Need help with dosing

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IttyBit

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I posted on main board as well. Itty Bitty had a bad DKA episode on 12/14/13. We were able to get him help in time thank goodness! Since then I can't seem to get him under control. He is literally all over the place. Not sure I'm 100% confident in my vets ability to instruct on this so reaching out here. I've got to get him back in a rhythm quickly. He was controlled well for over a year, we were able (with diet change after dx's) back off his insulin quite a bit. He was down to 0.6-0.8U often. Then around Aug he started creeping up so we kept increasing but ended up here :sad:

He's been on the same food pretty much since dx'd, only other we've tried was Wellness but he eventually crept up on it so we went back. He gets fed at 6am & 6pm at shot time. Occasionally they (I have 4) get an extra can here or there if they run out & I know he won't have food for several hours as I don't want him getting too low. No other change really that I can think of that created this. I do have a newborn at home & a back injury so I have neglected his needs a little I'm sure but I've got the time now to test often & fix this. I'll admit I don't know a ton about how this insulin actually works so I really need some help with dosing instructions. You'll see on his chart he has gotten some IM shots mid cycle based on vet instruction but I can't do that forever & not even sure it's the right thing to be doing obviously. I will also say (for what reason I don't know) he is most normal in the 120-250 range. If he gets below 150 he acts super lethargic, under 100 & he's glued to the floor/couch & won't eat. When it's Hi he acts ok other than a lil hyper & drinks more so I can tell that. But for whatever reason he functions better running higher than normal. Any help or suggestions greatly appreciated!
 
Hi ______, (What's your name?)

I'm glad you found your way over. (Several us post on Health and here; some of us just post here.) This is a small, friendly forum, busiest in the am and pm EST. If you ever have an emergency, post on Health where there will be more eyes.

I can see why you are confused - that is an amazing spreadsheet! It looks like you have been dosing 1.5 three times a day for the past few cycles? On 12/31 he was at 600 at preshot (which I think was probably a bounce from the 85 the cycle before) and you gave 1.5 He dropped 400 points by nadir - we consider 50% a pretty good drop - and then, I think, bounced back up for pmps.

I think if he were mine, I would do a restart at one unit. Get nadirs whenever you can. Hold that dose for a few cycles to see if he flattens out a little. If you decide to do this, be sure to test for ketones.

It may be that ProZinc is not his insulin but he did well at first and has certainly had some good low nadirs. It is the big swings that seem to cause the issues. It might be that he just bounces too much on this insulin, but it also could be that he is getting too much insulin and that is causing the big bounces.

Here is the protocol for ProZinc which may be helpful:
http://www.felinediabetes.com/FDMB/viewtopic.php?f=24&t=109077

Try to post daily - am and pm if possible - so we can see how he is doing and offer suggestions. I did see you might be giving some supplements that you thought might have too much sugar also? Cutting those out may help too.
 
Thanks Sue, my name is Candy :)

Part of what's so weird is he's been on it for 2yrs now. I really felt like we were headed towards remission like I mentioned above. He was getting very little. Then in Aug he started creeping up higher requiring more insulin. Not sure why as it was out of the blue but I was 3rd trimester & having lots of complications (in & out of the hospital a lot). Therefore I couldn't really do the excess testing & such to figure it out. Now since the DKA I can't seem to get it under control, I'm not sure if that's an effect of DKA, needing a different insulin, too much or too little ect. That's what I'm trying to sort through now. The vet school I took him to for emergency reamed me about under dosing him, said he wasn't getting enough insulin & that I never had it under control. I tried to explain if I increased he bounced so I backed off the insulin. She just kept telling me if his numbers get higher it's b/c it's not enough insulin that he needs more. However I suspect most of the diabetic felines they see aren't on a low carb diet! It was like talking to a brick wall to say you can't give a ton of insulin w/o the carbs to counteract it ohmygod_smile

