Queensland Protocol, Bouncing and Irregular Nadirs

[nepenthe]

My cat has resolving pancreatitis (fPL=6.4 12/03/12) and came off an EOD low dose of prednisolone (for chronic pancreatitis) on Dec 10.

Because of the pred leaving his system, I've started to see some lower numbers and cautiously lowered the dose from 2 to 1.75.

Problem is that he stays in good numbers at that dose for a couple of days and then gets lower and lower and then higher. Hard to discern whether or not its "bouncing" or the inflammation in his pancreas ebbing and flowing. And challenging for me to keep the dose consistent with the spread of highs and lows I'm getting.

In that Queensland Protocol, the dose is apparently set on the nadir - are we looking for the nadir within the 12 hr cycle?

What if the nadir doesn't come at 6-7 hrs and comes like 10+ hrs later? OR should we look for the lowest readings over a 3 day period?

(just worried that if he gets a really low PS, that'll require lowering the dose and make the roller coaster worse. My main goal here is to find the safest dose)

 

[Blue]

My cat has resolving pancreatitis (fPL=6.4 12/03/12) and came off an EOD low dose of prednisolone (for chronic pancreatitis) on Dec 10.

Because of the pred leaving his system, I've started to see some lower numbers and cautiously lowered the dose from 2 to 1.75.

Problem is that he stays in good numbers at that dose for a couple of days and then gets lower and lower and then higher. Hard to discern whether or not its "bouncing" or the inflammation in his pancreas ebbing and flowing. And challenging for me to keep the dose consistent with the spread of highs and lows I'm getting.

In that Queensland Protocol, the dose is apparently set on the nadir - are we looking for the nadir within the 12 hr cycle?

What if the nadir doesn't come at 6-7 hrs and comes like 10+ hrs later? OR should we look for the lowest readings over a 3 day period?

(just worried that if he gets a really low PS, that'll require lowering the dose and make the roller coaster worse. My main goal here is to find the safest dose)

The very first thing I see is that you have not a single test number after the pm shot, and many cats go lower in the pm, and getting a before-bed is something that's kind of important. People have found their cats are low at the bedtime test and needed to feed them a bit of higher carb food to be sure the cats did not go too low overnite.

The next thing is on 12/18, where you dropped the dose to 1u, then 1.25u that pm, and then back to 1.75u the next morning. Lantus and Levemir work better with as few changes to the dose as possible.
You have alot of frequent dose changes on the following days, which will contribute to numbers bobbing all over the place.

I am not clear why pred was needed for pancreatitis.... usually, you want something for nausea, maybe pepcid AC or cerenia if really bad, something for pain, maybe buprenex, and finally subQ fluids. For inflammation of the pancreas, giving your cat weekly B12 shots are quite helpful... they cleared up my cat's frequent pancreatitis attacks, and her fPLI results were usually in the high teens.

Nadir is not in one set place all the time, every cycle, but you will notice it's in a general vicinity.
One of my cats, the one with the pancreatitis attacks, had her nadirs usually around +5 or so, but my other cat was normally around +10 to ps, so his ps numbers were often his nadir. The only way you will know where your cat's nadir area is would be to do a few curves. If you are suspecting a late nadir, then try to get a test at +10 and then, you will know by his ps if he has a late-ish nadir.

When a cat is sick, and certainly with pancreatitis, you will see higher BG and will likely need to increase the dose, then when feeling better, you will need a lesser dose.... pain will cause higher numbers.

With a cat who has pancreatitis attacks, you will see the problem recur, so it would be a good idea to keep a supply of subQ fluids on hand as well as pain meds for use on the next attack.

I think it may be an idea for you to go to a 1.5u dose and stay put, holding that dose for a good 6 shots unless you see several numbers under 80 ... you are using the AT pet meter, right?

When you have time to do a curve, test every 2 hours between 2 shots and get a couple tests in the pm cycle as well. That info will be very good to help you in pinpointing your cat's nadir.

