? Is the dose too high?

[Kate and Geoff]

Jack's numbers have always been very variable and totally unpredictable however since our last post we have had a couple of staggeringly steep drops which have been difficult to control with food and honey and have taken several hours for us to to get him out of danger (our vet on late night alert with intravenous glucose in case things got out of hand). On the first occasion he dropped 12 mmol (220 mg/dl) in 1 hour 15 mins and at the bottom was dropping at a rate of 3 mmol (54 mg/dl) every 15 mins. We could administer honey and his glucose reading would rise slightly, however minutes later he would start dropping again and so the cycle would go on (for a couple of hours).

We wonder whether this could be a 'spluttering pancreas' or the result of the 'Somogyi effect'. We have not seen anything anywhere near this dramatic up to now.

Advice on dosing would be appreciated as we are now testing him almost hourly and dont feel happy leaving him for any time at all. A flat day today probably means some dramatic lows tomorrow. We have recently reduced his dose (PZI) from 2.75 u BID to 2.5 BID but wondering if this is right. Any thoughts would be much appreciated

 

[Rachel]

It does look like you're seeing some bouncing. Those greens were really surprising...glad you caught them. As for the blues you had the other day, I saw you gave some kibble. Was it a lot? Did he come back up on his own? Has anything in the routine changed or been different...especially on those days you got lower numbers?

 

[Kate and Geoff]

When his numbers have been in the blue, generally 20 small pieces of kibble (two or so times) seems to be effective with some wet food for a longer term boost. When he has been dropping quickly into the green then kibbles don’t quite do it. Honey on a finger is the only way we can stop the drop before it goes too far.

We always plot the curve on the Prozinc squared graph paper as this really helps us understand the speed of change and visualise the steepness

I guess there is a time lag with all food although the kibbles seem quite fast acting. Trouble is you never know if you have gone too far the other way until after the event.

Routinewise nothing has really changed. He just seems to like to surprise us. We think that anything under about 8 mmol (145 mg/dl) seems to trigger a bounce

 

[Djamila]

Forgive me if I'm missing something, but I'm not sure I'm quite following this...

You referenced him being in danger, but I don't see any lower numbers on the spreadsheet. Could you direct me to which date/cycle that occurred? I see some green numbers, but it looks like you are using a human meter. We use 50 as the "take action" number for human meters, but they are still quite safe at that point and not in need of honey unless they continue to drop after being fed/steered with appropriate food. I just want to be sure I'm not missing something.

Also, you cited TID dosing, but I only see two cycles per day on your spreadsheet, and it appears that they are 12-hour cycles. Was that just a typo? Did you mean BID? Or am I reading something wrong?

If you are giving kibble or honey on green numbers, that could be contributing to the unpredictable cycles you're seeing as an influx of carbs can make them a little wonky for a few cycles afterwards. Of course sometimes a cat really is hypo and that's necessary and just has to be managed.

Are there any other pets in the home? Do they eat the same foods or different foods? Is Jack inclined towards eating human food if he can sneak it? Does he ever go outside?

 

[Kate and Geoff]

Hi Djamila, firstly sorry it was a typo as it is BID not TID.

Thank you for looking at this for us. We have added a bit more detail as it may be useful

It was the evening of Saturday the 9th. We measured as low as 3.4 mmol (61 mg/dl) which we know definitely isn’t a danger however it was 3 hours before his normal nadir and the speed of descent was what worried us at a rate of 2.5 mmol (45mg/dl) every 15 mins. Unfortunately the spreadsheet doesn’t show this level of detail. We were taking readings this often to see how the food, which we had given him at around 6 mmol (108 mg/dl), was working but it was having absolutely no effect on the rate of descent. We were using an Accuchek human meter as well as our Alphatrak pet meter. Both gave the same 3.4 reading.

His readings were as follows

14.7 @ 20:29
5.9 @ 21:30
3.4 @ 21:45 (42 % drop within 15 minutes)
4.9 @ 22.05
3.7 @ 22.54 (second dip)
6.5 @ 23:24

We reluctantly gave kibbles at around 4.5 mmol (81 mg/dl) and finally some honey at 3.4 (61 mg/dl). This is really not something we like doing because as you mention it will end up causing a problem down the line. Should also mention that he never has kibbles as part of normal food/diet.

Looking at the individual readings in isolation and with the benefit of hindsight they don’t look that bad at all, but at the time the rapid drop showed no signs of bottoming out or slowing, despite intervention. Have added a clip from his graph below in case helpful . The black line is daytime and red is nighttime

We don’t have any other pets in the house and we definitely don’t leave human food around in case he helps himself. He did go outside and had a run about at around lunchtime as the weather was good, however we never let him out of our sight for a moment and his cat flap is permanently locked these days (outward only but would let him in if he escaped)

Thank you again for your thoughts

 

[Elizabeth and Bertie]

It was the evening of Saturday the 9th. We measured as low as 3.4 mmol (61 mg/dl) which we know definitely isn’t a danger however it was 3 hours before his normal nadir and the speed of descent was what worried us at a rate of 2.5 mmol (45mg/dl) every 15 mins. Unfortunately the spreadsheet doesn’t show this level of detail. We were taking readings this often to see how the food, which we had given him at around 6 mmol (108 mg/dl), was working but it was having absolutely no effect on the rate of descent. We were using an Accuchek human meter as well as our Alphatrak pet meter. Both gave the same 3.4 reading.

His readings were as follows

14.7 @ 20:29
5.9 @ 21:30
3.4 @ 21:45 (42 % drop within 15 minutes)
4.9 @ 22.05
3.7 @ 22.54 (second dip)
6.5 @ 23:24

That must have been very scary to see that steep drop. (((Hugs))) ...And given the point where you saw those numbers in the cycle I'd probably have done exactly what you did in giving some honey or glucose. Better safe than sorry....
I've actually used small amounts of glucose a number of times in Bertie over the years, and have found that one can get quite precise with administering it. I've found that small amounts have been helpful in steering my cat away from numbers that are potentially too low, and in his case it leaves the system fairly quickly, often not even altering the overall pattern of the curve.

A couple of thoughts...
Regarding lower numbers; while technically the lower numbers we see may be above the oft stated 'take action' number, it is also the case that: 'It's not what the number is, it's where it's headed'.
If you see a low number (or the numbers are threatening to drop low) and there is still some time to go until the (expected) peak of the cycle it may be appropriate to take action to slow or stop the drop in blood glucose.
If you see a low number at the (expected) peak of the cycle, that may be just fine.

Regarding kibble, the difficulty with this is that it can cause the blood glucose to stay high for quite some time. Apparently it can still be affecting blood glucose up to 24 hours or more after being eaten (depending on the carb content). It takes longer for cats to clear carbs from their bodies.
Simple sugars like honey and glucose tend to work fast and be out of the system in a relatively short space of time.
Complex carbs, like those in kibble, tend to act more slowly (usually) but then last longer in the system.
But as with all things to do with feline diabetes, 'your mileage may vary'...

Another thought about your kitty's steep blood glucose drop... Steep drops in blood glucose can trigger bouncing even if the number the kitty drops to isn't actually threatening. It's been observed here over the years that drops of around 5 - 5.5mmol or more per hour can trigger a bounce. So, for that reason alone - especially if a kitty is prone to bouncing - it can be helpful to slow down a steep drop in blood glucose.

....Looking at your kitty's SS, Kate, there seems to be a history of sudden dips in blood glucose, and then high numbers. Have you considered trying another insulin, such as Levemir, for example? Would your vet be willing to prescribe an alternative to Prozinc..?

Eliz