So before if he "bounced" we just rode it out till the next shot, usually hold dose & feed Turkey or a tad more insulin. However his bouncing usually wasn't over 400 whereas now I'm getting 500's/Hi's. The vet says dose him when this happens so that's what I've been doing. I understand how dangerous low numbers are but I guess I'm not aware of how ok the Hi's are? And for how long? I have no problem trying 1u, I'm just scared of testing mid cycle to see 500's. What do you do when you have that? My hubby gave him 1u this morning & here he was 500's/hi. I waited till 10+ & gave him 2U tonight. +2.5 he's down to 430. I'll keep testing thru the night & just ride it out till next shot time. Do you just check ketones daily?

I'll check out the link & continue to test/post often. I really appreciate the help!!
 
If you're going to reduce the dose, yes, I'd try a ketone test daily.

The 400/500s are certainly not good. The 30s are deadly. We want to get him away from both possibilities. I don't know what will work. All I know to do is try some things and see if things improve.
 
Hi Candy (and Itty Bitty)

Sue sent me a message to see if I could offer any advice. Probably because I've been in your shoes...

My kitty, Bob, was diagnosed in July, 2011. Before I could get any insulin in the mail, he took a really bad turn, and ended up in the ER for 3 nights with DKA. So while he hadn't been on insulin for two years like Itty has, he did go through the same thing.

I took a look at your SS, and it is hard to make sense out of, so I understand your frustration at not knowing what is going on. And I don't have any easy answers, but I do have some questions.

Your SS in the comments section says "1.5U IM at 1:30pm". Does the IM mean you are giving shots inter-muscularly? Is that what the ER vet advised you to do? If so, no problem, but I just wanted to be sure that's what it means.

Bob was only on PZI for 10 weeks, then went into remission. Unfortunately, after being OTJ for over two years, Bob had a relapse a couple of months ago, and went downhill very fast and I lost him. But the entire time he was on PZI, he got his shots "IM", into the muscles of his back legs twice a day. So I am familiar with it, and understand my vet's logic in advising me to shoot him that way. It's just something you rarely see "here" and I can only recall one other kitty who got IM shots besides Bob since then.

When your kitty was released from the vet and came home, did they suggest you giving him sub-q fluids at home? Or did they recommend any kind of supplements? DKA screws up their electrolytes, and some cats need supplements. Bob got potassium added to his fluids, and I had to give him fluids every day for a few weeks. Did the vet say all his blood tests looked good when they sent him home?

Are you still noticing any trace of that "ketone smell" on his breath?

Did they mention any type of infection that contributed to the DKA episode? Usually, infection is a part of the "recipe" for ketones and DKA. Is he on any meds at all besides insulin?

I also see that on a couple of cycles recently, you've given "booster shots" of insulin in between AMPS and PMPS. Before the DKA, had you ever had to do that? Had you just been giving shots every 12 hours? Or did you sometimes dose "as needed" due to high numbers well before the 12 hours had expired.

Sorry for all the questions, but I would like to understand better before giving you any bad advice based on my lack of understanding.

Carl
 
Candy,

Carl and I are worried about your kitty. (We've been brainstorming) He seems to have so much going on and his numbers don't make much sense. I'm with Carl. The DKA makes me nervous and I don't know why he had DKA with those low numbers (78, 96). And I am worried about the high numbers that come up so fast. But shooting three times daily hasn't helped much.

I think we are over our heads here. We just have our experiences to go on and his ss looks like nothing I have ever seen. Do you have a vet school near you? Do you live in an urban area? Maybe go on Health and see if anyone knows an FD experienced vet near you?

I am nervous about my advice to restart with the DKA looming. I hope you can get a ketone test soon.

Please answer Carl's questions and tell us what you are thinking.

What kind of meter do you use?
 
