New here, need dose adjustment help +5 338, +9 271

[Dimmu & KL]

Hi everyone!

Dimmu was diagnosed mid September 2017 in Amsterdam (we moved to Belgium 2 months later in November).

The vet never suspected diabetes, because Dimmu is on raw diet his whole life. We give him a couple of low carb grain free kibbles as treats sometimes, mostly he gets dried/freeze dried meat/fish as treats, and he’s never been obese. We actually brought him to the vet because of his arthritis flare up, our A’dam vet ran a blood test to check his liver and kidney values just to be sure, but instead found his elevated blood sugar level (432).

Our A’dam vet was a holistic vet, he didn’t want to put him on insulin right away, and that was also the way we wanted to go initially, so we changed his diet from normal raw/fresh food to a diabetic-specific raw diet, and with a bi-week vet visit for acupuncture treatments, Chinese medicine and other herbal supplements, we were able to bring his level down to the range of 180-270 in early November.

His BG level started rising since we moved to Belgium (stress?) mid Nov. last year, we continued with his supplements and diet, but he’s always in the high 200‘s to mid 300‘s. We decided it’s time for insulin. The first vet we visited here in Belgium prescribed a startling dose of 5u Caninsulin/ 24hrs. We have been reading and learning here on FDMB (Thank you, FDMB members!!) and despite Dimmu’s size, the vet’s dosing schedule seemed a lot and strange to us. We also asked for Lantus, he refused because he has never worked with Lantus before and it’s rather uncommon here in Europe. We managed to find a vet who Rx Lantus and started Dimmu on 0.5u on 01/27 AM, and increased to 0.75u 01/27 PM. He received again 0.75u 01/28 AM, but BG is still high, we’re wondering if we should increase it to 1u this evening. Or should we hold the 0.75u for a couple more cycles?

His bloodwork on 01/20: DGGR-Lipase was 40 UI/L. Fructosamine was 576 uMol/L. The vet suspected pancreatitis and suggested we do an ultrasound with a specialist, we will schedule it tomorrow.

 

[Dimmu & KL]

We noticed he drank a bit more (never more than 3.5 oz/day), but thought it’s because he took psyllium husk to help his occasional constipation. He lost some weight (from 27.5 lbs to 23) in 6 months prior to his diagnose, because we thought he was getting a bit stubby and not exercising enough so we put him on a diet, we later found out 27.5 lbs was his ideal weight.... Dimmu is a male Maine Coon, and even for a Maine Coon, he’s pretty big, almost 40 inches from nose to tip of tail. He was back to 26 lbs by the end of October, and lost about 2 lbs again since we moved, but his weight is stable overall and he still has a healthy appetite.

Except for the numbers, he barely showed any other clinical symptoms for diabetes or pancreatitis. He is of course slower, though. Another thing we noticed is that he’s more easily blotted and his stomach seems to gurgle more.

He’s currently on a raw diet with fresh beef pancreas (1/3 of his total food intake), green lipped mussel, glucosamine, CBD oil for arthritis. Probiotics, AVJ and psyllium husk for constipation. We want to add digestive enzymes to see if it’d help with the general GI health. If we add digestive enzymes, should we cut down on the beef pancreas? Has anyone had experience with this?

 

[Sandy and Black Kitty]

Hello and Welcome

We managed to find a vet who Rx Lantus and started Dimmu on 0.5u on 01/27 AM, and increased to 0.75u 01/27 PM. He received again 0.75u 01/28 AM, but BG is still high, we’re wondering if we should increase it to 1u this evening. Or should we hold the 0.75u for a couple more cycles?

Please do not increase. Start learning about Lantus and our group by reading the "new to the group" post. Read also about the TR protocol and SLGS method to see which one you think may be the best fit for you and Dimmu.

Ask questions - plenty of knowledgeable folks here.

 

[Ella & Rusty & Stu(GA)]

