? Need advice for what to do next

It's been almost a week since I increased Oliver's Vetsulin dose from 1 to 1.5 units so I thought I'd take a BG Curve today but it looks as if I've passed nadir already and I'm only at +2. I forgot to withhold food in the 2 hours prior to taking AMPS and after measuring +2 Oliver ate lunch so I'm thinking why bother with the getting anymore numbers for the curve.

I'm wondering if Vetsulin is helping enough to keep using.

Anyone have advice?

 

I'm not sure if this "picture is worth a thousand words" but here's a summary of Oliver's data (below--hope it pastes). The TREND lines (straight lines) do show a downward trend which means his urine and blood glucose are dropping, so he is moving in the right direction, albeit very slowly. But maybe this is too slow for "start low, go slow" strategy. His demeanor is back to his old self. He is no longer hiding and peeing everywhere or losing weight. He is grooming again and even had a hairball to vomit up (he hadn't done that in a long time). He's gained back at least a half pound of body weight and held onto it.

 

I wish I had advice to share . Slow here today I guess

 

It does look like it's not enough insulin. However, it would be helpful if you could get a before bed test every night so we can be sure that what you're seeing in the AM cycle isn't a bounce due to lower numbers during the PM cycle.

 

I never would have thought that low night-time BG's could be bumping the day-time numbers up! Thanks Sienne; that makes perfect sense! Back on Oct. 14, when Oliver was at 1 unit Vetsulin I ran a night-time curve and I can see the difference. I'll do it!

By the way, I'm such a wet-food newbie that I'm still learning that too. I finally found a bowl in my cupboard that Oliver can't push the food out of or get all over his ruff: a French Onion Soup bowl.

 

Nothing better than to see face in dish.

 

I do Oliver's AM cycle and my daughter takes over the PM cycle. She asked if the +2 (at midnight) would be "a before bed test". Yes? Also she wants to know for how long. A week?

 

Also, my daughter just gave me a tutorial on how to get rid of air bubbles in the insulin syringe. She is so much better at this than I am. She also sticks to the feeding schedule (no food starting 8 pm, small snack at 9:30 after PMPS, one can FF at midnight). When Oliver cries I give in and feed him, and I make Oliver exercise (running around the house) for his food. She does not.

I also pulled this picture from the data and it looks as if PMPS is more stable than AMPS. The only "blip" in the PM is when the Vetsulin increased.

 

I just took Oliver's +2 after PMPS and got 184 and am feeding 1 can FF per usual midnight DINNER.

I AM SO GLAD you told me to get bedtime numbers Sienne. I had no idea Oliver was going so low at night on the new 1.5 unit dose of Vetsulin. Your idea that this may be bouncing his daytime numbers may be correct.

I am depending on y'all to explain what I should do. Right now I'm going to stay up to get a +3 to be safe.

 

+3 sank lower to 126 so I fed RC Glycobalance dry and will stay up to get +4.

 

You're doing great! 126 is still a nice safe number! Next time, instead of going with high carb kibble, try just a couple of teaspoons of regular low carb canned. We want to (hopefully) just slow down the drop or even have it "even out" (we call this "surfing")

We usually don't intervene with high carb food until they drop below 68 on the Alpha Trak (50 on a human meter or the Libre). In those cases, you want to have some high carb food like Fancy Feast Gravy Lovers (the beef is 20% carbs). Usually just a teaspoon or two of the "gravy" part is enough to nudge them back up to a safer number. We don't like using kibble because it takes too long to break down and get into the bloodstream. If he drops too low, you want to get him back up pretty quickly. In the case of a low number, you continue testing every 20-30 minutes until you get 2-3 tests that are all heading up.

Don't fret about it though! We all freak out the first few times our cats drop too low or too quickly!

Remember...IF he drops below 90, he earns a .25 reduction in dose.

 

+4 went up slightly to 135 so I fed RC Glycobalance dry again and will stay up to get +5.

