Help please re insulin & high sugar swings

[Julie and Alice]

Please can anyone help re Alice, 3 weeks since diagnosis when had diabetic ketoacidosis (4+ ketones). She is alive but not well. She has Caninsulin 3 units at 8am and 7pm. I feed her & give insulin at the same time. I home test. Blood glucose is soooo high before each insulin shot. It drops after insulin for a very short time only. She is clearly not feeling good - wants to eat but has a little appetite until glucose has fallen a little, drinks ++ then seems to wait until her sugar is down abit (around 2-3 hours) & then will feel like eating, until then she has few mouthfuls or licks it. I am then going back & forth to encourage her to eat as much as possible within the first 3 hours. She then has a bit more around 4+ hours. Eventually she seems to feel a little better & will enjoy a roll on the floor and a fuss. She is very lethargic & not playing although at times shows an interest but no energy - I tell a lie - she tried to catch a butterfly today but missed it (thankfully!) it was good to see a moments action though!

I did my first glucose curve in the evening 28th March which surprised me as it started lower than usual:

Started - 18:00 BG 20.6 (immediately before insulin & food - I gave insulin 1 hour earlier as clocks soon to change & very hungry. Hungry & eating well.)
19:00 BG 22.9 (resting in her bed - hour one )
20:00 BG 19.2 (Eating ++!)
21:00 BG 17.2 (Fed when encouraged. Lethargic struggled badly with stairs).
22:00 BG 13.2 (Asked for food so gave a few grams only).
23:05 BG 11.6 (sleeping - nadir?)
00:00 BG 11.6 (sleeping)
01:00 BG 13.9 (sleeping)

I stopped there as vet said only wanted to see where turned at bottom (& it was rather late!)

I then checked the next am’s (29th) BG at:

07:00 BG 27.9 (Insulin & food then given. Poor appetite & drinking++ No ketones).
12:05 BG 9.2 ( 5 hours later - lowest EVER!)
13:05 BG 12.5 (resting)
18:05 BG 29.3 (Actually RAN upstairs no problem!!! A first since unwell. Insulin & food given immediately after this BG test as usual.

I haven’t given her vet these figures yet but he said I should give 0.5-1.0 more insulin if lowest nadir figure was over 11. I haven’t adjusted because of the low surprisingly at 9.2 once).

I have previous blood sugars if needed, usually 5 hours after shot (learning the lingo!).

My feeling is that this insulin is too short acting & she is usually very hungy and asking for food, 3-4 hours before its insulin time, its so hard to refuse & sometimes I just give her 5-10gms but it doesn’t satisfy. Her blood glucose shoots up between shots & then she suffers from poor appetite until it settles more often than not. It is miserable to see. She keeps going to the water bowl for the first 2-3 hours approx. after shot & food.

The vet has a different opinion. He thinks she is difficult - most of his patients aren’t. He would prefer to test for Cushings & maybe tumor causing the problem. I dread any time at the vets as she is very timid & petrified. She had a rotten time in Hospital, they had to put her in the quiet isolation pen - they removed her bed as she wouldn’t get in it & just tried to hide her head at the side of it like an ostrich! Instead they gave her a blanket which she hid under the whole time until I visited.p890a`

I will test for cushings if worth it, but wouldn’t she still need a different insulin. It doesn’t make logical sense to me to not be able to feed her because the insulin has run out! I may be wrong, vet says its suits his other patients. She is so thin I don’t want to mess around for ages & her get weaker. I don’t know how to get another insulin, he wouldn’t commit to it at any point. He asked if I would like a referral to a Vetinary consultant miles away. She hates travelling - I could Skype but she would possibly need MRI & tests. he can test for Cushings at his own practice.

My question is, why the very high sugar swings? Does she need a different insulin? If so HOW do I get it!!

I hope this rings a bell somewhere and that you are able to help. I am so pleased to have found your site - THANK YOU!

I don’t have children, may seem pathetic, but I so love this pussy, she’s a lovely little gentle friend who follows me, chats to me & waits for me when I’m out!

Thanks
Julianax

 

[Elizabeth and Bertie]

Hi Juliana,

Sorry for this short reply but I'm dashing out soon (but did want to reply to you first).

Why does your vet suspect Cushings? Sorry if I missed that bit...

