Need advice for fine tuning dosage

ESM

ESM

Member
We (Norton and I) would be very grateful for any suggestions about fine tuning his dose of Vetsulin to try and reduce the large differences between his AMPS and PMPS. Have tried not to "chase" the numbers and have been keeping his dose within .25 units but often his numbers bounce from mid teens to mid twenties. Not sure if I have enough values on his spreadsheet but perhaps someone can see a pattern that I'm missing. In general Norton seems to be doing well (stable weight, reasonable appetite etc). Thank you for any help.
 
Have you thought about talking with your vet to see if switching to a different type of insulin would be better? He just look like he isn't regulating on it. Some of his nadir's looked good with the 2 units, but the AMPS and PMPS were still very high. A slower release/depot insulin might be better to help flatten his curves some?
 
We are very data oriented here so it's difficult to offer much in the way of opinions without some current data to look at. Your last reading on the SS is from Jan. and the pattern can change over time. I am assuming your data may be looking somewhat the same but we really need more current data to see what is going on. If you have readings from the last 2 weeks or so along with the doses you are currently giving and can plot those on your spreadsheet, we'd be happy to see if we can help you sort Norton out.
 
Thank you for your responses. The vet and I did talk about switching insulin last year but then decided to persevere with the vetsulin. It feels like we're pretty close with the 1.75 units twice a day but I was hoping to get some suggestions for a bit of a sliding scale to respond to those variabilities in his pre shot numbers. I'm considering using the U100 syringes to make adjustments finer than .25 units and am familiar with the conversion chart. Linda, I am not sure if you can see
Norton's SS for 2019 as I have all his values on there up to and including this morning. Please let me know if you're not able to see those as I might have done something wrong when I set up this new thread yesterday. Thanks from Edith
 
Edith, I am totally gobsmacked. I checked the 2019 sheet when I looked before and I didn't see any data....it was a blank sheet. Goodness knows it would have been hard not to see all that colour! There have been some funky things happening with Google sheets lately. Alas I can see it now! :rolleyes:

It looks to me like Norton may need a bit of a dose increase however, before you do that, it would be helpful if you could grab a few night time tests. Obviously you need your sleep but if you can grab a test before bed at +2, 3 or 4 hours after the night shot, it would help to fill in some of the puzzle. Kitties are notorious for going lower at night than they do during the day. Norton got down to blue the other day so I think it's worth trying to see what Norton does at night as it may help explain those high pre-shots.

The other thing that would be helpful is to grab some more tests during the day cycle. Some kitties hit peak insulin action (nadir) early and others a but later so if you make it a habit to grab a random test every day that you are available between +3 and +7, it will also help show what the Norton's pattern of action is.

Sliding scale dosing can work for some kitties but only after you have found the right dose that keeps kitty in good numbers for an optimum amount of time each day/night. Right now I think you still need to find the right dose and in order to do that, we need to figure out just how low the 1.75u is taking Norton during the cycles. Pre-shot testing tells you it is safe to give insulin however it's the mid cycle tests that will steer the dosing.

See what tests you can get in over the next couple of days and we'll revisit the dose question. I am a bit concerned that you may be looking at some glucose toxicity keeping his numbers up but I am equally concerned that he may be dipping lower than we think at night. It's also possible that Norton is one of those kitties for whom Caninsulin is just not long lasting enough and/or too fast acting to keep him from bouncing up at the end of each cycle in which case as was suggested, you might want to look at a longer lasting insulin like ProZinc, Lantus or Levemir. Not sure where you are located but if you are in the UK, your vet might be more willing to consider a change to ProZinc than the others long lasting insulins.
 
I will try to get some random tests in over the next few days, both at night and during the day. I feed Norton his main meals in conjunction with his insulin but then divide the rest of his food up and feed him snacks at +4 and +8 hours day and night. Does this significantly impact these random tests ie. can I do a daytime random at +5 for example? Thanks for your help
 
You don't have to worry about snacks given in the middle of the cycle. Continue with your usual. Just make sure your pre-shot tests are not food influenced by withholding food for at least 2 hours prior to pre-shot testing. Feeding through the cycle is better than restricting food to shot times only. Then get some random mid cycle tests anytime you can regardless of whether Norton has eaten recently or not.
 
