Help with stabilising blood sugars - frequent hypos and hyperglycaemia

IduraH

IduraH

Member Since 2024
Dear Everyone,

I've been asked to make another thread as the last one was getting quite long.
https://www.felinediabetes.com/FDMB...quent-hypos-with-prozinc.286951/#post-3156669

Tiger's sugars continues to fluctuate up and down, it seems that particularly with her PM dose, she is not responding very much to the dose at all with nadirs between 400-499. However, she also tends to get hypoglycaemia in the day with the same doses.

She started last week being on 1.5 unit AM and 1 unit PM, we switched this to 0.75 units BD after the kind advice by @Suzanne & Darcy ; however, she still had a hypo on the 0.75 unit dose. This was then adjusted to 0.5, but she then had persistent hyperglycaemia. I've been quite worried about another DKA, so she's currently back on 0.75 units BD and hasn't had another hypo since Monday. But her PM nadirs are quite high still.

Can you please advice what I should do?
 
IduraH said:
Dear Everyone,

I've been asked to make another thread as the last one was getting quite long.
https://www.felinediabetes.com/FDMB...quent-hypos-with-prozinc.286951/#post-3156669

Tiger's sugars continues to fluctuate up and down, it seems that particularly with her PM dose, she is not responding very much to the dose at all with nadirs between 400-499. However, she also tends to get hypoglycaemia in the day with the same doses.

She started last week being on 1.5 unit AM and 1 unit PM, we switched this to 0.75 units BD after the kind advice by @Suzanne & Darcy ; however, she still had a hypo on the 0.75 unit dose. This was then adjusted to 0.5, but she then had persistent hyperglycaemia. I've been quite worried about another DKA, so she's currently back on 0.75 units BD and hasn't had another hypo since Monday. But her PM nadirs are quite high still.

Can you please advice what I should do?
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@Suzanne & Darcy
 
Hello! So good to hear from you. I have to admit that I was really getting quiet worried about Tiger. I am very relieved to hear from you! Let me look at what data you have from the last few days.
 
If you have decided to stay with the .75 unit dose then you need to hold that dose longer. Please do not increase the dose. See how she bounces anytime she gets into better numbers? You won’t be able to stop this by increasing the insulin. In fact, it could just make things worse and will also put her in danger of a real hypo of numbers significantly below 50 (on the Libre.) We really can’t rush the process too much. Tiger has been diabetic for a while now and it’s going to take patience and persistence and careful following of the dosing protocol to get her into better numbers— but it can be done. I know this doesn’t seem believable. I am sure you think that I don’t know what I am talking about and don’t understand your Tiger. The dosing protocols are based on good research.

Did you get a ketone meter? If Tiger isn’t producing ketones we don’t have to be afraid of DKA.
 
Diane Tyler's Mom said:
I really don't see a hypo on the 0.75 units Are you talking about the 2 green BG numbers on 2-26-24?
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There was a time when the Libre caught a hypo when the sitter was there taking care of Tiger. Those numbers should really be put into the spreadsheet for information.

Also we still need to differentiate between Libre numbers and Alpha Track numbers, Idura. On an Alpha Track a number below 68 is the take action number and on the Libre a number below 50 is the take action number. So of we are looking at the numbers and talking about potential hypoglycemia, it’s important to know. Those two greens in the 50s are perfectly okay numbers, although they definitely require further attention and testing since we don’t know if Tiger can surf in green on his own yet or just with a little low carb food.
 
Hi @Suzanne & Darcy , thank you for your advice. I do believe you and I do trust you. I'm sorry if it doesn't come across that way. I've gotten into fights with my partner about reducing the dose, but have persisted with reducing it (even if sometimes he does win, and I have to put it back up again). I'll persist on this dose for now.

There's a lot of worry about another DKA; I've bought the ketone meter but struggling to use it. I've just spent the last 30 minutes trying it, but to no success. I'll give tiger a break and try again with it in the morning.

