Newbie- advice appreciated (first 12 hr curve included)

[shadycat]

Hi everyone, I have posted on the facebook page a few times and this board was recommended- looks great! I will give some background and what I've been doing so far and would love to have any comments or advice.

I have a 12 year old neutered male, Shady. Diagnosed about 10 days ago after noticing increased drinking and urination. Not overweight, only other health problem is he had a fibrosarcoma (malignant tumor) at the base of his tail which was surgically removed, treated with radiation therapy, which he just finished a week ago, and will have a second surgery in a couple of weeks. Don’t think the diabetes is related to the cancer, unless it was partly brought on by stress of daily vet visits for 3 weeks.

As far as his diet, he used to eat about 1 can of Fancy Feast (the kinds with gravy) per day and free feeding Hills Rx TD (the dental health food). My vet recommended he stay on TD because even though it is high carb, it is high fiber so she said it was ok for diabetics. But from what I have read, and he was having high BG readings, so I stopped feeding it. Now he eats FF, both the kinds with gravy and the Classic, and I got some Wellness Core dry food. I know some say no dry, but I want him to have some food down at all times so in case he gets hypo while I am gone, he has something to eat. I can’t really leave wet food down because I have a second cat who will gobble up any leftover canned food.

Vet prescribed 3 units of PZI insulin every 12 hours. She does not recommend home testing, but after doing some research, and just my gut feeling that I didn’t feel comfortable giving insulin without testing BG first, I decided I wanted to home test. So I have been testing morning and night before his injections and giving insulin according to a table my vet gave me (under 200: 0 units; 200-300: 1u; 300-400: 2u; 400+: 3u), and today did my first 12 hour curve (per the vet’s instructions, she wanted a curve done at one week, whether it was there or at home).

So far these have been his readings:

4/16 pm: 425; 3 units PZI (at vet)
4/17 am: did not test; gave 3u
4/17 pm: 150 (no insulin given) - not sure why it was lower this time?
4/18 am: 480 (3u)
4/18 pm: 324 (2u)
4/19 am: 574 (3u) <-- concerned at high reading, so stopped feeding Hills td dry food that a.m.
4/19 pm: 403 (3u)
4/20 am: 368 (2.5u) <-- started tweaking the dose a bit at this point, giving half units, trying to be more accurate
4/20 pm: 232 (1.25 u)
4/21 am: 341 (2.5 u)
4/21 pm: 354 (2.5 u)
4/22 am: 291 (1.75 u)
4/22 pm: 425 (3 u)

12 hour curve 4/22:
AM: 291 (1.75 u administered)
+2: 201
+4: 119
+6: 156
+8: 268
+10: 460
+12: 425 (3 u administered)

I was disappointed in his curve today, it seems high overall, plus his BG got higher by the end of the day than it has been in several days.

I am a little frustrated because my vet has given me very little direction on this. Basically a vet tech quickly showed me how to test his glucose and give the injections. No advice on diet or much info about diabetes in general. I feel like I am kind of flying blind here. Usually she is a good vet and on top of the latest research, so I’m not sure what the deal is. Plus fighting this tumor at the same time has made it extra stressful.

I would appreciate any general advice but a couple of specific questions:
-Do you ever get to the point that the BG is stable enough that you don't have to home test anymore? I am willing to, but that is by far the hardest part!
-Should I be using ketone strips to test urine? Vet didn't say anything about it. Are they just strips for humans that you can get OTC at the drug store?
-The second night I left the insulin out overnight. It was at room temp for over 12 hours, part of it during daytime so it got some light. Should I get a fresh bottle just in case?

Any comments or advice on his curve and BG levels so far, insulin regime, diet, etc are very welcome. Thanks!!

 

[BJM]

I can’t really leave wet food down because I have a second cat who will gobble up any leftover canned food.

Have you tried freezing some of it to thaw slowly? It is harder to scarf that way. Another solution is to use a timed feeder. Note that it is normal for an unregulated diabetic to be ravenous; as he becomes controlled, this will calm down.

