Insulin not working?

[Lisa & Augustus]

Hi all,

We are new to this, but hoping to get some advice from you experts, and I will try to be detailed but brief!

A little background: Augustus (9 y/o) was flirting with diabetes a year ago summer (2017). We noticed that he was drinking heavily and his urine output was very high so we took him in and he was diagnosed as diabetic. Not a big surprise, at the time he was probably close to 20 lbs. We tried hard to manage it before having to go on insulin and luckily enough, we were able hold off on the insulin through diet. Slowly over time from 2017-2018 we noticed more and more vomiting from him, more than usual, so we took him in and got the IBD diagnosis. Long story short, this year we had a rough summer of diet changes, tests, worry, anxiety, and in the end, likely because of his diet change to a ZD diet (which DID help his IBD) the diabetes came back. So more changes in diet, worry, tests, anxiety and no luck in shrugging the diabetes. He is currently on a part dry DM diet and as much wet food as he will eat. I know he would be in a much better place with a wet only diet, please no judgement, it's not off the table, but with IBD and many many days of him not eating but the scantest amount, we are in a stable and decent place with this current diet.

So the problem is that his insulin just doesn't seem to be doing much. We started at .5 unit of lantus 2x a day, did a curve (I am doing my own curves, and sorry I don't have all of his numbers in front of me), numbers are in the upper 300's to low 400. We went to 1 unit 2x a day, same numbers. I believe it was at this dose that the last glucose check before his 2nd dose of the day his number went from upper 300's/low 400's to 270 or thereabouts. The vet thought maybe he is getting TOO much insulin, since it should be raising at this point. So we dropped back to .5 units 2x a day, same results. We went to 1.5 units 2x a day, same basic results, maybe SLIGHTLY lower overall at best. He is now on 2 units 2x a day and I will do another curve in a few days. I am not seeing any change in his drinking/urine, etc. Haven't all summer since we started futzing with all of this. The only time we see any significant changes in his drinking and eating is when he is having an IBD spell.

The vet is a bit unsure what to think about this (or that is at least my take), and seems hesitant to want to raise his insulin any higher. He has been losing weight, which was needed, but now we would like him to be maintaining his weight. He is at roughly 15 lbs. now.

Any ideas? Would changing to a different kind of insulin have any effect? I have wracked my brain about everything, tried different kinds of needles, thoroughly researched if I am giving his shot the right way (I know it's getting into that skin). I would love to hear some ideas or suggestions. I should mention that he is not on any medication for IBD other than a very small amount of prilosec and an anti nausea medication, neither of which should affect his blood glucose (according to vet).

Thanks!

 

[Kris & Teasel]

Welcome! You've come to the right place.

He is currently on a part dry DM diet and as much wet food as he will eat. I know he would be in a much better place with a wet only diet, please no judgement, it's not off the table, but with IBD and many many days of him not eating but the scantest amount, we are in a stable and decent place with this current diet.

Don't worry about his diet for now. The IBD problems need to be managed and insulin dosing can be worked around that.

So the problem is that his insulin just doesn't seem to be doing much. We started at .5 unit of lantus 2x a day, did a curve (I am doing my own curves, and sorry I don't have all of his numbers in front of me), numbers are in the upper 300's to low 400. We went to 1 unit 2x a day, same numbers. I believe it was at this dose that the last glucose check before his 2nd dose of the day his number went from upper 300's/low 400's to 270 or thereabouts. The vet thought maybe he is getting TOO much insulin, since it should be raising at this point. So we dropped back to .5 units 2x a day, same results. We went to 1.5 units 2x a day, same basic results, maybe SLIGHTLY lower overall at best. He is now on 2 units 2x a day and I will do another curve in a few days. I am not seeing any change in his drinking/urine, etc. Haven't all summer since we started futzing with all of this. The only time we see any significant changes in his drinking and eating is when he is having an IBD spell.

