Eve (UK) 10 May 23 - RE: #36 GENERAL QUESTION - INSULIN CHANGE (previously: vet + weird bounce)

[.:. in.active .:.]

Hello everyone, I have been lurking around for the past 2 months (since diagnosis) and even after joining, I was (and still am a bit) reluctant on posting, taking up a whole thread to introduce ourselves, given that 1) all important matters seem to be covered on the site (although some, more specific ones are very hard to find, due to the astronomical amount of information provided) and I don't want to be 'that person' who asks something that has already been chewed to the bone and should be obvious and 2) my issues may be too specific, trivial and/or irrelevant to a lot of other members, which makes me feel somehow guilty for taking up space in the form of an entire thread.

Anyways, here goes in a nutshell:
First and foremost: We are in the UK. I have three cats, all with their own issues, but this is about the middle guy. He is turning 10yo in less than a couple of weeks, a black and white used-to-be stray gay boy, who's very loving and "beta". He is the kindest, cutest baby boy, ever. Meet Rorschach (as the projective psychological inkblot test). [Others are PuddyKat (12yo black alpha female) and Scrooge (8yo white alpha male) - when I said Rorschach is the middle guy, I truly meant it, in every aspect.]

Dx: 21st March 2023 (two weeks after symptoms started - I hoped I caught it early, but numbers say otherwise)
SLGS: Caninsulin
Vet: PDSA weekly/bi-weekly
Monitor: AlphaTRAK 2.0
Food: 2x wet feed (Felix ~10% carbs for now), dry for grazing (Kattovit diabetic - hardly touches it, mainly left out for the other two) and post-BG prick treats (shrimp or tuna... have been giving him Lick-e-Lix until today, when realised it's actually a high carb snack)

Here is what bothers me/need opinion on, preferably sooner rather than later, as we have a vet appointment at 14:00 GMT tomorrow.

Home Testing:
As you can see from my spreadsheet, I hardly test PS. There are various reasons for that, one being the vet's advice ("if you feel the need to do so, just do it at the 6th hour, the other times are just uselessly stressing him out, for no reason"), other both his behaviour and my mindset/capability at those times.
However, I have a reoccurring phenomenon, namely that I would test him at a certain time during the day (time X), then catch him grazing (not much, just a few mouthfuls) and afterwards when I test him again at X+1 his BG would be lower. First I thought it was a one off outlier, but it has happened a few times now, and I'm not sure what to make of it? Testing time X varies so I can't pinpoint it to being close to his NADIR either.

Vet and Insulin:
I have the (low income) luxury of being qualified for free pet healthcare via PDSA (government funded, donation based veterinary service in the UK), which includes free of charge visits (normally £50+/check-up with private vets) as well as free insulin and needles. I am eternally grateful for this opportunity, however, some things don't sit well with me, but I feel like it'd be too entitled of me to "complain" about these. Given the nature of this organisation, we tend to see different vets on every visit, and although they do have access to my boy's records, I feel like the visits are always rushed. So far we have been:

- Not informed/briefed in detail on certain matters
- Given inconsistent and/or contradictory advice by different vets
- Given outright wrong advice/instructions by the vet (which I have followed through regardless, leading my boy into DKA)
- Told not to home test, not for BG nor for ketones ("you can, but it's not like you're allowed to change the dose without us seeing him anyway") and
- Constantly getting the topic of changing his insulin diverted​

Again, these people do not benefit financially from seeing us weekly, so why not advocate for home testing?
I've also just learned (although from a post from 2015-updated 2020) that the slower acting Prozinc was supposed to be prescribed for newly diagnosed patients, not Caninsulin. (I'm assuming the latter is cheaper for them to just give out.) It angers me, especially since I have asked them about slower acting insulin consistently for the past 4 weeks, and was always shooed away, with "Once he's stabilised, you can request those from a private vet based on our data" and "PDSA only has a certain list of insulins we can use, will ask the manager and get back to you" (cue: they never did). I'm wary about once my boy is regulated, they'll hit me with the "But he is fine, no point messing with it now" ... I want him in remission, and they know it.

Vet and Numbers:
His initial BG the day he was diagnosed, was 33+ mmol/L (594 mg/dl)... FASTED! (They seem to be reluctant sharing any numbers that go beyond 33 mmol/L as that is considered universally the "highest".
He has been and is now asymptomatic in the high 20s/low 30s, which indicates he was indeed in the dreaded 40s (700s) for at least those 2 weeks pre-diagnosis and pre-insulin.
His NADIRs at the vet are always in the 22-25 mmol/L range, but they keep shrugging it off as stress-BG numbers.
I have gone against their advice, and upped his dose a week ago, when again he showed DKA symptoms, and... Today I am ecstatic to see a PMPS of 22.8 mmol/L (410 mg/dl) which is for him considered low!!! (Note: he hasn't been eating much today, and received his normal dose of insulin, thus I can't help but wonder that's why his numbers are "decent".)

- The vet keeps saying not to bother about numbers, just focus on symptoms. But... aren't symptoms the indicators of things are being beyond control in his system?!
- The vet also keeps telling me to keep him on the same (low) dose for prolonged times, such as up to 3 weeks! With no home testing... WTF?​

I feel like I'm running out of time. Maybe it was wishful thinking on my part to have him regulated 2 months post Dx and even in remission sometime soon, but his daily averages still do not go below 20 mmol/L (360 mg/dl) and the vet... well... I don't even think they care?! Especially so, because they don't even ask/take into consideration when I'm explaining the change in his behaviour (which is incredibly apparent and worrying).

Since I did my own thing, and upped his dose slightly, he did gain some weight in this past week, but not much. I also bought Keto-Diastix and his ketones are at least "small" at the highest (his urine glucose is sky-high still). I'm worried they'll just say again tomorrow -due to the slight weight gain- to keep at the same dose for a few weeks, which I will definitely not do. I'm planning on printing out my spreadsheet, as well as a chart data and showing it to them.
He has lost a total of 1kg (2.2 lbs) in 2 months. He is literally deteriorating in front of my f*cking eyes, both physically, mentally and in spirits, and even though I am a strong spirited person, with a "solution finding" mindset, I'm finding myself crying to sleep every godd*amned night, because all I can think of is that if he's lingering in such heights for much longer, he'll develop further issues that will catch up with him and kill him sooner rather than later, just because I am advised to Stay-Low-Don't-Move.
I'm even considering biting the bullet and visiting a private vet for a second opinion, but I will not be able to afford that on the long run, thus I'm unsure whether I should just wait until he is regulated and do what my gut tells me to do is the best for him, regardless of it going against my vet's advice.