 

[nepenthe]

The very first thing I see is that you have not a single test number after the pm shot, and many cats go lower in the pm, and getting a before-bed is something that's kind of important. People have found their cats are low at the bedtime test and needed to feed them a bit of higher carb food to be sure the cats did not go too low overnite.

The next thing is on 12/18, where you dropped the dose to 1u, then 1.25u that pm, and then back to 1.75u the next morning. Lantus and Levemir work better with as few changes to the dose as possible.
You have alot of frequent dose changes on the following days, which will contribute to numbers bobbing all over the place.

I am not clear why pred was needed for pancreatitis.... usually, you want something for nausea, maybe pepcid AC or cerenia if really bad, something for pain, maybe buprenex, and finally subQ fluids. For inflammation of the pancreas, giving your cat weekly B12 shots are quite helpful... they cleared up my cat's frequent pancreatitis attacks, and her fPLI results were usually in the high teens.

Nadir is not in one set place all the time, every cycle, but you will notice it's in a general vicinity.
One of my cats, the one with the pancreatitis attacks, had her nadirs usually around +5 or so, but my other cat was normally around +10 to ps, so his ps numbers were often his nadir. The only way you will know where your cat's nadir area is would be to do a few curves. If you are suspecting a late nadir, then try to get a test at +10 and then, you will know by his ps if he has a late-ish nadir.

When a cat is sick, and certainly with pancreatitis, you will see higher BG and will likely need to increase the dose, then when feeling better, you will need a lesser dose.... pain will cause higher numbers.

With a cat who has pancreatitis attacks, you will see the problem recur, so it would be a good idea to keep a supply of subQ fluids on hand as well as pain meds for use on the next attack.

I think it may be an idea for you to go to a 1.5u dose and stay put, holding that dose for a good 6 shots unless you see several numbers under 80 ... you are using the AT pet meter, right?

When you have time to do a curve, test every 2 hours between 2 shots and get a couple tests in the pm cycle as well. That info will be very good to help you in pinpointing your cat's nadir.

The crazy thing is that when he had the pancreatitis attack back in Jan 2011, the vet thought that he had IBD/triaditis because up till that point he would vomit sporadically. So, she thought to put him on pred. At that time he got sub-q's for 2 weeks and pain meds etc.

Then he stayed on pred for 2 years. But to make things worse I was using this FreeStyle Lite meter until this past November. So for 2 years, I've had a false sense of his health as his numbers on the FSL were typically between a 135-288 or so. I was shocked to find out the true state of his BG.

Before he had that attack in Jan 2011, he used to get 1U 2x and after that attack, we put the dose to 2U, bypassing 1.5 - something I know now not to do. But the vet advised 2U. So I am worried that this cat has had an ongoing glucose toxicity/rebounding, because when I look at his numbers from last year, and take into account the wide gap between highs and lows, and the faulty glucometer, I wonder if what we see now isn't what its been like for 2 yrs.

So, I blame myself for using the wrong meter and keeping him on the pred for so long, esp since he just had an ultrasound Dec 6th which ruled out anything wrong with his liver or intestines. But he is showing the early stages of renal disease, likely due to the high BG over time and the roller coaster.

Before I started putting the dose back to 1.75, even when he was on 2U, there was a lot of ups and downs.

I typically test 10am/10pm, so its hard to get tests late in the PM, but do put food out overnight, and usually a spoon in the middle of the night when I wake up to go to w.c.

He started getting b12 shots and daily vitamin E last week and I will keep that up forever.

I am going to go to 1.5 units even for 5-6 cycles and do a curve and post that - but what happens if, say, for the next 3 weeks I keep giving him the same dose - 1.5 exactly, the same kind/amount of food, and his pancreatitis seems to get better and is getting properly treated with sub-q's etc, - but his numbers still keep going all over the map?

How would one know if that is because of some pancreatic inflammation - or maybe the cat might need a change of insulin?

 

[Blue]

If your cat is fairly healthy, just give the insulin in doses that get the BG in a range under 240 renal threshold. It doesn't matter why because you can treat the pancreatitis yourself at home.

