Finn's been too high lately, opinions needed

tehg

tehg

Member
My poor boy has diabetes, IBD, heart disease, CKD and chronic pancreatitis. He was doing ok-ish, but my vet left on maternity leave and, of course things went a little haywire.

After skirting hypoglycemia twice (once was my fault for pulling the wrong dose) Finn's entered a period of too high numbers for too many cycles (PS in the high 300s/400s) but I'm bit nervous about going back to the 2.25 units (+.25) twice a day because he drops differently at night.

I have a health issue that is exacerbated when my sleep is interrupted (hence the lower numbers of evening tests on the SS) so I really really need to get him on a safer and more even keel in the PMs.

FWIW I work from home 2 days a week, so while I can test more on those days, those ALSO end up being subq fluid days.

I'd been following my vets dosing advice but she's out on maternity leave so I am inclined to start SLGS or a modified version with a sliding scale to address evenings.

I'm waiting for the replacement vet to get back to me about his numbers and wondered if a) there is anything specific I should be asking the vet, and b) what the experienced ProZinc users suggest based on his curves.

SS is in signature but if it doesn't work let me know.

Thanks for the help.
 
Hi there. I do not see any hypoglycemia on 2.25 dose. I do see some green numbers that are within the healthy/normal BG numbers for cats. However, I do see that he tends to drop lower at night like many cats do. 2 units do not appear to be enough insulin at this time, even at night as he has been mostly in yellows and reds (except for one blue.).

Can you tell me what he eats? Also, what is your feeding schedule like. You are not feeding just twice a day are you?
By the way, you are doing an excellent job of testing.
 
Having said that, if you were following SLGS, he would have earned a .25 unit reduction anyway back when he dropped below 90. But you would have needed to go back up in dose with numbers in the yellows and reds after 7 days. But overall, it does look like he was doing better on the 2.25 units. I can understand though why you may not want him going green at night (although those recent greens were safe, as I said before.).
 
He’s on Lotus Just Juicy (Venison for the IBD)—canned twice a day-250 kcal per day. He’s definitely the type to break into an automatic feeder so I’ve been hesitant to go that route to switch to smaller meals while I’m away from home. I’m sure he’d love it though.

In re the food, it’s the lowest carb lowest phosphorus venison that I can find that’s regularly available and but it’s not low enough that I can forgo a phosphorus binder. My vet and I tried changing his diet when he was first diagnosed (to the tiki cat chicken/fish varieties) and he ended up in the ICU for 3 days. Basically with the shortage of venison and venison based foods, my only other option is to pay for a custom designed venison diet from the local vet school’s nutritionists then prepare it myself.

The alphatrak II book indicated the cut off is 65 & I was concerned enough to start feeding him at 4+ each time because based on what I know about the timing of his evening nadirs he would have gone below 65 without the extra food & my thought was it would be better to preemptively avoid things getting worse rather than watching and waiting for it to happen.

I’ve been contemplating switching to a human meter for a better match with the numbers on this site, but I always seem to end up with 100s of test strips when I contemplate it and end up putting it off.
 
Suzanne & Darcy said:
Hi there. I do not see any hypoglycemia on 2.25 dose. I do see some green numbers that are within the healthy/normal BG numbers for cats. However, I do see that he tends to drop lower at night like many cats do. 2 units do not appear to be enough insulin at this time, even at night as he has been mostly in yellows and reds (except for one blue.).

Can you tell me what he eats? Also, what is your feeding schedule like. You are not feeding just twice a day are you?
By the way, you are doing an excellent job of testing.
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Ugh. The temporary vet couldn’t see my spreadsheet and wanted to hold him at 2 units until after the long weekend when she could take a more in depth look. I’m doing it because this was my first ever interaction with her but I’m definitely ready to up his dose.

See above re food. Would it be better to feed 3 meals on the 4 days I am home and 2 on the days I’m not or is inconsistency just as big of an issue as only 2 meals?

I do wonder if he has a flare up of his chronic pancreatitis going on. Since he’s already on fluids and an anti nausea other than adding a pain med there’s not much else that can be done.

Going to go grab a human meter today.

Thanks
 
tehg said:
He’s on Lotus Just Juicy (Venison for the IBD)—canned twice a day-250 kcal per day. He’s definitely the type to break into an automatic feeder so I’ve been hesitant to go that route to switch to smaller meals while I’m away from home. I’m sure he’d love it though.

