First month of treatment - no success. Please help!

Hi everyone,

I'm terribly anxious about my boy's condition. Simba is 7 years old and he's like a baby to me, so I am very desperate to get any advice on what to do!

Simba's been relatively healthy up until the last two years or so, when he suddenly developed constant diarrhoea. Switched up his food to Hill's z/d hypoallergenic food and that helped. He also got some chin acne from time to time, but the flare-ups were treated. A couple of months back he got a cortisone injection to treat his coughing fits, which occurred roughly once per week. That all seemed to be under control. He had gained quite a bit of weight on the hypoallergenic food, so he started on a diet at the end of August 2020. He used to weigh 8kgs, currently he is around 6.5kgs.

In mid-November (2020) I noticed his excessive drinking, urinating and drastic weight loss and took him to the vet. He got diagnosed with diabetes and an UTI. We started on 2 units of Protaphane insulin in the morning and evening, along with a course of antibiotics and oral pain medicine to treat the UTI. I bought vitamins, probiotics, and a Freestyle Freedom Lite blood glucose monitor. The blood glucose when measured at the vet's at the time of diagnosis was 498 (24,7 mmol/L). This was at the end of November.

Simba has been extremely patient with the injections and glucose monitoring, I have stuck to a schedule of feeding him wet foor every 12 hours with a couple of tablespoons of dry food in the day. Currently his wet food is Royal Canin diabetic (with a mix of Hill's z/d) and dry food is Hill's m/d.

I try to stick with the following feeding schedule:
8am breakfast - wet food
noon - two-ish tablespoons of dry food
4pm - two-ish tablespoons of dry food
8pm dinner - wet food
10pm - two-ish tablespoons of dry food

The vet suggested to give him a bit of dry food after dinner, as he was vomiting bile every morning before breakfast for a couple of days. That seemed to resolve the issue. I am also trying to get him onto the Royal Canin wet food entirely, but because he's had tummy issues before I still mix it with the Hill's z/d.

He has just finished his second course of antibiotics for another UTI that was diagnosed on the 21st of December. Since his blood glucose hadn't improved the vet increased his insulin dosage to 3 units in the morning and at night. We are due for another visit to the vet in a couple of days, but I am freaking out about his blood glucose again. For a while it seemed like small improvements were happening, but I can't understand what can be causing the terribly high readings after making so many adjustments and two rounds of antibiotics.

I have kept a log of his blood glucose readings (date, time, reading + additional info):

2020
27.11. Started first course of antibiotics
28.11. 21:18 17,8mmol/L (1,5h after dinner)
29.11. 20:08 12,5mmol/L (before dinner)
2.12. 07:53 20,0mmol/L (before breakfast)
2.12. 15:55 10,1mmol/L (before dry food)
3.12. 07:05 16,8mmol/L (before breakfast)
4.12. 20:14 13,4mmol/L (before dinner)
6.12. 20:00 16,7mmol/L (before dinner)
8.12. 07:58 14,5mmol/L (before breakfast)
9.12. 19:58 21,2mmol/L (before dinner)
12.12. 19:50 22,4mmol/L (before dinner)
14.12. 07:46 19,4mmol/L (before breakfast)
15.12. 20:28 21,2mmol/L (before dinner)
16.12. 14:15 18,7mmol/L (between dry food)
16.12. 21:24 23,6mmol/L (after dinner)
17.12. 09:55 24,3mmol/L (before breakfast)
18.12. 11:38 10,9mmol/L (before dry food) + Started second course of antibiotics
18.12. 22:00 17,1mmol/L (before dry food)
19.12. 15:18 22,2mmol/L (before dry food)
19.12. 22:00 18,3mmol/L (after dinner)
20.12. 12:26 19,0mmol/L (during a long car ride)
21.12. 07:52 23,8mmol/L (before breakfast)
21.12. 11:51 15,1mmol/L (before dry food)
21.12. 19:31 17,1mmol/L (before dinner)
22.12. 07:49 21,9mmol/L (before breakfast)
22.12. 17:10 18,3mmol/L (before dry food)
23.12. 08:06 19,6mmol/L (before breakfast)
23.12. 18:19 19,4mmol/L (after dry food)
24.12. 07:50 22,2mmol/L (before breakfast)
24.12. 10:37 18,3mmol/L (after breakfast)
24.12. 19:41 18,3mmol/L (before dinner)
25.12. 11:43 10,1mmol/L (before dry food)
25.12. 19:51 21,7mmol/L (before dinner)
27.12. 08:24 17,8mmol/L (before breakfast)
28.12. 15:34 15,1mmol/L (before dry food)
29.12. 19:40 16,5mmol/L (before dinner)
30.12. 15:51 12,6mmol/L (before dry food)
31.12. 08:08 17,3mmol/L (before breakfast)
2021
1.1. 19:39 17,6mmol/L (before dinner)
3.1. 08:04 21,6mmol/L (before breakfast)
3.1. 19:11 15,9mmol/L (before dinner)
3.1. 23:00 21,2mmol/L (after dinner)

