Need insulin dosing advice for Lily

[Jen and Lily]

Hi there,
I have been treating my cat Lily for about 6 weeks now. She has been on Prozinc the entire time and has had a Libre 2 the whole time. She only eats fancy feast pates 4 times a day. She has not tested positive for ketones. The vet has steadily increased her insulin dosage from 1 unit 2x day to now 4 units 2x a day and it doesn't seem to be doing anything. She did start to act totally normal last week when we were on the 3-3.5 units 2x day but now she seems lethargic again. She was also treated with antibiotics for what the vet described as a mild case of pancreatitis. All the rest of her blood work looked good. I'm looking for anyone with experience to take a look at her spreadsheet and give me feedback on her progress, how we have been dosing her, and any thoughts on how to proceed. The vet would like to do more bloodwork and look for insulin resistance. I don't know what to think. She did start to respond at one point when she was on 2 units 2x day (see June 13-15) but then she went a bit low and I gave her some high carb treats (totally overreacted) and she never bounced back after that, so we just continued to up her dose. I'm just not sure what I am missing. Thanks for the help!
Lily's spreadsheet: https://docs.google.com/spreadsheets/d/1Cy_EIPLmgv10p_LYRkP3rAvyycRXTfp4YniR8QRmMpE/edit?usp=sharing
Jen

 

[Suzanne & Darcy]

Hello there and welcome. I'm sorry that you have been struggling so much to get Lily's blood glucose down. You don't happen to have her bloodwork to share, do you? Did the vet do a specific pancreatitis test on Lily? The Spec fPL test? Or which test was done? How are Lily's teeth? Dental problems can really create insulin resistance. My cat had acromegaly and that may be what your vet wants to test for, but I think it's a bit early to test for that yet.

 

[Jen and Lily]

Hi Suzanne! Thanks for the reply. I have attached her bw here. This is from the initial vet that was treating her. I moved her to a vet that does only cats a few weeks ago and they did the test for pancreatitis. The vet told me it was essentially a dip stick test that reveals a line if there is a case of pancreatitis and the darker the line the more serious the case is. She said Lily's case was mild (a faint line). I am uncertain if they checked her teeth.

 

[Jen and Lily]

One additional question, I feed her 4 times a day, AM, late AM, early PM and then PM, I saw somewhere though that I should not feed her after +5. Is that correct? Then I may need to stop the early PM feeding.

 

[Suzanne & Darcy]

Her liver enzymes are elevated. Did the vet say anything about this? If she were my cat, I would start supplementing her with a product called Denamarin that can really help the liver. I have had great success with it in my own cars. Can you pill her?

 

[Suzanne & Darcy]

One additional question, I feed her 4 times a day, AM, late AM, early PM and then PM, I saw somewhere though that I should not feed her after +5. Is that correct? Then I may need to stop the early PM feeding.

We generally recommend (for new people who don’t have a lot of data on their cats) that the cat be given no food for two hours prior to the AMPS and PMPS tests. This will make sure that the test value is not elevated by food (which could later wear off and BG would lower) and you will know if it is safe to shoot the dose of insulin.

As for feeding, I would recommend feeding her breakfast- at the same time you take the first test. Test, feed and shoot insulin- in that order and do it all within about 10-15 minutes. Then give her a teaspoon or two of her FF pate at +2, and another snack at +4. You can feed her up until about +6. It’s a little hard right now to determine where her nadir is, but it looks like about +5 or +6. We don’t recommend feeding much at all after nadir (the lowest point in the cycle) because it can shorten the duration of the insulin and cause numbers to rise toward the end of the cycle when the effect of the insulin is tapering off.

 

[Suzanne & Darcy]

Is she eating and drinking normally? Is she lethargic or behaving normally? Are you testing for ketones at home using either a blood ketone meter or the urine test strips?

 

[Suzanne & Darcy]

I have to go pick up myhusband whose car is in the shop, but I will come back later and try to answer more questions that I may have missed.

 

[Jen and Lily]

Her liver enzymes are elevated. Did the vet say anything about this? If she were my cat, I would start supplementing her with a product called Denamarin that can really help the liver. I have had great success with it in my own cars. Can you pill her?

The vet did not say anything about her liver enzymes. I will get the supplement you suggested. If I put it in her food is that ok? She is a voracious eater and never detects pills.

 

[Jen and Lily]

Is she eating and drinking normally? Is she lethargic or behaving normally? Are you testing for ketones at home using either a blood ketone meter or the urine test strips?

I upped her insulin 2 days ago to 4 units 2x a day and since then she has been lethargic. She is eating normally. I have the strips to test for ketones at home but have not done it before. How ddo I catch the urine?

 

[Marje and Gracie]

I agree her ALT is mildly elevated. It is something I would be concerned about. My kitty, Gracie, could get these mild elevations from time to time and I would give her milk thistle. She actually had a an issue with her bile acids and had to take ursodiol to help.

The Denamarin tablet shouldn’t be crushed and it is to be given one hour before any meal on an empty stomach. I prefer to use Adored Beast Liver Tonic which is a liquid with milk thistle or Herbsmith Milk Thistle powder available at Chewy.com.