I'll answer whatever you need! I just want to fix this if I can & with the DKA episode I know you've got to act quick! Btw I'm sorry for your loss :(

Ok ......
Yes IM means inter muscular, he's always gotten it SubQ but when I took him in for the DKA my vet said giving IM gets the glucose down fast (instead of waiting the norm of 4hrs) & that it also wears off quick. She says it wears off in 4hrs IM. So she instructed that if I get a high mid cycle give him an IM dose to get it down quick & then resume SubQ at regular shot times. So what's on my SS is the only IM shots he's ever gotten.

As for th ER it is the vet school here local, supposed to be one of the best in the country. However she didn't seem to comprehend what I was telling her that I completely changed him to the correct diet for diabetes. She insisted it couldn't be since it wasn't SD MD. Joke!! They wanted $1400 to hospitilize him for fluids. She ran a couple things, 8-10% dehydrated, high protein in blood, high ketones in urine. I think that's all she told me but I'll double check the report. No way could I afford $1400 so we waited 30mins for my vet to open, they called & I immediately took him to her. She gave him fluids SubQ & said he was only mildly dehydrated. But she felt a CBC & Chem would be more effective in a couple days when he was rehydrated. This was Saturday 12/14 & I took him for blood on Monday 12/16. When she called with the results she said his electrolytes weren't bad at all but I could give him a tiny bit of pedialyte in water for a few days if I wanted. We did for 3 days. His liver, kidneys & all others looked good, he was also concentrating his urine properly. Said his potassium was good to. I did ask her to run his thyroid since he's 13yo but won't get those results till tomorrow since it had to be sent out. She saw nothing else but the ketones in the blood work that was concerning. I asked her about upping carbs or food suggestions to combat all the protein but all I got from her as well was SD MD. I will ask for a copy of all the results when I'm there tomorrow & post them.

Honestly we need to get his teeth cleaned, his breath is horrid but I'm somewhat nervous about anesthesia with the bs issue so I've just put it off. It may have a hint of the DKA smell but very lil, it's hard to tell when it's always bad ya know? He has been on antibiotics for the teeth before, she said if they continued to get infected we'd have to clean them but for now it wasn't necessity. No other meds besides insulin & now that I think about it I wondered infection to, however wouldn't that show up in a CBC? She said that was clean so I don't know.

He was controlled until August of last year when he started to get higher ps numbers, 300's sometimes 400. When I ran nadir then he was a lil higher then I like so we were giving him like 0.2 SubQ at 6+ just so he wouldn't spike too high. If I gave him more at shot time he would just bounce, when I broke it up like that it wasn't so bad. However this was only for the pm shots 6+. I posted about that here as well & decided to stop that upon advice. I don't recall how long I did that for but I can go back & check my log book.

I guess my thought is kinda something else endocrine, ie thyroid, adrenals ect. I don't know what else it could be, I mean liver, kidneys look good & I kmow how tight the endocrine system is with BS. I had gestational diabetes myself due to an under treated thyroid condition. B/c my thyroid wasn't right it was hard to manage the diabetes. For me I could do low carb high protein diet & not need insulin but when I did that I was spilling high ketones. If I added carbs I had higher numbers but no ketones. But I did have to add insulin at that point, it was a real catch 22 to get it under control. But I've had thyroid/adrenal issues for over 10yrs now, when it gets really bad I always become "borderline diabetic" with wonky bs. When I'm controlled they're great. So for me I was curious (I know cats are different in the "need" of carbs) if he maybe needed a lil more carb to counteract all the protein. When I brought him home I gave the insulin & fed him FF beef (the higher carb) his numbers were good? That's the only other thing I can think of that maybe I need to bump him to like 15% carb instead of 10% or less. But maybe that doesn't make sense in cats like it did for me. But w/o knowing his thyroid results it's hard to tell. Or it could be as simple as we need a different insulin, I'm just not sure. I know a lot about human endocrine system but feline not so much.