Seeing as the optimal glucose should be between 3,9-8,3mmol/L... The closest Simba's had is 10,1mmol/L, and that's only happened on a rare occasion.

Any help, advice, words of wisdom and encouragement are deeply appreciated! Thanks to every single one of you who make it through this massive post. Are there any suggestions on what should I ask the vet?

Simba & Lina

 

Welcome to FDMB, Lina.

It sounds like you've been putting a great teal of time and energy into caring for Simba. The members here are very generous with their time and knowledge. We'll do what we can to help.

I'm guessing you're in Europe. Protophane isn't used by that name in the US. I believe it is the same as NPH/Novolin N although I can't tell if it's exactly the same. They are made by the same manufacturer (Novo Nordisk) The American Animal Hospital Assn recommends that Lantus (glargine) or Prozinc are the preferred types of insulin for cats. The insulin you're using is comparatively harsh in that it can drop numbers quite low and quite quickly. Lantus and Prozinc are longer lasting and gentler. You may want to discuss changing insulin with your vet.

The other issue is that what you're feeing your cat is high in carbohydrates. As a rule, most dry foods are hideously high in carbs. Even many of the canned, "prescription" foods are often high in carbs. (For example, the Z/D canned food is 35% carbohydrate. We consider anything over 15% as high carb.) We strongly advocate for a low carb, canned food diet -- food that's less than 10% carbs and most of the members here feed their cats closer to the 5% range. If you let us know where you're located, we may have recommendations for lower carb food than what you're currently using.

It's wonderful that you're home testing. I'd encourage you to look at this post on helping us to help you. There are instructions for what information to include in your signature (so we don't keep asking you the same questions over and over again) and how to set up a spreadsheet. If you look at any of our signatures, you'll see our spreadsheet are there. It's a means of keeping track of your cat's progress and it lets us observe, as well, so we have the necessary information to be able to make recommendations. You may also want to get more spot checks in addition to your pre-shot tests. The pre-shot value tells you if it's safe to give insulin. The other tests will tell you how low (the nadir) the dose is taking your cat's blood glucose (BG) level.

If you need help with the spreadsheet, I'm tagging Bhooma - @Bandit's Mom - and she can give you an assist.

 

Hi,

I’ll get to work on the spreadsheet and signature tomorrow, once I’m back on my laptop.

I am in indeed located in Europe, Finland to be specific. The manufacturer of the insulin pen is “Novo Nordisk”. I haven’t been able to find a lot of information on this type of insulin and I’ll definitely ask the vet about the other options. Even the high dose Simba’s on currently hasn’t given the results I was hoping for. What low carb foods would you suggest that are available in the European market?

