? New member - confusing low number and subsequent dose increase. Please help!

Courtnee P

Courtnee P

Member Since 2022
Hi everyone,

Penny was diagnosed in September by a vet that we have since switched over from since she had a very scary hypo episode. We trust our new vet, but I feel like the people on this forum might have some extra insight for us.

Penny eats Tiki Cat Born Carnivore Dry Food. It is the lowest carb dry food she has eaten consistently thus far. We have stopped trying wet food as her pickiness has only increased the stress of trying to get her regulated.

She has been on 2 units of ProZinc twice a day since December 19th. I have attached a spreadsheet that is admittedly sparse on a lot of her numbers. We are home testing with Alpha Trak 2.

Here's where we need some advice: On 12-27 I noticed she was a bit wobbly, so tested her: 39. I flipped out because her last hypo episode in November nearly killed her. I gave her 2 cc karo syrup and a high carb dry meal. Overkill? Maybe. Her number shot up of course, but I still cannot figure out why she had such a low number all of a sudden that day, about 3 hours before her next dose was due. At that point, her clinical signs had began decreasing and she seemed to be feeling better overall. But since that day, clinical signs have increased and I feel like we're starting over again. She is ravenous and drinking a lot of water. Could it be that she was close to needing a dosage decrease, but she is now rebounding from the hypo?

The vet had us do a curve on January 3rd, and yesterday she told us to up the dosage to 2.5. Gave the shot at 7, and By 10:46, Penny was at 60, so we gave her 1 cc of syrup and a regular meal. The rest of the night is documented on the spreadsheet. I am concerned that had we not been testing her, she would have had another hypo episode.

is it possible her dose didn't need to be upped? The vet doesn't think she's rebounding because she is still responding to insulin, but how else can we explain her increase of clinical signs since the hypo on 12-27? I feel like as soon as she starts improving, something happens and we're back to square one.

We are really needing some direction because I am concerned that either we needed to reduce her dose or that we missed it, and the vet is increasing it based on high numbers that might not be telling the whole story. Please help us out! Do we continue with the 2.5??

Edit: Took off original spreadsheet. Updated to one used on forum
 
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So a couple of thoughts:
The dose should have been reduced when you got that 39. Any time you get a number below 90 you should reduce by 0.25U. Since you got a 39 I actually would have reduced by 0.5U-0.75U probably, that's him telling you the dose is far too high. I would not increase dose until you can do a full curve, because right now you have a limited picture of how his cycles go. And if you do increase, it's only in increments of 0.25U. You need to know what nadir is, on a day he isn't bouncing, to accurately determine if dose is too high, low, or right.

I suspect those high numbers are from bouncing - the insulin is taking him too low, and often too fast, so his liver dumps stored glycogen to "help". So I think he's going low the other times you're not testing.

I would reduce to 1.5U and hold that dose for several days to a week. He's going to bounce again if he isn't already, and that can take several days to clear. Once it clears we can get an idea of where to go from there.

Have you been testing ketones?
 
@FrostD I think you've verbalized some of what I've been suspecting is happening behind the scenes. The vet is suggesting dosage increases but I don't believe she's taking the 39 into enough consideration. It was there for a reason! I agree that there have probably been other low numbers we've missed.

We have not been testing ketones, but we have the strips. That is my concern if we do reduce to 1.5, even if that's the best call... what if her numbers skyrocket? Will her body freak out with the reduction if insulin? How often would we need to test for ketones?
 
Her numbers probably will go up overall for a bit, but first she needs to settle down without all the wild BG swings. So you give her a week or so at that dose, do a curve, then see where she's at. If nadirs are right around 100, nothing to do but be patient, hold the dose, and wait for numbers to come down overall. The key is have to do a curve on a day they're not bouncing.
 
Ok, starting 1/7/22, we tried 2u again for 10 full days. The lowest she ever got (by our tests) was 193 on the 16th. I have updated the spreadsheet. Her morning pre-shot tests remained in the range of 400 & 600 the entire time. Shouldn't 10 days have been enough time for her numbers to start going back down again? They just didn't, really. Is it possible her insulin needs have just increased?

