New member, diagnosed 5 June

[Cloe & Jake]

Hello!

Thanks for this wonderful resource, this disease would be so overwhelming without all you experts to provide advice and protocols.

My 17 year old baby Jake was diagnosed with diabetes on the 5th June with a BGL of 42 (765). Believe it or not, he had normal BGLs on his bloods 10 days and 4 weeks prior! He had had many blood tests due to extreme thirst and then developed wobbliness when he was finally diagnosed. He commenced on toujeo and has had a very poor, but variable response to this. On 3 units, he would consistently hypo due to the large overlap of doses (usually nadir around + 14 hrs) but with 2 units, we couldn't get him below 20 (360). He also has CKD with severe proteinuria (UPC 1.5), which complicates his treatment. His specialist vet wants to change to actrapid and/or senvelgo treatment, but these both seem high risk to me...

This week, I have changed Jake to Glargine U100 (optisulin) to allow syringe dosing with half units. The response has been variable, with some days having nadirs of 6-9 (110-160), and others not dropping below HI (500+). When there is a response, the curve seems more predictable for 12 hourly dosing though. While not perfect, this already seems better than the almost three months of Toujeo.

His diet is medium carb as I am juggling other health issues with him too. The wet (which is most of his diet) is 12% ME carbs, this is a renal diet and the best I could find for carbs with his kidney needs. The dry is 9% ME carbs, but the lower carb options were too high in phosphorus for his kidneys. I am hoping this is an okay compromise. He eats very little dry compared to wet.

I would really appreciate your input on his spreadsheet and dosing. He changed to glargine on the 21st Aug. Should I maintain the 2.5 unit dose as some days it has a good response or should I increase to 3 units? I wish to do the tight regulation dosing or as close to that as possible. He has CGM via freestyle libre, however I work outside of the home so it is hard for me to treat hypos promptly if I am at work so this needs to be taken into account. The vet gets me to administer glucose when BGL is below 5 (90).

Thanks!

Cloe & Jake

 

[Tim & Pookey]

Hey Cloe, nice job getting everything set up and welcome. Bumping your post to the top…

 

[Sienne and Gabby (GA)]

Welcome to FDMB!

I'm not sure why your vet suggested Senvelgo. If a cat has been previously treated with insulin, Senvelgo is contraindicated. Actrapid, which is a fast acting insulin, at least in the US, looks like it's only used for managing diabetic ketoacidosis. It's not used as a general treatment for feline diabetes.

I'm glad you made the switch to glargine. Frankly, there's not much research on the use of Toujeo in cats. We actually set up an insulin support group for it's use and the traffic on that board is nonexistent. The traffic on our Lantus board, on the other hand, is enormous. In fact, I'd encourage you to read the sticky notes at the top of the Lantus board. I think your having a broader understanding of how glargine works will be helpful. I'd strongly recommend you take a look at the post on dosing methods. Many of us more senior members here are old hands at TR. It's a great method for managing your cat's diabetes. We have the instructions laid out in the dosing methods post.

I have a couple of thoughts. Lantus/glargine dosing is based on the lowest number in the cycle (i.e., the nadir). You do not adjust the dose based on the pre-shot numbers unless the number is unexpectedly low. Typically, you hold the dose at least 3 days (if following Tight Regulation) or a week with Start Low Go Slow. You've been holding Jake's doses much longer. Holding a dose that isn't getting your cat into the blood glucose range that closer to normal can cause glucose toxicity. The name of this is awful but what it means is that your cat's body begins to treat the higher numbers as his new "normal."

The other thing I think is happening is that Jake is "bouncing." His body isn't used to spending time in closer to normal numbers. When he drops into lower numbers, drops into a range his body misinterprets, or his numbers drop fast, his liver and pancreas panic. They release a stored form of glucose along with counterregulatory hormones that cause numbers to spike upward. The bounce can last for several days.

Regarding food, if your cat is on a renal diet, have you given any thought to the use of a phosphorus binder? You cat could eat any canned food since th binder will prevent any problems with kidney issues. If you've not already found this site, Tanya's guide to feline kidney disease is a wonderful resource. Is there a reason you're feeding your cat any dry food?

I'm also tagging one of our members who's in Australia. Bron may be aware of additional resources. @Bron and Sheba (GA)

 

[Cloe & Jake]

Welcome to FDMB!

