Glucose fluctuations | Feline Diabetes Message Board - FDMB

Glucose fluctuations

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Hi,
I was able to follow the link in your Sig, but I'm on a tablet and can't see detail well enough when I zoom it. It does look like Ozy is in the 200s and 300s most of the time... I have a few questions...

I can't read the timing of the tests. Are those tests at shot times? And are the shots 12 hours apart?

What type of food does Ozy eat, and how much / how often?

We can help you to figure this out. Just need more details :smile:

Welcome to the group,
Carl
 
You have a picture of your spreadsheet at your blog, not the spreadsheet itself, so reading it is rather difficult.

We like to use an online. Google Docs spreadsheet/chart to track the glucose levels and insulin injections, because it is easy to let selected others review it and give feedback. Instructions are here

What and how much are you feeding him? We recommend a canned or raw, low carbohydrate (< 10% of the calories from carbohydrates) diet which may be purchased over the counter. For a terrific printable food list, as well as important feline nutrition information, please go to veterinarian written Cat Info. Since you're already home testing a lot, you are able to make food changes while monitoring the impact on the glucose levels. If you are not already on a low carbohydrate diet, switching may reduce the glucose more than 100 mg/dL.
 
Hi, welcome to FDMB! From the looks of you chart it seems that you do not have consistent shot times. That is very important when using Lantus. It builds up a reserve (also called depot of shed) in the body which is slowly released over time. Changing shot interval or doses too frequently causes the shed to drain or need a few cycles to refill. You get wonky results. Also doses are based on the lowest (nadir) point in a 12 hour cycle, not on the preshot, so you need to get some mid-cycle tests to find out when the nadir is. Please read the info in the link that Karen gave you. There are a number of permanent posts (Stickies) at the top of the forum that will help you under stand Lantus and how we work around here.

One thing is a spread sheet on Google Docs. There are instructions for setting it up on the Tech forum. I could see a little more than Carl, but it overlapped some parts of your page. It helps to follow the same format so advice givers can review it quickly.

We follow a tight regulation protocol developed at the University of Queensland. We closely monitor BG and follow a schedule for dose increases, set out in the protocol. This is a very active board and we have members all over the world so there is nearly always someone around to answer questions.

There is a lot to take in at first, post any questions you have and we will do our best to give advice.
 
Thanks everybody. I will try to figure out that spreadsheet. It doesn't look obvious how to fill it out.

Ozy was diagnosed with pancreatitis three years ago. They said it was because of being on prednisalone which was because of an autoimmune reaction to a rabies shot. He is on canned food, Wellness no grain turkey and salmon. He has always been on wet food, but he used to get some dry food. No more. I do supplement his wet food with some real meat, cooked gently and some chicken broth (homemade, no ingredients but high quality chicken). He eats frequent small meals, which I have read can be good for diabetes. I do plan to add some taurine supplementation because it is good for his pancreas.

He is also on a couple of pain meds (Cerennia and buprenorphine) for his pancreatitis. He is already suffering from neuropathy in his back legs. His recent pancreatitis fPL was 19.5 ug/L. The vet said his pancreatitis is quite bad and his diabetes is moderate. His glucose readings two weeks ago were mostly around 350. They haven't changed much. We test before his insulin shot at 8 am and pm and do another test at 2 pm. If he is feeling poorly I often test again to see what his glucose is. Also, we are doing our second glucose curve today (first one was a week ago); on those days we test every 3 hours (5 am, 8 am, 11 am, 2 pm, 5 pm, 8 pm, 11 pm).

I am nervous about giving him medications because his reactions to medications have not been normal in the past. But I don't see a choice with diabetes. I've read that Lantus (glargine) can be a bad match because it is human. He gets his insulin at 8 am and 8 pm. The first week he got 1 unit of insulin at a time, we did a glucose curve and moved to 2 units. Today we are doing another blood glucose curve. His glucose readings don't seem to be moving much with the insulin. A few days after he started on 1 unit they dropped into the 200s for about 24 hours and then shot back up, even a little higher than before. A few days after he started on 2 units, the same thing happened. I am worried that his body is fighting the insulin.

