Is my dose for Celle too high?

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Melissa and Celle

Melissa and Celle

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Hi -- I'm new to the message board. We've been trying to regulate Celle for 6 months now, and I'm getting somewhat desperate to find something that works. But right now I have an immediate question about what dose to use tonight. Celle is dangerously high and I have no idea what dose to use to bring her down.

We went from PZI to Lantus to Levemir. We had been on 3 units Lantus and started Levemir at 2 units on May 23 (evening). Here's the data we had for that (sorry I'm not using the format others on the message board used)

Date Time Hours Post Injection Blood Glucose
27-May 11:10 PM 4.75 336
28-May 9:30 PM 3.25 365
29-May 6:25 AM 0 346
29-May 9:30 AM 3 207
29-May 11:30 AM 5 93
29-May 12:30 PM 6 108
29-May 2:30 PM 8 301
29-May 4:30 PM 10 359
29-May 6:20 PM 11.75 399
30-May 6:20 AM 0 352
30-May 10:15 AM 3.75 338
30-May 12:30 PM 6 239
30-May 3:30 PM 9 262
30-May 6:20 PM 11.75 372
1-Jun 11:35 PM 5 189
3-Jun 12:05 AM 5.5 369
3-Jun 6:05 AM 11.5 427
3-Jun 11:20 PM 4.75 410
4-Jun 6:25 AM 12 409

We then increased to 2.5 units on June 4 (morning).

Date Time Hours Post Injection Blood Glucose
4-Jun 10:45 PM 4.25 374
5-Jun 12:45 PM 6.25 157
5-Jun 2:35 PM 8 159
5-Jun 4:35 PM 10 248
5-Jun 6:20 PM 11.75 389
5-Jun 8:35 PM 14 387
5-Jun 10:30 PM 16 230
5-Jun 6:20 PM 0 389
5-Jun 8:35 PM 2 387
5-Jun 10:30 PM 4 230
7-Jun 6:05 AM 11.5 511
7-Jun 6:25 AM 12 447
7-Jun 11:30 PM 5 300
8-Jun 6:10 AM 11.75 354
8-Jun 11:35 PM 5 131
9-Jun 6:10 AM 11.75 551
9-Jun 7:20 AM 12.75 511
9-Jun 8:40 PM 2.25 380
9-Jun 10:10 PM 3.75 294
9-Jun 11:35 PM 5 179
10-Jun 6:10 AM 11.75 481

And (sorry to say) that we increased to 3 units last night and this morning:

10-Jun 10:15 PM 3.75 216
11-Jun 6:25 AM 12 514
11-Jun 6:25 AM 0 514
11-Jun 8:00 AM 1.5 515
11-Jun 9:35 AM 3 333
11-Jun 2:55 PM 8.5 391

So is this dose actually too HIGH? Should we have gone down from 2.5? Down from even 2? What should I do now? If this is rebound, how long can I expect it to take to stabilize her? Is there any hope for Levemir? If we go back to Lantus do we just start at the dose we were on before or lower?

Many thanks for any insight anyone can provide.
 
We've never had numbers over 500 before, and she's been on the same food since diagnosis. We've not switched to wet food because we have three cats and haven't figured out how to allow Celle to eat at the nadir unless it's dry food that the others will leave alone.

I'll try the spreadsheet, but I'm afraid that won't help me for this immediate question of what to dose her with tonight.
 
You should switch to wet. We were stubborn and didn't listen to our vet about switching and left him on regular dry cat food because of stomach issues he's had for over a year. It wasn't even the diabetic kind. We did that for a month and switched him to wet and his numbers are finally dropping. First time under 300 within two days of the switch. He's received 1 unit of Lantus twice a day since the start. He's already coming back to his old self.
 
Moe was over 500 a lot the first month when he was on dry. Still only gave him 1 unit of Lantus. His levels dropped immediately after switching him to wet food. The support group made sure I was aware to test him frequently while switching him in case he went too low. I mixed his wet with a little of his dry for a couple days to transition him all the wet. It's been less than a week since we switched him to wet and he's doing much better.
 
My Tonis does not know what to do with canned. I had very high BGs when I started Levemir. Some were Hi. I saw little reduction in BGs until I increased the dose to 6 units BID. Now I am slowly reducing the dose since BGs are continuing to go down.
 