In re the food, it’s the lowest carb lowest phosphorus venison that I can find that’s regularly available and but it’s not low enough that I can forgo a phosphorus binder. My vet and I tried changing his diet when he was first diagnosed (to the tiki cat chicken/fish varieties) and he ended up in the ICU for 3 days. Basically with the shortage of venison and venison based foods, my only other option is to pay for a custom designed venison diet from the local vet school’s nutritionists then prepare it myself.

The alphatrak II book indicated the cut off is 65 & I was concerned enough to start feeding him at 4+ each time because based on what I know about the timing of his evening nadirs he would have gone below 65 without the extra food & my thought was it would be better to preemptively avoid things getting worse rather than watching and waiting for it to happen.

I’ve been contemplating switching to a human meter for a better match with the numbers on this site, but I always seem to end up with 100s of test strips when I contemplate it and end up putting it off.
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Well, with the human meter you will want to keep him above 50 (above 68 on the AT meter.) Multiple smaller meals or lots of snacks during the cycle before nadir is always the best for diabetics regardless of which meter is used.
 
And you are giving him fluids and he has heart disease. I would caution you about how much you give and how frequently, but I have a feeling that you already are.
 
And I didn’t want to harass you too much last week, but I did want to ask about why you stopped insulin for so long last year. From the numbers I see, I do not believe that Finn was in remission (although he may have been getting close at that point while still needing a small bit of insulin support.). What is the major change that you see from last summer to now?
 
When he was diagnosed my vet gave me the canned food guidelines and told me that low carbs was more important than sticking with his novel protein for the IBD. So we switched foods and within a week the new diet had set off a day of vomiting and lethargy post-insulin dose & before my meter arrived. We went to the emergency vet for testing and in addition to discovering high BG his labs showed elevated creatinine. Recent earlier labs had been normal except for the BG.

Reluctance to discharge was probably due in part to the fact that they couldn’t discharge him with subq fluids due to the heart disease and in part due to the fact it was the beginning of a long holiday weekend. His kidney values normalized quickly after discharge & but slipped back up to be considered mild CKD though remained low enough to avoid the need for fluids for almost another year.

When it got to the point that he looked like he was going to need fluids somewhat regularly we did a cardio consult specifically to determine safety.
 
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Suzanne & Darcy said:
And I didn’t want to harass you too much last week, but I did want to ask about why you stopped insulin for so long last year. From the numbers I see, I do not believe that Finn was in remission (although he may have been getting close at that point while still needing a small bit of insulin support.). What is the major change that you see from last summer to now?
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My vet wanted the trial. I wasn’t particularly convinced he was in remission to be honest—my vets goal numbers have always seemed like a bit of a moving target to me.

I suspect, but can no longer confirm I was still testing regularly but not uploading the numbers to the SS if they were relatively the same back then.

Between summer to now he’s now in stage 3 CKD and now dropping down to 2 anymore; loss of almost a pound in body weight despite increased calories; decreased interest in food, though he still basically eats everything eventually; and more PU/PD. But with so many conditions this cat is hard to pin down: is the weight loss the IBD/small cell lymphoma, is the PU/PD due to the steroids, the diabetes, or now, the fluids, etc.
 
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Would you consider a switch to Lantus? He just goes too high on the ProZinc and then drops down in the middle of the cycle. He doesn’t seem to get good duration on PZ. I think Lantus could give lower, flatter curves with better duration. I was just thinking of you and Finn and thought I would stop by and say hello.
 
Thanks for checking in. It’s actually been a bit of a roller coaster since I was here last.

We had a minor crisis on the 27th when my otherwise garbage disposal of a cat turned his nose up at his 2nd portion of breakfast. He only refused food once before when very I’ll so I moved up his vet appointment and left him there for monitoring after. His latest blood work came back with a specFPL of 50 (sigh) but otherwise nothing stood out as unusual for him. Admittedly the FPL isn’t that much higher than it was last October (48.8) or August at (36.8) when his blood glucose was lower, but it isn’t good.

At this point there is so much going on that could be causing issues I get the impression the vets are playing whack-a-mole & the current mole is the pancreatitis. His insulin dose went up, more frequent B12, and opiates as needed. He also ended up on fluids every day for a short course while I religiously watched his resting respiration rate. This has been his first week back on the 3-4 day/week fluid dosing and I’m keeping my fingers crossed nothing major changes.

