Hope for Chester

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Jaye and Chester

Jaye and Chester

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Hello, Everyone...

I'm new to posting on the board, having finally gotten up the nerve to try making the official spreadsheet and profile (quite proud of myself, actually!) Sorry for this long introductory post

My little man, Chester, has been diagnosed since February of this year. We've tried just about everything, including Vetsulin, PZI (for a very short time), Lantus, and now Levemir (as of Thursday evening of this week). Chester, frankly, has been a struggle. Both the Vetsulin and the PZI caused quick and unexpected plunges to the low 40's so my vet put him on Lantus. We started low and I wish I could recall the dosage. In the beginning I didn't home test, just used the little litmus squares in the litterbox. They were constantly either dark purple or showed no change. It was then that I got fed up and started home testing.

Chester just didn't seem to respond to the Lantus like I've heard other kitties did. We kept upping his dosage but all the while I got the feeling that he was in constant rebound. Then, in June, he stopped eating and became dehydrated. He was NOT himself (the perpetual kitten) and a trip to the vet revealed a very faint abdominal mass on x-ray. A trip to the emergency vet for an ultrasound and needle aspiration. The vet said that he couldn't find a mass but thought that it was likely that his abdomen was filled with cancer. Needless to say, Hubby and I were devastated. We waited the weekend for the results. Come Monday, the phone call came and there was a very perplexed vet on the phone saying that they found no evidence of cancerous cells, that his pancreas (I'll probably get this wrong) had many necrotic cells and basically, they didn't know what the problem was ($700 later, of course).

We kept upping the dose and Chester would seem to respond, then either he would get too high or the bottom would drop out. His numbers were routinely in the 500s and even a very 600+ once. At those times we brought him down with the NPH I had on hand (my dog is also diabetic) At one time he was on 6.5 units of Lantus and it seemed like we finally had a bit of a breakthrough. We were able to start gradually dropping his dose but he still had a lot more pinks and reds than blues. The NPH made things even more unpredictable, creating sudden lows. At 5.5 units Lantus we got our first decent readings but then they just started becoming unpredictable again.

Throughout it all, Chester has been a trooper. He had neuropathy in the beginning, but once we "broke through" (for lack of knowing what to call it) that seemed to go away and he is a VERY happy, active, charismatic 10 year old boy. He has never shown ketones and even when high doesn't seem to lose his zest for life. He's never had a real hypo. If I catch him around 60 I try to stop further decline with canned low carb (and, if necessary, high carb) Fancy Feast.

This past week, after a full summer (which luckily I had off, being a teacher) of testing, my vet decided to switch us to Levemir. I'm not sure, but I think Chester is her first Levemir kitty. My vet has been a great support, calling each and every day, even weekends and holidays, to see how he's doing. We've both been very frustrated with his lack of consistency on Lantus (in fact, she just called...on Labor Day...to check on him while I was writing this post!)

I started on Thursday evening at a dose of 3.5 units because he was only in the low 100's pre-shot although we had planned to start him at 4. I was a bit worried that we were starting high, but knowing that Chester didn't show any results on low doses of Lantus I went along with the 4 units the next day(see SS). He was quite high at first, but no ketones and still playful. We supplemented with small doses of NPH to combat his post-meal spike while waiting for his insulin depot to fill up with the Levemir. We went up to 4.5. I know it was soon to go up, but from what I've read, Levemir can show results pretty quickly and he was already on a higher dose of Lantus. It was a NICE day! Although he started high, he gradually came down with no help from NPH, got a little lower than I like in the 70s but brought himself up nicely. No extra food, either...so it was a pretty reliable set of readings.

I'm feeling a bit of pressure to level him out, because the long weekend is almost over and I've been testing the poor guy within an inch of his life. Hubby is taking off work tomorrow to test him intensively for one more day. I've fluctuated between 4, 4.5 and 4.25 over the last few days. It's looking to me like 4.5 will be his dose for awhile, unless he gets too low tonight.

Question for Levemir users: Is it ever possible that your cat needs to alternate between two doses...say, 4.25 and 4.5? On the Lantus we saw that 5.25 wasn't enough, but 5.5 was often too much. Tonight my vet wants me to go back up to the 4.5 from the nice day we had yesterday because he's already 350 an hour before mealtime.. I agree, but think he might get too low tonight.

Sorry for the extra long post!
 
OK first off, welcome, and pats for Chester.

