Help with Humphrey

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jayrosen1576

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Hi all,

This is my first post on this forum but I've been doing a ton of research and the info I've gathered from this forum has been great. So Humphrey was diagnosed in July of 2014 after I noticed him drinking excessively and urinating a lot one day. Thought he had UTI but his BG was in the mid 400's. I switched him to 100% wet food and his bg went down to the mid 300's and my vet suggested we try ProZinc. I started him on 1U and over the course of about 45 days, his nadir #'s were never below 220 even having him on 4U twice per day. After some extensive research of my own, I discovered the tight regulation method suggested by Dr Hodgkins (http://yourdiabeticcat.com/protocol.html).

I have Humphrey on TID using Dr Hodgkins' method and I am seeing some much better numbers but they still seem all over the place. Never in the green but I am suspecting panicky liver. His drinking and urination levels have been normal for about a month now. Any suggestions / advice?

- Jason
 
He definitely is bouncing all over the place. We generally do not advocate dosing every eight hours, unless you have a lot of data, and the cat is consistently rising at +8. I think that is one of your problems. When you shoot a number that is still dropping, you give more insulin on top of insulin that is already working. The cat is then on a perpetual roller coaster, bouncing from higher numbers to lower ones. And bounces don't always last just one cycle - once he is being dosed between 2/4 units within a cycle or two, his numbers become really hard to decipher in terms of what dose might be best.

The other issue that could be causing problems is that there are no gradients in your sliding scale. If 3 units brings him down to a decent nadir, but a little higher than you want, then the next best dose to try is 3.25, not 4.

Have you seen the protocol we put together for ProZinc?

http://www.felinediabetes.com/FDMB/viewforum.php?f=24 It's the general approach we advocate - starting low and going slow, adapting the dose in small amounts. Merlin's spreadsheet is a good one to look at. He was difficult to get started but she kept working, slowly, and now he is on a small dose and in regulated numbers, headed toward possible remission. Also you might check the spreadsheets on the remission thread at the top of the page and see how people got their cats into remission.

I don't know whether you are sold on the YDC approach (developed by Dr. Hodgkins for PZI, but she is no longer associated with the site) , but if so, I don't have much advice. If you increased from one unit to 4 units in 45 days, I would guess his body never had a chance to adjust to a new dose and he has been on a perpetual roller coaster. If you'd llke to try our protocol, I'd be happy to try to help.
 
Yes! Any help would be immensely appreciated! The reason why I changed to TID was he seemed to peak in hours 3-4 and was never in the 100s. Of course I wasn't testing as diligently as I am now due to advice from my vet. The vet's recommendation was test once per week and if nadir is not in the 100s increase the dose by 1U. I wasn't too keen on that advice especially after all the research on home testing methods I did and instead of going to 5U/shot I decided to try TID.

So what is the best course of action for today forward? If I go back to BID, should I continue with 4U/shot or back it down? If I back it down, how far do I go? Back to 1U? Thanks so much for your help.
 
That's the hard part - deciding how much to reduce. How would you feel about maybe 2 or 3 units, getting a nadir whenever possible, for 3 (12) hour cycles and see how things look? If he drops anywhere close to 50%, then you're headed in the right direction. If you are going to reduce, I'd be sure to get ketone tests daily. We have no way of knowing whether he needs 6+ units or 2 units, so reducing is a little nerve wracking. But I think it's the only way to know whether he is overdosed and bouncing.

There are some conditions that require high doses of insulin. I would consider trying a lower dose and trying to calm the bouncing first, but you might read up on them and see if any of the symptoms sound like him.

http://www.felinediabetes.com/FDMB/viewtopic.php?f=12&t=375

So we'd like to see a smile curve - dropping from preshots to nadir (in that 5-7 hour range) and then starting back up. Sometimes an inverse curve is a sign of too much insulin - if the nadir is higher than the amps and pmps. The other question is, if he has been bouncing around for months, how long will it take for him to settle in? I don't know the answer - all I know is to gather data and do our best to interpret it.

Please know I have no vet training - all I can offer is knowledge I have gleaned helping PZI/Prozinc users for the last 6 years or so. But I certainly will try to help.
 