I don't anymore know how to approach these people tomorrow. It feels utterly pointless (apart from picking up more insulin and needles for him.) Any thoughts would be much appreciated.

Thank you,

Eve and Handsomest Baby Boi
(and Kiddy-Kiddy-Kiddy and Scroogie-Patoogie)

 

[Red & Rover (GA)]

Tagging @Elizabeth and Bertie who is in the UK.
Also tagging @Suzanne & Darcy @Wendy&Neko @Bron and Sheba (GA) - all experienced members.

Welcome. Waving from Canada.

 

[Bron and Sheba (GA)]

Hi Eve and baby Boi and welcome to the forum.
I would take no notice of the vets when it comes to home testing. Many don’t like it….I can’t work out why because it gives so much information and keeps kitties safe.
I would recommend you test before every dose of insulin to see it is safe to give the dose. Then test sometimes between 4+ and +6 with Caninsulin to see how low the dose is taking your kitty. This will tell you if the dose needs to be increased or not.
I am glad you are testing for ketones. If there is a trace of ketones in the urine, the dose of insulin needs to be increased. I would test every day for ketones at this point, especially if he has a history of DKA. I would also increase the amount of food you are feeding him each day. He needs to have a good meal before each dose (are you feeding 30 minutes before the dose and waiting for that 30 minutes before giving the insulin)?
I would also give at least 2 snacks of low carb wet food during each cycle, preferably in the first 6 hours after the insulin.

Given outright wrong advice/instructions by the vet (which I have followed through regardless, leading my boy into DKA)

Are you saying your boy had DKA? Was he hospitalised?
If this is the case could you please set up your signature and make sure you add that he had DKA and the date please
help us help you has the instructions how to set up the signature
Also if you could set up the spreadsheet and add any data you might have, we can help you with dosing. You will find instructions for the Ss in the same link.
The best way to get your kitty regulated is to feed a low carb wet diet and home testing the BGs and follow one of our dosing methods.

Prozinc is a much better insulin for cats than Caninsulin which is really a dog insulin.

If you can afford a private vet, where you can ask for Prozinc or Lantus insulin (both good for cats), we can help you with dosing so you don’t need to keep going back to the vet.
It is unlikely you are going to get him regulated on Caninsulin especially if the vet won’t increase the dose and doesn’t want you hometesting. So saying you need to get him regulated on Caninsulin before you try Prozinc is just plain ridiculous.

 

[Suzanne & Darcy]

Hello Eve. I’m so sorry for all that you’ve been going through with your baby boy. It sounds incredibly stressful and worrying. I would be angry with these vets too. They probably really just don’t know any better. Most vets have VERY little education/training in feline diabetes. Dogs do not respond to insulin in the same way as cats. I think you have good instincts. You’ve been around here long enough to know that Caninsulin is not a good insulin for cats; it hits too hard and doesn’t last long enough in cats. I would continue to push for a different insulin (ProZinc or Lantus/generic glargine). I commend you for doing your own thing and not listening to them. You’re going to have to do a lot more of that if you’re going to make progress with getting him regulated.

I don’t know how much positive feedback you will get from showing them your spreadsheet. These are the vets who are telling you not to bother to test, right? It’s so stupid! I would post here for advice and I would try to get a different insulin and I would try to follow the dosing protocols here to get him into better numbers. I don’t mean to sound simplistic, I am sure that I can’t fully appreciate how hard it may be to get them to prescribe a better insulin. But once you get it, just come here and we will walk with you every step of the way. I can see you are independent. That’s fine, but don’t feel like you’re taking anything away from anyone else on this Board by posting or asking questions. That’s what we’re all here for.

 

[Wendy&Neko]

Bron has made some very good suggestions. We can help you get him to a better dose of Caninsulin, while you work on trying to find a vet who will prescribe Prozinc. In the UK, it's harder to get Lantus as you have to prove you gave the other insulins a try and they didn't work. I am in Canada, and also prescribed Caninsulin first, "because that's what they do at the clinic". I also got other bad advice (it's OK to reuse the syringes up to three times, home testing is nice to do but not required, etc...). If any of those vets had a diabetic child they would be all over testing.

 

[.:. in.active .:.]

Thank you @Red & Rover (GA) for the shoutouts :waves back with a maple leaf: , poor @Elizabeth and Bertie was my first point of contact, and shamelessly slid into her DMs, prior to making the decision to post publicly.
And thank you all for taking the time to reply, I'll try and address everything below.

@Bron and Sheba (GA):

- I do have my spreadsheet linked in my signature, and I do predominantly run tests from +4 onwards. It was this forum that alerted me about NADIR may occurring earlier, my vet was/is always adamant on +6. Nonetheless, amongst all this vet bashing, I have to give credit, where credit's due: it does seem to hit him at +6 once he is used to his current dose. During the first few days if initial increase it drops significantly low at +4/+5 and hits me with a Somogyi* later on... That 39.8 mmol/L (716 mg/dl) on the 10th of May was peak... (*I'm not pretentious, I'm just Hungarian and feel obliged to use the official term as opposed to "bouncing" lol)

- I cannot test am pre-shot, seldom able to pm pre-shot, but that's easier. However, at this moment of time I do not have to worry about hypo and/or whether the shot is safe to give. Once his "highs" drop into the teens / below 20 mmol/L (360 mg/dl) and I'm able to wiggle his cycles to a more convenient time, I will definitely make a habit of it. (I am currently sleeping 3hrs max, and he is ravenous in the mornings. I'm also half blind, so it's really not ideal for either of us to test then, I tried, and did more harm than good, when I knew fully well his numbers would be high anyway.)

