Newbie-confusing curve-rebound? Help please :)

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hollymayb

hollymayb

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Hi Everyone,

My name is Holly & DH is Sean & DB cat is Max (7 yrs, 11.5 lbs) & civilian Leo (4 yrs, 14 lbs). Max was diagnosed a month ago, and we still don't have him anywhere near regulated. We're worried, confused & frustrated. Please help if you can. I'll try to be concise while including all the pertinent info.

Long story short, Max showed all the signs of DB, but we didn't put it all together until his hind legs became weak. Vet did full blood panel, ex-rays & urine, the only problem was BG of around 480. The vet put Max on Lantus, starting at 1 unit, twice a day. After an unsuccessful home curve (we were having problems getting samples) we had the vet do one in the office. This is all within the space of 4 days. The vet's idea of a curve was to pump him full of insulin until his BG was within the safe range, and told us to give him 5 units, twice a day, and had us up to 6 units, twice a day, about a week after diagnosis.

After the shock of the diagnosis wore off, I started doing some research online, and found that our vet was going about things much differently than was recommended by this site & others. After witnessing what we now think were a number of small seizures, we confronted the vet about his recommended dosage, and asked if Max might be experiencing Somogyi rebound. The vet didn't know what that was. Max tested as low as 60, and as high as 460 in the same day.

We stopped seeing the vet, & interviewed some others. Unfortunately, all recommended a high fibre diet, and didn't know what a rebound was. We decided to go rogue. Maybe not the best idea, but it seemed to us that our vet's advise could kill our cat, so we couldn't do much worse for now, until we find a better vet.

We have him on a very high quality low-carb (grain-free) kibble, with high protein wet food when he gets his shots (1 Tbs). We reduced his insulin to 2 units, twice a day but quickly increased to 3.5 because we were scared by the high readings (490ish). We did a full curve with readings every hour after 2 weeks @ 3.5 units twice a day. Here are the results:

Time BG Insulin (Units)
6/7/2010 8:00:00 24.6 3.5 Gave 1 tbs wet food, then ate a little dry food & drank. Active, alert & affectionate.
6/7/2010 9:00:00 21.1 0 Ate some dry food before & after test. Drank. Alert but lazy.
6/7/2010 10:00:00 17.6 0 Ate after test. Same.
6/7/2010 11:00:00 15.6 0 Alert. Under couch.
6/7/2010 12:00:00 15.4 0 Napping by the window
6/7/2010 13:00:00 14.3 0 Napping on test table.
6/7/2010 14:00:00 15.6 0 Ate & drank a little Used litter box. Small amount of urine & large, loose, very smelly stool.
6/7/2010 15:00:00 16.7 0 Ate & drank a little napping by the patio door
6/7/2010 16:00:00 21.1 0 Ate & drank a little napping in various places
6/7/2010 17:00:00 22.7 0 walking around & sitting
6/7/2010 18:00:00 23.3 0 Ate & drank a little. Same. Used litter box. Some urine,
6/7/2010 19:00:00 23.6 0 Alert & aggressive.
6/7/2010 20:00:00 25.8 4 Gave 1 Tbs wet food Alert & active

We decided to raise his insulin to 4 units twice a day because he still wasn`t getting low enough at his nadir. We`re doing another curve today, but the results are not looking good. (I`ll post below) We know advise can`t replace a vet, but we can`t see an alternative right now. Our best option for a new vet is a clinic 1 hr away, and we will try it if we can`t get Max regulated soon. Symptom wise, Max has made a remarkable recovery- his eating & drinking habits are back to normal, and his personality is back to being the sneaky but lovable guy we hadn`t seen in so long. His rear legs are still weak though.