What formula of PZI were you using when you used it? My Lucky did not have decent BG levels for a good 6 months into treatment because the beef/pork PZI didn't work for him. We had ketones a couple of times back then! I finally got the vet to order PZI all BEEF, which I purchased from Texas by mail-order, and he responded very well to the 100% Beef PZI. Lucky would not let me take his dry food away, because then he would stop eating entirely, but I managed to get decent BG's from him while we had him on PZI Beef twice daily for 5 years while he was free-fed Hills - can't remember the formula now, think it was WD, he grazed on dry and he had 2 to 3 times a day canned Fancy Feast. He was already 10 yrs old when he became diabetic, but with the PZI beef insulin from TX he had several more good years. He finally got a terrible abscess in his jaw from a bad tooth, causing his jaw bone to break pathologically, and there was nothing the vets could offer at that point, and he couldn't eat or drink because he had such mouth pain, so we had to let him go. We could see it, and the vet said he was suffering, and we couldn't bear to prolong it when nothing else could be done. I STILL miss my Luckyboy!

I suggest you check your kittie's Ketones. As far as dose, i am not sure what to suggest because you have changed insulin types and doses so frequently. I have been away from FDMB for quite some time, pop in from time to time to see if i can help, but just wanted to mention PZI 100% beef insulin to you. Hopefully somebody else can chime in to give you dose advice, but if your kitty's Ketones are moderate or high, you need to see a vet NOW. Good luck!
 
Yes, please lower it to 1U

Hi Melissa,

What your numbers show is a classic example of overdosing on Levemir. Some people seem to think that it is only overdosing if you see numbers go in to the 30s. What the numbers show is that on average they increased as you increased the dose. 500s on Levemir is a sign of too much insulin, unless the cat is newly diagnosed and has not been on any insulin previously or had very poor control on a previous insulin.

Some will tell you to keep increasing the dose. Please do not because if the 2U to start with had not been enough you would not have gotten that 93 reading at +5. 2U was too high of a dose to begin with. It should have been only 1U, if that, as more and more we are seeing cats coming to the Levemir ISG where we work with Levemir only(Insulin Support Groups). We can help you make sense of the numbers and no, a spreadsheet is not necessary right away. Some of us have been around long enough we can read numbers as you listed, although a format like this is a little easier to read:

AMPS (A.M.Preshot -time is not necessary unless it helps you) BG, dose
+2 (2 hours after shot) BG
+4 BG
+6 BG
etc
PMPS, BG, dose

This is the Levemir ISG: http://felinediabetes.com/FDMB/viewforum.php?f=10 We can help you. We also have some informative stickies near the top of the actual posts section, please check those out.

When you change to wet food - it is when, not if, it will be better for all your cats - it is imperative that you lower the dose to 1U. Right now the higher carb in the Purina DM is probably the only thing that is keeping her from getting hypo numbers on 3U, which would be below 40 on Levemir.

Realize that she had a 93 on 2U of Levemir while eating high carb dry food. And yes, 13% is high carb for diabetics. Check the ingredients on the bag, 2 of the first 4 are grain related - corn gluten meal and soy flour - that does not make it low carb, low carb for diabetics is below 10%. Please visit http://www.catinfo.org/?link=felinediabetes It will help you make sense of what the best diet for diabetics cats is.

If you could do one other thing to help Celle - please get some ketone test strips and try to catch some of her pee to test with them. That is very important as she has been running kind of high. Ketones are dangerous and she should be tested daily until you get her numbers better under control. Also, read this section of the Pet Diabetes Wiki, which will explain why you are right, that Celle is getting too much Levemir:http://petdiabetes.wikia.com/wiki/Rebound

Hope I haven't overloaded you with information, but your instincts are correct and you've come to the right place to figure it all out for Celle!
 
Thank you so much for the advice. We did last night's dose and this morning's (before reading your post) at 1.5 units, still with the dry food. So far, no improvement in the numbers: 431 at +3.5 last night and 519 again this morning. Can you tell me now what to expect as we move forward with a dose of 1 unit? How long should it take to see an improvement? It is hard to be patient. Is there anything else that we should be doing -- could they do something more for her at the vet right now to bring the numbers down?
 
More questions about switching to wet food. Are two meals a day OK? Or with four meals (as we do now), what about wet food at shot time and dry food at the nadir when we're at work/asleep? Or wet food before bed at +3 hours with dry food at the nadir when at work? Is there a good post on feeding times? I haven't been able to find one by searching.
 
