Foyi's journey

[fpa]

Hello and thank you for this wonderful resource. I'd be grateful for any help with the insulin dose and type.

Foyi was diagnosed 3 weeks ago and was started on 2.5 units of caninsulin/vetsulin, which was ineffective. I convinced the vet to switch to prozinc and this seems to have helped with his glucose. Three days ago the dose was increased to 3 units, glucose values seem somewhat better especially in the afternoon, but his diurnal range is still very big with some very high hourly values.

Should I keep him on 3 units for at least a week and see how it goes?

His late morning and afternoon glucose values seem lower than the overnight ones (see here), so I wonder if I will end up with different AM and PM doses.

I asked the vet if it's possible to switch to glargine as this seems to produce flatter curves and has better chances of remission, but he says that legally we need to try the animal licensed insulins first (I am in the UK).

Foyi is a 16 year old male, weighs 7 kilos and he's now eating only this wet food which seems to have 4.5% carbs. He is fitted with a freestyle libre 2 sensor.

Thank you for any help!

 

[DavidJ]

hello, I'm new here too, so i dont have any advice to offer Im sorry. My cat Charly too is newly diagnosed and her spreadhsheet looks quite similar. It is not nice seeing so much red and black I know. I hope both Foyi and Charly will regularly see better numbers soon.
I am hugely impressed with all the testing you are managing to do. I hope you are looking after yourself too and getting enough sleep!

 

[fpa]

Thanks, I am not testing it myself actually, all these readings come from a freestyle libre 2 monitor (which I know is not very accurate and it probably under-reads the glucose). It will only last for a few more days, so I'll probably have to start manual testing then.

Good luck to Charly!

 

[Suzanne & Darcy]

Hello and Welcome to the FDMB! You are already doing very well with feeding a low carb wet food diet and having the Libre on (not to mention that you already have a spreadsheet set up with loads of data… I am in heaven! LOL!). The Libre isn’t perfect, but it’s a useful tool especially if you are away from home for long periods of time. It’s also useful to have while you learn to test manually. We always recommend that even people with Libre sensors know how to test manually to re-check a low number, or for when the sensor fails, or the cat removes it. The number one problem with the Libre is it’s alerting you that there’s low BG when actually it’s not that low. It’s good to be able to spot check that so you can make the correct decision on how to proceed.

Now, looking at your spreadsheet, I would not advise increasing the dose at all at this point. See how you are already getting green nadirs (lowest point in the cycle) already on this 3 unit dose. In order to keep Foyi safe from a hypo, we have to take that into consideration for dosing. All those high reds and blacks on your spreadsheet are not the fault of the ProZinc, it’s just that Foyi is spending a lot of time bouncing. Bounces can occur any time the cat drops into BG numbers that their body is no longer used to. It’s a protective mechanism where the body releases Glucagon from the liver and other counter-regulatory hormones that work to elevate blood sugar and can keep it high for a while. Bounces can last up to six cycles (a cycle being the 12 hours from one insulin shot to another.). They don’t necessarily have to last that long. One sign of progress is when the time between bounces gets shorter (e.g. four cycles instead of 6.) Bouncing doesn’t mean that the cats dose is too high (although it could be)or that the cat has dropped into dangerous numbers (although, again, it could be) it just means that the cat has either dropped too rapidly or into BG numbers that are lower than what the diabetic body is now accustomed to. This is what I see on your spreadsheet. It’s very good that, when Foyi is not bouncing, you are having a good response to the ProZinc. You are getting a solid four hours in greens on this dose, which is excellent. You are also getting some additional hours in blue… also good. I look at a lot of ProZinc spreadsheets and this is very promising. Foyi may be one of those cats who does very well on ProZinc. If you increase the dose now, when you are already having green nadirs, I feel certain that it would drive his BG below 50 and put him at risk for hypoglycemia. Sure, he would still have high numbers when he’s bouncing…. But when the bounce starts to clear his BG would go too low. Does this make sense?

 

[Suzanne & Darcy]

We can talk more later. I must get out to the grocery store.

I would hold this dose for now and let’s see how it goes. You are already having nadirs in the target range for the Modified ProZinc Method. With MPM, you can increase the dose every six cycles if necessary (but right now you don’t need to). You decrease the dose any time your cat drops below 50 (a .25 unit decrease.)

