Intro/Highly Varient blood glucose readings

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awkohr

Member Since 2013
My Cat Macy was diagnosed with diabetes in early June 2013 but has probably been diabetic for at least the last two years as her water consumption was high. At first I was not that worried as she had been having urinary tract infections, my original vet treated with some meeds and I purchase a pet water fountain. Things seemed good as she was drinking more water and her infections went away though over the course of 2 years she started consuming more and more water. About a year ago my girlfriend helped took care of my cat every few days while I was on an extend vacation and coined the term pee bricks due to the volume of the clumps of litter. It only got worse over the year between vet vistas. In both 2012 & 2013 I mentioned it to my outpatient vet. He did not seem concerned in 2012 nor in 2013 until I got pushy about it not being a normal amount of litter as I was putting out 1.5 #####Gallon cans of litter a week. He said well I could get some blood work run but I would have to go somewhere else as he does not do blood work. The very same day I took my Macy to an animal hospital in the area and paid for a second checkup and blood work and have switched over to them as her vet.

Her blood glucose was initially in the High 400's on their Alphatrack but she had no signs of ketosis. They started me off on 2u Prozinc per day and very early on when that did not seem to be working as her mg/dl where still very high. So I put her on a diet at first still giving her 1/2 can wet food twice a day with a body weight proportional amount of dry food given at the same time, this gave me an hungry and annoying cat. I then without reading much tried dry only and I had an extremely hungry and annoying cat whom started breaking into her dry food bag, a few slices of bread from the bag and even managed to open and free feed herself from a 6lb+ plastic container of dry food that was well sealed after she had moved it about 6 feet across the floor. Once I eliminated any additional self feeding there was still no positive change in blood glucose levels. I then found some online info and switched her to all wet food at 1.5 cans morning and night with the shots. Her nonstop demands disappeared. After that I also without enough reading experimented with different wet foods to see what it did to her sugar levels until I found the chart from catinfo.org and have taken her off all gravy based foods and try for anything with a 7% or less wet sugar content. I then cut her back in calories to only 1 can twice a day as she was getting to much food/fat and now she usually doesn't start begging for food until about 1hr before she should be feed/injected.

Once I was done playing around with the food, my veterinary clinic (I have seen/spoken to 5 different vets in the proactive) and I have been adjusting the insulin levels (though not as quickly as I would like) and as of last friday she is up to 6U Prozinc twice a day. She is seeing some results from the insulin/diet change as I am refilling her water bowl much less ofter and her litter consumption is a little under 1/2 of what it's peak levels where. Though in my non-professional opinion it is still a lot of for one cat. Her current blood sugar levels jump around from about 162 to 316 on a Relion confirm blood meter even when feed the same exact same amount of food at roughly the same times of day. We have not done any fructosimine tests as I have been doing regular readiness and know Macy's blood glucose levels are still spiking high enough that they will tell me they are high.

So might anyone have any suggestions as to what I might be doing wrong/differntly to have her blood glucose levers jump around from the low 160's is up in the 300's just prior to feeding?
I have been careful to do an end over end rolling mix of insulin but not to much. I make sure I have the needle under the skin and not through the skin and every time confirm that her fur near the injection site is actually dry. I believe I have eliminated any sources of free feeding. I have unfortunately left the vial out to room temperature for a full 12 hours which caused it to start separating but that was before the wonky readings. The insulin is not out of date. I realize that the meeter should be within 20% of a table top reading but when you run a curve one day and that the relion confirm only has a 4 out of 5 on accuracy in the august 2013 consumer reports ratings. Might I be being to much of stickler on the numbers?
 
Welcome to sugarkitty Macy and her caregiver. Would you share your first name with us?

My name is Deb and that tuxie pictured to the right is my sugardude Wink.

Would you be able to put more of a time frame together for us. Answers to these questions will help us.
1. When you switched to the low carb food?

2. When did you increase the dose and by what increments?
2b. Starting date of the insulin?

3. Are you testing in the middle of the cycle? To see how low the dose is dropping Macy girl?
 
You want to test before shots to make sure it is safe to give insulin.

