looking for advice re possibly changing dosing

[Michele & Theo]

My Theo was diagnosed in January 2019. He started out at 1.5u Prozinc 2x per day, but my Vet slowly increased it to 3.5 u in the morning and 3 units in the evening. Although there has been a small improvement in the average AM and PM readings, I feel that they are still way too high. In the past few weeks, there have been 4 incidences where his level was in the 'normal' range and hence no shot given. His levels are swinging quite a bit (for eg, today's AMPS he was 17.1 mmol/L (308 mg/dL) at +6.5 hr he was 7 mmol/L (126 mg/dL) and at PMPS he was 27.9 mmol/L (501 mg/dL). I faithfully take his BG levels before his insulin injections (see his spreadsheet. I plan on doing another curve this weekend or early next week (I had planned on doing one this week, but was recovering from bronchitis/flu).

There has been no improvement in his neuropathy (even with the compounded Zobaline), but I'm thinking this is because his BG levels are not stabilized.

Any thoughts/advice re current dosing regime would be very helpful I am wondering if the morning 3.5u might be too high or the evening one needs to be upped to 3.5u????

thanks in advance.
Michele

 

[Jenna Josie]

Hi Michele, and welcome! *Great* job getting all those pre-shot numbers! Testing is the hard part when beginning this journey, so very well done!

I have a couple of questions . . . you're doing such a great job with the notes, documenting how much he's eating, but I wonder *what* Theo is eating? It looks like you maybe just tried a low carb wet food in the last couple of days? If he's typically eating a higher-carb food normally (and, unfortunately, much of the vet-prescribed food is in fact quite high carb), that may be contributing to the higher than comfortable PS numbers.

Second, it would be super-helpful if you could get at least a few mid-day numbers (I know you said you're planning to and that you've been sick -- hope you're feeling better!). We consider dosing based on the nadir -- the lowest point in the cycle -- which can vary from cat to cat but which is usually somewhere between +4 hours after the injection and +7 hours after. Without that data, it's not possible to tell if the dose is too high or not high enough.

For example, my guess is that Theo's yucky black pre-shot number this evening was due to his low (for him ) mid-day; i.e., he is "bouncing" in reaction to that low'ish mid-day. If we were just to see that number without knowing that the mid-day was quite good, we might think upping the dose would be the right decision . . . but it very well may not be and would instead lead to a higher bounce.

Getting that information would be very helpful to address your dosing questions.

 

[Michele & Theo]

Hi Michele, and welcome! *Great* job getting all those pre-shot numbers! Testing is the hard part when beginning this journey, so very well done!

I have a couple of questions . . . you're doing such a great job with the notes, documenting how much he's eating, but I wonder *what* Theo is eating? It looks like you maybe just tried a low carb wet food in the last couple of days? If he's typically eating a higher-carb food normally (and, unfortunately, much of the vet-prescribed food is in fact quite high carb), that may be contributing to the higher than comfortable PS numbers.

Second, it would be super-helpful if you could get at least a few mid-day numbers (I know you said you're planning to and that you've been sick -- hope you're feeling better!). We consider dosing based on the nadir -- the lowest point in the cycle -- which can vary from cat to cat but which is usually somewhere between +4 hours after the injection and +7 hours after. Without that data, it's not possible to tell if the dose is too high or not high enough.

For example, my guess is that Theo's yucky black pre-shot number this evening was due to his low (for him ) mid-day; i.e., he is "bouncing" in reaction to that low'ish mid-day. If we were just to see that number without knowing that the mid-day was quite good, we might think upping the dose would be the right decision . . . but it very well may not be and would instead lead to a higher bounce.

Getting that information would be very helpful to address your dosing questions.

Hi Jenna
Thanks for the response. Luckily Theo doesn't really mind the BG testing (and my Vet commended me on the fact that his ears were not in tatters due to all the testing) although he does not like getting his insulin shot (I have to wrap his head in a towel).

Re food, he eat the Purina ProPlan DM Savory Selects Dietetic management food... usually 2 cans a day (1can/meal) and his treat is the DM kibble (a palmful). I do have a problem in that he will only eat certain lots of the dm wet food... other lots he walks away from, not even tasting it (I think we've figured out what the lot/manufacturing plant is for the one he will eat). Last week we went thru cans in 4 different cases trying to find the lot he will eat; Purina is also trying to help us figure out the problem since there has been no formulation changes since 2012. He will not eat any pate nor does he like the general flavours such as beef, chicken, etc. The only commercially available food I found that he will eat is a Fancy Feast flaked fish & shrimp mix. If I'm really stuck with him not eating (because he doesn't like what's offered), he will eat canned tuna. I will also note that he is a nibbler when he eats... he comes back many times over a few hours to complete a meal.

