New w/ pancreatitis and roller coaster curves

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Picknickchick

Picknickchick

Member Since 2013
Hello, my 14 year old boy River was diagnosed with pancreatitis and diabetes. I have been giving him Lantus, and doing home testing. He eats mostly canned Wellness no-grain chicken or turkey (low carb), low carb homemade raw turkey and rabbit food, and sometimes Orijen kibble. He has a good appetite and weighs 5.5 kilos/12 lbs.

About six weeks ago, he became very sick, and I saw that he had ketones in his urine and rushed him to the hospital. He was diagnosed with pancreatitis, and possibly IBD. I suspect that he became allergic to the food I was giving him, as I had been giving him a raw beef diet for his whole life. I didn't know until then that beef is a common allergen for cats. Now that he's getting a different diet, he is getting better. This week I got a second ultrasound, and his pancreas looks better.

But there is still a problem, and I think that is with his insulin dose. I guess that as his pancreas heals, and he does better on his new diet, he will need less insulin. His numbers are getting so low that he is going into hypo territory, and this worries me. Plus his curves seem really "bouncy" with big highs and lows. Here are his curves, in mmoL/L

Sunday August 11
7 AM preshot19.8
8 AM 2.5 units glargine
11 AM 16.5
2 PM 11.5
5 PM 12.4
8 PM preshot 27.9
8:20 PM 26.2
8:30 2.5 units glargine
9 PM 28.9
4 AM 22.7
8 AM preshot 22.3
8 AM 2.5 units
11 AM 18.7
2 PM 16.6
When we spoke, the vet recommended increasing the dose to 3 units. She said to not be upset about the high 8 PM readings, as I could expect flareups from a cat with pancreatitis.

Sunday August 18
8 AM 3 units
10 AM 8.4
12 PM 4.7 - at this point I gave River 2 pieces of sweet potato with Karo and called the clinic
2 PM 6.6
5 PM 10.2
7 PM 18.9
7:15 PM 2.5 units - clinic said to reduce insulin to 2.5 units

Monday August 19
8 AM 2.5 units
10 AM 22.7
Went for checkup and ultrasound and vet recommended increasing back to 3 units for AM and 2.5 for PM shot. She said he was "well controlled" but I didn't think so.
7 PM 27.3
7:15 3 units - I gave 3 units because he was so high.
I emailed vet and said that ongoing, I am anxious about giving 3 units in the day because he's going into hypo range, and would prefer to do 2.5 units twice a day. Would this be ok? She did not respond.

Tuesday August 20
7 AM 15.6
8 AM 3 units
10 AM 13.1
12 PM 9.7
2 PM 5.4
3 PM 4.8 - Because his numbers continued to go down, I gave him some kibble and two small pieces of sweet potato with honey.
5 PM 7.1
8 PM - Just before his preshot reading, he had what I am guessing is a seizure! He was lying beside where I was writing on the table, and his eyes looked all wrong: tiny pupils and third eyelid partly covering. I called him, and shook him gently, and he was completely limp and didn't seem to be breathing. I started giving him mouth to mouth, and he suddenly came awake, and stood up. I picked him up in my arms and he shook himself so that he almost jumped out of my arms. I put him down on the deck, and he walked a bit. We went inside, and when I touched him he jumped and shook a bit; super-sensitive to touch. I thought he might be hypo so I got the Karo and stuck some in his mouth, and then got some rabbit/turkey raw food, which he was happy to eat. I was freaked out, and called vet to see if I should give him his 8PM shot, and what to do. They said to reduce the shot to 2.5 units.

Wednesday (today)
6:20 preshot 24.4
8 AM 2.5 units
10 AM 20.4

I don't know what to do except to keep him at 2.5 and see how that works, and find a vet who takes hypo a bit more seriously. Is there anything we can do about these big highs and lows? I know part of this is that he is recovering.
 
Hi Picknickchick,

I don't feel comfortable giving dosing advice, but I wanted to check something about your numbers. Are you using an Alphatrak or a human glucose monitor to test? What did your vet say hypo range was based on whatever meter you are using?

