On 10iu twice a day.....

[Cindy De Vries]

Hi all, our girl Amber is now on 10iu of caninsulin twice a day. She is 12 and diagnosed a year ago- had severe weight loss, lethargy coat awful etc. She also has megacolon which she is on granules for to help move things along.
We are in the UK and I feel our vets are going through the motions but aren't proactive in bringing new ideas to the table or telling me anything extra.
She has had curves over the past year which everytime are 11-16 at best - and highs of mid 20's. They want her to come down into single figures so the insulin has crept up to 10.
I am aware that the curves could be reading false highs due to her being stressed at the vets. We hired a monitor (and even tried my own as I had gestational diabetes in pregancy), however we just couldn't get enough blood out. I have since read on here about warming the ear...our vet never suggested that! So we have been stuck doing curves at the vets.
Over all she is much better but her coat seems dull again. She eats twice a day when injected - wet food only- just whiskas senior wet as we are in multi cat household so they have to be all on the same.
The vets have said youcan't really go above 10iufor her body weight of 5kg. So if her next curve (tomorrow) is still high I'm slightly at a loss??? I will next try curving her myself...but any advise out there for anything else?
I am concerned as had a previuos diabetic cat who died of a hypo, although he was only on 4 units, (he was 19 and had a heart murmer also bless him) I don't really like the risks of being on such a hugh dose.

BTW I am slightly confused by people allowing grazing...I thought the idea was that the insulin worked exactly when you feed and therefore by feeding inbetween this counteracts this? Also is the idea of injecting different amounts ie less at tnight to reduce the risk of hypos through the night when they are not eating?
Many thanks for your help. Thank you

 

[Mogmom and Goofus]

Welcome Cindy! While I'm not familiar with Caninsulin or its dosing, 10u twice daily sounds like a lot. Do you home test am and pm? If not, it's very possible that you've missed the "sweet spot" regarding the dose. Do you know what the carbs are in the food she's eating? Even tho it's wet food, it can still be very high in carbs. Maybe you could try feeding Amber in another room, that way only she would get the low carb stuff.

As to the grazing thing, my vet says "nope". Goof only gets one snack a day, usually around noon, and that's about 2 tablespoons of plain tuna.

 

[Larry and Kitties]

Can you post the most recent curve so we can see what is happening with time?
Curves taken at the vet van 6 or more (100 or more USA) points higher due to vet stress.
Also look at the following since Amber may have other problems that causes the high insulin needs.
http://www.felinediabetes.com/FDMB/...-other-high-dose-conditions-what-we-know.375/
http://www.felinediabetes.com/FDMB/threads/acromegaly-the-basics.373/
My MurrFee had acromegaly and was on 50 units twice daily

Have you talked with your vet about using a human insulin since Vetsulin seems not to be working.

 

[Squalliesmom]

Hi Cindy, welcome to FDMB!

10 U is a very high dose of Caninsulin! It can be a very harsh insulin, causing sudden, very steep drops in blood glucose. I use Vetsulin, the American equivalent, so I am pretty familiar with it. I have been very lucky and so far have had reasonably good results with it, but I think I may be the exception to the rule.

While it is definitely preferable to give the same dose each time every day, Caninsulin sometimes can be adjusted a bit if it's absolutely necessary and Amber's BG numbers warrant it. However, I am not a vet, so don't do so without first consulting with your vet and getting his okay on it!

If the food you are feeding is high in carbohydrates (and I suspect it is) you are kind of shooting yourself in the foot, so to speak. A low carb diet is a huge part of treating a diabetic kitty. We recommend foods that are under 10% carbs. I see that you are in the UK so I'm adding a link to European/UK foods:

http://www.felinediabetes.com/FDMB/...for-europeans-and-international-buyers.64843/

This list is a few years old and I believe there is a more recent one floating around here somewhere, another member may be able to direct you towards it. But here's the caveat: UNDER NO CIRCUMSTANCES should you transition to a low carb diet if you are not home testing, and able to closely monitor you kitty. To do so could result in a deadly hypo!

I also agree with Mogmom, it's very possible that, without home testing, you've gone beyond the "sweet spot."

 

[Olive & Paula]

Can you discuss a different insulin with your vet? You tried Vetsulin for a year so they have the documentation that it appears to not be helping. Good luck, let us know what happens.

 

[Wendy&Neko]

Welcome Cindy and sweet Amber. Since you are in the UK, you have a great resource available to you, the Royal Veterinary College are amongst the world leaders in feline diabetes. As Larry mentioned, it is possible that Amber has a high dose condition. Research conducted at RVC has shown that one in four diabetic cats has acromegaly, a condition that often means kitties need higher doses of insulin. Megacolon is also a symptom of this condition. I suggest you get your vet to test for axromegaly (test done at RVC) with blood your vet collects. RVC has an acromegaly clinic, as well as a feline diabetes remission clinic and are fabulous at providing help and information.

If Amber does indeed have acromegaly, I would strongly suggest s change from Caninsulin to a longer acting insulin like Levemir or Lantus. Levemir is a better choice for higher dose kitties, as Lantus can sting at higher doses. The longer acting insulins are better with grazing or multiple meals during the day.

 

[Critter Mom]

Hi Cindy

I just love your avatar pic!

I'm sorry that you've been having difficulty with Amber's regulation. I feel for you over the hypo worries.

