Dosing advice please

[Alfred's Human]

Hello,

I've been struggling with Alfred's pancreatitis for the last month. He's finally seeming better (fingers crossed) and his appetite has been pretty stable lately.

However, his numbers have been awful. Advice on dosing would be much appreciated. I feel like I'm totally messing this up and doing a terrible job. I get way too emotional about it and seem to keep making poor choices.

His spreadsheet is up to date.

The last two nights I haven't given him insulin because he was lower than I'm comfortable shooting. His nadir seems to be really late in the cycle and it's confusing me as to what to do. He seems to either he high and flat all day or have this late nadir which screws up the whole time table.

Looking back at the spread sheet it doesn't seem like much time ... but mentally and physically it feels like I've been doing this for soooo long and not getting anywhere.

 

[Yong & Maury GA]

Hi Alfred's human!
How have you been treating his pancreatitis? What meds, how often, etc? How is he acting?

One thing I think I see in his SS is that more than 2.75U looks like too much and less than 2.0U is too little. A couple patterns with those <200 PS numbers that you've skipped, but stalled (good thing to do and can be done in 20 minute increments which can make the actual shot up to an hour late), is that he rises most of the time. That's a key to starting to give shots on <200 PS readings. So you could try a reduced dose on those occasions if you will be around to monitor.

When a PS is much lower than the previous, with Prozinc, it can mean the dose is too high and then the next few cycles you see are high and flat, which is possibly his form of "bouncing". Bouncing can take an average of 3-6 cycles to clear (to really show you what a dose is doing). My boy was bouncy on Prozinc so he took longer than 6 cycles some times. Even now, he does better if I hold a dose longer than the protocols call for.

You've made better progress in these 2 months than my boy did starting off . One thing to keep in mind with insulin is that if he is higher, it doesn't mean giving more will help. It's not traditional medicine, insulin is a hormone. I know we hate seeing those high numbers, but try to get some consistent dosing, meaning minor adjustments to the dose to help you get 2 shootable numbers for PS's. I see some lower end nice greens in his nadirs and you're testing for ketones often so *I think* you could try to go back to 2.25U for a bit.

Also, as the pancreatitis starts to calm down you'll probably get a better idea of his working dose. Said working dose can still change though, so I don't refer to it as a "perfect dose".

And lastly, I know it's very difficult sometimes to not get emotional but try to stay calm. I am not able to be around as much as I used to but there are a few other Prozinc members who may chime in too. @Djamila @Kris & Teasel @Rachel .

My apologies if this post is not highly organized, it's kind of late and I am very tired but I'm staying awake for my boy . Best of luck with Alfred. I will try to check in tomorrow if you need clarification on anything I've said.

*Please keep in mind, this is just my opinion. I am not a professional*

 

[Djamila]

Hello,

I've been struggling with Alfred's pancreatitis for the last month. He's finally seeming better (fingers crossed) and his appetite has been pretty stable lately.

However, his numbers have been awful. Advice on dosing would be much appreciated. I feel like I'm totally messing this up and doing a terrible job. I get way too emotional about it and seem to keep making poor choices.

His spreadsheet is up to date.

The last two nights I haven't given him insulin because he was lower than I'm comfortable shooting. His nadir seems to be really late in the cycle and it's confusing me as to what to do. He seems to either he high and flat all day or have this late nadir which screws up the whole time table.

Looking back at the spread sheet it doesn't seem like much time ... but mentally and physically it feels like I've been doing this for soooo long and not getting anywhere.

First of all, you aren't messing this up, nor doing a terrible job! This sugar dance can be confusing, and since the kitties are the only ones who can hear the music, we are usually a step or two behind them. We all just do the best we can do at any given time, and Alfred isn't exactly making this easy for you!

I'm glad to hear his pancreatitis seems to be settling down. Hopefully he'll continue to get better.

As Yong mentioned, sometimes a very late nadir means a bit too much insulin. And other times it just gives you an opportunity to grab hold of a lower than normal number and get a better than usual nadir. The only way to know is to give insulin and then grab a couple of mid-cycle tests. If that is too anxiety inducing, there are two other options. One is to slighly lower the AM dose so that the PM pre-shot number is higher. I don't love doing that because it looks like he needs the insulin right now. The other option is to give a reduced dose. If you give a reduced dose, and then get a mid-cycle test around +3 or +4, you'll most likely see that Alfred is rising. Then the next time, it happens you can give a bit more. And as you collect data, you'll learn if it's okay to shoot on those lower numbers and gain confidence in doing so.

