? HELP ??? - Huge changes - slight remission? (Levemir)

[sheeboo]

Hello everyone! It's been a while since I posted because we'd found our groove and all was going well. Kahn was on 2.5u Levemir 2X/day and BGs were "stable"

Then, a few days ago, he was running around the house screaming and crashing into walls. My daughter (who has type 1 diabetes) immediately checked hs blood - 27. We checked again with a different meter (hers) and different strips: 26. Checked a third time while I filled an (oral) syringe with glucose gel: 32

His BG came up slowly, but it came up. Whew. Scary.

By dinner time/evening insulin he was only 107 so I didn't dose him.

Next morning he was 230 so I gave him 1u instead of 2.5 - (I was scared of another low, but also of ketones - checked blood, they were negative - in humans, we're told it is worthwhile to run above 180 for a day or two after a major low to let the liver replenish glycogen stores.)

I've reduced both am and pm doses to 1U.

It's been about 6 months since Kahn went from NPH to Levemir.

Thoughts? Suggestions? I'm going to keep spot checking BG and ketones

Sorry for the lack of proper formatting - here's the last few days of BG (food and insulin at 7AM and 7PM)

Thanks, all!
Brie

 

[sheeboo]

and....2pm MST: he's 48.

Help! It seems like even the 1U is too much but he also needs something

Does anyone have any ideas where to go from here?

Thanks!
Brie

 

[Veronica & Babu-chiri]

Hi I'm not an expert but have you given him some food at least MC so that he doesn't go any lower?

Also I suggest you change your title put at least a ? or 911 and your results so that everyone knows you need help fast

 

[sheeboo]

Thanks, Veronica - he just gobbled some food with maple syrup on top. I treated him before posting ;-)
I will check again soon and if he hasn't come up, I'll use some glucose gel, which worked well last time but he clearly hated having it shot down his throat (he won't eat it on food)

I will edit my title - thanks!
Brie

 

[Veronica & Babu-chiri]

Test him again in a few minutes and let us know how he's doing

 

[sheeboo]

62 - coming up. Gave him a few more cat treats to be safe

 

[saltycat]

I got scared seeing the 911 up there, you might want to adjust it to let others know you need some dosing advice due to sudden changes, but at this point it looks like you have things under control and Kahn is in good hands.

A few questions since the SS hasn't been updated in awhile (this helps us see the trends and not ask so many questions). How long ago was his dip into the 30's? Levemir is a depot insulin and it can take 6+ cycles for the depot to stabilize on the new dose. Even though you dropped him to 1u of insulin, the 2.5u he got the cycle before will still impact BG numbers for a few days. I'm having a little trouble with the picture you added in "seeing the bigger picture", i.e. how long ago the low was, how long you kept him at 2.5u after the low. Is today the 4th cycle on 1u of insulin?


Technically, he would earn a reduction with the 48 especially since you are on SLGS, but we want to make sure it was not too influenced by the depot. If he has a history of ketones or DKA, then you are 100% correct in wanting to make sure he gets some insulin/doesn't go too high while still making sure he doesn't go too low... I know, this dance is fun isn't it.

Any changes to food or medications that might help account for the sudden decrease in insulin needs?


I've found the syrups work pretty quick at getting numbers up when my boy pulls those dives. It wears off faster then MC or HC food, but also kicks in faster. I have some, but haven't tried the glucose tabs since the syrup worked and I'm not sure he would approve of the grape flavor.

Good to see him coming up. The hard treats are like dry food, they will raise bg, but take longer to kick in then wet food or syrups. Keep an eye on him as the syrup wears off in the next hour or so.

 

[sheeboo]

I got scared seeing the 911 up there, you might want to adjust it to let others know you need some dosing advice due to sudden changes, but at this point it looks like you have things under control and Kahn is in good hands.

Ah, okay - sorry to scare you! I was following a suggestion up above. I changed the title to "Help"

How long ago was his dip into the 30's?