Since her numbers remained consistently high, we bumped her to 2.25u the evening of the 18th. Her reading was HI this morning- first time that has happened in a while. :( Is that maybe a response to the increased dose? She's ravenous and I just feel so bad for her. We would love your input, @FrostD .
 
I can't say for sure since there aren't a lot of nighttime tests, she could be going lower at night and causing those bounces. But based on what you do have, you could increase to 2.25U.

The insulin is definitely working, she just keeps bouncing. So, you have two options - stick with it and see if she settles down, this could take a month or more. OR try a more gentle insulin like Lantus (or biosimilar semglee), I'd recommend the latter.

@Ashleigh & Ares is good example of how switching a bouncy cat to Lantus/semglee can help immensely
 
@FrostD yes, we have bumped her to 2.25. We've just been assuming her nighttime numbers look similar to daytime, but maybe we should start testing at night more often. She was initially on Vetsulin and changed to ProZinc about 2 months ago. The last time we switched insulins our vet had us start back at 1u again. Would that need to happen again if she is switched to Lantus?
 
Courtnee P said:
@FrostD yes, we have bumped her to 2.25. We've just been assuming her nighttime numbers look similar to daytime, but maybe we should start testing at night more often. She was initially on Vetsulin and changed to ProZinc about 2 months ago. The last time we switched insulins our vet had us start back at 1u again. Would that need to happen again if she is switched to Lantus?
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Whether you have to begin again or not (i cant say, not qualified enough), i would absolutely recommend getting lantus / semglee. It has made a whole world if difference for my Lil guy.
Also, i know it REALLY sucks having to set an alrm for middle of night, but is important to get some tests then. Ares could be blue all day and get low at night...i try to get at least one test in the wee AM hours and if kinda low, i will stay up for up to an hour to get another, just to make sure...of course depending on what numbers u get, u cud be up longer or shorter.....

Best of luck to you and Penny!
 
@Ashleigh & Ares I really appreciate your input! We've been trying to get this girl regulated going on 4 months now... I do get the feeling she is an especially sensitive kitty. So maybe having a talk with the vet about Lantus is a good idea. I think we'll give the 2.25 u a go for the next 2 weeks to a month or so, and if that doesn't help, try a different insulin.
 
I wouldn't hold the dose that long. Re-evaluate weekly, and if you aren't seeing nadirs getting close to 90, then increase by 0.25U. The longer her numbers stay high, the more glucose toxicity sets in, and you run the risk of neuropathy, ketones, possible kidney damage, etc.
 
@FrostD , will she not continue to bounce with increased doses anyways? She’s actually bounced to higher numbers so far with the 2.25u than she was with the 2u. So it seems like as long as she’s bouncing, her numbers will be sustained high regardless. How long is one supposed to wait for a bounce to level out before increasing the dose, especially if increasing will just cause continued/more pronounced bouncing, if that makes sense? That’s what I’m worried about. I’m still concerned that she has been bouncing around so much that maybe we missed a correct, lower dose, but I have no way of knowing.
 
Courtnee P said:
@FrostD , will she not continue to bounce with increased doses anyways? She’s actually bounced to higher numbers so far with the 2.25u than she was with the 2u. So it seems like as long as she’s bouncing, her numbers will be sustained high regardless. How long is one supposed to wait for a bounce to level out before increasing the dose, especially if increasing will just cause continued/more pronounced bouncing, if that makes sense? That’s what I’m worried about. I’m still concerned that she has been bouncing around so much that maybe we missed a correct, lower dose, but I have no way of knowing.
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This is why I recommended Lantus (or biosimilar semglee).

On ProZinc - If she's going to bounce anyway, hopefully increasing the dose at least keeps her in better numbers a little longer. I did mention you can hold the dose and see if she settles down, but then you run the risk of the other stuff - ketones, neuropathy, kidney damage, etc.