As Larry has requested it would be a great help to see recent curve data. Also, if you could run a home curve as soon as possible it will give you a much better picture of how Amber is responding to her insulin in a stress-free environment and would therefore be much more valuable as a reference for determining a safe and effective dose - and possibly whether a different insulin may work better for Amber. If it's possible, it might be better to run a night time curve if Amber tends to run lower at night; it would give you better peace of mind to have some solid data on what her BG levels are doing while you're asleep. (Also a 'before bed' test at about +3 hours after the dose is always a wise move so you know where the cycle is heading.)

As you know, legally vets have to first prescribe Caninsulin in the UK but if it can be demonstrated that the Caninsulin is working your vet can then prescribe another insulin (e..g. Lantus) under drug cascade rules. If you do decide that you'd like to try a different insulin for Amber, myself and other UK members can give you pointers on how to go about this if you need them. (Saoirse was on Caninsulin first but she did much better on Lantus. For information, she is not a 'high dose kitty'.)

If at all possible, it would help you a great deal if you could record BG data in one of the shareable FDMB spreadsheets. Here's a link to the templates and instructions - for the UK you'd need to choose the World Spreadsheet Template (mmol/L). The shareable spreadsheet would also help members here to get a better picture of Ambers' response to her insulin and perhaps make better suggestions for you to discuss with your vet. If you'd like to use one of the spreadsheets but would like some assistance setting it up, just give a shout and we'll find a member to help you with that.

When it comes to feeding, I had to strike a compromise between the way Caninsulin works and the needs of my cat. She has chronic pancreatitis and when the vets we were with at the time insisted she only be fed twice a day just before her insulin injections she started having painful vomiting bouts as soon as her tum became empty (just over 3 hours after her injection). I found this completely unacceptable so, regardless of her then vet's disapproval, I split her food allowance for each cycle into different sized meals so that she always had some little bit in her tummy and that stopped the vomiting and her pain. I gave 1/3 of her ration half an hour before the insulin dose; 1/3 at +3 hours after the injection, then about 1/4 of her food allowance at +6 hours and the balance as a very small snack at +9 hours after the insulin dose. Perhaps not text book but it was the right thing to do for my particular cat. The vet at our current practice understood the necessity of this approach and supported my choice, BTW.) It also helped me to sleep knowing she would have something to eat at regular intervals during the night. (A timed feeder is a godsend; the best one I've used is the Petsafe 5.)

Do you know the carb content of the Whiskas Senior food? ( @Elizabeth and Bertie - is this on your UK food list?).

Wendy has given you some great info about the RVC. They're very approachable and helpful. One of the vets in their diabetes clinic (Ruth IIRC???) had a chat with our own vet and I think it helped a lot when I was trying to get a change of insulin for Saoirse.


Mogs
.

 

[Elizabeth and Bertie]

Do you know the carb content of the Whiskas Senior food? ( @Elizabeth and Bertie - is this on your UK food list?).

Am on the case now.... BRB....

 

[Critter Mom]

Am on the case now.... BRB....

You're a star, Eliz.

Congrats again to you and Bertie!
.

 

[Jeanne & Dottie]

Hello Cindy unfortunately cats aren't dogs and they don't always follow protocol. Some cats can't or won't eat only twice a day. They get to feeling bloated or sick to their stomachs and then refuse to eat at all. A cat who doesn't eat can develop fatty liver disease pretty quick. As quick as 3 days.Also if they are thin and weak they may not be able handle two larger feeds. You have to get their nourishment into them when they're willing and able. And insulins aren't all the same in how fast acting they are.This is a great board and everyone is willing to help you. Lots of tips and tricks to help. Many cats have even gone on to remisson..OTJ!

 

[Elizabeth and Bertie]

She eats twice a day when injected - wet food only- just whiskas senior wet as we are in multi cat household so they have to be all on the same.

Do you know the carb content of the Whiskas Senior food? ( @Elizabeth and Bertie - is this on your UK food list?).

Hmmm.... There seems to be a bewildering assortment of 'senior' Whiskas foods available at the moment. (I feel quite dizzy just looking at them! ) But not all of them are currently listed on the Whiskas website, so I'm guessing they might be in the process of phasing some out...?

Of the senior ones listed on the website there's;
Whiskas 'Oh So' Fishy, Senior - 3.3% calories from carbs
Whiskas 'Oh So' Meaty, Senior - 3.1% cals from carbs
Whiskas '7+' selection in jelly, poultry/fish - 2.9% cals from carbs

There are also Whiskas '7+' selections in gravy, in both poultry or meat varieties; but I am puzzled by the nutritional analysis on these given that they would, outwardly, appear to be such similar foods... The 'meat' selection lists cereals in the ingredients and comes out at a stonking 16.3% calories from carbs (and it also contains 'vegetable protein extract' (usually soya, which some cats are very sensitive to). But the 'poultry' selection lists neither cereals nor 'vegetable protein extract' and comes out at just 2.9% calories from carbs.... (It may be that I've just calculated these values wrong because I need more coffee, so will re-check those again later....)
Edited to add: Aha! I see that on the website they've put the same analysis figures for the '7+' poultry selection in gravy as they have for the poultry selection in jelly. That must surely be an error since one would expect the gravy to be higher carb. (Sorry for this long-winded paragraph. I'll try to tidy it up later..... )

A food not on the website, but still in the shops, is;
Whiskas Senior in jelly, fish selection - 7.6% calories from carbs

Will pop back later and review these numbers....
.

