Newbie needs help using PZI TID with high numbers

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nancy and payne

nancy and payne

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I posted this on the PZI forum but no one uses the TR system. As stated below I am using the
every 8 hr. shot because my cat Payne is VERY prone to ketones. Thanks!

My cat Payne was Dx Oct. 11 and it has been quite a roller coaster ride! I posted before asking for
advice but I was using R with ProZinc and no one could help with the #'s because of that.

Well I am back, Payne is MUCH better and we follow the protocol. We have stopped the R and began
tight regulation 2 weeks ago. In the beginning Payne had three episodes of DKA and we worry/check
ketones constantly.

Because of the ketones and the addition of the R we were never sure just how well the ProZinc
worked with her, well now we are trying to see and her numbers are all over the place! Yet from the
moment we began TR she has perked up! is feisty and just a pain :) Yet her #'s are high. We chose
TR because of her ketone tendency and she seems to need more insulin because of that?

Could you please look at my SS! the 1st. SS listed is when she was doing 12/12 .... the 2nd. one
is when we changed to TR and the past week no NovolinR. You will see the +1 next to the PZI # that
is for my vet who I am bringing along but he did not want me to stop the R but had no good reason
why. (he follows the SS but doesn't know why the #'s are so bad)

I have learned so much, read so much but I still look at a SS and just see #'s and colors. cat(2)_steam
Since she is doing so well otherwise and the ketones have been in check, I really would like to level
her #'s out. So it's just ProZinc, could you give me your opinions on her numbers. I would appreciate
it.
Nancy and Payne
 
Hi Nancy,

The high numbers could be rebound. I have not worked with the new Prozinc -- only the older PZI which seems to be different.

I did do TID with Norton using BCP PZI using a sliding scale (adjusting his dose based on his BG --- a custom dosing scale based on his response history)

For the starting dose, we kept about the same total insulin per day -- he was an acrocat getting 8u BID (16u per day) and we started by splitting that into 3 doses (5u TID)

Our dosing scale is listed in our old FDMB profile - along with some pre-spreadsheet data.
http://www.felinediabetes.com/phorum5/p ... hp?25,5529

Your spreadsheet looks like you jumped to 3u BID on day two. So it is possible that you missed the best dose. I understand the concern about ketones - just observing.

I feel that the new Prozinc is different than the old PZI, so I really don't feel comfortable advising about dosing or response.

When you changed to TID -- you essentially jumped from 6u per day to 9 to 10u per day. This may be too sudden a change.

I do agree from your BID spreadsheet -- the insulin looks like it was gone by +8

It is possible and reasonable with TR to dose PZI QID - every 6 hours as long as the blood sugar is rising.
(test at +5 and +6 -- if rising by 20 pts, or over 200 (or your safe to shoot#) go ahead and shoot at +6)

So.... I'm feeling a bit wishy-washy, and hope some more experienced peeps chime in ---
 
Nancy, I have only used Humulin U and PZI Idexx but........worked with my, at the time, Critical Care vet and another diabetic that had fatty liver, ketones, high numbers and giving IDEXX PZI + 5 1/2units of R. Worked the way up on the R and suggested to vet it was like giving water, to stop it and consult with Dr. Hodgkins. He did, we took the cats b.i.d. dose and split it 3 ways. We didn't take the dose and just triple it, we split the b.i.d. Amazing results because not only did the cat decide to eat, but that he liked canned, the t.i.d. dose worked and within two weeks he was off insulin and took his own feeding tube out. He also was 31lbs orginally and slimmed down to a great weight of 18lbs. and has been off insulin for 4 years.

I believe you are giving too much insulin if you went from 3 or 3.5 units b.i.d. to that same amount t.i.d. What is recommended is to take the total b.i.d. dose and split that 3 ways and give that amount t.i.d.

Sometimes less is more. Also, Mishka as I posted before about, was prone to ketones especially in her first 3 months of treatment and had DKA several times. It took her time to adjust to canned food only, getting enough food till the insulin could help, giving everything time to come together.
 
If I may go back to square one ..... she was getting 3u of PZI and 1u of R b.i.d. so 8u insulin a day.
The dose was raised during a bad case of ketones, which hopefully is much better lately. I thought to
do TR you had to follow Dr. H's scale?

So what you are saying is take the 8u previous daily and divide by three, giving us three skinny 3u's?
regardless of how high she goes? I am afraid of ketones and at least the high insulin keeps those away?
She is doing so well, I think she is MUCH stronger than when she was first Dx and I feel in my gut she
is getting too much insulin. Is this what you are saying? I can't do every six hours because she starts
to fight the whole process, 8 hrs. is the best I can do.

Thanks
Nancy and Payne (not liking the q.i.d. talk :)
 
Nancy,

I've shot TID in the past with Layla when on PZI (on Levemir now).