It can take a while to get up to speed on home testing…. to het the cat accustomed to it and for you to be able to get blood… so I would start now while there’s no pressure because you still have the Libre sensor on Foyi. @DavidJ is also in the UK and he uses a GlucoNavii. He can tell you how he likes it and about costs, etc.

 

[fpa]

Hi Suzanne, thank you very much for your post. Very clear and it makes sense and I am glad to hear that Foyi's numbers look promising.

I'll try to start manual testing this weekend to see how he reacts. He is on two different tablets daily (maropitant and a blood thinner), so didn't want to stress him more, but perhaps he won't mind.

The vet suspects acromegaly too and we are waiting for the blood test results, but his early response to the insulin and lack of physical changes to his face make me think that he doesn't have it.

 

[Suzanne & Darcy]

His spreadsheet does not look like an Acromegaly spreadsheet to me, and my boy was an Acrocat. We don’t normally recommend testing for Acromegaly until the cat is at a higher dose, but I suppose anything is possible. I hope the results will be negative.

 

[Suzanne & Darcy]

Why is he on Maropitant? Does he have nausea? Why is that? And the blood thinner? Does he have heart disease?

 

[DavidJ]

We can talk more later. I must get out to the grocery store.

It can take a while to get up to speed on home testing…. to het the cat accustomed to it and for you to be able to get blood… so I would start now while there’s no pressure because you still have the Libre sensor on Foyi. @DavidJ is also in the UK and he uses a GlucoNavii. He can tell you how he likes it and about costs, etc.

GlucoNavii has been working fine for me. It requires one of the smaller blood samples of the glucose meters I could find and the strips seem not crazy expensive. They are about £22 for a 100 on Amazon. I'm not sure how this compares with other meters.
I found getting blood from the ear is quite tricky to start with but if you persevere and follow the various tips available here I'm sure you will be fine. Warming the ear up first made all the difference for me.

 

[fpa]

I wonder if anyone can comment on whether I am doing things right. Foyi's glucose readings (taken with a freestyle libre 3 sensor, so not very accurate) are consistently higher during the night vs daytime and it also takes longer for his glucose to drop after the evening shot.

Five days ago we increased the evening (~7pm) prozinc dose to 3.5 units, but kept the morning dose at 3 units. I can't really see much of an impact yet and there was one recent night (Friday) when his BG stayed very high throughout the night. I don't think we can increase the morning dose as his glucose drops during the day. He is not eating during the night, so it's not food that is causing this.

I wonder if there is anything else we can try (e.g. increase the PM dose to 4 units?) or just switch to glargine/lantus for a flatter curve or should I just be more patient and give the current protocol more time? The vet seems to prefer the more concentrated version of glargine (Toujeo), but I can see that not many people seem to use it here and there is not too much info online either.

Thanks for any help!

 

[Suzanne & Darcy]

I doubt if you will believe what I am going to say, but look at today’s numbers… you have had some amazing blue and quite low green numbers today. Do NOT increase the ProZinc dose at this time. Your sweet baby is not used to low numbers yet and is a very bouncy cat. He goes very high after he gets into healthier numbers that his body isn’t accustomed to anymore.

 

[Suzanne & Darcy]

He tends to get lower numbers during the day, which is causing the higher numbers at night. It requires a lot of patience to see if the bouncing gets better. I would not advise, at this point, a higher dose (especially a half unit increase) at night. For now you have been getting away with it, but he has had a few low numbers at night that I am afraid may become too low when his numbers start to smooth out. You have the Libre, so hopefully that will alert you to possible low numbers and you can back check it with a handheld meter to see if they’re really low.

 

[fpa]

I doubt if you will believe what I am going to say, but look at today’s numbers… you have had some amazing blue and quite low green numbers today. Do NOT increase the ProZinc dose at this time. Your sweet baby is not used to low numbers yet and is a very bouncy cat. He goes very high after he gets into healthier numbers that his body isn’t accustomed to anymore.