- He has a great appetite and eats well, always have. Since he is out of his 30-40s mmol/L now slightly less ravenous, but still hungry, so I have no problem on that front, thankfully :knocks on wood: I do not always wait 20mins post feeding, but again, he always has substantial amount of food in his belly before I shoot. He has incredible self-awareness and knows that something is wrong with him. If he hadn't finished his food before I shoot, +30min/+1 post-shot he goes back and finishes it. He has been doing this since Day 1., it's like as soon as the onset, he feels safe finishing his meal, because he knows he won't crash afterwards. (I have a bunch of intolerances myself and was pre-diabetic for years, thus I can relate to those post-meal crashes, they're awful.)
Funny you say the low carb wet food "lunch"/snack, that is exactly what I've been starting to do as of yesterday! Great minds think alike haha! This is also my attempt on introducing a variety of low carb foods to him, pick out which ones he favour the most, so gradually I can fully transition him on them.

- I may have misused the term "going into/having DKA". Perhaps I should have said, he had severe symptoms of DKA. Namely (apart from the obvious thirst/urinating cycle) neuropathy/collapsing of hind legs, depression/reluctance to move, deep but harboured breathing issues and the most terrifying and blatant giveaway: he was a walking cotton ball filled with acetone. This happened three times so far, usually always around the weekends of course. (Called the out of hours emergency line, whom are useless as well, as they are admittedly mainly trained for trauma response.) He rode it out all three times.
I'd like to mention here, although I always thought he was on the oblivious/silly/dumb-dumb side of the cat spectrum, this boy rode out an amphetamine poisoning on his own (ingested ADHD medication), which obviously had to happen on a weekend. Scariest two days of my life, but it just to show he is a very strong boy, so when he is actually symptomatic, I know something is really wrong.
With that said, I have no idea whether he actually had DKA or not. I let you guys be the judge of it.

- I do test every day for ketones. It's easy when he is peeing a lot, although it's becoming less frequent now (yay!), like 2-3x a day, once after each meal (between feeding and insulin onset) and 1x during the day, but I see him dropping that slowly too. His ketones are either "negative" or "trace" in the mornings and "small" in the evenings - I do not worry about that much, because he has (low carb) snacks during the day, he is after dinner and I just shot him up, so I know he'll be fine within an hour tops.

@Suzanne & Darcy and @Wendy&Neko:
- I will push for ProZinc in a few hours when I head over. As above, I was told on numerous occasions that "We have a list on insulins we can work with, I'll ask my manager and get back to you, but most of our clients get them privately prescribed". I do wonder though,, what that list may be... given that the only two regulated insulins used by vets in the UK are Caninsulin and the slightly more expensive ProZinc. To me it sounds like diversion and an excuse to save money, but I guess today I have to put on my inverted bob and ask to speak with that often mentioned manager.
My main worry is that once I go back to the private vet for a single check-up and/or prescription, I may lose all the privileges at the free clinic, for further check-ups and/or needles etc in case they didn't want to take the responsibility, after all I won't be using "their" medication. I enquire about it today too.
I would also be able to receive human insulin and needles free of charge, however, definitely not feline insulin, unless it comes from PDSA. Either way, I gotta do what I gotta do. This guy not only lives, but will go into remission. Periodt.

- I was actually told the exact same things about being able to re-use the needles (one needle for two cycles) and well yeah... home testing (both glucose and ketones) being pointless.

Edit: Home Testing:
- To anyone looking at my spreadsheet, I feel the need to be transparent and point out, that I am using AlphaTRAK 2.0 with FreeStyle Lite strips. I know it is frowned upon by many, but in case you wondered why is the last column "AT strips" there, now you know. Again, at this moment of time, the readings are close enough to me (AT reads slightly higher than FS) to see the curve, and at present we are far from having to worry about hypo. Please note, that I do have dedicated AT strips, which I will be using on the regular basis, once his numbers are lower and needs closer monitoring and also during transitioning to a different insulin. Please don't judge. I'm not stupid or reckless, I just need to budget carefully.

- I also got my hands on a FreeStyle Libre, for free. Any opinion on those? I feel like it'd be too soon to use, as his numbers are still incredibly high and probably wouldn't even read. Maybe during (when/if) transition? Private vet more likely to help me with the application as well, given PDSA is against of any type of testing...​

 

[Suzanne & Darcy]

Hi! Good luck today. I’m sitting in my car — out feeding feral cats early in the morning. I’ll write more later, but I wanted to point out that Symogi is not really the same thing as a bounce.

I hope that things go well today. Do you seriously have to take him to the vet every week or every two weeks? They’re wasting resources on that for sure. How unnecessary and stressful for your boy!

 

[.:. in.active .:.]

Yes, since they don't approve of home testing, they want to see him at +6 on a regular basis to be able to make the insulin adjustments (again, "No point testing at home, it's not like you're allowed to adjust his dose without us seeing him"). This being one of the reasons they telling me to "Up the dose by 0.5 and come back in 3 weeks". I choose not to do that. In all honesty, they always ask me what dose he is on currently, which indicates they don't even have his current numbers recorded on their system. I'm thinking of making my next appointment for 3-4 weeks time, and based on his current numbers, and manually increasing his dose by 0.5 every week until then, he should be in the perfect zone. I think he needs a total extra of 1 or 1.5 unit to reach the sweet spot. That is unless they give in, and give out ProZinc today (which is highly unlikely).
Oh, and to make matters worse, I don't drive. The vet isn't too far, but is still a bus ride away. Fun times. Thankfully he is the calmest out of my three, so he is mostly unfazed about these journeys.

Rorschach approves of your deed, since he used to be a stray kitten, bound to grow into a feral adult. He is sending his love to his cousins

Right, I've gotta go and get ready. Thank you again for all the support and enduring my vet-rants.

 

[Bron and Sheba (GA)]

Hi Eve
It looks like you have all three cats in your signature. To stop any confusion, would you mind removing the two that are not diabetic please and just leaving your diabetic boy there please.

 

[.:. in.active .:.]