Just for my own knowledge, why do you think tigers sugars are higher in the PM, but she seems to respond better to the insulin during the day? is the PM high BMs a reaction to the close to normal daytime sugars?
 
Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).
 
Red & Rover (GA) said:
Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).
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ooh, thank you for the explanation. I understand now, Her sugars are usually quite good in the AM/daytime, so she's bouncing in the PM. That makes sense
 
Fortunately, Tiger seems to clear the bounces fairly quickly and get back to business and yes it’s usually in the daytime. Maybe that’s good though- for now- as you can sleep.
 
Are you having trouble getting enough blood for the ketone meter? It may require a little more than you are used to. If you get some blood you can kind of use your fingers to “milk” the ear a little bit by pressing the ear slightly to push a little more blood out. Hard to explain.
 
Suzanne & Darcy said:
Are you having trouble getting enough blood for the ketone meter? It may require a little more than you are used to. If you get some blood you can kind of use your fingers to “milk” the ear a little bit by pressing the ear slightly to push a little more blood out. Hard to explain.
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I am having a lot of trouble with this; I thought I managed to get enough blood at one point - but it turned out I just poked myself.

I'm going to buy her some low-carb food and start trying it out from next Wednesday; I've managed to arrange for a cat sitter to stay with her whilst I go to work. I'll update the excel sheet for today after her PM shot, but no hypos so far which is good.
 
IduraH said:
I am having a lot of trouble with this; I thought I managed to get enough blood at one point - but it turned out I just poked myself.

I'm going to buy her some low-carb food and start trying it out from next Wednesday; I've managed to arrange for a cat sitter to stay with her whilst I go to work. I'll update the excel sheet for today after her PM shot, but no hypos so far which is good.
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Okay. The low carb food should help her as long as you make the transition slowly and have someone to be with her to make sure she doesn’t drop too low. Can’t wait to see her numbers for today. I check in on her a lot :)
 
Thank you Suzanne for your help. It's been quite stressful with tiger having diabetes and living in the city alone, I've been struggling with quite bad anxiety over this, and constantly worry about coming home to her unconscious etc. I feel a lot more reassured and a lot less anxious now. We appreciate your support more than you know.

I've updated some of her numbers today :bighug:
 
Oh Hooray! I am so excited! Look at those blues!!!! Seriously! Blues! I almost feel like crying. She really is making progress. :joyful::joyful::joyful:
Ignore the forthcoming bounce. It will pass — and she will have more good numbers and more chance to get used to the lower healthier numbers (and hopefully that will mean less bouncing.). She is doing better and will continue to improve. I needed this today! Thank you for updating her spreadsheet.
 
Good Morning,

@Suzanne & Darcy , you were spot on with the bounce. She bounced quite hard last night, and even vomited once. She is still eating and drinking, and playing okay and is otherwise herself.

Her levels this moring 3 hours post 0.75 is 27.5 on alphatrak and the ketone on the meter was 0.6.

What do you advice we do ?
 
IduraH said:
Good Morning,

@Suzanne & Darcy , you were spot on with the bounce. She bounced quite hard last night, and even vomited once. She is still eating and drinking, and playing okay and is otherwise herself.

Her levels this moring 3 hours post 0.75 is 27.5 on alphatrak and the ketone on the meter was 0.6.

What do you advice we do ?
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Hello. Love that photograph of Tiger! :-) She's still in that bounce. Keep holding the .75 units. Hopefully, she will clear that bounce soon and we will start to see some better numbers (and judge by her nadir when she's not bouncing whether she needs an increase of .25 units or not.) Congratulations on getting a reading on the ketone meter. Ketones can fluctuate throughout the day. If, as you say, she's eating, drinking and playing and is acting like herself then I would not worry about DKA. My cat produced a lot of ketones (way higher than .6) for a long time and then they started to go down. If he ever went off of his food, I would have him back to the vet to have his white count checked (usually it was elevated and we put him on antibiotics.) Fluids/hydration are very beneficial so I would add some water to her food if she will tolerate it.
 