His nadirs finally tested in the blues @3 units, but it was while on daily subqs. I remain very frustrated by his pre-shots. The vet wants Alphatrak numbers so I’m actually testing with both meters most days and the preshots look much scarier with the pet meter.

I’d been wondering about Lantus before all of this, but held off asking for it as part of my first discussion with the new vet. With everything that’s going on now, it’s either try to eliminate possibilities by addressing one thing at a time or throw the kitchen sink at him… I’m not sure how to gauge the ideal time for a switch, or even when to ask.
 
tehg said:
Thanks for checking in. It’s actually been a bit of a roller coaster since I was here last.

We had a minor crisis on the 27th when my otherwise garbage disposal of a cat turned his nose up at his 2nd portion of breakfast. He only refused food once before when very I’ll so I moved up his vet appointment and left him there for monitoring after. His latest blood work came back with a specFPL of 50 (sigh) but otherwise nothing stood out as unusual for him. Admittedly the FPL isn’t that much higher than it was last October (48.8) or August at (36.8) when his blood glucose was lower, but it isn’t good.

At this point there is so much going on that could be causing issues I get the impression the vets are playing whack-a-mole & the current mole is the pancreatitis. His insulin dose went up, more frequent B12, and opiates as needed. He also ended up on fluids every day for a short course while I religiously watched his resting respiration rate. This has been his first week back on the 3-4 day/week fluid dosing and I’m keeping my fingers crossed nothing major changes.

His nadirs finally tested in the blues @3 units, but it was while on daily subqs. I remain very frustrated by his pre-shots. The vet wants Alphatrak numbers so I’m actually testing with both meters most days and the preshots look much scarier with the pet meter.

I’d been wondering about Lantus before all of this, but held off asking for it as part of my first discussion with the new vet. With everything that’s going on now, it’s either try to eliminate possibilities by addressing one thing at a time or throw the kitchen sink at him… I’m not sure how to gauge the ideal time for a switch, or even when to ask.
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Well it does seem like Cerenia, fluids, pain meds are necessary for Finn (possibly other anti nausea meds if he doesn't do well on that.) Did they give you Cerenia? It can really be helpful for pancreatitis flares. I'm glad you are down to less fluids... I understand religiously counting breaths!!! Those preshots do look scarier on the pet meter! You've really had your hands full.

Looking at that spreadsheet, I still really think he would do better on Lantus. It could give you much better preshot numbers. Some of the numbers he's getting right now area really hard on his kidneys. Are his kidney values stable right now, by the way? I hope so!!!
 
I'm waiting to hear from the vet on the latest numbers and just sent a follow up asking about Lantus.

I hope to get a call from her tomorrow. I have no idea how it will go, she seems on top of things but maybe a little conservative because she doesn't know Finn. But she can be interesting… For example, I broached the idea of using a human meter and while she was ok if I wanted to use a Freestyle Libre she didn't support use of a regular human glucometer. Since there's no logic there other than the Libre is covered in the AAHA guidelines and other human meters aren't. It wasn’t worth it to me to push for a real explanation, so I’m now testing with both the alphatrak and the contour until I’m more comfortable with the contour numbers at which point I’ll just use the alphatrak for curves.

Provided nothing goes terribly wrong, his regular vet is due back in two months so I can revisit anything I’m unhappy with then.

Finn's kidney values are stable (3.1 creatinine down from 3.4 in October & 61 BUN up a little from 58 in October)

He had a standing prescription for Cerenia, I asked about zofran but she didn’t want to add it unless we see vomtting or additional refusal to eat. I'm a little concerned about zofran adding to his constipation. Basically other than the reduced amount and frequency of fluids, it's the standard pancreatitis protocol.

I'm not sure if I wrote this out before but the current regimen is:
Budesonide 1mg daily
Cerenia 8mg daily because even before the latest pancreatitis flare every time we tried to taper him off he loses interest in food (monitoring liver levels)
phos-bind (1/8 tsp per meal for a total of 1/4 tsp/day)
miralax (1/8 tsp per day)
Normosol 75 ml every other day
B12 0.35ml weekly

As needed:
Bupe
Mirtaz
 
Well that didn’t go well. The vet feels that a switch isn’t needed yet because he’s still on a lowish dose of ProZinc.

Her previous claim that they really want to wait 10-14 days after adjusting a dose to make a change somehow became 21 days and she wants a full 2 hour curve next week. Not that I’m sure about what to do with his dose now, but without giving me any context, her decision to go past the AAHA recommended time to hold a dose is just annoying.