You also want to test around the expected lowest glucose level - the nadir - to see just how low it is going. For ProZinc, that is around +5 to +6 hours after the shot.

Here are some glucose reference ranges used for decision making using glucometers. Human glucometer numbers are given first. Numbers in parentheses are for non-US meters. Numbers in curly braces are estimates for an AlphaTrak.

< 40 mg/dL (2.2 mmol/L) {< 70 mg/dL for an AlphaTrak}
- Treat as if HYPO if on insulin
- At nadir (lowest point between shots) in a long term diabetic (more than a year), may earn a reduction.

< 50 mg/dL (2.8 mmol/L) {< 80 mg/dL for an AlphaTrak}
- If before nadir, steer with food, ie, give modest amounts of medium carb food to keep from going below 50 (2.8).
- At nadir, often indicates dose reduction is earned.

50 - 130 mg/dL (2.8 - 7.2 mmol/L) {80 - 160 mg/dL for an AlphaTrak}
- On insulin - great control when following a tight regulation protocol.
- Off insulin - normal numbers. (May even go as low as the upper 30s (1.7 mmol/L){60s for an AlphaTrak}; if not on insulin, this can be safe.

> 150 mg/dL (8.3 mmol/L) {> 180 mg/dL for an AlphaTrak}
- At nadir, indicates a dose increase may be needed when following a tight regulation protocol.

200 mg/dL (11.1 mmol/L) {230 mg/dL for an AlphaTrak}
- no shot level for beginners; may slowly reduce to 150 mg/dL (8.3 mmol/L) {180 mg/dL} for long-acting insulins (Lantus, Levemir, and ProZinc) as data collection shows it is safe

180 - 280 mg/dL (10 - 15.6 mmol/L) {may be 210 - 310 mg/dL for an AlphaTrak}
- Any time - The renal threshold (depending on data source and cat's renal function) where glucose spills into the urine.
- Test for ketones, glucose is too high.

>= 280 mg/dL (15.6 mmol/L) {may be >=310 mf/dL for an AlphaTrak}, if for most of the cycle between shots
- Uncontrolled diabetes and thus at risk for diabetic ketoacidosis and hepatic lipidosis
- Follow your insulin protocol for dose adjustments
- Test for ketones; if more than a trace level of ketones, go to vet ASAP.
 
Dates should be fairly accurate as I am spreadsheeting the stuff including sugar readings.
Note: Relion Confirm/human Readings all taken with same meter and test strips from the same lot code even though I have bought more than one box of strips.
I have taken some curves.

Diagnosis date
6/8/2013 (based on 6/7/2013 tests)

Starting date of the insulin?
6/10/2013 2U ProZinc twice a day.
preshot 411mg/dl on an original AlphaTrak
6/11/2013 Started messing around with food including the weight appropriate per lable "Starvation" sugar rich dry only diet.
6/17/2013 423mg/dl at 6 hour mark. Increase to 3U ProZinc twice a day
6/18/2013 picked up a loaner alphatrak original for testing readings all over the place as didn't have food chart.
6/20/2013 6/26/2013 1/2can wet/ .33oz dry diet twice a day
6/27/2013 Switched to Full Wet 1 can 2X per day. Experimenting with different foods and sugar levels.
7/6/2013 Looks like the day I stopped feeding Gravy based wet foods and by
by 7/13/2013 using catinfo list for food mostly food feed under 7% sugar.

7/15/13 PM Dosage increased to 4U 2X daily

7/20/12 Curve. (readings taken every two hours)
308 mg/dl Relion confirm (prefeeding/shot)
6 hr range 193mg/dl Relion confirm
~12 hr range 326mg/dl Relion confirm

7/30/13 PM Dosage increased to 5U 2X daily
8/4/13 Curve.
Start Just before food and shot 231mg/dl RelConf
+2 hr 256mg/dl RelConf
+2hr 235mg/dl Relconf
+ 2hr 224mg/dl RelConf
+ 6h 208mg/dl RelConf