I would ditch the dry altogether. you can freeze wet food in ice cube trays and put out for snacks later. all your kitties should be eating lo carb wet to prevent any of them becoming diabetic. there are lower priced LC foods the cheapest being special kitty from walmart. you can also invest in a timed feeder if need be. wet food is ok out for 8 hours as long as your house is not extremely hot
 
i too would take the dry completely out....i switched both cats to wet and havent gone back.
we were on the prescription dry when first dx'd 2 yrs ago, people on this board got me to change both cats because like you i couldnt and didnt have the time to feed one this one that....
 
melissagk said:
Thank you so much for the advice. We did last night's dose and this morning's (before reading your post) at 1.5 units, still with the dry food. So far, no improvement in the numbers: 431 at +3.5 last night and 519 again this morning. Can you tell me now what to expect as we move forward with a dose of 1 unit? How long should it take to see an improvement? It is hard to be patient. Is there anything else that we should be doing -- could they do something more for her at the vet right now to bring the numbers down?
Click to expand...

It will take a while, 3 or 4 days, to see if the numbers come down. The problem you may have now is insulin resistance caused by the high numbers. By giving too high of dose, a response between the pancreas and liver was created where the liver creates extra blood glucose, what's known as Somgoyi Rebound. That becomes the body's new "normal," so it can get stuck in a high numbers cycle. It is even possible that not very low numbers or fast drops can cause this effect now that Celle has had high numbers for a while.

She's had even some 100s as recent as Wednesday, so I hope we're not too late. 1.5U is OK for now. What we'd like to see is less of the "bouncing" going on - the blood glucose should remain steadier on Levemir, even if it is in the 300s. But if the bouncing continues, the dose t 1.5U is still too high. And my recommendation to go to 1U if you switch her to wet food still stands.

Do you know if she likes wet food? And Dian's suggestion of a timed feeder is an excellent idea when you have more than 1 cat. Cats soon learn what sounds it makes and know it has food for them when they hear it open a new tray. Also, she needs food with her BG so high. Please do not withhold it from her. Poor food intake is a factor in ketone production. We don't want that. Have you had her checked for any infections, such as urinary or poor oral hygiene? If she has gone outside the box or has any trouble urinating, it might be a good idea to take her in. Teeth would be if she has plaque build-up or if she's never had a dental.

Hope this helps. Thanks for asking. Patience is difficult on the longer acting insulins, sometimes members sabotage their progress by trying to drive the numbers down too quickly with higher doses. Hang in there. Also, please let us know if you need help finding a ketone test kit. You want just the ketone kind, you are testing BG, you don't need the urine strips which test for both ketones and sugar in urine. Once you get them, we can help with some ideas about how to catch urine! Fun!

Good luck.
 
Thank you again for all the helpful advice.

Celle will eat anything, so switching to wet food will not be a problem from her perspective. She has continued to eat her regular amount through all of this (no loss of appetite). I take it that I should feed her more while her sugar is so high? How should I factor that into interpreting her BG level?

She had a UTI recently and was at the end of her 2-week antibiotic treatment on Monday, so I doubt an infection would explain what we're seeing. She could use a dental cleaning, but I don't think the vet thought it was serious enough to consider given the risk of anesthesia for her right now.

Can you explain more of why I would want to test for ketones? I assume that given her numbers we wouldn't be too surprised to find some now. Is there anything that we would do beyond what we're already doing to try to get her numbers down?
 
Here is some info on ketones and DKA that may help:


The Hows and Whys of Ketones

from Kathy and Cashew (GA)


--------------------------------------------------------------------------------

Energy Supplies of the Body

Before we discuss Diabetic Ketoacidosis let's review how ketones are used in the body. There are two basic forms of fuel the body uses to keep the body running at its most basic cellular level. The primary form of energy used is glucose. Glucose is obtained from digested foods (carbohydrates). Protein can also be converted to glucose in a process called gluconeogensis. Fat when digested is broken down into fatty acids and glycerol. Glycerol can also be converted to glucose. Fatty acids can used by the body or be converted to ketones. In addition to digested food, the body has reserves of fuel in the liver called glycogen, which can be converted to glucose when needed. There are also small stores of glycogen in muscle tissue. When necessary protein can be stripped from muscle mass to convert to glucose in times of extreme need. Likewise fatty acids can be converted to ketones by breaking down fat stored in adipose tissue and converting it into ketones in the cells of the liver.

Ketones: Do they deserve their bad reputation? When do they become a problem?

It may seem like ketones have a bad reputation since we've seen so many problems occur with DKA but ketones are actually used by the body everyday to provide energy to some primary body organs like the heart and can be used as an alternate energy source when glucose is lacking. They also help reserve the glucose supply for those organs that prefer it like the brain. They can be found at normal basal levels in blood and urine. When we talk about losing weight and burning fat, we are actually talking about using ketones. Dieters and people stranded in the wilderness rely on ketones to survive.

Ketones only become problematic when they replace glucose as the primary energy source. It's the excessive use of ketones which can cause the body's PH to lower and turn the blood acidic creating metabolic disorders such as diabetic ketoacidosis. When ketones have reached the level where they can be detected using urine test strips – that is the danger sign.