Now, on first glance at the ss, it looks like you are jumping around in dose and that is one thing you cannot do with Lantus and Lev because of the shed. If you jump all over, your numbers will do the same. See the below links with info on the insulins:
Tight Regulation Protocol
LANTUS & LEVEMIR – INSULIN DEPOT –AKA- STORAGE SHED
Lantus&Levemir – Data Ready to Shoot Low Numbers

See if you can try the protocol for a bit and maybe you will see some better, more stable numbers with the holding of doses.

What did you mean that Chester does not respond to Lantus like other kitties? Rebound's not likely but it sure looks like you have some bouncing going on. Just imagine taking a tennis ball and pounding it hard into the ground .... you are going to have some serious high bounce following the hit on the ground. You get a big enough bounce and some kitties can take up to 3 days for it to clear.

I can't comment on the NPH at all; I have used Humulin R to pull down high numbers, but not often now.

Others will be along with more replies.
 
I can't say anything about the N, but what I see is I think you should have stayed down at 3.5 at least, for a while. What I am seeing (admittedly limited info but this is what I see) is a day that goes fairly low over a long period of time and then a quite high evening. Like a really looooooooog slow rebound. I think, if I were you and since he is happy and no ketones etc. is I would back off, at the least to 3.5u for now and give it a good 4 or 5 days before I thought of adjusting. I agree with the previous post, there is just too much movement in dosage too soon, and I think maybe you are up too high right now.
 
Hi there and welcome!
Not much info, yet, on the spreadsheet, but congrats for getting started on that!

I agree that moving the dose up and down with each shot is not usually a good way to go. It's definitely not good on lantus. It takes time for doses to "settle" before you can see what the dose does. It's not the numbers "per shot" that you look at for dose determinations. You must look at how kitty reacts to the same dose over time. If you were upping and lowering the doses on lantus the way you have done on levimer, that could be why you didn't get good results.

There are some sticky threads on the use of levimer on the levimer forum that you might wish to read. Could be helpful to you.
 
"We kept upping his dosage but all the while I got the feeling that he was in constant rebound."

And he's going to do the same on Levemir unless the dose is lowered. Rollercoasting the way he's doing (going from 400's to double digits in less than 6 hours) can mean too much Levemir is being given.

Although you're not sure of your beginning Lantus dose, if it was more than 1U, that may also have been why Lantus was such a struggle. The goal should not be merely double digit numbers, but steady lower numbers, even if those numbers are in the 200s. Throwing more insulin at the blood glucose to simply achieve double digit numbers is not healthy for them, as you saw when he lost his energy.

How is the pancreatitis? That may also cause wacky numbers because some insulin resistance develops, which would explain the "break through" dose you thought you had on Lantus.

Please make sure you test his urine with ketone test strips during any major dose reduction. That can be done several different ways to capture urine - some cats will even go in a litterless box. Some cats will tolerate owner visiting them while they are using the box and you stick the strip in their urine stream or catch it in a ladle. But that requires that you're present to catch them going! You could try covering litter in box completely with plastic wrap, so that the urine will pool, but some cats may tear it up while they scratch. It's trial and error really to find a way that works for both of you.

Hope this gives you some ideas to further discuss with your vet. The Tilly protocol is invaluable, but sometimes needs some tweaking as Every Cat Is Different.
 
I agree with Vicky that your dose should be lowered. Most likely you have missed your optimal dose and that is why he is rebounding.

I would recommend dropping back to 1U twice a day. Keep him at that dose for at least a week before making any changes. It takes at least a week for the body to adjust to a new dose before you can determine if you need to change it.

Also, what are you feeding Chester? Diet also plays a major role in getting diabetes under control.
 
I'll admit that I had a major meltdown after reading the responses to my post...cried for hours...literally. It was just too much for me to bear after thinking that I had had my first "good" day in months...the first time being in the 100's for any stretch of time.

We had a horrible night, numbers-wise. Behavior-wise was a totally different story. He is flipping around at my feet with exhausting energy and enthusiasm. No ketones. Believe it not, I just put him in his box and asked him to pee for me. He looked at me like, "Uh...okay" and did it. :-D

I know myself and my tolerance for stress (and fear and worry!) and right now I'm at the breaking point. We just found out our other cat is in severe renal failure and I've had to learn to give sub-Q fluids. Needles are NOT my thing. And it doesn't look like she's getting much better. I appreciate the advice so much (hence the reason for joining the site) but I KNOW that emotionally I can't back down to 1U...not now... The thought of him alone all day possibly going into ketoacidosis...can't handle it. I know it might be best for Chester, but that is too far for me to still be able to function. I'm being as honest as I can...even though it makes me feel like a failure.