Howdy neighbour! There are a few Canadians here although the vast majority are Americans and there are members from all over the planet as well. Best place you never wanted to be. One big happy family with a shared interest and love for felines and their well being. :D
 
I will try to do more random tests - unfortunately yesterdays +5 was a dud after he got into something he shouldn't have. That almost never happens but... I have been puzzling over the results of his fructosamine tests done last year and maybe you can help me make some sense of them. The first one (544) was done about 6 weeks after starting insulin and showed that there was no regulation and that one made sense because I hadn't started home testing and after experiencing that hypo event on his first day of insulin the dosage was dropped right back. However, the next test done just 3 weeks late at 227 as I interpreted the results from the lab seemed to show that he might be getting too much insulin and that again did not come as a surprise because his home testing showed very high numbers in the am and by pm they were too low to dose. The vet was not concerned with the result felt it was ok for him. However was agreeable to try and gradually reduce his dose to that he was able to get insulin every 12 hours. In October his home testing showed less variablity and he seemed generally doing OK but a fructosamine level was done to confirm that his dose was good. When it came back at 220, again the vet was satisfied with the result, but the idexx lab interprets the results as less than 300 may indicate - cat is in remission (we can rule that one out), may be in good control or may be experiencing prolonged hypoglycemia. It doesn't seem to indicate that there might be a need for more insulin. In trying to get more stable numbers for Norton that has been one reason I've been reluctant to try an increase along with the unexpected drop he experienced at the end of August when he was getting 2 units. Not sure if any of this is relevant now.....will try to get another random test today. Again, thanks for your help.
 
The fructosamine test is an interesting beast. It is useful for diagnosing a cat with diabetes because it can show that BG has been elevated over the past 2 to 3 weeks. The fructosamine gives you an average but once insulin is in the picture, it doesn't tell you how low kitty has been going or how high. If there have been significantly low BGs or significantly high BGs or a combination of both, the test really doesn't tell you much at all and can be misleading.

Personally I had a very interesting and confounding result. I was told my cat was well regulated. Her daily BG tests for the period covered by the test however indicated her fructosamine should have come back showing nothing better than fair control at best. Fructosamine tests can be influenced by other blood values that are not normally checked at the same time. So while the test serves to give you an average for the past 2 to 3 week period and is certainly better than no testing at all, the validity of that average really doesn't help you figure out dosing because significant lows and highs tend to cancel each other out and skew the results.

From looking at Norton's home BG testing in the weeks prior to the fructosamine tests you had done indicating Norton was in a non diabetic range or having prolonged hypoglycemia, Norton was jumping around from lovely greens all the way to very high black BGs. The question is how long each day was Norton in good BG range and was he in fact having hypoglycemic periods. It's quite possible he was going low and then bouncing back up because of the body's natural defence system that spills glucose into the bloodstream when BG drops too fast, too low or by a significant amount or to levels the cat is not used to. Caninsulin can cause significant, fast drops in BG.

The only way to figure out how Norton is doing is to get those random tests. :)
 
Norton's numbers in the random tests today showed a pretty flat curve and then at +12 he gave me an unexpected yellow. I'm never confident in how to deal with yellow PS numbers. I tend to err on the side of caution and drop his dose by .25 but even then he sometimes pops into the red the next morning. Yet another time I have not changed the dose and his AMPS reading is "in the pink". I plan to test him again randomly tonight and will see how it looks in the morning.
 
Glad to see those mid cycle tests. That is exactly what we need to figure out your furry friend and get him into some better numbers. Next time Norton gets down to the yellows, if you can monitor the cycle a bit, then go ahead and give him the full dose....no need to reduce. Let's see what he does tonight. He has been somewhat flat all day and he seems to have hit nadir later than most cats on Caninsulin. Getting tests tonight should shed a little more light on the situation. You're doing a great job! :joyful:
 
Thanks for the advice and the support. When the next yellow PS comes along and I can be around to keep an eye on him, then I will try to stay the course. For tonight, thought I'd do a random at +4 and depending on what that shows, might do another later. Have never seen him drop early in the cycle prior to +4 and when he has been in the greens it's been usually at +6 or later. Again, thanks for your help.
 
ECID (every cat is different) but a nadir at +6 with Caninsulin is not as common as a +3 to +5. One of the keys to figuring out our kitties is to know your cat and that will serve you well going forward. Just be aware that nadir doesn't always occur in the same time frame every day and can change over time. That is why we advocate random testing to get an idea of kitty's norm and their idiosyncrasies.
 
Last night was interesting and to prove the point about the nadir possibly moving about . After the +6 test seeing that the numbers were heading back up Norton and I both fell in to bed. As has been his pattern for many month now, he got
1/2 oz portion of cooked chicken breast at 0200 from our sanity-saving auto feeder. We started that because he seemed to have trouble going from his snack at +4 to the next feeding at +12. We feed him friskies chicken pate giving him a half can morning and night and a quarter can at +4 again morning and night. After we added the cooked chicken in the middle of the night and mid afternoon, he also seemed to be a bit better at holding his weight. His weight is considered healthy.
Retrospectively I'm wishing I could have tested him a couple more times later in the night to see at which point his blood sugar went so high, but I'm guessing he ran out of insulin before he ran out of food.
I'm not sure what to make of all the results we obtained in the past couple of days but am interested to hear others thoughts. Thanks from Norton and me:)
 