Vet prescribed 3 units of PZI insulin every 12 hours. She does not recommend home testing, but after doing some research, and just my gut feeling that I didn’t feel comfortable giving insulin without testing BG first, I decided I wanted to home test. So I have been testing morning and night before his injections and giving insulin according to a table my vet gave me (under 200: 0 units; 200-300: 1u; 300-400: 2u; 400+: 3u), and today did my first 12 hour curve (per the vet’s instructions, she wanted a curve done at one week, whether it was there or at home).

So far these have been his readings:

4/16 pm: 425; 3 units PZI (at vet)
4/17 am: did not test; gave 3u
4/17 pm: 150 (no insulin given) - not sure why it was lower this time?
4/18 am: 480 (3u)
4/18 pm: 324 (2u)
4/19 am: 574 (3u) <-- concerned at high reading, so stopped feeding Hills td dry food that a.m.
4/19 pm: 403 (3u)
4/20 am: 368 (2.5u) <-- started tweaking the dose a bit at this point, giving half units, trying to be more accurate
4/20 pm: 232 (1.25 u)
4/21 am: 341 (2.5 u)
4/21 pm: 354 (2.5 u)
4/22 am: 291 (1.75 u)
4/22 pm: 425 (3 u)

12 hour curve 4/22:
AM: 291 (1.75 u administered)
+2: 201
+4: 119
+6: 156
+8: 268
+10: 460
+12: 425 (3 u administered)

I was disappointed in his curve today, it seems high overall, plus his BG got higher by the end of the day than it has been in several days.

I am a little frustrated because my vet has given me very little direction on this. Basically a vet tech quickly showed me how to test his glucose and give the injections. No advice on diet or much info about diabetes in general. I feel like I am kind of flying blind here. Usually she is a good vet and on top of the latest research, so I’m not sure what the deal is. Plus fighting this tumor at the same time has made it extra stressful.

Good for you on the testing!!! He's not controlled yet, as you can see, and you are learning how this insulin, food, schedule, etc works for him. Getting spot checks at times around the probable nadir - around +5 to +7 hours after insulin - whenever you can will help you see yow low he goes. Its not just about the pre-shot tests.

Also, vets have so many species to know about that they are not always up to date on contemporary feline diabetes management. If you think your vet is open to some journal articles, we have some we can provide. There's also a sticky post in Feline Health called "Convert A Vet" which you might find helpful.

I would appreciate any general advice but a couple of specific questions:
-Do you ever get to the point that the BG is stable enough that you don't have to home test anymore? I am willing to, but that is by far the hardest part!
-Should I be using ketone strips to test urine? Vet didn't say anything about it. Are they just strips for humans that you can get OTC at the drug store?
-The second night I left the insulin out overnight. It was at room temp for over 12 hours, part of it during daytime so it got some light. Should I get a fresh bottle just in case?

Any comments or advice on his curve and BG levels so far, insulin regime, diet, etc are very welcome. Thanks!!

Home testing is a safety issue. You home test to make sure the cat is safe to shoot. You home test frequently unless and until the cat achieves diet-controlled status. Even then, illness and stress can return the need for insulin, so you never quite give it up. You may reduce to weekly or monthly, depending on what you see.

In my signature block is a list of secondary monitoring options. While they are less precise than blood glucose test or blood ketone tests, they do provide some clues about how the diabetes management is going. And yes, standard pharmacy urine test strips are what we use.

As far as the insulin being left out of the fridge, yes, it may have weakened it, though it may still be somewhat useable for a while. When you get a new vial, you may need to drop down a unit or so to allow for that.

 

[BJM]

If you'd like to add your signature or brief notes about Shady at the bottom of your posts (age, date of diagnosis, insulin, dose) instructions are here

 

[Carl & Polly & Bob (GA)]

Hi and welcome!

I see you are feeding evo dry and "why". One thing that will help is to ditch the gravy style FF and just feed the classics. The classics are lower in carbs and are better for Shady. Long term, you definitely want to remove the dry completely, but we'll have to figure out how you can do that.