Suzanne & Darcy said:
Hello. Love that photograph of Tiger! :) She's still in that bounce. Keep holding the .75 units. Hopefully, she will clear that bounce soon and we will start to see some better numbers (and judge by her nadir when she's not bouncing whether she needs an increase of .25 units or not.) Congratulations on getting a reading on the ketone meter. Ketones can fluctuate throughout the day. If, as you say, she's eating, drinking and playing and is acting like herself then I would not worry about DKA. My cat produced a lot of ketones (way higher than .6) for a long time and then they started to go down. If he ever went off of his food, I would have him back to the vet to have his white count checked (usually it was elevated and we put him on antibiotics.) Fluids/hydration are very beneficial so I would add some water to her food if she will tolerate it.
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I've given her the PM dose with her first low carb meal (MjAMjAM from the list on the UK thread). It might have possibly been a fur shot though, feeling a tad bit anxious about that. But I shall see what happens tonight. No further vomitting or incontinent episodes. The vet today has also suggested a referral to an internal medicine specialist for tiger - so progress on that front.
 
Suzanne & Darcy said:
Does she have other diseases that would warrant an IM veterinarian’s consultation?
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Not that I know of, she has arthritis but is on solensia for that. I think the vet is just really struggling with Tiger's diabetes control.

Re the switch to the low carb food, my plan is as follow:
1. Saturday - Tuesday - PM meal to be replaced with low carb food (she will be home alone for most of the day time for Monday and Tuesday)
2. From Wednesday - both AM and PM meals to be replaced with low carb food, she continues to get dry Hill's metabolic for lunch (The cat sitter has agreed to stay her during these days whilst I go to work)
 
Suzanne & Darcy said:
And you are going back to work on Wednesday?
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I'm back at work on Monday, so I'm hesitant to do the full food switch any sooner than that. The cat sitter is away until Wednesday so can't help any sooner than that.

The vet also suggested today that she needs an increase in her insulin dose after looking at the graph, we have a further phone call on Monday to discuss this. I'm not comfortable with any further increase at the moment in view of the fact she's home alone for most of the day, and tends to hypo during the day time.
 
I definitely would not recommend an increase yet. She’s bouncing a lot and the vet is probably looking at those numbers. But the only way to keep her safe from hypo is to know the nadirs for each dose. We need a few more days or cycles to determine nadirs.
 
Morning @Suzanne & Darcy

Tiger had a low glucose episode this morning, and it went as low as 3.1 on the freestyle libre.

I don't think she ate very much of the new food, which might be why this happened
 
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It's going now, and is 7.1 about 20 minutes post food. Can I check quickly, if it goes above 12 in the next hour, can I still give her the insulin?
 
IduraH said:
Morning @Suzanne & Darcy

Tiger had a low glucose episode this morning, and it went as low as 3.1 on the freestyle libre.

I don't think she ate very much of the new food, which might be why this happened
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It could actually be the new, low carb food, which has a tremendous impact on reducing blood glucose - and yes, if she doesn’t eat at all that’s pretty low carb, right?
 
IduraH said:
It's going now, and is 7.1 about 20 minutes post food. Can I check quickly, if it goes above 12 in the next hour, can I still give her the insulin?
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Sorry, this was at 3:44 a.m. my local time. I was asleep. I want to take a look at her spreadsheet carefully.
 
Suzanne & Darcy said:
Sorry, this was at 3:44 a.m. my local time. I was asleep. I want to take a look at her spreadsheet carefully.
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ooh, no worries. I've decided to omit the morning dose, because it's still below 14 as of now.

I'm just a bit worried about tomorrow because she'll be at least home on Monday and Tuesday from 8am-6.30pm at least.

