Modified Prozinc Method

[AliceL]

I haven't been on the forums since 2023 after my cat Evie went into diabetic remission. She has recently relapsed and is back on insulin.

The second time around I am much calmer and wiser, having learned so much about FD in the last two years. I got so much invaluable help from amazing members (specifically @Suzanne & Darcy and @Shelley & Jess) on these forums when I was a newbie so I have tried to pay it back in kind by being active on the Facebook group associated with this message board. I also joined the UK FD Support Facebook group (which is aligned with my time zone) and have spent the last two years learning so much more... while also reassuring newbies, sharing my knowledge, and helping to guide others along on this FD journey.

Last time I did SLGS with a modified reduction point, this time I would like to try MPM because I do test enough and I feel confident to manage it appropriately. Evie has only recently fallen out of remission because of systemic inflammation (due to my misguided decision to change her food brand) and I feel she has a good chance of getting back into remission if I follow a more aggressive dosing protocol. I caught it quickly because we still did glucose tests and weighed her monthly: mid-Dec testing was all normal, but in the mid-Jan test she had high glucose and lost 400g in the last 4 weeks. She spent the remainder of January having bloodwork and sonars to rule out any other obvious causes - no infections, diseases, tumours, kidney and liver all fine - and finally started insulin beginning of Feb.

I've spent the last two weeks doing SLGS while I get her inflammation issues under control and we are almost there. She had developed ketones this time around because of stress and pain from the inflammation - ketones were 1.6 two weeks ago but are now down to 0.4 (she started insulin plus I adjusted food to slightly higher carb wet food and added water to every meal).

I've been reading the sticky note on Prozinc dosing methods and a few things worry me about MPM:
- collecting a +9 test in the PM cycle. I shoot 5am/5pm so I'm awake from 5am through to 9pm, and hubby manages the additional testing until 12am but then he sleeps in later in the morning. I don't think we could manage an additional 2am wake-up on this already tight schedule. Is there a way around this?
- Precision drawing of the dose. I shoot Prozinc in a 0.3ml u100 syringe which is 0,2u dose change increments at a time. I don't have calipers yet but I could get some if it is necessary.
- Subsequently dealing with Evie's inflammation. Some days are better than others in terms of inflammation which can show up as higher or lower glucose readings, nadirs all over the cycle etc. It seems to be getting more leveled out now but she is still sensitive to any small changes.

Any thoughts on all this?

 

[Suzanne & Darcy]

Hello Alice! I most certainly remember you when we got the beautiful little lady Evie into remission last time. She’s one of our great ProZinc success stories. I’m sure you remember how much work it was getting her into remission last (I mean she started earning reductions so quickly that she kept you and your husband on your toes all the time.) I feel very confident in your ability to manage this. I am sorry that she fell out of remission due to a food change. What kind of food set off the inflammation and what kind are you feeding her now? Why did you decide to change her food?

 

[Suzanne & Darcy]

I would not have a problem with you following MPM at all and using the U-100 syringes is absolutely fine because you are familiar with using the conversion for using a U-40 insulin (ProZinc) with U-100 syringes. I actually like the option to make changes in .2 increments.

As for a +9 test at night (early morning really) I would not make this a daily requirement. It is possible that, if Evie is really earning a lot of reductions you might occasionally need to get a test at that time, but most likely not unless she has extremely late nadirs. You already know that ProZinc usually onsets at about +2 for most cats. Are you finding that is true for Evie this go around? My suggestion is almost always for people to get a +2 and give the small LC snack at that time. For newbies, I usually tell them to give another snack at +4. Some people can get away with a +6 snack as well, while others need to feed most of the food a little prior to this time depending upon when their cat nadirs. What is your current feeding schedule for Evie?

 

[Suzanne & Darcy]

How does her inflammation manifest itself? Does she vomit? Refuse to eat? Have diarrhea?

 

[AliceL]

Hi Suzanne! So nice to chat with you again, I hope you've been well.

What kind of food set off the inflammation and what kind are you feeding her now? Why did you decide to change her food?

How does her inflammation manifest itself? Does she vomit? Refuse to eat? Have diarrhoea?