By giving pepcid, you can check and see if your cat eats better an hr later or so. You can watch for your cat 'meatloafing', and vomiting, plus higher BG numbers are some signs you may see.
By giving a wee bit of bupe, and you find your cat relaxes, then it's possible there was a bit of pain.
By giving fluids, your vet has shown you how to check for dehydration I hope, you can try to give maybe 50ml fluids and see if your cat responds in a positive way.

One of my cats was quite prone to pancreatitis, so I knew her signs, not eating, a bit of vomit, meatloafing and hiding in dark places... I'd give her pepcid first to see if it cleared up the nausea, and she seemed not well, I did try to give her some bupe. She also did a growling thing when I stroked the sides of her belly, and that's when I knew we would be giving her fluids for a few days, just until the BG came down a bit and she was more active, not growling, and eating a bit again.

You can't know for sure, from day to day, without spending a fortune on all sorts of tests and Xrays and u/s, and even then, many vets still don't know. So treat the symptoms, just like you do with insulin. If you test and the BG are rising, you increase your dose, yes? And when the BG come down, go lower, you drop the dose to match.

You know how your cat was acting just prior to any positive pancreatitis test, so if you see any of those signs, you can treat it at home to see if it helps. Try to make use of your ss to put notes of your observations into the comments column, and it will help you with any futures difficulties.... you will see the patterns in the BG numbers and how your cat was acting from your notes.

Neither of my cats vomited all the time with pancreatitis. One never vomited and the other who had most of the attacks did vomit a tiny bit every once in awhile, but it was the other signs that clued me in, not the vomiting.

As for the meter, well, the meter is not the problem but rather it's the new strip technology. How were you to know? Many people saying there's no problem with them, and even the Consumers Report magazine tooted the meter as excellent. Well, the proof was in the readings that many many cats got .... a person trying with 4 meters, and all post a high BG but the FreeStyle was never over 300, that was enough for those people and the others who listened to them. I would not feel badly because even if you gave too little insulin, you were still giving more than no insulin.

So, first things first. Talk things over with the vet and get your supplies for at home. Try to go with a lesser dose of 1.5u just to see if the numbers level off. That's what you want.... numbers to be level as possible. After a few days, we hope to see a bit of settling, and then you can decide what to do with the dose. .... maybe stay put, or maybe try a 1.75u.
Be sure to get a before bed BG test number so you can start to see what's going on in the PM cycles.

 

[nepenthe]

Try to go with a lesser dose of 1.5u just to see if the numbers level off. That's what you want.... numbers to be level as possible. After a few days, we hope to see a bit of settling, and then you can decide what to do with the dose. .... maybe stay put, or maybe try a 1.75u.
Be sure to get a before bed BG test number so you can start to see what's going on in the PM cycles.

This am he was really high - 460-ish. I don't know if this is because of his dose lowing down to 1.5 already or due to that I didn't give him sub-q's or his codeine yesterday as he seemed so well. (seems like the two days last week when I didnt give sub-qs - sun when I had a hard time with it and yesterday - his BG was higher.)

I broke down and gave him 1.7 again, and this aft he dropped to 342 at +6.

Would you still stay at 1.5?

What if I do that, and his numbers stay high for days?

 

[DebH]

Hi,
I'm sort of in the same boat as you with my Xuxu and pancreatitis with bouncing numbers. I've been posting over on the general Feline Health board. If you read those messages (topic Yoyoing, can't get him regulated), you see that we are having many of the same problems. Xuxu's diabetes also started with pancreatitis in Aug of this year. We have been trying many of the things Blue suggested. The specialist we called said stay away from steroids, but then we didn't discover his pancreatitis until he was already diabetic. It sounds like you were fighting pancreatitis before he became diabetic, so steroids were probably warranted.