He was 26/27/32 on Tuesday around noon MST
I gave him glucose gel and he came up to 150 after an hour (it was a sloooow rise). He was 107 at 7PM, which is when he gets his evening shot. I did NOT give any insulin that evening so the numbers in the photo until the first 7AM were all without an evening dose.

how long you kept him at 2.5u after the low. Is today the 4th cycle on 1u of insulin?

Next dose after the low-- none. I gave no insulin until the next morning when he was 230. I gave 1U at that time and for every dose since.

Yep - today is the 4th day of 1U doses 2X a day

How long ago was his dip into the 30's?

He was 26/27/32 on Tuesday around noon MST
I gave him glucose gel and he came up to 150 after an hour (it was a sloooow rise). He was 107 at 7PM, which is when he gets his evening shot. I did NOT give any insulin that evening so the numbers in the photo until the first 7AM were all without an evening dose.

If he has a history of ketones or DKA, then you are 100% correct in wanting to make sure he gets some insulin/doesn't go too high while still making sure he doesn't go too low... I know, this dance is fun isn't it.

Jonathan doesn't know if he was in DKA when first diagnosed and the vet who helped him through that has retired. From what he's told me: significant weight loss over the course of a week prior to dx, I am guessing he was in really bad shape. Jonathan said he hardly moved for the first few days after starting insulin.

I thought it was bad when my kid has low-lows like that! At least she can tell me how she's feeling. I'm afraid to leave the house with Kahn this unstable

Any changes to food or medications that might help account for the sudden decrease in insulin needs?.

None! We added wetfood around the time I first posted here and have been decreasing the dry ever since - but that's been a good number of months since and spot checks were all from 90-230

I've found the syrups work pretty quick at getting numbers up when my boy pulls those dives. It wears off faster then MC or HC food, but also kicks in faster. I have some, but haven't tried the glucose tabs since the syrup worked and I'm not sure he would approve of the grape flavor.

Maple syrup is definitely slower than the glucose gel I used. But he will eat that on food. This is what I've been using. I shoot it down his throat with a medicine syringe

Good to see him coming up. The hard treats are like dry food, they will raise bg, but take longer to kick in then wet food or syrups. Keep an eye on him as the syrup wears off in the next hour or so.

I will! Do you think I should drop down his doses to .5U? I am really afraid of ketones/DKA

I also have some Baslagar (lantus) in the fridge ..... worth trying?

Thank you so much for thinking this through with me, sharing your wisdom and holding my hand!
Brie

 

[sheeboo]

He's 123 now

 

[Veronica & Babu-chiri]

Good to see he's going up, you did handled it very nicely, specially since when you posted he was already 48 and going down

 

[sheeboo]

Good to see he's going up, you did handled it very nicely, specially since when you posted he was already 48 and going down

Thanks, Veronica! My teen has had type 1 diabetes for over 5 years, so we have a lot of experience handling lows
Brie

 

[saltycat]

You are doing great and asking the right questions. No problem helping where I can, I've had many members help me through "situations" and it always helps to have a community to support you!

It doesn't sound like he has too much of a DKA history, more suspected then confirmed. DKA episodes generally require hospitalization for a few days. Some cats here have been through multiple DKA episodes and that can change the dosing advice since every cat is different.
Ketones generally develop when the cat is not getting enough food, not enough insulin and an infection of some kind. Those 3 together can be a bad recipe. If Kahn is eating and numbers are where they currently are, I would not stress too much over ketones (especially if all his tests have been negative and you are continuing to spot check)

It might be that his pancreas is starting to work better again, which would reduce the insulin needs.

I also have some Baslagar (lantus) in the fridge ..... worth trying?

I would NOT recommend switching insulin right now, adjusting the levemir would be a much better option.

