New here, looking for some help

[LinuxJon]

Hey everyone, this place seems great. Wish I'd thought to find it sooner.

I have a 13-15 yr old deaf white cat named Carlos. He was diagnosed with diabetes over 8 years ago and has been doing pretty great for most of that time. He's been on Lantus, with the dose at between 3-5 units for the last handful of years. I didn't know about home monitoring as an option- we just did a glucose curve with the vet every six or eight months to adjust. He never had a hypo episode. I should mention he also lives with my parents part-time, as I travel for work and my wife is too allergic to care for him properly.

He was diagnosed with very early stage renal issues in December and we started adding daily Sub-Q fluids. I feel like since then, his diabetes has become much, much harder to manage. In January, he had one hypo event that my parents recognized and treated at home. After that, I started to home monitor. He was dipping into the 60's, so I adjusted the dose down to 4 units (from 5) by myself.

Then two weeks ago, he had another hypo event while my parents had him. He was unresponsive and they took him to the vet with a BG tested there at 32. Thankfully, they got him back up and home the same day. They adjusted down to 3 units. When I came to get him a couple of days later, his BG was <20 (min meter reading) but thankfully he wasn't yet having symptoms. I used the normal syrup and food protocol to get him back to a safe number.

Now I have him full-time so I can more closely monitor for the first time. Things seem to be all over the place. If I do 2 units 2x a day, his BG is in the high 200's or even 300's most of the day. When I go to 3 units 2x per day, I had an event the other night where he got into the 60's before bed again. It seems to be totally variant day by day.

My question is- where do I even start? I'm trying to keep track today with a 12-hour curve so I at least have more data to share. But could the sub-q fluids impact his sugar and be changing his curve? The fluids aren't always administered the same time of day.

Any advice is much appreicated!

 

[tiffmaxee]

Welcome. Please start by reading the two protocols used here, TR and SLGS. You can find them on the lantus board at the top. Lantus likes consistency. So jumping around with dosing is not the way to get the most bang for your buck as it’s a depot drug. Since you can now test it’s important to get a test before injecting every time and then periodically to figure out the nadir, lowest point in the cycle. Dosing is based upon the nadir which I’m sure you already know.

I found that my diabetic cat did not increase his BG when I started fluids.

We need more info to help you. What are you feeding Carlos? How’s his weight? Do you feed any You will want to start a spreadsheet. All you need is a google account.

 

[Kris & Teasel]

The Lantus forum has a lot of knowledgeable people who can help you sort this out.

 

[Nan & Amber (GA)]

Welcome!

Not sure about sub-Q fluids (I don't think they have a big effect as far as I know), but one thing that may be going on is that hypos can make a kitty more insulin-sensitive than before. It's great that you are hometesting now and have him full-time so you can keep an eye on him-- it's likely going to be crucial in keeping Carlos safe, because (as you've discovered), his response to the insulin may be harder to predict than before.

Getting more data is going to be really helpful going forward. You'll probably notice that most of us have a link to one or more spreadsheets in our signature-- we use a standard template (instructions for setting it up are here: FDMB SPREADSHEET INSTRUCTIONS). It's a great tool for stepping back and seeing overall patterns in BG numbers. One of the hardest things about figuring this stuff out is that the BG numbers you see on one day are not necessarily just a response to that day's insulin (especially with an insulin like Lantus-- you'll be reading about the depot in the Lantus stickies). In addition to how a depot insulin works, there's a physiological phenomenon we call "bouncing", where a cat's body responds to low numbers by releasing stored glucose, raising numbers. This phenomenon can last up to three days , which obviously complicates the picture.

Last thing: we usually change doses in smaller increments, usually 0.25 or 0.5U. You may be missing Carlos' ideal dose by changing in full units, so if you don't already have them, try to get some syringes with half-unit markings (we just eyeball the 0.25 changes).

Finally, to answer the question you asked , if I were you I'd start with the spreadsheet and setting up your signature with the info Tiffmaxee suggested (type of insulin, food, glucose meter, any other meds, etc.).

 

[crazypsychokitty]

Have they changed his food to a k/d diet? Is he getting fluids every day? Normally, pets only need fluids 2-3x per week. Did your vet tell you to give it every day?

I think you should contact your vet. Do a complete glucose curve one day. At the vet, we normally do it 3 hours apart after the initial dose. Being at home, you could do that multiple times - more so than the vet could (we take 3 samples). Call your vet and either bring the curve to them or give it to them over the phone. They may want to examine your pet or do their own curve. I assume they did a full blood panel? (As in, sent to the lab). This would rule out underlying conditions as well.
Eight years is a long time fore a diabetic cat, so changes in glucose levels are not unusual. As others have stated, you may be dropping too low by going a whole unit.