The student at the vet school did tell me they have Endo's & IM vets on staff at the school. She recommended once I got him stabilized to consult with them about his needs b/c I'm not fully confident my vet can treat this. As soon as I get all his results I plan to set this up. I'm a lil concerned about the financial aspect of it if they want more testing after consult though :( I've got a new baby, a back injury costing me a ton & I just took an additional 2wks off work unpaid to have my gall bladder removed. This last visit for him cost me $300. He's worth it to me but so much at once is just a lil tough right now. But hopefully my tax return will be enough to get this all sorted out.

We use the Relion Prime, it's about 6mths old.
 
Morning Candy,

I went back and tried to read your posts over the past few years. It does look like he was in very nice numbers for quite awhile. What precipitated the trip to the vet for DKA? Did he seem very ill or have a string of high numbers or a high ketone test at home?

I am wondering if he has a serious tooth infection and that is causing the high numbers. What I can't get my head around is that he does drop, though. With an infection, you would think he would just stay high.

It is very discouraging if the local vet school is advocating dry food.

I think there are some options but unfortunately I don't know which is the most logical, or even the safest.

1. Drop the dose to one unit, shoot twice daily and see if he settles down. Take a ketone test daily. I am worried about this option if he has an infection in his teeth as infection + high numbers can equal DKA.

2. Take the dose and split it into thirds (so maybe 2 units divided by three?) and shoot that amount every 8 hours for a few cycles.

3. Change insulin. While this may be the best option as he seems like a very bouncy cat, the downside is that he will need a week to settle into the dose (you can't change up doses with Lantus or Levemir like you can with PZI) and I would worry about the possible high numbers during that time in combo with a possible tooth infection.

4. Get his teeth done. I don't know if that is an option moneywise or if the vet would feel it is safe with his volatile numbers. But if he has an impacted tooth or some raging infection in his mouth, it may be impossible to get his numbers down until the dental is done.

All have up and downsides. And I have no idea which is best. As I said, we give advice from our experiences and I feel a little confident dealing with normal numbers and dosing. But I don't feel confident at all dealing with all his multiple issues.

One question I don't think we asked - is he eating okay?
 
Well he started getting higher numbers back in Aug but like I said I didn't have the means to test him enough or get him to the vet to figure it out. We just tried to dose him based on those numbers best we could. As for the "incident" he was acting normal the night before, around 4am we heard him howling so my hubby got up. He was hovering over the water bowl weirdly so he checked him, it was 500 something but 2hrs before shot time. He gave him a token dose of 0.2 right then. I came up & checked him again at 5:30 which read Hi. But when I picked him up he was wet noodle with his eyes dilated so I knew something was wrong. Packed him up & took him to the school. He laid lifeless for 2 days & we had to syringe feed him. Sun evening within 4hrs he did a 360 back to normal like nothing ever happened. We've been chasing him ever since. He's eating fine, acting a lil lethargic & high water intake. He's not urinating a ton tho & I can tell he's still pretty hydrated.

Last night you can tell he had a pretty decent cycle but I gave him 1U this morning & now here +3 he reads Hi. Ugh I just wish I could figure this out or had a vet competent enough in FD who could!! I don't know what to do anymore as nothing is working. Would a CBC show infection? I would assume it would show high WBC correct? I may call the school & see if I can talk to a vet today.
 
I am thinking there is something going on besides the diabetes. Either a raging mouth or other infection or some underlying issue. But yes, it is so hard to pinpoint what that could be - heck, in humans, much less cats.

Wish I was of more help. Maybe when Carl gets off work, he will have mulled over it and have a brilliant idea. :mrgreen: I hope so.
 
Ugh I took him to my vet & asked her to monitor him for the day. Just called to check & all she said was give him rx diet (here we go with the SD crap AGAIN!!) & give 2U every 12hrs. I really really do not want to use that food!! For 1 I have 4 cats! 2. They're picky they get a different flavor at each feeding. 3.Itty Bitty is pickier yet, he WILL flat out refuse to eat it if he doesn't want it. I ask her this & she says a cat won't starve himself over a flavor. Yea I beg to differ! Any suggestions here? I'm due to pick him up soon, I'll buy a few of the stupid cans to shut her up but I need a better alternative long term. Is there something made up more like the MD? Which I believe is the idea of 1/3 fat, 1/3 carb, 1/3 fiber or something like that.
 