I ask because I know there's a difference in measurement between the two, particularly at lower ranges.... I dug up one of the Roomp/Rand protocol articles that are used widely here and it looks like the lowest number you got was a 4.7 - which appears to still be above the hypo concern number of 4.4(80) for the Alphatrak - the number for a human meter is even lower at 2.8(50)

Every cat is different and so I wouldn't say that your cat didn't have a hypo episode at 7.1- but that number is actually the high end of normal if not even more (again, it depends on whether you are using a feline or human meter).

Here's where i got the info from http://www.uq.edu.au/ccah/docs/diabetesinfo/link4.pdf

I know how frustrating and worrying the ups and downs can be - but you're right - its a part of the process and it often takes quite a while for the cat to settle in and give you those nice gentle curves, so hang in there.

Em
 
Em, what nice words of assurance! I have been sick with worry ever since the seizure, and the crazy up and down numbers.

I am using a Bayer EZ meter, so it's a human meter.

The vet's technician just called and said that the seizure (she thinks) doesn't have anything to do with the low numbers and is some other problem (oh great!)

Also, I have asked for some injectible B12, hoping that this will help. He sure needs it!

I'm doing a curve for him today, and his 12 PM was 19.7. Not the best, but not too low, and he's not yet at his nadir.

The numbers so far today:
Wednesday (today)
6:20 preshot 24.4
8 AM 2.5 units
10 AM 20.4
12 PM 19.7
2 PM 20.2
 
Em, I just read the link about how to read the meters. So, with a human meter, the readings I was getting yesterday of

12 PM 9.7
2 PM 5.4
3 PM 4.8

were actually good numbers, is that correct?

I was going by aiming to keep the blood glucose above 100 all the time, and below 200 as much as possible.
5.6 mmol/L = 101
11.1mmol/L = 200

So I was panicking when I was getting readings under 5.4.
But since I'm using a human meter, I should not worry unless I am getting readings around 2.8, is that correct?
The vet didn't say anything about what her definition of too low is. She said his numbers were good, which confused me because I thought they were getting in the hypo range.

Anyway, if this is the case, I should put his dose back at 3 units. Also, since his numbers are so high now, should I give him any insulin now, or wait until 8 PM injection time?
 
ETA: updated to add mmol/L and AlphaTrak estimates.

Here are some glucose reference ranges used for decision making using glucometers. Human glucometer numbers are given first. Numbers in parentheses are for non-US meters. Numbers in curly braces are estimates for an AlphaTrak.

< 40 mg/dL (2.2 mmol/L) {< 70 mg/dL for an AlphaTrak}
- Treat as if HYPO if on insulin
- At nadir (lowest point between shots) in a long term diabetic (more than a year), may earn a reduction.

< 50 mg/dL (2.8 mmol/L) {< 80 mg/dL for an AlphaTrak}
- If before nadir, steer with food, ie, give modest amounts of medium carb food to keep from going below 50 (2.8).
- At nadir, often indicates dose reduction is earned.

50 - 130 mg/dL (2.8 - 7.2 mmol/L) {80 - 160 mg/dL for an AlphaTrak}
- On insulin - great control when following a tight regulation protocol.
- Off insulin - normal numbers. (May even go as low as the upper 30s (1.7 mmol/L){60s for an AlphaTrak}; if not on insulin, this can be safe.

> 150 mg/dL (8.3 mmol/L) {> 180 mg/dL for an AlphaTrak}
- At nadir, indicates a dose increase may be needed when following a tight regulation protocol.

200 mg/dL (11.1 mmol/L) {230 mg/dL for an AlphaTrak}
- no shot level for beginners; may slowly reduce to 150 mg/dL (8.3 mmol/L) {180 mg/dL} for long-acting insulins (Lantus, Levemir, and ProZinc) as data collection shows it is safe

180 - 280 mg/dL (10 - 15.6 mmol/L) {may be 210 - 310 mg/dL for an AlphaTrak}
- Any time - The renal threshold (depending on data source and cat's renal function) where glucose spills into the urine.
- Test for ketones, glucose is too high.