Oh my god, you guys! I think ya'll brought us good luck!

We've had over an hour wait on site to see the vet, during which I spoke to the manager, who confirmed that they only work with Caninsulin, and had no idea why numerous her vets state otherwise, nor why do they advocate against home testing. She was very impressed with my knowledge, information and terminology I used, which is all thanks to you lot and this forum! She suggested to go private, should I decide in favour of a different insulin, however, as suspected, they will no longer be able to treat him for any diabetes related issues then. She said although she knows it's a grey area, because "insulin is insulin", they can not take any responsibility for something they don't dispense, which is fair enough.

That hour wait pushed my already too early shot even further, into +8. But he read 18.4 mmol/L (331.2 mg/dl) which is amazing for him, especially considering the bus journey and hour wait in a closed area with full of dogs. It was also confirmed -albeit more precisely than my jumping on the scale with him, then deducting my own body weight- that he has indeed gained almost 0.5kg (1 lb) in the past 11 days!

I also realised I'm a judgemental a*hole.
We have seen a guy today whom I was always a little wary of. In all fairness, I have seen him twice briefly, once when I dropped my other cat off for surgery, and two months ago, when he hit me with the diabetes diagnosis for handsome boy. On both visits I was emotional, and only later did I realise that his lack of eye-contact and general curtness are likely to be due to him being autistic too, just like myself.
Today he was blown away by my spreadsheet, and let alone was I not scolded for upping baby boy's dose against their advice (turns out they do record units as and when they please, vet dependant I assume), but... listen to this... He sent us off with a month worth of vials and a verbal agreement of increasing his dose myself weekly with 0.5 or 0.25 depending on how I feel fitting. Furthermore, his "final dosage for ideal range" aligns exactly with my calculations!

I am ecstatic, and for once feel validated, for what it's worth.

I have booked us in for three weeks time (for the 7th day of the supposed ideal dosage cycle) back-to-back both with PDSA as well as with my local private vet, with a disclaimer that I may cancel either one of those appointments. He did say, he doesn't see a reason for changing if Rorschach regulates well on Caninsulin, as remission is a very either/or, hit-and-miss thing anyway, but I was amused by the fact that they were not at all against it, but actually helping me out this time with advice. (Likely to do with having to fund one less patient on their end, but whatever, at this point I don't even care, they were kind and helpful today. )

I have three weeks and a bunch of data to collect to make the decision. First step is to swing by the private vet, likely today, and ask them for a list of insulins they prescribe. If there's anything I can get my hands on for free or discounted, then it's a no-brainer. If not, I will have to ponder on my options and do my research on where to source and what.

That is all. Today is a good day.

Edit: I have received his medical record, and about to email it over to the private vet. I have spoken to them, and was assured that upon receiving the information they need, they'll get back to me prior to my appointment in three weeks, whether or not they can give me a 6 month prescription (£20) for Glargine. They do stock ProZinc for £120 per bottle Should I decided to go down that route, I'll be better off to ask for a 6 month prescription for it, and order it online for £60/vial.
I also popped into Lidl where they started to stock Sheba Fine Flakes, which based on the data on the package is 0% carbs as opposed to 1.9% (not like it matters on the greater scheme ). And guess who just inhaled 2.5 pouches! And tonight post-feed ketones were "trace" as opposed to "small". Still, keeping his dose the same for the night, and will up it tomorrow morning, when I can monitor him closely, given the huge 8-10% downsizing in carbs, with no fuss and/or the need for slow introduction. (Lawd, my guy loves his food, just as much as I love my wine. )

Today is a really good day!

Update: It's currently 02:38, I fed him at 19:30 ish with the super low carb food, and shot him at 20:00 with his not-yet-upped dose, thus we've been at this bottom curve in the past half-an-hour/hour, and he is back to his pre-diagnosis self! I haven't seen him like this in months! He's chipper, wouldn't let me live with his neediness and asking for ear rubs (that was always his fave spot, but lately hardly even let me touch them, for obvious reasons) and his purring is about to wake up the entire apartment complex! I am even more hopeful now, than I was all afternoon.
My baby is back, and it's only feed #1 on the new food, and without upping his insulin! Today was the first day in two months I didn't tear up, but I think I'm gonna go and cry myself to sleep again, but tonight for a whole different reason. I'm so so happy!

 

[Elizabeth and Bertie]

- I also got my hands on a FreeStyle Libre, for free. Any opinion on those?

Hi Eve, just on the Freestyle Libre...
These are becoming more popular in the UK now, with quite a few vets suggesting using them (even vets who say they don't agree with using human glucose meters... )

People's experiences of the Libre seem to vary...a lot... Some people have great experience with it. Others have issues with it. Issues include things like getting the device to actually stay on the cat (some folks use little onesies to hold it in place...), malfunctions with the device (stopping working, etc), and the accuracy of readings.

The Libre measures glucose in interstitial fluid, not blood. So it's thought that the test may not be a 'real time' test, but could be out by about 15 minutes or so. This is very important to bear in mind if dealing with a low number or hypo situation when minutes can really count. And in this situation a hand held BG meter should be used to test the cat, to ensure greater accuracy and safety.
Also, because it measures interstitial fluid it's important that the placement of the device isn't somewhere that the cat can lay on. If the cat lays on the device this may affect the interstitial fluid and hence also the test result.

Despite the issues that there can be with it the popularity of it seems to be increasing. And - even allowing for its possible shortcomings - it may play a useful role in some cases. It may be the only alternative for people who cannot test blood glucose any other way, or a temporary measure for those who are still learning to test blood glucose. And - on the basis that 'almost any data is useful data' - this seems to me to be a good use for it.
It also allows for data to be gathered at night when many people will be less likely to get BG tests. And it may be useful to use on kitties when the caregiver is on holiday and there is nobody to test the cat's BG.