Thanks in advance,
Lina & Simba

 

Protaphane® is an isophane insulin suspension (NPH)
https://www.novonordisk.com.au/cont...au/Patients/Documents/Ins Susp Penf PIL 5.pdf

 

Some info on Protaphane from the PetDiabetes wiki:

https://petdiabetes.fandom.com/wiki/Protaphane


Mogs
.

 

Here's a food list for the UK but many of these foods are available in Europe. It's a good place to start.

 

It won't take me more than a minute to set it up, so let me know if you have any problems setting them up. Welcome!

 

I think I've managed to set up my signature and now I'm just trying to wrap my head around entering the data in the spreadsheet. Could you help me out please?

 

Good job with the Spreadsheet and Signature!

This sticky explains how to enter data in the SS. If you still have trouble, let me know
https://www.felinediabetes.com/FDMB/threads/understanding-the-spreadsheet-grid.156606/

 

Do you buy food from zooplus? And if so, where?

I'm from Denmark. Nice to see a Scandinavian
Diabetes sucks big time, but you're in the best possible place

 

Thanks for the help! I think it's all set up now, let me know if something looks totally off.

 

Hi, fellow Scandinavian!
I order food from the zooplus online store. I actually got a huge package today with Royal Canin Diabetic wet food, but now I'll have to research to see if the nutritional value is suitable for Simba... he's currently dealing with an upset stomach (very loose stool, no shape to it) and both of his eyes have this red crusty bit forming on the inner corners. He's been drinking and peeing a lot again and I'm extremely worried so I've booked him in to a visit at the vet's tomorrow.

 

Perfect!

Are there some days when there are no tests before giving insulin? AMPS and PMPS cells are empty.

 

Correct, I haven't been testing him every time before giving insulin. My vet said I could test him "occasionally" and that it wasn't necessary, but for my own peace of mind I've been aiming to test him at least once per day.

 

Zooplus.uk? De? Dk? Se? Do Finland have one too? It might be cheaper in Germany, it usually is for me. Or perhaps Sweden.

You really need to test before every shot, to make sure he's high enough to get insulin. Every time, to be safe. As I understand it's a very harsh insulin you're using.

 

Zooplus.fi, Finland have their own webshop. I'll definitely start testing more frequently now. Although this insulin hasn't helped Simbas glucose levels go down, as they consistently creep back up to where we started from. Will discuss this with the vet tomorrow to see if we can switch him to Lantus and cancel out any other serious health issues.

 

@Critter Mom - Mogs: It looks like from the link you posted that this is the same as Humulin N/Novolin N. However, the information is not consistent with the onset, duration, and nadir in cats. What's posted is more consistent with the pharmacology in humans. I don't know of any insulin that's used in cats with a duration of up to 20 hrs.

 

Sienne, the link I posted doesn't make such a claim for Protaphane's duration in cats.

From the linked page:

This type of insulin tends to have an onset of 2-4 hours, a peak action of 4-10 hours, and a total duration of 10-20 hours, in humans.

These times seem to be similar in dogs, but considerably compressed in cats, possibly because of cats' faster metabolism.

Cats seem instead to experience a 1-2 hour onset, a peak action of 4-6 hours, and a total duration of 8-12 hours maximum, according to user surveys on Felinediabetes.com​

[Emphasis mine]


Mogs
.

 

https://www.google.dk/url?sa=t&sour...FjANegQICBAB&usg=AOvVaw2czpUg4HezOdBu4RL22U4l

Looks like it's a long lasting insulin.
I can do more research if you'd like, or call Novo Nordisk - it's a Danish company.

 

https://diabetesindogs.fandom.com/wiki/Protaphane

 

Looks like it's commonly used in Australia.
@Bron and Sheba (GA) do you know anything about it?

 

I have not heard of or seen this insulin used in cats in Australia.
Lantus is the commonly used insulin for cats in Australia.
As far as I am aware, the protaphane insulin mentioned above is for humans. Cats metabolism is much faster and will only last about half the time it will in humans.

