New Member - Insulin Resistance - Dosing & Feeding Advice Sought

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Linda & Steve

Linda & Steve

Member Since 2019
I have been on the Facebook group for a while but first time posting here. I am looking for advice in general. My cat has has been insulin resistant for a while now. I am at a new vet who seems to be managing this better than the last one. Looking for advice on my feeding routine and if there are any pointers with the Lantus dosing. I do know about the types of food and checking BGs & Ketones, etc.

My questions are:
  • Is feeding him so frequently adding to the high BGs? Should I space out food and give larger quantity or does it not matter?
  • Is there any advice/pointers re: the Lantus dosing? I just did a curve this weekend and I anticipate hearing from my vet to increase to 4U or she's probably going to refer me to an internist to test for acromegaly.
  • Are there any other medical conditions I should be aware of that could cause insulin resistance?
  • What are next steps with an insulin resistant cat?
Steve is 12 years old and was diagnosed with diabetes July 2019. When I started tracking BGs his #s were in the high 200 & 300s then suddenly Nov 2019 his #s spiked into the 500s. Vet had no answers...just increased Prozinc. However FDMB Facebook Group suggested dose might be too high. Worked to decrease dose and saw no change and vet increased dose back up without really seeing any change.

We are now at a new vet at the animal hospital where Steve stayed for 3 days during his DKA episode in January this year. During this hospital stay they also diagnosed pancreatitis. Steve was given Cerenia and Omeprazole which he is now off of. Steve also has some dental issues but new vet wants to get diabetes under control before subjecting him to anesthesia (old vet said stomatits, new vet not disagrees).

Steve is has been switched to Lantus since Feb 27, 2021. Starting dose was 2U in am & pm. Dose increased to 3U am & pm since March 12, 2021. I just performed a second curve this past Sat. Awaiting recommendation from vet. New vet has mentioned acromegaly but Steve has not been tested for it yet as the vet is trying to see if Lantus will work (not looking good so far).

Steve is a hungry-hungry-hippo. He is fed about 4 cans of Fancy Feast pate daily:
- 8am - 1 can - insulin dosing time
- 10am - 1/3 can
- 12pm - 1/3 can
- 2pm - 1/3 can
- 5pm - 1/2 can
- 8pm - 1 can - insulin dosing time
- 10pm - 1/3 can

I test pre-shot am & pm (but honestly his BGs have been high for so long I sometimes give the poor guy a break).

All in all, Steve has been doing much better since his DKA episode in January. He does not look so worn out at the end of the day, with glazed over eyes, hugging his water bowl. He still urinates large volumes and eats and drinks a lot. He also does not groom himself much at all (possibly because of dental issues but he's been this way almost since the beginning of being diagnosed with diabetes).

Links to BG spreadsheets:

Spreadsheet for Lantus Only: https://docs.google.com/spreadsheets/d/1voznTOuVEBPOyZpOVKe1mpf72O9FJQ3-c3ue7nAwMo4/edit?usp=sharing

Spreadsheet of ALL BG readings:
https://docs.google.com/spreadsheets/d/1ToaPKvNzpR-Ew2HF18ICz_GbZqlL6AauCXwZSWuJxxw/edit?usp=sharing
 
Poor Steve....I don't blame him for not grooming. Those are some ugly numbers but:

it looks like you were started at a high dose from the beginning and 2U is the least he's ever been on and then dose changes have been mostly in whole units (with some half unit). It's totally possible he needs a higher dose, but before I'd suggest changing the dose, I'd like to see some more tests. Lantus dosing is based on how low it takes them which means you need to be getting mid-cycle tests on the AM cycle and some "before bed" tests on the PM cycle. If you can't do mid-cycle tests due to work, it's even more important for you to get some testing on the PM cycle and any other time you can.

We don't suggest testing for acromegaly or IAA until they're above 6 units twice a day, but we also want to have started low and gone up in .25 to .5 unit increments to make sure we didn't bypass what might have been a good dose.