I tried to stress that the diabetes is basically the only thing we can treat at this point, but to no avail. I’ll try to revisit the conversation in the context of wanting something closer to a peakless insulin after completing the curve and see how it goes.
Are there any other tips for discussing a switch?
 
It definitely looks like a dose increase is warranted. The 3 units has been held too long - although I advocate for doing a curve or getting some mid cycle tests in like +5/6 and around there. You have a higher blue mid cycle test in there not too long ago. It’s just that in these higher numbers, you can have glucose toxicity which basically means that it will be harder to get the numbers down as his body is acclimated to higher numbers.

This vet sounds really difficult!
 
Diabetes is hard on the kidneys already and seeing so many pink numbers with red and some black is just not good for Finn. He’s spending a lot of time above the kidney threshold.
 
tehg said:
The vet feels that a switch isn’t needed yet because he’s still on a lowish dose of ProZinc.
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Doesn’t make sense. He’s on a lowish dose of ProZinc but she doesn’t want you to increase the dose yet to get him into better numbers.
 
Thanks. I talked to her again and got the impression she really didn’t want to entertain the idea of a switch— trying to put me off it because we’d have to “start over at the bottom of dosing with Lantus”.

I’m basically done with her. Asking her to explain the inconsistencies in her advice or switching to someone else in the practice for the next 6 weeks doesn’t make sense, so I guess I’m going to grit my teeth and use the SLGS behind the scenes rather than keeping him on the next higher dose for at least 3 weeks before changing.
 
tehg said:
Thanks. I talked to her again and got the impression she really didn’t want to entertain the idea of a switch— trying to put me off it because we’d have to “start over at the bottom of dosing with Lantus”.

I’m basically done with her. Asking her to explain the inconsistencies in her advice or switching to someone else in the practice for the next 6 weeks doesn’t make sense, so I guess I’m going to grit my teeth and use the SLGS behind the scenes rather than keeping him on the next higher dose for at least 3 weeks before changing.
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We don't do "resets" here. We take into consideration the current dose of the current insulin. And we use a judgment to decide how much the dose of the new insulin should be. There are loads of people here with experience in doing this. It's not that hard. But I understand you would need an Rx. Over on the Lantus/Levemir/Biosimilars forum, under dosing, there is an explanation about dosing when switching from the previous insulin. You definitely do not start over at the bottom. This can be dangerous and can put a cat into danger of DKA in some cases (when the numbers go really high from too low of a dose.) You must be frustrated.
 
Our vet did not seem to cooperative with dosing so we switched vets and had an much better out come. The new vet installed a libre sensor for 2 weeks and found that the amount of insulin was too high. That was 5 months ago and we ended up cutting her insulin by half. Now she is mainly in a good range of under 200 and the occasional bounce but is doing better on 1/2 the amount of insulin. It doesnt hurt to get a 2nd opinion.
 
Hey there. I see you switched to Lantus. Are you posting over on the Lantus Levemir Biosimilars Board? I haven't seen anything? He looks like he needs an increase. If you do TR then you can make dose adjustments every 6 cycles (3 days) if needed.
 
Thanks for checking in.

His dose is going up asap. I made the insulin switch but haven’t moved boards yet… I was trying to absorb all the info and waiting until I had a question, which means getting labs, discussing with the vet first, etc.
 
It looks like he was due for a dose increase, although the spreadsheet isn’t up to date so I can’t see what nadirs he’s been getting lately. I would not have advised starting at only 1.5 units considering he was on 3 units of ProZinc. But now that you have seen how he’s doing on 1.5 units, you should be able to make the .25 increases per the SLGS protocol.
 
My human meter spreadsheet got a little sparse while I was actively tracking AT number for the vet, I had them, but wasn't inputting them, this is now fixed.

I wasn't happy with the 1.5 either. Now that we have the labs, based on the results, his BG readings, and yet another concurrent condition, we've got a lot to do. It's hard to say whether all his organs are starting to shut down because he's hit the point where he's just old and sick, or if some of it could be reversed for a while. Since the diabetes is the easiest/only thing to treat, we're taking a more aggressive approach and did a jump to where we should have started the glargine, seeing where that gets him then evaluating what method to use going forward.

He's had a couple of yucky days which I thought might be a pancreatitis flare, but based on the numbers seems more likely to be an increase in CKD.
 
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