I will definitely be taking some midday readings and doing a curve this coming week to see what is happening. I kind of wish I had been able to do a midday one today (I was out of the house for the afternoon) as again he spiked out high at the PM reading (a reading of 'HI' on the glucometer... twice tested) from a decent 17.6 mmol/L for his AMPS reading. He is eating as normal after his PM shot. He was a bit quieter today as compared to yesterday, but not what I would call lethargic.

I will let you know when I get the curve done although I plan on raking a midday test daily when I'm home.
Michele

Michele

 

[Jenna Josie]

Is it at all possible to get him off the dry food? I know you are just giving it to him (he is so beautiful, btw!) for treats, but that stuff may be like giving him a palmful of sugar cookies — the only purina dry on Dr Lisa’s chart is the DH (that’s different than the dry you give him?), which is 33% carbs! https://catinfo.org/chart/index.php The DM savory selects is at the high end of what we recommend for diabetic kitties (all kitties, really) at 10% but it sounds like he’s as picky as he is handsome, so maybe try a low carb treat in place of the dry and see what that brings. (It would be interesting to see if the days he got a lot of kibble correlate to the cycles he had a high PS?)

For low carb treats, Djamila taught us about these minnows, and Josie is crazy for them. (The ones for cats and for dogs are exactly the same, but the cat ones cost more for a smaller bag, go figure. ). And sometimes when she’s pretending she’s starving but it’s too close to shot time for food, I’ll give her a cube or two of freeze dried chicken to tide her over.

Looking forward to seeing what the curve tells us!

(Also, any sort of mid-cycle test can be helpful, even if it’s not part of a full curve or at +6 exactly. Anytime between +4 and +7 is a good range to see how the dose is impacting him, so don’t worry if you can’t get a truly “middle” midday. All data is good data!)

 

[Michele & Theo]

Is it at all possible to get him off the dry food? I know you are just giving it to him (he is so beautiful, btw!) for treats, but that stuff may be like giving him a palmful of sugar cookies — the only purina dry on Dr Lisa’s chart is the DH (that’s different than the dry you give him?), which is 33% carbs! https://catinfo.org/chart/index.php The DM savory selects is at the high end of what we recommend for diabetic kitties (all kitties, really) at 10% but it sounds like he’s as picky as he is handsome, so maybe try a low carb treat in place of the dry and see what that brings. (It would be interesting to see if the days he got a lot of kibble correlate to the cycles he had a high PS?)

For low carb treats, Djamila taught us about these minnows, and Josie is crazy for them. (The ones for cats and for dogs are exactly the same, but the cat ones cost more for a smaller bag, go figure. ). And sometimes when she’s pretending she’s starving but it’s too close to shot time for food, I’ll give her a cube or two of freeze dried chicken to tide her over.

Looking forward to seeing what the curve tells us!

(Also, any sort of mid-cycle test can be helpful, even if it’s not part of a full curve or at +6 exactly. Anytime between +4 and +7 is a good range to see how the dose is impacting him, so don’t worry if you can’t get a truly “middle” midday. All data is good data!)

Hi Jenna
Given his BG spike last night and elevated reading again this morning, I agree that the kibble is likely impacting his readings and I will go back to given him only a few kibbles at at time on the floor rather than leaving some in a bowl... as noted he is a nibbler, so the ones in the bowl are eaten over a longer time rather than a few on the floor (I use them to get out of the house as he runs to the door when he knows I'm leaving. I will look for some other freeze dried treat... I tried the minnows, but he would not have anything to do with them! I saw some freeze dried shrimp that he might like since he does eat the Fancy Feast (FF) fish and shrimp food (he had 2 cans for breakfast today). I looked on the database you provided, but that flavour of FF isn't on the list although it is on another low carb cat food list I have (79 protein; 21 fat; 0 carbs - no info on total calories). I might alternate between this one and the vet prescribed diet to see if there is any impact. This would be helpful given the issues trying to get a lot of the prescription food he will eat.
Have a good day...
Michele

 

[Djamila]

Hi Michele-

Even a few pieces of kibble can make a big difference. I would do everything you can to eliminate that as soon as possible. My cat was a total kibble addict when he was diagnosed and it was a rather painful process for us both, but so worth it in the end. It's fine to leave out wet food for Theo to graze throughout the day. I was really nervous to do that at first, but turns out that it works just fine. Adding in a couple of tablespoons of water can help so it doesn't get dried out and gross.