Well Yesterday morning I switched back to the BID routine and was able to produce a nice curve for the day. However, since his AM preshot # was 208, I only gave him 2u. His # shot up to 419 2 hours later so I gave him another 2u which got him down to 164 at peak. He got his second dose of 4u and this morning he was at 518! Granted he was locked in a room for about an hour before I woke up so I'm guessing the stress may have contributed but this is the same pattern I was seeing before putting him on a TID routine (high am #, peak around 200bg during the day). So I'm kind of at a loss as to what to do next. It doesn't appear the the dose is too high since he didn't bounce at all yesterday during the curve. My main concern is that the insulin is being metabolized way too quickly so it never reaches its full potential. Is that what this looks like to you? I'm also wondering if splitting the doses up (2.5u @ 5am, 1.5u @ 7am, 2u @ 5pm 1.5u @ 7pm) would effectively smooth out the curve and extend its effectiveness. Do you know of anyone that has done something similar to that? I'm considering switching to BCP insulin since it's bovine-based and closer to a cat's own insulin but other than that I'm not sure what else to try.
 
We have cats on higher doses; we have cats who have done TID. I think the jury is still out on Humphrey. I am wondering whether he went lower than usual and bounced up to the
Black or if this amps is too little insulin or the insulin not lasting long enough. No way of knowing without some more data.

Yesterday you gave 2 units at amps and 2 units at +2 and then by +6 he was in the blues?, So I am wondering whether last night 4 units got him into the blues again and he bounced for this am or whether the insulin petered out. How about sticking with the 4 units (or 4.5 if you like that better) for a few cycles and see if he settles in with better numbers?

As hard as it is, I would urge you to shoot only every 12 hours for a few cycles and reevaluate. Even the 2 units on top of the 2 units yesterday gave him a double nadir possibility, and the pmps was really +10/12. It's hard to figure out and, I think, hard for his body to adapt.

Once we see what a dose every 12 hours really does, then you can decide how to proceed - - bigger dose, TID, another insulin (if you are going to change, I'd suggest Levemir as it works completely different and that might help)

There are also high dose conditions. Have you looked at that info to see if any of the symptoms fit?
http://www.felinediabetes.com/FDMB/viewtopic.php?f=12&t=375
 
Today's AMPS looks like a bounce to me. Those blues last night could cause that. Will you be able to get a nadir today by chance?
 
I like his numbers better. What do you think? It'd be nice if he'd be lower at preshot - not sure if that is a bounce or the insulin isn't lasting long enough. You could give it a few more cycles and if the preshots are still too high, increase by .25. Sometimes a short cycle is just not quite enough insulin; sometimes it's a bounce.
 
Rachel - He's usually in the 400's in the am on BID I think because the insulin is wearing off early (+10 instead of +12). I saw this pattern before I put him on TID a few weeks ago too which was one of the reasons why I went to TID. I doubt it's a bounce since this same pattern was present before and he never got below 200-ish. He was curving nicely last night just not low enough. Today his overall #'s seem a bit lower. I didn't catch nadir this morning since I was only able to get home at noon (+7) but the 213 @ +7 seems to coincide with the curve from last night (154 @ +5, 186 @ +6). I'll catch nadir tonight but I expect it to be around the 150 mark @ +5 again, maybe a bit higher since I think I got a partial fur shot at the pm shot. He likes to move around a bit when it's shot time although he barely notices when I test him. Go figure.

I took him to the vet yesterday to do a 2 month re-evaluation and other than a minor bladder infection he checked out ok - no ketones. One of his kidney readings was a little above normal - I forget which one - but the vet said that the more important kidney measurement was in normal range so she wasn't too concerned about it. Something to do with urine dilution I think. I asked the vet to order a trial of BCP PZI since I've heard a lot of good things about it. I'm hoping it will be better tolerated since it's bovine but we will see. I should have it by Friday so I will probably up his ProZinc dose a bit tomorrow to see if that has much of an effect before switching to BCP Saturday or Sunday when I can do a full curve again.

