Help with stabilising blood sugars - frequent hypos and hyperglycaemia (Part 2)

This is a continuation from a previous thread: https://felinediabetes.com/FDMB/thr...and-hyperglycaemia.287222/page-2#post-3161429

@Suzanne & Darcy , here is tiger's update from the RVC

She was seen by an internal medicine resident

- She's admitted because they want to do further testing
- The vet seems to imply that I've been 'overmonitoring' and reducing her sugars too much
- She says that we should allow for hypos because apparently with even in normal non diabetic cats, even 1 units BD of prozinc is safe
- She called earlier to say that's probably what they'll recommend on discharge. I told her that if she does want to do that, then she should do it now from her PM dose and see what happens especially when she's already admitted and being closely monitored, instead of starting it when she's home


I know they're the experts and I believe them, and the resident has confirmed she's spoken to her seniors etc. But this idea of just letting her hypo and not caring about it really frustrates me, because she's home alone and can't self regulate. She's had three separate episodes of hypo on 0.75, her sugars are high today, but yesterday it was bang normal on 0.4

I'm picking her up at 6pm tomorrow and will update again after...

 

Well you know that I don’t agree with letting her hypo. I really don’t understand that at all. I certainly don’t agree that giving 1 unit of ProZinc to a non-diabetic cat would be safe. @Marje and Gracie

 

I’ve read the previous thread and this one. A few things I want to clarify:

1. there is a difference between low blood glucose and a hypoglycemic episode. I don’t see any BGs on her SS which would result in a symptomatic hypo so I think it’s best to get the semantics correct to keep anyone from thinking she is actually having symptomatic hypos. While a cat can have a symptomatic hypo in the 40s, in almost 14 years here, I’ve only seen one time where a cat “might” have had some symptoms (like glazed eyes and staring) in the 40s on a human meter.. I’ve never seen one in the 50s on a human meter. While it is imperative we closely monitor any BGs below 50 on a human meter, it’s best to only use the term “hypo” when we see symptoms.

2. I have seen symptomatic hypos in diabetic cats receiving as little as 0.25u of insulin. When a vet says a nondiabetic cat can be given 1u of PZ without a hypo, that can possibly happen. I remember one instance here where a member’s family member accidentally gave the insulin shot to their nondiabetic cat. We were up all night with the member monitoring the cat, and the BG was fine. But that is one shot in a cat that is able to regulate the insulin and blood glucose in its body. That is not a diabetic cat whose body has lost the ability to deal with insulin and regulate its blood glucose. While PZ is not a depot insulin in the pure sense of the term as Lantus and Levemir ( and biosimilars are), we have noted it can, at times, have a residual effect from one cycle to the next so continuing to give too much insulin to a diabetic cat is going to result in a symptomatic hypo. I would not suggest 1u bid for Tiger at this time. Also….shooting three times a day can be done with PZ and we’ve had members do it effectively but if you are gone long hours, I wouldn’t do it. We’ve gotten thousands of cats regulated shooting twice a day.

3. While I understand why some members need to use the Libre, it does run low at low numbers. Because of that, if we aren’t seeing a test when the BG is low with a handheld meter, it’s difficult to know if the dose is correct. I am also confused when you are using an AT and not so a better way to make that apparent would be appreciated.

4. One reason you are seeing so much and such drastic bouncing is because she isn’t being fed the correct amount of food to work with her insulin. Dropping from Hi to 440 or 256 to 59 in two hours is too fast. The faster the drop, the harder the bounce. It’s really important to feed her something in the 6-10% of calories from carbs divided up into four meals at PS, +1, +2, and +3 (to start) to work with the onset of the insulin. You might find a different feeding schedule works best for her but that is where we usually start. In addition, because bounce clearing cycles are very active, I often see the BG drop below the reduction point but the cat is not ready for a reduction. However, due to our dosing methods, we suggest a reduction out of safety because the dose can always go back up. You might find if she’s fed correctly, the drop would be slower and she wouldn’t drop so low as the bounce clears. If you have an early indication the BG is dropping fast (say a big drop between PS and +2), you might want to feed a little extra carbs (MC like 13%) just to slow it down.

5. She is losing duration and that could be due to absorption issues, the shot isn’t being given exactly subq, or the dose isn’t right. An example is on 3/1 where she went from 169 to 398 in two hours. Most people will tell you it is the start of a bounce but it’s actually loss of duration and then a bounce hits on top of it.

6.For DKA to be present, there must be infection. Did they identify this? A cat does not develop DKA in the absence of infection. And while DKA can occur in cats who look tightly regulated (I’ve seen two), typically DKA also indicates there isn’t enough insulin.

7. I absolute do not agree that any cat should be allowed to drop so low it experiences a symptomatic hypoglycemic episode. I can’t possibly know what the vet meant by allowing her to hypo but our guidelines here are reductions are earned with a drop below 50 on a human meter, 68 on a pet meter for a newly diagnosed cat like Tiger if the CG is using TR method of regulation. If using SLGS, which you should be doing since she’s eating dry food, it’s below 90 on any meter.