So much to explain here so I hope you'll bear with me. Evie held her remission quite well for the last 18 months. She continued to eat the same LC wet food diet (junky supermarket brand) that she was on when she went into remission, I tested her BG monthly and everything was going well. Over the months I became slowly aware that she was sensitive to certain proteins so I eliminated fish and beef flavours and she was thriving on eating mainly poultry flavours. I started toying with the idea that she may have mild IBD because, along with seemingly needing a somewhat hypoallergenic single protein diet, we also saw thickened intestines on sonar in 2023 plus she has FHV and is prone to other inflammation issues such as stomatitis so it all seems very likely. Despite this, I was always much more fixated on controlling her diabetes rather than thinking about IBD.

Over the months her weight slowly climbed back up to where it had been pre-diabetes, 7kg. She is quite a large breed anyway but ideally her weight should be around 6kg. Knowing that being a little chonky can trigger diabetes I decided to put her on a much better quality wet food around Oct 2024 - different brand, still low carb and mostly sticking to poultry flavours - to see if it would help to shift the weight. At first I tested BG meticulously to check it did not affect her sugars and everything seemed to be ok. I relaxed and went back to monthly tests. Mid-December her BG and weight were still fine. I went away for work overseas for 4 weeks and when I returned mid-January I noticed a whole lot of things at once - she appeared to have lost some weight, she was drinking water again, she was coughing, vomiting, redness on the gums, conjunctivitis with brown coloured gloop and the worst thing, her BG was 290. ie her body in hyperdrive and all previous issues flaring up.

I had to go back to work overseas for another two weeks so I got my husband to take her to the vet. As mentioned, they ruled out any other obvious causes for the high BG and a fructosamine test came back in the 500s. She needed to go back on insulin but I was away for another week so we decided to wait because Charlie has never shot insulin. During that week she suddenly became very ill with ketones increasing to 1.6. She stopped eating and had to go on intravenous fluids at the vet and start insulin immediately. My poor husband had a very steep learning curve in shooting insulin and subsequent monitoring while I guided him from another country. Evie went back and forth to the vet a few times that week. Sometimes they gave her a non-steroidal anti-inflammatory shot after which she would have low blood sugar where we could not shoot insulin safely or have to reduce her dose. That got me thinking that this was some sort of inflammatory cause and the only thing I changed was the food...

When I got home I did some research and found some of the new food contained shrimp as well as a higher content of organ meats which could have all contributed in various ways to raising BG and triggering her IBD, increasing inflammation and causing pain and stress, a perfect storm for coming out of diabetic remission and developing those ketones. I immediately removed all the offending flavours and now she is back on a diet of mostly that junky 4% carb supermarket brand that she did well on initially (I don't know if it is junk, it's just really cheap and some of the ingredients are vague) as well as some of the new foods (only tolerable proteins) which are slightly higher carbs at 7% to help clear the ketones. So far I have seen vast improvements in all those previously mentioned symptoms. I can't put her back on the supermarket brand full-time yet, I did that for the last few days in an attempt to try to get her curve more consistent but I checked ketones this evening and see they have increased slightly to 0.7 so back on the slightly higher carb she goes. Note, this is all wet food and all under recommended carb percentages for diabetic cats.

Long story short, I made a mistake with her food by not prioritising her other health issues when making a food change. Her inflammation was so well controlled previously almost by default while managing her diabetes so I didn't realise all of this would happen by changing her food. Plus I had a really busy work schedule overseas for the last 2-3 months so I wasn't around much to catch it until it was too late.

You already know that ProZinc usually onsets at about +2 for most cats. Are you finding that is true for Evie this go around?

Honestly difficult to say. I think while we try to get the other issues under control I'm not seeing any real consistency in her spreadsheet yet. Sometimes she has low AMPS and will go higher during a curve like I did a fur shot (but I didn't). Sometimes she has full curves in blue numbers and some days it doesn't make a budge on her yellow numbers. Sometimes her nadir is later at +7 and sometimes earlier at +3. It's all over the place really. Maybe have a look at her spreadsheet and let me know what you think?

What is your current feeding schedule for Evie?

Pretty much the same as before. Bigger feed at insulin time, smaller feeds every 2-3 hours thereafter. All BG tests during the curve are mostly at least 2hrs fasted so they aren't food influenced. Self-imposed longer fast later in the curve from around +8 to the next shot time (she is usually sleeping during afternoon nap or overnight). Two hours strict fasting pre-shot. The only thing I'm not doing is limiting her food intake, with the ketone issue I'm letting her eat as much as she asks for in an effort to stop the weight drop and reduce the ketones. That being said she is still averaging the correct amount of wet food a day for her weight bracket. So she is not really under or overeating.