Overall he looks and acts like nothing is wrong so I am guessing his body has a much higher tolerance for high bg's than a lot of cats. His only symptom was excessive drinking and urination which returned to normal about a month ago. Of course, I hate to see any #'s above 325 at pre-shot but I'm not as worried about it as I used to be. If the BCP switch is ineffective, I'll try to hold the ProZinc dose at no more than 5u for a week or two and see if his #'s start coming down. I suspect they will since he seems to be a bit more consistent than he was a few weeks ago when I made the switch to TID.
 
What would you think about raising the dose by .25? You've been on 4 for three cycles and gotten a little better numbers -especially the blues, but he can certainly drop more. I'd say .5 except those blue overnight numbers look pretty good and he does seem to go lower at night. (If you can sure monitor at night, then I'd go for a .5 increase)

With ProZinc, high preshots can be because the insulin just doesn't last long enough or because the dose is not high enough or because of a bounce. Those blues might have caused a bounce - hard to tell about the last overnight cycle but it looks higher. I'd go with a little higher dose and see if the pre shot numbers improve.
 
Yeah I boosted him to 4.8u (just got some u100 syringes so I can better control the dose) yesterday from 4.5u that he was on previously. I'm almost 100% convinved that he is peaking at +5 and I'm hoping the new BCP insulin will assimilate better. He had a bout of diarrhea from the clavamox which I stopped yesterday. I'm giving him some probiotics until that clears up then I'll try the clavamox again. He has a minor bladder infection so I want to take care of that ASAP but not at the cost of him becoming dehydrated. Poor cat doesn't deserve to go through all of this but I'm pretty sure we will get through it just fine.

His new BCP insulin should come in sometime this week which is u100 strength so getting the u100 syringes yesterday was necessary anyway. I do like having better control of the dose with these however the brand that my vet had does not have 1/2 or 1/4 markings so I still need to eyeball it a bit. Do you have a brand of u100 syringe you can recommend? The ones I have are 1/3cc so maybe the 1/2cc would have those finer markings?
 
WalMart and ADW, our shopping partners through the link above, have 3/10 mL, 30 or 31 gauge needle syringes with half unit markings. The larger the syringe, the less likely it is to have half unit markings.
 
Had some issues with my meter today. PMPS reading was 589 so I immediately did a retest and it was 441. Just tested at +2 and the first reading was 509. Retest was 455. Now I'm not feeling so confident about the meter I'm using (Relion Micro). Any suggestions?
 
I don't think many people report any issues with ReliOn. All meters have a 20 variance so certainly the second set of your numbers are within that variance. I am more concerned with his general trends. I really think you are increasing too fast and not accounting for bounces. On 9/26 he got a great drop from 4.8 Nice enough that he probably bounced at least through the next cycle. I agree that the dose on the 333 could have been a little higher - maybe a 4.2 or 4.4 So the next cycle was undestandably a little higher. On 9/27 we don't know what his pmps was and the dose was increased.

I don't like his numbers but I am concerned that a fast rise in dosing, without accounting for his reactions when his nadir is lower, is not helping. I am concerned that you are at 4 units, higher than many of the other cats on the forum. I am not sure whether he is bouncing around or whether ProZinc is not the insulin for him or whether he has a high dose condition. Hard to tell when things are changing so fast.

Did you check out the forum on high dose conditions to see if any of the sypmptoms sounded like Humphrey?
 
i think i forgot to record his pm pre shot # on 9/27. i always test before shooting so I'm not quite sure what i did there. as for the dose increase, i am holding the dose for at least 3 cycles (usually 5) which i thought was the recommended strategy. how long should i hold it for? as for the high dose conditions my vet said he doesn't meet any of them.
 
My thought was that 9/26 interrupted the pattern of 3 cycles and change. The blue nadir was a nice sign that the dose was working, then the next preshot was lower but maybe you dosed a little low and created a higher cycle the next round. It's a matter of interpreting the data, and my interpretation could certainly be wrong. :mrgreen:

Most vets don't see high dose conditions; that doesn't mean they don't exist. I live in Colorado with one of the few vet schools that does surgery on one of the conditions (Acromegaly), so those vets think it exists.

http://www.felinediabetes.com/FDMB/viewtopic.php?f=12&t=375

I am not saying that Humphrey has a high dose condition; I just think it is worth checking out.
 