He is not on tight regulation, although I did talk to the vet about that. The vet is terrified of hypoglycemia. She feels with his multiple issues we should go slow. I am torn about what to do. I know I am jumpy because of his previous reactions to medications (rabies shot and prednisalone).
 
I agree with you and the on the "go slow due to multiple issues going on".

As far as Lantus goes. Yes it is "human". But in studies, it has been shown to be the best insulin for treating cats. There is only one insulin that I am aware of that is specifically "made for cats", and that is Prozinc/PZI. The others are human or dog insulins.

About "hypos"... I'm sure someone will correct me if I am wrong. But in the study that resulted in the Queensland tight regulation protocol used by most people here, there were no instances of clinical hypoglycemia noted. It is an aggressive method of treating feline diabetes. But also has proven to be safe as well as giving a cat the best possible chance of remission.
 
There are two types of insulin which are recommended by the AAHA (American Animal Hospital Assn) for the treatment of feline diabetes -- Lantus and Prozinc. This is a link to their guidelines for treatment. The AAHA is the veterinary organization that accredits animal hospitals.

There are any number of medications that were developed for humans that are also used with animals. There is a body of published research using Lantus with cats. It is a very safe type of insulin. I'm not sure where you read that Lantus isn't recommended for cats. Nothing could be further from the truth. The Tight Regulation Protocol, in fact, was published in a leading veterinary journal. Between the research literature and the AAHA recommendation, all I can tell you is that your vet recommended one of the best types of insulin for your cat.

What you're seeing with respect to the fluctuations is not your cat's body fighting the insulin. Rather, it's a normal response. There's no way to know for sure how long your cat was diabetic. As a result, if Ozy's numbers drop into a range he's no longer used to, his numbers then bounce back up. Because his system isn't used to the lower range, his liver and pancreas "panic" and release a stored form of glucose along with counterretulatory hormones which cause the spike.

There are any number of people here who, for various reasons, use an approach that we call "start low and go slow" (SLGS). I would point out, though, that with either SLGS or Tight Regulation, you only raise doses in 0.25u amounts. We would not recommend a dose increase from 1.0u to 2.0u.

I'm having trouble reading your Excel file, as well. The spreadsheet may not be immediately clear but let me see if I can explain.
  • AMPS/PMPS - Shot times are referred to as AMPS and PMPS (AM Pre-Shot and PM Pre-Shot tests). This is the test result immediately before you give an injection.
  • U - This is the column that refers to your "units" of insulin or dose.
  • +1, +2, +3, etc. - The "plus-number" refers to how much time has elapsed from when you gave a shot. A +1 is the blood glucose (BG) test result if you tested an hour after your shot just like the +7 would be the BG test result from 7 hours after shot time. We refer to times this way since we are all in different time zones and it gives a clearer indication of where in the 12-hour insulin cycle your cat is.
I think if you can get past the learning curve with our spreadsheet form, you'll find it pretty easy to use. Likewise, we'll be able to offer you more help since its very hard to read the graph in Ozy's blog.

I would also encourage you to read through the starred sticky notes at the top of the Board. They will help to give you a firm foundation in how Lantus is used.
 
Ozy glucose readings as requested (thanks for the help setting it up)

https://docs.google.com/spreadsheet/ccc?key=0AqCxgyuIGH9TdEkzWDlYcU9OYmtoemtMV1oxS0ZnTEE&usp=sharing



As for where I read Lantus can be bad, here are a couple of links.

http://yourdiabeticcat.com/protocol.html

Even on this site it says "Human insulin, in general, does not successfully replace the cat's own insulin, and diabetes is not well-controlled in most cats when human (e.g. Humulin) insulin is used for treatment. Bovine (beef) insulin is most similar in molecular structure to feline insulin, and it is thought for this reason, to be most effective for these cats."

http://www.felinediabetes.com/pzi.htm

I am drowning in information. I feel sort of sea sick.
 
I can understand your confusion and frustration with the overload of information available to you.

