? Sebastian PMPS 42 +1 87 +2 123 +4 57 +5 135 +7 94 +8 78 +9 60 +10 68 +11 69 Ketones +9 0.8. 7u

[Justin & Sebastian]

+8 was 74. I put a couple more tsp of LC into him, hopefully get him to stop dropping.

 

[Gill & George]

Earlier on this thread you talk about taking him back to 3u because he was fine on that a while back. My concern with that approach is that since then he has had two episodes of DKA and ketones developed to moderate levels just a week ago, and the vomiting/pancreatitis flare is active at the moment. So taking him down by too much and leaving him with not enough insulin in his system is a risky approach as it opens the door to ketones developing and that can very quickly become DKA.

I took a look at the curves you run in 2018 they don't tell us much and in any case in FD terms they are ancient history, even if he was showing green on one of them, insulin requirements change over time so what was a reasonable dose then might not be a reasonable dose now.

The data you have gathered in the last couple of weeks is more telling. The fact that once you took the DM dry out of the picture, his numbers started this downward trend, points towards his numbers having been inflated by all the extra carbs in the DM dry, which has resulted in you having to dose at 7u, this is a figure at which you also noted historically that he did well weight wise and other signs and symptoms of FD were improved.

Cutting out the DM dry has seen his insulin needs drop, this is a good thing, even though it has been stressful the last 24hrs.

Where do you go from here??
It's a difficult choice, I don't know if you have read this thread, of a kitty that went from 5.5u to zero in no time at all, it makes for quite a read.
https://docs.google.com/a/ibbs.co.uk/spreadsheets/d/1IWcZY9aekWM0grm7WFYZRHZoEtPNuNcVuGywt6Gn8No/pub?output=html# look at 2/19 that's when kibble was removed from the whole house
this is the condo http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=114022
Will Sebastian go to zero, my gut says probably not because he's been diabetic for such a long time. (if I remember right you said he was first diagnosed 4yrs ago/ Correct me if I am mis remembering that fact) but it illustrates how powerful the carbs can be in inflating those BG numbers. With the history of DKA, skipping shots and draining depot is not really a safe option and taking the dose down too quickly is also a big risk, following Scooters CG approach in my opinion would be risky for Sebastian.

If you are going to keep the DM dry of the table as a regular food for him.
I do think that he needs a bigger reduction than the standard 0.5u, because you have really had to fight to keep those numbers up.

History has shown that 3u was enough to keep him from DKA.

With the recent Ketones developing to moderate, and the vomiting/pancreatitis flare shooting 3u would make me very nervous, I know that hypo seems worse, because managing it feels very intense, but actually DKA scares me much more, ketones can also become critical in a very short space of time.

I want to say split the difference and do 5 but I feel like that might be too much also. So maybe, in light of the pancreatitis, 4?

I was thinking along the lines of 5u, but because of the pancreatitis/DKA, even this is not without risk and you will need to keep on top of the ketone monitoring. It may also not be enough of a reduction, and the next couple of cycles may still have Sebastian seeing numbers lower than you are comfortable with, the sizable depot from the 7u will still, more than likely influence the numbers for a number of cycles, so just because the numbers are good in the first few cycles following the reduction it doesn't mean that its a good dose or too much of a dose.
You should prepare yourself for a few hectic days ahead, until you can settle the dose down and he levels out with the correct dose for his new diet. I'm sorry I know that it all seems very daunting and overwhelming, and dealing with dropping BG is nerve wracking, we've all had this experience at one time or another, but I do think that taking it down by more and 'working up the dose' as you put it, is by far riskier because of the DKA history.

Can your wife perhaps help you with the testing/feeding/monitoring?? So you could get some rest at night? We've got many couples/even families that use a team approach so to speak so that everyone can get some rest when things get crazy. Although I manage George's FD, my hubbie does step in to help give me a break when I need it.

It would also be wise to get some R and have it at hand, just in case the dose reduction sees a return of the ketones, as an in and out insulin it could be used to manage the ketone situation should it start to get out of hand (but please only use it with some advice of folk that have experience with it, like @Sandy and Black Kitty, @Marje and Gracie and @Wendy&Neko we would make sure you have some support when you are using it and can play tag team if needed), because Lantus as a depot insulin takes time to reach the full effect of the dose it's not as useful when trying to manage a kitty where ketones are becoming a concern.