It could be a useful option for you too, given that your ability to test is limited at the moment. Having the Libre data might help to fill in some of the blanks.
That info may help to shed some light on the current BG numbers. While many of the numbers are high and 'flat', it's important to be aware that high flat numbers are not always caused by insufficient insulin. 'Too much' insulin can also result in patterns of high flat numbers due to bouncing (rebound). Bouncing happens if, for example, the BG drops too low, too fast, or both. 'Too low' doesn't necessarily mean dangerously low. A cat's BG can bounce even if it just drops significantly lower than its body has lately become accustomed to. The BG dropping too fast can also trigger bouncing, even if it does not drop particularly low.

While most of the numbers on your kitty's SS are very high, I don't personally think there is enough data to be able to rule out bouncing. And I do wonder if there are occasional lower numbers or steep drops that are being missed... This kind of thing is not at all uncommon...
'If this was my cat' I would not increase the dose without first ruling out bouncing. That would require more BG data. And that is where the Libre might be able to help at the moment. If you can rule out any lower numbers or steep drops in BG that would make it safer to increase insulin dosage. Insulin dose should always be based around the lowest numbers that a cat's BG can drop to.

...Anyway, just my ten cents...

PS - So glad the vet visit went well.

 

[.:. in.active .:.]

Thank you Eliz, although I was mostly aware of the above, it is great to have all this information together in one place. My main concern is that his numbers are still in such heights that a human meter wouldn't recognise those, simply just read "Hi". But given the fact he loves to roly-poly and was never was accepting toward collars, let alone toward kitty vests or any sort of clothes, I believe I might just give it a miss. For now, anyway.
You are correct about my sheet being very patchy, but looking at the trends, I doubt he would have any steep drops outside of the +4 to +8 zone, which I am monitoring. Nonetheless, I am committed to try and test more often, I just hate hate haaate how much it bothers him. (I would have used the term "hurt", but I want to believe it's more of an inconvenience rather than pain for him. I hope, anyway. ) His signature "fave spot" was never the bottom of tail-, headtop- or chin-, but ear rubs, and recently it was taken away from him with the pricks.
But today was a good day on that front, and all tests went smoothly so far, so here's hope.

'Too much' insulin can also result in patterns of high flat numbers due to bouncing (rebound).

Now now... I am familiar with the Somogyi effect/rebound (fellow Hungarian here ), however, I was corrected earlier, that it is not to be referred to as the so called "bouncing" used on the forum often (which is exactly how I referred to it previously too).

I wanted to point out that Symogi is not really the same thing as a bounce.

Do you girls feel like "fighting it out", or shall we agree to disagree and call it a simple subjective / perceptive / semantic issue?
Or have I misunderstood something, and the rebound/bounce you two are referring to is something completely different to my understanding of:
"Somogyi effect and posthypoglycemic hyperglycemia is a rebounding high blood sugar that is a response to low blood sugar."
When I'm referring to Somogyi/bouncing/rebound, this is what I mean (that is regardless whether it's happening during the night with elevated BG in the morning, or any other time of the day, the phenomenon is the same).
Please correct me if I'm wrong tho.

 

[Wendy&Neko]

How about a research paper disproving Symogyi in cats? Rebound hyperglycaemia in diabetic cats.pdf

 

[.:. in.active .:.]

How about a research paper disproving Symogyi in cats? Rebound hyperglycaemia in diabetic cats.pdf

It is Somogyi.

The first thing you'll notice entering the world of science, is that there is no such thing as a "proven" or "disproven" hypothesis, only those that "being supported" (or not) by evidence. I know it's only semantics, but as a scientist myself, and given the nature of the paper you've linked, I thought I'd point this out.

I am also a little confused:

1. You guys have links (although broken) to Somogyi effect in your FAQs. [Q6.4. - A6.4.]

Why, if you think it is not supported/a non-existent phenomena in felines?​

2. The above paper states that Somogyi effect associated with insulin resistance is extremely rare [but not non-existent] in cats treated with Glargine.

These right here, are immediately two limitations to the study on it's own.​

3. "Rebound hyperglycaemia [aka Somogyi effect] without persistent insulin resistance is more common, occurring in 25% of cats, albeit infrequently."

I do not see it being unsupported at all, but the exact opposite. That is quarter of the felines treated (on Glargine only) experiencing the effect, even within this incredibly limited study (the sample size is ridiculously small).​

4. "It is also important to determine the frequency of rebound hyperglycaemia when using intermediate acting insulin, because shorter-acting insulin might have a higher frequency of occurrence."

Not it's actual occurrence/existence. It's frequency. (You can not observe something's frequency, if said something does not exist.) And this statement here alone is applicable of all Caninsulin users, saying we are bound to experience more of said Somogyi effect, than Lantus/Levemir... etc. users.​

I'm not here to argue with you or to be difficult, I just don't see what you're trying to get to with this, because what you have claimed, and the very evidence you provided to support your claim is let alone contradictory, but outright '''disproves''' your own statement, per se. And it is very evident, once the lab report is read further than its abstract... Just saying.

If your point was to highlight that Somogyi effect is not the same as what you refer to as "bouncing" across the forum, then well done, I guess?
It still doesn't answer my question that what is it then, that you call "bouncing" here, if not the posthypoglycemic hyperglycemia, [which] is a rebounding high blood sugar that is a response to low blood sugar. Which is, in fact, the definition of Somogyi effect.

Edit: Or is it really simply going to come down to perspective and/or differing terminology used between users (which is exactly what I have jokingly enquired about in my previous post, but now finding more and more hilarious, if really that's all that is to it) of:
> Somogyi effect = one bounce
> a sequence of occurring Somogyi effects = bouncing?

Seriously though, what's up with this?
(I've been looking at all sorts of FAQs and links on this site for the past few hours now to the point of developing a headache, and granted I can not find a single posted-by-a-moderator "official" description of it right now when I need it, and the search engine is still useless, producing nil results, whatever is typed into it.)

 

[Suzanne & Darcy]

It still doesn't answer my question that what is it then, that you call "bouncing" here, if not the posthypoglycemic hyperglycemia, [which] is a rebounding high blood sugar that is a response to low blood sugar. Which is, in fact, the definition of Somogyi effect.