The scale your vet gave you is almost like the one my vet gave me. Her name wouldn't be "Murray" would it? :lol: I also used PZI with Bob, was shown how to shoot and test, but I learned most of what I have learned "here" after that. I'm sort of surprised she started off with 3u though. I started at 1u BID and went up from there, but when the doses got as high as 3u, she gave me a scale to shoot by.
I'm glad you trusted your gut on home testing. Many vets do recommend it, but too many don't. I've spoken to some of them about why they don't. In some cases it seems like "I want you to rely on me", but in other cases, it's because they just don't believe we "can" do it, or that we will stick with it. Too many of them seem to sell us short.

Looking at the early days you were shooting, and starting with 3u, it looks to me like the dose was too high. There are a couple of possible reasons for that really low number on the PM of the 17th. One, the dose may have been too high and caused really low numbers or a really longer than normal duration. Or, two, you not knowing what that number was on the morning of the 17th, it may have been low then too. He could have gone really low during that daytime cycle.

The high number on the 19th makes me believe that Shady went really low on the 18th. That looks like what we call a "bounce". When their BG goes really low, it can cause his body to react in self-preservation mode. His liver will actually respond to signals from his pancreas and dump "sugar" into his blood because his body feels like the BG has gone too low. That usually results in a really high number for your next test, which is what I think the 574 was. All that said, it could be that the overall scale is just a little bit too high.
And that is where the mid-cycle tests will be your best "weapon" against diabetes. If you test in between shots, especially in the 5-7 hour time frame after a shot, you should see the "low point", or nadir of his 12 hour cycle. Knowing that number will tell you if the dose is too high, too low, or just right.

This might be what you saw when you did that curve today. That 119, although not scary "hypo" low, might feel "too low" to his body. And if it caused his liver to react, that could have caused the higher number at +10 and +12.

One thing you should be aware of regarding food. If you do ditch the gravy food, you should see an overall lowering of his BG numbers (even more so if you ditch the dry food). That will mean his insulin needs will drop. So although right now if you see a 350 you might shoot 2.5u, that dose might be too much on a .50 in the future, because the higher carb foods won't be in his system to counteract the insulin. In other words, 2.5u might do more then than it does now with pushing his BG down. So if you change diet, you want to pay attention to the mid-cycle numbers closely. Definitely hold off on changing things until you have a day you can spend at home monitoring him.

As far as "when can I not test"? Not until he is off insulin. Testing is all about safety. Even if you have a day when you can only test twice, it has to be done before any insulin shot is given, especially since you are using a scale. You have to know the number you are shooting into to make sure the dose is safe. Once the insulin is in, you can't get it back out... and yes, home testing is the hardest part for most people (and cats). I can assure you that the more you do it, the easier it is for both of you. Make sure and give a low-carb treat as a reward for every test, even if you don't get blood. In time, the tests will be something Shady actually looks forward to (as hard as that may be to believe now).

I am not sure what effect, if any, the cancer had but I'm sure there are others here who can help with that.

-Should I be using ketone strips to test urine? Vet didn't say anything about it. Are they just strips for humans that you can get OTC at the drug store?

Yes, they are sold at any drug store and are the ones humans use. Ketones are not common, but they can be really bad news. They are usually caused by a combination of too little insulin, too little food, and some sort of infection present. You just try to catch him peeing, get the stick wet, and the box should have a color guide to tell you what the results are. If you see anything above "trace" please post for advice.

OK, I'll let somebody else get a word or two in!

Carl

 

[Julia & Bandit (GA)]

Bandit is a gobbler and will eat any and all canned food you leave out until it's gone, which meant that my other cat also wouldn't get fed if I just left food out. However, I was gone all day for work so I wanted to make sure Bandit had food at his nadir (the lowest point of the cycle, about 6 hrs after the shot) in case he dropped low. So what I did was get two auto-feeders, one for each cat. I have these feeders, but the most popular one here is this feeder. I froze portions of food and set the feeders to go off at the same time. It worked great!

One thing that helped was to feed each cat every meal in a specific spot away from each other--I fed Gabby at one end of the kitchen for every meal, and Bandit at the other. They would not get their food until they were in their spots. That way when I set the autofeeders, at opposite ends of the kitchen, they would each run to their feeders when they heard them go off.

Even grain free, lower carb dry food can keep BG high for a lot of cats. It has to do with the way the food is manufactured--it has to use a starch to bind the food together, and these starches effect blood glucose levels. Bandit can't even have a few pieces of EVO dry (8% carbs) or it raises his blood sugar.