I had already dosed at 4.5 when I read the responses to the post. I'm thinking that, if I've got to back down, it's got to be gradual as well. Today I'll try going down to 4.25 and see where we are. My husband took off work today to test him.

Is it possible that he's a high dose kitty? We had our first 100s only after hitting 6.5 and then backing down (on Lantus).

Question about the rebound. I tested him virtually every hour for 24 hours and he had no quick drops, nor did he go below 71 (and brought himself back up) so I was thinking that he wasn't rebounding. I see that there is a large variation between his high and low, but it was gradual. Or maybe it is because I'm used to the quick, unpredictable drops he had on Lantus...which he theoretically wasn't supposed to have.

Chester is eating strictly canned low carb food.

Diabetic dogs are SO much easier! *sigh*
 
*bump*

Hoping some more eyes can stop by here and help Chester get regulated, and preferably without giving his Mom a heart attack.

MJ&Donovan
 
I think the recipe for DKA is a mixture of not eating, infection, not enough insulin. I may be wrong.
I'm not that experienced in recommending dosage, but if some one with more experience recommended 3.0 units, how would you feel about that? Would you have a weekend off, where you could test him all day on a lowered dose?
These are just some thoughts that popped into my head. Others will help you more than I.
 
I don't know about being a high dose kitty.
You can look at Oliver's spreadsheet to see a high dose kitty.
If you needed more insulin, you would have constant and steady high numbers, but you don't have that with Chester.
You will likely need to lower his dose, and until you do, you may well keep seeing this bouncing.

You really need to hold each dose. Oliver does not respond to a new dose for at least 6 shots, and if he responds sooner, I know it was too big of a change.

When I first adopted Oliver, I also did not want to go all the way back down to 1u, but I did. I had to be sure that I had not passed his fitting dose as some had suggested, and so I followed the protocol. You can see what the numbers look like when the dose is too low: steady high numbers.

In order to find the correct dose for your cat, it is best to start low and go slow. Otherwise, you will pass the proper dose and end up on a perpetual roller coaster of numbers.

I can't say what dose you should give but I think it should be a bit lower.
 
Hi Jaye and welcome to FDMB.

First, take a deep breath. No one is going to force you to do something you feel is risky for Chester. We're here to be a sounding board. As others have suggested, take a look at the starred, sticky notes at the top of the Lantus Board. The Lantus ISG is home to many Levemir users since the two kinds of insulin act in much the same way.

I would encourage you to pick a dose and stick with it. Lev, like Lantus, really needs consistent dosing -- the same dose twice a day -- for several days especially when you're building the shed and after any dose change. The long-acting types of insulin also require patience. You won't see the quick changes you get with NPH or shorter acting types of insulin.

I completely understand your fear of DKA. However, a question -- is Chester prone to developing ketones? From the look of his SS, he is not constantly running in high numbers. You're not using an NPH bolus in the mornings and Chester is still seeing some green or blue numbers. With this amount of variation in his numbers, unless he's prone to developing ketones, I don't think you need to be overly worried as long as you've got Ketostix and you're using them. Like MJ suggested, other than a ketone prone kitty, the risk is increased with not enough insulin in a cat who is not eating and has an infection.

What I'm seeing on your SS is that Chester is bouncing. I don't know if the NPH is contributing to the bounciness but that may be worth considering. I'll be curious to see what Chester's numbers look like today since you've haven't given any NPH for over 24 hours. Also, it can take up to 72 hours for a bounce to clear. The liver dumps counterregulatory hormones, as well as stored glucose, which drives the numbers up. Again, this is another one of those points where you need to sit on your hands and be patient in order for the bounce to clear.

Is there a dose you feel comfortable sticking with and shooting twice a day? Part of the reason that we tend to encourage starting low is to avoid rebound as much as possible as well as it's easier on us to bring the dose up rather than see dramatically low numbers and to have to titrate the dose down, especially if you aren't at home to monitor all the time. Chester's shed should be pretty well formed at around a 4.25u dose.

Also, what were you dosing with Lantus, Vetsulin, and PZI (if you remember. If it's in your profile, I apologize. I'm at work and didn't have time to take a look). Lantus and Lev initial doses are based on your cat's ideal weight but the dose on a previous insulin is taken into account.

As far as the possibility of Chester being a high dose kitty, the best way to answer that question is to get him tested. Generally, once a cat is in the 6.0 - 7.0u BID range, I will start thinking about either acromegaly or insulin auto antibodies. Gayle and others can give you advice about where blood gets sent for IGF (growth factor for acro) and IAA testing if that's something you and your vet think is worth pursuing.
 