I also wanted to address the feeling that you were given conflicting advice, it is true that we try not to feed after +10 so that we know that the PS is not food influenced. To every rule their is an exception and if kitty drops below 50 that is the exception in this case. Usually at the end of the cycle, if kitty is on a good dose a little LC will be enough to bump them up over 50. But we have a suspicion that Sebastian is on too high of a dose at the moment given the food change so in his case it may well take more to bump his numbers up.
In some situations with FD there is no Black and White, FD varies from cat to cat in the way they respond and even from cycle to cycle. We try to use our personal experience and our experience in helping others to give you the best advice given the situation.

You have a number of very experienced folk following his progress and trying to come up with an approach that's going to keep Sebastian safe. I just wanted you to know that, just because we are not all posting at once doesn't mean we aren't following the developments.

What you decide to do at AMPS with regards to dose is your choice, and we will support you in your choice. I hope with the above I have been able to give you some food for thought to allow you to make a more informed decision.

When you get to amps, start a new thread and tag me.
I'll be checking on you throughout the morning anyway.

Here are a couple of posts on handling low numbers
http://www.felinediabetes.com/FDMB/...y-to-shoot-handle-lower-pre-shot-numbers.147/
http://www.felinediabetes.com/FDMB/threads/dont-panic-or-how-to-handle-low-numbers.210109/

 

[Gill & George]

One other thing, once you have had some and feel a bit more human perhaps you could update the SS with last nights numbers.
It's easier and much quicker to see what went on by looking at the SS than reading through the whole thread. If you made notes on what you fed when, please add those to the ss as well. All that extra info helps us help you.
Thanks Justin.

 

[Justin & Sebastian]

Earlier on this thread you talk about taking him back to 3u because he was fine on that a while back. My concern with that approach is that since then he has had two episodes of DKA and ketones developed to moderate levels just a week ago,

It's only been once in November, which was a result of undiagnosed pancreatitis and no monitoring. The elevated levels of Ketones last week were from the Vetsulin. For whatever reason it does not have the same effect on him as a similar dose of Lantus. We tried Vetsulin twice and both times he started building ketones. The first time we went from 2u of Vetsulin to 3u of Lantus and that was enough to remove the ketones. At that point he had been off the Lantus for a couple of days so the depot might not have been totally gone but would have been reduced.

dose at 7u, this is a figure at which you also noted historically that he did well weight wise and other signs and symptoms of FD were improved.

I'm starting to suspect that wasn't really the case and it was some other factor or combination of. He's been at 7u for about a week now and his weight hasn't improved. True we've got some p'titis in the mix this time so there's no direct correlation either way.

he's been diabetic for such a long time. (if I remember right you said he was first diagnosed 4yrs ago/ Correct me if I am mis remembering that fact)

5 years, close enough.

You should prepare yourself for a few hectic days ahead, until you can settle the dose down and he levels out with the correct dose for his new diet. I'm sorry I know that it all seems very daunting and overwhelming, and dealing with dropping BG is nerve wracking, we've all had this experience at one time or another, but I do think that taking it down by more and 'working up the dose' as you put it, is by far riskier because of the DKA history.

Can your wife perhaps help you with the testing/feeding/monitoring?? So you could get some rest at night? We've got many couples/even families that use a team approach so to speak so that everyone can get some rest when things get crazy. Although I manage George's FD, my hubbie does step in to help give me a break when I need it.

It won't be the end of the world if it comes to that. I'm self employed and work from home so I'm 100% flexible and available for what I need to do for him. The hardest part of the day for me is like 8pm-11pm, if i'm up that late I'm always ragged regardless of how much sleep I've had. Past 4am I'm usually good even if I've only gotten a few hours. Eventually I will be able to nap for a few hours in the afternoon and catch up a little.

I've considered getting my wife to help but she's never done any of it and there'd be a learning curve which would be very steep right now, plus I'm a bit of a control freak and a data nut so I like to be on top of things myself.

It would also be wise to get some R and have it at hand, just in case the dose reduction sees a return of the ketones

I will pick some of that up today while I'm out getting the ondawhatever for nausea and appetite stimulant.

You have a number of very experienced folk following his progress and trying to come up with an approach that's going to keep Sebastian safe. I just wanted you to know that, just because we are not all posting at once doesn't mean we aren't following the developments.

Yup and I really appreciate it. I think I'm square on all the exceptions I need to know about and feel a bit more comfortable how to handle the low numbers now. I won't be surprised if something else comes up but I feel like I'm in a better place than I was even 12 hours ago.