As for feeding, I think you're doing fine...until his numbers come down, he's going to continue being a hungry-hungry hippo. Right now, no matter how much he eats, the glucose his cells need isn't able to get in ...it just stays in the bloodstream so he's basically starving to death despite eating all that food. Think of insulin like it's a key and on every cell of the body there's a lock. Without the right number of keys, no matter how much he eats, the glucose the cells need to survive can't get through the door.

I'm tagging @Wendy&Neko who has a lot more experience with higher dose cats than I do. She may have some idea's.
 
Hi and welcome to you and Steve,
How bad are the dental issues?
If it is stomatitis, that is painful and inflammatory and could easily be raising the BGs.
Has the vet had a good look in his mouth?
I would consider getting him looked at by a vet who specialises in dental issues.
Plenty of cats have dentals done under anaesthetic when they are a diabetic and their BGs improve afterwards.
 
Chris & China (GA) said:
Poor Steve....I don't blame him for not grooming. Those are some ugly numbers but:

it looks like you were started at a high dose from the beginning and 2U is the least he's ever been on and then dose changes have been mostly in whole units (with some half unit). It's totally possible he needs a higher dose, but before I'd suggest changing the dose, I'd like to see some more tests. Lantus dosing is based on how low it takes them which means you need to be getting mid-cycle tests on the AM cycle and some "before bed" tests on the PM cycle. If you can't do mid-cycle tests due to work, it's even more important for you to get some testing on the PM cycle and any other time you can.

We don't suggest testing for acromegaly or IAA until they're above 6 units twice a day, but we also want to have started low and gone up in .25 to .5 unit increments to make sure we didn't bypass what might have been a good dose.

As for feeding, I think you're doing fine...until his numbers come down, he's going to continue being a hungry-hungry hippo. Right now, no matter how much he eats, the glucose his cells need isn't able to get in ...it just stays in the bloodstream so he's basically starving to death despite eating all that food. Think of insulin like it's a key and on every cell of the body there's a lock. Without the right number of keys, no matter how much he eats, the glucose the cells need to survive can't get through the door.

I'm tagging @Wendy&Neko who has a lot more experience with higher dose cats than I do. She may have some idea's.
Click to expand...

Thank you, what is a good mid-cycle time to check +4?

I will ask my vet about smaller dose changes. Curious, what would be a "low starting dose" (1U)?

Should I suggests to the vet we decrease down to 1U of Lantus am & pm and see how Steve responds? Or is this too dangerous? When Steve was first diagnosed he was on Prozinc 1U am & pm and the vet increased him to 2U only after a week. About a year ago after suggestions on the Feline Diabetes group I reduced Steve from 3U & 3U of Prozinc to 2.5U & 2.0U. Had him on this for a bit and his BGs were still high.
 
Bron and Sheba (GA) said:
Hi and welcome to you and Steve,
How bad are the dental issues?
If it is stomatitis, that is painful and inflammatory and could easily be raising the BGs.
Has the vet had a good look in his mouth?
I would consider getting him looked at by a vet who specialises in dental issues.
Plenty of cats have dentals done under anaesthetic when they are a diabetic and their BGs improve afterwards.
Click to expand...

His gums are pretty red but they got better with some antibiotics. After the antibiotics he does not seem to be having issues eating like he was back in Dec. Could the dental issues be causing the high BGs? I asked the vet this & she didn't think so.
 
Hi there, and welcome. You have had some good feedback already. I agree, some tests at night would help fill in the other half of the puzzle, right now, we can speculate that he's not doing anything different than the am cycle, but seeing even a before bed test for a few cycles can offer a lot of additional details on what the dose is doing. You could try changing up a test one night perhaps +3, another +4, and then another +5.

goodril said:
Should I suggests to the vet we decrease down to 1U of Lantus am & pm and see how Steve responds? Or is this too dangerous? When Steve was first diagnosed he was on Prozinc 1U am & pm and the vet increased him to 2U only after a week. About a year ago after suggestions on the Feline Diabetes group I reduced Steve from 3U & 3U of Prozinc to 2.5U & 2.0U. Had him on this for a bit and his BGs were still high.
Click to expand...