I'm not sure why your vet suggested Senvelgo. If a cat has been previously treated with insulin, Senvelgo is contraindicated. Actrapid, which is a fast acting insulin, at least in the US, looks like it's only used for managing diabetic ketoacidosis. It's not used as a general treatment for feline diabetes.

I'm glad you made the switch to glargine. Frankly, there's not much research on the use of Toujeo in cats. We actually set up an insulin support group for it's use and the traffic on that board is nonexistent. The traffic on our Lantus board, on the other hand, is enormous. In fact, I'd encourage you to read the sticky notes at the top of the Lantus board. I think your having a broader understanding of how glargine works will be helpful. I'd strongly recommend you take a look at the post on dosing methods. Many of us more senior members here are old hands at TR. It's a great method for managing your cat's diabetes. We have the instructions laid out in the dosing methods post.

I have a couple of thoughts. Lantus/glargine dosing is based on the lowest number in the cycle (i.e., the nadir). You do not adjust the dose based on the pre-shot numbers unless the number is unexpectedly low. Typically, you hold the dose at least 3 days (if following Tight Regulation) or a week with Start Low Go Slow. You've been holding Jake's doses much longer. Holding a dose that isn't getting your cat into the blood glucose range that closer to normal can cause glucose toxicity. The name of this is awful but what it means is that your cat's body begins to treat the higher numbers as his new "normal."

The other thing I think is happening is that Jake is "bouncing." His body isn't used to spending time in closer to normal numbers. When he drops into lower numbers, drops into a range his body misinterprets, or his numbers drop fast, his liver and pancreas panic. They release a stored form of glucose along with counterregulatory hormones that cause numbers to spike upward. The bounce can last for several days.

Regarding food, if your cat is on a renal diet, have you given any thought to the use of a phosphorus binder? You cat could eat any canned food since th binder will prevent any problems with kidney issues. If you've not already found this site, Tanya's guide to feline kidney disease is a wonderful resource. Is there a reason you're feeding your cat any dry food?

I'm also tagging one of our members who's in Australia. Bron may be aware of additional resources. @Bron and Sheba (GA)

Thanks for the welcome
I had been following the vet’s advice on dosing but I’m frustrated with the lack of results so I have decided to do my own thing now and look at the protocols and evidence instead, which seem to suggest different things to what she is telling me to do. When I asked about the senvelgo, she just told me specialists know more than me and she doesn’t have time to go through the evidence… though the manufacturers guidelines clearly say it is not for use with insulin dependent diabetics! Anyway, that is why I had been holding doses for long periods.
If Jake is bouncing now, should I hold his current 2.5 dose and wait that out, or should I increase it anyway?
As for diet, unfortunately it’s more the protein content that is the issue with his severe proteinuria rather than phosphorus otherwise a binder would be much easier! He only has minimal dry and it’s mainly there incase he runs low while I’m not home. The vet did tell me he must have dry food access at all times for this but mainly a wet diet otherwise, which is what I’ve done.
Thanks for your help

 

[Bron and Sheba (GA)]

Hi and Welcome Cloe and Jake.
I agree with everything Sienne was said. My Sheba was a real bouncer and it can be frustrating and confusing as to what to do with the dose until you understand what bouncing is. As Sienne said, glargine dosing is based on the nadir, so if Jake is getting blue BGs on 2.5 units, I would wait at least 10 cycles before increasing. Try not to be freaked out with the higher numbers that the bouncing is creating.

What dry food are you feeding? All dry food in Australia is high carb. The lowest carb would be Hills diabetic which is around 17% carbs which is high carb but not nearly as high as most other dry foods.

What wet food are you feeding?
What stage CRD is he? Oh I see stage 3. Unless he is very advanced, the current thinking is nit to restrict the protein.
What medications is he on?
I’m glad you found us

 

[Cloe & Jake]

Hi and Welcome Cloe and Jake.
I agree with everything Sienne was said. My Sheba was a real bouncer and it can be frustrating and confusing as to what to do with the dose until you understand what bouncing is. As Sienne said, glargine dosing is based on the nadir, so if Jake is getting blue BGs on 2.5 units, I would wait at least 10 cycles before increasing. Try not to be freaked out with the higher numbers that the bouncing is creating.

What dry food are you feeding? All dry food in Australia is high carb. The lowest carb would be Hills diabetic which is around 17% carbs which is high carb but not nearly as high as most other dry foods.