A couple of points that occur to me right now before I go to bed, and I will let it go at that:

What we call “bouncing” here can be a result of a fast or steep drop, e.g. if a cat drops 100 points or more in an hour. It does not have to be a drop anywhere near real “hypoglycemic” levels. In addition, I frequently see cats who are bouncing from blood glucose levels that are nowhere near hyperglycemia, e.g., a cat who has been in pink or red numbers for a long time finally has a yellow BG (in the 200s). This cat then bounces as a result and in neither of these two cases I have mentioned would the bouncing be high blood glucose due to hypoglycemia. These are just two instances that I thought of, because they occur commonly in FDMB members’ cats.

 

[.:. in.active .:.]

Thank you!
I do wonder though, because said bouncing happens as a shock reaction to steep drop(s) which their bodies perceive to be a hypo. Granted it is technically not, not for us two-legged ones anyway, with understanding of numbers. But the basis of the phenomenon is exactly the same, whether or not they/you/anyone/anything have the privilige of number reading. So there comes in my previous comment, that we may have had different, subjective perceptions on the matter, thus have been using the terminology according to those.
I've been looking at it from the feline point of view. You guys are looking at it from the human point of view. That is all.
It does make perfect sense though, and now at least I see the reasoning behind why you said above that the two (the rebound and the Somogyi rebound) are not exactly the same... so thank you!

 

[Elizabeth and Bertie]

What we call “bouncing” here can be a result of a fast or steep drop, e.g. if a cat drops 100 points or more in an hour. It does not have to be a drop anywhere near real “hypoglycemic” levels. In addition, I frequently see cats who are bouncing from blood glucose levels that are nowhere near hyperglycemia, e.g., a cat who has been in pink or red numbers for a long time finally has a yellow BG (in the 200s). This cat then bounces as a result and in neither of these two cases I have mentioned would the bouncing be high blood glucose due to hypoglycemia. These are just two instances that I thought of, because they occur commonly in FDMB members’ cats.

Yes, exactly so.
...My girl Bonbon is prone to intermittent steep drops in BG, completely out of the blue. If I don't catch that drop early on to 'steer' it, and it hits over 5mmol per hour for any length of time, the resulting bounce can cause her to fly into the BG stratosphere of high unresponsive numbers for several days...

 

[.:. in.active .:.]

and it hits over 5mmol per hour for any length of time

THIS would have been my other question! Thank you for reading my mind!
I know every cat is different, but it's good to have a rough idea on what to look out for. I never recorded drops in such heights/lows (but again, admittedly I have a very patchy sheet here), but those two steep ups that stood out for me were in the 4.5 mmol/L per hour range, although he didn't stay high for days, like your Bonbon.
Is she on Bovine PZI like Bertie? I don't see her in your signature, nor either of their spreadsheets. I'm just asking, since that meant to be a much longer acting insulin than Caninsulin, which makes me wonder about the hows and whys of those huge drops in your numbers? (I found your own replies to the Caninsulin vs HB PZI vs Glargine/Detemir from 2012, I'm doing my daily research and you always seem to be a huge part of it! )

Here are the entries I was referring to, but these happened straight after finding his "breakthrough dose" of 3IU, the one that actually started to bring his numbers down significantly/finally pushing him out of the 20s he was in for so long, even if only for a few hours.

09th May: 14.6 [+2] 23.3 = 4.35 mmol/L per hr
10th May: 21.6 [+4] 39.8 = 4.55 mmol/L per hr

So my reasoning says they were one offs, but my conscience is screaming at me right now for falling back asleep after his morning shot today (and only getting 1.5 hr sleep myself) so I think I may make myself hated, and do a proper half a curve on him for the first time today from +6, hourly.

If you don't anymore hear from me, I've had my eyes clawed out.

 

[.:. in.active .:.]

OK guys, I caught it. And I caught it the worst possible time, the only day of the year when my autistic arse actually leaves the house, and won't be home until +5/+6.

His AM +11 was 32.2, I fed him half an hour later, and my gut was screaming at me to test him pmps, regardless it being 30min after he has eaten, and his BG likely to be raised even more. It was 24.4.

What is going on?

Is it to do with the "bounced up" insulin finally has something to tackle (the food)? Or is it something I need to be worried about? I have left some food out for him (Felix, higher carb, about 10%) just to be safe.

What's worse, is that let alone I have no time to brows the forum for answers atm, I will have to lock my phone away into a yonder pouch in an hour when I enter the venue, given that I'm seeing a famous comedian, so I may not even see your replies.

If your advice is "turn back home or he'll die" please do scream at me in the next hour!

 

[Red & Rover (GA)]

24.4 was okay to shoot.

 

[Wendy&Neko]

In future, if you are worried and have to leave the house, just leave food out for him to munch on and keep himself safe. For hoovers (which I had instead of grazers), an automated pet feeder can slow down how much they eat at once. And as mentioned, he was plenty high enough I wouldn't have worried too much.

 

[.:. in.active .:.]

Thank you both!

His numbers make me age in dog years. How can he drop 8 mmol/L in less than an hour, after eating, right at the top of the curve?

Putting together his (very little) PM +1 to +6s with his (patchy) +5 to +12s AM data makes me believe he's constantly in the 20s, with a drop around +6, from which he starts curving up nicely, then for whatever reason shoots up, then shot, and he's back in the high flat 20s.

These drops after food baffle me the most.

I just hope the private vet gets back to me sooner rather than later about the switch.

Edit: He's not too bad with eating, but yes, I left food out for him. About to see how much he's eaten and what state he is in, once I walk in.

 

[Wendy&Neko]

How can he drop 8 mmol/L in less than an hour, after eating, right at the top of the curve?

Add in that there is also some allowed variability in the meter numbers, what we call meter variance. I'm not sure what the limit is in the UK, but in the US it's 20%, which is quite a difference in higher numbers, and not so significant in the lower ones.

 

[Red & Rover (GA)]

I'm seeing a famous comedian

Who was it? And how was it?

 

[.:. in.active .:.]

I'm not sure what the limit is in the UK, but in the US it's 20%

I'm using an AlphaTRAK, so I believe we are on the same page on this one, for what it's worth

He was fine and his happy self when I got in, no pissy paw prints around the litter box either.