 

Thank you Chris, your kind and informative reply helped my heart to stop racing! I must admit that I should have bought some gravy FF as you said. (I'd read before tonight that I should have it on hand.) I still haven't bought a ReliOn meter either. Shame on me. I need to focus more on the big picture and stop getting stuck on details.

 

We've all been there! With China, the first time she went below 50 I didn't have any high carb food either but I had maple syrup, which I knew I could use but wasn't clear on how much to give her....so I dumped about a cup full into a bowl and gave it to her (she loved it!) Needless to say, her blood glucose went up...and up...and up

Later, I learned I was supposed to give a drop or two, not half the bottle....LOL

 

Thanks again! I needed a good laugh.

 

Hi there I’m Serryn, I’m going to keep an eye out for you and Oliver. Is +5 in around 30-40 mins?

 

Yep. In 25 minutes.

 

I’ll be watching,

 

Thank you so much! I hope you aren't losing sleep too.

 

Oliver's sleeping like a baby. Wish I didn't have to wake him in 5 minutes.

 

He's back up! 239 for +5. So I guess I don't need to take any more BG's tonight. Thank you for watching!!!

 

He’s gorgeous, not keeping me awake I’m in Australia so it’s 7pm. What time is it there?

He was quite definitive that you should get some sleep too lol

 

It's 3 AM here. Thanks again. I really appreciate your kind generosity Serryn.

 

You really want to get a before bed test every, single night. If you're daughter is getting a +2, with Vetsulin it will tell you if numbers are dropping like they did last night. Vetsulin has an early onset and nadir and it can drop numbers hard and fast which is why getting those tests is important.

Just a thought for your consideration... Would it make sense to shift Oliver's shot time to a bit earlier. 12:00 is late to be. up monitoring on a regular basis. Obviously, it depends on everyone's schedule.

There's not much you can do to "fix" bouncing. It's a normal process that ultimately will take care of itself as Oliver gets used to spending time in more normal BG numbers.

 

Thank you for taking the time to look at this and advise me. I really am grateful Sienne. You explain things very well. Glad to know "bouncing" is happening and that it's normal and that it will fix itself over time.

I hope that Vetsulin will give Oliver enough time in the normal BG range to "reset" his definition of "normal"! Other than dosing him with insulin, is there anything else I can do to help maximize that time? Does exercise or diet schedule help, for example? Or would a more frequent and smaller dose of Vetsulin help (e.g., every 6 hours)?

The vet started the 10am/10pm schedule. Can I shift by 15 minute increments every day until I get to 8 am/8 pm or should I try for a 1-hour phase shift over a week and then wait a week and do it again? Or what?

 

I'd still suggest grabbing tests

Vetsulin typically has a short duration in cats. That said, there are some cats that do OK on it, but they are the exception rather than the rule. If Oliver proves to have a typical response to Vetsulin and doesn't get long enough duration then the next step would be to consider a switch to an insulin with a longer duration in cats (Lantus, Basaglar, Levemir, Prozinc).

While I have seen some here attempt dosing every 8 hours with Vetsulin (total current amount of insulin for day stays the same but it's divided by three) it's exhausting in practice because it typically involves lots of testing and very little sleep in order to keep the cat safe. It is not a treatment method I would recommend.

I have never seen anyone attempt to give Vetsulin four times a day. I think it would be unsafe.

This is very much a matter that you need to discuss with your vet. My recommendation would be to switch to one of the longer-acting insulins mentioned above.


Mogs
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Thanks Mogs, your generously offered, well-explained information makes me such a better "Cat caregiver"!

 

As an alternative, provided Oliver's ketone-free (check via urine test) and doesn't have a history of testing positive for ketones or episodes of DKA, you could skip a dose and then give the next one at your preferred shot time and subsequent shots at 12-hourly intervals. Depends on how urgently you need to change the schedule.


Mogs
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Thanks! Very helpful information.

 

Hey Cat Caregiver! Great to see you got at least some sleep last night! I know all about those late night pajama parties!

