Need advice: Nadir is acceptable but AMPS & PMPS >400

[G2 & Buddy]

I have previously posted on the Main Forum, and have read through some others, but need some specific PZI experience. Buddy was diagnosed 1/25/2023, was started on PZI and increased up to 3 units, and has now been on PZI 1.25 unit q12hr for over 2 weeks. His spreadsheet and labs are posted. We use AlphaTrak, and he eats wet Purina DM pate over 2 hours 4x day. His Vet has set his normal range goal between 100-250 mg/dl. His AMPS and PMPS are usually in the 400's, occasionally 300's, but midcycle numbers drop to 120-140 around hours +5 to +8. I'm reluctant to increase his dose further as he did have hypo's (40-60) on previous doses 1.5 units and above. (The protocol indicates no dose change for nadir 90-149 with a human meter which reads 40-50 points higher than my AlphaTrak using the control solution.) Clinically he is really good, now with a stable weight and energy. His behavior gives me no clue to what his BG is doing even when BG are low.
My question is this: Is a daily BG drop of 250-300 mg/dl with PZI the norm? The shape of his BG curves seem almost right, but those steep changes are problematic for me. I was hoping the range would narrow with time but see no trend that way. He obviously is sensitive to the PZI effect, it just does not last long enough. I'm hoping experienced members here could give some perspective.
My Vet and I are thinking that Lantus or Levemir might be a better alternative, although I do see some posts about not bringing down higher numbers that give me pause.
Thanks for your guidance.

 

[JanetNJ]

I have previously posted on the Main Forum, and have read through some others, but need some specific PZI experience. Buddy was diagnosed 1/25/2023, was started on PZI and increased up to 3 units, and has now been on PZI 1.25 unit q12hr for over 2 weeks. His spreadsheet and labs are posted. We use AlphaTrak, and he eats wet Purina DM pate over 2 hours 4x day. His Vet has set his normal range goal between 100-250 mg/dl. His AMPS and PMPS are usually in the 400's, occasionally 300's, but midcycle numbers drop to 120-140 around hours +5 to +8. I'm reluctant to increase his dose further as he did have hypo's (40-60) on previous doses 1.5 units and above. (The protocol indicates no dose change for nadir 90-149 with a human meter which reads 40-50 points higher than my AlphaTrak using the control solution.) Clinically he is really good, now with a stable weight and energy. His behavior gives me no clue to what his BG is doing even when BG are low.
My question is this: Is a daily BG drop of 250-300 mg/dl with PZI the norm? The shape of his BG curves seem almost right, but those steep changes are problematic for me. I was hoping the range would narrow with time but see no trend that way. He obviously is sensitive to the PZI effect, it just does not last long enough. I'm hoping experienced members here could give some perspective.
My Vet and I are thinking that Lantus or Levemir might be a better alternative, although I do see some posts about not bringing down higher numbers that give me pause.
Thanks for your guidance.

I know you said you are nervous about going to 1.5 but I might dial it up just a tad. Like juuuust under 1.5. Try to consistently get that mid cycle number. Id aim for 90-100. Normal on an Alphatrak is about 68-150.

 

[Suzanne & Darcy]

I do not find his curves to be atypical of ProZinc. I also don’t like the highs at AMPS AND PMPS. I hate to see that. There is still an element of bouncing that I believe we have talked about before. Bounces can last up to six cycles and, in Buddy’s case, it seems to take about that long. I expect on or about 4/12 that he will break the bounce and go into the blue. Probably unfortunately followed by another bounce. As for duration, I don’t think that you are feeding after his nadir (which can shorten the duration of the insulin.) ?

As for Lantus or Levemir, I have used both and I like them. They will give flatter curves in general, although you would have to get used to shooting lower numbers (it takes a while getting comfortable doing this.). Depending upon your schedule- you can consider one or the other. Levemir tends to nadir a little later in the cycle than Lantus.

 

[Suzanne & Darcy]

As for bouncing, it’s just something that can’t always be avoided. The more time he spends in lower numbers the more he will have a chance to get used to being there and less bouncing “should” occur. It depends upon the cat.