That's called a rebound check, and they rarely work. Most people who try to do a rebound check end up having a cat in higher numbers, and that ends up building even more glucose toxicity. Your cat is already in high numbers, and has had history of DKA so going back to 1u can potentially put him at higher risk than he is already to suffer another DKA episode. I wouldn't do it.
 
I just heard from the vet who is recommending increasing the Lantus to 4U based on the curve from Saturday and perform another curve in a week. I've responded and asked her about the risk of increasing another full unit and if his high BGs can be dental related (which I have asked about before).

My question for you all is, what is the real worry about increasing another whole unit, a hypo episode? Steve was on 4U am & pm of Prozinc when he went DKA in January so it's not like he has not been on that much insulin before.

Can too much insulin cause DKA or it only really causes hypo events?

What would your next step be if Steve was your pet? Would you jump right to an internist? This has been 16months of messing around with insulin and not seeing the numbers budge. I want to trust my vet and I am realistic that they do not have a crystal ball.
 
goodril said:
My question for you all is, what is the real worry about increasing another whole unit, a hypo episode? Steve was on 4U am & pm of Prozinc when he went DKA in January so it's not like he has not been on that much insulin before.

Can too much insulin cause DKA
Click to expand...

No, actually among other things, too little insulin is one of the causes of DKA.

Here is a primer on ketones: https://www.felinediabetes.com/FDMB...and-diabetic-cats-a-primer-on-ketones.239971/

Increasing by a whole unit may mean you go past a good dose, although if the am cycles are any indication, following our Tight Regulation dosing method, if nadirs are above 300 you could increase by 0.5u. I guess if it were me, I'd get a couple of evening tests, before increasing to 3.5u since there really haven't been any tests at night, and to me, you're missing half the picture.

Then, if after 3 days the 3.5u isn't doing much, and nadirs are still above 300, you can increase again by 0.5u. TR does require you to test each preshot, and at least one mid cycle, since it is considered an aggressive dosing method, and as soon as you start seeing improvement, (nadirs under 200) then you lengthen the time between increases.* see ETA

Perhaps others will be along with some thoughts.

ETA: I should also note you would also go back to 0.25u increases as well.
 
Last edited:
Christie & Maverick said:
No, actually among other things, too little insulin is one of the causes of DKA.

Here is a primer on ketones: https://www.felinediabetes.com/FDMB...and-diabetic-cats-a-primer-on-ketones.239971/

Increasing by a whole unit may mean you go past a good dose, although if the am cycles are any indication, following our Tight Regulation dosing method, if nadirs are above 300 you could increase by 0.5u. I guess if it were me, I'd get a couple of evening tests, before increasing to 3.5u since there really haven't been any tests at night, and to me, you're missing half the picture.

Then, if after 3 days the 3.5u isn't doing much, and nadirs are still above 300, you can increase again by 0.5u. TR does require you to test each preshot, and at least one mid cycle, since it is considered an aggressive dosing method, and as soon as you start seeing improvement, (nadirs under 200) then you lengthen the time between increases.

Perhaps others will be along with some thoughts.
Click to expand...

Thank you! This is very helpful and makes sense. I was thinking about getting some evening nadirs data before upping the dose as I do understand it is critical data I am missing with Steve's BGs. Is there reading material somewhere on this site for Tight Regulation dosing method?
 
goodril said:
Thank you! This is very helpful and makes sense. I was thinking about getting some evening nadirs data before upping the dose as I do understand it is critical data I am missing with Steve's BGs. Is there reading material somewhere on this site for Tight Regulation dosing method?
Click to expand...
You're welcome, happy to help.

Of course! we do have plenty of reading material, I thought you'd never ask :D Here is the info on dosing methods.

https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/

I have more, but I don't want to overwhelm you with info pages!
 
goodril said:
Could the dental issues be causing the high BGs?
Click to expand...
Absolutely! Or could be just one piece of the puzzle.
goodril said:
Can too much insulin cause DKA or it only really causes hypo events?
Click to expand...
Nope, it's indication he's not getting enough insulin. The formula for developing DKA is insufficient insulin + inappetance + infection or other systemic inflammation. Sounds like his appetite is more than great, he's got infection and inflammation in his mouth. I would definitely pursue getting a referral to a dental specialist vet, who are used to dealing with more complicated pets.