Thank you Suzanne and I do believe what you say, it makes a lot of sense

Doing nothing and giving more time to Foyi to adjust to the insulin was my preferred option, but I thought I should ask here too. He did get a a few hours with better BG overnight and he's now doing his typical morning bounce.

I just wonder if his curve stays like this in the next few weeks, whether I should eventually switch to lantus/toujeo.

 

[fpa]

Hi Suzanne (and everyone), I am interested in your take on Foyi's BG trends. His numbers have been coming down relatively nicely (perhaps too aggressively?) and I was ready to reduce the insulin dose today by 0.25u, but his BG was quite low this morning so I just skipped the morning dose.

It's now coming close to the time of his PM shot (so 24 hours since the last insulin shot), but his BG is still relatively low (135) so I'll probably skip the evening shot too.

I wonder what is going on though, I doubt this is remission as my understanding is that you need to gradually reduce the insulin dose before remission is achieved, but in any case his pancreas seems to be producing some insulin today (or perhaps I have been injecting too much of it!)

No clinical signs of a hypo, he is himself and he is now urinating 4-6 times a day (compared to 10-12 times a month ago).

Thanks for any help!

 

[Suzanne & Darcy]

Wow. He had lovely green numbers today and I see he is trending upward a bit this evening. Just keep tracking his BG so we can make decisions for going forward.
What date did you make the change to low carb wet food?

Also, it’s important to mention that, with the lower numbers he’s been getting— he has earned reductions in his dose several times just in the last few days (when he dropped below 90).

 

[fpa]

Thanks, the change to low carb food was made pretty much upon his diagnosis (almost 2 months ago).

Unsurprisingly his BG was higher this morning (using a human glucometer now) so I injected him at the usual time with a slightly lower dose (3 units vs 3.25 previously), but his numbers during the day still look on the low side, so I wonder if I should reduce the PZ further (to 2.75u) or stick to 3u for a few days. His weight is 7.2kg (pretty normal now as he is a big male cat), so 3u of PZ is 0.42 per kg.

 

[fpa]

Even though I reduced yesterday's evening dose to 2.5 units, his BG was again low this morning so I skipped the AM shot.

If BG rises during the day, I am thinking of trying 2u or even 1.5u of insulin tonight.

Clearly though his pancreas must have started producing insulin again and it gives me some hope of remission, but I know I have to tread carefully.

 

[Suzanne & Darcy]

He earned a reduction down to 2.25. However, with the lower AMPS this morning, I would have stalled for 30 minutes or so without feeding to see if his numbers were stable or rising. I would have given a small amount of insulin— maybe just .5 units as long as I could be around to monitor his cycle a bit. It looks like he’s heading up toward yellow right now.

 

[Suzanne & Darcy]

Important question:

What and when is he eating? What is the schedule? Are you giving him anything other than low carb wet food when he’s in these nice greens?

 

[Suzanne & Darcy]

Why is he on a blood thinner and Cerenia (Maropitant)? What other health conditions does he have. Could you add his age, date of diagnosis, type of meter being used, type of insulin, other health conditions and medications. I won’t have to keep asking you the same questions over and over if you do this.

 

[fpa]

He earned a reduction down to 2.25. However, with the lower AMPS this morning, I would have stalled for 30 minutes or so without feeding to see if his numbers were stable or rising. I would have given a small amount of insulin— maybe just .5 units as long as I could be around to monitor his cycle a bit. It looks like he’s heading up toward yellow right now.

I stalled feeding for an hour actually but his BG was just not rising. It's been in the blues most of the day (150-180) and it's now 2.5 hours before the evening shot.

I spoke to the vet today and he thinks if at the time of injection his BG is <160, then I shouldn't inject and if >160 then I should try 2 units and see how it goes. He was very encouraged by the BG numbers. I like your idea too of injecting just 0.5 units if BG is low.

As for the questions, I had some of that info in the spreadsheet, but it makes sense to add it to my signature. We struggled with the blood thinner (clopidogrel) as it's a big and bitter pill, but the cardiologist thinks he needs to take it daily.

We tried several times to stop the maropitant, but he becomes quite restless and also vomits 1-2 times a week, so the vet thinks it's ok to keep him on it.