Until she is eating no dry, you must use SLGS method of reduction and reductions come when the BG drops below 90, human or AT meter. I see three times when this has occurred since she was dropped to 0.75u.

My gut tells me she likely needs at least 0.75u bid (because her reductions were earned when she was dropping quickly when clearing bounces) but if you aren’t able to manage her curve properly to get it to flatten out more, it’s safer to give 0.5u bid so that would be my dose suggestion for now. I also think she would benefit a lot from Lantus. PZ is not working well for her. But, even with Lantus, you have to manage the curve better or you will still get these wild dives and bounces.

 

Thanks, Marje.

 

You’re welcome!

 

Dear Marje and Suzanne,

Thank you for such thorough advice.

To clarify a few things,

Re 3 - I indicate where it is done by AT with the word (AT) next to it on the chart. I also really agree re freestyle being unreliable on lower numbers, so I always make sure to double check with alpha trak.
Re 4 - food she is currently having:
For AM + PM: Wet food - MjAMjAM; this has between 1.3-9.8 % carb
For dry food that she's given at 1-2pm: Thrive premium plus - close to 10% cals from carbs or a bit above

The food list is from the UK member thread, and here is the link https://docs.google.com/spreadsheets/d/1J5JpMe6TDXrHq_aTl9hUtHy6Gs9oRBqlz4nPGKxtySA/pubhtml#

Re 6 - they have not identified an infection. The urine was clear

Re 7 - I genuinely agree. I understand that 0.6 is a small dose and that 1 unit is a common starting dose for most cats. However, I feel like they're enforcing protocols on Tiger without taking into account her current trends and patterns and personalising them to her.

They are doing a scan on her today to rule out pancreatitis, and they said they were going to do some additional test to check for inflammatory triaditis and chronic enteropathies.

 

I’m glad they’re checking her over thoroughly. I guess they mean they will do an abdominal ultrasound? I’m wondering if they will also do the Spec fPL test for pancreatitis? Here’s an interesting study on the feline pancreatitis tests - comparing the SNAP fPL to the Spec fPL.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661714/

 

I have been pondering what the vet meant by “allowing” for hypos. We cannot assume Tiger can just regulate herself back into higher numbers in time to prevent a symptomatic hypoglycemic event. Anyway, I hope you will have her back home and healthy again…. and I so hope that they will allow you to switch to Lantus. I really think it would help Tiger more than the ProZinc has done.

 

I did see that but, for instance, the AMPS on 3/3 doesn’t make sense since you have “67, 67 (AT), > 56 ten minutes after”. So is the first 67 the Libre and is the 56 the Libre or AT and why is it > since the meters give you an exact value?

Consistency (amount, time fed, carbs) in feeding is pretty important and if you are just giving her food at AMPS and PMPS and then not again until 1-2 pm which really doesn’t mean anything to me since I’m not on your time zone (we speak in “hours since the last shot” not actual time), then you are not giving her any calories to work with the insulin. It’s not only important to try and feed at the same times each cycle but also the same carbs unless you need to add some if the BG is dropping too low. If you are gone to work, using an auto-feeder can help.

I’m not trying to be critical but you just aren’t managing her insulin correctly and that’s why you are getting this wild swings.

There are many other sources of infection like teeth. I’m glad they are checking her out for other things but we typically don’t see pancreatitis, triaditis, etc as a cause for DKA. DKA results typically from not enough insulin + not enough food/water + infection.

Are you seeing the vets in the feline diabetes clinic at RVC because they’ve done some ground- breaking work but the advice given on the dose and letting her “hypo”, whatever that means, does not sound like advice the feline diabetes clinic would give.

 

Hi everyone,

Thank you for the detailed advice

Re her scans:
- she has hyperechoic changes in her liver
- they found some incidental lesions in her spleen
- She also has slightly dilated ?ureters- something in the renal region was dilated. They think it's from the excessive peeing

re her blood test
- her kidney functions have deteriorated slightly, it's now in upper end of normal and she has raised ALP

re her weight
- she has gained 0.8kg in the last 2 weeks since coming off metabolic

@Marje and Gracie , thank you for the detailed advice as always. ooh:

• essentially, 67( 67 - AT) --> 56 10 minutes after ; you're right, this means that it was 67 on the freestyle, and then 67 on the AT. It's not meant to be >56 but it's meant to be ---> 56 to show progression of time, but I take your point that it's hard to read and will find a better way to organise this
• I've considered the auto feeder, but I'm not sure tiger will be responsive to one that gives her wet food, because it'll just open and I'm not sure she'll eat it. With her wet food that is given with her AM shot example, she tends to only eat a bit, doesn't finish it, and then grazes on it for the rest of the day. I'll try and buy an auto feeder that allows for wet food and see how she gets on.
• Her teeth have been checked, they are fine. The vet has informed me that no source of infection was found anywhere

@Marje and Gracie and @Suzanne & Darcy , yes, this is the diabetes clinic at the RVC. I spoke to them again today, tiger nadir on 1 unit today is 4.2. They're happy to continue. She explained to me that cats are highly resilient and resourceful, and have the natural inbuilt mechanism to fight off hypo and so it's okay to let it happen, and I shouldn't worry about it happening when she's alone.