Hi and welcome!
Dimmu is a big kitty! There is a weight formula for beginning Lantus, but I am on my way out the door at the moment and don't have time to look it up. I know that someone will be along very soon who will know what it is. Since Dimmu is such a large cat, you may very well have started at too low a dose, but it is important to increase according to the protocol so you do not bypass a good dose. Often too much insulin can look like too little. Lantus dosing is very different from Caninsulin. It is based on the nadir (how low the blood glucose goes in the 12-hour cycle), not on the blood-glucose number at pre-shot. For this reason we like to get in mid-day tests. If you read the informational posts ("Stickies") at the top of the Lantus/Levemir forum you will have a lot of information (too much information?!) at your fingertips. Start at "New to the Group". It is not necessary to learn everything at once.
One thing is very important to keep in mind: we hold a dose for 6 12-hour cycles before increasing or decreasing. This is because Lantus is a "depot" insulin that leaves some of itself in the cat's body. When you first begin Lantus, or when you change the dose, the depot needs to recalibrate to reflect the new dose. The key word is "patience" (as you will hear here a lot!).
Great job setting up Dimmu's spreadsheet and I see that you are testing regularly. This is super! At some point you will have to decide which of the two protocols you will follow: TR (Tight Regulation; since you are able to test regularly this would be a good choice, especially since you are feeding raw or canned food), or SLGS (Start Low Go Slow). Both are described in one of the Stickies at the top of the forum.
I know that some of the more knowledgeable people here will be able to help you with your specific medical and nutritional questions.
Just want to say: welcome!

 

[Dimmu & KL]

Hi Sandy and Ella,

Thank you for the fast reply and help! We have him 0.75u again, I am so grateful that your replies came in in time so we didn't increase his dose. We have read the stickies many times, but got so overloaded with info and forgot some of the important points....

Since Dimmu is such a large cat, you may very well have started at too low a dose, but it is important to increase according to the protocol so you do not bypass a good dose. Often too much insulin can look like too little. Lantus dosing is very different from Caninsulin. It is based on the nadir (how low the blood glucose goes in the 12-hour cycle), not on the blood-glucose number at pre-shot. For this reason we like to get in mid-day tests. If you read the informational posts ("Stickies") at the top of the Lantus/Levemir forum you will have a lot of information (too much information?!) at your fingertips. Start at "New to the Group". It is not necessary to learn everything at once.
One thing is very important to keep in mind: we hold a dose for 6 12-hour cycles before increasing or decreasing. This is because Lantus is a "depot" insulin that leaves some of itself in the cat's body. When you first begin Lantus, or when you change the dose, the depot needs to recalibrate to reflect the new dose. The key word is "patience" (as you will hear here a lot!).

We didn't have a good reference to start with because it's very unusual to prescribe Lantus for cats here, and we couldn't find a vet with such experience, so we thought it's probably safer to start low but quickly felt we started too low (after 1 cycle.. Patience, Patience, Patience!). We'll definitely go through the stickies again and again, but in the mean while, thank you guys again!

 

[Juliet]

Hi and welcome!
Dimmu is a big kitty! There is a weight formula for beginning Lantus, but I am on my way out the door at the moment and don't have time to look it up. I know that someone will be along very soon who will know what it is. Since Dimmu is such a large cat, you may very well have started at too low a dose, but it is important to increase according to the protocol so you do not bypass a good dose. Often too much insulin can look like too little. Lantus dosing is very different from Caninsulin. It is based on the nadir (how low the blood glucose goes in the 12-hour cycle), not on the blood-glucose number at pre-shot. For this reason we like to get in mid-day tests. If you read the informational posts ("Stickies") at the top of the Lantus/Levemir forum you will have a lot of information (too much information?!) at your fingertips. Start at "New to the Group". It is not necessary to learn everything at once.
One thing is very important to keep in mind: we hold a dose for 6 12-hour cycles before increasing or decreasing. This is because Lantus is a "depot" insulin that leaves some of itself in the cat's body. When you first begin Lantus, or when you change the dose, the depot needs to recalibrate to reflect the new dose. The key word is "patience" (as you will hear here a lot!).
Great job setting up Dimmu's spreadsheet and I see that you are testing regularly. This is super! At some point you will have to decide which of the two protocols you will follow: TR (Tight Regulation; since you are able to test regularly this would be a good choice, especially since you are feeding raw or canned food), or SLGS (Start Low Go Slow). Both are described in one of the Stickies at the top of the forum.
I know that some of the more knowledgeable people here will be able to help you with your specific medical and nutritional questions.
Just want to say: welcome!

Just to clarify - the 6 x 12 hrs cycles for holding a dose is for TR protocol only. If you’re going to follow SLGS you hold the dose for 7 days.

 

[Ella & Rusty & Stu(GA)]

Yep, that's right. Sorry! I forgot about that!

 

[Sienne and Gabby (GA)]

Welcome to the group!

Dimmu is indeed a big boy, even for a Maine Coon!

Can you help me to understand the notations on your spreadsheet? What do the L and R signify? ("R" often refers to a different kind of insulin -- Humuliln R which is a fast acting insulin that can be given in conjunction with Lantus. I suspect this isn't what you're doing.)

