HYPOISH - New - but old - Member - Buster needing advice (and goodbye Elmsley)

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Scott & Buster

Scott & Buster

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Hi Everyone. I used to be Scott & Elmsley on this forum. Elmsley was the neighborhood stray who collapsed on my porch a few years ago in really bad shape. Besides diabetes, we struggled with malabsorption and other chronic issues which really impacted his diabetes treatment. Depending on where we were on his health roller coaster his insulin needs would swing wildly. It was a struggle, but by the end Elmsley had doubled his body weight and looked like a normal cat again. Even though he never had the tightest regulation, we had minimal hypos, a good quality of life, and in the end didn't die from complications of diabetes but instead an aggressive lymphoma which made itself known the morning he crossed the bridge. Even though he's missed, I call coming back as well as he did a diabetes success story.

I hadn’t even made it from the emergency vet to aftercare with Elmsley when our regular vet called, wanting Buster to come in for a fructosamine test. I wasn’t shocked at the ask - he had lost weight since his last vet visit without a change in appetite, and I’d noticed he was drinking more. Three days later he had his diabetes diagnosis with a 2 unit starting dose of Prozinc. I spent the first few days testing without shooting, trying to get him used to eating the bulk of his we food at once since he is the slowest eater ever. When it was time to start shooting, after 2 years of insulin roulette with Elmsley there was no way I was doing 2 units right off the bat with Buster and started him at .5 units. I didn’t hold the dosage for a week and run curves before increasing because the vet wanted him to start at 2, his weight-based dose was around 1.5 units, and I wasn’t seeing much movement in his numbers testing at +4 post shot.

It wasn’t long until we were up at 1.5 – 1.75 units, and it looked like it might finally catch a few times as he had some decent movement, but then it would be like shooting water. Some of it was probably my fault – with Elmsley’s issues you couldn’t shoot 250 and 200 with the same dose of insulin, so I did retreat on some lower than normal readings (which I’m TRYING to be better about consistency now – I have to keep reminding myself Buster doesn’t have the same issues). We hit 2 units and hovered around there without much movement.

That vial of insulin was Elmsley’s last, and at the end of his life the combination of the raging lymphoma and being on Varenzyn caused me to lose control of his sugars – we hit 2.25 units and his numbers wouldn’t budge when 2 weeks prior a half unit did the trick. Since I was seeing similar in Buster’s numbers I replaced the insulin vial thinking it might be bad. We retreated back down to 1.5 units of insulin just in case it was more potent, but within a week we had climbed back to 2 units, and at this point we’re at 2.5 units.

Besides changing out the vial, I’ve tried side shoots instead of scruff, and moved his injection from +1 after testing to immediately after I’m certain he’s going to eat (luckily he’s doing better with scheduled feedings). Sometimes it doesn’t move, sometimes his sugar just goes up, sometimes it looks like he might have bounced, and once and a while I can get him below 200. I ran a curve the other morning and it happened to be a morning his sugar was stubborn and climbed. I’m at a loss if we should stay at 2.5 units, increase, or retreat back to around 1.5 units and let it ride and I’m looking for input from the group. As far as switching to Lantus – the vet wasn’t onboard with it for Elmsley (and neither was I due to the swings in dose that we needed) – but I am for Buster… once he’s close to regulated on Prozinc or shown he can’t be regulated on it. I would rather have him on an insulin I only need to worry about for 12 hours instead of a depot insulin while finding the right dose.

For food, he was on wet to begin with (he fully transitioned off dry once Elmsley was in the picture). He’s a picky eater, so it was fortunate he decided he’s a Fancy Feast junkie - Chunky Chicken and some of the classic pates. He’s getting up there in age so I did try to get him to be on some of the lower phos lower carb foods (Nulo, Wereva, Friskies, etc.) but he’s not a fan so what I have of those have been relegated to small snack sized portions at +4 in the cycle. All his canned foods are under 6% carbs, with the norm being 4%-ish. He also gets plain shredded baked chicken for treats, though he is on Lysine treats that he gets a single treat “cheat” every day.
 