8/22-24/13 Curve
8/22 8:07PM Prior Feeding 309 human
8/23 2:15AM 160 human
8/23 8:04AM 290 human

8/24 10AM 302 prior to food and shot,
12:17 222,
2:13 199,
3:13 211,
4:17 216,
5:15 193,
6:14 185,
7:10 176,
9:02 194 (Prior to feeding) All relion Confirm


8/30/2013 PM Dosage increased to 6U 2X daily

9/3/2013 Curve. (might be a bit to soon for good 5U readings)
9:49AM 233 prior to feeding and shot.
11:59 278
2:43PM 263
3:56PM 252
5:02 218
5:57 207
7:11 262
8:52 316 (just prior to shot and feeding)
 
It may be that your cat is insulin resistent or you may need a different type of insulin. But since you are on ProZinc, I would work with it awhile. You had an encouraging cycle on 8/24. It lasted longer than 12 hours and the numbers looked good. I would have let that dose settle a few cycles and if the nadirs and shots didn't lower, increased by .25 units. Increasing by a whole unit at a time can take you over a dose that might have given you good results.

You could consider going back to that dose and slowly increasing. If you do, be sure to test for ketones as too little insulin (plus an infection usually) can cause ketones and DKA. You should be able to see in a few cycles if the dose gives you better numbers than the higher dose you are on.

No change of an infection or bad teeth?
 
I agree with Sue. Those numbers on 8/24 were all below renal threshold.

So it's possible that:

1. You've bypassed the appropriate dose
2. You haven't found a good dose yet.
3. Your cat is insulin resistant

I do think that smaller increases would be better. We usually recommend 0.25U dose changes.
 
In rereading earlier posts I forgot to mention/answer the earlier question. As for the Pets Caretake's name, My name is Alex. I have updated my signature so that does not happen again.


Macy was on the 5U 2X per day most of the month both before and after a vacation where she only got 5U once daily. During the non vacation time (where she was not measured at all) She had lots of pre-feed/ shot 300mg/dl on a human meter and just 12hrs after the end of the 8/24 curve had a pre-feed 346 and a a lot of other 300's but as low as 290 on the pre-feed and when I tested at the 6 hour mark in the 170 to 190mg/dl on a human meter.
Those Hidden readings are unfortunately not below the renal threshold. Also I am really hoping to be able to do tight regulation in hopes that I might be able to reach the most likely unobtainable goal of getting her off insulin and to do that I am under the impression I need to be in the NADIR range labeled "great control" above, which I am not yet at.



I was actually starting to think she might be insulin resistant based on the numbers and how they keep working and her weight. Though I have seen signs of improvement, she is much friendlier,hangs out in the same room as me more, more relaxed, more energetic ,producing much less liter waste and here huge eye crusties which she has had for a few years are about 10% of their peak size. Macy is a currently bit large and all my vets/vet techs keep saying he instead of she (though it may just be due to her blue collar.) When I initially took her in she was a very slim and underweight for the end of november semi-feral cat that had been kicked out of her old home. Since then she had ballooned up to 16lbs due to tapes worms that where successfully treated. She then slowly lost weight and at the start of her insulin (early june) she was in the upper 12lb to lower 13lb range and now she is in the lower 14lb mark. Even though I know fat is insulin's mortal enemy and am not overly excited about it my one vet found this as good news because it was indicative of the cat not being in ketosis.
Is their some kind of insulin resistance test that can be done on cats? I was reading about one for humans that usually only get done in research type settings involving using an intravenous glucose solution.


As for the infections, the same vet at the practice also mentioned how her gums looked infected and that can reck havoc with regulating diabetes. When I immediately said "I know it is a pricey proposition as the cat needs to be sedated. Lets get her teeth cleaned, so that the insulin works right." The vet changed her tune to she did not think it was necessary as the "teeth/gums were not that bad." I have also noticed that since she has been diagnosed her one teat seems to be occasionally having a build up of a white semi-crystaline substance in her fur which I never noticed before. . Have not talked to my vet about the later as I keep forgetting. I and my vets both believe she is spade based on a surgical scar and her lack of a period though she was probably around 8 when I brought her in and is probably about 13.5 now, so I doubt it is lactation.