As to the meters, the pet meters such as the Alpha Trak read higher than the human meters. For example, your “take action” number with an Alpha Trak is 68 (where you intervene with high carb food, etc.) and with a human meter the take action number is 50.

 

[G2 & Buddy]

I know you said you are nervous about going to 1.5 but I might dial it up just a tad. Like juuuust under 1.5. Try to consistently get that mid cycle number. Id aim for 90-100. Normal on an Alphatrak is about 68-150.

Yes, I have considered going up to 1.5 units and now agree with you. The last time he bottomed out was on the way down in dose when there was a big change using 3 units for weeks. Thanks.

 

[G2 & Buddy]

I do not find his curves to be atypical of ProZinc. I also don’t like the highs at AMPS AND PMPS. I hate to see that. There is still an element of bouncing that I believe we have talked about before. Bounces can last up to six cycles and, in Buddy’s case, it seems to take about that long. I expect on or about 4/12 that he will break the bounce and go into the blue. Probably unfortunately followed by another bounce. As for duration, I don’t think that you are feeding after his nadir (which can shorten the duration of the insulin.) ?

As for Lantus or Levemir, I have used both and I like them. They will give flatter curves in general, although you would have to get used to shooting lower numbers (it takes a while getting comfortable doing this.). Depending upon your schedule- you can consider one or the other. Levemir tends to nadir a little later in the cycle than Lantus.

Thanks for your comments. The AMPS & PMPS bother me greatly also. I’ve read the comments on bouncing, and thought he would be past that after two weeks, but Buddy is Buddy. This week I want to see a BG curve similar to the last one done, hopefully with more blues. I feel we are close to his magic dose and am going to try the slight dose increase to 1.5 units suggested by JanetNJ. If no improvement in leveling out, an insulin change will be in order. Your info about Lantus/Levemir is noted and appreciated.
No, I do not feed him after the nadir, but usually at 0 hours and about 4 hours later, and he grazes on it for a couple of hours. Early on I checked for post-prandial bumps but did not find anything consistent…. That would agree with a grazing cat eating few carbs directly, but instead with glucose production in high gear all the time. I think insulin needs to dampen that system a bit more. There is evidence of a similar pattern in some humans with T2DM.

 

[G2 & Buddy]

I expect on or about 4/12 that he will break the bounce and go into the blue.

Well, Suzanne, you hit the date exactly. This AM his BG is 141 and last night's bowl is empty ! I was planning to do a BG curve today but will need to wait a bit. Glad I did not increase his dose yesterday. Let me see how his numbers play out today. Buddy ate some so I will check again in an hour and decide on his insulin.

 

[Suzanne & Darcy]

I hope all goes well for you and Buddy today! I know you will be watching him.

 

[G2 & Buddy]

I hope all goes well for you and Buddy today! I know you will be watching him.

Oh yes, and he has been very cooperative, even napping on the towel where I draw his blood. BG stayed down for another 2-3 hours, then went up over 300. I gave him a token dose of 0.5 units today and will resume his regular schedule tonight with some late checks. Being on the cusp is not fun, but I will take a mild hypo if it means approaching remission.

 

[G2 & Buddy]

As to the meters, the pet meters such as the Alpha Trak read higher than the human meters. For example, your “take action” number with an Alpha Trak is 68 (where you intervene with high carb food, etc.) and with a human meter the take action number is 50

I do have human meters around the house for my teaching, and should have them out for kitty backup just in case. I have run tests using the AlphaTrak control solution on one. From the numbers suggested to me here, it seems that the human & pet meter readings are not a constant ratio so I will have to run a few double blood samplings to get a comparison curve.
BTW, how do y'all check for ketones in an emergency ? So far that has all been done at the Vet's... and been negative. I do have a dual glucose-ketone meter for humans that might be useful IF it will work for cat blood.

 

[Suzanne & Darcy]

I am not sure why you delayed the insulin for so long this morning. When confronted with an unexpected low number, try stalling the shot and do not feed the cat. Wait 20-30 minutes. See if the BG is rising on the next test after the 20-30 minute stall. If it is rising then you may be safe to shoot the whole dose as you can see that the insulin from the previous cycle is wearing off and kitty is rising on his own. You have options at this point: shoot full dose if you are home and can monitor; shoot a reduced dose and stay relatively on schedule or skip the dose (I would not recommend this unless your cat is not rising after stalling or if you will not be home to monitor, etc.)