 

Thank you fo

Thanks for the offer! I will see what the vet says about the insulin, I am secretly hoping she'll switch it to Lantus. I'll post an update later, Simba is currently sedated at the vet's after 45mins and three unsuccessful times trying to draw his blood. The vet also mentioned that the glucose monitor I'm using isn't accurate, which I'm aware of... It still shows proof of Simba's high blood glucose in contrast to sampling my mum's cats blood.

 

I just received my order of a massive multipack of Royal Canin Diabetic wet food. Debating whether to send it back and order something from the list, as I couldn't find this particular food on the list. Not entirely sure is the nutritional value suitable?

This is from Royal Canin's website:
Analytical constituants: Protein: 8.9% - Fat content: 3.2% - Crude ash: 1.7% - Crude fibres: 1.1% - Moisture: 82.5% - Essential fatty acids: 0.54% - Total sugars: 1.3% - Starch: 1.2% - source of carbohydrates: modified corn starch - rice.

 

Using the above figures gives a value of 13.5% kcals from carbs, so would be classed as a medium carb food.


Mogs
.

 

Thank you! I'll be returning that and ordering something with less carbs. Simba's been on hypoallergenic food before so I'm looking at something as close to "natural" as possible. I'll look into making food at home as well eventually, once the current situation settles. So much going on right now!

 

In humans, yes; in cats, no. The info at that link applies to human patients, not cats.

Cats metabolise insulin significantly faster than humans and dogs (see the info in post #18 above to see the comparison of onset, peak and duration between humans and cats).

NPH insulin in cats typically hits hard and fast and has short duration (hence the recommendation in the FDMB Novolin guide to wait 60 minutes after feeding before administering the insulin dose).


Mogs
.

 

Simba update:

I am back at home with my boy after a very stressful day at the vet's. Three separate veterinarians tried to hold Simba down to get a blood sample, but after 45minutes they gave up and sedated him. I believe it was for the best as at this point he was very agitated and stressed - he's usually such a gentle giant. I spent the longest 2 hours waiting to be able to go and pick him up. On the bright side I used this time to order some better food for him.

Blood glucose measured at 25.68mmol/L (462mg/dL)
Fructosamine measured at 655
The vet also mentioned that his electrolyte potassium had gone down by 3.3, but didn't really elaborate any more on what that meant.
From the urine sample the vet concluded that it contains glucose and ketones.

Awfully high numbers, but I'm not surprised given the rare occasion his blood glucose measures relatively close to a normal range. I discussed the possibility of switching up Simba's insulin to Lantus, but the vet explained that Protaphane is used because it is a longer lasting/longer acting insulin. She also questioned my injection technique and shaved two patches on Simba's side as guidelines for where to inject. We will go back in a week and (hopefully!) see improvements. I doubt that my injection technique is to blame, I just don't think this insulin is doing Simba any favours. I also got Simba some moisturising eye drops and canikur pro paste to deal with the other issues.

I'm just happy to have Simba back home with a good appetite and just a bit drowsy. Measured another very high BG pre-shot, let's see if this "new technique" is any different!

 

If the info in the petdiabetes wiki is correct and Protaphane is an NPH insulin (which Wikipedia also advises) then it is definitely not a longer lasting insulin than Lantus in cats.

Of the cats I've seen here on NPH insulins, typically their BG drops hard and fast in the first couple of hours and the dose is pretty much spent around the 8-hour mark at which point BG typically returns to the preshot level. (Note: If the cat is bouncing, BG may go even higher.)

In comparison, Lantus is a depot insulin that builds up a little 'tank' of insulin under the skin, which gives it much better duration of effect. Lantus typically has a gentler action than NPH insulins and, with sufficient testing, it can be safely administered at lower preshot levels. This means that it is possible to regulate cats more tightly on Lantus (also Levemir) and thus increase chance of remission.

According to the most recent AAHA guidelines for management of diabetes in cats and dogs, NPH insulins are only considered suitable for canine diabetics (they have slower metabolisms than cats).