Well, congrats on getting that curve!
Please don't be discouraged by the BG numbers: For three weeks post diagnosis those numbers don't look bad to me! (These are way better than Bertie's were at this stage of the game!)
Cats can get better at 'using insulin' too as time goes on. The effects of 'glucose toxicity' lessen and it can become easier for the cat to utilise the insulin.
That first curve shows that your kitty is responding to insulin, and the drop is quite a nice one; not too steep, and BG dropped quite steadily by about 50%. (The second set of numbers show a rather steeper drop.)
But the swing upwards in BG that you're seeing by the time of the next shot is probably because Caninsulin has usually done it's stuff by about 8-9 hours post shot; and with no insulin in the system the BG will swing up. Some folks here have used their testing data to demonstrate this to their vets in order to get a longer lasting insulin.
If it turns out to be the case that steep blood glucose drops are common for your kitty then that could also be used as a reason to ask your vet for longer lasting insulin. Longer lasting insulins tend to give gentler BG drops than shorter acting insulins.

Again, well done on getting those tests!

Eliz

 

[BJM]

Hang in there - you are making progress.

Caninsulin was developed on DOGS and they have a slower metabolism than cats. Thus, it is wearing off faster than 12 hours - more like 8-10. So ... can you possibly test and shoot every 8 hours? That would make sure there was always some insulin working in her body. You would total up her current daily dose and divide by 3, then give it every 8 hours (or reasonably close to it). If you want to test that, I have a TID spreadsheet for that - here. Just save a copy to your own account.

Also - when you do a curve again, go ahead and do the full 12 hours - it will provide proof that the Caninsulin is not lasting long enough. (ie, she is a normal cat!) This can allow you to get a longer acting insulin such as Lantus, Levemir, or Hypurion PZI which will last 12 hours.

 

[Julie and Alice]

Hi Eliz & BJM,

Thank you for your speedy replies & help, it was great to find! Thanks for the encouragement, Alice looks very much like your Bertie Eliz! I sincerely hope she does as well.

I think the vet thought cushings may be there because of her high glucose numbers or just that she was so unstable, I’m not sure.

I must admit I am discouraged by the high numbers & seeing her drinking the water & off her food. I cant see how she can have steady numbers with a short acting insulin as the bottom number was only down for 1 hour. A vet at the hospital said that unless her numbers are below 10 for 12 hours in every 24 hours then she is not controlled. I’m not sure if that was unrealistic.

The glucose curve I did started at 20.6, that really is unusual for her, I did start an hour earlier & wonder if her glucose shoots up more in the last hour.

I am getting better at getting the blood than I was but I need someone else to hold her. I tried on my own today & 2 out of 3 jabs drew blood but she moved & I was holding her by one ear so failed to get one as she struggled!

I’m not sure what I can expect with the Caninsulin. The high numbers don’t seem to have a downward trend at all yet & she seems to be feeling unwell. I am grateful that it is keeping her alive though.

I am wondering why her glucose shoots up so high when the insulin wears off, especially overnight, even though she is not eating.

I am tempted to try the 3 times a day insulin with Caninsulin. The problem is though that I am sometimes at work & it would mean we would have to have one of us here every afternoon at 4 pm. At the moment I cant give the insulin without my hubby holding her & he hasn’t had a go yet. Its hard to find a long enough space to put the needle into as she only has thin folds of skin, twice I’ve managed to come out the otherside or she’s moved! I would love to get long acting linsulin for her

Yes I will try a 12 hour curve. Do I need to do it hourly or could part of it be two hourly?

Thanks for the TID template, I may yet use it but it doesn’t seem like a very workable option at the moment as it could be impossible to be here at the right time some days. Theother thing that bothers me is injecting into the same site so often. At the moment she’s shaved, I’m not sure I will manage well into fur!

Thanks again,
Best wishes, Julianax

 

[BJM]

When you do a curve, checking every 2 hours is fine.
For a mini-curve, you can check every 3 hours.

Proving that the insulin is wearing off too soon would be the reason for doing another one.

 

[Elizabeth and Bertie]

...Alice looks very much like your Bertie Eliz! I sincerely hope she does as well.

Juliana, your Alice has every chance of doing very much better than Bertie.
She may even surprise you and be one of the lucky ones that goes into remission ('remission' means diabetes can be diet-controlled).
High numbers at this early stage are just 'par for the course'. Everything is subject to change. ;-)

I think the vet thought cushings may be there because of her high glucose numbers or just that she was so unstable, I’m not sure.