 

[Suzanne & Darcy]

See how he was rising this morning with all your tests? This shows that he was on his way up? So it was safe to shoot.

 

[G2 & Buddy]

I am not sure why you delayed the insulin for so long this morning. When confronted with an unexpected low number, try stalling the shot and do not feed the cat. Wait 20-30 minutes. See if the BG is rising on the next test after the 20-30 minute stall. If it os rising then you may be safe to shoot the whole dose as you can see that the insulin from the previous cycle is wearing off and kitty is rising on his own. You have options at this point: shoot full dose if you are home and can monitor; shoot a reduced dose and stay relatively on schedule or skip the dose (I would not recommend this unless your cat is not rising after stalling or if you will not be home to monitor, etc.)

Understood, and thank you for your close following. With hindsight I was too cautious. Yes, he was on his way up but I waited until the BG was >250 because the full dose effect on past curves has been a drop of up to 250-300...and I really hate those Hypos!
I doubt the lower AMPS was due to any residual insulin effect after 12 hr. Talked with the Vet and she suspected Buddy might be nearing a remission phase...so caution. (He showed a similar rapid change when at 3 units q12 for 2 weeks, and the unpredictable drops continued a couple of cycles even though the administered insulin dose was decreased substantially, and he did not need those higher doses again.) So I opted to shoot a 40% dose mid-cycle and stay on schedule q12hr.
Whatever the trigger, the event was short-lived and he is back to his AM 400's. So I am proceeding with the planned dose increase to 1.5 units PZI and will monitor mid-cycles closely.

 

[G2 & Buddy]

Oops. The dose increase did not go as planned. His BG stayed up for 4 cycles, then another low AMPS today. So this time I held his food and insulin 2 hours until his BG trended upward, but ended up with a hypo 56 @ +5. Lots of blue and yellows but food wasn't enough to prevent the drop, and needed a bit of glucose to get him out of the green. So his dose is back down to 1.25 units again. Dang.

 

[Suzanne & Darcy]

Don’t be upset. Just because he didn’t do well on 1.25 before doesn’t mean it won’t work better this time. Normally we congratulate people when their cat earns a reduction. So let’s just wait and see. Instead of waiting and shooting an hour or two late when he has a lower preshot, next time consider shooting a half dose or something similar. Of course you would go ahead and feed him at that time and do the planned snacks in the early part of the cycle. Sometimes you just have to do this and gather data on how he does with the reduced dose at certain preshot numbers. Also, this is a silly question perhaps, but when you shoot an hour and a half late in the morning, you are also shooting an hour and a half late in the evening, right (or at least an hour late?) Make sure the shots are not less than 12 hours apart especially after you have had a lime green. Then you can work your way back to your normal shot time in 30 minute increments. Maybe if he’s bouncing and has a very high preshot value it would not matter much to shoot earlier than 12 hours, but under normal circumstances, it’s best to keep the shots as close to 12 hours apart as possible.

 

[Suzanne & Darcy]

Also, did you try giving a teaspoon of high carb food when he was in the lime green? Fancy Feast Gravy Lovers is a good one for this. Even sometimes just a little of the gravy will do the job. A lot of time, by using high carb food, you can avoid the use of Karo syrup or honey.

 

[JanetNJ]

Oops. The dose increase did not go as planned. His BG stayed up for 4 cycles, then another low AMPS today. So this time I held his food and insulin 2 hours until his BG trended upward, but ended up with a hypo 56 @ +5. Lots of blue and yellows but food wasn't enough to prevent the drop, and needed a bit of glucose to get him out of the green. So his dose is back down to 1.25 units again. Dang.

Welp good he earned the reduction!