Who directs the body and tells it when to use which fuel?

Hormones in the body work like air traffic controllers signaling positive and negative instructions regarding its energy needs and fuel supplies. Insulin for example inhibits the production of ketone bodies by inhibiting the breakdown of fat (ljpolysis) in adipose tissue while in the liver it inhibits the conversion of free fatty acids into ketones. Glucagon, a pancreatic hormone stimulates the release of natural insulin which in turn inhibits ketone formation however in diabetics when there is either none or little supply of insulin to be stimulated, glucagon actually stimulates fat breakdown (lipolysis) in adipose tissue and enhances the conversion of fatty acids into ketones in the liver (ketogenesis) and can cause DKA. Stress hormones (catecholamines) such as epinephrine, norepinephrine, ACTH in addition to glucagon also stimulate ketone formation.

Why does DKA occur?

Diabetic Ketoacidosis occurs when glucose cannot reach the cellular level. The body tries to compensate by increasing the level of glucose in the blood. It does this by breaking down the glycogen reserve into glucose (glycogenolysis) and by creating new glucose from protein and glycerol (gluconeogensesis). The body will use whatever protein is available either from ingested food or it will strip muscle mass from the body. In a predator such as a cat the body will only strip so much muscle mass from its body since historically it knows that in order to eat, a cat must be able to walk and hunt thus promoting use of ketone formation more readily. Insulin deficiency promotes the acceleration of ketone production by stimulating fat breakdown (lipolysis). The body will try to answer the demand for fuel by breaking down more fat to convert to ketones to substitute for the lack of glucose. This causes a high level of ketones in the blood (hyperketonemia) and excessive polyuria causing dehydration and electrolyte loss and acidosis in the blood.

In an analogy I once used in an fdmb post, if the body cells were hungry guests at a party and were anxiously awaiting the pizza man (insulin) to deliver the pizza's (glucose) the host (liver) might start serving chinese food too (ketones) to placate the guests. The longer it takes the pizza man to deliver the pizzas the more chinese food gets used.

DKA prevention
To prevent DKA, all diabetic kitties should routinely be monitored for ketones in the urine using Ketostix. This will provide an early warning system so that if detected, intervention can be started before ketones progress to diabetic ketoacidosis.

Anorexia and/or insulin deficiency can lead to a lack of glucose at the cellular level which can lead to DKA. To prevent DKA a kitty must have a sufficient incoming glucose supply and must be given insulin in order to allow the glucose to enter the body cells. Anorexia is a typical sign of illness in a kitty and needs to be taken seriously with diabetic kitties because they need the glucose (even if they are currently at a high bg) to replenish their glycogen supplies. You also want your kitty to eat so you can give your kitty insulin. If a kitty refuses to eat or eats little but has a high bg and you hometest you can give a reduced dosage of insulin to move some of that glucose into the body cells and discourage ketone formation. If you don't hometest, it's more difficult to monitor the effect of a reduced insulin dosage and you have to weigh the odds of hypo risk versus ketone risk. The basic cause of the anorexia needs to be discovered. Most times DKA occurs when infection is present. This usually causes the kitty to be anorexia and the infection itself can cause bg levels to rise because of the body's greater demand for energy to fight the infection. A visit to the vet whenever anorexia lasts longer than a day is always a wise idea as well as increasing the frequency of ketone testing whenever a kitty is ill.

DKA Treatment
When a kitty is diagnosed with DKA the typical treatment involves a slow rehydration which will help flush out ketones and restore the pH level of the blood and replace electrolytes, and begin moving the body back to using glucose as its primary fuel. Usually a kitty is given fluids, electrolytes, glucose and small frequent amounts of regular insulin to facilitate glucose delivery to body cells. Antibiotics are usually given also since most times the cause is an underlying infection. When a kitty is back to eating and drinking with negative ketones they are on the road to recovery

There actually is a great explanation at this website on the whole biochemistry of it all [www.powerpak.com].
 