What you decide to do at AMPS with regards to dose is your choice, and we will support you in your choice. I hope with the above I have been able to give you some food for thought to allow you to make a more informed decision.

So let me ask, with the clarifications I provided above in relation to the DKA episodes and the Vetsulin cause, would you modify your recommendation of 5u?

 

[Justin & Sebastian]

One other thing, once you have had some and feel a bit more human perhaps you could update the SS with last nights numbers.
It's easier and much quicker to see what went on by looking at the SS than reading through the whole thread. If you made notes on what you fed when, please add those to the ss as well. All that extra info helps us help you.
Thanks Justin.

I've been updating them as I read them. Are you not seeing them? I've got entries for every pm + except 3 and 6.

 

[Justin & Sebastian]

One other thing, once you have had some

Unfortunately no coffee for me. I've got some physical anxiety issues and sometimes it can set me off which I absolutely don't need right now. And when I'm on low sleep my stomach is pretty sensitive and coffee makes it 10x worse. Nope, I'll be heading to WaWa for a breakfast burrito and some OJ after I get a +9 here in 20.

 

[Justin & Sebastian]

+9 is 60, still dropping. I also got a blood ketone reading on him of 0.8. He definitely didn't eat enough tonight. He only ate a 3oz can of the HC gravy, a few bites of various wet foods, and the maybe 6tsp of LC wet I was able to syringe him.

 

[Justin & Sebastian]

The other thing is to be careful when you give fluids. We’ve found in “some” cats, giving fluid can drop the BG.

I'm going to hold off on giving him more sub-q today since his numbers are running so low and this might be contributing. He's doing a lot better about keeping food down, he's only vomited once since yesterday morning and that was when I flipped him over immediately after eating, so that was probably on me. Definitely want to stay on the anti-nausea for at least another day and supplement with onda and get some appetite stimulant in him so hopefully he starts eating LC on his own again.

 

[Bobbie And Bubba]

Oh what a night you've had! I want to apologize if my advice seemed contrary to what you have learned about feeding within 2 hours of shot time. It concerned me that he was still dropping after he was fed and so late in the cycle. And with Sebastien not eating well and vomiting and a depot looking to big for him right now, holding off feeding a dropping low number is never a good idea.

You did a great job last night and thanks to @Dyana for staying with you. I had to sign off to take care of my mom.

I hope you will be able to get in a nap today.

 

[Gill & George]

He's been at 7u for about a week now and his weight hasn't improved. True we've got some p'titis in the mix

He's been sick this last week and not eating like himself so that could be a factor.

It's only been once in November, which was a result of undiagnosed pancreatitis and no monitoring. The elevated levels of Ketones last week were from the Vetsulin. For whatever reason it does not have the same effect on him as a similar dose of Lantus. We tried Vetsulin twice and both times he started building ketones. The first time we went from 2u of Vetsulin to 3u of Lantus and that was enough to remove the ketones. At that point he had been off the Lantus for a couple of days so the depot might not have been totally gone but would have been reduced.

None the less I would describe him as ketone prone and therefore I would exersise caution. Some cats just dont develop DKA, no matter what you throw at them, clearly this is not Sebastian. Though I think that you may be right and the Vetsulin doesn't agree with him, I suspect that an important factor was that 3u of insulin, no matter what insulin would not be enough. Vetsulin with it's faster, in out action probably left him with a lot less (if not zero insulin) for long periods of the day. Lantus with its depot and longer action would have had a less marked response, but I still think it would have only been a matter of time.

I will pick some of that up today while I'm out getting the ondawhatever for nausea and appetite stimulant.

That's good to have it in your store cupboard, again I will reiterate that it is very potent stuff and needs to be used with extreme caution, please don't use it without having someone with experience using it guide you. I was considering using it just a short while ago after George relapsed with FD following a Steroid shot, I was glad his numbers started moving and I didn't need to use it.

I think I'm square on all the exceptions I need to know about and feel a bit more comfortable how to handle the low numbers now. I won't be surprised if something else comes up but I feel like I'm in a better place than I was even 12 hours ago.

I'm glad you feel better about it.

So let me ask, with the clarifications I provided above in relation to the DKA episodes and the Vetsulin cause, would you modify your recommendation of 5u?

I think that while you observations of what happened in the past are valid, but they are too far in the past to be of any real value.
Personally if this were me and George, I would be leaning to the 5u, but I would also be fully aware that I might need to fight to keep his BG up, and that I would have to effectively suck it and see if the dose proved too much or not enough. As I said DKA worries me more than the low numbers, but too some extent you are caught between a rock and a hard place.