Some cats can have very high numbers at diagnosis; much higher than you're seeing with Alice. And the blood glucose numbers that you've listed so far don't appear to me to show any particular "instability". Curve results do vary. There are many factors that can affect how the cat's body uses (or doesn't use) the insulin we inject.
We do occasionally see Cushings cats here though, but not that often. (I'll try to find a list of symptoms for you, to see if anything there rings a bell with you.)

...I’m not sure what I can expect with the Caninsulin. The high numbers don’t seem to have a downward trend at all yet & she seems to be feeling unwell. I am grateful that it is keeping her alive though.

It's very early days, Juliana. But I do understand that it's hard to be patient when we see our cats with high blood glucose numbers. Our cats didn't become diabetic overnight; it took time. And recovery takes time too. But recovery does happen; sometimes very slowly, sometimes astonishingly suddenly and fast.

What do you mean when you say that Alice "seems to be feeling unwell."? Any specific symptoms? Is she eating? Does her breath smell normal? Are you testing her pee for ketones?

I am wondering why her glucose shoots up so high when the insulin wears off, especially overnight, even though she is not eating.

Many cats have lower blood glucose levels at night.
Are Alice's morning pre-shot numbers higher than her evening ones?
If so then there is a possibility that her blood glucose is dropping lower at night than her body is comfortable with, and then 'bouncing' up higher again. That doesn't necessarily mean that her blood glucose is dropping dangerously low. Over time the diabetic cat gets used to higher blood glucose levels: It sort of learns a 'new normal'. So, if the glucose drops significantly lower than it has become used to then the body can become panicked into pushing glucose out into the bloodstream as a protective measure.

Or... Is it the case that there are 13 hours between the evening and the morning shots? (7pm - 8am?)
In which case the higher morning pre-shot number may just be because Alice's body has gone an extra hour without insulin.

...I am tempted to try the 3 times a day insulin with Caninsulin. The problem is though that I am sometimes at work & it would mean we would have to have one of us here every afternoon at 4 pm. At the moment I cant give the insulin without my hubby holding her & he hasn’t had a go yet.

Giving Caninsulin 3 times a day ('TID') might be an interesting and useful experiment for you; but not everyone's schedule can accomodate that. (I did it myself for quite a long time (5am, 1pm and 9pm)).
I recall seeing a post here (years ago) from someone asking if doing 'TID at weekends' would be of any value, and the consensus was that, yes, this could be helpful, since that would still be 2 days a week when the cat would have insulin in it's system around the clock.
If you wanted to try it then you could, as BJ suggested, take the current total daily dose and split it into 3 doses (so, 3 x 2 units instead of 2 x 3 units?)

Giving the shots will get easier over time. Really. Be kind to yourself.
Have you tried giving Alice the shots while she's eating?
And what technique are you using? It may be that you just need to tweak it a bit, or try a different variation on the theme.

..Yes I will try a 12 hour curve. Do I need to do it hourly or could part of it be two hourly?

It doesn't need to be hourly. Some people take tests every 2 hours. Some take tests closer together at certain points in the cycle to get more detail: For example, to find out when the insulin typically starts to take effect ('onset'); to find out when the cat typically reaches the lowest blood glucose level during the cycle (blood glucose 'nadir', or insulin 'peak' - this is particularly important info); when, and how fast the blood glucose level drops, and rises; and how long the insulin lasts in the cat's system ('duration').
(Incidentally, Juliet ('Dr Schrodinger') once posted a pic of a graph she'd made of one of her cat Milo's Caninsulin cycles. I wish I'd kept a link to that because it was such a typical 'Caninsulin curve'. Maybe she still has that somewhere...?)

Curves are useful for finding out how an insulin cycle works in your cat. Ongoingly though, many of us find that 'spot checks' during the day or evening are all that's needed. The data you collect during your curve/s will let you know when it would be most useful to do spot checks.

..The other thing that bothers me is injecting into the same site so often. At the moment she’s shaved, I’m not sure I will manage well into fur...

It is a good idea to change the site where you give the shot, but this doesn't have to be a big change; it can just mean going a little bit to the left or right, or forwards or back. But you can actually inject almost anywhere there is loose skin. (There's a natty diagram here somewhere...)
There are different injecting techniques too. Some people pull up the loose skin into a 'tent' and then give the shot through the imaginary 'door' of the tent, parallel to the spine. I pull up a little handful of loose skin between my thumb and fingers, and then inject almost directly downwards into the skin I'm holding. And I expect there are many other ways of doing it. You will find a way that works for you.

Eliz