 

[AliceL]

@Suzanne & Darcy I'm thinking that I'm going to continue on SLGS for now until we get a few things sorted out in preparation for MPM. I've just increased her dose by 0.2 in keeping with SLGS guidelines. Just feel so worried that sometimes her dose results in a good curve and other times it doesn't seem to do anything. I'm worried about her health and I want to get her into the greens asap but I have to deal with a few issues first:

1. Inflammation is still on and off and thus nadirs and curves are all over the place which will make tracking MPM readings difficult I think. I've ordered some lysine paste and better probiotics, hopefully these will help settle her system.

2. I'm continuing with food testing to see what she is tolerating and what she isn't. I've ordered some single-protein wet food and waiting for it to arrive.

3. My husband has been struggling with the night routine, he often leaves food out by accident or doesn't set the overnight feeder properly. Also, Evie got into our other cat's kibble last night because hubby fell asleep while feeding her. I woke up in the middle of the night, realised Evie was not in her bed, went looking for her, and found her neck deep in the kibble tub having a feast. Evie's BG is very high today as a result and she has a gloopy eye with brown discharge again. Seeing her reaction I'm starting to think it's likely that the kibble situation has happened more often lately, this could be another contributor to why Evie has come out of remission. I've been away most of the last 3 months working in the UK so I've not seen what's been going on. I don't want to assume but hubby wouldn't admit it to me anyway, he knows I am a fierce mama bear when it comes to Evie's health Anyway, he is doing his best but I need to take charge of the situation and sort out the two cat feeding situation in my household this week.

 

[Suzanne & Darcy]

This makes perfect sense!

 

[AliceL]

I'm ready to start MPM this week but I'm feeling really worried about her numbers lately.
We are not achieving good nadirs despite dose increases every week (following SLGS guidelines) and her pre-shot numbers are even higher in general than when we first started back on insulin.
I was wondering if some sustained bouncing is going on but I'm too not sure because it's very subtle - I do see a little bouncing here and there in her chart when she goes low - but overall it just seems like she is not getting enough insulin? I know too much can also look like not enough. I can't figure this out on my own. She is up to 2u from today from 1u beginning Feb.
Would really appreciate it if someone more experienced could take a look and share some thoughts?

 

[Suzanne & Darcy]

Hello, Alice. How is Evie’s inflammation in the gut doing? Do you feel like you have sorted out the food situation? How is the stomatitis? You manage this just with controlling her diet? No other supplements or meds? Does she seem to feel better to you? How is her demeanor? Eating? Playing? Going outdoors? Bowel and urine output is normal or not?

 

[Suzanne & Darcy]

Regarding the dosing: it looks like you have done everything correctly. She is not overdosed. If she was, you would have seen a time when she dropped too low if she were overdosed. You have held the doses long enough to see that she just isn’t getting enough insulin for her current needs. It was good that you increased to 2 units. I do believe that we should plow ahead with the increases every 3 days unless she starts seeing more well-defined nadirs (and lower nadirs.)

 

[Suzanne & Darcy]

The insulin just isn’t moving her numbers much at all. Most days she hardly has what we would consider a nadir. Perhaps this will not be a bad thing though really. Maybe she will have somewhat flat curves and that will, be a blessing. We will see. I know this isn’t at all what you expected. You are doing simply an amazing job of caring for Evie. That doesn’t surprise me because I know what an active caregiver you are, but I feel badly for how frustrating it is for you to not see a lot of movement in the BG numbers with each increase. We will find a breakthrough dose soon, I hope — and we have a better chance of doing that with MPM.

 

[AliceL]

Hello, Alice. How is Evie’s inflammation in the gut doing? Do you feel like you have sorted out the food situation? How is the stomatitis? You manage this just with controlling her diet? No other supplements or meds? Does she seem to feel better to you? How is her demeanor? Eating? Playing? Going outdoors? Bowel and urine output is normal or not?

Most of the symptoms have abated now but we are still dealing with a runny eye. Vet had a look and said it's not an infection. I think it's related to her FHV and the stress of having high blood sugar. Last time I noticed her FHV flareups slowly cleared up as we achieved lower BG numbers so I'm hoping that will work out the same way this time. I've been cautious about giving her supplements because they contain additives that can spike glucose and trigger her tummy issues. She seems to be doing very well on single protein food alone. Not lethargic, playing, eating well, no issues in the litterbox. Ketones have cleared. The insulin is making her coat fluffy and soft too!