It was after 2am here when I saw your post and wanted to make sure you weren't alone until Oliver was at a comfortable number for you and then asked Serryn if she'd take over (I knew she was in Australia so it was early evening for her)

You'll see we work a lot like that around here. Those of us that have been around for awhile know where each other lives so if it's getting too late for us, we can "hand off" to someone in another time zone. If I couldn't have found somebody I knew would be able to help you if you needed it, I would have stayed until you were confident that things were OK with Oliver. That's just how we roll here.

I second the advice Mogs gave you. TID dosing is very hard on the caretaker and the few people we've had try it usually got burned out pretty fast and went back to BID. Your better bet would be to go to one of the longer lasting and gentler insulin's like Lantus, Basaglar, Levemir or ProZinc. They're more expensive, but we know where to buy them the cheapest and they're usually much better insulin's for cats.

OK now Oliver!! You should know better than to bounce in the house! Get off that trampoline!

 

Like Mogs and Chris noted, I would not recommend more than twice a day dosing with Vetsulin. It could unduly complicate things and potentially be unsafe. Just as an FYI, Vetsulin is no longer recommended by the American Animal Hospital Assn for the treatment of feline diabetes. Lantus and Prozinc are the two insulins that are endorsed. (Basaglar is a generic form of Lantus and Levemir is very similar.)

As far as feeding schedule, I can't yet tell where Oliver's nadir falls. Once you have a better sense of where that is, you may not want to feed too much after nadir. There's less insulin available to to offset the effect of food post-nadir.

 

Sienne, Your efforts are SO APPRECIATED by Oliver, me and my daughter!!! Last night's help from Serryn in Australia was amazing.

 

Last night I learned not to feed carbs until BG hits 68 on the AlphaTrak.

Oliver's PMPS was 427 and I just measured +2 at 104 so I'll take a +3 and more until he goes back up.

Mogs, I'm so GLAD you told me I could skip last night's insulin and change the dosing schedule. It's 7am/7pm now.

 

Lucky for me Oliver's +3 went up to 132. He just vomited. I need to get him off the Vetsulin and onto a longer-acting insulin.

 

AGREE

 

Do I need to involve my vet at this point?

She proved uninformed about cat diabetes at diagnosis, by not telling me to switch foods and then when I asked about food, she sold me RC Glycobalance, or as my daughter now calls it, GlycoUNbalance.

My goal is to get him into remission (or maintenance if remission not possible) and do it as inexpensively as possible. Can I just buy some insulin without a prescription and try on my own?

Any advise?

 

Glad the skip tip helped, CC.

WRT switching insulins I think one really needs to have a vet on board for all treatments a cat is receiving, especially if a cat has a chronic condition like diabetes. That said, when working with a vet who has not in the first instance prescribed a longer-acting insulin a little bit of negotiation may be required and having a bit of 'ammo' can help with that.

The first - and most important - evidence you can present is Oliver's response to Vetsulin as demonstrated in his spreadsheet:

* Vetsulin is dropping his BG too hard and too fast at the beginning of the cycle, triggering bounces and driving BG up really high again and this is keeping numbers up in subsequent cycles.

* Oliver is getting very poor duration - even by Vetsulin standards. Numbers are on the rise by +5 and the dose seems to be conveying little or no BG-lowering effect past +7. Between this and the bouncing, Oliver is spending too long each day in high diabetic numbers.

* Increasing the dose is not an option. On the contrary, the current dose should be immediately reduced for safety because for Vetsulin a BG level of 104mg/dL (Alphatrak) doesn't leave a wide enough safety buffer between nadir and the hypo threshold (feline BG reference range is 70-150mg/dL on Alphatrak, according to my vet).

Below I have attached a copy of a peer-reviewed study of cats treated with Lantus, Levemir and Prozinc. It covers the improved duration and chance of remission in cats offered by these insulins and also has details of the proven dosing protocol used.

Here is a link to the current AAHA 2018 guidelines for management of diabetic cats and dogs. According to the guidelines, Vetsulin is now only recommended for use in dogs, not cats.

Perhaps you could use Oliver's spreadsheet data plus the professionally authored references I've given you here as a foundation for negotiations with your vet?


