My cat's bg keeps diving below 2.8

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Kim & Twice

Kim & Twice

Member Since 2013
Hello all. We are new to this community and new with feline diabetes. I found out near the end of August that my sweet boy, Twice, has diabetes. My vet thinks it was most likely brought on by prolonged use of prednisone to deal with a growth on his tongue. He had lost a significant amount of weight during the month long steroid tx, and they tested and confirmed he had diabetes. He was started at 2 units bid for two weeks, then 3 units bid following a glucose curve at the clinic. Finally 4 units bid two weeks after that. My vet suggested I monitor him at home on this dose for awhile as he is way too stressed when at the clinic. I did a ton of research online and got myself a glucometer. I have been tracking his progress and it is just so sporadic. I did change his diet from Hill's w/d dry to Hill's m/d wet as well as fancy feast wet for variety. His bg numbers are all over the place and often dive under 2.8mmol (yesterday as low as 1.6mmol four hours after his insulin ). When this happens I give him some dry Hills m/d and his numbers come up again. He hasn't yet shown signs of being hypo, other than the numbers, but I decided to decrease his dose this morning to 3 units. He was at 31.4mmol at 4am. When I got home at 4:30pm he was 11.6. I rechecked at 5:30pm and he was 13.3 so I fed him his soft food and gave him only 2 units. I retested every hour until 8:30 tonight and he was down to 2.8mmol. I ended up giving him some kibble because I'm worried it will keep dropping and I might be asleep. I feel like I just cant get a handle on this and I dont know what I'm doing wrong. My vet thinks 4 units is the right dose, but my gut is screaming that it is just too much with the diet change and the numbers seem to agree. Should I lower the dose even more for tomorrow morning?? I know I am rambling on....just super stressed. Thanks for reading this and any reply will be greatly appreciated.
 
Hello Kim, and welcome to FDMB!

OK, first off: You absolutely 'can' do this. You appear to be a fantastic care-giver!

Secondly, I rarely give dosing advice but I have to say that I absolutely agree with you that the insulin dosage is too high.

The normal range for a cat's blood glucose is approximately between 2.7 to 7.2 (or a smidge higher or lower in some cats). (My non-diabetics usually test at around 4 - 5 mmols). If your cat has dropped to 1.6 at four hours after the insulin shot then it is clear that the insulin dosage needs to be reduced. The 'all over the place' numbers you seem to be seeing could well be caused by your cat's body responding to the very low numbers by pushing glucose (from the liver) out into the cat's system in order to raise the blood glucose levels as a protective measure. It's sometimes called 'rebound'. So, your cat might be dropping low and then rebounding over and over again. The varying numbers could also be affected by the varying mix of dry and wet food. Dry food can elevate blood glucose levels enormously, so reducing/stopping dry food can lower blood glucose levels, in some cases significantly.

Is your cat off the steroids now? It could well be that your cat's diabetes was caused by the steroids, is 'transitory', and could go into remission after a short course of insulin. (Remission means that the diabetes is diet-controlled). (Actually, I wonder what his blood glucose levels would be like if you held off on the insulin and fed only low carb wet food....? (I'm not suggesting you do this; just 'thinking out loud'...))

What insulin are you using, Kim?

Elizabeth

PS. I apologise for the brevity of this post as I think there is a lot more to say here but I'm dashing out. Others will be online very soon. :smile:
 
If its going too low, its too much insulin! Read over the following, then ask questions.

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}
- the lowest level pre-shot for ProZinc, PZI, or other non-depot insulins.

> 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 mid-cycle 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.
 
Please let us know which insulin you are using.
It sounds like 3u might be too much. And 4u definitely sounds too high.

Two units may or may not be, depending on which insulin it is.
 