Lipase levels are meaningless in cats. They are often elevated in dogs that have pancreatitis. I would not be feeding pancreas unless Dimmu has been diagnosed with exocrine pancreatic insufficiency which is fairly rare and since he hasn't lost a great deal of weight, I think the diagnosis is doubtful. Digestive enzymes are another matter entirely and are likely fine as long as what you're giving is formulated for cats. @Marje and Gracie have more experience than I do with supplements and holistic approaches. This is a link to our Primer on Pancreatitis. Are you seeing any of the symptoms described? Is Dimmu looking like he's in pain? (Pancreatitis is painful) and most cats experience loss of appetite, aren't active, etc. There is a test for pancreatitis, fPLI that is available through IDEXX labs. I don't know if it's available in Europe although when I Googled IDEXX Belgium, a webpage did come up. The Snap fPLI can be done as an in-office test that gives a positive or negative value vs it being sent to the lab for a numerical result.

Your approach -- starting a what is likely a very safe dose for Dimmu makes sense. The dosing formula that Ella wasn't recalling is: initial dose = cat's ideal weight in kilograms x 0.25 or, for a cat his size, approximately 3.0u. With Lantus, the initial dose is held for 5 - 7 days in order for the depot to form. After this period, the dose is increased every 3 days/6 cycles if the lowest point in the cycle, the nadir, is not usually in the normal range. Sandy's recommendation is based on giving the depot an opportunity to become established.

 

[Juliet]

Welcome to the group!

Dimmu is indeed a big boy, even for a Maine Coon!

Can you help me to understand the notations on your spreadsheet? What do the L and R signify? ("R" often refers to a different kind of insulin -- Humuliln R which is a fast acting insulin that can be given in conjunction with Lantus. I suspect this isn't what you're doing.)

Lipase levels are meaningless in cats. They are often elevated in dogs that have pancreatitis. I would not be feeding pancreas unless Dimmu has been diagnosed with exocrine pancreatic insufficiency which is fairly rare and since he hasn't lost a great deal of weight, I think the diagnosis is doubtful. Digestive enzymes are another matter entirely and are likely fine as long as what you're giving is formulated for cats. @Marje and Gracie have more experience than I do with supplements and holistic approaches. This is a link to our Primer on Pancreatitis. Are you seeing any of the symptoms described? Is Dimmu looking like he's in pain? (Pancreatitis is painful) and most cats experience loss of appetite, aren't active, etc. There is a test for pancreatitis, fPLI that is available through IDEXX labs. I don't know if it's available in Europe although when I Googled IDEXX Belgium, a webpage did come up. The Snap fPLI can be done as an in-office test that gives a positive or negative value vs it being sent to the lab for a numerical result.

Your approach -- starting a what is likely a very safe dose for Dimmu makes sense. The dosing formula that Ella wasn't recalling is: initial dose = cat's ideal weight in kilograms x 0.25 or, for a cat his size, approximately 3.0u. With Lantus, the initial dose is held for 5 - 7 days in order for the depot to form. After this period, the dose is increased every 3 days/6 cycles if the lowest point in the cycle, the nadir, is not usually in the normal range. Sandy's recommendation is based on giving the depot an opportunity to become established.

Only on the TR protocol. Starting and holding dose is different for SLGS. Might be worth clarifying that.

 

[Wendy&Neko]

Hello and welcome. My Maine Coon cross girl would have looked like a kitten beside Dimmu! She too was on a raw meat diet. I have seen home made raw diets that say no more than 20% organ meat, and that includes heart and liver. 33% beef pancreas seems like too high. I wouold substitute good quality muscle meat for the protein. Maybe the pancreas is impacting his GI system? Plus I would get rid of the kibbles. Kibbles digest at a much slower rate than raw and mixing the two in the digestive system can cause tummy upset.

Take a read of the Sticky Notes on this forum. As per the one on the Insulin Depot, you need to hold the initial dose to stabilize the depot, then decide where to go in dose from there. Also read our two dosing methods, Tight Regulation and Start Low Go Slow. You test enough for TR and it can get you faster to a better dose, but you have to chose which dosing method works for your lifestyle.

Beautiful part of the world you are in. I used to visit Waterloo often for work. And now I'm thinking of chocolate and fries.

 

[Dimmu & KL]

Thanks everyone for explaining the initial dose and why I should wait for the depot to form.

Welcome to the group!

Dimmu is indeed a big boy, even for a Maine Coon!

Can you help me to understand the notations on your spreadsheet? What do the L and R signify? ("R" often refers to a different kind of insulin -- Humuliln R which is a fast acting insulin that can be given in conjunction with Lantus. I suspect this isn't what you're doing.)