 

[Cindy De Vries]

Dear all, thank you so much for your replies. You are probably wonderering what happened to me and Amber! We had to work abroad for 2 months then back home for a week then back away for 2 months again. Whilst away, my laptop and phone was stolen. So its taken me a while to get all relaced and back up to normal, remembering passwords abnd logins etc. So so sorry, as it seems I was just ignoring everyone. I will reply to you all in turn asap

 

[Cindy De Vries]

I hope all of you and your cats are doing great. The good news with Amber is that Protiname Zinc Inhibitor (PZI) became licsensed in the UK whilst I was away. So we swapped vets and she has just started a lower dose of 2U/ml, compared to the crazy 10 U/ml of Caninsulin. My new vet thinks the high curves could actually be the Somogyi effect, giving false high readings (very interesting and something my old vet never spoke of as being a possibility) . She will have tests in 7 days to see how the new insulin has done and we will try home testing again. (new vet showing us technique with a needle as well as the lancet as we had real trouble getting enough blood out of the lancet last time)
I will report back in with results, so excited to see something new available in the UK, as we could only have caninsulin before.

 

[Cindy De Vries]

Welcome Cindy! While I'm not familiar with Caninsulin or its dosing, 10u twice daily sounds like a lot. Do you home test am and pm? If not, it's very possible that you've missed the "sweet spot" regarding the dose. Do you know what the carbs are in the food she's eating? Even tho it's wet food, it can still be very high in carbs. Maybe you could try feeding Amber in another room, that way only she would get the low carb stuff.

As to the grazing thing, my vet says "nope". Goof only gets one snack a day, usually around noon, and that's about 2 tablespoons of plain tuna.

Hi Mogmom, hope you are well. Yes will be testing myself at the end of the week after first curve with vet after being on the new insulin PZI for a week. I agree the previous curves could have been false readings caused by the Somogyi effect ( I will post this here- soooo interesting!). Re food, I have been sent a list of the carbs in whiskas- so will look through. But first we are trying new insulin to see effect, then will swap food (if poss in multi cat household) to what vet suggets, if we swap too much at once we wont know whats working. Thanks

 

[Cindy De Vries]

The Somogyi effect
An important reason for conducting a blood glucose curve, ie, evaluating blood glucose levels every 2 hours following the morning Vetsulin® (porcine insulin zinc suspension) treatment is the possibility of Somogyi effect or rebound hyperglycemia. In cats, the “Somogyi overswing” occurs when the insulin dose is too high and the patient’s blood glucose plummets below 60 mg/dL.

The Somogyi effect occurs when the body attempts to counteract the life-threatening decline in the blood glucose concentration through a chain of reactions:

• The blood glucose concentration falls rapidly or approaches hypoglycemia (blood glucose concentrations of less than 60 mg/dL [3.3 mmol/L]) following the injection of insulin. The cat becomes hungry and restless or lethargic.
• In response to a declining blood glucose concentration in the central nervous system, adrenaline and subsequently cortisol, glucagons, and growth hormone are released.
• These hormones increase blood glucose concentration (through gluconeogenesis, release of glucose from hepatic glycogen, and increased peripheral resistance to insulin).
• The resulting hyperglycemia produces polyuria and polydipsia. This can be mistakenly attributed to an inadequate insulin dose.

If the morning polyuria is thought to result from an insufficient insulin dose and a higher dose is given, the problem will be aggravated. An even more pronounced Somogyi effect will follow. Eventually the counter-regulatory mechanisms may become exhausted, resulting in severe hypoglycemia.

The Somogyi effect can occur in both cats and dogs, but cats are particularly prone to develop this rebound hyperglycemia. The appropriate corrective action is to decrease the patient’s insulin dose to prevent insulin-induced hypoglycemia.

When to suspect a Somogyi overswing

• Minimal glycemia: <65 mg/dL or 3.6 mmol/L
• Maximum glycemia: 400–800 mg/dL or 22–44 mmol/L
• Persistent morning glucosuria: >1% or 1–2 g/dL (strips)
• Morning glycemia: >400–450 mg/dL or 22 mmol/L
• Clinical signs:
  • Polyuria, polydipsia, weight loss
  • Hypoglycemia (weakness, convulsions, ataxia, behavior changes)
• High insulin dose: close to 2.2 IU/kg and greater

Diagnosing Somogyi effect
A blood glucose curve can help detect a Somogyi effect and confirm that a cat’s insulin dose needs to be reduced.

Any of the following blood glucose curves can be suggestive of the Somogyi effect:

• Hypoglycemia (low nadir) followed by rebound hyperglycemia.
• A rapid decrease in glycemia with an adequate nadir followed by rebound hyperglycemia.
• Persistently high blood glucose values with no discernible nadir (rebound hyperglycemia can persist for a few days following the hypoglycemic event).

See the following graph for an example of a blood glucose curve in a case of rebound hyperglycemia.Insulin was injected at time=0 hours.

Blood glucose curve indicating Somogyi effect
Blood glucose measured in mg/dL
Click on thumbnail for full image:



Solution
Decrease dose by 50% or return to starting dose of 1 IU twice daily, whichever is lower.

See About glucose curves for details on making a glucose curve.

Hyperglycemia due to a Somogyi effect can persist for as long as 3 days after a single hypoglycemic episode. As a result, blood glucose concentrations do not always stabilize within a few days after lowering the insulin dose.