Gonna do some homework/research on BG dropping after eating "for no apparent reason" though, it seems to happen quite often, and I don't like not understand the hows and whys of it.

Who was it? And how was it?

"Oi oi!" Micky Flanagan, he's very big in the UK. Typical dark, dissing, English humour, with a very strong cockney accent (East London, he's from the borough I reside.) Vulgar too, definitely not for the faint hearted. It was great, I laugh-cried so much, one of my contacts fell out.

(I watched a bunch of "Americans react" to this particular video [ya'll seem to get on board with it], but given my already tainted reputation on this forum and the fact that I'm having to walk on eggshells, I may get cancelled for being offensive, but hey-ho. Proceed with caution: Can I Come In Your House)

 

[Red & Rover (GA)]

Micky Flanagan,

I've seen him a couple of times on WILTY. He's funny.

 

[.:. in.active .:.]

Just received a call from the private vet regarding my email, which describes our circumstances, my dilemma, my financial situation, with the attached medical records and data (aka spreadsheet) provided.
My explicit query was, whether they're licensed and would be willing to prescribe either of the human insulins to him, preferably Detemir. I made it clear, if the answer is a definite "no", I wouldn't take up the place for the appointment, as it's a waste of time another pet in need could use.
So she called, moving the appointment to be had with one of their seniors, and kept tiptoeing around my question. She kept mentioning ProZinc (which I explicitly stated I'm not interested in) and insisted I needed an appointment to discuss matters, when, in theory, all I asked could be answered with a "yes" or "no". She also stated that we would need regular check-ups with them. Then she went on to say, the 15min consultation is £55 (which I knew about), then said since it will likely to be an extensive consultation, they'll be charging me for 30min, thus £110. Then upon reiterating the Glargine/Detemir side of things to her, she went on more about ProZinc (which again, is £120/vial + £20 prescription) at their clinic, and I am not interested about.

Am I in the wrong to think, it's sheer money grabbing? Or am I selfish? I understand their perspective of it being a liability and/or a serious decision to be made, and I do understand they'd need to see him before the transition.
But this whole thing just doesn't sit well with me, for some reason. AITA?

 

[Wendy&Neko]

In the UK vets have to prescribe pets imsulins first, meaning Caninsulin and/or Prozinc, until it's proven they aren't working. Prozinc is a way better option than Caninsulin. Sounds like vets really vary about how willing they are to prescribe human insulins.

 

[Red & Rover (GA)]

From: https://www.rvc.ac.uk/Media/Default/small-animal/documents/feline-diabetes-guide.pdf

"Use a long-acting insulin to reduce the pathological hyperglycaemia

Two insulin preparations are currently licensed for treatment of feline diabetes in the UK: Caninsulin® (MSD Animal Health; porcine lente type insulin) and ProZinc® (Boehringer Ingelheim; protamine zinc recombinant human insulin); these preparations should be considered first before other insulin types are used. While there is no legitimate reason to switch cats that are well-controlled on Caninsulin to ProZinc, current treatment guidelines recommend to initiate treatment of DM in cats using insulin preparations with the longest possible duration of action. In the cat, protamine zinc insulin (ProZinc) is therefore preferred (Sparkes et al, 2015). Most studies found protamine zinc insulin, glargine and detemir to be associated with the longest duration of action, though direct comparison studies are still lacking (Gostelow et al, 2014). Insulin types with a lower concentration (veterinary licensed options: 40 units/ ml, versus human insulin types: 100 units/ml) enable more accurate administration of typical cat dosages. Each patient will show an individual response to an individual insulin type, introducing a significant element of unpredictability. The bottom line remains: use the insulin type that achieves the principle goal of sufficiently lowering the blood glucose to enable a good quality of life without hypoglycaemia or diabetic ketoacidosis."​

 

[.:. in.active .:.]

I've seen both of your replies as and when you posted them, thank you!
In fact, I've been busy ever since, doing my homework and money mapping, given that it seems so we really cannot skip the ProZinc part of things financially. I guess I'm having to take that one to the chin.

But let me finish up with some positivity:
We've just gone and read his first ever single digit!!!
I'm so so happy, I really thought this day would never come! My boy does everything to end these stressful days on a good note!

 

[Wendy&Neko]

Single digit (mmol/L) is awesome news! Great progress. How did he feel/behave then?

By the way, I know you know you are using custom colours on your spreadsheet, and they do differ from what the rest of us use who have followed our spreadsheet template. I only mention it because those of us who have been looking at many spreadsheets start to see patterns in numbers, partly from the colours we are used to. Which helps us see trends and help us figure out how the cat is doing on the insulin. We won't be able to provide that same help to you. But we can still help, just not as much.

The other disadvantage of not using our spreadsheet format is that you don't have the US mg/dl tab, which is automatically converted from the mmol/L data you enter. There are many of us here who speak mmol/L, but a large number of our users are in the US, and they do not. The server is hosted in the US. So that means the US folks won't be able to help as much with dosing either. I am in Canada - and am bilingual in blood sugars. LOL.

 

[.:. in.active .:.]

Hah, so it was you popping up in my sheet! I seent it

I know, I'm sorry, but I could not get behind your colour coding, it was doing diabolical things to my already mushy brain! So was the set-up of having to scroll far right for notes, thus I cram them in-text instead, and other comments at the bottom of the month.
I made all the "good" numbers various shades of green though, so hopefully that's self-explanatory when looking at it. As long as we reach a predominantly green slate, all is good. It's fine for now, re: dosing too. If we do change, and can't skip ProZinc, I'll be having to see the private vet way too often for my liking, who'll want to navigate the dosing. They made that veeery clear on the phone today

I did add the mg/dl conversion now though, regardless it being in your blood *badum-tss*

He was his awesome happy little self! I'm seeing a pattern of his numbers running havoc for three days (6-7 cycles - especially on cycle #6) after a change in dose, then they seem to settle once his system is used to it.
I'm not sure whether it's just me talking out my arse now (it's almost 2am here), but I'm picking up on his numbers reading the lowest after he'd have an excessive peeing session (normally only happens once a day now, around +4/+5). Do you think there's a correlation between the two? (No ketones, yes glucose, but today that even had dropped a shade... just about. And then we read a 9.2 straight after)
It's like his blood reads higher until he releases his body's toxins via his bladder. I don't know, I'm just yapping aloud, I probably don't make any sense now...