Unfortunately this is just one of those things where you have to decide what works best for you and your cat, there's no solid right answer. Again, if it were me, I'd try Lantus or semglee
 
FrostD said:
This is why I recommended Lantus (or biosimilar semglee).

On ProZinc - If she's going to bounce anyway, hopefully increasing the dose at least keeps her in better numbers a little longer. I did mention you can hold the dose and see if she settles down, but then you run the risk of the other stuff - ketones, neuropathy, kidney damage, etc.

Unfortunately this is just one of those things where you have to decide what works best for you and your cat, there's no solid right answer. Again, if it were me, I'd try Lantus or semglee
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Ok, I see what you’re saying. We do have ketone strips that we can use. I think we’ll try this 2.25u for at least a week then and do a curve; from there we’ll talk to the vet about possibly changing the insulin if she is still not where she needs to be. Your input has been so helpful.
 
Sorry I realized that came off as a bit of a tone - none intended! Was just trying to get a reply in quickly
 
Ok @FrostD and @Ashleigh & Ares , I am planning on doing a curve this weekend at the 2.25u, but something is really bothering me... Look at these numbers from about a month ago (readings are from when she had a FreeStyle Libre monitor), when she was at a 1.5u dose. These are two of her best days. She was bouncing a bit on the days before and after, but her numbers were lower overall during this period of time than they are now. I can't shake the feeling that we have missed the correct dose within the last month, and the high numbers we're seeing now are from her constantly bouncing because she is getting too much. How do I know this isn't happening?? If that's not the case, is it really possible that her insulin needs could have changed so much in just a single month?

I'm worried her body is trying to tell me something I've missed, and I am SO afraid of increasing her dose again this weekend if the numbers on her curve are only high due to bouncing.

December 13
https://drive.google.com/file/d/1NBWQ6dqhfZXnJm5VMAABtn2OIzJSngrR/view?usp=sharing

December 17
https://drive.google.com/file/d/1zbilzzQpdqKVK_WDBrQpUBM706TgykhZ/view?usp=sharing
 
i cant giv dosing advice, but i have read on some posts here that the freestyle gives readings that may differ from what u get w an ear prick.
 
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I really do need to see it in our standard spreadsheet when you get a chance. I personally don't have a lot of faith in the Libre, I've seen it wrong more often than I've seen it correct. That's not to say it isn't possible! Those bounces are definitely from lower numbers, question is how low.

What you need to do is a curve on a non-bounce day...without seeing our typical spreadsheet it's hard for me to tell you how to identify a non bounce day based on her trends. The other option is when you see those low numbers (blue and lower, especially green) cross check with a human meter
 
@FrostD How do I go about creating/posting that spreadsheet? Is there a template somewhere I can use? I will do it as soon as possible!

Edit: I found yours and I'll use that as template.
 
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Courtnee P said:
@FrostD How do I go about creating/posting that spreadsheet? Is there a template somewhere I can use? I will do it as soon as possible!

Edit: I found yours and I'll use that as template.
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if u have trouble using @FrostD 's under the main Forums, there is whole board on spreadsheets. lots of info on how to set up and links to make copies
 
FrostD said:
Do you have a human or pet meter? Besides the libre
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Yes, we use an AlphaTRAK 2 for all of her tests. We do have a human meter, the ReliOn one, but we haven’t used it on her. I don’t know how to convert the numbers. She no longer wears the Libre monitor.
 
Courtnee P said:
Yes, we use an AlphaTRAK 2 for all of her tests. We do have a human meter, the ReliOn one, but we haven’t used it on her. I don’t know how to convert the numbers. She no longer wears the Libre monitor.
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There is no conversion between meters, we just take the numbers at face value.

When was the Libre taken off?