 

[Cindy De Vries]

Can you post the most recent curve so we can see what is happening with time?
Curves taken at the vet van 6 or more (100 or more USA) points higher due to vet stress.
Also look at the following since Amber may have other problems that causes the high insulin needs.
http://www.felinediabetes.com/FDMB/...-other-high-dose-conditions-what-we-know.375/
http://www.felinediabetes.com/FDMB/threads/acromegaly-the-basics.373/
My MurrFee had acromegaly and was on 50 units twice daily

Have you talked with your vet about using a human insulin since Vetsulin seems not to be working.

Hi Larry, Yes just swapped to human insulin PZI- will post first curve when doen in next week or so. She suspect Somogyi effect, hence previuos re4laly high redaings when actually she could have been very low. ( I posted Somogyi efffect under here). The food- i will be adjusting but have to change one thing at a time to see whats working. I will ask my new vet about Acromegaly- she may have looked at this as we had very complex bloods done last week before swapping insulin to check what esle could be going on. Thank you so much for you input.

 

[Cindy De Vries]

Hi Cindy, welcome to FDMB!

10 U is a very high dose of Caninsulin! It can be a very harsh insulin, causing sudden, very steep drops in blood glucose. I use Vetsulin, the American equivalent, so I am pretty familiar with it. I have been very lucky and so far have had reasonably good results with it, but I think I may be the exception to the rule.

While it is definitely preferable to give the same dose each time every day, Caninsulin sometimes can be adjusted a bit if it's absolutely necessary and Amber's BG numbers warrant it. However, I am not a vet, so don't do so without first consulting with your vet and getting his okay on it!

If the food you are feeding is high in carbohydrates (and I suspect it is) you are kind of shooting yourself in the foot, so to speak. A low carb diet is a huge part of treating a diabetic kitty. We recommend foods that are under 10% carbs. I see that you are in the UK so I'm adding a link to European/UK foods:

http://www.felinediabetes.com/FDMB/...for-europeans-and-international-buyers.64843/

This list is a few years old and I believe there is a more recent one floating around here somewhere, another member may be able to direct you towards it. But here's the caveat: UNDER NO CIRCUMSTANCES should you transition to a low carb diet if you are not home testing, and able to closely monitor you kitty. To do so could result in a deadly hypo!

I also agree with Mogmom, it's very possible that, without home testing, you've gone beyond the "sweet spot."

Hi Squalliesmom, hope you are well. Yes such a high dose so thank fully just swapped to new insulin PZI .Yes will be testing myself at the end of the week after first curve with vet after being on the new insulin PZI for a week. I agree the previous curves could have been false readings caused by the Somogyi effect ( I will post this here- soooo interesting!). Re food, I have been sent a list of the carbs in whiskas- so will look through. But first we are trying new insulin to see effect, then will swap food (if poss in multi cat household) to what vet suggets, if we swap too much at once we wont know whats working. Thanks

 

[Cindy De Vries]

Hi Cindy

I just love your avatar pic!

I'm sorry that you've been having difficulty with Amber's regulation. I feel for you over the hypo worries.

As Larry has requested it would be a great help to see recent curve data. Also, if you could run a home curve as soon as possible it will give you a much better picture of how Amber is responding to her insulin in a stress-free environment and would therefore be much more valuable as a reference for determining a safe and effective dose - and possibly whether a different insulin may work better for Amber. If it's possible, it might be better to run a night time curve if Amber tends to run lower at night; it would give you better peace of mind to have some solid data on what her BG levels are doing while you're asleep. (Also a 'before bed' test at about +3 hours after the dose is always a wise move so you know where the cycle is heading.)

As you know, legally vets have to first prescribe Caninsulin in the UK but if it can be demonstrated that the Caninsulin is working your vet can then prescribe another insulin (e..g. Lantus) under drug cascade rules. If you do decide that you'd like to try a different insulin for Amber, myself and other UK members can give you pointers on how to go about this if you need them. (Saoirse was on Caninsulin first but she did much better on Lantus. For information, she is not a 'high dose kitty'.)

If at all possible, it would help you a great deal if you could record BG data in one of the shareable FDMB spreadsheets. Here's a link to the templates and instructions - for the UK you'd need to choose the World Spreadsheet Template (mmol/L). The shareable spreadsheet would also help members here to get a better picture of Ambers' response to her insulin and perhaps make better suggestions for you to discuss with your vet. If you'd like to use one of the spreadsheets but would like some assistance setting it up, just give a shout and we'll find a member to help you with that.

When it comes to feeding, I had to strike a compromise between the way Caninsulin works and the needs of my cat. She has chronic pancreatitis and when the vets we were with at the time insisted she only be fed twice a day just before her insulin injections she started having painful vomiting bouts as soon as her tum became empty (just over 3 hours after her injection). I found this completely unacceptable so, regardless of her then vet's disapproval, I split her food allowance for each cycle into different sized meals so that she always had some little bit in her tummy and that stopped the vomiting and her pain. I gave 1/3 of her ration half an hour before the insulin dose; 1/3 at +3 hours after the injection, then about 1/4 of her food allowance at +6 hours and the balance as a very small snack at +9 hours after the insulin dose. Perhaps not text book but it was the right thing to do for my particular cat. The vet at our current practice understood the necessity of this approach and supported my choice, BTW.) It also helped me to sleep knowing she would have something to eat at regular intervals during the night. (A timed feeder is a godsend; the best one I've used is the Petsafe 5.)

Do you know the carb content of the Whiskas Senior food? ( @Elizabeth and Bertie - is this on your UK food list?).