What I did was not normal - so big disclaimer, but, I shot insulin, and then after her peak (often at +5 or +6), as soon as she was on her way up I'd shoot again. I did not shoot on an 8-hour schedule.

I don't understand how the numbers are not coming down at all - even with the R insulin. Is the insulin new - not shaking the insulin, right?

I agree you need to get the numbers down as soon as possible. If you are there to monitor you can shoot early (disclaimer) as long as you are testing and have the numbers there to provide the proof.

I'm happy to help anyway I can. We shot TID for about 3 years on the PZI insulins and now 3+ years BID on Levemir.

If you shoot TID I would reduce the amount of R insulin - just a thought.

Pam & Layla
 
Nancy, just to answer your question about TR and Dr. H's scale. Tight Regulation means trying to keep the glucose levels in a tight range, it can be accomplished by a variety of techniques, not just one. Some cats allow it through BID dosing (regardless of insulin), while others require TID or "out of the box" thinking. Protocols such as the Tilly and Rand protocols are TR protocols, Dr. H's protocol is also a TR protocol.

The key to any technique used is data collection to determine which variable to change (number of shots vs. total amount of insulin per day for example) when needed since ECID.

I agree that you probably need to step back and back off the total amount of insulin being given on TID since adding so much insulin in a single 24 hour period may have caused some rebound. I personally like a single dose instead of a sliding scale (but that is what worked for my Splash until his insulin needs started decreasing and I HAD to reduce what I shot). I found that with both PZI Vet and Lantus (which is what my Friday was on) both cats dropped a larger amount from a higher number and a lesser amount if they started a cycle from a lower number (for example, there may have been a 300 point drop if the preshot was 400, but only a 50 point drop if the starting number was 275). This was happening with the same dose given, not a sliding scale.

I hope hearing what some of us have done helps you think through how to continue approaching Payne's treatment. We aren't here to tell you what to do, but to share what worked for us and help ask the questions you need to discover the answers to. I think you have done a great job keeping the ketone monster at bay and Payne obviously appreciates that!
 
In managing human diabetes, the longer acting insulin is referred as the base insulin. This is usually kept at a regular dosage level. The shorter acting insulin also called the bolus insulin is usually the insulin administered on a sliding scale depending on the blood glucose level. Your vet should have set up a sliding scale with you if he or she wanted you to use R insulin too. Usually in humans the R insulin is given only when the BG is over a certain llimit such as 250. There is even some debate amoung human medical professionals about how high or how low the BG should be before using the bolus insulin.

Most literature I have read state that DKA can start at a BG of 250 to 300. I thought that the 250 sounded way too low until my cat had his second round of DKA at a BG of 240. Besides just a high BG there are also many other factors that make a cat prone to DKA. Nomad my sugar kitty was extremely thin and also had many skin infections. Once these were resolved the ketones have not been above a trace level. It sounds like you are hopefully past the ketone dance. (Paws crossed).

Since I do not use the TR model I will not give any specific advise about insulin dosage. However, what some prevoius members said about total daily insulin dosage is generally also true in human medicine. If someone is on 20 units BID and the MD went to a TID schedule then the dosage would be about 13 units TID.

Some individuals, wether cats or people, metabolize at different rates. There is one woman I know who metabolized both lantus and levemir at twice the normal rate. It wasn't until they did a couple of curves on her that they figured this out. She ended up getting Lantus twice a day instead of the usual human once a day dosage. Ironically this woman also loves cats so maybe some feline metabolism rubbed off on her. LOL

I am glad your cat is doing better and I hope you are over with the ketone dance. The sugar dance can be just as challenging. :-)
 
I remember your post a few weeks ago about the ketones. I still can't believe the numbers she is getting with 3u of R each day :shock:

Since she has no ketones right now, it very well could be rebound. Maybe try cutting down the R to 0.5u plus your dose of prozinc to see if that changes anything or if ketones come back. If you are still negative on the ketones after a few days, try cutting out the R.

I know from experience and from others telling me their experience with R - it is good to use to bring down numbers quickly in delicate situations, but should not be used long term because it is very hard to regulate a cat when including R in the dosing. Ultimately, you want to try to find a dose of prozinc that works at keeping the ketones at bay.


edit to add: If the ketones come back up when you try to cut the R, then I think it is time to get tested for insulin resistance (IAA) and acromegaly.
 
Kelley, she was using 3 units of Prozinc and 1 unit of R and she has sinced stopped the R and if I am reading it correctly, she has gone T.I.D. and added another 3 units of Prozinc.
 
Hope + (((Baby)))GA said:
Kelley, she was using 3 units of Prozinc and 1 unit of R and she has sinced stopped the R and if I am reading it correctly, she has gone T.I.D. and added another 3 units of Prozinc.
Click to expand...

According to the spreadsheet, last night she gave 4u of prozinc + 1u of R though.
 