Mogs
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I could never come close to seeing this as excellently as you just described in writing for me. Thank you Mogs. I get it and will go forward with the vet onboard. (Or I might change vets. I'll do a little research and read your attachment again.)

 

Vet Interview/Screening Topics & Check List

For your convenience

 

Thanks!!!

 

Mogs, I've been reviewing all the information I've learned from everyone and somehow missed that you said I should lower Oliver's current dose. So sorry. I will go to 1.25 units Vetsulin tomorrow morning. Thanks you for keeping on eye on this. Getting Oliver to the vet may not happen for another few weeks or more so I appreciate your advice immensely.

 

Just had a look at Oliver's spreadsheet. His PMPS was lower this evening so for safety I very much recommend checking where he's at tonight at +2 and +3 just in case he might drop down to the low 100s again.


Mogs
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Definitely...I learned my lesson. I'm sort of getting to know how he behaves seems to reflect his BG level.

BTW, He has me trained to give him food when he rings a bell, which I think might be better than me deciding when and how much to feed, esp. since he knows how he's feeling and I don't. I added this to the spreadsheet.

 

I'm really losing it...replying to my own post! While re-reading everything I realized that I'm feeding during the "2-HOUR NO FEED" time before AMPS and PMPS again. Oliver definitely has me bell-trained.

 

The ReliOn meter and strips arrived today and I lowered Oliver from 1.5 to 1.25 units Vetsulin at his evening shot.

The ReliOn has worked fine so far with the blood sample (even tho it needs 0.5 micro-liter of blood compared to the AlphaTrak's 0.3). The strips are hard to get into the meter and require a little wiggling and pushing but that's my only complaint so far. Can't beat the price!

I will feed carbs if BG<50 on the ReliOn but I don't expect Oliver to go that low. I'll be watching of course.

 

Working thru the ReliOn learning curve. A bit frustrated.

With the AlphaTrak I could preload the strip without activating the meter and then just push it in when I was ready to poke the ear and the tiny bit of blood always worked. With the ReliOn I cannot preload it because the strip must be forced into the slot with two hand otherwise it bends; so having to activate the meter before poking the ear has often left me time-ed out.

The ReliOn samples the blood with a flat edge which flattens out the fur causing the sample to spread out and doesn't leave enough to activate the meter. The AlphaTrak's tiny, needle-like projection can slide between the fur to take a quick sample of the smallest amount of blood. And, the AlphaTrak has two sides so if the right side didn't activate the meter, you can squeeze the ear again and use the other side of the strip without having to reload the meter with a new strip.

Obviously you get what you pay for and I need to economize so I may try the petroleum jelly on his ear, use a bigger lancet (AlphaTrak needed only 33 gauge), shave the fur on his ear, or keep trying and hope I get better at it.

I now have 3 night-time curves to compare, see below. Doesn't really tell anything that we didn't already know: Vetsulin pushes down BG within the first few hours and is doesn't last more than half a cycle.

 

Interesting Hubby uses the same and does the same and hasnt had problems with strips bending.
a thin layer of Vaseline will help the blood pool for a sample. (Apply vaseline then wipe off leaving a thin film.)

hope this helps.

 

Absolutely try it with just the thinnest smear of vaseline. It keeps the blood from dispersing into the fur so it forms a lovely droplet. (I started with the AT2 and switched to a Relion Premier and my success rate has been much higher with the Relion, but that may be because I'm just more practiced at it now. I haven't had any problem inserting the strips with one hand. I wonder if my model is different from yours?)

 

(Be sure you don't accidentally get any vaseline on the test strip when you're plugging the strip into the meter. I use my left hand for the vaseline and my right hand for the meter & strip.)

 

Thanks for the tips y'all. I bought the ReliOn Prime and wonder if the strips just don't fit this model as well. I really have to work to get them into the meter and often have to pull them out and start over because the meter fails to turn on. Maybe I should get another model.