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I wouldn't worry about feeding Buster only two larger meals. It's fine if he grazes. You just need to pick up his food 2 hours prior to shot time. You don't want your pre-shot test to be influenced by food.

Maybe I'm not understanding. You said, "...moved his injection from +1 after testing to immediately after I’m certain he’s going to eat..." The +1 is an hour after you shoot. If you're now waiting until Buster is eating, you are not giving a shot at a consistent time. It could be 30 min or 90 min after you test and he eats. Ideally, you test, feed, and shoot all within a very brief time (think 10 min or so). The +time refers to the number of hours after you've given your kitty his insulin.

Right now, it looks to me like Buster needs more insulin.
 
Hi there. I agree that he needs an increase. I would try to follow the dosing methods as closely as possible. Have you read the ProZinc dosing methods? I would hold this new dose for 7 days and test as much as possible and try to catch a nadir if you can. You definitely should test, feed and shoot all within a few minutes of time (which I think you are doing now?) Are you free feeding now? I normally would recommend a snack feeding schedule, but if you are leaving out low carb wet food for him I will not. Do pick up food two hours prior to each preshot test.
 
Suzanne & Darcy said:
Hi there. I agree that he needs an increase. I would try to follow the dosing methods as closely as possible. Have you read the ProZinc dosing methods? I would hold this new dose for 7 days and test as much as possible and try to catch a nadir if you can. You definitely should test, feed and shoot all within a few minutes of time (which I think you are doing now?) Are you free feeding now? I normally would recommend a snack feeding schedule, but if you are leaving out low carb wet food for him I will not. Do pick up food two hours prior to each preshot test.
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I've read the dosing methods, I'm still adjusting from 2 years of having to pivot a dose based on what was going on with Elmsley's health... and I thought I could get away with stepping quickly through to what his vet assigned dose was. I'll hold this unless he starts to hypo from it.

Yes, testing, eating, and shooting is within 10-ish minutes of each other since the note on his SS. Test, make his food, give it to him, go draw his dose and shoot while he's eating. I was waiting until he ate most of it before because of slow eating as well as he's notorious for going on hunger strike with foods he normally likes.

I harass him to finish the can within 90mins-2 hours, which he's pretty decent about doing. He gets a +4 test that I can move to +6 (if Elmsley was going to hypo he'd be there around +4), and thats when he gets a snack (~1.5oz LC wet) that I will let him graze all day on until its gone or time to pick it up before his fasting period.
 
Update - Nadir last night 198, AMPS - 148. I did NOT give insulin this morning. I'll be checking here over the next 90 mins or so if someone says to do something different, but as of now no insulin.

This is where I struggle the most - giving 2.75 units at 375 and 210, for example, when I just watched the dose drop his BS 227 points in a cycle. I get the dosing method says it might be wise to reduce the dose... but by how much?

Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.
  • Below 150 mg/dl (8.3 mmol/L), don't give insulin.
  • Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
    • a.) give nothing
    • b.) give a token dose (10-25% of the usual dose)
    • c.) feed as usual, test in a couple of hours, and make a decision based on that value
  • Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
  • In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
  • Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.
 
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Sounds good. In fact, grazing during those first two hours is excellent— as long as he will reliably do it. I would hold this dose for 7 days and then we can reevaluate to see if he needs another .25 increase based on nadirs. I would like to see him in better numbers. It would be a good idea if you could vary the times that you test. A +2 is a very good indicator of how the cycle is going to go.
 
Scott & Buster said:
Update - Nadir last night 198, AMPS - 148. I did NOT give insulin this morning. I'll be checking here over the next 90 mins or so if someone says to do something different, but as of now no insulin.

This is where I struggle the most - giving 2.75 units at 375 and 210, for example, when I just watched the dose drop his BS 227 points in a cycle. I get the dosing method says it might be wise to reduce the dose... but by how much?

Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.
  • Below 150 mg/dl (8.3 mmol/L), don't give insulin.
  • Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
    • a.) give nothing
    • b.) give a token dose (10-25% of the usual dose)
    • c.) feed as usual, test in a couple of hours, and make a decision based on that value
  • Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
  • In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
  • Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.
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Just seeing this. I wrote the above post earlier this morning and didn’t get a chance to send. Let me look at his spreadsheet
 
First of all, if it’s only been 30 minutes- can you retest him to see if his numbers are going up? Or has he already eaten? If so, then we can’t do a “stall.”
 
So if he was at 145 you have a few options:
1) stall without feeding and retest in 30 minutes to an hour — depending upon your schedule — if numbers are going up, then you may see that it’s okay to shoot the full dose, provided you can monitor the cycle.

2) I rarely see a skipped dose work out well for a cat, but the thing is to gradually figure out your cat’s patterns and see what works. The goal is to be able to gradually shoot lower numbers, but we only do that as we gather data to support it. In his case this morning, I would probably have shot a half-ish dose of 1.25 units or 1.5 units and I would get a +2, which is about the time the ProZinc will onset and begin to lower numbers. I would monitor the cycle carefully. Most likely, his numbers would continue to rise for those first two hours and he would get a food bump as well.

That nadir last night was encouraging to see! That is progress.
 
Suzanne & Darcy said:
2) I rarely see a skipped dose work out well for a cat, but the thing is to gradually figure out your cat’s patterns and see what works. The goal is to be able to gradually shoot lower numbers, but we only do that as we gather data to support it. In his case this morning, I would probably have shot a half-ish dose of 1.25 units or 1.5 units and I would get a +2, which is about the time the ProZinc will onset and begin to lower numbers. I would monitor the cycle carefully. Most likely, his numbers would continue to rise for those first two hours and he would get a food bump as well.
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Its been about an hour, he's eaten about half a can of Fancy Feast so far.

He's at 244 right now... so you're saying give him a half dose & watch?
 
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Scott & Buster said:
I gave him 1.25 units just now, and the rest of his food. Will watch & I realize this pushes meal time out tonight as well.
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Okay. So how late was the shot? 1.5 hours? See how he had already gone up to 244? That number was probably a little bit influenced by the food, but not hugely. He will probably run a bit high today, but we will see (not as high as he would have with zero insulin.) It’s just one cycle so don’t worry about it. You can get him back on track. Tonight you can give his evening shot one hour late— although, if his BG at his regular shot time is quite high, it won’t hurt him to just shoot at the regular time.
 
Suzanne & Darcy said:
What os your shot time? And your time zone? I am Eastern.
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8:10am Eastern this morning, morning usually between 6:45am - 7:15am, night time is usually around 6:45pm - 7:15pm. It just depends if I am chained to my desk at work at the time. I'll test as normal and see where we are. Thinking we'll be ok to shoot at a normal time since it really was a token dose.
 
Scott & Buster said:
8:10am Eastern this morning, morning usually between 6:45am - 7:15am, night time is usually around 6:45pm - 7:15pm. It just depends if I am chained to my desk at work at the time. I'll test as normal and see where we are. Thinking we'll be ok to shoot at a normal time since it really was a token dose.
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I think so too.
 
I hope he has a better cycle tonight.
It’s all good data anyway. Now we know that most likely if he starts out at a similar number then he will be okay with more than half a dose. We can work our way up by giving a little more insulin and testing to see how the cycle goes.
 
Just a small FYI -- if you are stalling to see if pre-shot numbers are rising, don't feed Buster. You still want the pre-shot to not be influenced by food. If you end up stalling for more than 30 min., you will need to move the shot time back gradually to your preferred time. Trying to preserve your shot time is the downside of stalling.
 