As for the BG monitoring, it's mostly done with the freestyle libre 3 sensor. I have also used a glucometer (accucheck) around 20 times now and I found that the FS3 tends to overshoot by ~20% at the extremes, but it's otherwise not bad at all.

Thanks again for your help.

 

[Suzanne & Darcy]

I stalled feeding for an hour actually but his BG was just not rising. It's been in the blues most of the day (150-180) and it's now 2.5 hours before the evening shot.

I spoke to the vet today and he thinks if at the time of injection his BG is <160, then I shouldn't inject and if >160 then I should try 2 units and see how it goes. He was very encouraged by the BG numbers. I like your idea too of injecting just 0.5 units if BG is low.

As for the questions, I had some of that info in the spreadsheet, but it makes sense to add it to my signature. We struggled with the blood thinner (clopidogrel) as it's a big and bitter pill, but the cardiologist thinks he needs to take it daily.

We tried several times to stop the maropitant, but he becomes quite restless and also vomits 1-2 times a week, so the vet thinks it's ok to keep him on it.

As for the BG monitoring, it's mostly done with the freestyle libre 3 sensor. I have also used a glucometer (accucheck) around 20 times now and I found that the FS3 tends to overshoot by ~20% at the extremes, but it's otherwise not bad at all.

Thanks again for your help.

Where are you now in the cycle? How far from PMPS. I was at the vet earlier when I wrote to you. Let me look at the spreadsheet now and see what’s going on

 

[Suzanne & Darcy]

My cat with heart disease was on Clopidogrel also. I cut the pill and put it into a gelatin capsules to give it to her. They are large pills, depending on which manufacturer makes them (which varied for us depending upon what the local pharmacy gave us each refill. And it’s a notoriously bad tasting pill. It is very important that he gets it daily to help prevent blood clots. I also put my girl on Nattokinase and she never had a clot in 4 years.

 

[Suzanne & Darcy]

Oh, also, my Cardiologist also put her on Rivaroxaban after her heart got a lot worse - based on a study showing cats on both Clopidogrel and Rivaroxaban did better in terms of clots. But your boy isn’t at that stage yet and I hope he will stay stable for a long time.

 

[fpa]

Where are you now in the cycle? How far from PMPS. I was at the vet earlier when I wrote to you. Let me look at the spreadsheet now and see what’s going on

1 hour before PMPS and his BG is still stable (around 180) and I just confirmed it with the glucometer too (it showed 177). If it remains stabler or goes higher, then I think I'll try 2 units of PZI tonight

If it drops, then I'll probably try 0.5 units.

 

[fpa]

My cat with heart disease was on Clopidogrel also. I cut the pill and put it into a gelatin capsules to give it to her. They are large pills, depending on which manufacturer makes them (which varied for us depending upon what the local pharmacy gave us each refill. And it’s a notoriously bad tasting pill. It is very important that he gets it daily to help prevent blood clots. I also put my girl on Nattokinase and she never had a clot in 4 years.

Good idea, I'll try this as I do think he needs to take the Clopidogrel daily (and he hasn't really).

 

[Suzanne & Darcy]

The approach I would like to use with Foyi is to try to keep him in green numbers more of the time. We call the green numbers the “healing greens” because those are normal numbers for a cat. It allows the beta cells of the pancreas to heal. We find that gradually reducing the dose (adjusting to keep him safe, of course) generally ensures a long- lasting remission. I think his pancreas is sputtering back to producing insulin. Do you know what triggered the diabetes? A steroid shot (which would be awful for him with HCM and probably would trigger congestive heart failure.). Just high carb food? A dental problem?

 

[fpa]

The approach I would like to use with Foyi is to try to keep him in green numbers more of the time. We call the green numbers the “healing greens” because those are normal numbers for a cat. It allows the beta cells of the pancreas to heal. We find that gradually reducing the dose (adjusting to keep him safe, of course) generally ensures a long- lasting remission. I think his pancreas is sputtering back to producing insulin. Do you know what triggered the diabetes? A steroid shot (which would be awful for him with HCM and probably would trigger congestive heart failure.). Just high carb food? A dental problem?

Interesting, will try to keep it green then.

I think his diabetes was caused by steroids, plus high carb dry food and being overweight (8kg). Hopefully this means that remission would be easier!