Stock up on the HC wet food, you may need to feed that fairly regularly to keep his numbers up. Something I used to do, was add a couple of drops of honey to Georges HC gravy food, to boost the carbs further, I used a 28% carb wet food (not available in US) and even that at times wasn't enough if he drop hard and fast early in the cycle.
You want to be careful about how much honey you give in one dose as it can make them feel sick. Also if he were to drop into the 30s rubbing some honey on his gums is quick way to get it into his system

 

[Justin & Sebastian]

So another thing that concerns me about the dosage, looking at all of yesterdays numbers. We gave him some of the HC Gravy in the morning and that bolstered his numbers into the high 100s-mid 200s for a good 6 hours. In the evening I had even more of the HC Gravy than he had in the morning, plus 2ml of honey, and it barely dinged him into the 100s for an hour or two before it was back down. If that trend continues, nothing is going to help the next one.

 

[Justin & Sebastian]

+10 is 68. Up a bit, however he was up and then down before the PMPS so we'll see.

 

[Gill & George]

+10 is 68. Up a bit, however he was up and then down before the PMPS so we'll see.

that's flat if he'll eat give him a couple of teaspoons of LC now. then no more food, unless he drops too low.

 

[Gill & George]

Remember last night I mentioned staying ahead of the numbers with the feeding.
It's easier to keep them level than it is to fight a BG that has gathered downward momentum. Er on the side of caution. As long as it's wet food it will be in and out of his system quickly, so it won't have a prolonged effect. If he were getting into danger area, you could also use a little of the DM dry as it is so high in carbs, I would use that as a last resort so to speak, first of all seeing if the wet HC and honey will do it for you. Only because the dry stays in his system longer and muddies the water further.

Once they drop they can be hard to bring back up, so if you can feed to stay ahead of the drop, then it should make it easier to keep him up. That's why I suggested making sure you are stocked up on the HC wet food, if you could plan to feed him that as his regular meal, it will go further to bolstering his numbers. The 7u depot is still in play and that is going to be driving the early part of this next cycle whether you shoot 3u or 5u.
It is probably safer to over carb him with the wet food at the moment, easying up on it's use and switching to LC or a mix of the two if the numbers start to trend up. So a more cautious approach if you like.

 

[Justin & Sebastian]

Okay I gave him 2 more tsp of the LC. He didn't want to let me syringe it but he's got an appetite right now so I just squirted onto a plate and he licked it clean.

 

[Gill & George]

I've been updating them as I read them. Are you not seeing them? I've got entries for every pm + except 3 and 6.

I can see them now thanks, perhaps they hadn't refreshed earlier.

 

[Justin & Sebastian]

Once they drop they can be hard to bring back up, so if you can feed to stay ahead of the drop, then it should make it easier to keep him up. That's why I suggested making sure you are stocked up on the HC wet food, if you could plan to feed him that as his regular meal, it will go further to bolstering his numbers. The 7u depot is still in play and that is going to be driving the early part of this next cycle whether you shoot 3u or 5u.
It is probably safer to over carb him with the wet food at the moment, easying up on it's use and switching to LC or a mix of the two if the numbers start to trend up. So a more cautious approach if you like.

Okay so just to make sure I'm crystal clear:
Unless his +11 drops, don't give anything.
If his +11 drops, give him a bit of wet HC. Or LC? With or without honey?
For his next few meals give him HC wet, tapering into LC wet as his numbers stabilize.

 

[Justin & Sebastian]

+11 is 69

 

[Justin & Sebastian]

We're walking back his shot towards proper schedule today, so PS and feed will be in 30 minutes at 9AM EST. He's already taken his Cerenia.

 

[Gill & George]

We're walking back his shot towards proper schedule today, so PS and feed will be in 30 minutes at 9AM EST. He's already taken his Cerenia.

Ok grab a test just before you feed, if he's below 50 then don't feed and stall.

 

[Gill & George]

waiting for your amps. If he's rising or flat go ahead and shoot. Feed, I'd opt for HC or HC mixed in with LC on a 50/50 basis, giving you some MC food, just because that depot is still going to be in play in the early part of this cycle and we want to keep ahead of those numbers.


If he's dropping stall.

 

[Justin & Sebastian]

Started a new thread for today. AMPS was 73. Was going to tag you but realized I don't know how.