 

[G2 & Buddy]

Don’t be upset. Just because he didn’t do well on 1.25 before doesn’t mean it won’t work better this time. Normally we congratulate people when their cat earns a reduction. So let’s just wait and see. Instead of waiting and shooting an hour or two late when he has a lower preshot, next time consider shooting a half dose or something similar. Of course you would go ahead and feed him at that time and do the planned snacks in the early part of the cycle. Sometimes you just have to do this and gather data on how he does with the reduced dose at certain preshot numbers. Also, this is a silly question perhaps, but when you shoot an hour and a half late in the morning, you are also shooting an hour and a half late in the evening, right (or at least an hour late?) Make sure the shots are not less than 12 hours apart especially after you have had a lime green. Then you can work your way back to your normal shot time in 30 minute increments. Maybe if he’s bouncing and has a very high preshot value it would not matter much to shoot earlier than 12 hours, but under normal circumstances, it’s best to keep the shots as close to 12 hours apart as possible.

No silly questions here. Yes I have used the high carb food before but had better success with small amounts of Karo since his lows tend to be sustained. I try to keep 12 hour intervals but read here about holding the dose and food for low AMPS. Last time I waited too long and then gave half a dose…which gave high numbers all cycle. So this time I gave the full dose as soon as he trended up… and he hypoed. And no I did not delay his next dose timing at a lower dose because he was already in the mid 400s, but I checked later and he was good.
It’s those steep changes he has at the start and end of each cycle that are making it difficult to control. So it’s either low dose PZI 3x a day or glargine q12… We’ve been doing this dance for 2-1/2 months and he shows much improved insulin sensitivity but poor control through a whole cycle. I’m a fan of patience but doubt the current regimen will produce a good result for Buddy. We talked and the vet will write me a glargine script next week.

 

[G2 & Buddy]

Welp good he earned the reduction!

Yes he did indeed..

 

[Suzanne & Darcy]

No silly questions here. Yes I have used the high carb food before but had better success with small amounts of Karo since his lows tend to be sustained. I try to keep 12 hour intervals but read here about holding the dose and food for low AMPS. Last time I waited too long and then gave half a dose…which gave high numbers all cycle. So this time I gave the full dose as soon as he trended up… and he hypoed. And no I did not delay his next dose timing at a lower dose because he was already in the mid 400s, but I checked later and he was good.
It’s those steep changes he has at the start and end of each cycle that are making it difficult to control. So it’s either low dose PZI 3x a day or glargine q12… We’ve been doing this dance for 2-1/2 months and he shows much improved insulin sensitivity but poor control through a whole cycle. I’m a fan of patience but doubt the current regimen will produce a good result for Buddy. We talked and the vet will write me a glargine script next week.

Okay good. We can help you with the Lantus/glargine insulin as well. I personally used Vetsulin, ProZinc, Lantus and Levemir. I’m a fan of depot insulins for giving nice flat cycles.

 

[G2 & Buddy]

Okay good. We can help you with the Lantus/glargine insulin as well. I personally used Vetsulin, ProZinc, Lantus and Levemir. I’m a fan of depot insulins for giving nice flat cycles.

That is so good to hear from a user since a flatter cycle is definitely what we need. I know what a boon Lantus & Levemir have been to human clients. Life would be much simpler if we can get a 150 mg/dl variation per cycle instead of 300!
One question has come up. I looked for U-100 syringes, 3/10cc, with 1/2 unit markings but can find only 5/16 inch (8mm) needles. I was told 1/2 inch needles were preferred for thicker cat skin but cannot locate a brand. Going to 5/16” is doable with injection technique changes, but I wondered what others have used.

 

[Suzanne & Darcy]

I like these. I certainly never had a problem giving injections with them. They’re sharp and I had a lot less problem with air bubbles with these than other brands.

 

[GaneshMom]

Has anyone found a supplier of U-100 syringes that only has 5 - 10 units max? Every source I've found sells them with 30 units and that makes it VERY, VERY difficult to read markings of 1.5 units for those of us with small animals getting much less insulin.

 

[Suzanne & Darcy]

Has anyone found a supplier of U-100 syringes that only has 5 - 10 units max? Every source I've found sells them with 30 units and that makes it VERY, VERY difficult to read markings of 1.5 units for those of us with small animals getting much less insulin.

Sorry. Mine are 30 units. I know people here who have purchased a lighted, head mounted magnifying visor to really see well when drawing small doses. Amazon has a lot of them for sale as, I am sure, do other places.

