is better!
 
@Melanie and Smokey - I'm not sure what a phosphorous binder is? And thanks for the tip, I will definitely ask for the Cerenia pills if she recommends them again.

@Julie & Aztec (GA) - Thanks for checking in! Peppin has had two readings so far today (600s and 400s), his next will be in an hour and a half. I picked up some of the Fancy Feast classic (Petco didn't have much of a selection, I plan on trying a couple other low carb/low phos types if I can find them online or at a specialty pet store). My pet sitter is actually coming over this evening as well to show me how she gives fluids, in case I can learn any tips. She also has some smaller gauge needles which I think will help :)
 
One of the newer foods we've been seeing a lot around the message board that's both low carb and low phosphorus is Mauri . The kangaroo has been a big hit with lots of kitties!

The bad part is it's kind of expensive and so far kind of hard to find. Those of us that have found it have only seen it at specialty food stores (so no PetsMart/PetCo)
 
I think typically you don't begin using phosphorus binders until levels reach a certain point - I'm unsure what that is, but Punkin had chronic kidney disease as well - many diabetic cats do - and we never got to the point of needing binders. I switched him to low phos foods and his lab tests moved back into normal range, just from the food switch.

We used the list on Dr. Lisa's site for low phos foods. I printed it out, looked at everything that had phos less than 200, and carbs less than 8% or so. Circled everything that met those 2 criteria, then I went shopping and bought a can of each thing I could find at about 3-4 stores. We settled on Friskies Special Diet Turkey and Giblets, which everybody liked. I understand it's not going to be made anymore now, however. I think there were about 10 foods that met the criteria, though, so you should have several to try from.
 
I see Chris & China covered what the phosphorus binder was. I wouldn't really recommend feeding Fancy Feast to a kidney cat on a regular basis without a binder, even if a cat hasn't went over the normal levels of phosphorus. Phosphorus is really hard for unhealthy kidneys to deal with and FF is one of the worst foods out there for phosphorus. You run into that balance of getting them to eat and making sure treating for one disease does not worsen another.

I'll have to check for Mauri next time I am picking my Stella & Chewy's. Not sure I can get mine to venture into Kangaroo thougho_O
 
I was shocked when punkin's diagnosis came back and I looked at Dr. Lisa's lists - we'd given him fancy feast classics and they are practically the worst for high phosphorus. I suspect that's one reason his lab values went back into normal range after we switched his food to low phos - the switch was from very high phos to low phos.
 
When you started, it looks like 2 units sent him into greens, and at that time, you were feeding low carb, right? So hopefully he'll respond really well to the new low carb food too!
 
Phosphorus binders shouldn't be used until the phosphorus is six or over unless he was higher but dropped back down.

If you can post his labs. It would be easier to help.
 
Peppin's numbers have been fantastic today! 298 this morning, 98 at lunch, and 389 this evening! I am really encouraged with the results I'm getting :) Quick question - I had been using 29 gauge needles and accidentally bought 31 gauge (quite a bit shorter) - has anyone had luck using these shorter needles? I gave the insulin with them this evening and the needle went through, but I felt like I could smell insulin on his fur afterward. I know it's not safe to double dose so I didn't, just curious if any of you have experience with these?

Thanks!
 
Gauge and needle length are two different things....Most of us use 30 or 31 gauge needles because they are so tiny....with gauge, the smaller the number, the bigger the "hole" they make....if you're doing something like giving fluids (where you need to give a lot), you'd use smaller gauge needles (like 22) so the liquid would flow though faster and get into the cat.

Needle lengths are usually either 8mm (5/16") or 1/2" (1/2" are longer)....I think most of us use the 8mm unless we have a lot of furshots with them or have cats with really long hair

What I've found works better with China is to grab her fur with my thumb and forefinger and then "roll" my wrist to pull up on her skin and when I see a little strip of skin, I shoot (instead of doing the "tent" you see on a lot of video's and a lot of vets will show you) It's something you just have to get used to.
china skin (Custom).jpg
(not a great picture, but hopefully you'll get the idea)
 
@Chris & China Ah, yes, the first set of needles I was using were 1/2" and the new ones are 5/16", so that would be the big difference. I injected this morning using the method you suggested and it seemed to work much better - thanks for the tip!
 
Quick question - when you are considering whether or not to increase the initial dose after 5-7 days, do you take the average of all nadirs?
 
No - your most important numbers are the lowest. You want to always assess "how low can this dose make my cat's blood sugar go?"

In your case I would stay with the 1.0u for the moment. Resist bouncing back and forth to 2.0u when you see higher numbers. It makes it hard to assess the dose. The 2.0u dose is still influencing the blood sugar today and likely contributed to the 98. Here's what I wrote about it above. Just stick with the 1.0u for at least 6 consecutive cycles, and then you can evaluate what it does. I'd encourage you to post here and ask for help before you increase the dose. Someone can help you "see" if you are looking at bounce numbers, or if Peppin really needs a dose increase.


julie & punkin (ga) said:
Lantus is a depot insulin - meaning that when you inject, some of it goes to work right away, some of it forms a precipitate in the body and sort-of slow releases. Think of it as being timed-released. That's the depot. The size of that depot is in relation to the size of the dose. So a large dose = a large depot and a small dose = a small depot.

When a dose is increased, the depot has to build to equalize with the larger dose. It can take 6 cycles (3 days) to see what a dose can really do with the blood sugar. When the dose is decreased, that larger depot can take as many as 6 cycles to deplete and equalize with the now smaller dose.

Because of how the depot works, Lantus works best to keep the dose steady for at least 3 days at a time. The way your vet suggested dosing is just right for the older insulins. Lantus just works differently. It's also not dosed based upon the preshot value, but instead upon how LOW the dose can make the cat's blood sugar go. So the most important number is, most of the time, in the middle of the cycle. The low point (nadir) can move around however, and isn't always at +6.

There are a few times when high numbers are not an indicator that the cat needs more insulin. I'm thinking those crazy highs 500+, that you got, where probably from your kitter having gotten into low numbers. Take a look at this link on New Dose Wonkiness, Failed Reductions and Bouncing. I want to point out the NDW and Bouncing parts to you - you probably are seeing those phenomena reflected in his tests.
Click to expand...


Here is a post on Testing & Shooting Tips that has more on the shooting technique that Chris is talking about. The one thing to watch for - I helped someone locally who was using that and she had the needle so close under the surface that I could see it while it was in. You need to get it in far enough - i just pulled up a hunk of fur (like a handful) and shot close to the body. It never failed for me.

Doesn't matter if you use a short or longer needle - both work. I used both and you do tend to get used to whatever you're mostly using.

Great job getting tests in both the am and pm cycles! That really helps to see the picture of what's going on!
 
If you are ever wondering about whether to increase, feel free to post the question here by starting a new post. We like to start a new thread each time, with a link to the old one, as they can otherwise get quite long. I see green the SS today - looking good!

When considering whether to increase, we ask the question "how low can the cat go on this dose", so we take the lowest nadirs into consideration. Bounces cycles can be ignored.
 
Status
Not open for further replies.
Back
Top