Might just give her 0.5 tomorrow morning (if her AM PS is okay)
 
And your vet wanted you to increase the insulin dose! I am so glad that you have the Libre to alert you.

We can’t give shots based on BG readings after food and honey are given, because her numbers are artificially raised by the food and honey. This is why, by the way, we have the “no food for two hours prior to each insulin shot” rule.

She has earned another reduction with the low BG. Even on your Alpha Trak she had a 67 (slightly below the take action number.). Her new dose going forward will be .5 units. It’s definitely possible that, with the low carb food, she will need even less insulin (i.e., earn another reduction.) This is why we stress to make the switch to low carb food very gradually.

You may want to mix a little in with her old food? I don’t know if she will like it though. You could try giving her small amounts of it first and see if she will eat a little, then give her some of her other food. You will work something out, I am sure.

Having said all that, she’s going to bounce hard from that low, but ignore those high numbers and stick with the plan of reducing her dose to .5. She will definitely come back down after clearing the bounce (you see that now as we are are learning her patterns.)
 
IduraH said:
I'm just a bit worried about tomorrow because she'll be at least home on Monday and Tuesday from 8am-6.30pm at least.
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So you are saying she will be home alone for all of those hours on Monday and Tuesday? I would at least leave her regular food out for her to eat. Even with the reduced dose, if you combine it with the low carb food, she could drop too low.
IduraH said:
Might just give her 0.5 tomorrow morning (if her AM PS is okay)
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And yes, as explained above, her new dose going forward is now .5 unit. So that is exactly correct. I still am worried about her being alone. Do you have an automated feeder to dispense food?
 
Hi there,

Yes, I do have an automatic feeder. It gives her 10g of kibbles (Hill's metabolic dry food) at about 2pm which is when she tends to hypo.

I'll continue with 0.5 from tonight.

She's had two episodes of low sugars on 0.75 unit BD - the first being last Monday, and the second being today. I'm worried that today's one was an anomaly secondary to her not eating much of her wet food. But we shall see how she gets on with the dose and can always increase if needed. I'll keep monitoring her for signs of DKA in the interim.
 
IduraH said:
Hi there,

Yes, I do have an automatic feeder. It gives her 10g of kibbles (Hill's metabolic dry food) at about 2pm which is when she tends to hypo.

I'll continue with 0.5 from tonight.

She's had two episodes of low sugars on 0.75 unit BD - the first being last Monday, and the second being today. I'm worried that today's one was an anomaly secondary to her not eating much of her wet food. But we shall see how she gets on with the dose and can always increase if needed. I'll keep monitoring her for signs of DKA in the interim.
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I know it’s hard to ignore the high BG numbers, but she will come back down (I mean the numbers she is going to have in the upcoming bounce.). So to some extent, you will also have to ignore the effects of the dry food as well, which will also raise her numbers. This should be a slow and careful process as the food transition is made.
And you definitely have the right attitude. We keep her safe first and foremost and you can always increase the dose back up if the numbers warrant. Some cats take a little while to settle into a new dose, and Tiger also has a lot going on right now — a skipped shot, a food transition, and a forthcoming bounce. It is really easy for me to say “be patient” and a lot harder for you to be patient when you see the high numbers and also how unwell she feels when she is in the blacks. Thank goodness you didn’t increase as the vet advised. That vet is probably going to give you a hard time when you speak again on Monday as I believe you said you were going to do. But you are on the right track now with Tiger.

can you check her ketones now when she’s in blue numbers?
 