Here is what I see:
4/25 Tuesday AM 2.5u dropped into the 20's PM no shot, stayed in the 100's
4/26 Wed AM 1u amps 230 130@+10.5 PM 1u pmps261(food influenced from 5:30 meal?) low of 130@+7
4/27 Thur AM 1u amps 202 100@+8 PM 1u pmps 173
4/28 Fri AM 1u amps 137 48@+7

The skipped shot tuesday night helped drain the depot a little, this morning was the 6th cycle since his dip into the 20's. After 6 cycles, the depot should be pretty close to stabilized, some cats do take longer though.

I'm not as experienced as some of the veterans here and my cat is at the other end of the spectrum with dosing so I'm not making any recommendations, just some observations and what I might do if it was my cat.
You could stay at 1u, but make sure to have high carb stuff on hand and be prepared for potentially a long night

If it were me, I would probably reduce to .75u, how to measure small doses. Even on .75u , I would get some extra tests in since his patterns are changing and we are not sure what he has planned, hopefully you don't work tomorrow. Any time a dose is changed, the depot needs time to equalize on Levemir. A .25u reduction is what the SLGS guidelines call for when a cat dips below 90.
You could also reduce to .5u and see how his numbers look. That is a big drop from the 2.5u earlier in the week and might be too big of a reduction. You can always go this route and if the numbers climb too much, call it a failed reduction and go back up a bit.

I've tagged a few of the more experienced members and hopefully they see the alert before shot time tonight and can help give some insight.
@Wendy&Neko
@tiffmaxee
@Tricia Cinco(GA) & Harvey

PS good job keeping a close eye on Kahn and making sure he stays safe, and yes, it sure would be nice if the cat talk... It would make this a lot easier!

 

[sheeboo]

Thank you! I'll see what BG is at 7 and go from there
My daughter's Dexcom (continuous glucose sensor) transmitter just gave a low-battery warning, which means we need to switch it out in the next few weeks. I'm half tempted to shave a spot on Kahn and tape this sucker on there. Thoughts? 24 hours of straight data every 5 mins would be sweet
Brie

 

[Veronica & Babu-chiri]

I think if you could get one and it can be attached to him I think it would be very cool.

I actually bought the freestyle libre for Babu with that idea but the sensor they use is huge and has an even bigger needle that has to be inserted on some muscle and there was no way of having an area big enough and with sufficient muscle for him to have it without hurting him and with the risk of the needle puncturing an organ or hurting a bone so I had to forget about it

 

[tiffmaxee]

Hi. Glad he came up. Good catch. I would take him down to .75 provided you can monitor tonight as the depot will be in play. See what the pmps number is and post. I'd actually suggest a +11.5 in case it's low.

 

[sheeboo]

Hi. Glad he came up. Good catch. I would take him down to .75 provided you can monitor tonight as the depot will be in play. See what the pmps number is and post. I'd actually suggest a +11.5 in case it's low.

He's 182. I dosed .75 and will check throughout the night

 

[sheeboo]

I think if you could get one and it can be attached to him I think it would be very cool.

I actually bought the freestyle libre for Babu with that idea but the sensor they use is huge and has an even bigger needle that has to be inserted on some muscle and there was no way of having an area big enough and with sufficient muscle for him to have it without hurting him and with the risk of the needle puncturing an organ or hurting a bone so I had to forget about it

Libre is larger than Dexcom and I think the sensor wire is much thinner. It will still be a "large" device on his small kitty body.

A dexcom sensor should never go into muscle. I didn't realize Libre was different like that. Dexcom sensors should only be inserted into fatty tissue, although I know athletes who just put it wherever

I bet I'd have to put an e-collar on him so he doesn't pull it out

Poor guy - not sure it is worth putting him through that

Brie

 

[Veronica & Babu-chiri]

Yes Dexcom seems more comfortable and smaller, and if the sensor is a wire also not so dangerous for them (the other is an actual a hard needle and probably around 8 to 10 mm long and not sure about the gauge but is not a thin one ) but still if he has to wear an e-collar may not be a good idea, but the idea of knowing exactly how he is doing is really tempting

 

[Veronica & Babu-chiri]

How do you order Dexcom because I remember I tried and they ask for insurance?