Thank you everyone for your replies. This is my first time on a message board of any type, and I realize this will sound sappy, but your replies to my post made me feel so much less alone, and for the first time in all this I feel a bit of a weight off my chest. I am very grateful.
Twice has been off the steroids for about 2 months, and he is on Caninsulin. I gave him only 1 unit this am as he was at 23.9mmol, as I am not sure at what point in his curve last night he hit the 2.8 (was it going to drop more...) and I was afraid he would go even lower while I was away today, so thought maybe a lower dose would be safer. I just got home from work and checked him again and he is at 25.3mmol. He is ready to be fed and I will just give him the 1 unit again this time so I can chart what is happening. Would this be a reasonable way to go about things? I understand from my readings that the results can vary from day to day and that Twice would need to maintain a dose level for awhile to get a more accurate picture about what is going on overall. I just hope that dropping all the way back down to 1 unit isn't going to be too low of a dose. I am just afraid that the 2 units will see his numbers going below 2.8mmol, and quite frankly, that scares me. All that being said...I think his being at 25.3 right now is pretty high, but could that be a result of my tampering? Maybe he does just need to get used to a lower dosage?
I realize that this is hard to read/understand....my thoughts are very disorganized right now which is reflecting strongly in my writing.

Kim
 
I should mention his demeanor. He seems a bit crazed, ravenously hungry, and has drank more water than he has been lately at the higher dose.
 
He can be ravenously hungry from both too much and too little insulin.
- With too much insulin, the hunger is to keep from going too low.
- With too little insulin, the glucose can't be used, and the hunger is an attempt to fix that, although it is unsuccessful without insulin.
- It can be a side effect of steroids, too.

When a diabetic goes to an unaccustomed lower glucose level, the body reacts to compensate and hormones release a form of stored sugar into the body, raising the glucose level. This bounce back up may take a day or so to clear and let the glucose level settle back down.

Fortunately, Caninsulin is an in and out insulin, so each shot is a fresh start.
 
Hi BJM. Thanks for your reply. I gave Twice the 1 unit at about 5pm with his soft food feeding. At +1 he was 25.4 and at +2 he is 20.3mmol. This is the slowest his numbers have declined so far. I was seeing very fast drops at 4 units (ex. 28.9 down to 6.6mmol at +2). Should I stick at the 1 unit dose for awhile?
 
Caninsulin can be a little harder to work with when treating a cat (as opposed to a dog) because cats metabolize insulin about twice as fast as dogs do. It think it is common that you see "early" drops in BG with caninsulin, and in most kitties, it doesn't seem to last a full 12 hours between doses. But it's what you have to work with right now.

When you have been seeing the tests in the 3.0 range or lower, have they been happening early in the cycles?
 
The big drops happen between 2-4 hours after insulin. If they would go lower still I have no idea because after 2.8 I have been intervening.
 
OK, that's actually a "good thing", and great that you have been able to catch the low numbers when they have happened. :-D

Have you seen the " Vetsulin/Caninsulin user's guide" here?:

http://www.felinediabetes.com/FDMB/viewtopic.php?f=19&t=302

I am not sure what your feeding schedule is. But one thing suggested is that you split the shot-time meal into two portions.
You feed 2/3 of "breakfast" about 20-30 minutes prior to giving the shot. So you would test pre-feeding to get the fasting BG number, then feed 2/3 of a normal meal. 20-30 minutes after Twice is done eating, you would give the shot. Then, around 1.5 to 2 hours after the shot, you'd feed the last 1/3 of the meal.

This accomplishes two things.
1 - you make sure that he eats well, then you know it's ok to give the shot. Caninsulin is supposed to start kicking in around 2 hours after the shot.
2 - When you feed a little more food at 1.5 to 2 hours after the shot, you are putting a "buffer" in place. That 2nd snack will try to raise the BG right about the time the insulin starts trying to push it down. It can stop the sharp drops at +2 or earlier that you've been seeing, and make the curve less severe, and more gradual.

I never used caninsulin, but from the reading I've done, it can be helpful to use the food and the insulin "in concert" with each other and enable you to "shape" the pattern of the BG numbers.

As others mentioned, steep or deep drops in BG can cause an instinctive reaction in his system where stored "sugars" are released by his liver when his body senses that his BG has fallen too far too fast. We call it "bouncing", and the end result is higher BGs later on in the cycle than you might see if his numbers didn't drop so low.

Breaking the meals up to work along with the way this insulin works might allow you to give a dose higher than 1u without putting him at risk when you can be around to monitor.
 