Melissa, don't assume there will be ketones, just be aware that they can happen with higher numbers AND too little food AND an infection (or sometimes just two of those factors). It's just safer to test for them right now. If you want to understand more about the process, here is a link: http://petdiabetes.wikia.com/wiki/Ketoacidosis

FYI, petdiabeteswiki is an excellent site for information on feline diabetes: http://petdiabetes.wikia.com/wiki/Main_Page

On feeding: I have five cats. Two are diabetic (Beau is diet controlled/no insulin), two have hyperthyroid (one is over 18, the other is Beau), and two are 3 years old. They all eat the same thing and I free feed them. I make a batch of food that is two large cans of cat food, mixing Wellness or Evo and Sophisticat (3 flavors in the large cans are low carb), about 10 ozs of water and taurine supplements. I scoop out 1/3 C into five bowls in the morning and again at night leaving it down all day so they can free feed. I do this all year round, even the summer, but I run AC if the temps outside are over 80 or so. They all get treats when I test and shoot Jeddie. In the am this is 8-12 kibbles of "better" dry food and at night its pieces of boiled chicken or turkey. I also use a freeze dried chicken treat now and then. It's actually a dog treat, but it is a lot cheaper than Halo (who makes a "cat" freeze dried chicken treat). I get it at PetSmart and stock up when it is on sale: Prime Taste Freeze Dried Real Chicken Dog Treats.

I agree with Vicky that it looks like Celle has been getting too much insulin for a while. Decreasing to 1.5u should result in better numbers. Especially when you eliminate the dry food. She may need even less insulin once the dry is gone. Finding the right dose is a process that involves a lot of patience. Every dose change needs to settle (on Lev and lantus especially), data looked at and another dose change planned, repeat the steps - again and again and again. Eventually you find a good dose and can fine tune it with very small changes (of .1u or even .05u). When you get to that stage, there is info on how to get the small dose adjustments on the Lev ISG in the Sticky labeled Lev 101.
 
melissagk said:
She had a UTI recently and was at the end of her 2-week antibiotic treatment on Monday, so I doubt an infection would explain what we're seeing. She could use a dental cleaning, but I don't think the vet thought it was serious enough to consider given the risk of anesthesia for her right now.
Click to expand...

Both bad teeth and UTIs can cause BG to go up and stay up until the infections/inflammation is taken care of. I couldn't regulate Bandit until he had a dental. After his dental, his numbers dropped way down on the same dose of insulin.

The three most common things that will prevent regulation are 1. dry food, 2. too high a dose and 3. secondary infections/dental problems.
 
This looks similar to but not identical to the dosing protocol that I was following. My confusion is that so often I get results that are so different from each other that the protocol would suggest a different course of action depending on which I looked at. What do you do then? Do you always go by the lowest number you get no matter how unusual it seems to be? That is ultimately why we gave up on Lantus. It was only a matter of time before a dose that seemed to be working quite well would give us a low reading and we'd back off, ultimately to a dose that didn't seem to do enough just so that we could be safe.

Celle was 434 pre-shot yesterday morning, so I had hope things were improving, but this morning she was 490, not much better at all. Patience, right?
 
Honestly, I don't think the problem is/was the insulin, but the dry food and the UTI/needing a Dental. You have to get those factors ruled out before making more changes.
 
But Celle was just treated for a UTI, and the vet didn't think her dental issues were serious enough to make the risk of anesthesia worth it. I'm not sure what more we're supposed to do.
 
If she's finished treatment on the UTI, then that can be ruled out now. But I'm not sure what your vet means by "risk of anesthesia." Does Celle have an underlying condition like a heart problem that would make anesthesia dangerous? Does she need extractions or just a cleaning? The vet should do bloodwork ahead of time that eliminates risk factors for the dental. Bandit just had his last week (poor guy needs two more teeth out).

If she has any inflammation in her gums, then it could cause her BG to go up. If you take a look at Bandit's spreadsheet, he didn't regulate until after his dental.
 
My vet said she wouldn't risk anesthesia until Celle's diabetes was under better control. I don't understand what exactly the risk is. I did have a kitty die under anesthesia before though, so my vet is probably extra cautious with me in particular (and I am extra cautious in this regard as well). Celle doesn't need extractions. As far as I understood she just needs a cleaning for some plaque build-up.
 
Well, if you're really hesitant you could always wait and see how the wet diet affects her BG. But if you're still having trouble regulating, then you may need to do the dental. My old vet said something similar...that she'd like to see Bandit better regulated before getting it done, but the problem was that his mouth was keeping him from being regulated, and the health risks associated with an unregulated cat were far worse than the risk of anesthesia. So it was a catch 22, and since it was impossible to regulate because of the mouth, I had to get the mouth done.

If there's no inflammation or discoloration in her gums because of the plaque, then you might be able to wait, but if they are red and sore then you'll have to get it done.
 
If there aren't any obvious, painful lesions, you might do some home dental care.

If there is inflammation, tooth resorption, or obvious decay ... home care ain't gonna cut it and likely the cat won't allow it (per Dr Pierson, DVM, on other posts). And getting a dental done asap will help immensely in regulating the glucose levels.
 
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