@Bandit's Mom thoughts for how to handle the spreadsheet here? 2021 tab would be a mix of Libre and AT. 2022 not sure

Sorry if I've asked before - do you withhold food for 2 hrs before preshot? Based on the data you do have, looks like your best bet is to do a curve on a day you get a preshot that is about 425 or lower. The higher ones seem to indicate she's bouncing..it's good data to have, but it doesn't tell us how low she goes when not bouncing, and that's what's important
 
FrostD said:
There is no conversion between meters, we just take the numbers at face value.

When was the Libre taken off?

@Bandit's Mom thoughts for how to handle the spreadsheet here? 2021 tab would be a mix of Libre and AT. 2022 not sure

Sorry if I've asked before - do you withhold food for 2 hrs before preshot? Based on the data you do have, looks like your best bet is to do a curve on a day you get a preshot that is about 425 or lower. The higher ones seem to indicate she's bouncing..it's good data to have, but it doesn't tell us how low she goes when not bouncing, and that's what's important
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Our last Libre readings are from December 18th. That's when we started using the AlpaTRAK. Should I include the libre readings when I make the spreadsheet?

We do her preshots within 5 minutes after she is finished eating, and she does not eat any food between those 2 mealtimes (6:30 AM & PM). Pretty much of all her preshots within the last week have been around 500 on average. I am going to work on the spreadsheet this morning. Should have it up late morning/early afternoon.
 
@FrostD I have posted the spreadsheet with her January and late December numbers. The furthest my data goes back is late November, but I did not record dosing details at that time or the day that we switched from Vetsulin to ProZinc. Waiting on that info from the vet, and then I'll fill in what I can for 2021. The data will still be pretty spotty during that time.

However, do you have any thoughts based on what you see for late December & January?
 
Thanks!

First thought is she is just an incredibly bouncy cat, and there's not exactly a solid way to predict bounce clearing cycles. So just do the curve whenever is convenient and we'll make some educated inferences if it's bounce cycle.

Second thought is we're going to have to tweak that feeding schedule to hopefully slow these bounces. It would be wise to do this regardless of which insulin you stick with. I would divide her food up into 6 even meals actually, get an autofeeder if you don't already have one. #1 at AMPS, #2 @ AM+1, #3 @ AM+3, #4@PMPS, #5@PM+1, and #6@PM+3. Doing that will get her carbs at strategic times to hopefully slow/prevent those huge drops, and hopefully help her even out overall. That means her nadir will become higher, but that's the intent - it will allow you to raise the dose safely while keeping her curve flatter.

It will take more than a week to see results. Not sure how much of your vial is left, but I'd give her about 2-3 weeks with a new feeding schedule to see how she does
 
FrostD said:
Thanks!

First thought is she is just an incredibly bouncy cat, and there's not exactly a solid way to predict bounce clearing cycles. So just do the curve whenever is convenient and we'll make some educated inferences if it's bounce cycle.

Second thought is we're going to have to tweak that feeding schedule to hopefully slow these bounces. It would be wise to do this regardless of which insulin you stick with. I would divide her food up into 6 even meals actually, get an autofeeder if you don't already have one. #1 at AMPS, #2 @ AM+1, #3 @ AM+3, #4@PMPS, #5@PM+1, and #6@PM+3. Doing that will get her carbs at strategic times to hopefully slow/prevent those huge drops, and hopefully help her even out overall. That means her nadir will become higher, but that's the intent - it will allow you to raise the dose safely while keeping her curve flatter.

It will take more than a week to see results. Not sure how much of your vial is left, but I'd give her about 2-3 weeks with a new feeding schedule to see how she does
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That makes sense. There definitely is no way to make the multiple meals happen without an autofeeder, and at that, we have 2 cats, so I'm not sure how feasible that will be for us. What about 3 meals a day? And would you recommend doing a curve/increasing meal # in lieu of asking about switching to Lantus? I have been reading about Lantus and does sound like a better fit for her, especially if she is super bouncy.
 