 

[Suzanne & Darcy]

He earned another reduction on the PM cycle of 4/28. He's been bouncing since then so be careful. With no nighttime tests he could be dropping low at night and bouncing up during the day, we have no idea. Any idea why he dropped so much on that night of 4/28. Did you give a snack at +1 and +2. I cannot stress enough the importance of giving these snacks for cats who dive like that. Perhaps you already did give snacks. If so you may need to bump up the carbs in the snacks depending on what percent of carbs you are giving now. With no mid cycle tests for the last few days we have no idea what he's been up to (or rather down to). Perhaps he has stayed in a bounce or perhaps he has gone lower than he's comfortable with only to go back up high again.

 

[G2 & Buddy]

He earned another reduction on the PM cycle of 4/28. He's been bouncing since then so be careful. With no nighttime tests he could be dropping low at night and bouncing up during the day, we have no idea. Any idea why he dropped so much on that night of 4/28. Did you give a snack at +1 and +2. I cannot stress enough the importance of giving these snacks for cats who dive like that. Perhaps you already did give snacks. If so you may need to bump up the carbs in the snacks depending on what percent of carbs you are giving now. With no mid cycle tests for the last few days we have no idea what he's been up to (or rather down to). Perhaps he has stayed in a bounce or perhaps he has gone lower than he's comfortable with only to go back up high again.

You raise good points but I don’t have good answers, sorry. I do not expect perfect control in this cat, and just try to keep his weight stable with minimal diabetes signs.
I don’t think he is ‘bouncing’ metabolically more, but instead changing his routine with the warmer weather. Buddy is inside/outside so I don‘t know all his activities. His recent hunting of moles and anoles definitely modified his diet. His BG was high and delayed coming down that day 4/28, then dropped that night. The drops are seen without any real pattern known, and can be dramatic… it might be extra outside activity which can activate hypoglycemic systems for hours. I never know. He shows no symptoms to speak of. He has been eating a bit less this week and is not ravenous like before insulin.
Routinely doing BG 4-5x daily is not doable unless I have planned a curve day.
Buddy did have some stress related to our new cat Milo, a feral, who has been in an enclosure and is just getting his first Vet visits. The two have actually become pals. Buddy refused to eat when Milo was gone overnight.
Re snacks: I put his food out 4x daily and he eats it over 2-3 hours so food is available at +1 & +2 if he is around. Of late, his eating pattern is even more stretched out. He gets Friskies pate or Purina DM… no pattern to his BG response.
Confession: Since the standard dosing is not keeping control, since the insulin effect wears off before 12hr, and since I hate seeing BG of 400-500s, and since he can sometimes drop 250-300 points after a dose, I have done a trial of using 1.25 units if the pre-insulin BG is <400 and 1.5 units if BG>400… Just to try to treat those highs a bit more. Not ideal I know, or per your protocol, but looking for a trade-off between control and safety.
Later this week he will be changed to glargine. But first we are dealing with another cat and traveling to the vet…almost done.
Hope this has not come across as snarky or defensive. I do appreciate all y’all’s input. Yes, I am a bit frustrated by the less than perfect BG profile, but my Vet reminds me that cats are difficult patients.
Thanks.

 

[G2 & Buddy]

Okay good. We can help you with the Lantus/glargine insulin as well. I personally used Vetsulin, ProZinc, Lantus and Levemir. I’m a fan of depot insulins for giving nice flat cycles.

So, finally, I have the glargine and proper syringes. We will start glargine in the next 48 hr. I will move on to the proper forum but wanted your thoughts on the transition so I can keep his Vet updated. For Buddy’s current weight of 12lb, I calculate a glargine start dose of 1.36 units q12hr. Since he has been on ProZinc 1.25- 1.5units recently, this seems safe enough, maybe even too conservative. We will do AMPS, PMPS and midpoints, and then do a full BG curve in a few days. Thoughts?
Buddy has been quite active recently, outside till very late, and sleeping in. BG’s are still quite unpredictable. I’m hoping his curves will flatten out substantially in the next weeks. Thank you all for your kind help.