 

Also, Oliver was so fed up with what I put him through last night, that this morning he hissed at me when I gently petted him! And, although he's ringing his bell for snacks, he's refusing to do any extra exercise!!!

 

Awww hes on strike! Come on Oliver you love your mommy.

 

He'll get over it even if he does have a stubborn streak. I did mess up his little ears last night. Lots of vein-hitting with boo-boos today.

Is the ReliOn Premier better than the Prime? I bought 200 strips and noticed that I'd have to buy Premier strips if I switch so I'm kind of reluctant, but maybe after I exhaust these strips I can switch if it's better. Very frustrating trying to get the strips pushed into the Prime right now.

 

I couldnt tell ya which is better. When Leo buys something he sticks with it like its made with glue. He's never complained though so...thats something. Yeah I would use out those strips then decide whether to switch or not.

I'm surprised you havent more responses from people that use the meter.

 

Thanks for keeping up with Oliver and me. I'm practicing on him this morning because he's sleeping. Using the bigger (28-gauge) lancets. I load the meter, activating it. Poke and if it quickly bleeds a lot I can hold the activated strip up to be bead of blood and get a reading. I just need to make sure I get a good drop on the first poke or it will time out quickly. I'm learning. ReliOn simply requires a different technique than the AlphaTrak2. Make it bleed, big and fast!

Good news: the vet office called back and I have a phone consultation November 3. I will tell her the following and see what she says.

• Changed to wet, low carbohydrate (<5%) diet; eating 300-400 kcal/day (i.e., 3-4 three-oz. cans Fancy Feast)
• Added exercise to his daily routine
  
• Gained 1 pound over last month
  
• Demeanor is much improved: no more hiding, grooming again, runs and jumps sometimes.
• Still peeing too much, about 600 ml/day
• No ketones (tested urine every day)
• Vetsulin not lasting more than 1/2 cycle and over-all blood glucose levels not normalized

This morning's (10/31) BG Curve for 1.25 U Vetsulin/ReliOn is looking a lot like the 1.5 U Vetsulin/AlphaTrak on 10/26. Weird. Different insulin doses, different meters/scales. If Alpha gives higher #'s than ReliOn, then does that mean Oliver was better off at 1.5 U? He did finally get into BLUE on 1.5U.

 

Hey @Cat Caregiver! I am wondering how you measure Oliver's pee output in mL each day? I would like to do something similar for Dixie . I have been tracking her water intake since diagnosis and it has been really nice to see how the water intake trendline goes down as time goes on, but is seems like she still pees so much!

 

Originally I wanted to track water intake but I have another cat who likes to drink from the same water bowl. And switching over to wet food made tracking water intake seem not too accurate.

I use a Breeze litter box with the pee pad removed. Everyday at 8 p.m. I measure the urine for the last time and tally up all the totals for that day. I measure the urine when I pour it out, once in the morning and then again at 8 in the evening . I have never had the tray overflow with my pouring it out only twice a day.

I guess I'm lucky. Oliver took to the breeze box instantly. And the other cat never has even looked at it. I was running out of money paying for all of the scoopable litter without knowing that Oliver had diabetes. Now with the breeze litter box it's cost-free.

I use a homemade graduated cylinder measuring device. I'm too cheap to buy one haha! I drew the calibration lines myself using a medicine syringe.

The Breeze pellets last forever if you scoop out the wet ones into an old aluminum pie pan so they can dry better. If you leave the wet spot in the litter box it tends to get moldy.

Oliver recently had a bout of bad diarrhea. And actually the breeze box wasn't too bad with it.

 

Also: He started with the box back in the end of September and I still haven't had to add any pellets, even tho I've had to throw out a bunch with diarrhea and what little stick to his poop everyday. Some people say they wash the pellets but I see no reason to do so as long as you scoop out the wet ones for a good drying before throwing them back in. They are designed to not absorb the urine and they don't. The little bit of wetness where he pees dries away cleanly as long as you scoop it out in a pan to dry.

I've had no problem with smell. The urine is so water-down because of the diabetes that I'm guessing that's maybe why I don't smell it.