Courtnee P said:
That makes sense. There definitely is no way to make the multiple meals happen without an autofeeder, and at that, we have 2 cats, so I'm not sure how feasible that will be for us. What about 3 meals a day? And would you recommend doing a curve/increasing meal # in lieu of asking about switching to Lantus? I have been reading about Lantus and does sound like a better fit for her, especially if she is super bouncy.
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Yeah multiple cats make it difficult. They do make RFID smart feeders but those can be $$$$.

Can you do 4 meals possibly? The preshots, and +1.5? I'd try that for maybe 2 weeks and see. With the way she reacts to ProZinc she really needs that +1.5 meal in both cycles, at minimum.

The Lantus/semglee is up to you. I do think it would be a better insulin for her regardless, but if financially you need to make the ProZinc work longer the meal split should help. Perhaps the vet could write a script just to have? Or you could just call them in a week or two once you make a decision?
 
FrostD said:
Can you do 4 meals possibly? The preshots, and +1.5? I'd try that for maybe 2 weeks and see. With the way she reacts to ProZinc she really needs that +1.5 meal in both cycles, at minimum.
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We could hypothetically do 5 meals, if we move her shot time back an hour. Realistically, though... we have busy weeks and are often not home on weekday evenings when we would need to do the 2nd cycle +1.5 meal. We aren't home at consistent times in the evenings (aside from shot times). It seems like we'd never be able to leave/plan anything. A preshot morning meal, +1.5, +5, and preshot evening meal are the only ones we could reliably do at the same time. Other evening meals would depend on what we have going on that week. I would rather not commit to that many meals if any inconsistencies will defeat the purpose of doing it.

I would love to get a microchip feeder... maybe for my bday in a few months. Wouldn't be the first time Penny got a gift on my bday :rolleyes:

Do you think it's worth doing a curve on Saturday or should we go ahead and up to 2.5? I am getting increasingly worried/impatient as she's starting to show some signs of neuropathy and has been absolutely ravenous the past couple weeks. It's killing me knowing how unregulated she still is. Just want her to feel better!
 
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Yes, safe to increase. You could go up 0.5 if you wanted but might not help bouncing. Could always try it a few cycles and see. More conservative would be 0.25U.

Sorry if I've asked, are you giving B12 for neuropathy?
 
FrostD said:
Yes, safe to increase. You could go up 0.5 if you wanted but might not help bouncing. Could always try it a few cycles and see. More conservative would be 0.25U.

Sorry if I've asked, are you giving B12 for neuropathy?
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Am not. Is that something we can ask the vet for? We did go ahead and do the curve yesterday and increased to 2.5 starting last night.
 
@FrostD Numbers have definitely come down a bit over the last week, but pre-shots are still high. Seems like she definitely goes lower at night. I think we will do another curve this weekend. What are your thoughts on dosing higher in the mornings than in the evenings?
 
It's very common for cats to go lower at night because they're nocturnal, and AMPS are also often higher for that same reason (like how your own blood sugar is the opposite - highest before bed but lowest in the morning).

I wouldn't do split dosing yet. It looks like she is bouncing during the daytime cycles, eventually (hopefully) she'll settle down and won't do that as much.

You have a good variety of tests, I'd say you're good to increase to 2.75U. but if you want to do it "by the book" yes.you can do a curve. I just don't want to hold this dose any longer than necessary, already 10 days. I also suspect a curve will be exactly what happened last time, not going to tell you a whole lot because her night numbers are lowest
 
There's probably no harm in going up 0.5U, we usually say if most nadirs are above 200 then it's ok. You just got those string of mid blues a few nights, plus the gaps in testing - I'm saying 0.25U on the conservative side. Totally your call.
 
@FrostD Penny's nadir was 73 today. Her pre-shots are still higher than they need to be but not as crazy high as they were. Should we decrease .25U starting her PM shot because of the 73? For how long? We were going to do a curve at the 2.75U this weekend but according to the ProZinc dosing methods we should go ahead and decrease... this is new territory for us and I'm confused as to why after only 6 days at 2.75U she would need to decrease to 2.5U when we already had her there for 10 days. Thoughts?

