Seems as though the insulin is doing nothing

Status
Not open for further replies.
Cindy & Pets

Cindy & Pets

Very Active Member
So, yes, she's on humulin N, I have plans on bringing it up to the vet again, and this time not budging on a dose increase on humulin N. Actually, it's been the vet techs doing that, jeez. :/ I hate dealing with them as they don't know Tip as well as her typical vet and I does. So the patterns they see might not be the ones the vet or I see. So I don't actually have a problem with the vet(she's amazing, was ECSTATIC to the point of scaring me when I showed her I did a curve and that I was testing at home, etc, etc.). I DO plan on switching on Tuesday, but first I want some thoughts from you guys as to what might be happening, if it's poor Tip here, or if it's something wrong with the insulin. Part of why I love my vet so much is she ONLY works with cats, not dogs. There's one other at the office that only works with cats too, I like her as well. So I know I won't be changing vets soon....

I've been dutifully testing, and trying to get curves in shortly after she changes doses, and it does not look to me like she was bouncing. I feel as though her numbers around 4/19 are off simply because of the lack of insulin, then suddenly back on insulin, then changing doses every half day just about REALLY threw them off. I was thrilled(and expecting a bounce from the numbers) on 5/11 and 5/12 as she got down to the 180's, lovely numbers in my opinion. I also loved the numbers she was getting on 2.5U. Anyways, it seems like after each dose increase, things just aren't changing anymore. I'm not seeing bounces, she isn't acting like she's bouncing, she isn't losing that much weight(yeah, the vet tech said she lost weight going from 9lb 7oz to 9lb 8oz, really now. :/ he even said he sees a lot of cats regulated on 5-6U of humulin N, SURE. ), if anything, she's gaining like it's getting under control. So I've got a few questions....

1. Might there be something wrong with the insulin? I'm getting down to about 1/3rd of the vial and did previously accidentally leave it out for 4 hours.

2. Could she become resistant to it? Is it kind of like how I am with pain medication, and she's just becoming immune to it?

3. Might there be something wrong with my meter? I hope not that.

4. I'm noticing that maybe the jump from 2 to 3U was likely not a smart idea, but it was requested by the vet. Think that that might've been the dosage she should've stayed at? I'm thinking about bringing up those numbers and possibly ask for a dose decrease to that, rather than keep increasing.

And yes, switching will happen if it turns out that it's just that she's not responding. That'll definitely happen.

One other question I thought of: What in the world would cause the bG level to be higher before food than after food? She occasionally gets that and I just don't understand it, it's not much of a difference though.

EDIT: Sorry if I've come off a bit snappy in this. Just really frustrated as it feels as though a nasty game of telephone is being played with Tip and some other things out of my control have been bothering me.
 
I had a look at your spreadsheet for awhile. Its very red isn't it. :YMSIGH: Though I don't feel right about making recommendations, I'll make these comments in hopes it bumps your question and some others will have ideas.
9lb7oz is about 4.3kg, that's not a huge sort of cat. Sometimes bigger cats need a lot of insulin.
I guess from a note on her ss that you have her off dry food (I'm sorry if you've established that somewhere else already). Are you sure she's not sourcing dry from anywhere? I remember another cat from here, was very good at sneaking dry on the sly.
You can double check your meter next time you're at the vet, by getting some of the vet's blood sample for your meter, and then comparing what your meter and the vet's meter say.
How long ago did you leave vial out for 4 hours? that is, what date?
I haven't heard of cats becoming immune to insulin.

You will have read these tips (Start low go slow) http://binkyspage.tripod.com/SLGS.html ?
One important one is "Don’t increase the dose until your cat has been on it for at least a week." As you say, there was a lot of chopping and changing for awhile there.
Meanwhile you've only been on 3.5U for a couple of days: too soon to increase.
But I would worry about ketones, do you have a ketone tester? You can pick one up in pharmacies in Australia, not sure where you are.

Looking at the last row of numbers, there's a nadir in the evening of 5/20. Looks like Tip went from 432 down to 249, that's nearly a drop of 200 which might be enough to have set off the response where the liver makes excess bg? I expect that's not the right wording for it, but it means that the cat's system goes into a panic and arranges for the BG to go high again. But I'm not sure if that would have happened as each reading has some degree of uncertainty in it, like 10% or so? So 432 means some level between 390-475, and 249 is somewhere between 225-275. So the max drop would be 470-225 = 250, the minimum drop would be 390-275= 115. So Tip experienced a change in BG somewhere in the range 115-250. The high end of that drop would I think (if I remember rightly) be enough to make the liver kick in.