QUOTE: "Could you please look at my SS! the 1st. SS listed is when she was doing 12/12 .... the 2nd. one
is when we changed to TR and the past week no NovolinR. You will see the +1 next to the PZI # that
is for my vet who I am bringing along but he did not want me to stop the R but had no good reason
why. (he follows the SS but doesn't know why the #'s are so bad) "

She is still showing the +1 R because her vet told her to keep giving R --- but she said that she stopped the R when she went to TID. She shows the spreadsheet to her vet.
 
Phoebe_Tiggy_NortonGA said:
QUOTE: "Could you please look at my SS! the 1st. SS listed is when she was doing 12/12 .... the 2nd. one
is when we changed to TR and the past week no NovolinR. You will see the +1 next to the PZI # that
is for my vet who I am bringing along but he did not want me to stop the R but had no good reason
why. (he follows the SS but doesn't know why the #'s are so bad) "

She is still showing the +1 R because her vet told her to keep giving R --- but she said that she stopped the R when she went to TID. She shows the spreadsheet to her vet.
Click to expand...

ah, thank you. Good to know that the R is out of the picture now and the ketones are still being kept at bay.

Because of the history of ketones, though, I would not advocate going back down to 1u. Maybe try 2u TID and monitor the ketones?
 
I'm sorry for my confusing post, trying to please a vet I like and want to "bring along" because
he is willing to learn, but I find it so interesting that vets know so little about FD and throw in
rampant ketones! most run screaming! he stuck with me but being a young male (not a hit) he
wants to drive the bus, but it is MY bus.

Yes, I stopped giving the R when we started TR, two weeks ago, saying prayers every moment
of each day. So far we have had NO ketones and a cat that is thriving on t.i.d. Seriously being
a pain! I had 2 litters of newborns four years ago a week apart. Mothers were very feral and
would not take care of, Payne was one of those kits. She was the leader and taught the other
10 all the tricks to learn, inventing some along the way!

I think I am going to back up .... I like the idea of taking what was her base? insulin and giving
it in 3 doses. I would be too nervous going down much lower than 3u because of the ketones,
but will make them skinny 3's. Thanks for all the crossed paws :)

I read Dr. H's book "Your Cat" and still got the feeling TR was only done ONE WAY! I feel so
relieved knowing it is about the individual cat and my knowledge of my cat. I knew the R
should only be used for situations like ketones, and not given everyday. I told him that but his
fear of DKA was too great.

Thanks everyone for your help, I have learned so much in the short time I have been here,
I shutter to think where Payne would be at this moment in time without you all. Just the
change in food was worth the price of admission ;-)

Nancy and Payne (sending you her wink too)
 
Nancy

Dr H's way of TR was done only one way, but there are many other ways that are as individual as the cat and the human being involved. Dr H's old message board was highly controversial and I wouldn't advocate it one bit. Use the resources of the people here who have offered, I'm sure you will find what works best for the two of you.
 
I don't like Dr. H's old message board or the one now .... it seems there is only ONE way and we all
know that isn't true. I REALLY like this board, so many opinions, so much wealth of knowledge. I
am so happy to have found you all, because I could not visit the bridge one more time this year.
(we just recently lost one of Payne's civvies) Plus, because of you all her quality of life is just so
good, not like a sad sick cat. And not feeding dry will improve the health of all my other cats and
those to come, forever! Thanks!
Nancy and Payne
 
Such good advice is given here!! I started Saturday night last shot giving Payne a skinny 3u and you
should see her SS, she has leveled off!!! So she was rebounding with all the insulin. I did a curve
yesterday and normally she is all over the place but this one is beautiful! (well the #'s are still high)
Instead of treating this all like a sprint, it really is a marathon and maybe now everything can come
together and level her off.

Thanks to everyone! I would not have thought of going back and doing this but it is working! with
no R and NO KETONES!! You are all the best!
Nancy and Payne (who is glad the curve is DONE!)
 
just loo ked on..i shot tid for awhile. the one thing i see that altho' payne's number are level which is wonderful...they are still too high. i ask for myself as well as you nancy...how do you lower them without increase. i am not suggesting increase. actually maybe leveling for several days will in itself lower his numbers gradually.
good luck nancy,
lori
 
Nancy, I'm glad to see the leveling out but.....you originally had Payne on 6 units total and then you went t.i.d. and added another 3 units. Usually going t.i.d. means taking the total amount of units.......6.......dividing by 3 and go 2 units t.i.d. I still think it is too much insulin but give it another few days and then maybe try 2.5 t.i.d...down from 9 units to 7.5 units.
 
hope i get what your saying. when will i finally learn that if a little is good too much is not better ohmygod_smile
 