Now to address the dose and possible secondary conditions that mean he needs more insulin. If you've had vets speculate on acromegaly, I would definitely get him tested for it. And by the way, I like your new vet for suggesting that. About one in four diabetic cats has it. It's caused by a benign tumour in the pituitary that sends out excess growth hormone. Insane appetite can be a symptom. Although we suggest cats on higher doses get tested for it, it doesn't mean you have to wait for the dose to get higher. There have been cats on as low as 1 unit with acromegaly. Newer guidance is that cats that aren't regulated after a period of time should get tested for it.

The other conditions that can cause a need for higher doses (though there have been some on less) are IAA (insulin auto antibodies - like an allergy to the injected insulin) and Cushings. There are other conditions that cause insulin resistance too, though not usually such higher doses, such as hyperthyroidism, heart disease, pancreatitis. My girl had both acromegaly and IAA, which caused her to need to get up over 8 units of Lantus. We've had some cats on much more.

Going forward - please get a test before every. Those preshots are key to making sure it's safe to give insulin. Cats have been known to surprise us. Get some of those night time tests. If you post in the Lantus forum, we might even be able to fast track some increases. His numbers look ugly and are hard on him. We need to get him into better numbers as fast as we safely can.
 
Wendy&Neko said:
Absolutely! Or could be just one piece of the puzzle.

Nope, it's indication he's not getting enough insulin. The formula for developing DKA is insufficient insulin + inappetance + infection or other systemic inflammation. Sounds like his appetite is more than great, he's got infection and inflammation in his mouth. I would definitely pursue getting a referral to a dental specialist vet, who are used to dealing with more complicated pets.

Now to address the dose and possible secondary conditions that mean he needs more insulin. If you've had vets speculate on acromegaly, I would definitely get him tested for it. And by the way, I like your new vet for suggesting that. About one in four diabetic cats has it. It's caused by a benign tumour in the pituitary that sends out excess growth hormone. Insane appetite can be a symptom. Although we suggest cats on higher doses get tested for it, it doesn't mean you have to wait for the dose to get higher. There have been cats on as low as 1 unit with acromegaly. Newer guidance is that cats that aren't regulated after a period of time should get tested for it.

The other conditions that can cause a need for higher doses (though there have been some on less) are IAA (insulin auto antibodies - like an allergy to the injected insulin) and Cushings. There are other conditions that cause insulin resistance too, though not usually such higher doses, such as hyperthyroidism, heart disease, pancreatitis. My girl had both acromegaly and IAA, which caused her to need to get up over 8 units of Lantus. We've had some cats on much more.

Going forward - please get a test before every. Those preshots are key to making sure it's safe to give insulin. Cats have been known to surprise us. Get some of those night time tests. If you post in the Lantus forum, we might even be able to fast track some increases. His numbers look ugly and are hard on him. We need to get him into better numbers as fast as we safely can.
Click to expand...

Thank you Wendy! This is very helpful and puts my mind at ease a bit having this informaiton and knowing I am not struggling through this alone. I have already started to check Steve's BGs +6h in am & pm. I'll post those #s after I get a few3 days worth. I should have knocked on wood becuause Steve is not eating well this morning. I have reached out to my vet to push along referral for internist/acromegaly testing and dental. I have read about Cushings and will make sure we get all those tests done.
 
Thank you everyone for all the support! :bighug: This has calmed my nerves and helped me focus and know how I need to move ahead with getting Steve the help he needs. You are all angels for what you do!
 
You don't have to get a test at +6 all the times, nadirs or low points can and do move around. Testing in the 4-7 hours range after the shot can still be useful. And at night, if you get a test before bed, presuming it's at least 2-3 hours after the shot, and you see a big drop from preshot, then it's time to set an alarm to wake up later. Otherwise, get your sleep.
 
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