 

[LinuxJon]

Thanks for the input guys. Here's the answers to some of the questions:

-Carlos eats mostly Friskies Salmon Pate (I know). I've tried diabetic foods and he flat out refused. He also flat out refuses the K/D foods now. When I adopted him, he would only eat dry. I eventually got him to eat anything that was a super-smelly fish (actual tuna, or salmon pate) but he's a very picky eater. Not sure that I'm going to ever be able to address this with food choice. I've also been having some success with him eating the Rachael Ray tuna flavor wet food lately, which I assume is at least better quality than the Friskies, as it looks like it's made of actual fish.

-He gets fluids daily. We tried 3x per week and his creatinine levels were still increasing. Since it's not a financial or ability issue, the vet suggested we get ahead of it by doing it daily. Is there a downside someone is aware of with this?

-I'll definitely look for the 1/2 units slin pins. Anyone have a link where they are buying them online?

-His weight is good. He's about 18lbs right now, same as he's been since diagnosed. Overall, for an older diabetic renal cat, he's very healthy looking. He still climbs our cat tree, plays, ect. Not lethargic at all.

-I'll definitely download the spreadsheet and use it

Serious question- for an olderish cat that's been diabetic for so long, what's an acceptable swing in their numbers throughout the day? The best I've seemed to have done was high 300's at the peak, bottoming out around 100, sitting around 250 most of the day.

 

[JL and Chip]

I've had multiple CKD kitties over the years, as well as two who were also diabetic. I did daily subQ fluids with several of them and, YES fluids can impact BG, typically by LOWERING it. It's important to remember that every cat is different, but I'm a data person so I (and several others in the board who were dealing with the same issues at the time) started collecting data. I was using 100 ml subQ daily and found that in my cat it could impact BG downward by 50-75 points on average within the first few hours. You might want to do some testing to see if you see similar in Carlos. I actually timed the fluids to the cycle to try to impact the highest BGs (and to definitely avoid administering around nadir).

Just be careful with fluids in cats who have cardiac issues. You didn't mention that, but I'm putting it out there for others who might be reading.

Edited to add: Also wanted to mention that famotidine was standard fare while dealing with CKD. They are notoriously poor or picky eaters as the kidneys become more compromised. We used 1/4 of a 10 mg tablet twice a day to help with any nausea and it really took the edge off. If Carlos has been picky long term, it might not have anything to do with kidney impairment but hey, whatever works, right? It's available over-the-counter as "Pepcid AC" (NOT "Pepcid Complete"), just be sure to get the 10 mg dosage.

 

[LinuxJon]

Thanks JL. I'll look into the Pepcid and see if perhaps that will help. He's always been picky, but there's certainly days where it's worse than others.

Carlos is a big guy and gets 200 ML daily of the Sub-Q fluids. Both of his hypo episodes were at night, after they administered them. I'm now trying to switch his fluids to the morning, so at least I'm here and awake to keep an eye on him.

I've already done a ton of reading on the SLGS this morning since someone above suggested it. I feel terrible now for making all of the panic changes in dose the last week based on his glucose numbers.

I gave him a low dose last night because he'd been in the 200's all day. He started off today off the meter (600+) and is only down to 538 at +5 hours. I just hope I didn't cause any permanent damage by letting it get this high. I'm going to continue on the current vet prescribed (3 unit) dose for a week and just keep an eye to make sure it doesn't get too low. At that point, I can do an actual accurate curve... which I should have done before making any changes at all

 

[Bellasmom]

You are in a great place for help, these guys are awesome

 

[Nan & Amber (GA)]

I can see your spreadsheet, great getting that set up so fast! (though I'm guessing from your username that you're pretty tech-savvy, hah!)

The Friskies isn't bad at all with respect to the diabetes, may not be the best for CKD. Check out Dr. Pierson's food charts (linked in the yellow sticky at the top of this forum)- she has carb counts and phosphorous content for a very large number of commercial cat foods. For feline diabetes, you want to try to stick to below-10% carbs. Big warning: if you've been feeding higher carb foods and you do the switch, insulin needs can go waaaay down! So that's another good reason you are home testing.

adwdiabetes is a good place to buy syringes with half-unit markings. What most of us do with Lantus is use the pens like a mini-vial-- take off the cap and poke the syringe needle into the spongy bit at the top of the pen. If you've been using the pen-needles with a pen, I don't think there's any way to do half-units.

I feel terrible now for making all of the panic changes in dose the last week based on his glucose numbers.

Don't beat yourself up! We all do the best we can, and it is so hard to see them in numbers like that! And with a different insulin, changing doses in response to pre-shot BGs and spot checks isn't the wrong strategy. Lantus/Levemir are just different in that they are dosed on the low points, so they're harder to intuit. One of the great advantages to having the two methods used in the L+L forum (SLGS and TR) is that they give you systematic strategies to changing doses without having that emotional response to individual numbers. It's nice to have some rules to fall back on!