I've been looking at the info collected over the past couple of days as well as all the other numbers over the past year and it looks to me like Norton's response to the Caninsulin is just not at all predictable. Even in doing just his pre-shot tests the amount of variability between morning and night has been a concern but seeing the recent numbers it looks like he spends more time "out of the zone" than in it. I'm considering approaching my vet with my concerns and asking her to switch him to Prozinc. Based strictly on clinical signs he seems to be doing OK but I see long periods of time when he seems kind of dazed and disinterested. By contrast, he has short times when he's more alert and engaged and I think these are when his blood sugar is in a good range. I know that it's a crapshoot with insulin but it sounds like the Prozinc might level out his bs a bit better and maybe allow him a bit more time "in the zone". In the past my vet has indicated that she would consider Prozinc as the next option. I don't like the idea of starting all over with another insulin, but it feels like we need to do something different to get a better result. I'd appreciate feedback as I'm not entirely sure if this is my frustration talking or if this is a course of action that's reasonable. Thank you
 
It looks to me like a couple of things are in play with Norton. He is obviously getting down to some better numbers through the cycle but then bouncing back up to where he had been and sometimes higher. He seems to be hitting nadir around +5/6 hours post shot and not sitting in the lowest range long at all. Just to complicate matters Norton did stay in the yellow range for longer on the 5th of Apr. and his numbers suggested he might have had longer action that day. It's also interesting that he went into blue range on a lower dose of insulin the night of Apr. 5th. Sometimes too much insulin can look like more is needed and it's difficult to make a determination based on a couple of days of extra mid cycle testing.

He's been on Caninsulin for awhile and the higher numbers at the end of each cycles may be from an insulin duration problem in which case ProZinc would be better choice. Lantus would also be a good choice. It looks like Norton bounced up this morning from those lower blues last night. Bouncing happens when BG drops quickly, drops too low or to lower levels kitty is unaccustomed to. Norton it appears (although difficult to say given the lack of much past mid cycle testing) has been sitting in the same numbers for quite some time which could mean he has some glucose toxicity.

If he were my guy, I'd try increasing the dose to 2u as long as you can get some mid cycle tests to see if that brings him down a little more. You don't want him going too low at nadir (aim to have BG at nadir no lower than 5 to 5.6mmol). He needs to stay in the lower range numbers longer and more often to get used to them and that should lessen the bouncing with time and bring those pre-shot numbers down too.
 
Thank you very much for taking the time to check out Norton's issues so thoroughly. I'm thinking long and hard about your suggestion to try going to 2 units but my problem is that I'm so afraid of him going too low. In May and August of last year when we gave the 2 units he dropped to BS 3 and 3.5 respectively and I just thought that was too close for comfort. Additionally in May on the 2 units we ended up not being able to give any PM insulin because his preshot values were too low and we had to drop back down. As you can probably hear, am feeling a bit gun shy. I don't want to be hovering over him and feeling the need to test him constantly for fear of putting him at risk but..... would you see it as being reasonable to give him the 2 units tomorrow (I'll be around all day to do a couple of random tests) and be more conservative with the PM dose. I'm thinking if his PMPS is "in the pink" or above tonight I would give his usual 1.75 but if it's in yellow (can't imagine why it would be but he's surprised us before) I would want to drop his dose to 1.5 and either way do a BG test before bed. Again, thank you
 
The decision about what to try is entirely up to you and I can understand your concern. Norton did drop down to a low on one occasion in May and one in August last year but while those were a bit low for a cat on Caninsulin, they were not hypoglycemic readings. They also occurred last year which in the life of a diabetic whose needs change over time, is something to keep in mind (hence my suggestion of trying 2u only if you can monitor) but not necessarily indicative of what Norton might do now.

As I mentioned, switching to a longer lasting insulin less prone to dropping BG quite so fast would be a good alternative to try. You have given the Caninsulin a good run but Norton is still spending a considerable amount of time over the renal threshold (11 to 12 mmol). Have a chat with your vet and see if he/she will prescribe either ProZinc or Lantus. Lantus is even longer lasting than ProZinc and can really flatten out the cycles for some bouncy kitties. You also mentioned Norton looking "spacey" at times and that could be a side effect of the Caninsulin combined with the sharp ups and down he may be experiencing on a daily basis.
 
Thank you once again for your very thoughtful advice. You're right - those lower numbers were not dangerous and it was many months ago so I'm going to try again with the 2 units. Because I feel less confident about what happens at night I gave him 1.75 last night and tested at +4 but this morning gave 2u and I will test him a couple of times at mid cycle. I'm not able to see the vet for a few more days anyway so in the meantime I want to see how it goes giving the Caninsulin one more "shot". Still hoping to find that sweet spot:)
 
What to make of those numbers today. So different from those lovely blues in the past few days! Any insight would be appreciated cause I'm pretty much flummoxed.
 