Lipase levels are meaningless in cats. They are often elevated in dogs that have pancreatitis. I would not be feeding pancreas unless Dimmu has been diagnosed with exocrine pancreatic insufficiency which is fairly rare and since he hasn't lost a great deal of weight, I think the diagnosis is doubtful. Digestive enzymes are another matter entirely and are likely fine as long as what you're giving is formulated for cats. @Marje and Gracie have more experience than I do with supplements and holistic approaches. This is a link to our Primer on Pancreatitis. Are you seeing any of the symptoms described? Is Dimmu looking like he's in pain? (Pancreatitis is painful) and most cats experience loss of appetite, aren't active, etc. There is a test for pancreatitis, fPLI that is available through IDEXX labs. I don't know if it's available in Europe although when I Googled IDEXX Belgium, a webpage did come up. The Snap fPLI can be done as an in-office test that gives a positive or negative value vs it being sent to the lab for a numerical result.

I thought the L R notations would be confusing, it's just to help me remember to alternate ears and sides of body when hometesting and giving shots.

Dimmu has never been an active cat, but there are days he's clearly more lethargic and you can tell something is wrong. He also has tensed belly from time to time and it puffs up to the sides (close to the hip joint) a bit if we look from the top, but this only happens when he's constipated. And when this happens, I can still touch and massage his belly to help his bowel movements, and he seems to like it most of the time. I take it it's a sign that he's not in pain? Other then being slow and having stomach issues, he doesn't fit other common pancreatitis symptoms, but again, he also didn't really shows signs for being diabetic.

I found a vet that does the SNAP fPLI, and scheduled an appointment this Friday, am curious what the result would be.

Your approach -- starting a what is likely a very safe dose for Dimmu makes sense. The dosing formula that Ella wasn't recalling is: initial dose = cat's ideal weight in kilograms x 0.25 or, for a cat his size, approximately 3.0u. With Lantus, the initial dose is held for 5 - 7 days in order for the depot to form. After this period, the dose is increased every 3 days/6 cycles if the lowest point in the cycle, the nadir, is not usually in the normal range. Sandy's recommendation is based on giving the depot an opportunity to become established.

Since we started so low, does that mean we have missed the chance to follow TR? Or is there a way to transition from SLGS to TR?

 

[Dimmu & KL]

Hello and welcome. My Maine Coon cross girl would have looked like a kitten beside Dimmu! She too was on a raw meat diet. I have seen home made raw diets that say no more than 20% organ meat, and that includes heart and liver. 33% beef pancreas seems like too high. I wouold substitute good quality muscle meat for the protein. Maybe the pancreas is impacting his GI system? Plus I would get rid of the kibbles. Kibbles digest at a much slower rate than raw and mixing the two in the digestive system can cause tummy upset.

Take a read of the Sticky Notes on this forum. As per the one on the Insulin Depot, you need to hold the initial dose to stabilize the depot, then decide where to go in dose from there. Also read our two dosing methods, Tight Regulation and Start Low Go Slow. You test enough for TR and it can get you faster to a better dose, but you have to chose which dosing method works for your lifestyle.

Beautiful part of the world you are in. I used to visit Waterloo often for work. And now I'm thinking of chocolate and fries.

Will stop with the kibbles, had not idea that kibbles digest at a slower rate, what about freeze dried and dried 100% meat/fish treats?

My boy friend and I got very tired of Amsterdam being ever more crowded and wanted to move abroad. Belgium wasn't our first choice, but the chocolates and fries and beer definitely help a great deal!

 

[Ella & Rusty & Stu(GA)]

Since we started so low, does that mean we have missed the chance to follow TR? Or is there a way to transition from SLGS to TR?

You have not missed any chances. It is up to you (and your schedule) to decide which protocol you want to follow. When you begin Lantus it can take 6 cycles or more (3+ days) to fill the "depot" . During this time some of the insulin will be going into the depot and therefore not available to work on the blood glucose. So you may see higher numbers than you care to see. The 0.75U dose may indeed be too little for a large cat like Dimmu, but you have no way to know until you have been on it for at least 3 days. Actually, the "Sticky" on the TR protocol recommends 5 to 7 days to hold the initial dose when starting Lantus "unless the numbers tell you otherwise." So if the numbers stay high after about 3 days, you probably need to raise the dose.
So monitor Dimmu as well as you can and see what happens. Feline Diabetes is, as they like to say, a marathon--not a sprint. When looking at Dimmu's numbers you can try to determine when the insulin is beginning to act. This is called "onset". Normally with Lantus onset begins about 2 hours after the shot. Blood glucose numbers may rise before onset. After onset they will normally begin to fall until the "nadir" (lowest number of the cycle) is reached. Then there may be a leveling off period (you will see us refer to this as "surfing"--part of our slang), after which numbers will rise to the end of the cycle. This is a rough description. Every Cat Is Different (ECID).
Good luck. And keep on asking questions. The collective knowledge on this board is amazing.