Edit: I obviously meant twice a day, not once a day. Lawd, I need sleep.

 

[Elizabeth and Bertie]

Is she on Bovine PZI like Bertie? I don't see her in your signature, nor either of their spreadsheets. I'm just asking, since that meant to be a much longer acting insulin than Caninsulin, which makes me wonder about the hows and whys of those huge drops in your numbers?

Bonbon was on Caninsulin when I adopted her. I did switch her to Bertie's Hypurin bovine PZI, and she went into remission for a year.
Hypurin PZI was discontinued by the time she came out of remission (damn shame...) so she's now on Levemir. She has multiple health issues now, and that is 'very possibly' why her numbers are variable these days. Concurrent health issues can really 'throw a spanner in the works' when it comes to regulating diabetes...

Eliz

 

[.:. in.active .:.]

so she's now on Levemir

Eliz, where do you source Levemir from in the UK? I have been looking literally everywhere online, but cannot find it anywhere, not even the pens, let alone a vial!
I have spoken with my GP on Monday re: prescriptions and she told me she's unaware of they being licensed to provide prescriptions for a pet, even with receiving a valid veterinary prescription, as she said she hasn't come across anything like this before. Is that right, or do I just have to press on a little more?
I could order Lantus from Weldricks if/when I acquired a prescription for that, but I'm incredibly hesitant on Glargine, thus I wouldn't even mind paying more if I could source Detemir.
ProZinc is out of question (and yes, cascade system etc... but it's very vet dependant, they don't all and always push for it).

I did the math last night, and yet again I came to the conclusion the private veterinary industry is a ginormous rip-off!
Based on his current data I could calculate his perceived future dose, both on ProZinc and Lantus and the approx. cost of his yearly treatment, not including vet check-ups, that can obviously wary between £55 (regular check-up) to £500 (glucose curve) /visit.
ProZinc (prescriptions + vials + needles) ~ £1,200 ---> Glargine (prescriptions + vials + needles) ~ £300

Edit: Or are you ordering it in from Canada too? That would still be much cheaper than buying ProZinc in the UK!!! Like... half the price! It's sheer madness!

 

[Elizabeth and Bertie]

Eliz, where do you source Levemir from in the UK?

Hi Eve, I order it online from Weldricks with a prescription from my vet. It's not listed on the site, but they are usually super helpful if you contact them. They even set up a specific Levemir page on the site just so I could order the insulin, bless them...
It is not licensed for cats, but can be prescribed off label under the 'cascade' system by a vet.

Most other UKers I know who use it just get it from any human pharmacy, just with a private veterinary prescription. I seem to be one of the few who gets it online.
It's usually prescribed as a pack of 5 pens, which can be used like little vials with syringes. These last a long, long time... We're lucky in the UK in that the depot insulins, Lantus and Lev, seem to be cheaper than in the US.

A veterinary prescription costs on average around £15. In practice it can be anything between about £12 and £18. My vet charges £14. And in fact I get most of my veterinary meds online with prescriptions from her.

ProZinc (prescriptions + vials + needles) ~ £1,200

You don't need 'proper' Prozinc syringes, any generic U40s are fine, and are a lot cheaper.
Prozinc usually lasts much longer than is suggested on the package insert. Quite a few folks use it for many months before it sparks out.

£500 (glucose curve) /visit.

'If' you can get your kitty to tolerate home testing this will save you a heap of money.... I know that it's not an easy thing for you though...

...One thing though... With the depot insulins hometesting blood glucose is even more important... The 'accumulative'/overlapping effect of the doses really does need more careful monitoring...

 

[.:. in.active .:.]

Eliz, you're a star, thank you so so much!
I saw on Weldricks how straight forward and cost effective it is to order u100s and Glargine vials. (That's where my friend used to source his from, before his cat crossed over to the other side.) Him working in the human drug development industry also said the same as you above (but about Lantus) regarding shelf life... Which I needn't to worry, if Levemir is prescribed in 3ml pens/cartridges as opposed to in a 10ml vial.
Oh I wasn't even talking about "proper" ProZinc u40s... The costs would add up only by my vet's £20 prescription + £60 vial / month (cheapest I found online, in-house the vet sells it for £120 vial). But I'm already in the process of registering with a different vet.
Since my boy's numbers finally seem to drop in the teens (200-300s), I'm testing him regularly. He is getting used to it, although we have better days and worse days. Testing always seem to be much easier when his numbers are low; let alone is he less edgy, I'm able to get decent sample bubbles, for his blood not being so thick and concentrated.

*GENERAL TALK* Caninsulin to Levemir *NOT DOSING ADVICE*

Rest assured, if and when we transition, I will open a thread in the allocated space!
His numbers are finally dropping to an acceptable range, although we are still one or two weeks (0.5iu - 1iu bid increase) away from reaching what is best for him and would make me content. HOWEVER, his pre-shots although dropped, are still in the 20s (400-500 range).
Question #1: Is it known for pre-shots to linearly (and substantially) "even out" enough in accordance with his nadirs on Caninsulin with the dose increase, or am I playing with fire keeping him on it? The last thing I want for him is to go from hyper-to-hypo-to-hyper in a 12hr period. If both his pre-shots and nadirs dropped by approx 200 mg/dl with 4iu, it is unlikely I can achieve his pre-shots to drop a further 200 mg/dl without his nadirs to fall into the dangerously low range at this point, right? The 1iu tops increase would put his nadirs to an ideal range, but likely keep his pre-shots high based on my math.
Question #2: Am I to wait it out until his nadirs in a sweet spot, and only then (when I have proof of his pre-shots are being high regardless) shall I go and see the vet regarding the prescription request for Levemir, or...?

I guess the ultimate question is, whether I shall have my hopes up for regulation on Caninsulin and wait a couple of more weeks still, or shall I get the Detemir ball rolling, sooner rather than later?