It appears to me that Norton bounced after those beautiful blues the other day and is just now starting to come out of the bounce. Those yellows today are better than those pinks yesterday. Drops that are large (over 5 to 6 mmol) or drops that occur quickly or BG dropping to levels kitty is not used to can trigger the bouncing.
 
Thank you once again. I can appreciate what you're saying about Norton bouncing (he started bouncing the very first day the vet gave him insulin) but I'm unsure as to where to go from here. I can't keep testing him multiple times a day cause he's already becoming withdrawn and as far as trying to do a mid cycle test, I have no idea when that might be???? To make matters worse, I have to be out almost all day tomorrow. I'm thinking I'll see how tonight goes testing him at +4 and then see what his pre shot number is in the morning and then decide between the 2 u or 1.75 u.
 
You've done a fair bit of testing in the last few days and the goal is certainly NOT to make Norton into a pin cushion. If you can try to get at least one mid cycle test each cycle (before bed is good to let you have your beauty sleep ;)), scattered between +3 and +7, you will see when Norton's BG starts to drop and will catch his nadir some of the time. He seems to usually be a later nadir kitty from what he's shown the last few days and in earlier testing. We all have lives and all you can do is work around your other responsibilities/commitments. I was on my own with my girl and sometimes my plans had to trump her shots/dosing. I empathize completely.

The other thing you could try, is to lower his dose to 1.5u and see if that brings about higher or lower numbers. Too much insulin can look like too little and its hard to figure that out with just a few days of testing. If you go that route, hold the 1.5u dose for a minimum of 3 cycles unless Norton goes lower than desired (5 to 5.5 mmol). If that happens, then drop the dose down to 1.25u and repeat the process.

I would definitely speak with your vet about changing insulin to see if that works better for Norton. The best insulin for Norton is the one that works for him and you've given the Caninsulin more than a fair trial at this point in time.
 
Today we were able to get a test at +6 and for the 3rd day in a row that value has been slowly dropping. I think at this point it might be worth trying the 2 units morning and 1.75 evening for a couple of more cycles. Norton seems more like himself today whether that's from less testing or just that he feels better with these numbers....who knows. Would it be reasonable to try as above and if that shows little/no further improvement I would certainly be willing to try the 1.5 dose for a few days. The back up plan would be to speak with the vet about changing the insulin. Thank you again for your help.
 
Would you have any suggestions as to what to try in an effort to get his AMPS value down out of the red. Looking at his daytime cycle it seems the 2 u of Caninsulin is able to drop his bs considerably and his PMPS value seems to better but even with the lower dose in the evening, it's back into red by morning. Thank you for your thoughts.
 
This might be a terrible idea, but I wonder if anyone has tried to give smaller doses more times throughout the day (people that work from home or are retired maybe). Like instead of 2 normal doses - have 3 to 4 smaller doses to try to flatten the curve out. Maybe the nadir wouldn't be too low to shoot on the smaller dose but the numbers wouldn't get too high - less bouncing? Similar to a depot - as soon as one dose starts wearing off they get topped off? You'd have to be way more vigilant of hypo, but it might help the kitty have better numbers for longer...
 
I think this is a combination of a bit of a bouncing and possibly a lack of duration although that doesn't appear to be much of a problem on the day cycle. It would be easier to see what a dose is really doing if the dosing was consistent morning and night. A lot of cats go lower at night naturally and then bounce back up by AMPS and that might explain the higher AMPS readings.

I've seen folks try dosing every 8 hours rather than every 12 but it takes more monitoring and obviously is far more time restrictive for the caregiver. If duration is a problem, I think it's far easier to switch to a longer duration insulin that go for dosing 3 X daily.
 
I appreciate the responses and can see that it might be possible to get tighter control with more frequent dosing, but.....Norton barely tolerates the pre shot testing done twice a day. These last few days of increased testing have left him more
withdrawn. In terms of getting a consistent dose to see what is going on at that dose, given the results of the past few days does it seem reasonable to try 1.5 morning and evening for a couple of days. If that doesn't help to even out the PS
readings somewhat then I'm ready to move on and try another insulin.
 
Try the 1.5u for a period of 2 or 3 days but do try to get some random mid cycle tests in. I know Norton is not happy with testing but it's important to keep him safe and figure out dosing. Are you giving him a treat when you test? A little bribery sometime works wonders.
 
Yes.....the miracle of freeze dried chicken. We'll give this a try and I'll get some random tests over the weekend. Have a good weekend and thanks:)
 
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