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Suzanne & Darcy said:
I know it’s hard to ignore the high BG numbers, but she will come back down (I mean the numbers she is going to have in the upcoming bounce.). So to some extent, you will also have to ignore the effects of the dry food as well, which will also raise her numbers. This should be a slow and careful process as the food transition is made.
And you definitely have the right attitude. We keep her safe first and foremost and you can always increase the dose back up if the numbers warrant. Some cats take a little while to settle into a new dose, and Tiger also has a lot going on right now — a skipped shot, a food transition, and a forthcoming bounce. It is really easy for me to say “be patient” and a lot harder for you to be patient when you see the high numbers and also how unwell she feels when she is in the blacks. Thank goodness you didn’t increase as the vet advised. That vet is probably going to give you a hard time when you speak again on Monday as I believe you said you were going to do. But you are on the right track now with Tiger.

can you check her ketones now when she’s in blue numbers?
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Her ketones are 0.5
 
Hi there! I've been quietly following and see that Suzanne has been giving you rock solid guidance (as always!)

I'm chiming in as second to everything Suzanne has said - please feel confident with your decisions when talking to the vet and know that you're doing all the right things to keep Tiger safe.

Cats tend to bounce harder when the drop from preshot to nadir is more than 50%. I calculated one of your drops at 87% - it's no wonder you're seeing massive bouncing.

Tiger's body is in charge. If she's gonna bounce, she's gonna bounce. Truly, it'll take time for her body to become accustomed to lower, safe numbers.

And, you're absolutely right - It's the lows that you've been seeing that are more concerning. More insulin won't stop the high numbers bouncing that your vet seems to only see. More insulin could actually make it worse.
 
Thank you everyone for the helpful advice, I will try my best with the vet tomorrow and report back what the decided outcome is

Tiger is having the expected bounce right now, knowing why it's happening definitely makes me feel more at ease - I only wish that I have some antiemetic I can give her to help cause it breaks my heart when she's nauseous.

She is otherwise eating and drinking, and playing with her toys still.
 
Poor baby. That must be hard to see. Does she vomit always when she is in the black? Is it liquid or food? I do not know if Cerenia (Maropitant) would help in this situation. It’s quite effective at controlling vomiting in cats. Here you must have a prescription for it.
 
Now since you have to go back to work tomorrow, I would like to talk about feeding schedules again. Going back to what Shelly was mentioning about the rate of drop causing more severe bounces: I know you said you have a feeder to dispense some of the dry food at 2 p.m. which is when she typically has low numbers — and that is fine, but what we really want to do is to to support her with food earlier in the cycle. We do what we call feeding the curve. I like to see our diabetic cats get a snack at about +2 when the ProZinc kicks in (onsets) and another snack at +4. Feeding multiple small snacks (a spoonful or two) of even low carb wet food can really stabilize BG and helps to prevent steep drops in BG that then just set the cat up for a bounce. I hesitate to mention this now as I have already thrown a lot at you already and I know that some of these suggestions can be really disruptive to your existing routine. I don’t know if your auto feeder can dispense more than one snack, but since I am worried about you not being at home for the next two days… I brought it up. On Wednesday you will have a sitter and that person could give a snack at +2 and +4 for you. I’m not saying it will eliminate bouncing overnight, but it can help stabilize the whole cycle and can prevent bounces in many instances.
 
Good evening Suzanne,

Thank you for being so diligent in checking on Tiger. Apologies for the late reply, I've been at work all day and didn't get a notification you've replied. She was okay overnight but was >20 the whole time, no vomiting that I know of though.

She does tend to get nauseous on higher sugars, but just liquid and no food.

Re Snacks, I can probably do that, what do you recommend for snacks? Her usual dry food is quite high in carbs, and the feeder can only give it in 10g portions.

She's having hiccups now and looks a bit nauseous. Ketones is 0.6 and BM is unrecordably high on Libre but 25.1 on alpha trak.

The vet postponed our conversation to 9am tomorrow, so I'll ask re oral anti-emetics then.
 
I’m wondering what her BG was before +7 today. I wonder if it was lower or at least some lower yellows. The sitter who begins coming on Wednesday will be able to scan the Libre? And give the spoons of food at +2 and +4? What we call snacks or mini meals usually consist of a spoonful or two of low carb wet food.
 
Hi Suzanne,

I just got home and managed to scan her again, and will update the sheet ASAP.