He could be insulin resistant and he hasn't been tested for that yet and I know that his bladder infection is almost certainly raising his #'s because if you look at AMPS for 9/26 & 9/28, both of those readings were taken after a full day of antibiotics (given on 9/25 & 9/27). I had to stop the antibiotics per the vet due to his bout with diarrhea and I should be getting a different type of antibiotic today. Once that is cleared up I am assuming his numbers will come down on their own so I think I will hold the dose for at least another week and see where we are then. I should also be getting his BCP insulin this week.
 
The UTI can definitely raise his levels. That could make a big difference. Watch his numbers carefully. Some cats drop dramatically when the infection clears.
 
Humphrey's bg was sky high this morning (569, 578; taken with 2 different meters). I even bought a new meter yesterday b/c I thought the one I had was malfunctioning due to consecutive readings several seconds apart varying by 100+. The crazy thing is, even with his high numbers, he shows no signs of hyperglycemia. Urine output and drinking is normal. He has energy. You would never guess anything is wrong. That's the part that I don't quite understand. Hopefully after the bladder infection clears things will normalize a bit. His new insulin (BCP) should arrive today and I am going to start him on it Saturday so I can monitor him all day. This will also give the antibiotics a few more days to help clear the infection.
 
For anyone reading this:
ALL over the counter meters in the USA may read +/- 20% from what a lab would get. At higher numbers, 20% can be very large. At higher numbers, it doesn't matter. High is high and you want to take action to reduce it. It is not, by itself, an emergency.
Ex
A reading of 100 represents a range from 80 to 120, a span of 40
A reading of 200 represents a range from 160 to 240, a span of 80
A reading of 300 represents a range from 240 to 360, a span of 120

Once you're over 240, or so, you should test for ketones in urine (inexpensive test strips) or blood (expensive meter and test strips). More than trace ketones is a medical emergency as it may signal diabetic ketoacidosis, a potentially fatal, expensive to treat complication of diabetes.
 
I don't know, Jay. Those blacks are ugly. I am glad he seems to be feeling well, but I agree with Bj, that testing for ketones is necessary. Especially if he has an infection.

He is very confusing. He got decent drops into blues with 4.8 but gradually worked his way back up to the blacks. So it isn't that the insulin isn't working - it did with that cycle- it's that it doesn't seem to work consistently. The high preshots sort of look like he doesn't get a long enough cycle, but that's not consistent either. TID meant he bounced all over. The infection can certainly raise the numbers, but the first antibiotic should have done something.

I guess I'd raise the dose again. He can't sit in those blacks. I hope your BCP affects him differently but we haven't seen any big differences between BCP and ProZinc. If he were mine, I think I'd try Levemir. It is what most higher dose cats use, as it stings less at higher doses.
 
And if you decide to try Levemir and are in the UsA, you may find that ordering it from Canada is your least expensive option.
 
I just tested him and he was at 403 at +7. Going completely in the wrong direction lately. He was tested for ketones and was negative. He did feel a little warm this morning and I noticed a sneeze or two over the past few days so I'm not sure if that could also be a factor. Either way the antibiotics will need a few more days to be effective so time will tell. I am hesitant increasing the dose any more since it seems (at least from the recent numbers) that going from 4.8u to 5u is what triggered the higher numbers. Either that or the bladder infection / possible cold. He has never been in the black before these past 2 weeks except maybe once. Most of his #'s were in the 300s & 200s. If I can't get this under control within the next week, I may try going back to TID but keeping the doses more consistent. He may have been bouncing a bit but his pre-shot #'s were much better. Kind of at a loss as to how to proceed.
 
I am glad he was negative for ketones; I would make testing those a regular practice as long as he has an active infection. What is the new medicine? Any chance that there is sugar in it? Some antibiotics do raise bg levels.