Q. .25U and .5U dosing of 40U insulin
Am I just supposed to eyeball 1/4U dosages. The needles I currently am using are from my vet and have only single 40U markings and no minor 1/2U markings. I have not found or read about any 40U syringes that have .25 or .5 U markings? Do you know of any that are. (The Prices of the needles at my vet are a about that of vet-VIPPS certified online pharmacies once you factor in shipping, and their insulin is much cheaper, so I have just been using them.)

Also the particular vet that I dealt with at my last in person vet visit was aghast and highly against using 1/2 u marked 100U needles even though it was just a simple X2.5 conversion. I didn't feel like picking that battle at that time, is it something I should be much more adamant about for closer to .25U adjustments.



Sticking with ProZinc.
I have read the U of Queenland Center for Companion Animal Health Dosing protocol for cats on glargine or detemir using daily … to adjust insulin doses last updated in 22 April 2009 and found it intriguing. I also read http://www.felinediabetes.com/glargine.htm and I believe some other study with I think about 10X as many test subjects which mentions higher remission rate on glargline than a bunch of other insulin's when combined with hight protein diet. I have been picking the battle to switch insulin's with my vet due to these studies and potential cost savings due ~50% cheeper needles and about 2.5 time the Us for about 2 time the dollars. Though maybe even more units for the same cost if I where to use the pen cartridges.
 
There are no insulin syringes that have 0.25U markings. There are U100 syringes that have 1/2 unit markings, some of the 3/10cc size. You need to eyeball the smaller increments with the U-40 syringes. I've never found a source for U-40 syringes that have 1/2 unit markings on the barrel. Don't think they exist. That is why some people like to use U-100 syringes with a U-40 insulin. It's easy to get very accurate doses using a conversion chart.
 
Okay so I will definitely fight the battle for a prescription for 100U/ml needles with 1/2 U minor marks and assure them that I can easily do the 2.5X pre U conversion for dosing but we will always talk in 40U/ml terms when discussing ProZinc dosing levels.

Due to some reading I had done over a month ago, I had asked the vet on what tests where run for things that are commonly misdiagnosed in cats as diabetes to make sure we where treating the right thing. (I know I asked about casts, I think there was something with the liver and a few to several other things.) I don't remember if Acromegaly/IGF-1 was on that list. I will have to dig up that paper.
 
While you're using the U-40s, you might try this:

Making a Reference Gauge for Half Units or Smaller

Or, get a metric ruler with millimeters marked, line it up with the bottom of the syringe barrel and see how many millimeters (mm) measure up to the 1 unit mark. Then you may line up your dose based on the mm. Not perfect, and you won't have a volume measure, but it will be a way of making a standard draw.
 
Hello and welcome to the board!

Can I ask specifically what kind of wet food you are feeding? Brand/type? Just curious as I know you said low carb but they do vary.
thanks

Wendy
 
General Update.
FYI. Since she has been on the 6U per day her eye crusts have decreased even further and her urine production is down somewhere slightly under 2/3 of a can/week when she had been generating 1 and 1/2 cans/week at the peak.

BJM.
While I may not be the cleanest or sterilist of guys I don't think I would ever feel comfortable reusing a syringe on my cat, and I don't think I would want to mark and box after box of needles that way.

Wendy.
Below is the wet food that I have been feeding my cat. I tend to mix it up though occasionally she will get two cans in a row of the exact same food. Also I do occasionally give Macy some table scraps of solid meats but I will not give her anything that is covered in BBQ Sausce/Glaze/Honey or that is Fried or Breaded or in any other way sugared meats. (She absolutely does not get dry food anymore.)

The numbers with the foods are all Taken from http://www.catinfo.org/docs/FoodChartPublic9-22-12.pdf which I know is out of date. In June before I found the chart a employee at a major chain pet store was bemoaning the fact that it seemed like everybody had just change the formula's of their entire product lines. They where reading ingredient lists with me to try to help and I had to keep steering them away from potato. Of Course that was before I found the catinfo.org list to guide me to what labels to analyze.