 

[shadycat]

Thanks everyone! Sounds like the first thing I need to work on is further changing his diet? Eliminate the dry totally and switch FF Classic. A timed feeder may be worth trying. Unfortunately Shady is pretty picky, he doesn't like the FF Classic nearly as much as the Elegant Medleys or gravy varieties, and he already lost some weight from diabetes, so I really want him to eat. I guess I need to just try some different things. Would mixing canned chicken or tuna with FF Classic be ok? And I am assuming that all of these low/no-carb foods are good for my civilian kitty Ella also?

As far as my vet, I emailed her Shady's curve today so she will probably call or email tomorrow, so I will know more of her opinion then. I hope to not butt heads with her too much. Actually she is a cat only vet and has been her whole career, and I believe her BS and MS were in animal nutrition. She publishes in journals, speaks at conferences, etc, seems to be well regarded and on top of the latest research, so I'm not sure why she is not on board with home testing and no carbs. Hopefully she will be supportive. I hate to think what would have happened if I gave Shady the 3 units prescribed to him the night he was at 150!

With the curve and his am/pm readings, I guess it just takes time, but I don't see any pattern yet... It almost seems totally random. :? Hopefully that will change in time. Home testing still has its ups and downs, there are times I get the blood sample with no trouble and other times that it takes me several tries, he growls and hisses, the meter malfunctions, etc, and I am nearly in tears.

I can't think of any other specific questions right now, but I'm sure I will have lots more as I go along! Thanks!

 

[shadycat]

Actually I do have one more question! Carl and BJM both mentioned doing additional BG checks around the nadir- how often do you do those? What levels do you like to see? I thought in the low 100s was good, but Carl said that could have felt low to Shady.

 

[BJM]

There's an entire protocol written up in the Lantus Tight Regulation forum about how to safely monitor and adjust for optimal insulin control. It requires a lot of testing and commitment. Done correctly, it might get him to a diet-controlled stage.

You're still collecting data on how he responds to his insulin dose. As you collect more data, you will learn how low you can safely give insulin. Initially, the cut off is 200 for no shot. Then, it may be brought lower, as you find how he handles it.

If he is below a 40, he may be heading into a hypoglycemic state and you should have your hypoglycemia kit ready, especially if you tested earlier than +6, the average nadir. Some cats may show no symptoms at that level, and may be on the brink of going lower, which can send a cat into fatal seizures. Once the insulin is in, you can't get it out, so being prepared with high carb food, karo syrup, and oral syringes is prudent.

 

[Carl & Polly & Bob (GA)]

Oh, don't misunderstand, low 100's IS good! A diabetic cat is "used to" numbers that are high. Could be 300's or higher most of the time before diagnosis. To that cat, the high numbers become the "new normal". Then you start with insulin treatments, and all of a sudden "normal" isn't there much anymore. So the body, feeling a number in the 100's is "too low" will try to boost the number up because it feels different. As he sees more numbers in the lower range, he'll get used to them again, and he won't "panic" instinctively. Once that happens, the curves flatten out a little bit, because the preshot numbers start getting lower. That then forces the lows for the day into the less-than-100 range, and you might see the same sort of thing happen again. His body will go through these cycles of "re-learning" what it is like to have lower numbers as time goes on. Ultimately, you'll be able to lower the dose and hopefully all the numbers over the course of day will be within the "normal" (50-120) range. If and when that happens, it can mean kitty no longer needs insulin, and will just become a "diet-controlled diabetic" like my Bob (and lots of other kitties) did.

Carl

 

[Sue and Oliver (GA)]

Late to the party, but wanted to say hi and welcome. And give you some homework. This document has everything you always wanted to know about PZI. It's too big and has lots of links, but full of good info:

http://www.felinediabetes.com/FDMB/viewtopic.php?f=24&t=32799

Also be sure to stop by and check out the PZI forum. Everyone there uses your insulin. Checking out their spreadsheets and seeing how they are working with the insulin can be helpful. http://www.felinediabetes.com/FDMB/viewforum.php?f=24

As far as not liking the classics, some cats like it better when you add warm water to make a gravy.