I think you have a lot of things going on with the infection and antibiotic. Sugar cats are hard to figure out when it's just the insulin :mrgreen:
 
When I goggle it, I can't find any specific articles with feline diabetes, but there is caution for human diabetics. When I search on this forum for it, it looks like others have had issues with it raising the bg levels. This from an old post from Linda and Guiness:

It's not Clavamox, it's Cephalexin for Oral Suspension, USP. He doesn't do well on Clavamox, so she wanted to try this. After tasting a small amount myself and finding it sweet, I looked it up online and found this..."Cephalexin suspension contains sucrose (sugar), which may adversely impact the management of diabetic pets. Consult with your veterinarian prior to administering cephalexin to diabetic pets."
 
I've done a little research too and found the same. it would make sense that the oral suspension i gave him does have sugar in it. going to tablets tomorrow. you would think the vet would know this may not be a good option for a diabetic cat. I'm not a fan of tablets but I'm going to make sure i chase the pull with some water to make sure it goes down all the way.
 
Yes, definitely chase with water. i think the duck pill pockets are supposed to be low carb. Some people use a small piece of soft cheese to hide the pill.
 
You can chop up the pill, put it in an oral syringe, add water, and dissolve the tablet. Add a bit of food to help mask the taste.

Aim for the back and side of the mouth when giving it.
 
Just picked it up from the vet and they are chewable tablets. Well, maybe chewable for a human but not a soft chew treat that a cat would actually eat. They are easy to crush and I put it in his food. Didn't even notice it was in there. As for the sugar in the oral liquid...you would think that a vet with a diabetic patient would NOT recommend a medication potentially containing SUGAR! Sometimes I think that I, with zero medical training, have more sense than the doctor...

Anyways, his #'s this morning were still high, 383, and his last dose of the liquid antibiotic was yesterday afternoon so I was not surprised at that (at least it was not in the 500s like before). However, I just tested him at +7 today and he was even higher than this morning, 473. Could this still be from the sugary antibiotic given yesterday? He got his insulin this morning on time with no miss/fur shot so I'm wondering what's going on. I got his new insulin, BCP, today too so I'm anxious to try that out but I have to wait until saturday so I can do a nice curve. One benefit of this brand is it's (supposedly) once a day dosing and gentle onset like ProZinc. I'm starting him off on 1u to see what that looks like even though the vet recommends 2u as a starting dose. Again, I am second guessing my vet but I think I may have just cause to do so. *fingers crossed*
 
No, it is still dosing every 12 hours due to the cat's more rapid metabolism. Perhaps they were thinking of dogs.
 
I would give it a cycle and see what the numbers look like. An inverse curve sometimes means too much insulin. I am not necessary leaning that direction because he's been at this dose awhile and that's the first one we've seen. I sure liked that first cycle at 2 units but you've gotten similar nadirs at 4.50 also. I don't understand his patterns - he doesn't seem to have any. And I wouldn't want you to try lower until the infection is completely gone. All I can think is that the infection is playing havoc with his levels and he won't settle in to predictable patterns until it is gone. I am alittle nervous about your reducing when you start the BCP. If you do, be sure to test for ketones often. (DKA is usually high bg levels, infection + poor appetite.)

I am not aware of any insulin that can be given once daily. No one here using BCP tried it. All insulin lasts 12 hours or so in cats. Sometimes we see a longer cycle, later nadir with Levemir or with ProZinc when the dose is too high and the cycle continues to drop past 12. But those are rare and certainly not a pattern that repeats.
 
According to the BCP website:

"Most cats can be regulated with only one dose per day, as opposed to the twice-a-day routine many cats require when using synthetic human insulin. Once-a-day insulin injections obviously offer a considerable compliance benefit for pet owners."

http://www.bcpvetpharm.com/products_bovine.htm

I read a few articles too that stated this about BCP so I'm holding out hope that it is the case. Either way, as long as I get better results I will be happy.
 
I don't think we've seen good control on once a day dosing here, unless the cat was nearly off insulin.
 
Hi Jason,

I snuck a peek at Humphrey's SS. Still looking pretty bad. Either he is seriously overdosed ( I know you tried lower doses for a few cycles and nothing changed. Not sure if you gave it enough time, but I understand the danger of lowering a dose if not needed) or something else is wrong. He does get some yellows but you really should see more movement at the doses you are giving. He definitely does seem to do his share of bouncing, but I can't see that bouncing would explain his consistently higher overall numbers.