I would not suggest going back to 2.25u, although I do agree with Yong that the steadier you can hold the dose, the better. Moving the dose around frequently can sometimes make the numbers do strange things, which can then make it hard to be consistent. So maybe try 3 or 3.25 for several cycles and see if that helps him settle down a bit.

I'm also wondering about any other health problems that might be keeping his numbers elevated? When was his last dental exam? Blood work?

 

[Kris & Teasel]

You've been given good advice from Yong and Djamila. I agree with the importance of finding a workable dose and holding it steady there for a few days. Too much dose tweaking makes a bouncy cat like your boy even more volatile. This FD thing can be very hard if your cat doesn't follow the rule book.

 

[Alfred's Human]

Thank you all so much for your replies.

Hi Alfred's human!
How have you been treating his pancreatitis? What meds, how often, etc? How is he acting?

One thing I think I see in his SS is that more than 2.75U looks like too much and less than 2.0U is too little. A couple patterns with those <200 PS numbers that you've skipped, but stalled (good thing to do and can be done in 20 minute increments which can make the actual shot up to an hour late), is that he rises most of the time. That's a key to starting to give shots on <200 PS readings. So you could try a reduced dose on those occasions if you will be around to monitor.

When a PS is much lower than the previous, with Prozinc, it can mean the dose is too high and then the next few cycles you see are high and flat, which is possibly his form of "bouncing". Bouncing can take an average of 3-6 cycles to clear (to really show you what a dose is doing). My boy was bouncy on Prozinc so he took longer than 6 cycles some times. Even now, he does better if I hold a dose longer than the protocols call for.

I'm treating his pancreatitis with ondansetron for nausea and buprenorphine for pain. I'm currently just giving them as needed. The pain medication seems to be the key to keeping him eating. I'm giving it to him once a day now so I can try to stretch out my supply for as long as I can. He's also got pretty bad arthritis in his right hip and lower spine which seems to be bothering him a lot as well.

I've tried Cosequin for his arthritis. Was giving it to him twice a day for 3 months and it didn't seem to do anything. He still limped, so I've stopped giving that.

He's got a lot of issues, he's got a weird heart rhythm, early kidney disease, pancreatitis and diabetes. Overall he seems to be feeling pretty well lately. If I keep his pain under control he seems to be a lot happier and eats much better. I try to give him sub q fluids 2 - 3 times a week for the kidney stuff but I'm not always great about doing that. I was trying to keep his phosphorus in the food under 200 but he won't eat those foods so he gets what he'll eat.

I hope your kitty is doing well and he had a good night and gave you good numbers last night!

First of all, you aren't messing this up, nor doing a terrible job! This sugar dance can be confusing, and since the kitties are the only ones who can hear the music, we are usually a step or two behind them. We all just do the best we can do at any given time, and Alfred isn't exactly making this easy for you!

I'm glad to hear his pancreatitis seems to be settling down. Hopefully he'll continue to get better.
[...]
I'm also wondering about any other health problems that might be keeping his numbers elevated? When was his last dental exam? Blood work?

I've been wondering about his teeth as well, but unfortunately I don't think he can have a dental again. With his weird heart thing the vet is hesitant to put him under. I get him an anesthesia free dental (they just scrape the surface tartar off) once a year. He had that done in September. He did have a full dental at the vet three years ago and didn't have any extractions or issues then. Since then I've done the anesthesia free cleaning once a year and the hygienist has said everything looks good, but they aren't doing x-rays etc. Next time he's at the vet I'll bring it up.

His last blood test was high for kidney values and the pancreatitis test. He was not feeling well when I took him in that time and hadn't been eating so he was in a rough place. I was planning on getting everything settled down and then getting him in again to get bloods drawn. I want to keep a closer eye on the kidney values since I've been bad about dealing with that issue given the pancreatitis flare up and just needing to get him to eat anything so i can shoot insulin.



I decided to go with 3 units and will hopefully get a shootable number tonight so I can hold that dose and see what happens. My husband is off work all this week so he can test for me in the afternoons. His AMPS was 526. I expected it to be high since I skipped last night.


Thank you all so much for your advice!! I hope all your kitties are doing well and their numbers are nice and blue and green!!