 

[Michele & Theo]

Is it at all possible to get him off the dry food? I know you are just giving it to him (he is so beautiful, btw!) for treats, but that stuff may be like giving him a palmful of sugar cookies — the only purina dry on Dr Lisa’s chart is the DH (that’s different than the dry you give him?), which is 33% carbs! https://catinfo.org/chart/index.php The DM savory selects is at the high end of what we recommend for diabetic kitties (all kitties, really) at 10% but it sounds like he’s as picky as he is handsome, so maybe try a low carb treat in place of the dry and see what that brings. (It would be interesting to see if the days he got a lot of kibble correlate to the cycles he had a high PS?)

For low carb treats, Djamila taught us about these minnows, and Josie is crazy for them. (The ones for cats and for dogs are exactly the same, but the cat ones cost more for a smaller bag, go figure. ). And sometimes when she’s pretending she’s starving but it’s too close to shot time for food, I’ll give her a cube or two of freeze dried chicken to tide her over.

Looking forward to seeing what the curve tells us!

(Also, any sort of mid-cycle test can be helpful, even if it’s not part of a full curve or at +6 exactly. Anytime between +4 and +7 is a good range to see how the dose is impacting him, so don’t worry if you can’t get a truly “middle” midday. All data is good data!)

Hi Jenna
I did some midday readings yesterday and 1 so far today (will do another later this aft when I get back from an appt). Want to have a look... the one I just did has him at 3.3 mmol/L from a stating point of 14.5 fat the AMPS. I'm thinking the 3.5 may be too much if his starting level is that low. I gave him some more food after this last reading as I will be out of the house for a couple of hours. He isn't showing any indication of going hypo as of now. Still plan on doing a curve this week, but I keep having to go out for part of the day.
Re kibble, I will stay away from them. I know he doesn't like the freeze dried minnows (tried them before) so yesterday i got him freeze dried shrimp since he eats shrimp in his canned food..... nope, won't eat them! Will try another flavor.
Let me know what you think of the latest readings

 

[Jenna Josie]

Wow — is that “off kibble”? That’s a big drop — about 75% — and into some very pretty greens!

Yes, I would think 3.5 is too much, though I’d base that more on the nadir than on the PS number. That is, we dose based more on the nadir (low point in the 12 hour cycle) than on the pre-shot number, which is really to be sure that kitty is high enough to shoot.

When is your shot time, and which time zone are you in? If this is an indication of where his off-kibble numbers are headed (and it can take a bit to clear that extra sugar out of his system), I would be very thoughtful before deciding on how much to lower the dose.

Honestly, though, I don’t have any experience with adjusting a dose after going off kibble, so I’m not sure what help I can be My instinct would be to back off quite a bit and watch him carefully (getting at least a +3) to see where the cycle is heading.

Tagging @Djamila @Rachel @Kris & Teasel to see f they might weigh in on thoughts about dose reduction for newly-off kibble/first time greens.

 

[Michele & Theo]

Wow — is that “off kibble”? That’s a big drop — about 75% — and into some very pretty greens!

Yes, I would think 3.5 is too much, though I’d base that more on the nadir than on the PS number. That is, we dose based more on the nadir (low point in the 12 hour cycle) than on the pre-shot number, which is really to be sure that kitty is high enough to shoot.

When is your shot time, and which time zone are you in? If this is an indication of where his off-kibble numbers are headed (and it can take a bit to clear that extra sugar out of his system), I would be very thoughtful before deciding on how much to lower the dose.

Honestly, though, I don’t have any experience with adjusting a dose after going off kibble, so I’m not sure what help I can be My instinct would be to back off quite a bit and watch him carefully (getting at least a +3) to see where the cycle is heading.

Tagging @Djamila @Rachel @Kris & Teasel to see f they might weigh in on thoughts about dose reduction for newly-off kibble/first time greens.

I'm in Ottawa, Canada... Eastern standard time zone. His next shot is in about 1/2 hour so we'll see if he went high enough to shoot, but he's surprised me before.. these days I just don't know what levels to expect. If all goes well tomorrow I will be doing the 12 hour curve. After that will be talking to my vet to discuss the dosing. I find it scarier to see his numbers that low (worried about going hypo) than at a constantly higher value... He may also have another UTI so may need another shot of antibiotics.

 

[Jenna Josie]

I see his PS is 169! That's a great number, but not so great for coming up with a dose. What are you thinking about or were you thinking about skipping?