I had her on 6u of PZ and 2u of R .... so I took the 8u divided by three and we are giving 3 skinny units t.i.d.
My hope is that as she gets stronger and having everything level for awhile, will help her body heal. She is
still on 2.5 mg. pred. which we have reduced to every other day and are getting ready to go to every
third soon. Getting the pred out of her system, not having the R revving her up, eating good low carb food,
etc. and hopefully the numbers will drop but she is doing WONDERFUL!!!! and not a ketone to be seen!
Nancy
 
Nancy, I did not count the R because IMHO it may bring them down but maybe the PZI hasn't kicked in yet so they go back up after R is through working. I just saw with cat I was working with that the R ended up like we were just shooting water and that was at 5 1/2 units of R. So instead of splitting the dose of 6 units of PZI you added another 3 units of PZI and then split it 3 ways so you actually are giving Payne more PZI which may not be needed. Time will tell in the next few days.
 
Her #'s are starting to creep up again. Her last shot last night was 406 and this AM 346 .....
should I stay with the three skinny 3u's for awhile? or go down to 2.5U? she seems really
good and still no ketones, thank God.
 
nancy, you cannot count the R into this equation. just your basal insuln of PZI, so I would drop it back to 2 u TID and see what happens
 
I'm with Dian on this ........2 units t.i.d.........but didn't want to scare you so was hoping to get you to go at least down to 2.5 which is still more than he was getting b.i.d. of the pzi. When you go from b.i.d. to t.i.d. it is not a matter of adding more units...you are still giving the same amount but in smaller doses split over time.
 
right Hope and Nancy
this same dose over every 8 hours (TID) covers the time when insulin may be pooping out so you are basically having a little overlap of the doses to keep him going . by the time the first dose is wearing off, the second dose should be kicking in or shortly there after. been a while since I used PZI but we did TID and even QID (4X a day) with same dose divided into 4 not an increase in dosage
 
Nancy and Payne said:
Okay, I'll trust everyone on this, gulp ..... 2u t.i.d. starting with the middle dose at 2:00 pacific time ohmygod_smile
Click to expand...

Could definitely be worth a try. You already know this, but keep diligent on that ketone testing!
 
Nancy and Payne wrote:Okay, I'll trust everyone on this, gulp ..... 2u t.i.d. starting with the middle dose at 2:00 pacific time ohmygod_smile
Click to expand...
it is no less than you we were doing before you increased dose. just watch. test for ketones and test BG. you may be surprised. sometimes less is more KWIM ?
 
Just remember......it was Dian who said 2 units t.i.d :lol: When I first saw you go t.i.d. and add another 3 ohmygod_smile I meant it to be 2 t.i.d. but opted to have you at least try 2.5. So glad you are giving this a try. I worked with a woman close by me.......OMG.......nervous and obsessive......got that kitty going good on t.i.d. but she couldn't take it........nerves got to her......it was easier to go back to b.i.d., shoot more, watch the higher numbers and test for ketones and this cat had already been through DKA in the beginning. Even though she saw excellent results she didn't keep it up. She literally spent all day every day watching everything her cat did, loved on her, fed her turkey slices, did everything wrong because it was easier and eventually after many months she lost her kitty. She was so bad my own IM vet fired her as a client nailbite_smile
 
I understand the nervousness having dealt with DKA 3X and almost losing her on the third go around,
which was only 6 weeks ago. I hope I don't come across like the woman you worked with, I have
many civvies, dogs, birds and kids. I work from home when the stock market is open and I have a
large non-profit that distributes dented and damaged goods to the needy.

Yet,I have never felt so oven my head, ever. This newbie thing would be funny if it wasn't that your
animals life hangs on your quickness with the steep learning curve that a cat with diabetes poses,
then add in the DKA and everything else.

I appreciate all the help and I will do what I need to do for Payne, who seems to do better on the
t.i.d. schedule, which is no problem. Thanks!
Nancy and Payne (loving all the attention!)
 
Trust me, Nancy......no one could be like her :lol: You are doing great. In those first 3 months with Mishka and DKA......I'd get her home for 2 days, ketone free, and back in on the 3rd IN DKA. I still took it slow with the insulin which was Humulin U at the time. I think her being vaccinated right before I got her, a weight loss of 10 1/2lbs, and stress did her in. I never totally relax with her and take it for granted, even 7+ years later, because I know she is prone to ketones at the drop of a hat. Vet kept her and finally started her on 1 unit of L, at the time, called me and said 1 unit wasn't doing it so he upped her to 2. I told him it was too much too fast. Guess who called me back later that day and said Mishka had a hypo event? Backed her down to 1 1/2 units but L wasn't doing it for her so switch to U. That was discontinued so went to PZI IDEXX. That has now been discontinued and time is coming when I have to switch. You are not the only one who is nervous. I hate switching insulins with a passion.

Please let us know how Payne is doing and I'm sure many of us are watching that SS.
 
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