 

[Suzanne & Darcy]

Last night, you shot a 158 with 2.5 units and he had an amazing cycle. He is higher than that now. Now, according to SLGS, he did earn a reduction down to 2.25 units If we want to go for remission though, you should consider the Modified ProZinc Method which will keep him in greens more of the time.

 

[Suzanne & Darcy]

Interesting, will try to keep it green then.

I think his diabetes was caused by steroids, plus high carb dry food and being overweight (8kg). Hopefully this means that remission would be easier!

Yes. Since you have removed the steroids (I hope) and the HC dry food — that’s why he’s doing so well now. Steroids and HC food definitely increases the chance of diabetes. Did he have fluid on his lungs? Is that how the HCM was discovered? Or did he have a murmur and then an ultrasound?

 

[fpa]

Last night, you shot a 158 with 2.5 units and he had an amazing cycle. He is higher than that now. Now, according to SLGS, he did earn a reduction down to 2.25 units If we want to go for remission though, you should consider the Modified ProZinc Method which will keep him in greens more of the time.

I'll read again the Modified method, but how would it differ now in terms of dosing? His BG has just gone to 230, so I'll shoot at this. I'll do 2 units as per the vet and see what kind of cycle it produces (hopefully mostly green), but yeah 2.25 might be a better number.

It has all happened very quickly obviously without having proper time to reduce the insulin gradually, but let's see.

 

[fpa]

Yes. Since you have removed the steroids (I hope) and the HC dry food — that’s why he’s doing so well now. Steroids and HC food definitely increases the chance of diabetes. Did he have fluid on his lungs? Is that how the HCM was discovered? Or did he have a murmur and then an ultrasound?

Yeah the steroid (low dose of prednisolone) only lasted 10 days and was reduced gradually, but still seems to have caused damage. The HC dry food was stopped immediately at diagnosis and thankfully he likes the low carb wet food.

He did have a slight murmur and hence the heart scan and diagnosis.

 

[Suzanne & Darcy]

I'll read again the Modified method, but how would it differ now in terms of dosing? His BG has just gone to 230, so I'll shoot at this. I'll do 2 units as per the vet and see what kind of cycle it produces (hopefully mostly green), but yeah 2.25 might be a better number.

It has all happened very quickly obviously without having proper time to reduce the insulin gradually, but let's see.

You can try the 2 units. If it’s not enough you will know. He’s full of surprises lately so who knows. For now, he’s clearly on his way up. Two hours from now when the ProZinc kicks in we will see.

 

[fpa]

You can try the 2 units. If it’s not enough you will know. He’s full of surprises lately so who knows. For now, he’s clearly on his way up. Two hours from now when the ProZinc kicks in we will see.

Yeah and the vet always reminds me that it's better to take longer to achieve remission (if ever) than to get a hypo.

 

[Suzanne & Darcy]

Yeah the steroid (low dose of prednisolone) only lasted 10 days and was reduced gradually, but still seems to have caused damage. The HC dry food was stopped immediately at diagnosis and thankfully he likes the low carb wet food.

He did have a slight murmur and hence the heart scan and diagnosis.

There is a very good Facebook group operated by a vet in the UK. She is very knowledgeable about cat heart disease. It’s not just for cats with blood clots, although they know a lot about that there. There’s a lot more that can be done for our heart kitties that the vets (even the cardiologists) will not tell you because they’re not aware.

 

[Suzanne & Darcy]

This is another good one where I learned about Rapamycin for cats with HCM. I wish I had been aware of it earlier in our journey. My cardiologist was aware of Rapamycin but said she would not prescribe it before UC Davis had published their studies. It’s very promising for HCM and other diseases. I obtained it from another vet, but too late for my baby girl.

 

[Suzanne & Darcy]

Yeah and the vet always reminds me that it's better to take longer to achieve remission (if ever) than to get a hypo.

Absolutely! You track your boy so well that you can prevent any hypo for sure! Do you have a hypo kit available? High carb wet food, honey or real maple syrup or corn syrup? Every diabetic caregiver should have these ready — and I am sure you already know about this, but we never talked about it before so I thought I would ask.