 

[sheeboo]

How do you order Dexcom because I remember I tried and they ask for insurance?

The Dexcom sensor wire is platinum and about the width of three human hairs. It is very, very thin, although the needle that inserts it is much larger. There's an inserting device that shoots the needle into the skin and deposits the wire then you retract the needle (it doesn't stay in, just the thin wire does)

Dexcom is only available in the US with a doctor's prescription, although you can buy it out-of-pocket if insurance won't cover it (but you still need the prescription). I think you may be able to buy it in Europe without a prescription, but I'm not certain

My 13 year old daughter has type 1 diabetes so she wears Dexcom 24/7. The transmitter lasts three months and hers just gave the "battery will shut off in two weeks" alarm. Since I have the new transmitter sitting in the closet, I could swap out this one before it dies and put it on Kahn. I'm just not sure I want to put him through that. The sensor insertion isn't painless and wearing the device might be super annoying to a cat!

This is what the sensor wire looks like:

And this is the insertion process

I know they've been used on dogs but not sure about cats.

Brie

 

[Tricia Cinco(GA) & Harvey]

Hi Brie.

What a scary incident you had a few days ago! Thank goodness you knew what was happening and what to do! After an actual hypo, many kitties are more sensitive to insulin, so I'm not surprised Kahn has gone low again.

Do you think you could plug all those numbers into your spreadsheet for us? I'm having trouble getting the complete picture, even with Wes' explanation (I'm a bit slow). Seeing them on the SS would really help.

I'm glad you reduced the dose and are monitoring. If the amount of dry Kahn is getting has decreased, that could be another reason he is needing less insulin. We've even seen cats go into remission when dry was removed.

 

[sheeboo]

I redid Kahn's numbers @saltycat. Here's the google doc. I'll update my sig too

Brie

 

[Tricia Cinco(GA) & Harvey]

Brie, you put them on the Template tab. Could you copy and paste them to the first tab, please? Or rename the Template tab to 2017? Some of us are easily confused. Also, it says you shot 1 unit tonight, but I think you said you shot .75, correct? (I know - picky, picky!)

 

[sheeboo]

Brie, you put them on the Template tab. Could you copy and paste them to the first tab, please? Or rename the Template tab to 2017? Some of us are easily confused. Also, it says you shot 1 unit tonight, but I think you said you shot .75, correct? (I know - picky, picky!)

Oh, you're right! Thanks for catching the .75 and sorry about the document naming - I can see how that would be confusing! I didn't mess up your template, did I? I can delete the info and do it again

Brie

 

[Veronica & Babu-chiri]

The Dexcom sensor wire is platinum and about the width of three human hairs. It is very, very thin, although the needle that inserts it is much larger. There's an inserting device that shoots the needle into the skin and deposits the wire then you retract the needle (it doesn't stay in, just the thin wire does)



My 13 year old daughter has type 1 diabetes so she wears Dexcom 24/7. The transmitter lasts three months and hers just gave the "battery will shut off in two weeks" alarm. Since I have the new transmitter sitting in the closet, I could swap out this one before it dies and put it on Kahn. I'm just not sure I want to put him through that. The sensor insertion isn't painless and wearing the device might be super annoying to a cat!

I know they've been used on dogs but not sure about cats.

Brie

It seems like the insertion even though it may be kind of painful is not more than when they have to inject meds and it is considerably smaller than the freestyle but still the transmitter seems a bit big for a kitty specially if he is active it's a hard decision

 

[sheeboo]

What a scary incident you had a few days ago! Thank goodness you knew what was happening and what to do! After an actual hypo, many kitties are more sensitive to insulin, so I'm not surprised Kahn has gone low again.