On the YDC website, I would point out a couple things. First, the site was, I believe, originally created/based upon the experiences that Dr. Hodgkins had with feline diabetes. She designed a "tight regulation" protocol used with PZI that is claimed to have had a good deal of success. However, the page you saw "predates" the invention of Prozinc information, and spoke specifically about the "old" PZI insulin, which was bovine/porcine based insulin. You can still get compounded PZI which is bovine based. Prozinc is an rDNA human insulin, engineered to work with cats.
Bovine insulin has a much closer amino acid structure to the cat’s own insulin than does human insulin, a likely explanation for it superior results in managing feline diabetics.
Click to expand...
Members of YDC are huge proponents of the Hodgkins Tight Regulation protocol However I believe that Dr. H herself no longer has any association with the website.
They also make a claim that I find disturbing:
As long as you are feeding your cat ONLY low-carbohydrate foods, you do not need to be fearful of clinical hypoglycemia. In fact, those blood glucose numbers in the 60-120 range are the objective of the protocol. Even if the blood glucose drops to 30-50, do not feed sugar syrup or dry food.
Click to expand...
To me, that's dangerous advice, and can be fatal to the cat. While a study might not reveal an actual symptomatic hypoglycemic episode, telling people that it won't happen, or advising that they don't intervene on BG numbers that are below normal, is completely irresponsible advice. There's a real fine line between " no clinical signs" and a coma.

There are cats here who use Prozinc/PZI, but they don't follow a tight regulation protocol that I am aware of.

The other link might also predate the replacement of "old PZI" by Prozinc for the most part. Prozinc hasn't been around for too long. And if so, it predates the emergence of so many people using the Lantus TR protocol in the past few years.

Most of the older human insulins, like Humulin, Novalin and the like, are far less suited to manage feline diabetes. The duration is too short, and the action is too "harsh". But human insulins like Lantus and Levemir have been very successful.

Cats can go into remission on compounded PZI. Mine did. But it's definitely an "every cat is different" thing. He may have gone into remission regardless of insulin type.
 
So, here's the scoop. The YDC (Your Diabetic Cat) website was originally developed by Elizabeth Hodgkins, DVM. At the time, PZI, as it was then referred to, was one of the few types of insulin available for veterinary use. As noted on the website, it was a bovine insulin derivative. However, PZI in that form has been discontinued and has been unavailable for several years. The website is out of date. There is a newer variety, Prozinc, which is a human recombinant insulin. Thus, it is similar in its derivation to Lantus.

For any number of reasons, and if you asked me to venture a guess I'd say these were political reasons, Hodgkins did not appear to like Lantus. I don't know if there was a professional rivalry between her and one of the major Lantus researchers, Jacqui Rand, DVM. Rand and her colleagues have published extensively on the use of Lantus in cats. I've found only one journal article by Hodgkins in the last 10 years and that dealt with diet. Hodgkins has some very loyal followers who have maintained the website and message board. Unfortunately, they have not stayed current with the times or the website would have been updated and made current with the pharmacology of Prozinc.

And you're right. If you don't know the background, it's like you're getting pulled in a variety of directions. I'd encourage you to ask questions if something is unclear or if you're finding conflicting information. The people here are incredibly generous with their time and knowledge. The front end of the learning curve is overwhelming. We've all been there. It really does get better!

Looking at Ozy's spreadsheet (SS), you really aren't seeing a huge amount of variation in the numbers. What I would also encourage you to do is to get at least one test every night during the PM cycle. Lantus dosing is based on the lowest point in the cycle -- the nadir. If you can get a test every night before you go to bed, it will allow you to know if Ozy's numbers are dropping lower during the PM cycle.

Also, what does your kitty weigh? And, is this a good weight? The initial dose of Lantus is based on a cat's ideal weight. (Initial dose = 0.25 x ideal weight in kilograms).
 
Everything you've shared is very helpful. It gives me some perspective, especially on Lantus and alleviated some of my fears. I am still confused about tight regulation and what it means. That is, how much you adjust the dose. I think part of it is that I now see that I ran into at least two different tight regulation protocols.