Wendy has given you some great info about the RVC. They're very approachable and helpful. One of the vets in their diabetes clinic (Ruth IIRC???) had a chat with our own vet and I think it helped a lot when I was trying to get a change of insulin for Saoirse.


Mogs
.

Hi Crittermom, thank you for your reply, hope you are well. Re new insulin and Cascade- I must admit both my old and new vet said in UK it is only now that any other insulin other than Caninsulin (your Vetsulin in USA) can be used as PZI only licsensed for cats in last month. Even with Cascade to go through they said there was no other insulin previusoly to go to. But at least now I have this new one to try. Yes will be testing myself at the end of the week after first curve with vet after being on the new insulin PZI for a week. I agree the previous curves could have been false readings caused by the Somogyi effect ( I will post this here- soooo interesting!). Re food, thank you guys-I have been sent a list of the carbs in whiskas- so will look through. But first we are trying new insulin to see effect, then will swap food (if poss in multi cat household) to what vet suggets, if we swap too much at once we wont know whats working. Thanks. We will have to weigh up the pros and cons of feeding her alone in a room ( she may get stressed) and then can be on different food to the rest. Thanks again PS My avitar pic- yes had all my animals at our wedding- just in pictures..couldnt be with out them! lol

 

[Cindy De Vries]

Can you discuss a different insulin with your vet? You tried Vetsulin for a year so they have the documentation that it appears to not be helping. Good luck, let us know what happens.

Hi Woodyswife, hope you are well. Yes can now try PZI as now licsensed in UK- will be testing myself at the end of the week after first curve with vet after being on the new insulin PZI for a week. Thank you

 

[Cindy De Vries]

Hmmm.... There seems to be a bewildering assortment of 'senior' Whiskas foods available at the moment. (I feel quite dizzy just looking at them! ) But not all of them are currently listed on the Whiskas website, so I'm guessing they might be in the process of phasing some out...?

Of the senior ones listed on the website there's;
Whiskas 'Oh So' Fishy, Senior - 3.3% calories from carbs
Whiskas 'Oh So' Meaty, Senior - 3.1% cals from carbs
Whiskas '7+' selection in jelly, poultry/fish - 2.9% cals from carbs

There are also Whiskas '7+' selections in gravy, in both poultry or meat varieties; but I am puzzled by the nutritional analysis on these given that they would, outwardly, appear to be such similar foods... The 'meat' selection lists cereals in the ingredients and comes out at a stonking 16.3% calories from carbs (and it also contains 'vegetable protein extract' (usually soya, which some cats are very sensitive to). But the 'poultry' selection lists neither cereals nor 'vegetable protein extract' and comes out at just 2.9% calories from carbs.... (It may be that I've just calculated these values wrong because I need more coffee, so will re-check those again later....)
Edited to add: Aha! I see that on the website they've put the same analysis figures for the '7+' poultry selection in gravy as they have for the poultry selection in jelly. That must surely be an error since one would expect the gravy to be higher carb. (Sorry for this long-winded paragraph. I'll try to tidy it up later..... )

A food not on the website, but still in the shops, is;
Whiskas Senior in jelly, fish selection - 7.6% calories from carbs

Will pop back later and review these numbers....
.

Hi Elizabeth, thank you soooo much for your time and help with this. Will be adjusting food just after we know the effect of the new insulin PZI so we know what is working. Will update soon! Thanks again

 

[Cindy De Vries]

Hello Cindy unfortunately cats aren't dogs and they don't always follow protocol. Some cats can't or won't eat only twice a day. They get to feeling bloated or sick to their stomachs and then refuse to eat at all. A cat who doesn't eat can develop fatty liver disease pretty quick. As quick as 3 days.Also if they are thin and weak they may not be able handle two larger feeds. You have to get their nourishment into them when they're willing and able. And insulins aren't all the same in how fast acting they are.This is a great board and everyone is willing to help you. Lots of tips and tricks to help. Many cats have even gone on to remisson..OTJ!

Hi, thank you Jeanne for this. Will be adjusting her food after we see how the new insulin PZI works. Thanks

 

[Cindy De Vries]

Hi Cindy

I just love your avatar pic!

I'm sorry that you've been having difficulty with Amber's regulation. I feel for you over the hypo worries.

As Larry has requested it would be a great help to see recent curve data. Also, if you could run a home curve as soon as possible it will give you a much better picture of how Amber is responding to her insulin in a stress-free environment and would therefore be much more valuable as a reference for determining a safe and effective dose - and possibly whether a different insulin may work better for Amber. If it's possible, it might be better to run a night time curve if Amber tends to run lower at night; it would give you better peace of mind to have some solid data on what her BG levels are doing while you're asleep. (Also a 'before bed' test at about +3 hours after the dose is always a wise move so you know where the cycle is heading.)

As you know, legally vets have to first prescribe Caninsulin in the UK but if it can be demonstrated that the Caninsulin is working your vet can then prescribe another insulin (e..g. Lantus) under drug cascade rules. If you do decide that you'd like to try a different insulin for Amber, myself and other UK members can give you pointers on how to go about this if you need them. (Saoirse was on Caninsulin first but she did much better on Lantus. For information, she is not a 'high dose kitty'.)

If at all possible, it would help you a great deal if you could record BG data in one of the shareable FDMB spreadsheets. Here's a link to the templates and instructions - for the UK you'd need to choose the World Spreadsheet Template (mmol/L). The shareable spreadsheet would also help members here to get a better picture of Ambers' response to her insulin and perhaps make better suggestions for you to discuss with your vet. If you'd like to use one of the spreadsheets but would like some assistance setting it up, just give a shout and we'll find a member to help you with that.