Next question is if she continues to bounce to high numbers even with low nadirs, how long do we try to wait that out before trying something different like Lantus?
 
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Awesome! I would proactively decrease by 0.25U. not quite sure how low she went today, or the days without mid cycle tests. That should put nadir hopefully right around 90-100, and possibly lessen bouncing.

I'd give her about 3 weeks of consistently blue/green nadirs to see some progress on lower preshots/less bouncing/more duration. If there's no change at all, I'd think about Lantus...but sometimes the same thing does happen on Lantus just less dramatically. If she does make progress, we can think about it then and if it's "enough" progress to keep sticking with it.

Edit: you haven't selected a dosing method, or at least it's not in your signature. The more "aggressive" one requires a low carb wet diet and reduces below 50 on a human meter, but would require a midcycle test every cycle which you currently aren't doing. The more conservative one reduces below 90. https://www.felinediabetes.com/FDMB/threads/prozinc-dosing-methods.225629/
 
FrostD said:
Awesome! I would proactively decrease by 0.25U. not quite sure how low she went today, or the days without mid cycle tests. That should put nadir hopefully right around 90-100, and possibly lessen bouncing.

I'd give her about 3 weeks of consistently blue/green nadirs to see some progress on lower preshots/less bouncing/more duration. If there's no change at all, I'd think about Lantus...but sometimes the same thing does happen on Lantus just less dramatically. If she does make progress, we can think about it then and if it's "enough" progress to keep sticking with it.

Edit: you haven't selected a dosing method, or at least it's not in your signature. The more "aggressive" one requires a low carb wet diet and reduces below 50 on a human meter, but would require a midcycle test every cycle which you currently aren't doing. The more conservative one reduces below 90. https://www.felinediabetes.com/FDMB/threads/prozinc-dosing-methods.225629/
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Considering this is the first green number we've gotten on this dose, do you think we should stay with 2.75U tonight and see if her nadir goes that low again before reducing? I am hesitant to reduce without being on the same page as my vet (she has advised us not to change doses without consulting her), so I'm trying to balance the advice I get here with hers. We are using the SLGS method.
 
So with SLGS you would reduce because she went below 90.

You can hold the dose if you'd like, but when is the next time you talk to the vet? If you hold, make sure you have a hypo kit and get a +4 every cycle. She may have gone near 50 today
 
FrostD said:
So with SLGS you would reduce because she went below 90.

You can hold the dose if you'd like, but when is the next time you talk to the vet? If you hold, make sure you have a hypo kit and get a +4 every cycle. She may have gone near 50 today
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I should hear from the vet tomorrow. I'm planning on testing her +4 and +6. We have karo syrup and high carb food ready if needed. I gave her a small bit of food when I got the 73 earlier- might not have been totally necessary, but the low numbers scare me after our past experience with a hypo episode.
 
@FrostD Penny's nadirs have been good the past few days after a decrease to 2.5U (she was at 87 last night) but she's definitely bouncing still. Today her nadir was 300, about 200 more than it's been in almost a week. Any thoughts on that?
 
Bounces can last up to 6 cycles.

What did vet say?

It's entirely possible she was much lower than 87 last night, she nadirs at +4 sometimes. I also would have taken another test about half an hour after the 87 to make sure she wasn't still dropping. Given that, I'd move night testing to maybe start at +3 or +4 to stay ahead of low numbers. I'd also reduce to 2.25U.

Hoping those preshots come down, she's having such big swings
 
@FrostD The vet agreed with the decrease to 2.5U a few days ago, but the numbers have already gotten low again in 4 days. I'm waiting to hear back from her about another decrease to 2.25U. The vet doesn't like the bounces either and mentioned trying lantus if things don't settle down soon. Penny has bounced since she got diagnosed though so I'm anticipating an insulin change over the next few weeks.
 
I think insulin change would be good, just might take a little longer to come down overall since Lantus is gentle - takes longer to bring down numbers but keeps them flat. But some cats behave almost exactly the same on it and ProZinc lol it's a wild card lately.
 
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