My daughter gets ALL the credit for thinking to check his BG so quickly. The two of them watch out for each other - he yowles at her sometimes when she's low too! Or, he comes and yowles at me.

When type 1 humans go really low (below 50) and the low lasts for some time, they can deplete their glycogen stores (the glucose put out by the liver when BG gets low). We're taught to run high for a few days after a low-low to let glycogen build back up. I wonder if that's part of why cats seem more sensitive to insulin after a low? The other thing that can happen is a rebound - the low causes too much glycogen which leads to a high. I would guess that happens in cats too?

I'm glad you reduced the dose and are monitoring. If the amount of dry Kahn is getting has decreased, that could be another reason he is needing less insulin. We've even seen cats go into remission when dry was removed.

We started moving him to a primarily wet food diet (thanks to everyone here ) at the end of Sept/early Oct. We tested frequently during that time and then, once the Levemir was figured out (we moved up .25U every four-five days, so it took some time to get him to the 2.5U), we tested before meals a few times a week. For a while, he was on 2U during the day and 2.5U at night, then he needed more during the day, too

Since December, all the cats (3 of them) are down to 1 cup of dry that I put in a shared bowl during the day and a little more for overnight (it scares me not to have food available to Kahn when we're not home or sleeping). Everyone eats a few mouthfuls here and there. From what I can tell from checking his blood 90-120 mins after he eats some dry, it isn't making a huge difference to his BG

Tricia, have you heard of cats who go into remission or regain some beta cell function after 7 months of wet food and Levemir (he was previously on Vetsulin)? Is this too long after the changes we've made to see something like this?

In humans with type 1 diabetes, stomach issues can cause poor carb absorption which leads to scary lows. Once after a stomach bug, my daughter only needed a quarter of the insulin she used prior to getting sick - and that lasted for almost three weeks! Undiagnosed celiac can have the same impact. However, they're also more prone to ketones during this time so it is a crazy balancing act of needing to get some insulin in their bodies but not too much (that's why I've been checking Kahn's ketones)

So, I guess I'm concerned that there's some kind of malabsorption of food going on if he hasn't had some kind of uptick in insulin production

Thank you for your comments! And also to everyone who has said we're doing a good job - that means a lot! I feel really guilty that he was so low. I'm sure he'd been low before that and we were just very, very lucky to catch it

Brie

 

[Tricia Cinco(GA) & Harvey]

The other thing that can happen is a rebound - the low causes too much glycogen which leads to a high. I would guess that happens in cats too?

If you're referring to the Somogyi Effect, there is no documented evidence that it occurs in cats, although many vets seem to think it does. Cats do something we call "bouncing". When the BG drops low too quickly, or to a number that is way lower than the body is used to, the liver "panics" and releases stored glycogen to bring the numbers back up. That is why a cat can go from 400 to 40 and back to 400 again in an hour, and why we stress tests in the middle of the cycle. The dosing for Lantus and Lev in cats is based on how low they go during the cycle, not on how high.

Tricia, have you heard of cats who go into remission or regain some beta cell function after 7 months of wet food and Levemir (he was previously on Vetsulin)? Is this too long after the changes we've made to see something like this?

We have had cats here that went into remission after several years on insulin. Check out Furball's SS (@carfurby ) or Trixie's (@Amy&TrixieCat ). Never say never.

 

[Veronica & Babu-chiri]

Tricia, have you heard of cats who go into remission or regain some beta cell function after 7 months of wet food and Levemir (he was previously on Vetsulin)? Is this too long after the changes we've made to see something like this?

Babu has been on Lantus and on wet food ( we changed from dry to wet when he was diagnosed ) for 9 months now and hopefully we are about to finish the OTJ trial

 

[carfurby (GA)]

We have had cats here that went into remission after several years on insulin. Check out Furball's SS (@carfurby ) or Trixie's (@Amy&TrixieCat ). Never say never.

Furball went into remission after 3 1/2 years. There is always a chance.