>= 280 mg/dL (15.6 mmol/L) {may be >=310 mf/dL for an AlphaTrak}, if for most of the cycle between shots
- Uncontrolled diabetes and thus at risk for diabetic ketoacidosis and hepatic lipidosis
- Follow your insulin protocol for dose adjustments
- Test for ketones; if more than a trace level of ketones, go to vet ASAP.
 
You're welcome.

Be like a Boy Scout, and be prepared:

Its a good idea to read over the hypo protocol, make sure you understand it, and print it out.

Plus, pick up any supplies - extra test strips and lancets (always have a box of each in reserve if possible), oral syringe, Karo - and determine the location, directions, and phone of nearest 24 emergency vets, etc.

Make sure you know how to get there by alternate routes in case there is construction, etc.
 
I already have the extra supplies, and the idea of familiarizing myself with the hypo protocol is great.
After what happened on Tuesday, I want to avoid repeats, if at all possible.

I have to find another vet, as the two I've been dealing with at the emergency hospital seem quite cavalier about hypos. One didn't reply to my email and phone calls about my fear that the insulin dosage was too much and he'd been going hypo (which he did), and then afterwards got her vet tech to call and say "The seizure has nothing to do with hypoglycemia. He's 14 years old, so it's probably a brain tumor or something." Later that day another vet called me, because I was requesting injectable B12 (which they won't give me), and said that he probably did have a hypo, but said not to worry about him being low while I was at work, because cats are really tough and there probably will be periods during the day when he goes into hypoglycemia. And these are the "experts"!
 
Vet Interview Topics - You'll want a vet who:

1) supports home testing of blood glucose and is OK about using a human glucometer

2) supports feeding a low carbohydrate over the counter, canned or raw low carb food.

3) is either up to date, or willing to do the homework to become up to date on feline diabetes and common comorbidities.

4) if up to date, is familiar with the use of ProZinc, PZI, Lantus, and/or Levemir IN CATS; ask how they determine initial dosing and how often the dose is given. This may be based on lean body weight (verify it if they say based on weight as some vets forget this, per Dr Pierson) or may start low at 0.5 units. Dosing should be twice a day.

5) has pricing you can live with - check office visit fee, vaccine fee, CBC and chemistry fee, etc. Ask how often they have you bring the diabetic cat in and for what reasons (if you are home testing, you can do curves and averages at home, and the cat doesn't get 'regulated' at the vet office where stress makes the numbers unreliable)

6) if currently treating diabetic cats, ask how long they usually survive (should be several years, barring other conditions)
 
Hello and welcome to the board!

Its great you are all set up - love the crown!!

I am looking at his SS and if i were you I would hold this 2.5 dose for a day or so and see how it does. (Unless he drops under 50). I wouldnt say its Somogyi so much as just bouncing off of normal green levels.. (see below). I actually think the 3 units was working pretty well (bounces considered). If you dont see any greens or more blues by say end tomorrow, I would take him to 2.75 and see how that does.

Also I would try and always get a before bed test (2-3 hours after PM shot) since many cats drop lower at night and if that number i lower than your PM shot you might want to set the alarm for a test in a few hours as it may be an active cycle.

Wendy

Bounces - what are they and is my cat doing them?
When a cat is first diagnosed, the blood glucose has probably been high for a while. As the insulin starts to take effect and numbers start to come down, the liver has to learn to adjust to the lower numbers. We call this "liver training school". But before it relearns that low numbers are ok, when the BG drops to a number lower than the liver is accustomed, or if BGs drop low, or if the BG drops suddenly, the liver”panics” and reacts by releasing counterregulatory hormones and glucagon. This drives the BG back up. This is what we call a "bounce". Bounces can take up to 72 hours to clear so we are generally careful about increasing doses during the bounce. Once the bounce clears, then you can see the "real" numbers and determine if the dose needs to go up or down.
Click to expand...