 

[Djamila]

Why did your vet recommend giving two different doses?

He didn't go too low today, although he was certainly working the insulin. And if that is unusual for him (there isn't a lot of data to go off of here, but my hunch is this was unusual), then he will likely run high tonight, so I wouldn't reduce the dose tonight (assuming he's high enough to shoot).

It's good that you'll be keeping a close eye on the numbers over the next few days as the absence of the kibble may reduce his insulin need fairly quickly. Again kind of guessing, but I don't think he's been getting enough insulin for his needs, so you may not need to lower the dose, you might just need start seeing better numbers.

 

[Djamila]

Just saw Jenna's post -- I would not recommend skipping, although I can understand that what I'm going to say might make you really nervous -- but Theo has been running in high numbers for quite awhile. I would recommend that you give him a half dose tonight.

I know hypos are scary, but if you don't give him any insulin, and after going lower than usual today, he will most likely run really high tonight if he doesn't get any insulin.

Can you stall for about a half hour, and then test again and see if he's rising? That might make the idea of giving him some insulin tonight less scary.

 

[Jenna Josie]

Just saw Jenna's post -- I would not recommend skipping, although I can understand that what I'm going to say might make you really nervous -- but Theo has been running in high numbers for quite awhile. I would recommend that you give him a half dose tonight.

Yes, I wouldn't recommend skipping either. My thoughts wavering between one and two units . . . I like the splitting the difference with the half dose!

 

[Michele & Theo]

I see his PS is 169! That's a great number, but not so great for coming up with a dose. What are you thinking about or were you thinking about skipping?

Hi Jenna... my Vet told me not to shoot if his levels were below 12 mmol/L (or 216 mg/dL). This was confirmed by the emergency Vet after one of the earlier times. There was also a discussion around giving him 1/2 of the regular dose, but that was when his values were always high at the 0 and +12. Now that his avg morning and afternoon levels seem to be lower, I'm hesitant to give him 1/2 dose since he seems to have such a steep drop in BG levels. Definitely something to talk to the vet about.

 

[Michele & Theo]

Just saw Jenna's post -- I would not recommend skipping, although I can understand that what I'm going to say might make you really nervous -- but Theo has been running in high numbers for quite awhile. I would recommend that you give him a half dose tonight.

I know hypos are scary, but if you don't give him any insulin, and after going lower than usual today, he will most likely run really high tonight if he doesn't get any insulin.

Can you stall for about a half hour, and then test again and see if he's rising? That might make the idea of giving him some insulin tonight less scary.

Ok, I will test in about 1/2 hour and if he is rising give him 1/2 dose (1.5u).

 

[Michele & Theo]

Yes, I wouldn't recommend skipping either. My thoughts wavering between one and two units . . . I like the splitting the difference with the half dose!

Hi... his PMPS +1hr was 19.1 mmol/L (344mg/dL) so I gave him 1.5u rather than his normal 3. We'll see what the morning brings.
Thanks for your help.
Michele

 

[Jenna Josie]

He came up fast there at the end, didn't he? Hoping he settles in . . .

 

[Michele & Theo]

@Jenna Josie @Djamila
Well, I finally got the full BG curve done today. Needless to say, Theo is not happy with me given all the testing over the last few days. He starts running when he sees me with the towel
I'm a bit confused as the curve looks different from previous ones. Maybe he is finally adapting. thoughts???
I will be sending this to my vet as well for his input.
Michele

 

[Jenna Josie]

That’s a beautiful curve! Just like a ProZinc curve is supposed to look. Very smiley.

From today and two days ago, it looks like he drops about 75%, which is a big drop ( we hope for 50%), but it didn’t bring him anywhere near dangerous, so that’s all right.

I wonder what would happen were you to keep consistent AM and PM doses? I see that your vet recommended that, but I don’t know why? It’s true that a lot of cats run lower at night, but again, he’s nowhere near a dangerous level, and consistency is very important. Just something to think/ ask about ...

 

[Michele & Theo]

That’s a beautiful curve! Just like a ProZinc curve is supposed to look. Very smiley.

From today and two days ago, it looks like he drops about 75%, which is a big drop ( we hope for 50%), but it didn’t bring him anywhere near dangerous, so that’s all right.

I wonder what would happen were you to keep consistent AM and PM doses? I see that your vet recommended that, but I don’t know why? It’s true that a lot of cats run lower at night, but again, he’s nowhere near a dangerous level, and consistency is very important. Just something to think/ ask about ...