The dose was increased by 0.5u, which is something we do under the Modified Prozinc Method (MPM) when nadirs are this high so it’s not unheard of or uncommon. Insofar as the response at 2u, it’s difficult to say why that occurred just for those few cycles but we do know absorption can vary quite a bit from shot to shot. But she does not look overdosed to me and with that amount of testing, it would have shown up with a dive into lower numbers.

Please be sure you test for ketones as lethargy could be an early sign. I made little foil trays that I could slip under Gracie’s bottom as she squatted. Then you immerse the strip in the urine and check it against the bottle at exactly 15 sec. This last part is really important.

 

[Suzanne & Darcy]

I agree that the ALT is elevated, but is not hugely so... because vets often say they are not concerned unless the ALT is elevated three times the upper limit. In this case, I would still use either milk thistle or Denamarin. Marje has made some great suggestions. I, personally, do not give Denamarin on an empty stomach (even though I know the directions say so... but I still have had my cat's ALT go from quite high to back within normal limits... I suppose I should not say that I do this... that I give it to my cats with food.) Milk thistle can be mixed into food as well.

I used a blood ketone meter (but the urine strips are much less expensive). Unless you know that your cat is prone to ketones, I would probably just try the ketone strips if you are able.

I agree that, even with the increases, it does not look like your Lily is overdosed. You may not have reached her good dose yet. I would make sure of things like teeth. I'm not too sure about a dipstick pancreatitis test, but if she's eating and drinking normally, I would not suspect pancreatitis. If she shows signs of vomiting, lethargy, lack of appetite, I would especially make sure to test ketones, but with these higher numbers it's a good idea anyway.

 

[Suzanne & Darcy]

Also, I forgot to say that we don't recommend testing for Insulin Autoantibodies or Acromegaly until the dose reaches 6 units. These are conditions that can cause major insulin resistance.

 

[Marje and Gracie]

Here’s what I would recommend on dosing:

I suggest an increase of 0.25u after every four cycles for a couple rounds and then let her go six cycles. At that point, we will see where she is and determine how we need to proceed. If, at any time, you start seeing more BGs under 300 and definitely if you see any BGs under 200, we need to slow it down so the above advice is just if she continues to see BGs mostly above 300.

Would you be comfortable with that?

NOTE to other members: this advice is for Lily only. Because Jen has a CGM on Lily, we see a lot of data and know her BGs more than most who are hand-testing. Please do not follow this dosing strategy. If you need help with dosing strategy for your own cat, please ask for assistance in a thread.

 

[Wendy&Neko]

we don't recommend testing for Insulin Autoantibodies or Acromegaly until the dose reaches 6 units. These are conditions that can cause major insulin resistance.

Unless there are other symptoms that suggest the testing be done sooner. The large research study that found 1 in 4 diabetic cats has acromegaly found acrocats on as small as 1 units insulin dose, though the average was more like 7 units. We've also seen IAA kitties on just 3 units here. Some cats have both conditions, like my girl Neko did.

 

[Jen and Lily]

Here’s what I would recommend on dosing:

I suggest an increase of 0.25u after every four cycles for a couple rounds and then let her go six cycles. At that point, we will see where she is and determine how we need to proceed. If, at any time, you start seeing more BGs under 300 and definitely if you see any BGs under 200, we need to slow it down so the above advice is just if she continues to see BGs mostly above 300.

Would you be comfortable with that?

NOTE to other members: this advice is for Lily only. Because Jen has a CGM on Lily, we see a lot of data and know her BGs more than most who are hand-testing. Please do not follow this dosing strategy. If you need help with dosing strategy for your own cat, please ask for assistance in a thread.

sorry for the delay in responding! She ended up back at the vet and he found her with a fever, constipation, and an elevated heart rate. The vet was worried she was having heart issues so we kept her on 3 units 2x day of Prozinc until we could get her an echocardiogram this week. She has been cleared of any heart disease so we are back to focusing on the diabetes. The vet had me up her dose to 3.5 units 2x a day on Wednesday. Her numbers are still HI on the Libre preshot and her nadir is anywhere between 250 and 350. So to follow your suggestion, if I upped her .25 every 4 cycles is that 4 days or 4 shots? Guessing 4 days. And thank you all so much for the help!

 

[Marje and Gracie]

sorry for the delay in responding! She ended up back at the vet and he found her with a fever, constipation, and an elevated heart rate. The vet was worried she was having heart issues so we kept her on 3 units 2x day of Prozinc until we could get her an echocardiogram this week. She has been cleared of any heart disease so we are back to focusing on the diabetes. The vet had me up her dose to 3.5 units 2x a day on Wednesday. Her numbers are still HI on the Libre preshot and her nadir is anywhere between 250 and 350. So to follow your suggestion, if I upped her .25 every 4 cycles is that 4 days or 4 shots? Guessing 4 days. And thank you all so much for the help!

A cycle is 12 hours; there are two cycles in a day. So four cycles is two days.