Suzanne & Darcy said:
Since you had a yellow nadir today and you have held the dose long enough, you can increase to 3 units now.
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I'm not sure how I missed this, but I did. I'm confused by this direction - he started 2.75 units the night of 7/24, had his AMPS under 150 the next day 7/25, and we're increasing the night of 7/26? Is it because I am moving in .25 increments I can change dose so fast?

We had another set of blue nadirs and PS values, down to 126. I stalled, shot 1.5 units, and the tests were better than I expected. But this is twice in 5 days he had to get a modified shot. The back half of his cycle is usually when I am the busiest and not able to test, but I got a +7 and +8 yesterday trying to see if he's going low and he's not. The numbers this dose round really look like angry bounces to me, especially since he's not getting any food except shredded baked chicken the back half of his cycle.
 
Doses (when following SLGS protocol) are held for 7 days. You are almost at 7 days on 2.75 units now and can go to 3 units at that time (if he keeps on about the same as he is now.) Last Friday night, I was suggesting a little fast tracking for Buster to safely get him into some better numbers. Most of the blue nadirs have been higher blues.

If you wish to follow the Modified ProZinc Method (MPM) doses would only be held for 3 days. So what I was suggesting was based on your testing data and something more like the Modified ProZinc Method for Buster -at least temporarily to get him into better nadirs. If you would like to hold the 2.75 units for 7 days then that’s fine. You’re almost there.

It looks like he’s getting better duration at night than in the daytime. This may be due to lack of snacks at night? Does he have any food available at night? Or what time is his last snack before you go to sleep? Does he have an automatic feeder to dispense snacks for the evening cycle?

I normally recommend feeding small low carb wet food snacks at +2, +4 and nothing after the typical nadir time (+6-ish for many cats.). Feeding much other than small bites of low carb “testing treats” after nadir can shorten the duration of the insulin, causing numbers to rise prematurely. Tell me what kind of feeding schedule Buster has so that I can understand.

Regarding the lower preshots, July 25, that was not enough insulin to keep him from going high. On July 28 it was also not enough, but I like how you proceeded cautiously and increased a little bit on the 28th and tested to gather more useful data for handling lower than expected preshot numbers. Now we know that next time he has a similar AMPS you can give more insulin (like maybe 2 units— and if he still goes too high you can give more next time — as long as you are able to monitor, of course.

I feel like you are making progress with Buster; I see it in his spreadsheet. His body still isn’t used to being in the lower/normal BG numbers, and the only way we get him used to them is for him to spend more time in the greens and low blues. Fortunately, he’s not a crazy “diver” and as long as he gets his regular small meals/snacks, I am not concerned about him dropping too low on 2.75 or 3 units. Let me know your thoughts.
 
Suzanne & Darcy said:
It looks like he’s getting better duration at night than in the daytime. This may be due to lack of snacks at night? Does he have any food available at night? Or what time is his last snack before you go to sleep? Does he have an automatic feeder to dispense snacks for the evening cycle?

I normally recommend feeding small low carb wet food snacks at +2, +4 and nothing after the typical nadir time (+6-ish for many cats.). Feeding much other than small bites of low carb “testing treats” after nadir can shorten the duration of the insulin, causing numbers to rise prematurely. Tell me what kind of feeding schedule Buster has so that I can understand.
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Its almost the opposite - he has more access to a food overnight than during the day. Here is his feeding schedule:
  • Buster gets 2.75 - 3 oz (a can of Fancy Feast or a 1/2 can of the LC foods in the 5.5oz can) at shot time. It generally takes an hour+, sometimes 2 for him to finish it.
  • Around +4 he gets 1.37 - 1.5 oz (1/2 Fancy Feast or 1/4 5.5 oz can). This is mostly gone by +6 during the day, and if its not gone by then its going to be hours before he comes looking for it again so it usually gets thrown away.
    • At night the pick and throw is different because +4 is approaching 11PM and I am usually done for the day by +5 so it stays out until its gone or I inevitably can't stay asleep and make a pass of his food area at +9.
  • During the day he generally doesn't get anything but a handful of shredded baked chicken after +6, but at night he has access to his snack during the back half of his cycle if he hadn't eaten it all earlier in the night. Overnight he might be able to eat the rest of his food around 3 or 4 AM where he can't do that at 3 or 4 PM because its been picked up and he's stuck with chicken treats. Makes me wonder if I should just let him keep his snack past +6 during the day since the nights seem more controlled.