It's looking like her nadir for the past three cycles have been consistently 15mmol/l - it hasn't really gone below that.

Spoke to the vet today, and she will be referred.

He wants to do a fructosamine for her, but it sounds like he's quite keen on increasing the levels. He's of the opinion that the hypos are anomaly episodes and should be use to guide treatment. He'll use the fructosamine to guide his decision re increase/decrease. I did explain however that I work and she's home alone quite a bit, even if they are anomalies, they can be deadly if they happen as I cannot intervene

He also mentioned that he wonders if we might be overmonitoring slightly with the free style libre and as such too quick to change her doses etc.

I'll take her in for a blood test this weekend hopefully.
 
Today, she could have been lower than the yellow that you caught before you got home. We can’t know. Will she have a cat sitter with her tomorrow while you’re away?

I think you already understand that hypos can be fatal quickly and that hyperglycemia is dangerous but much more slowly than a hypoglycemic event. You have said so to the vet. I feel like you are a very intelligent advocate for Tiger. I doubt if your vet has managed the daily care of a diabetic cat - every day, day in day out - over time. That’s not an insult really, it’s just not what vets have been educated in and not what they deal with every day. In veterinary school, they receive very few hours of instruction in diabetes care and that is mostly for dogs — which doesn’t translate to cats.
 
Good Morning Suzanne,

Apologies for not updating the spreadsheet yet, had a long day at work yesterday and fell asleep. I'll make this a priority today

Re your query re whether there could have been a lower value before I got home, the freestyle libre stores data for 8 hours-ish. As such, when I come home, I still get the data for the preceding 8 hours.

This does mean there is an hour or two lost, but she's usually unrecordably high when I leave, and it is unlikely that there is any lower values in the 2 hour of missing data.

The cat sitter is with her today, and we're making some further changes:
1. Insulin given 30 minutes before meal (vet advice to do this)
2. She will now also have low carb meal for AM and PM meal (before today, it was just PM)
3. the cat sitter will give her a snack at +2 hours and +4 hours.

I shall update you later in the day how she gets on with the changes today, hopefully less bounces. Thank you for your help as always
 
Thanks. I will check in on her spreadsheet later or when you get a chance to update it. I will not be around for most of today as I will be driving a long way to take one of my cats to a specialist. I will still have a little down time to check in on her at some point. I hope you are having a good work day. I’m pleased there is a sitter with her today :) can she scan the Libre also?
 
ooh, drive safely today and I hope your cat is okay.

I've updated it now, also, I've just realised that you can use the freestyle to generate a more thorough report with clear numbers. Please click here for the link . I don’t usually update with the app when I give her insulin and when I give her food, so the data on that is not as comprehensive...

Yes, the cat sitter can scan the freestyle, and is giving me regular updates
 
That report is really interesting. I don’t see how you would need to bother with the Fructosamine test (unless you’re just trying to placate the vet) because your Libre gives you such detailed information. The Fructosamine will give average BG for the last 2-3 weeks.

As to delaying feeding her for 30 minutes after the shot, I don’t see the logic behind that. ProZinc onset is about 2 hours in most cats. Her BG will rise in between the preshot test and the insulin shot 30 minutes later. If you tested her again 30 minutes after the first test and meal you would most likely see that her BG is higher. But the ProZinc doesn’t really get to work the minute it’s injected— as I said, it’s about two hours for the average cat (some a little less/some a little more.)

Anyway, I look forward to seeing her numbers for today.
 
@Suzanne & Darcy , I've made a mistake again.

Her sugars have been high and the vet and everyone was telling that she needs an increase and that the hypo was probably an anomaly.
So I gave her 0.75 and she's below 4 again now :( But thankfully 5.4 on alpha trak.

I wish there's a needle that'll let me give her 0.6 or something.

Also, just got confirmation that she has an appointment with the London Royal Veterinary College next Thursday.
 
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