What wet food are you feeding?
What stage CRD is he? Oh I see stage 3. Unless he is very advanced, the current thinking is nit to restrict the protein.
What medications is he on?
I’m glad you found us

Hi Bron, thanks for your reply. I will hold on increasing for a few more days and see how we go. I am feeling optimistic with the glargine so hopefully we can break through the bouncing. The food is the Hills M/D - the website says 15% carbs dry matter and when I worked out the calories from carbs percentage I thought it was 9% but perhaps I miscalculated. He was on K/D before that so it’s a huge improvement but it is high in protein so not ideal but these sugars would be destroying his kidneys anyway so I’m trying to compromise. The wet food is Purina Pro Plan Vet Renal Advanced pouches. I think the thinking is to reduce protein due to his severe proteinuria as this has very poor prognosis regardless of CKD stage sadly. He isn’t on any medications as they can’t start him on one for the proteinuria until he is stable with his diabetes and dehydration etc. His electrolytes are improving thankfully so hopefully with the new insulin we can get everything looking a bit more positive

 

[Bron and Sheba (GA)]

He isn’t on any medications as they can’t start him on one for the proteinuria until he is stable with his diabetes and dehydration etc. His electrolytes are improving thankfully so hopefully with the new insulin we can get everything looking a bit more positive

My Sheba was on benazapril for proteinuria and she was certainly not stable at the time. I’m going to ask @Wendy&Neko and @Suzanne & Darcy to comment on that.
A good protein which is a pure protein and low in phosphorus is cooked egg white. I used to give it to Sheba. I would hard boil the eggs and mash the egg white in her food and she ate it ok.

 

[Wendy&Neko]

The vet did tell me he must have dry food access at all times for this but mainly a wet diet otherwise,

Huh? That's the first time I've ever heard that. Wet food is best for kidney cats.

My Neko had stage 3 CKD, as well as the diabetes and heart disease and small lymphoma. And was put on benazapril when her UPCR hit 1.0. It did get as high as 1.4. You really do want to treat for the proteinuria now or the kidney disease will progress more quickly. Telmisartan is an alternative medication sometimes used for proteinuria now. Any chance you can get a referral to an internal medicine vet. Seems Jake may be out of your vets wheelhouse now. IM vets are great for complicated cases, and prioritizing issues and balancing meds. An aside, Neko's IM vet said her raw diet was the best thing she could be on.

A favour to ask on the spreadsheet, could you put a blank line between the days you stopped using Toujeo and started using Lantus (good move). And label it "start Lantus". That blank line makes it easier for us to see the change. Typically starting doses are held for 5-7 days to build the Lantus depot. It looks like you just held for 3.5 days?

 

[Cloe & Jake]

Huh? That's the first time I've ever heard that. Wet food is best for kidney cats.

My Neko had stage 3 CKD, as well as the diabetes and heart disease and small lymphoma. And was put on benazapril when her UPCR hit 1.0. It did get as high as 1.4. You really do want to treat for the proteinuria now or the kidney disease will progress more quickly. Telmisartan is an alternative medication sometimes used for proteinuria now. Any chance you can get a referral to an internal medicine vet. Seems Jake may be out of your vets wheelhouse now. IM vets are great for complicated cases, and prioritizing issues and balancing meds. An aside, Neko's IM vet said her raw diet was the best thing she could be on.

A favour to ask on the spreadsheet, could you put a blank line between the days you stopped using Toujeo and started using Lantus (good move). And label it "start Lantus". That blank line makes it easier for us to see the change. Typically starting doses are held for 5-7 days to build the Lantus depot. It looks like you just held for 3.5 days?

This advice is all from an internal medicine specialist! Honestly, I thought the general vet’s advice to change to a low carb food and glargine rather than Toujeo was more logical than the specialist’s plan to add actrapid and senvelgo so I have done that instead… but they are just following the specialist on the kidney stuff. I’ll fix the spreadsheet. I went up after six doses as I thought that’s what the TR post said to do if having nadirs over 300 but now I see that is bouncing. I’ve held on with the 2.5 now and haven’t increased further.

 

[Wendy&Neko]

If all the numbers are above 300, you can go up after six doses, but he did see some numbers below 200 on the 2.0 units. Think about answering the question "how low can this dose take my cat?". Numbers under 200 mean you increase by 0.25 units, but after 6-10 cycles. You'd hold longer for low 100's (blues), less for high blues. So far he's see a 133 on this dose.

A note about the World version of the spreadsheet, it doesn't translate "Hi" to the US version, so you have to manually go and replace those on the US tab.