When it comes to feeding, I had to strike a compromise between the way Caninsulin works and the needs of my cat. She has chronic pancreatitis and when the vets we were with at the time insisted she only be fed twice a day just before her insulin injections she started having painful vomiting bouts as soon as her tum became empty (just over 3 hours after her injection). I found this completely unacceptable so, regardless of her then vet's disapproval, I split her food allowance for each cycle into different sized meals so that she always had some little bit in her tummy and that stopped the vomiting and her pain. I gave 1/3 of her ration half an hour before the insulin dose; 1/3 at +3 hours after the injection, then about 1/4 of her food allowance at +6 hours and the balance as a very small snack at +9 hours after the insulin dose. Perhaps not text book but it was the right thing to do for my particular cat. The vet at our current practice understood the necessity of this approach and supported my choice, BTW.) It also helped me to sleep knowing she would have something to eat at regular intervals during the night. (A timed feeder is a godsend; the best one I've used is the Petsafe 5.)

Do you know the carb content of the Whiskas Senior food? ( @Elizabeth and Bertie - is this on your UK food list?).

Wendy has given you some great info about the RVC. They're very approachable and helpful. One of the vets in their diabetes clinic (Ruth IIRC???) had a chat with our own vet and I think it helped a lot when I was trying to get a change of insulin for Saoirse.


Mogs
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Hi again Mogs, re the spreadsheet link, thank you - I will use for upcoming results with the new insulin. Brilliant! Thank you

 

[Elizabeth and Bertie]

Dear all, thank you so much for your replies. You are probably wonderering what happened to me and Amber! We had to work abroad for 2 months then back home for a week then back away for 2 months again. Whilst away, my laptop and phone was stolen. So its taken me a while to get all relaced and back up to normal, remembering passwords abnd logins etc. So so sorry, as it seems I was just ignoring everyone. I will reply to you all in turn asap

Hi Cindy, welcome back!

Eliz

 

[Mogmom and Goofus]

The Somogyi effect
An important reason for conducting a blood glucose curve, ie, evaluating blood glucose levels every 2 hours following the morning Vetsulin® (porcine insulin zinc suspension) treatment is the possibility of Somogyi effect or rebound hyperglycemia. In cats, the “Somogyi overswing” occurs when the insulin dose is too high and the patient’s blood glucose plummets below 60 mg/dL.

The Somogyi effect occurs when the body attempts to counteract the life-threatening decline in the blood glucose concentration through a chain of reactions:

• The blood glucose concentration falls rapidly or approaches hypoglycemia (blood glucose concentrations of less than 60 mg/dL [3.3 mmol/L]) following the injection of insulin. The cat becomes hungry and restless or lethargic.
• In response to a declining blood glucose concentration in the central nervous system, adrenaline and subsequently cortisol, glucagons, and growth hormone are released.
• These hormones increase blood glucose concentration (through gluconeogenesis, release of glucose from hepatic glycogen, and increased peripheral resistance to insulin).
• The resulting hyperglycemia produces polyuria and polydipsia. This can be mistakenly attributed to an inadequate insulin dose.

If the morning polyuria is thought to result from an insufficient insulin dose and a higher dose is given, the problem will be aggravated. An even more pronounced Somogyi effect will follow. Eventually the counter-regulatory mechanisms may become exhausted, resulting in severe hypoglycemia.

The Somogyi effect can occur in both cats and dogs, but cats are particularly prone to develop this rebound hyperglycemia. The appropriate corrective action is to decrease the patient’s insulin dose to prevent insulin-induced hypoglycemia.

When to suspect a Somogyi overswing

• Minimal glycemia: <65 mg/dL or 3.6 mmol/L
• Maximum glycemia: 400–800 mg/dL or 22–44 mmol/L
• Persistent morning glucosuria: >1% or 1–2 g/dL (strips)
• Morning glycemia: >400–450 mg/dL or 22 mmol/L
• Clinical signs:
  • Polyuria, polydipsia, weight loss
  • Hypoglycemia (weakness, convulsions, ataxia, behavior changes)
• High insulin dose: close to 2.2 IU/kg and greater

Diagnosing Somogyi effect
A blood glucose curve can help detect a Somogyi effect and confirm that a cat’s insulin dose needs to be reduced.

Any of the following blood glucose curves can be suggestive of the Somogyi effect:

• Hypoglycemia (low nadir) followed by rebound hyperglycemia.
• A rapid decrease in glycemia with an adequate nadir followed by rebound hyperglycemia.
• Persistently high blood glucose values with no discernible nadir (rebound hyperglycemia can persist for a few days following the hypoglycemic event).

See the following graph for an example of a blood glucose curve in a case of rebound hyperglycemia.Insulin was injected at time=0 hours.

Blood glucose curve indicating Somogyi effect
Blood glucose measured in mg/dL
Click on thumbnail for full image:



Solution
Decrease dose by 50% or return to starting dose of 1 IU twice daily, whichever is lower.

See About glucose curves for details on making a glucose curve.

Hyperglycemia due to a Somogyi effect can persist for as long as 3 days after a single hypoglycemic episode. As a result, blood glucose concentrations do not always stabilize within a few days after lowering the insulin dose.

I believe this is what is referred to as a "bounce" here on the board, so if you see someone using that term, you'll know what they mean.