Hi Jenna
Thanks for the input. Good to hear this is what is suppose to happen. The vet had changed to two different doses as he was consistently higher at his PMPS but after the change we were getting higher AMPS. Then he started to get lower readings at various times including AM and PM readings.
Which dose (3u or 3.5u) would you see as his consistent dose? I'd like to be prepared for the discussion with him I will say, my vet is very easy and good to talk to and will ask for my input for his treatment, which I really appreciate.

tx again

 

[Jenna Josie]

Well, his numbers are too high (though still, we need to see what happens now that he’s off the kibble), so I think I’d probably go with the 3.5 and see if you can’t get him to give you some longer cycles now that the kibble won’t be interfering. Ideally, ProZinc can last 14 hours, which gives a little “overlap” between when one shot is wearing off and the next is onsetting. That’s what can bring down the preshot numbers overall and hopefully get him out of the pinks and into low yellows (or even better!) for preshots.

 

[Michele & Theo]

Well, his numbers are too high (though still, we need to see what happens now that he’s off the kibble), so I think I’d probably go with the 3.5 and see if you can’t get him to give you some longer cycles now that the kibble won’t be interfering. Ideally, ProZinc can last 14 hours, which gives a little “overlap” between when one shot is wearing off and the next is onsetting. That’s what can bring down the preshot numbers overall and hopefully get him out of the pinks and into low yellows (or even better!) for preshots.

hi Jenna....
So this morning he was at 358mg/dL and gave him his normal 3.5u... I did not do any mid day testing to give him a break, but tonight his PMPS is 158. His BG levels are all over the place these days. I will retest in about 1hr, after he eats, and if levels are around 299 or over will give his full dose of 3u. Does that sound reasonable? He had no treats today and ate his one can of the DM dietetic food this morning.

I was planning on starting the PM dose at 3.5u to match the morning dose, but he isn't in a 'normal' curve right now. My vet is away until Monday and will speak with him then.

 

[Jenna Josie]

Hi Michele. His BGs *are* all over the place, and I still think he could benefit from consistent AM and PM doses. But as we say around here, you hold the syringe, so if you feel better waiting until you can talk with Theo's vet, I totally get it!

One word about "stalling": the normal protocol is to wait 20-30 minutes without feeding and then re-test to see if his numbers are on the way up. This is so that you can tell if they are truly on their way up on their own; i.e., without being food-influenced.

I do have to wonder if the no-treats day contributed to his lovely blue PMPS!

 

[Michele & Theo]

Hi Michele. His BGs *are* all over the place, and I still think he could benefit from consistent AM and PM doses. But as we say around here, you hold the syringe, so if you feel better waiting until you can talk with Theo's vet, I totally get it!

One word about "stalling": the normal protocol is to wait 20-30 minutes without feeding and then re-test to see if his numbers are on the way up. This is so that you can tell if they are truly on their way up on their own; i.e., without being food-influenced.

I do have to wonder if the no-treats day contributed to his lovely blue PMPS!

thanks... I did give him a bit more than 3u (not quite 3.5) as he was 394 after eating (~1hr after). I was not planning on waiting to speak to the vetm to increase the PM dose to 3.5u, but this low PMPS threw me for a loop...

Thanks for the info re the 'stalling'. I had been told by the emergency vet to feed then retest and shoot if retest after 1hr was higher/raising, but you're explanation makes total sense and more appropriate as I know food makes the BG go higher. What do you do in the scenarios that he is not 'rising' or is? Asking in case I come across this given his fluctuating BGs.

thx again. You and Djamila have been a great help.

 

[Jenna Josie]

What do you do in the scenarios that he is not 'rising' or is?

Ha! I remember being soooo frustrated by this very question when Josie was first diagnosed!

If he's not rising, you can stall again and re-test in another 20 minutes. There's about an hour of wiggle room with ProZinc, so you can do the stall/retest a few times.

 

[Michele & Theo]

@Jenna Josie
HI... Thanks for this... it was very, very helpful this morning. Theos' AMPS was 126 mg/dL and subsequent testing over the next hour without feeding did not show any significant BG increase (max was 135) hence I did not give him his morning dose. This action was confirmed by the vet at the clinic when I called for advice. Interestingly today Theo is the most active, playful and chatty than I've seen in a long time. Fingers crossed he stays in this 'zone'. I will do a midday test then he PMPS check and we'll see what's happening...

 

[Jenna Josie]

Well, the bad news is that he came back up into the pinks, huh? But the (relative!) good news is that he didn't really climb much after the +6.

It could be that he just had a really long cycle last night, getting some of that nice "overlap" I was mentioning earlier in the thread.