I do believe that we should plow ahead with the increases every 3 days unless she starts seeing more well-defined nadirs (and lower nadirs.)

Started her on 2.2U this morning after 6 cycles/3 days on 2U. Already seeing better curves today.

Regarding the dosing: it looks like you have done everything correctly. She is not overdosed. If she was, you would have seen a time when she dropped too low if she were overdosed. You have held the doses long enough to see that she just isn’t getting enough insulin for her current needs.

how frustrating it is for you to not see a lot of movement in the BG numbers with each increase.

I thought as much, but yes it has been frustrating not seeing her react much to the insulin some days. Anyway, hopefully MPM will get us to the right dose faster now.

I've been testing +3/+5/+7 and will throw in some alternating days +2/+4/+6/+8 to track low points. She doesn't move much before +3 due to food spike at insulin time and I've been seeing her nadir is usually between +5 and +7. Do you think that will be ok for MPM or should I also do +9 as per MPM guidelines? Just wondering what the point of +9 is...

 

[Suzanne & Darcy]

Nadir at +5 today. Her numbers are a little better on this dose. You are doing great.

 

[Suzanne & Darcy]

Is this what you are talking about?

 

[Suzanne & Darcy]

It is my understanding that this is a recommendation for new people who are just beginning with ProZinc and MPM — those who don’t have much data and aren’t familiar with their cat’s patterns yet. In Evie’s case, I do not believe a +9 is necessary unless you find that she is nadiring quite late a lot of the time.

 

[AliceL]

Is this what you are talking about?

It is my understanding that this is a recommendation for new people who are just beginning with ProZinc and MPM — those who don’t have much data and aren’t familiar with their cat’s patterns yet.

Gosh, you're right. I read it right in the beginning of this process and was thinking it's still a requirement for later on in MPM. Sorry, feeling a little frazzled lately...

 

[Suzanne & Darcy]

Gosh, you're right. I read it right in the beginning of this process and was thinking it's still a requirement for later on in MPM. Sorry, feeling a little frazzled lately...

That’s very understandable!

 

[AliceL]

Unexpected big drop from 181 @+3 to 100 @+5 on the night time cycle. Not panicking but we just fed her a good sized meal of her usual food to try surf it just in case it isn’t her nadir yet. We will check her again in an hour at +6.

 

[Suzanne & Darcy]

Actually a drop of 81 in two hours isn’t bad. It should be close to nadir. You did just right by feeding LC.

 

[AliceL]

I think it was quite an unusually steep drop for her, she normally doesn’t move so much in two hours. Anyway, this morning we seem to have a huge bounce up at AMPS. The last week or so she has been going lower during night cycle than the morning cycle - not usual for Evie and not what we experienced last time. Perhaps I should be feeding a bit more along the curve at night to prevent more bouncing. What do you think?

 

[Suzanne & Darcy]

I think it was quite an unusually steep drop for her, she normally doesn’t move so much in two hours. Anyway, this morning we seem to have a huge bounce up at AMPS. The last week or so she has been going lower during night cycle than the morning cycle - not usual for Evie and not what we experienced last time. Perhaps I should be feeding a bit more along the curve at night to prevent more bouncing. What do you think?

I always encourage feeding before nadir to help smooth the cycle. LC of course, unless she’s dropping really low. I think it’s possible that her patterns may be different this go around with insulin. But we will see. You will find your way.

 

[Suzanne & Darcy]

It was good to see a more normal AMPS this morning and some blue today. Will you go ahead with the increase tomorrow? Most of her blues have been mid or above so it’s probably okay to go ahead with it. It’s also okay if you would like to wait another day before increasing.

 

[AliceL]

I did go ahead with the increase this morning. She had quite a late nadir today so I’m expecting a low PMPS today. I’m just feeling a little bummed out that we are already up to 2.4u and still no greens. It feels like the increases will never end

 

[AliceL]

The insulin has literally done nothing to her on this morning's cycle. I just feel so defeated. We have been talking about getting another bottle of insulin to see if maybe we have a defective or expired batch. No expiry date on our current bottle. It looks cloudy but no bits floating in it so I'm not sure that's it... this is just super frustrating.