She's still there, and I'm picking her up tomorrow.

The plan is:
1. Discharge on 1 units BD
2. They will monitor her trend remotely, and I'll call them again in 5-7 days
3. if she has values below 2.9, then we can switch to 0.75
4. We discussed the possibility of oral anti-hyperglycemic, but we decided against this for now as she is showing good response to insulin and also, it can cause euglycaemic ketoacidosis which most vets are not familiar with

I also asked about lantus, she said she doesn't think it's needed because she has good response to prozinc and it's lasting for as long as they would like it to last etc.

 

Well be sure to leave quite a bit of food out for her to graze then when you are not at home -- to make sure if her BG drops a lot that she can eat as she will hopefully become hungry as a result of the drop. I'm good with the reduction if she drops below 2.9.

My cat also had both hypo and hyperechoic changes on ultrasound after his DKA. We even did fine needle aspirates of some of the areas and found nothing. I actually put him on Denamarin for his liver (milk thistle is also good) and his liver values improved to normal.

 

She’s discharged now

I got some interesting advice that I’m a bit worried about:
- only treat for possible hypo if it says LO on the freestyle which is below 2.2
- only reduce the dose to 0.75 it it says LO (I’m okay with this one)
- do not omit regardless of the value, even if it’s LO, just give 0.75. As long as it’s not LO, even if it’s 2.5 etc - just give her 1 unit still

my partner is coming over and staying with me this week as he’s off work for study leave for an upcoming exam, so she’ll be with someone. I’ll follow their advice and see what happens, someone can intervene if she gets unwell. I’ll trust that they know what they’re doing even if I genuinely cannot understand the rationale for some of it

 

Wow. I am almost speechless. I read this about 30 minutes ago, and I am trying to process this information. I feel like they are playing Russian Roulette with Tiger’s life. Perhaps those instructions are designed for a cat who is admitted in a clinical setting with the ability to intervene with an IV glucose drip, etc.

I also believe that just letting her drop like that will create bounces that are very high and prolonged. Maybe if you can feed her more according to the timeline that Marje spoke about, it could work. Who knows what they mean by treat for a possible hypo, but I feel confident that you will at least feed her if the Libre is approaching LO.

I’m very happy to hear that Tiger will have someone with her this week. Let us know how you get on. If you know me, you know I will be checking for spreadsheet updates.

 

I'm very concerned about the advice to give her 1 unit of insulin even if her Pre-shot values are in the 3 and 4 ranges, and to not intervene unless it's "LO".

I've emailed them and asked that they give me written confirmation that this is their advice.

It's so bizarre to me, so I need written confirmation before I'm happy to fully follow through with all of it. I think it's easy to give this kind of advice when it's verbal; I'm not sure if they're writing in their notes that this is the advice they're giving me. With written confirmation, if anything happens, then there's no she-said he-said.

I've only seen the residents, not their seniors. As a resident myself, I trust that they have enough knowledge to get the post, especially because it's such a competitive one. At the same time, I'm not sure they've run their advice on the above with their attending/consultant to confirm it's safe.

 

Just another further update, after I've send the email confirming that is exactly what they wanted. I got a reply which is very different to what was said in person.

"At the time of administration if you are going to check the Libre then we can make note of what the glucose is at this time and what the previous nadir has been:

• If Tiger is eating and her glucose is >7mmol/l administer insulin. If <7mmol, leave that dose until next time (you can also confirm it is not an error with your Alphatrak)
• If Tiger's curve in the 12 hours prior to this dose has consistently been higher than "low" then administer ONE unit
• If during that previous curve the Libre read as " low" at any point then administer 0.75 units instead.

If during the day you detect a low reading then offer Tiger food and reassess in 30 minutes. If it increased continue with the next plan dose reduction. If she is showing clinical signs of hypoglycemia, then again give food and call for advice. "

This is vastly different than what was said to me in clinic. Regardless, I'm much happier with this advice and feel safer with this; I knew that if there was a written trail, they would be more careful with their advice.

 

Interesting! Are you able to put any BGs and doses they gave her at the hospital into the SS, please?

How do you know LO on the Libre is 2.2 (40 mg/dL)? I’m asking because other members use the Libre and check with a handheld and they don’t get that BG consistently.

I would suggest you look at Start Low Go Slow and follow that guidance. It’s very close to what they are suggesting but it’s something you can easily look at for guidance…..or ask here.

Did you discuss with them starting Lantus?

 

Yup, I also asked about Lantus; she said she doesn't think it's needed because Tiger has a good response to zinc, and it lasts for as long as they would like it to last, etc.

ooh yes, sorry, I've been bad at updating the graphs over the last few days, will do this now.

Re LO on the freestyle being any value they consider to be lower than 2.2, it's as per the libre website: https://www.freestyle.abbott/qa-en/...reading,glucose monitoring system user manual.

But Libre gets quite inaccurate at lower values so tend to read lower than what it actually is, so even though a libre might perceive the blood sugars to be LO/<2.2; it probably isn't. I'll make sure to always double-check any LO values it reports.

 

How is Tiger?

 

Idura, how is Tiger getting along?