 

[fpa]

Absolutely! You track your boy so well that you can prevent any hypo for sure! Do you have a hypo kit available? High carb wet food, honey or real maple syrup or corn syrup? Every diabetic caregiver should have these ready — and I am sure you already know about this, but we never talked about it before so I thought I would ask.

Yes, absolutely. Thanks so much for all the links and info, will check them out. Rapamycin looks promising.

 

[Suzanne & Darcy]

Another drug that was an absolute game changer for my Ginger was Pimobendan. It just made her heart pump so much more strongly. Hopefully you are not at that point yet.
Rapamycin is really going to make a difference for HCM cats and is being studied with very good results. I always want to help everyone with a heart kitty.

 

[fpa]

Do you think I should ask the cardiologist to prescribe Rapamycin or is it too early? I don't even know if this is possible in the UK yet.

 

[Suzanne & Darcy]

Do you think I should ask the cardiologist to prescribe Rapamycin or is it too early? I don't even know if this is possible in the UK yet.

That’s what I’m not sure about (availability of Rapamycin is in the UK.) I will try to find out. I think it would be good to start it sooner rather than later because the studies that have shown success have been done on cats with earlier stage HCM.

 

[fpa]

I noticed that I could get it from the US here

Lots of greens again overnight even with the 2u dose. If it stays there at AMPS then I'll probably shoot 0.5u.

 

[Suzanne & Darcy]

Beautiful numbers last night — especially for a Libre since if they were checked with a regular glucometer they would likely read a little higher.

I am happy you gave a small dose this morning. It is looking very good so far and that little bit of insulin should hopefully help keep him from climbing too high at the end of the cycle. He is doing soooo well.

 

[Suzanne & Darcy]

I noticed that I could get it from the US here

Lots of greens again overnight even with the 2u dose. If it stays there at AMPS then I'll probably shoot 0.5u.

That os where I purchased mine from — upon recommendation from several people who had purchased theirs from there - Dr. Kevin Toman. (Sp?)

 

[fpa]

Beautiful numbers last night — especially for a Libre since if they were checked with a regular glucometer they would likely read a little higher.

I am happy you gave a small dose this morning. It is looking very good so far and that little bit of insulin should hopefully help keep him from climbing too high at the end of the cycle. He is doing soooo well.

Thanks, your recommendation was very good. If BG numbers are similar tonight and tomorrow morning, then I am thinking of trying 1u in the morning in order to get more greens during the day. I read that in the modified PZ method too (50% of the previous dose if the preshot number is low)

 

[fpa]

That os where I purchased mine from — upon recommendation from several people who had purchased theirs from there - Dr. Kevin Toman. (Sp?)

Small world Unsurprisingly, the cardiologist said that she'd prefer waiting for the results of the clinical trial, but I am inclined to try it now due to the better results for earlier stages of HCM and due to the lack of significant side effects.

 

[fpa]

Tonight even though I stalled for 1 hour, his BG was just not rising (~130). Didn't want to skip again, so shot 1u as I prefer having the larger dose in the morning for better monitoring of any hypo during the day.

Depending on his overnight nadir, I plan to shoot 2u in the morning or 1.75

 

[fpa]

That os where I purchased mine from — upon recommendation from several people who had purchased theirs from there - Dr. Kevin Toman. (Sp?)

I spoke to him and he told me that Rapamycin can raise the BG and affect the insulin dosing, do you know much about it?

Foyi's numbers continue to look very good, I shot 1 unit this morning and so far it looks good even though I am bit nervous shooting at low PS numbers. Depending on today's nadir, I plan to make both AM and PM shots 0.75 units and see how that goes.

 

[fpa]

I am amazed and thrilled at the BG numbers we are getting even though we reduced the prozinc shots to 0.5u too quickly. It's been in the greens for more than 48 hours now, so I wonder if I should stop the insulin completely now or make it just one shot daily of 0.5u

The vet thinks I should stop now or try one injection of 0.5u daily for 3 days and then stop.

I could try injecting 0.25u, but not so easy with the U40 syringes.

 

[Suzanne & Darcy]

I spoke to him and he told me that Rapamycin can raise the BG and affect the insulin dosing, do you know much about it?

Spoke with your regular vet about the Rapamycin?