Thanks for the responses, Everyone...

Sienne and Gabby said:
I would encourage you to pick a dose and stick with it. Lev, like Lantus, really needs consistent dosing -- the same dose twice a day -- for several days especially when you're building the shed and after any dose change....Is there a dose you feel comfortable sticking with and shooting twice a day?
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I see now that he probably is too high...last night and today were flatter than before but high. I lowered his dose to 4.25 this morning and gave the same this evening. He stayed in the 200s for most of the day and was at 327 at pmps. I feel comfortable there for a few days...not low enough (hopefully) for skyhigh numbers, not high enough (again, hopefully) for him to go too low. I will check him tonight about midnight but I won't be home tomorrow to test him. This weekend, if things are looking as they should, I'll try to lower some more. Hopefully, this won't go on until November, but if it does, Hubby is home full time for two months and can tackle the testing!

I completely understand your fear of DKA. However, a question -- is Chester prone to developing ketones?
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He hasn't had issues yet, but I'll admit to being a recent tester for them. I did buy the Precision Xtra that tests for ketones as well but those strips are WAY expensive. I'm saving them for a really high number when he won't cooperate and pee.

I don't know if the NPH is contributing to the bounciness but that may be worth considering.
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I'm really not crazy about using the NPH. We started that one day when he tested over 600...scared me to death. He was on 2.5 units of Lantus then. But it certainly seems to cloud the issue when I don't know which is peaking with him. I'm planning on using that very sparing...if ever...from now on.

I'll be curious to see what Chester's numbers look like today since you've haven't given any NPH for over 24 hours.
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Just updated.

...it's easier on us to bring the dose up rather than see dramatically low numbers and to have to titrate the dose down...
Click to expand...

But doable, I hope? Because I'm REALLY not comfortable going back down to 1 unit (or even in the vicinity) so suddenly...

Chester's shed should be pretty well formed at around a 4.25u dose.
Click to expand...

So I should be seeing what his "real" reaction to that dose is fairly soon?

Also, what were you dosing with Lantus, Vetsulin, and PZI
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I'm wracking my brain to remember, but I just don't. I only started testing in July, so anything not written down is vapor by now in my brain. I see by my old spreadsheet (which I didn't post....way long and convoluted) that in July he was on 2 units of Lantus, but we didn't stay there long.

As far as the possibility of Chester being a high dose kitty, the best way to answer that question is to get him tested.
Click to expand...

After looking at Oliver's SS above, I'm starting to think Chester isn't high-dose, just "over" dose...but we'll gradually work on that.
 
You mentioned about lasting past November - there is no way to set a timetable for regulation, etc. Chester will be the one to decide what happens and when.

Here are the guidelines for the protocol:

"General" Guidelines:

--- Hold the initial starting dose for 5 - 7 days (10 - 14 cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 cycles).

--- Each subsequent dose is held for a minimum of 3 days (6 cycles) unless kitty earns a reduction (See: Reducing the dose...).

--- Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.


Increasing the dose...
--- Hold the dose for 3 - 5 days (6 - 10 cycles) if nadirs are less than 200 before increasing the dose.

--- After 3 consecutive days (6 cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.

--- After 3 consecutive days (6 cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.


Reducing the dose...
--- If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further.

--- If an attempted reduction fails, go right back up to the last good dose.

--- Try to go from 0.25u to 0.1u before stopping insulin completely.


Random Notes...
Because of the cumulative nature of Lantus and Levemir:
An early shot = a dose increase.
A late shot = a dose reduction.

A "cycle" refers to the period of time between shots. There are 2 cycles in one day when shooting twice a day.

Sometimes a dose will need to be "fine tuned" by adding some "fat" or "skinny-ing up" the dose.
 
Welcome, Jaye and Chester. For someone that has had a recent meltdown, you really seem to have things together pretty well! I hope you don't think anyone was being critical of how you're handling this - lots of advice in a short amount of time can feel that way.

Great job on getting a profile put together (looks like you have quite a household to take care of) and a spreadsheet started. Chester is in good hands.

Have you checked out the Lantus user group? viewforum.php?f=9 Both Lev and Lantus users post there - many of us start a new thread each day to record that day's BGs and other particulars.

I'm sure Chester will be just fine...
 
Nina and KB said:
Welcome, Jaye and Chester. For someone that has had a recent meltdown, you really seem to have things together pretty well! I hope you don't think anyone was being critical of how you're handling this - lots of advice in a short amount of time can feel that way.