The one that comes from Australia seems to say you adjust the dose every three days according to the glucose readings (the low) and according to the size of the cat.

http://www.drjohnson.com/a_article_companion_animal_cat_lantus_diabetes.html

Ozy went from 1 unit to 2 units after a week of mostly being over 300 and sometimes dipping into the 200's. Adjusting to 2 units seems in keeping with his ideal weight, which would be about 15.5 lbs (he is down to 14.5 lbs these days). He eats a lot but he isn't making use of much of it. Today we are doing a glucose curve with glucose reading every three hours. Tomorrow the vet will recommend what to do next.

If 2 units of Lantus haven't brought it down yet, is it time for a larger dose? Should I be taking more blood tests? Shouldn't his glucose be dropping? What does it mean that it isn't? Is he difficult to regulate ...I know I read that most cats can be regulated on Lantus in 10 days.
 
The link you shared is based on the same protocol we use. However, the protocol date is 2006 on the Dr. Johnson link. We use a more recent update that was published in 2009.
Neither version adjusts dose based on weight. The initial dose is based on your kitty's ideal weight. The earlier version was more aggressive and Rand & Marshall felt that it could be dangerous for cats that weren't being treated in an animal hospital setting:
  • initial dose = 0.5 x ideal weight in kilograms vs.
  • initial dose = 0.25 x ideal weight in kilograms
After the first several days, doses are changed based on the nadir and increased or decreased in 0.25u increments. If you look in our Tight Regulation Protocol sticky note, we have a simplified version of this protocol described there. There are also links to the protocol from the University of Queensland and to the Tilly site that is the counterpart of this Board in Germany and where the data was collected for the Rand & Roomp studies.

Fundamentally, you've been looking at the same thing. I think the language in the more formal versions can be a bit confusing. The version we use here is pretty straightforwad.
 

Attachments

Thank you so much for the time you took to post all that information and the links. I am still digesting all that. I am studying Gabby's chart to understand the reality of how this works.... when you go down a bit, etc.

After four years you are testing Gabby ten times a day? When are you sleeping? Can you go anywhere, even for say six hours? How do you manage?
 
Well.... I do work. I have some flexibility with my schedule so that helps. I'm gone pretty much from 9:30 to 6:00. I'm also very fortunate to have friends who are "cat people" and just as devoted to their kitties as I am to mine. They also like to go out for early dinners which means I can shoot and then go out for a meal and be home to test by +3 or so. I'm also not of an age where I want to be out carousing until the early hours. And failing all of that, I cook really, really well and like to entertain so I have people over to my home.

Actually, sleep is much better now than at the beginning of this sugar dance. In the past, if I saw a green number at night, I'd stay up to be sure nothing would happen. I operated on very little sleep. I do better if I stay up vs. set an alarm and get up to test. I'm also fortunate in that Gabby usually has an early nadir.
 
I figured out how to edit the google doc (as opposed to uploading a different file and updating the links).

Now, can you others see my updated SS and is it colored by how high the glucose is? That part has gone away when I view it now. I don't know why.
 
The link isn't working. Here are the directions. If you look at the section on how to include the link in your signature, you won't have to copy it all the time. Also, make sure you have the access permissions set to "anyone with the link."
 
I'm sorry to hear Ozy isn't feeling well. Is he still having a pancreatitis flare?

Did you lose the color coding on your SS? If you look at your SS, the coding for the numbers is across the top. Let us know if you don't know how to set the conditional formatting.

It may be time to increase Ozy's dose. How do you feel about increasing him to 2.25u?
 
I think when his glucose gets up to 350, he doesn't feel so well. He is feeling much better and his glucose is down to 225 now ...225 is a pretty low reading for him. He's been mostly in the 300-350 space.

We were supposed to talk to the vet today but it turns out she is out. Now someone else who knows nothing about him is supposed to call. Really, I think we are on our own mostly. This board is a great help. We are thinking of increasing his does by .5, which seems in keeping with my reading of the directions (given how high his lowest readings are with the exception of the one we just took). Why .25? What is the advantage of a smaller increase of .25 versus .5?

Also, is it likely we are going to have to monitor him closely for years like you have your dear kitty and several others whose glucose charts I looked at? How do you deal with the constant emotional roller coaster, cuz I already feel like I am on one? Up and hopeful when he feels better. Torn apart when he is worse.