Wendy
 
Wendy&Tiggy,

Greetings, my fellow Canadian! I have been reading here for a long time and know that you are a very good advice-giver, so thanks for your message.
I'll see how he's doing today and adjust accordingly. I've only been doing increments of .5 units at at time so the .25 might be challenging at first, but hey, so was testing ;-)
Night testing - great idea. I'm so focussed on the day when I'm not here that I'm forgetting about the night.

A question: what is an active cycle? I've seen this term used in some of the posts, but don't know what it really means. I looked it up in the glossary, so as not to ask when I could just look ;-)

I have to confess that the crown was just for his birthday. But he knows he's the king of the household at all times.
I have only 2 readings so far today, but his behaviour is great. It's the first day in a while where he's up, active, following me around, talking...

Many thanks,

Lara
 
Hey there

Are you using he BD ultra fine ii with the half unit markings? Then just pull the plunger between the lines to get 1/4 unit

Many cats drop low at night so you might be surprised.

Active cycle means he might drop low as opposed to sitting flat or going up.. might mean more testing or even breaking out the high carb food if he drops too low (under 50 or so).

Have you read this protocol? http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=1581

Also where do you get your strips? I get my Bayer ones on ebay under $50 for 100.

Wendy
 
Yes, I am using the BD Ultra-Fine II. I find it a bit of a challenge to do the half units, but I will - I must - give the 1/4 units a try. I can try with the discarded syringe from the AM shot and practice filling it with water until I get the hang of it.

I've read the Lantus Tight Regulation protocol, and now I guess I'm doing it! Up until this point, I have just been doing what my vet tells me to do, which hasn't been hugely helpful. Since he's got out of the hospital, he's been improving, so I don't want to blow my chance for remission.

Today his numbers are high. I don't know yet if this is a bounce, or he needs the increase of 1/4 unit.
His numbers for today so far:

7:50 AMPS 19.7
8 AM 2.5 units Lantus, and raw food
10 AM 22.7
12 PM 19.6
1 PM 20.0
2 PM 20.7
4 PM 20.7

Not so great. I should have not interfered yesterday.

The only time I've been doing night readings was when my vet requested them, but I've realized that got me nowhere.

And the price on eBay is half of what I'm currently paying. Thanks for the tip!
 
That's very kind of you, BJM!
I hope I can get another day like yesterday's numbers, and this time I'll be happy to see them :oops:
 
Looks like River is bouncing from the blues the other day. I'd hold this dose for another couple of cycles.

Would you make a change to your SS please? If you make the Remarks column wider on the US tab of the SS, than we can see more of the patterns over a week or so. Would you be wiling to do that suggested change? Looks like you already did this on the world tab.
 
I'd be happy to. I thought that if Imake a change on one sheet it's going to be copied to the other, so sorry, I hope you didn't have to do too much squinching your eyes and scrolling.
Thank you for the hold the dose advice. It is so great not to go through this alone, and blindly.
 
When you use the World version spreadsheet setup, usually the changes you make on the World version show up on the US version. This particular change, with the wider columns did not carry over. I know that any data you enter on the World version does get copied over to the US version.

I shrunk the view down to 50%, and was able to get about 5 days of data on my screen. :-D
 
Let me know if that's okay - I can give you editing rights as well, so that you can display it however is best for you. I'd be happy to!
 
You have got the BD ultra fine with 1/2 unit markings right?

Ebay I use shorefront medical. The 100 strips comes with a pack of free lancets too. $50 includes shipping. Sometimes you can find ones cheaper on auction too just watch the expiry dates.

Wendy
 
Yes, I use the syringes with the half units, 31 gauge. I have the 8mms and they work fine for me, although for a while I tried the longer ones.
I had a careful look at a syringe today and the quarter unit is definitely doable. A new skill awaits.

Thanks for the eBay tip! Testing strips are probably my biggest expense, after good-quality local game for raw food, and a 5K hospital bill, but we won't talk about that! grr_red
 
You're sweet! I live in Quebec, and the only break I've gotten on strips so far is that the ones at the Pharmaprix (Shopper's Drug Mart, now owned by Loblaws as you probably know), are one dollar cheaper than the pack of 50 at the Jean Coutu.
 
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