Any advise is greatly appreciated!! Do you think we have him on too much insulin (are we seeing a rebound?) or too little? I know some of you will say we need to stop guessing and take him to a vet, but we've already spent $2000 in vet bills, not including DB supplies, and even if we knew of a knowledgeable vet, we can't afford to go for another couple weeks. Here's today's curve so far:


Time BG Insulin (Units)
8:00:00 21.2 (381) 4 @home gave 1 Tbs wet food & treat. Drank water. Excited, alert, vocal, affectionate.
9:00:00 15 (270) 0 ate & drank a little Grumpy, alert, relaxing by window.
10:00:00 15.6 (280) 0 active, alert, prowling, resting.
11:00:00 15.7 (282) 0 hiding under couch
12:00:00 13.9 (250) 0 ate & drank a little napping & resting on shelves
13:00:00 13.7 (246) 0 alert, hanging out
14:00:00 14.2 (255) 0 napping
15:00:00 15.6 (280) 0 used little box- small amount of urine napping & hanging out
16:00:00 16.3 (293) 0 napping
17:00:00 16.4 (295) 0 napping

Thanks in advance,
Holly, Sean, Max & Leo
 
Welcome Holly, Sean, Max and Leo,

It sounds like you are working hard and fast to educate yourselves, and doing much better than your vet. Have you read the stickies on the Lantus Insulin Support page? They will give you lots of good info about the way Lantus works: viewforum.php?f=9

Lantus users will be along. They can give you advice on what to do with the dose.

But one thing you can do now, with the high numbers, is to be testing for ketones: http://petdiabetes.wikia.com/wiki/Ketoacidosis This is addition to your blood glucose testing. (Fantastic that you are doing that by the way.)

The other thing I would suggest is to dump the kibble. Even grain free dry is not great for diabetics (http://www.catinfo.org) and if they will eat lo carb wet, it is better for both of your cats. You can freeze the wet and let it thaw out during the day if feeding during the day is the problem.

You are doing great. Continue to read and ask questions.
 
> The vet put Max on Lantus, starting at 1 unit, twice a day.

Starting with Lantus, 1u twice a day is a good start. (Good insulin choice, good generic starting dose.)

Did your vet mention anything about Max having ketones or diabetic ketoacidosis (DKA)? Are you currently testing for ketones?


> This is all within the space of 4 days. The vet's idea of a curve was to pump him full of
> insulin until his BG was within the safe range, and told us to give him 5 units, twice a
> day, and had us up to 6 units, twice a day, about a week after diagnosis.

Was this the same vet or a different vet at the same practice? It sounds like s/he's not really familiar with the nuances of how Lantus works. At four days on insulin the storage shed is still filling up.


> After witnessing what we now think were a number of small seizures, we confronted the vet
> about his recommended dosage, and asked if Max might be experiencing Somogyi rebound.
> The vet didn't know what that was. Max tested as low as 60, and as high as 460 in the same day.

Actually, the seizures sound like they could be hypos; seizures can occur during hypos during rebound, but you can be in rebound without seizures.


> We decided to go rogue. Maybe not the best idea, but it seemed to us that our vet's advise could
> kill our cat, so we couldn't do much worse for now, until we find a better vet.

You can ask on the board to see whether anyone has any suggestions for your area. Alternatively, you can try working with your original vet on dosing, particularly if you've had a good relationship with the vet in other areas. If I have a good vet and a good relationship with him/her, I don't necessarily look at their lack of knowledge in treating a single disease as a deal-breaker. I *will* consider an unwillingness to *educate* themselves about new ways to treat a disease to be a deal-breaker.

ETC: change "working with your on dosing" to "working with your original vet on dosing", because sometimes it's useful to include nouns when you're trying to communicate.



> We did a full curve with readings every hour after 2 weeks @ 3.5 units twice a day.

You were probably *still* at too high a dose. i think what happened is that Max was put on 1u twice a day, but had the dose upped after four days, which hadn't given the storage shed enough time to fill up. Once the storage shed *did* fill up, he started having hypos and rebound. If Max is testing negative for ketones, I'd suggest dropping down to 1u twice a day and see what happens with that. (Disclaimer: I am not a Lantus user, so please give heavier consideration to the dosing advice of real Lantus users.)


Besides the three or four stickies near the top of the Lantus forum, I'd also suggest reading Melissa and Popcorn's post on recognising and treating hypos. Read it, print it out, and tape it to the side of your fridge -- when you suspect a hypo is *not* the time to find that your internet connection has gone down. I'd also suggest going through Jojo and Bunny's post on stocking your hypo toolkit.


And, if you're not already doing so, I'd also pick up some ketostix from your local pharmacy and test for ketones. Ketones are not-common but still possible side effect in any person or animal with unregulated / under-regulated diabetes. Small amounts of ketones may be treatable at home; large amounts of ketones may require hospitalisation in a 24-hour care facility. If you test for ketones at home, you can catch them early and hopefully avoid the expensive hospitalisation.