Suzanne & Darcy said:
I feel like you are making progress with Buster; I see it in his spreadsheet. His body still isn’t used to being in the lower/normal BG numbers, and the only way we get him used to them is for him to spend more time in the greens and low blues. Fortunately, he’s not a crazy “diver” and as long as he gets his regular small meals/snacks, I am not concerned about him dropping too low on 2.75 or 3 units. Let me know your thoughts.
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If it weren't for the random trips into the blue after nadir drops of around 150 points I wouldn't blink at moving to 3 units. It makes me think its too much and his body angry dumps for 2 days in response. But I will move to 3 tomorrow morning, depending on his glucose being up or not. I also have a message into my vet that I want to put him on the Libre so we'll see how quickly that happens.
 
Well, empirically, he is getting better duration at night — better more long-lasting numbers. It is very common for cats to drop into lower numbers at night. He isn’t supposed to be eating for the two hours prior to the preshot tests to make sure that the preshot BG tests are not artificially inflated by food. He is making progress, and I am really happy to see it. However, he is spending too much time above the kidney threshold in pinks and higher yellows and reds. His BG numbers recorded on your spreadsheet indicate that he would be safe to receive the increase to 3 units.
 
Suzanne & Darcy said:
His BG numbers recorded on your spreadsheet indicate that he would be safe to receive the increase to 3 units.
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He did it again this morning - nowhere near as low as the other 2 times, but significantly under his normal PS reading. He's been trending at least 350, but lots of 400s, and this morning I shot 2 units on 221 after a stall from 216. I suspected this was going to happen this morning based on his trend since moving to 2.75 units.

I really struggle with the concept of holding a dose that's been shaving 150-200 points off his reading when he barely has it, or doesn't have it, to give. :confused:
 
Today we had what I thought was going to be a great day - we started off with a BG high enough to feel comfortable shooting 3 units on, he stepped down into a nice blue nadir and I was able to ninja him today while he was in the litter box to test for ketones (negative).

Then he started mobbing me for food a bit earlier today and right before it was test time he threw up bile & water... and boom 65 blood sugar for PMPS. Even after a stall it was only 72. I thought about giving a token .25 unit, but good thing I didn't as his appetite is in the toilet. He's been nursing his can of Fancy Feast for 3 hours - its finally just over 90% gone, and we're paying for it a skyrocketing BG now, but at least he's not in danger of a low with a poor appetite.

Guessing he feels like crap because his PMPS went from 400 yesterday to 65 today.

I see the value in 3 units the past 2 cycles, but guidelines say to drop him down a quarter unit next shot. Except we just moved him to 3 because 2.75 wasn't moving the needle often. Should I stick with the 3 again next cycle AND make sure he has a snack between nadir & +9 to blunt the drop (in addition to his pre-nadir snack), or should we retreat to 2.75 and keep a normal feeding schedule?
 
When he had the 69 at PMPS, I still would have given some insulin- maybe if even only 1 unit, to keep him from being too high like this morning. Even more so since you stalled an he was at 72 indicating that he was not dropping further but was stable in the good safe green range.
 
In addition to my suggestion above, can you tell me exactly how much he ate yesterday and at what hours during the cycle?

If he’s not eating this morning at all, then I might not shoot 3. If he is grazing and eating small amounts that’s okay for him and even is a good thing. If he wants to graze all the way to +6 then just fine. After that, I would decide if he needs any more food based on his BG (other than the always-allowed test treats, of course.)
 
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