All I can think of is a high dose condition. We seldom see a cat above 5 units BID on any insulin unless he has a high dose condition. Do any of the symptoms sound like him?
 
I can't see your spreadsheet on my phone. I notice the link has ccc in it.
Would you try something? Log in and select File, Publish to Web and copy that link into your signature or a post? I need to see if that will let my phone see it.
 
I can see the SS on my phone. My only thought I'd s high dose condition like Sue said. Honestly...I'm not the best at spreadsheet interpretation and this is pretty confusing. Have you looked up the symptoms of high dose and seen if that sounds like Humphrey?
 
So here's a quick update. Humphrey's bg #'s have been way better this week. He had a blood test and urinalysis on Monday so we'll see if the bladder infection is gone but I suspect it is. Also the BCP does work better than the Prozinc since his numbers are more consistent so I'm happy with the new insulin so far. I also had the lab run a test for IAA so we'll see what that comes back with.
 
Yeah he does seem to be reacting more consistently with the BCP and he no longer has a bladder infection so I'm sure that plays a huge role too. Today's #'s look great so far and the lower dose (4u vs 5u) I gave this morning is working well since he's been in the blues most of the morning. I did not get the IAA test results back yet but it should be in early next week. Not sure why it is taking so long.
 
Ok so I have a question. If you look at Humphrey's numbers from yesterday (10/22/14) he was in the 100's for almost the whole day. I was shocked to see him at 110 at PMPS (retested and he was at 109 so I know it wasn't a mistake). Since he was in the normal range I didn't give him insulin (first time that ever happened). At PM+3 he was still below 200 so I didn't want to give him insulin then either and throw off his schedule. This morning he was at 502 which seemed really high but not completely unexpected since he only had one shot yesterday. So my question is this: Should I have given a shot at PM and if so at what dose given his recent data? Also, since he was able to go almost the whole day in the 100s even after eating twice since AMPS (noon and 6pm) does that mean that his pancreas does have some ability to lower his bg since his insulin dose has been consistent lately?
 
I would suggest no insulin under 180 (tops) as his numbers are all over the place right now and it is hard to predict how low the insulin could take him. He certainly is doing better! With the low pmps, no, I wouldn't have shot a number in that range. Not only was he very low but you didn't know if the number was rising. When he was up to 199, you might have shoot but a smaller dose BUT you would have to rearranged your schedule so your next shot could have been 12 hours later. (or at least +10, rising and then have the ability to monitor carefully)

Generally a preshot that low means the dose preceeding was too high. One of the signs of a dose that is too high is a cycle longer than 12 hours with a unshootable preshot at the end. Although reading past history on the ss is not 100% reliable, it does look like the 4 on that 300+ range may have been too little but 4.5 too much. Maybe gradiants of .25 are the way to go when you increase or decrease a dose? It also looks like he takes two cycles or so to react to a change in dose?

I am glad he is looking better and you are getting some lower numbers. Does he act more like himself?
 
The BCP insulin is a 100u insulin so i can't really shoot in .25 increments. The syringes I use are not even marked with 1/2u markings but I don't even think they sell 100u with 1/4 markings do they? I am happy with the progress as of late since he is definitely showing signs of improvement. The pre-shot #'s are lower and there are very few 400s anymore. Since I work 7:30am to 5:30 pm its hard to get good data during the week except for at noon when I can get home for lunch. So I'm not sure how low he went yesterday between noon and 6pm but he very well could have been below 100. No bounce though which is good so if he did go that low I know he can handle it well.

His nadir today was a 60% reduction of the AMPS and his PMPS was good so I know his reaction to the insulin dose is much more predictable since the bladder infection is no more. That being said, an increase or decrease of 1/2u has never had much of an effect even before the bladder infection so I don't think the dose adjustment of 1/4u would do much. I have noticed that the onset with the BCP is a bit longer then with Prozinc, about 3-4 hrs instead of 2-3 so I probably could have given him a unit or two at PMPS but I didn't want him to go too low with out me being there (awake) to monitor. As far as his temperament, he's never acted like anything was wrong even when his numbers were consistently high (with the exception of the excessive drinking). He's always as active as a 14 yr old cat should be so he seems to tolerate the high bg pretty well.
 
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