To test for ketones at home, pick up some ketostix from the diabetes section of your local pharmacy. (I've always found them in the aisle, though some folks report their pharmacist keep them behind the counter.) You test for ketones by sticking the the stick in fresh urine. If the stick changes color, ketones are present.
 
Thanks for the replies so far!

In response to both your questions, Max has been treated by the same vet throughout, and was initially (upon diagnosis) negative for ketones. We're not sure how to test at home for ketones (as Max & Leo share a litterbox) but we'll read up on it.

We've learned so much from you guys already- please keep it coming!

Thank-you all sooo much,

Holly & Sean (+ Max & Leo)

PS- While we're happy with our vet in other situations, if anyone knows of a good vet in or around Surrey, British Columbia, Canada, we'd love to know! Can't be too far as Max freaks out in the car. :sad:
 
Regarding Sue and Oliver's suggestion to drop the kibble: I agree with her about getting rid of it, but please be diligent about testing when you change the food and, if you haven't already dropped the amount of insulin you're giving when you change the food over, please *do* drop it then.


Ah, yes, the elusive urine sample ... :)

Can't help you with the multiple cats using the same box thing, I'm afraid, but other ideas for getting samples:

Some folks stalk their kitties to the litterbox, and slip the ketostix under their rear while they're going. If they'll let you in the room but won't let you stick your hand under their butt, some folks use a long-handled spoon or ladle to catch a sample mid-stream.

You can try replacing the kitty litter with gravel from a fish tank. If your cat always goes in the same spot, you can plant a ceramic or glass bowl there and just use the urine in the bowl when they leave. And some folks wrap half of the litterbox with Saran Wrap, so the urine will puddle and they can get their sample.

If there's a bit of litter that's saturated, you can try testing that with the ketostix as well. However, before you can have any faith in doing that, please test the litter just by itself -- some litters have ingredients that will trigger color changes in ketostix. To check your litter, grab a handful and wet it down with tap water, then stick a ketostix in the litter. If the ketostix changes color, you'll either have to try one of the other methods or use a different litter. (Litter sampling can also be a bit difficult to do if you let the urine soak into the litter too much; also, different litters have different absorption rates.)
 
my vet also suggested or maybe it was someone on here. they said that cats like to pee on plastic bags.(or saran wrap) so replace the litter with a plastic bag and when your cat goes on the bag you can get a clean urine sample. i have not tried this yet, but if it come to it i will. they did also tell me about the fish tank gravel
 
These graphs might be helpful.
 

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So we're starting him back at 1 unit twice a day... are there any Lantus users out there who might have any advise to share?

Thanks,
Holly
 
Holly,

You need to set up a spreadsheet for the Lantus Insulin Support group. (It's a really busy forum and they have dozens of spreadsheets a day to look over.) The spreadsheet is color coded and really helps you see patterns. The instructions are here: http://felinediabetes.com/FDMB/viewtopic.php?f=6&t=16 It's pretty easy and a great tool to have. Then head over to the Lantus page and ask for help: viewforum.php?f=9

Be sure to test often when reducing the dose and also test for ketones. (The plastic wrap idea is a great one. So is the aquarium gravel. We put Oliver in the room with the gravel and the box and waited. It worked!)
 
Holly -

I think you've made a good decision to start over at 1 unit. That's what I did with Porky - I had trusted my vet with the dose of 3 units, but when Porky had a pretty low pre-shot number, I panicked, and the good advice I got here on this board was to start over at 1 unit.

I had also changed his diet to all canned low-carb, which also made a huge difference in his numbers.

You will have to be patient, though - it may take a while to see any changes in the numbers. But stick with the protocol - it DOES work! Porky was able to get off of insulin in around 6 weeks, and he's been OTJ for almost 6 months!

Good luck!
 
I don't rely on my vet for anything related to FD; they just don't know.
They are awesome for other stuff and dentals, so that's why I need the vet.
Dosing does not come from the vet for us. They just don' know.

You can post on the Lantus group and you will be amongst several others who can give you plenty of advise and support.
 
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