Would a CBC show infection? I would assume it would show high WBC correct?
Click to expand...
I am not 100% positive, but yes, I believe an infection would show up as an elevated WBC on his labs.

It is good that he seems to be eating OK. DKA or just the presence of ketones seems to happen when three things combine.... Not enough insulin + not enough food + an infection of some sort.

So, short term -
Test as often as you can for ketones on the sticks. Anything above trace is an issue, and they can get out of control quickly.
Feed him whatever he will eat, even if it's cap'n crunch. It's important that he not go without eating. If you have to give a higher dose to compensate for the carbs, so be it. You can humor them by taking home some of that prescription crap. Then next week, bring all but one can back for a refund. Tell her that he refused to eat it. And she's wrong. A cat will certainly at least attempt to starve itself by refusing food. And while he does that, his system will become weaker and he'll be more subject to infection, or worse stuff like ketones or lipidosis. And end up having to be syringe or tube fed. Ask your vet if she would be willing to foot the bill for any consequences related to his refusing her prescription diet plan.

Did she test for infection?

Does she advise IM shots or just sub-q every 12 hours?

Short term, can you test regularly? Would you feel comfortable giving more than 1u doses provided you can test for low numbers by +4 or so? You can protect against low numbers with food if needed.

I don't know what is the root cause of the high numbers. But if they are bounces from low numbers, then you need to be able to see the lows if/when they happen.

You can also consider the 3x per day shots, but you have to be sure that the issue is "short duration" to do that safely. It's likely that IM shots would absorb faster and not last as long. But I don't think I agree with whichever vet told you "four hours". Bob was on compounded PZI, and got IM shots. Every cat is different of course, but he usually got 8-10 hours out of a dose, with a nadir around +4-+5. That is not much of a difference than most cats on compounded PZI get from sub-q shots. From what I have seen, compounded PZI doesn't last as long as Prozinc in general.

Did the vet get the thyroid results back today?
 
The dental infection could be part of the problem. If his mouth is painful, that is stress and stress raises glucose.

If he might eat it, try some lighlty cooked gizzards. They are fibrous enough to help clean the teeth.
For the nutrition ignorant vet, ever so politely give her a printout of Dr Pierson's Cat Info. Dr Pierson focuses on feline nutrition. There are some downloadable versions there, as well as a downloadable nutrition chart for many retail canned cat foods. You can show her the different carb levels for th Rx vs the Fancy Feast.

There are some rare conditions which could happen, however we would focus on more likely possibilities first.

Without shooting IM, could you do a curve this weekend? That means testing every 2 hours from shot to shot. Especially test at +5, +5.5, and +6 (around the likely nadir) so we can see how low he goes? We may be able to identify if he is bouncing, or if the insulin is wearing off too quickly. If it is wearing off, you may need another insulin. If bouncing, there are some tactics which may help.
 
Well I picked him up, I confirmed why I don't think she's competent enough to treat this. They (her techs) tested his BS twice. She never looked at him. Didn't test ketones or anything today. They simply left him in the cage & tested him twice. Charged me $14 for the test strips. Said she reviewed the SS I dropped off so that was her advice, 2u SubQ every 12hrs & md or wd food for 1wk. She generally suggests SubQ but when they were getting so Hi she said IM just to get them down quickly. They were packed & I was pissy so I just asked for a copy of the results. Got home to look them over & the thyroid isn't on there! I'll have to go back tomorrow to get it I guess. But I have the CBC & Chemistry results, does anyone know how to read those? There's several outta range, I know myself a few them could be from the dehydration/ketones. But like his cholesterol is super high. Now I know that's regulated by thyroid as well so I'm curious to see those levels. I'll go ahead & list what she ran:

WBC Assay
Lymphocyte concentration-1.4L Range 2-7
All others normal

RBC Assay
Hematocrit (calculated/spun)-25% L Range 30-45%
All others normal

Platelet Assay-Normal

Plasma Appearence-Normal

Plasma Protein-9.4H Range 6-8

Chemistry Serum
Urea Nitrogen-26
Creatinine-1.1
Protein Total-7.9
Albumin-4.3
Globulin-3.6
Calcium Total-10.9
Phosphorus-2.4L Range 2.7-6.5
Sodium-147L Range 150-163
Potassium-3.1L Range 3.6-5.5
Chloride-95L Range 116-130
Bicarbonate-27H Range 13-20
Anion Gap-29
Sodium:Potassium ratio-47
Alanine transaminase-59
Alkaline phosphatase-29
Creatine kinase-69
Bilirubin total-0.3
Cholesterol-438H Range 75-271


Keep in mind these were run 12/16 after the DKA episode 12/14 so 2wks ago. I can run a curve this wknd for sure. While I'm working next week I'll have my sister test him every 2-3hrs so we watch it close for a week. He's eating fine & doesn't seem to be in pain from eating. Although he is refusing treats at shot time now. Could just be tired of them. I'm comfortable giving him however much he needs to try to fix this. And again I'll test him frequently the next week. PMPS tonight was 290, I gave him 2U & that crap food so we'll see what happens. I'll do FF tomorrow evening for 2 cycles as well to see if it's different. I'll hold on the 2U every 12hrs & test. We have a consult appt next tues at 11am with an Internal Med Vet at the college. Thanks so much for all your help!! I just wanna fix this guy!
 
Candy,
I've asked a couple of friends if they can "drop by" and take a look at the lab numbers. They all know a lot more than I do about them.

I just noticed that for some reason your SS link is "broken". Can you look at your signature file and see if you can "fix it"?

Carl
 
Thank you! Well crap I'm not sure what's wrong with it? I've deleted & re posted it so I'm not sure what the issue is :/
 
I'm one of the people Carl asked to look at the labs. Can you scan them and post them? That would be the easiest thing because we need to see the reference ranges on everything. Reference ranges can vary by lab.

One thing that stands way out to me is his HCT. He is anemic. Do you live in an area where there are fleas? I'm asking because cats can get Feline infectious anemia. Cats can become anemic as part of chronic kidney disease but his renal values are fine. He's definitely anemic, though.
 
Candy,
You might have said earlier, but what city/state do you live in? There may be someone that lives in your area that might be able to suggest a good vet.
 
There are a couple of members with Manhattan KS listed as their location. You could try to PM them. They haven't been active in a while, but maybe they still get the emails telling them that someone from FDMB has sent them a PM.
http://www.felinediabetes.com/FDMB/memberlist.php?mode=viewprofile&u=4436
http://www.felinediabetes.com/FDMB/memberlist.php?mode=viewprofile&u=5441

This looks like a more currently active member, but only lists Kansas. Spreadsheet looks like Pete may have just gone off the insulin a couple days ago. http://www.felinediabetes.com/FDMB/memberlist.php?mode=viewprofile&u=8896

You just click on Members, and then click twice on Locations, and start scrolling through the list.

You can also change your first Subject Line to say something like "Need good vet near Manhattan KS".

Good luck in finding a vet you like.
 
Thank you Dyana I will certainly check those out!

I played with the link this morning & got it working again. It was a good cycle but he did bounce clear back up to Hi right after. I seriously think he does a lil better in the just above normal range. He gets pretty lazy & acts hypo less than 150 for some reason. This morning between 10-11am he was playing in the kitchen by himself lol.

I'll check out the link but yea we don't have any fleas thank goodness! I do know for humans with thyroid conditions it makes it very hard to retain proper vitamin/mineral levels. So I'm anxious to see that level! I called 3x this morning to get it but they just kept saying someone would call me back. They're only open 3hrs on Sat so I never heard :/ Will call again Monday.
 
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