 

[Dimmu & KL]

You have not missed any chances. It is up to you (and your schedule) to decide which protocol you want to follow. When you begin Lantus it can take 6 cycles or more (3+ days) to fill the "depot" . During this time some of the insulin will be going into the depot and therefore not available to work on the blood glucose. So you may see higher numbers than you care to see. The 0.75U dose may indeed be too little for a large cat like Dimmu, but you have no way to know until you have been on it for at least 3 days. Actually, the "Sticky" on the TR protocol recommends 5 to 7 days to hold the initial dose when starting Lantus "unless the numbers tell you otherwise." So if the numbers stay high after about 3 days, you probably need to raise the dose.
So monitor Dimmu as well as you can and see what happens. Feline Diabetes is, as they like to say, a marathon--not a sprint. When looking at Dimmu's numbers you can try to determine when the insulin is beginning to act. This is called "onset". Normally with Lantus onset begins about 2 hours after the shot. Blood glucose numbers may rise before onset. After onset they will normally begin to fall until the "nadir" (lowest number of the cycle) is reached. Then there may be a leveling off period (you will see us refer to this as "surfing"--part of our slang), after which numbers will rise to the end of the cycle. This is a rough description. Every Cat Is Different (ECID).
Good luck. And keep on asking questions. The collective knowledge on this board is amazing.

Thank you, Ella. I was already wondering why I was not able to tell when the nadir might be. On day one the curve was looking like a textbook curve to me and I thought the nadir would be around +6, but then on day 2, it looked like it was a couple hours later, and today the numbers barely changed for 8 hours. So could this be the depot is not properly filled up yet (given that there were no fur shots involved)?

I will hold the initial dose of .75u for 5 days. If I want to follow the TR protocol and his numbers are still high after 5 days, do I increase the the dose to 2.75u immediately (suggested initial dose, 0.25u/kg, according to TR), or do I skip the TR initial dose and build up from the 0.75u he's receiving now? This is what I meant to ask about whether I have missed the chance to follow TR.

Our French is very rusty, and living in the French speaking part of Belgium with a diabetic cat is quite challenging, but like you said, the collective knowledge on this board is amazing, we have learned so much from the members on FDMB and it really helps us a lot!

 

[Wendy&Neko]

Hold the dose for 5 days, then use the data you collect what to do next with the BG's. If he had been solidly in the pink and reds, we might suggest increasing sooner/faster, but you are seeing some yellow. Also, if you aren't already, try to get a before bed test every night. A lot of cats go lower at night, so those before bed tests can be a great indicator of how well a dose is working.

Another thing you are probably seeing in the blood sugar numbers is what we call a "bounce". The definition is in tne New to the Group Sticky note. His body is getting used to insulin. It's a hormone, not a drug, so you'll see a lot of what looks like randomness at first.

 

[Ella & Rusty & Stu(GA)]

If I want to follow the TR protocol and his numbers are still high after 5 days, do I increase the the dose to 2.75u immediately (suggested initial dose, 0.25u/kg, according to TR), or do I skip the TR initial dose and build up from the 0.75u he's receiving now?

I don't think you should go up to 2.75U in one big increase. It would be a shock! The reason the protocols work is because we increase by prescribed amounts (0.25U; under certain circumstances, 0.5U), hold the new dose for the prescribed time, and then see how it is going. With a big cat like Dimmu who might be having numbers that are too high and flat, you might increase by 0.5U, but I believe that it would not be a good idea to increase by more than 0.5U [Someone please correct me if I am wrong. ] The reasoning behind the protocol is that if you increase by too much you could bypass a good dose. Once that happens it can be very difficult to get back on track (too much insulin sometimes produces high numbers just the way that too little insulin does).

I agree with Wendy: hold the dose for 5 days, gather data, and we'll see what happens.

p.s. My previous diabetic cat, Stu, was overdosed by his vet, who raised his insulin by 2 Units every week. The poor kitty almost collapsed. That is when I found this board!

 

[Sienne and Gabby (GA)]

There isn't a missed opportunity since there's no way to know for sure how any cat will respond to insulin. As Wendy noted, we can always fast track the dosing if need be.

Freeze dried, raw, etc. are all fine. The only dry food that isn't permitted is kibble -- especially if you are following TR. It is specifically noted that a cat can't be eating kibble.

Thanks for clarifying the L-R!