 

[Elizabeth and Bertie]

The good news with Amber is that Protiname Zinc Inhibitor (PZI) became licsensed in the UK whilst I was away. So we swapped vets and she has just started a lower dose of 2U/ml, compared to the crazy 10 U/ml of Caninsulin.

Cindy, can you clarify which insulin you're using?

The PZI insulin that's very recently become available in the UK is called 'Prozinc' (made specifically for cats).
There is also another 'human' PZI which has been available here for some time called Hypurin bovine PZI.
These two are quite different insulins. Which one are you using for your kitty?

Eliz

 

[Critter Mom]

Hi Cindy,

Good to see you back.

Re new insulin and Cascade- I must admit both my old and new vet said in UK it is only now that any other insulin other than Caninsulin (your Vetsulin in USA) can be used as PZI only licsensed for cats in last month. Even with Cascade to go through they said there was no other insulin previusoly to go to.

Both vets are incorrect. Although not formally approved for use in cats, it has been possible to get Lantus under cascade rules - at the very least since 2014 (but probably earlier). It was prescribed under the cascade for Saoirse when I was able to demonstrate that Caninsulin was not keeping Saoirse properly regulated and also that it was making her really poorly. That was in August 2014. Sara (@phlika29) also treated Remi with Lantus in 2014. @Elizabeth and Bertie should be able to tell you more about how she secured a prescription for the insulin she uses (hypurin bovine PZI, IIRC).

But at least now I have this new one to try.

That's all that matters. I'm very relieved to hear that Amber's not getting 10IU BID of Caninsulin any more; your new vet sounds much more switched on WRT feline diabetes.

Fingers and paws crossed that Amber will do brilliantly on her new insulin.


Mogs
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[Elizabeth and Bertie]

Both vets are incorrect.

Yes, indeed.... It's rather shocking, isn't it!?

That was in August 2014. Sara (@phlika29) also treated Remi with Lantus in 2014. @Elizabeth and Bertie should be able to tell you more about how she secured a prescription for the insulin she uses (hypurin bovine PZI, IIRC).

Quite a few of us have managed to get 'alternative' insulins from our vets. And as well as Lantus/glargine and Hypurin PZI, some others have managed to get Levemir (although this seems to have happened more in Scotland for some reason).
Although not licensed for animals these insulins are being prescribed under the cascade system. And all it requires is that your vet fills out an itsy bitsy form to say that Caninsulin didn't work and so they're prescribing Lantus/Hypurin PZI/Levemir instead....

Edited to add:
@Cindy De Vries, I'm guessing then that your vet has given you Prozinc, as this did only become available here recently, and it's a veterinary insulin...

Eliz

.

 

[Olive & Paula]

Cindi, it sounds like you have been having a time of it. Regardless of the insulin, I hope it's better than the canisulin you've been on. Can't wait to see how the new stuff will work.

 

[Cindy De Vries]

Cindy, can you clarify which insulin you're using?

The PZI insulin that's very recently become available in the UK is called 'Prozinc' (made specifically for cats).
There is also another 'human' PZI which has been available here for some time called Hypurin bovine PZI.
These two are quite different insulins. Which one are you using for your kitty?

Eliz

Hi I am using the newly available Prozinc made by Boehringer Ingelheim. It says Insulin human as protamine zinc insulin on the front?

 

[Cindy De Vries]

Yes, indeed.... It's rather shocking, isn't it!?


Quite a few of us have managed to get 'alternative' insulins from our vets. And as well as Lantus/glargine and Hypurin PZI, some others have managed to get Levemir (although this seems to have happened more in Scotland for some reason).
Although not licensed for animals these insulins are being prescribed under the cascade system. And all it requires is that your vet fills out an itsy bitsy form to say that Caninsulin didn't work and so they're prescribing Lantus/Hypurin PZI/Levemir instead....

Edited to add:
@Cindy De Vries, I'm guessing then that your vet has given you Prozinc, as this did only become available here recently, and it's a veterinary insulin...

Eliz

.

Guys I am am so shocked! The recent new vet has it wrong as well then. I will take this thread to her on Friday and see what she says. She has been soooo much better than the last vet but needs to know this! Thank you

 

[Cindy De Vries]

Cindi, it sounds like you have been having a time of it. Regardless of the insulin, I hope it's better than the canisulin you've been on. Can't wait to see how the new stuff will work.

Thank you so much..yes it's all been a bit mad! But just so hoping now to see an improvement. To think that the high dose could have been totally unessecary has really angered me.

 

[Elizabeth and Bertie]

Hi I am using the newly available Prozinc

Okey dokey.

Prozinc has been in use in the US for quite some time, and there are quite a few Prozinc users on this forum.
You may be interested to see the FDMB Prozinc user guide here:Protocol for ProZinc/PZI
Note: The blood glucose numbers in the document are US numbers. To convert to UK numbers you divide by 18.

Eliz

 

[Elizabeth and Bertie]

Guys I am am so shocked! The recent new vet has it wrong as well then. I will take this thread to her on Friday and see what she says. She has been soooo much better than the last vet but needs to know this! Thank you

My vet said it was really straightforward. He filled out a short form. Just a formality...
.

 

[Elizabeth and Bertie]

To think that the high dose could have been totally unessecary has really angered me.

Well, we don't know for certain that the high dose was unnecessary. Some cats do need high doses. But they are in the minority.
And cats that do need high doses do better with longer lasting gentler insulins rather than Caninsulin....
.