I don't know what happened to my colors. It happened after I turned on conversion. I have a question on the tech forum for how to fix it. Do you know?
 
Welcomes to LantusLand, the best place you never wanted to be. :lol: :lol: You are doing a fantastic job! Ozy is lucky to have you for his bean. :-D You are getting excellent info from some very experienced members who really know FD. I've been around for a while and I learned some things today. :-D
Liz, Zener's other mom
 
I have a question about the nadir. Is the most recent nadir the important one in making an adjustment? Is it the nadir for the whole period of time or the most recent nadir that decides how much to increase in dose?

Ozy has been on 2 units for one week. Today his nadir looks to have been about 225. That is the lowest reading he has had all week. So I guess either way this time .25 units is the correct dosage increase.
 
Also, is it likely we are going to have to monitor him closely for years like you have your dear kitty and several others whose glucose charts I looked at? How do you deal with the constant emotional roller coaster, cuz I already feel like I am on one? Up and hopeful when he feels better. Torn apart when he is worse.
Click to expand...

This is definitely an "every cat is different" thing. Some kitties are switched to low-carb canned food, and quickly improve, needing no insulin, or very few days on insulin. Some, like my cat, go into remission in a couple of months or so.

Some cats will never get to "remission", but can live long healthy lives regardless (just like human diabetics can).

I am fairly certain that for people like Sienne who have been doing this for years, it's not a big deal at all. She isn't tied to treating FD like it's a ball and chain around her ankles. It's just what life is like for Gabby. Others have treated their sugarcats for longer than that. Some here have done this with 2, 3, 4 or more cats, not because they have to, but because they choose to. They adopt diabetic cats, cats who might otherwise be put to sleep because their caregivers couldn't do it for whatever reason. Lots of them are rescued from shelters.

All of us ride (or rode) the same emotional roller coaster you mentioned. Some kitties go off of insulin, and then for some reason a couple of years later, they end up "back" to being insulin dependent. I guess we all sort of just roll with the punches. Personally, I have come to believe that Bob becoming diabetic was a blessing in disguise. It might not have been the best thing that ever happened to him, but it's been the best thing that's happened to me for quite some time. It changed my life, and all for the better in hindsight. I sure didn't feel that way when the vet said "your cat has diabetes", though.

I have a question about the nadir. Is the most recent nadir the important one in making an adjustment? Is it the nadir for the whole period of time or the most recent nadir that decides how much to increase in dose?
Click to expand...

That depends on which protocol you elect to follow.
In the "tight regulation protocol", it would be the most recent nadir that determines a decrease in dosage. Because you would decrease the dose any time you got a nadir under 50. And as far as increasing dose, it would be an overall look at the past 3-5 days of data. If the numbers haven't improved, it would indicate an increase is called for. Adjustments would be in increments of .25u, except in rare cases when .5u would make sense. That doesn't seem to happen very often from what I've seen.

Following the "start low, go slow" protocol, it's more of a look at a whole week of data to evaluate the dose.

Each protocol has very clear "conditions" for increasing or decreasing dosage spelled out.

With the lowest nadir you've seen for a week being today's 225, I would say that an increase of .25u is the way to go.
 
Thank you, Carl. It's the emotional roller coaster I am having trouble with, not the ball and chain. Though I do hope to somehow manage to go camping again. And hiking.

Tonight his glucose is suddenly plunging... after two weeks mostly in the 300s and having started today at 350, it was 166 a little bit ago. I have been testing every hour because the plunge seems so rapid. He was at 202 when it was time for his injection two and a half hours ago. I am feeling afraid to go to bed. He is feeling great and I am happy to see lower numbers but it is a sudden plunge. Should I be worried?

donaleen
 
Worried? I don't think so. I understand completely though, because it's the lowest number you've seen. :smile:

Excited would be a better way to feel! You were talking about a dose increase earlier. Perhaps he "heard you". You'll see people mention sometimes that all it seems to take is the threat of a dose increase, and amazingly the numbers improve nearly instantly. I'll go back to your thread in the Health forum so you aren't having to hop from forum to forum tonight.
 