Format
Brand
Name
% call Protein % Cal Fat %Cal Sugar mg Phos/100kcals kcals/5.5oz unless otherwise noted.
Friskies special diet
Beef & Chicken Entree
35 60 5 242 181
Turkey & Giblets Dinner
37 58 5 189 166
Ocean Whitefish classic patee
37 59 4 351 172

Merrick
Ocean Breeze (I know it is a bit higher than the rest at 8%)
42 50 8 420 141
TurDuckin (not in a while)
38 52 9 219 163
Before Grain (BG) 96%-Beef
41 58 1 163 76/3.2 oz
BG 96%-Chicken
31 67 2 341 89/3.2 oz
BG 96%-Quail & Chicken
33 66 2 506 79/3.2 oz
BG 96%-Turkey
31 67 2 178 85/3.2 oz

9 Lives
Tuna & Cheese
66 31 3 201 171
Tuna & Egg
66 31 3 201 171
Liver & Bacon
33 61 6 315 169
Chicken Dinner
35 61 4 358 163
Prime Grill Beef
36 58 6 349 163

EVO
Turkey/Chicken Cat/Kitten
33 64 3 266 200
95% Venison
30 65 6 417 218

Wild Callings. (96% of the animal in the name)
Wild Calling Rabbit Burrow
Wild Callings Pheasent Roost

Core Grain Free
Turkey & Duck Formula
38 57 5 265 188

BFF
Tuna & Chicken 4Eva
69 29 2 234 65/3 oz
Tuna & Pumpkin Valentine
64 31 5 243 63/3 ozBFF

Dick Van Pattens Natural Balance
Ultra Formula Original (only used once when pricking Macy's ear was only 12mg/dl prefeed than the frisks Ocean whitefish )
31 56 13 276 200/6 oz
 
BJM said:
While you're using the U-40s, you might try this:

Making a Reference Gauge for Half Units or Smaller

Or, get a metric ruler with millimeters marked, line it up with the bottom of the syringe barrel and see how many millimeters (mm) measure up to the 1 unit mark. Then you may line up your dose based on the mm. Not perfect, and you won't have a volume measure, but it will be a way of making a standard draw.
Click to expand...


The syringe barrel that BJM was talking about would be a reference syringe. You would take a used syringe, use a colored liquid to draw up into the syringe, do the measurements, and you now have a reference syringe.

BJM.
While I may not be the cleanest or sterilist of guys I don't think I would ever feel comfortable reusing a syringe on my cat, and I don't think I would want to mark and box after box of needles that way.
Click to expand...
Very few of us here reuse insulin syringes. The needles get dull very quickly for one. Nor do we mark box after box of needles. You would be making a reference syringe with BJM's method.
 
Wait I just reread the making a Reference gauge link above and comprehended that it was supposed to be done onto cardboard. That does not seem so bad. Will have to find my compass.

-Alex
 
Followup on the infection. According to the one vet whom I had to see in order to board my cat at their facility for a few days as she is diabetic , the crystaline substance near the teat is most likely breast cancer and should be removed and a sample set off to test for to see if it is benign tumor or not. He gave her a shot of Convenia. (Just read about it on Lisa A. Pierson, DVM site, oh my adverse reactions as bad a death. Luckily she only had the runs but they could have been caused by the stress of boarding her the next day.)

According to a vet at my regular practice whom I purposely did not have the paperwork sent over for, so I could get an unbiased opinion, It is probably just an infection of some kind and should be treated with antibiotics. I then told him the other vets diagnosis, and responded with he would not rule it out but since she is most likely spade, the chances of her getting cancer are drastically less and he wanted to try a different daily administered antibiotics to see if it clears it up.
 
awkohr said:
Wait I just reread the making a Reference gauge link above and comprehended that it was supposed to be done onto cardboard. That does not seem so bad. Will have to find my compass.

-Alex
Click to expand...

Exactly! I wouldn't re-use syringes for injection. I might take a used one to fill with colored water for someone else to use as a comparison.
 
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