Thank you for the advice and resource Carl. Looks like I have some homework to do, lol! Twice is now +4 at 12.6mmol and looks a lot more comfortable than he did earlier. With the help of all you good people, I may just get a handle on this yet, without sacrificing Twice's sanity and patience in me!
 
Twice is now +4 at 12.6mmol and looks a lot more comfortable than he did earlier.
Click to expand...

To recap the evening.

PMPS ~ 25.3 (455) gave 1 unit
+1 ~ 25.4 (459)
+2 ~ 20.3 (365)
+4 ~ 12.6 (226)

Great info to know. So 1 unit, over four hours, basically cut his BG in half. That's not bad. Naturally, you would like all of the numbers to be lower, but 1 unit pushed it down about 230 points, which is good. And if this is nadir (which is supposed to happen around +4 or +5 with caninsulin), a number like 226 shouldn't cause much (if any) of a "bounce" because it wasn't a drastic drop in numbers.
 
Hi Kim,

I started out on Caninsulin with Bertie and so do have some experience of this insulin. As Carl says, with Caninsulin the insulin peak (ie when the insulin has it's strongest effect and the blood glucose is at it's lowest ('nadir')) seems to often happen around 4 - 5 hours after the insulin shot (but there are always exceptions!). In our case Bertie's lowest number was usually about 4.5 hours after the shot.

Cats' blood glucose levels can 'bounce' because they drop too low, OR too fast. "Too low" can mean either that the blood glucose level is potentially dangerously low (ie. hypoglycemic levels) OR that it is just too low for the cat's comfort (cats who have been diabetic for a while can get used to higher blood glucose levels and this can reset the body's idea of what is 'normal' or 'comfortable'). "Too fast" means that the drop happens sufficiently quickly for the body to sense danger that the blood glucose might drop too low. Sometimes the blood glucose drops too low AND too fast. As regards 'too fast', I've read on this site that a drop of around 5.5mmols per hour can trigger a bounce. In Bert's case it takes a drop of over 6mmols per hour. But I'm guessing that 'every cat might be different' in this regard.

When we were using Caninsulin we did as Carl suggested (he's a smart guy!) and fed a snack a couple of hours after the insulin shot. This acted as a buffer and slowed the blood glucose drop down a tad. In many cases this was enough to stop the blood glucose dropping too low (or too fast) and could prevent a 'bounce' from happening. I have the good fortune to work from home, but most people don't, and so for those folks who are out of the house most of the day it may be possible to have a timed feeder set to give a snack at an appropriate time. If I was out all day and it was still 'early days' in my cat's feline diabetes history - and this is only my personal opinion - I would give a reduced dose if I wasn't going to be around to monitor blood glucose levels.

Kim, I can feel it 'in my bones' that you are going to do just fine with this. And Twice is one very lucky cat to have you care for him. :smile:

Please, please do post here as often as you need to with any questions or concerns that you may have. You are part of this FDMB family now. And we are here for ya! ;-)

Eliz
 
Thank you Carl and Elizabeth! I just got home from work and checked Twice. He was at 23.9 so I fed him and gave him the 1 unit. I was relieved to see it wasn't higher, but I do realize this is still too high. I'm going to check him every couple hours tonight and try to stay up late enough to get a +6 reading....
Question: If I leave him on 1 unit for a week or two, would his numbers start to go down (assuming it is the right insulin and the correct dose he needs)? I have tried to find some pictures of other kitty curves online, to get a feeling for what they start out like and how they progress, but not enough was out there to be found.

Kim
 
He may 'settle' into a dose somewhat. You're using a non-depot insulin, so you'll need to learn your cat and how the insulin works at different levels. ECID = every cat is different! (And they like to surprise us!)
 
Kim,
If you look at most people's signatures, they have a link to their cat's BG data spreadsheets in them. They might be a bit confusing at first until you get used to how they are done, but we can help explain them. We can even help set you up with one for Twice. :smile:
 
Thank you both for the replies. Here is last nights bg's: pmps 23.9mmol-fed and gave 1 unit. +2-10.6mmol, +4-8.4mmol, +6-10.7mmol. I wish I could have gotten more data to see how long he stayed in the happier zone. Today's amps he was back up to 25.8mmol Thoughts?