Carl said pretty much what I would have said about managing a kitty's diabetes over the longer haul. One of the comments that many people make is that it has a very positive effect on your relationship with your cat. I'm not entirely sure I can describe how it changes that relationship, but it does. I do think that many of our cats understand that what we're doing, between the pokes and the shots, is keeping them alive and allowing them to feel better.

What is the advantage of a smaller increase of .25 versus .5?
Click to expand...
Tight Regulation is a relatively aggressive method of treating diabetes. As a result, you don't want to miss what can be a "good" dose for your cat. It's a balance between increasing the dose at a faster pace than with some other approaches and the size of the increase. With TR, you are increasing in a systematic way in a small amount until you find a dose that brings numbers into normal range. It is also safe. If you were to increase by 1.0u, for example, there's a risk that it would be way too much insulin and your cat could experience symptoms of hypoglycemia. A cat's numbers can drop low even with a 0.25u increase but the advantage is that you're monitoring and the numbers typically can be brought up with food. I should point out that if a cat's nadirs are consistently above 300 or the cat is on a large dose of insulin, then the protocol does indicate that increases of 0.5u are appropriate.

As for Ozy's numbers, I think he looks really good in blue! As for why, well..... Sometimes a dose just clicks. That may or may not be the case. We'll see what happens this morning. The good news is you're seeing movement in Ozy's numbers. Don't be alarmed if he bounces.
 
Welcome to Lantus land! this is the best place to be and I see you are all set up! His numbers are looking good!

To help us help you better at a glance can you please edit your signature to include

Your name and cats name ie Donaleen & Ozy
the insulin, dose and meter type ie Lantus 2IU and ? meter
what food you are giving ie Wellness grain free

thanks
Wendy
 
Thanks everybody. He is feeling SOOOO good. Like himself. And yes, I think he knows we are trying to help him.

Now, this morning he is at 228 (one hour pre insulin)... his nadir was around 145. I read and re-read the protocol. Am I correct that we should hold the does the same? We were planning on increasing it, but maybe not?

And what is a condo?

donaleen & Ozy (Ozymandius King of Kings)
Lantus 2IU and meter is Kroger OnSync (soon to move to True Result which we bought at Amazon because the strips cost .22 versus one dollar)
Wellness grain free (turkey and salmon) supplemented with home made chicken broth and real meat.
 
If it were me, I'd increase Ozy's dose to 2.25u. You don't want to hold doses overly long if the dose isn't bringing your cat into normal BG numbers (below 120).

[url=http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=1581:le0hpaa1][b:le0hpaa1]Tight Regulation Protocol sticky[/b][/url] said:
"General" Guidelines:
  • Hold the initial starting dose for 5 - 7 days (10 - 14 consecutive cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 consecutive cycles).
  • Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction (See: Reducing the dose...).
  • Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.

Increasing the dose:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
Click to expand...

A condo is what we refer to as your daily thread. Because Lantus Land (LL) is a social place, people stop by and visit. It sounds silly to visit a thread. In addition, cats have condos (like cat trees). So, at one point, someone referred to a thread as a condo and it stuck. We have a fair amount of slang.
 
You start a new condo every day, and link to your previous days condo.

*** Daily Threads (condo) & Posting Instructions ***

•Please start one new thread(condo) each day. This will keep all your questions, comments, and replies in one place.
•Start your daily thread with the date, kitty's name, and AMPS
•Your thread will be bumped to the top of the list when you or anyone else posts on your thread.
•link to your previous day's condo.
Click to expand...

How to - Linking to previous thread/condo.
1. Tomorrow morning, open this thread which we call a condo.
2. Copy the browser address. Then go the main Lantus Land page and click on "new topic" just like you did today.
3. Put the cursor in the text box and then click on the "url" button above the text box. It will put this in the text box:
.

4. Put the cursor after the second bracket and right click to paste the link you copied in between the boxes so it looks like this:
YOUR LINK.
5. To give it a title, do it like this: yourcatsnamehere 6/30 condo

Make sense?
Click to expand...
 
Unfortunately I didn't see your reply about increasing the dose until after he got the shot. Can we give him just a quarter dose booster? It's been half an hour.
 
No, boosters are not a good idea. Not a real problem, you can increase tonight instead.
 
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