We've had Xuxu on Orbax (antibiotic), famotodine (antacid for nausea), Tumil K (potassium supplement), cerenia (pain) and we are supplementing with 100 cc Ringer's Lactate fluid at night. Since he's never vomited or really shown signs of nausea, we've recently stopped the famotodine, and it appears that his pancreatitis has calmed down substantially, and he doesn't appear to be in pain now, so we stopped the cerenia. He does appear to have a liver infection now (probably because of the high sugar for a while), and some kidney problems possibly starting. So we started a 2nd antibiotic, Zithromax concurrent with the Orbax, a OTC antioxident supplement with Vit E, and Denemarin for his liver.

I don't know if Ultrasound is available in your area, but it has made a huge difference in diagnosing and planning a treatment for Xuxu. He was in such bad shape at first, we wanted to know if it was cancer. With the pancreatitis diagnosis, and recommendations that he could fight it off, we started trying to control his BG. But when his levels stayed high (750+), we did another ultrasound to make sure we hadn't missed any cancer, or any infection. That's when we found the liver infection.

Best of luck for you and yours, perhaps the same protocols will work for both of us.

Deb H and Xuxu

 

[nepenthe]

Mine was diagnosed diabetic in Feb 09 and was negative for pancreatitis - his Spec fPl then and went into remission shortly after for 1.5 yrs. THen when he became diabetic again in June 2010, again he was negative for pancreatitis. I don't know if the diabetes caused the pancreatitis, but at least I know that it pre-existed the pancreatitis on 2 occasions.

With him its not really ever an acute attack, with Spec fPls of around 6.4, its more of a chronic, low smoldering inflammation enough to slowly dehydrate him, and cause inappetence and mess with his BG.

Both times, I've thrown pain meds and sub-qs at it right away. The first time he was hospitalized overnight due to dehydration. He was on an IV overnight. They gave him Cerenia then for nausea, Buprenex (Vetregesic) for pain and some metronidazole in case of infection. The first time he had slightly elevated liver values, but not this time this December 3rd. On the 17th of December, he got an ultrasound which confirmed pancreatitis (mild) and the liver and intestines looked very good.

What I think is happening with us is that the pancreatitis never really goes away. It is always there to some degree and the inflammation rises and falls. There are two things which greatly affect BG - pain and inflammation. And with pancreatitis, we have them both.

I asked the vet for pain meds and sub-qs 10 days ago and have been giving him 75ml fluids and transdermal codeine (nice mild analgesic) for the pain. I've been giving him 250mcg B12 shots every 6 days (there are dozens on here who swear by this to help with the chronic inflammation).

Real dangerous thing is that before this episode, he was on prednisolone for 2 years for the pancreatitis (and it didn't' stop a recurrence). So, I tapered him off slowly and gave it to him for the last time on Dec 10th.

Before that, he got 2 units Lantus BID and the vet told me to just not test him too often and give him a consistent dose and he'd be fine. I was leery of that b/c with the pred leaving his system, I knew his dose requirements would go down and also, when the pancreatitis inflammation subsides, his insulin requirements might go down again as well.

This suspicion of mine turned out to be true. The other day my boy went down to a nadir of 54 (on the alphatrak meter) with a dose that was 25% less than what he had before. If you look at my SS, you can see all the shaving by .25 that I've been doing. The bouncing I think is a bunch of stuff: variability of shot absorption (which is higher with Lantus than Levemir), the rising/falling of the inflammation itself and the pain from it. Sub-qs and pain meds can lower BG too.

I think there is a big risk of hypo with a pancreatitis cat, because of all of these factors. One really has to watch them close because when the flare-up gets better, the dose likely has to be adjusted, or the cat could start bouncing due to the ("panicky") liver's reaction to what now might be too much insulin.

At least this is what I am sure I am seeing in this cat.

From now on I've got to be pretty vigilant about this pancreatitis, looking for all the subtle signs. Dehydration and signs thereof - less grooming, changes in fur, slight weight loss etc, less appetite, etc. and When the signs look like he is having a flare-up, and the BG's start rising again, wthout any other measurable cause - then I've treat the flare as such. If I see that after a week or two of pain meds and sub-qs before the symptoms and inflammation get worse - and the BG starts to come back down, then I have my answer.