From linked document:

NPH(U-100 human recombinant; Neutral Protamine Hagedorn, Humulin N, Lilly or Novulin N, Novo Nordisk)is an intermediate-acting insulin that is used in dogs. The Task Force does not recommend use of this insulin in cats due to its short duration of action. ​

[Emphasis mine]


Mogs
.

 

When did your vet last read up on feline diabetes?
Like Mogs say, it is long lasting in humans, but not depot as I understand. And there's absolutely no information on Google, a little about treatments in humans and a tiny bit of dogs...
I can't figure out how your vet came up with that idea?
And you have showed it doesn't work as intended. If kitty now has ketones, it's REALLY important to get the BG down.
I really think you need to talk about to your vet about her reasons, knowledge about diabetes and insulin...
Are you checking for ketones at home?

 

Correct. NPH insulins are in-out.

Maybe they're more used to treating canine diabetics?


Mogs
.

 

I have yet to read a single positive thing about the insulin I'm currently using. I have booked an appointment in two days time and I'm determined to get a prescription for Lantus.

 

I went to a clinic that has veterinarians who are "specialised" in treating cats. Unfortunately this is not the impression I got, just a bigger bill than the previous vet. This lady was insisting that I kept using the same insulin and come back in a week but I can't stand another week of uncertainty and fear about Simba's well-being.

 

Way to go!!!! Ask her to read up on treatment for feline diabetes. Really, you can't get anything better than Lantus.
If she refuses ask her to make a simple Google search, or show you where exactly your insulin is being recommended for cats.

 

The irony in this whole ordeal is that I went to a "specialist" vet - supposedly specialised in treating cats. This is a different vet to the one that prescribed Protaphane in the first place and I was shocked that she confirmed that it's the best option. I haven't measured ketones at home, but looking at buying ketostix (or whatever the equivalent in Finland is) ASAP!

 

I'll do exactly that! I can't wait any longer for my bubbas health to deteriorate due to inefficient treatment. Last resort will be calling every vet in the city and asking for the prescription.

 

And if she still refuses, I'll need some info on sending insulin by snail mail. I have two pens of levemir, the temperature should be cold enough to ship.
So we can prove her wrong!

 

Or depending on where you are in Finland, I could find someone to bring it and keep it in the fridge. My dad used to drive a truck to Norway, and was very often in Finland. Maybe he still have some contacts!

 

Ohhhh you're an angel! I've asked my diabetic friends what insulin they're on and I still have a few cards up my sleeve but I'll definitely get in touch if all else fails.

 

Oh that's a good idea! You can look further down on the forum page, there's a lantus/levemir forum, prozinc- not human, and treshiba I believe it's called, to see witch is used in cats. Perhaps your diabetic friend knows someone else on lantus for example. A few pens will get you a long way!

 

I've just measured Simba's BG at +4 hours post dinner shot and it's the lowest it's been in two weeks at 187. Previously he's measured similarly between +4 and +7 hours post shot. Should I set an alarm to check on him in a few hours in case of a sudden drop or are we comfortably in the safe zone? I'd be VERY surprised if it was anything close to 350 in the morning as usually it's waaaay up because the insulin has completely worn off.

 

Always a good idea to do PM tests too.
And it's not uncommon to see a rise after the injection. I wouldn't be surprised if he's lower than you expect at amps.
Also I've learned a lot just by looking at other people's spreadsheets. Not to copy dosing, but just to see how a BG fluctuate, bouncing, nadir, time-line of onset and so on.

 

It’s 1:20am here and I’m just wondering should I test him again or leave it be until tomorrow morning.

 

I test mostly out of curiosity really. I did a +2, even though it never tells me anything, but I'm just curious. I'm still going to set my alarm for 3 this morning, its 00.25 here. Cause IF she goes low, I can catch her in time at +5. It's really the only test in both cycles I absolutely won't miss. So up to you, but you can never test too much. Find your own routine and what works for you and your schedule.