We can definitely help you with dosing. It's great that your vet started on a low dose. Figuring out a good dosing range takes a lot of time and going by the results of periodic BG curves can be a less than ideal way to do it. I speak from experience here - I spent many months doing curves for my vet to try to get my guy into decent numbers. It didn't work. He was diagnosed in January 2016 and I finally tried the "FDMB method" in August of 2016. That's when I began to see what was happening, learned why the curve method was unsuccessful and saw how very erratic and unpredictable Teasel is.

The vet is a bit unsure what to think about this (or that is at least my take), and seems hesitant to want to raise his insulin any higher.

Many cats do well at a dose in the 1 to 3 units twice a day range. There are some, though, who need much larger doses for a variety of reasons. It's too early to know what your kitty's dose range will settle at.

Would changing to a different kind of insulin have any effect?

Lantus is a great insulin for many cats. It's too early to be thinking about trying a different one. You can certainly get him doing better on Lantus with our help.

Here's what I recommend for now:

1. Go to the Lantus forum and introduce yourself. There are loads of very knowledgeable people there to get you started.
2. Take the time to read these yellow info stickies about Lantus:

http://www.felinediabetes.com/FDMB/threads/the-basics-new-to-the-lantus-basaglar-levemir-group-start-here.18139
http://www.felinediabetes.com/FDMB/threads/what-is-the-insulin-depot.150/
http://www.felinediabetes.com/FDMB/threads/start-low-go-slow-method-slgs.129446/
http://www.felinediabetes.com/FDMB/threads/tight-regulation-protocol-tr.1581/

Here's something I put together for new members a while ago:
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It would help us if you set up your signature (light grey text under a post). Here's how:

• click on your name in the upper right corner of this page
• click on "signature" in the men that drops down
• type the following in the box that opens: kitty's name/age/date of diabetes diagnosis/insulin you're using /glucose meter you're using/what he eats/any other meds or health issues he has.

Another thing that will help us help you now that you've started BG testing at home is to set up a spreadsheet like the one we use here. We can all see it and look at it before offering advice: http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

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Here's the basic testing routine we recommend:

1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
3. do extra tests on days off to fill in the response picture
4. if indicated by consistently high numbers on your spreadsheet, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
5. post here for advice whenever you're confused or unsure of what to do.

This is useful: http://www.felinediabetes.com/FDMB/threads/hometesting-links-and-tips.287/

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Here's an explanation of what we call "bouncing". It explains why a kitty's BG can go from low to sky high:

1. BG goes low OR lower than usual OR drops too quickly.
2. Kitty's body panics and thinks there's danger (OMG! My BG is too low!).
3. Complex physiologic processes take glycogen stored in the liver (I think of it as "bounce fuel"), convert it to glucose and dump it into the bloodstream to counteract the perceived dangerously low BG.
4. These processes go into overdrive in kitties who are bounce prone and keep the BG propped up varying lengths of time (AKA bouncing).
5. Bounce prone kitty repeats this until his body learns that healthy low numbers are safe. Some kitties are slow learners.
6. Too high a dose of insulin can keep them bouncing over and over until the " bounce fuel" runs out and they crash - ie., have a hypo episode. That's why we worry so much about kitties that have had too high a starting dose prescribed by the vet and the owner isn't home testing.

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Here are some tips on how to do urine ketone testing (VERY important if BG is high and kitty isn't eating well!):

• put the end of the test strip right in his urine stream as he's peeing
• slip a shallow, long handled spoon under his backside to catch a little pee - you don't need much
• put a double layer of plastic wrap over his favourite part of the litter box and poke some depressions in it too catch pee.

Most test strips have to be dipped and allowed to develop for 15 seconds before viewing the colour change in very good light.

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The reason that relying on curves alone isn't the most effective method is that the BG profile on a curve day might be artificially inflated from that rebound phenomenon we call bouncing. It can look like a dose is too low when, in fact, it isn't. By accumulating BG spot test data over many days you get a better feel for what the dose is doing. You're more likely to make a proper assessment of the dose.

Ask a million questions - we want to help!