Great job on getting a profile put together (looks like you have quite a household to take care of) and a spreadsheet started. Chester is in good hands.

Have you checked out the Lantus user group? http://felinediabetes.com/FDMB/viewforum.php?f=9 Both Lev and Lantus users post there - many of us start a new thread each day to record that day's BGs and other particulars.

I'm sure Chester will be just fine...
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Thank you so much! I alternate these days between being somewhat on top of things and a total basket-case.

I've read several of the posts in both the Lantus and Levemir sections. Would I need to repost the information from this thread or just refer to it?
 
Hi, jaye-

you came to the right place. These folks know their stuff, and they offer a huge amount of support and guidance. in my opinion, you have definitely found a forum that can give you a better chance for Chester...they have helped my guy immensely.

see you on the other forums, and hang in there.

Celi & binks
 
Update on Chester...

After eating this morning his numbers climbed enough that I could go to work w/o too much stress. I left him some food in his autofeeder, just in case. Called the vet clinic when I got to work and found out that my regular vet is on vacation until next Wednesday...I almost had a heart attack!

Talked to the other vet there...she knows Chester as well...and told her about the advice I got from this site about lowering his dose. She agreed that he is probably on too high of a dose (said that although lowering it to 3.75 this morning was okay, she would have probably lowered it to 2). Those of you who read my previous messages know that I was extremely nervous about that notion. She said she suspected that his 100s last night could have also been the result of the insulin from earlier still working on him.

She advised me (knowing my "lack of" comfort level) to go to 3 units 2X and STAY there (sit on my hands, I think she said) for at least 3 or 4 days, expecting him to be high until things settle and we see how he is reacting. I told her my concerns about DKA and the expense of several days in the hospital. She reassured me that "we won't let him get that far" and that, if he gets dangerously high, I do have the NPH on hand to help bring him down if absolutely necessary. She thinks, in general though, that he seems to tolerate the higher numbers (not prone to DKA) and is otherwise healthy and eating (playful, as well) and that everything will be okay.

So that's the plan...3 units and sticking to it (unless he gets dangerously low) for several days. Scares me, but I'm trying to have faith.

I was quite surprised that, even after the relatively lower dose this morning (3.75 instead of 4.25) and all the food he ate today, that he was "only" 352 when I got home. For him that was actually quite low for pre-shot. I've often seen him in the upper 400s.

I'm wondering how many times I need to test him tonight. I'm trying to talk him into peeing on my ketostix but he's not "into" that right now.
 
Your vet sounds like she agrees on reducing the dose and holding it until it really settles, and understands that there was still some residual action from the higher dose. Sometimes you don't see the result of a dose change in that cycle, but the next one would show it (due to "the shed").

The bottom line is that YOU have to feel comfortable with whatever you do, and we know you have Chester's well-being as your goal.
 
I just checked him at +3, thinking that he would certainly be high and I should be ready to try to test for ketones. He was only 180! That's pretty low for my little unregulated guy! I'm getting pretty excited about the possibilities here...and the possibility that someday I may be able to sleep through the night again. :razz:

One thing, though... We discussed holding him at 3U for several days, but if he gets too low that will probably change. I absolutely cannot be home to monitor him during the day until the weekend and don't want to risk a hypo. The plan right now is that if his amps is >300 tomorrow, I'll give him the 3U, but if he's below 250 she advised me not to shoot any insulin because I can't be home to monitor him. She also suspects that we'll end up on a considerably smaller dose eventually.

That would be nice!
 
Keep in mind that if Chester were to go very low overnight, he could easily bounce and by morn, his amps would be over 300, so basing your dosing on ps may not be a great idea.
Protocol has doses based on nadir, so be sure you get a before-bed test so that you know where Chester is when you go to sleep.

In the morn, if possible, you can test at +11 and then get his amps. That way you will know where his numbers are heading and may put you at ease with the dose you give him.
 
Gayle and Shadoe said:
Protocol has doses based on nadir, so be sure you get a before-bed test so that you know where Chester is when you go to sleep.
Click to expand...

I plan on testing at 10:30 p.m. (+5), 1:30 a.m. (+8) and 4:30 a.m. (+11) so at least I only have to get up once tonight (since I get up for work at 4:15 a.m.)
 
Well, +5 was just 214, so he's headed up a bit and I'm off to bed! Will test again at +8 (if my addled, sleep-deprived brain hears the alarm clock!)
 
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