 

Hi Lina,

I'm going to tag one of our most experienced members, @Deb & Wink, to ask whether she might be able to give you some pointers on the Protaphane insulin you're currently using.


Mogs
.

 

I actually don't know anything about the Protaphane insulin. Don't feel that I'm able to help in this situation.

 

@Deb & Wink - Thanks for replying, Deb. You were the only member I could think of who might possibly have come across it.


Mogs
.

 

Update: Simba's regular vet switched him to Lantus. We are starting tonight. Our regular vet is lovely and she was very concerned about the ketones and glucose in his urine, as this was a new development since our last check-up with her. I've had Simba on 3 units of Protaphane for around 3 weeks now and she suggested I'd continue with the 3 units, and lower it to 2 if his glucose is around 190 prior to food + shot. This does sound a bit harsh to me as a starting dose...

Thoughts on this? Should I start on a lower dose just to see how his body reacts?

 

Hi Lina,

Great news about the switch to Lantus. There are many members experienced in its use here so we should be able to help you two much more going forward.

On the Lantus start dose, because Simba's already been receiving insulin treatment, the dose used for the previous insulin should be taken into account and the starting dose of Lantus should be somewhere in the same ballpark as the dose of the previous insulin. Also, because Simba has tested positive for ketones extra care is required when setting the starting dose to make sure that Simba gets enough insulin to reduce the risk of ketone generation. (Did you manage to get ketone test strips/a ketone meter yet, BTW?)

I'm going to tag @Wendy&Neko to ask her to help you with setting the Lantus start dose.


Mogs
.

 

Okay, thanks! Unfortunately my local pharmacy didn't have any keto test strips in stock so I'll have to shop around or possibly order online. I want to be extra careful switching the insulin tonight in case of a hypo event. Feels unlikely but I don't want to risk it! I am also running on an average of 5 hours of choppy sleep over the last week or so and it's starting to take its toll...

 

If you have any vitamin shops nearby, that might also be a source of ketones strips.

As for dosing, how closely can you monitor on the first cycle of Lantus? Do you have U-100 syringes with 1/2 unit markings? I agree with Mogs that the 3 units would be a good place to start, provided you can monitor closely. Sounds like you still have higher carb food around should the dose prove to be to high.

 

I placed an order for some strips, they should arrive early next week. I’m just about to inject the first dose of 3 units after Simba’s done with his dinner. PMPS was high again, I’ll update my spreadsheet with the info. I have the insulin pen so only whole units available. I’ve read up on the information about Lantus and I’ll go into the pharmacy to ask for small syringes as well. And yes, I still have Hill’s z/d in the cupboard, that was quite the carb bomb.

 

Start with a +2 or +3 tests after the shot. Paws crossed he likes the Lantus better.

 

Thank you for the advice! I have a good feeling about this.

 

I just realised I'd skipped this part of the question! But I've measured at PMPS +2, about to measure +4 and see if I can sleep for a couple of hours. Should I wake up to test at +6 nonetheless or sleep until +8? I know I could've started Lantus tomorrow morning but I was very eager to switch ASAP.

 

A favour to ask of you. Could you put a blank line in the spreadsheet before your first dose of Lantus, and label the line something like "start Lantus". That just makes it really easy for us to find when you started it.

As for testing tonight, get some sleep. It takes several days (5-7) for the depot to build when you first start Lantus, and you may or may not see much action for a few days. But who knows, this is cats we are talking about. If the +2 is above the preshot number, most likely a quiet cycle. Info on what to look for on Lantus is in the sticky notes on top of the Lantus forum. Might want to pop on over there and start reading if you haven't already.

 

Fixed my SS to clarify things. I was too nervous to sleep through the night but I think I'll leave the nightly testing for next week and see his +2 or +3 post PM shot for now. Last night leading up to this morning looked pretty stead with no major crashes as previously experienced with Protaphane. And thanks, I'll look at the sticky notes on there as well.