 

[Diana&Tom]

Hi Cindy from another UKer
I can't add anything much to what others have said above, but I am familiar with giving very high doses of insulin and it is rather a different kettle of fish to the norm here. You may have noticed that there's a special forum on this board for cats requiring high doses (apologies if this has already been mentioned).

I wish you the very best of luck.

Diana

 

[BJM]

Because you've changed the dose and insulin so drastically, it would be a really good idea to check for urine ketones.
Ketones form as a by-product of fat breakdown. Too many ketones may result in diabetic ketoacidosis, an expensive to treat, potentially fatal, complication. of diabetes.
You should be able to get urine ketone test strips (ex KetoStix or KetoDiaStix in the US) either online or perhaps from the local chemist/pharmacist.
See my signature link Secondary Monitoring Tools for some other assessments you may find helpful in evaluating your cat, such as dehydration checks.

 

[Cindy De Vries]

Thank you for this, will check this

 

[Cindy De Vries]

Hi Cindy from another UKer
I can't add anything much to what others have said above, but I am familiar with giving very high doses of insulin and it is rather a different kettle of fish to the norm here. You may have noticed that there's a special forum on this board for cats requiring high doses (apologies if this has already been mentioned).

I wish you the very best of luck.

Diana

Thank you, I will check this out and just about to post results of first curve just finishing today at home x

 

[Cindy De Vries]

Because you've changed the dose and insulin so drastically, it would be a really good idea to check for urine ketones.
Ketones form as a by-product of fat breakdown. Too many ketones may result in diabetic ketoacidosis, an expensive to treat, potentially fatal, complication. of diabetes.
You should be able to get urine ketone test strips (ex KetoStix or KetoDiaStix in the US) either online or perhaps from the local chemist/pharmacist.
See my signature link Secondary Monitoring Tools for some other assessments you may find helpful in evaluating your cat, such as dehydration checks.

Thank you for this will check out

 

[Cindy De Vries]

Hi all, just done a a day of home testing, every hour, 15 times in total. I've put most of the results on the spreadsheet but I accidentally started way down on the sheet- I will log back in to change I presume? No curve to show really, just high levels all day (she's on 3iu of PZI), ranging from 18.8, lowest 17.4 then ending 1 hour after food at 21.1. The dose presumably is too low so far and not having any effect, but I know I have to be patient. Will discuss with vet shortly!

FYI Amber has lost 300g weight in 10 days and coat looks awful. I realise this is a process as we are starting again with this new insulin, but very worried about her weight. I will double check with vet re Acromegaly and Cushings and whether the very complex blood test she had included tests for these. ( Also she has Megacolon and her enzymes were raised in her Pancreas indicating Pancreatitis. Vet believes this caused by DM so treating for that goes hand in hand.)

Couple of questions re spreedsheet- what is AMPS and PMPS and what are the 500 etc's at the top- bodyweight? I couldn't find a legend anywhere? Also there's no space for more then +11 which I presume means hours after food? Many thanks !

 

[Olive & Paula]

AMPS is the morning g preshot test. The 50", 400, 300. At the top is the glucose ranges. + 1 is one hour after shot, +2 is 2 hrs after shot etc. PMPS is your evening test.

After the +11 which is 11 hrs after test. The next column would be your PS number (when you give next shot)

Look at my below. I also put the time at the top. I shoot at 7 a and 7 p.

Congrats on your first curve. For the future a curve us done every 2 hrs for 12 hrs or every 3 hrs for 18 hrs. There is no need to do it every hour.

 

[Wulfwin]

FYI Amber has lost 300g weight in 10 days and coat looks awful. I realise this is a process as we are starting again with this new insulin, but very worried about her weight. I will double check with vet re Acromegaly and Cushings and whether the very complex blood test she had included tests for these. ( Also she has Megacolon and her enzymes were raised in her Pancreas indicating Pancreatitis. Vet believes this caused by DM so treating for that goes hand in hand.)

Couple of questions re spreedsheet- what is AMPS and PMPS and what are the 500 etc's at the top- bodyweight? I couldn't find a legend anywhere? Also there's no space for more then +11 which I presume means hours after food? Many thanks !

The number ranges at the top of the sheet refer to blood glucose ranges based on US meters - to convert to UK readings, I think you divide by 18 (please someone who's more familiar with US-UK conversions than I am confirm that). So 500 (the black on the spreadsheet) on a US meter is around 27.8 on a UK meter. The different ranges are color coded to provide an easy visual cue of how the insulin is affecting the blood glucose.

I would also suggest talking to your vet about whether Amber needs other medication for the pancreatitis - my most recent sugar cat Rain was just diagnosed with chronic pancreatitis and some pain medication (pancreatitis is very painful) and regular anti-nausea/anti-emetic medication (right now, I'm using Cerenia - not sure if that's the same in the UK) has made a tremendous difference in her attitude, appetite, weight, diabetes, and overall health. Check out the Primer on Pancreatitis in the Health Links forum.

 

[MrWorfMen's Mom]

Hi Cindy, I was interested in your post since I am a high dose kitty parent. I notice there was some question about the glucose ranges on the spreadsheet. You have the right Spreadsheet template but you have entered your readings onto the US tab as opposed to the World tab. If you copy all your entered readings from the US tab and paste them onto the World tab sheet a couple of lines down (you've lost the formatting in the first line), all the conversion between the UK readings and US will be done automatically. Any questions, just holler.

 

[Critter Mom]

to convert to UK readings, I think you divide by 18

That's spot on, Sarah.


Mogs
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