Yes I would love to learn to do a spreadsheet please!!!
 
Heres spreadsheet instructions http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207

Take a look and give it a go - if you run into difficulty let us know and we can help you set it up.

Also ask your vet about the insulin called Lantus - since you are in Canada you can get it in any pharmacy (including walmart and costco $99 for 6 months worth) without a prescription. Its a better insulin for cats, easier to manage and better chance of remission. We can provide papers that support this.

Also if you want to save money you might want to change to Fancy feast pates or friskies pates. Just as good for diabetes but more palatable and cheaper.

Wendy
 
Kim & Twice said:
...Here is last nights bg's: pmps 23.9mmol-fed and gave 1 unit. +2-10.6mmol, +4-8.4mmol, +6-10.7mmol. I wish I could have gotten more data to see how long he stayed in the happier zone. Today's amps he was back up to 25.8mmol Thoughts?
Click to expand...

Hi Kim,

In many cats (I expect there are exceptions!) Caninsulin only has a short duration, and it can be out of the system in around 8 hours; so after that the blood glucose will rise because there is no insulin in the system to control it. This may be what is happening in your cat, and is one of the things that can make Caninsulin one of the harder insulins to work with.

As Wendy suggests, if Caninsulin isn't working for your kitty then it may well be worth trying a longer lasting insulin such as Lantus, for example. There are many folks on this forum who use Lantus, so you'd get lots of help with this.

Edited to add: Kim, I've read your other post and see that you also have access to PZI (and also Levemir?) If that's the case then you truly are spoilt for choice if Caninsulin isn't working for you!

Eliz
 
Thanks ladies. I just (finally) think I figured out the SS and attached it to my sig. Been studying up on Lantus...Lots to learn...but it looks like it's maybe something that needs a stay at home mom?? Still reading through information tho.
 
Hi Kim,

Well done for doing the SS! (That's something I've never ever worked out how to do!!!! :lol: )

And there are some interesting numbers in there too. On the mornings of the 8th and 9th of Oct Twice's blood glucose was in normal numbers. It's highly unlikely that there would have been any Caninsulin in his system at that point so it's very possible that Twice was producing some insulin of his own! Sometimes, when the pancreas starts to work again it works intermittently (producing bits of insulin here and there) and it may be that this is happening with Twice. This, if it is the case, could be another piece of the puzzle in the eratic numbers you've been seeing. His numbers were pretty good on the evenings of 8th and 9th Oct too.

Sometimes the injected insulin drops the blood glucose and then the cat's own body can sort of 'pick up the ball and run with it' for a while. Then, when the insulin is no longer present (either injected insulin or the cat's own insulin) the blood glucose will scoot up again.

Regarding the amount of testing needed, well, 'you can do what you can do'. All of us have lives, and many folks here are out to work in the day (or night). Some of us are lucky enough to work from home and so testing is much easier. The most important tests to do are those immediately prior to the shots. The other tests you routinely do will depend on your schedule. And I see (from your other post) that you have quite a range of insulins available to you, So I'm sure you will find an insulin and a strategy that works for you and Twice. :smile:

Eliz
 
With any insulin ( including Caninsulin and Lantus) I would recommend 3-4 tests a day depending on your schedule. Many people here have day jobs, so its just a case of making the timing work for you- see below! i wouldnt let this put you off Lantus - you need to test just as much with Caninsulin - if not more because its a harsher insulin!

- always before the shot - this is mandatory as you don't want to shoot when too low. As a newbie this too low number is 200 but is reduced over time once you have the data to know if its safe.
- mid cycle - 5-7 hours after morning shot depending on your schedule. This is to see how low he is going. The low point "nadir" is what you base dose changes on since you don't want him dropping too low (under 50). If you work during the day , set the occasional alarm for night, and get this at the weekends
- before bed (2-3hours after Pm shot) to get an idea of what his overnight plans are. If this number is less than the pre shot test number you may want to set the alarm for a test a few hours later as this implies an active cycle.

wendy
 
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