It's not a bad idea to add in the other BG numbers (plus doses) you have from whenever you started hometesting [edit: to your spreadsheet]. It's more information for folks to look at (though, be warned, it will mean that probably every new person commenting will say something about the frequent dose changes ). You'll also definitely want to put the info about when Carlos was diagnosed and the recent hypos (and other key bits of history like the CKD) [edit: into your signature]. It's basically so you don't have to repeat yourself every time you have a new person in one of your threads, and so folks can get the really important info quickly before offering advice/suggestions.

 

[tiffmaxee]

Just want to add that the first time I gave Max fluids his bg did drop. After that it had no effect. I agree about the warning in regards to fluids to a heart kitty. Max wasn't a heart kitty until the end and I think the fluids led to his demise. If you have a copy of the most recent labs and can add then to the labs tab on the spreadsheet some of us can give you more ideas. Fluids aren't usually needed until the creatinine is 3.5 or more but some believe in starting early. I instead believe that adding water to the canned food in the early stages is better as the extra sodium in the fluids is not needed. It just has to be in the fluids to make them safe to inject.

As for pepcid, again it's not always the answer to nausea. Many cats that have ckd and diabetes get nauseous and often get pancreatitis. Two good nausea medications are cerenia, a veterinary drug, and ondansetron, a human drug. Picky eating is often a sign of nausea. I didn't know that until Max got pancreatitis which is likely want led to his diabetes.

You have come to the best place for help. Lots of smart people here.

 

[Veronica & Babu-chiri]

Hi and welcome!

Don't be too hard on yourself is complicated, specially with kitties that have multiple issues, you can do an actual curve at any time but since you skipped and changed the dose an all that if it were me I'll wait at least 6 cycles ( 12 hour periods that would be 3 days) before doing it.

Kidney diets are usually very high in carbs and can really mess up his diabetes so unless he's in a very advanced stage of CKD (I don't think you mentioned what stage he's) is better if try to give him some low carbs low phosphorus food that he likes (is important that he eats and maintains his weight) also you could add some phosphorus binder to his food if he absolutely refuses to change

Here's a link to a page that has a lot of very good information on CKD that you may find useful http://www.felinecrf.org/how_bad_is_it.htm

 

[Nan & Amber (GA)]

Serious question- for an olderish cat that's been diabetic for so long, what's an acceptable swing in their numbers throughout the day? The best I've seemed to have done was high 300's at the peak, bottoming out around 100, sitting around 250 most of the day.

OK, this is weird, I swear I wrote out a whole answer to this, but now I don't see it! Anyway, here's more or less what I think I said:

The pattern you describe isn't far away from a decent goal of keeping him under renal threshold (below around 200-250) for a large part of the day. That alone would be hugely beneficial to his health (esp. with kidney issues already). It may be possible to do even better than that, and have him spend a large part of the day in normal BG (50-120 on a human meter), which would take off even more stress on his pancreas and kidneys. Some cats can do really really well, even as long-term diabetics, once you are able to keep a close eye on BG at home and adjust their insulin dosage to their true need. But then some cats, even newly-diabetic ones, are just really hard to regulate at any level. There's really no way to tell how things are going to go for Carlos until it happens (caveat: there are folks over on the Lantus+Levemir forum with exponentially more experience with this than I have, and if you ask this question over there you may get different answers, at least more detailed ones)

 

[Veronica & Babu-chiri]

I gave him a low dose last night because he'd been in the 200's all day. He started off today off the meter (600+) and is only down to 538 at +5 hours. I just hope I didn't cause any permanent damage by letting it get this high.

Is actually more dangerous that they go too low hypos can kill so is always better to be on the safe side and being on high numbers even though is not good is not as dangerous

 

[JL and Chip]

You might want to consider splitting the 200 ml subq into 100 ml in the morning and 100 ml at night. I had a vet tell me to do 200 ml at once on one of my larger cats and I ended up overloading him. Every cat is different ... but please pay attention for puffy legs, changes in breathing, and other such signs before giving the next round of subq. Sometimes our kitties have undiagnosed heart issues and knowing what to look for is important. Knowledge is power.

A BG range of 100-300 is what many vets will tell us to strive for, but that's often a goal for owners who aren't as engaged as you seem willing to be. The goal is to keep the cat in safe BG ranges, of course. With Lantus, and the input of many knowledgeable people here who live "in the trenches" of this disease, odds are you will likely be able to do better.

 

[LinuxJon]

Thanks Nan, Veronica and JL.

I'll definitely consider splitting the sub-q doses, and I definitely will make sure I'm looking to see there's no swelling before the next dose.

I'm hoping that with the help of everyone here, we can get his BG numbers really well regulated again. His creatinine has been back and forth between 2.9 and 3.7 for the last four months, so his outlook on the kidney side wouldn't be that bad if we can get this BG in check and keep doing fluids.

 

[Veronica & Babu-chiri]

Congratulations on getting the SS up and running keep asking ( I would recommend you post in the Lantus forum where there are some real experts on Lantus ) do consider the changing of food to a low carb low phosphorus or using a phosphorus binder to help his kidneys while helping his diabetes