Which might suggest you need to ... lower the shot?

BUT Looking at the advice on the Start Low Go Slow page,
at Step 3 it says "If the lowest point of the curve is above 150 mg/dl (8.3 mmol/L), increase the dose by 0.5 unit. "
which would suggest increasing the dose, as the nadir here is 249; but this advise assumes that you started below the amount of insulin needed by the cat, and are not fighting against the liver in the way described above.

I don't see these comments as very conclusive. I find Tip confusing too. I wonder what others will say. I am going to keep an eye to see, because I don't blame you for sounding worried. I wouldn't have said 'snippy' but I can imagine your post read out in snippy tones. It adds to the worry, and I'd be worried too. Mainly about ketones, in the short term.

Is Tip looking alright? You say she's gaining weight, is she bouncy? Playful? Does she have dandruff?
 
Snippy is fine :mrgreen: we know you want your kitty to get better and it can be very frustrating.

I think it is the nature of the insulin. You generally have come decent midcycle numbers, and then it peters out before 12 hours. (a full curve would probably show this best. I am guessing she would start down after the am shot, down to her lowest point somewhere between 4-6 hours, and then skyrocket back up)

Some cats do okay on Humulin. For some reason, they get a longer cycle with it. But it doesn't look like it is lasting long enough for her.

Reassure yourself about your meter by trying it out on yourself.

I hope when you get a milder longer lasting insulin, she will respond much better.
 
When Akbah was on Humulin N, I remember someone suggested I go to 3 shots a day.
It makes sense, if you look for example at 5/11/2012, you might start at 355, give a shot (probably start back at 1U)... the nadir on 3U occurred around +4 at 186, got back up to 260 by +8 when you might then give the second shot. But three shots a day would be hard to maintain. Twice a day was hard enough for me! If you have an option for a different insulin (longer lasting) that sounds like a better deal.
Akbah solved the problem of short cycles on Humulin N by responding well to diet change and getting OTJ.
 
If you look at your SS, you can see the N is not lasting past +4, sometimes even +3 and then she starts going back up. N is notorious for being fast acting insulin with short duration and is not the best for cats. It is the only Humulin left to use,( R is used for ER basically), since they discontinued L and U. Many of us years ago did use L and U and they worked great. Now the insulins are usually ProZinc, Levemir and Lantus.

Increasing her N dose is not going to extend the duration, it is just going to add to the risk of too much and going hypo. She actually looked better on the 1 unit dose. IMHO, time to get her off the N and on to one of the other 3 insulins that give much longer duration and even using those insulins you still only increase in .25 or .5 increments and wait about 5 days before increasing again.
 
Unfortunately, this is the problem with using Humulin N in cats. It does not work well--and the dose goes up and up because of consistent hyperglycemia. The poor action of the Humulin N leads to constant hyperglycemic numbers, which in turn causes greater insulin resistance. The sooner you switch to a different insulin, the sooner you'll see improvement. This is exactly the reason why Humulin N should not be used in cats.

Please share this document with your vet and get the insulin changed. I've said this before, but the longer you wait to switch insulins, the less of a chance you have of reaching remission. http://www.uq.edu.au/ccah/docs/diabetesinfo/link2.pdf
 
@akbahsMum: Yeah, I was so worried about "what's going wrong? What should I do?" that I actually wound up deciding it was doing more harm than good for me to stay up.

Yeah, she's never been a large cat(underweight most of her life for her build, despite all our efforts of weight gain), but it was scary when she got down to just 8lbs, she was all skin and bones, doesn't feel so much anymore.

Yes, she is off dry food, but her sister Christmas is not. Christmas is a real picky eater, so I'm still trying to figure out what, of the dry food, she likes. I've tried slow switching her, cold turkey, nothing yet. So it's quite possible, but I've actually been much better about not falling asleep for a little after feeding them since now that it's summer, my friends are pulling me to stay out late. I've been convincing them that I need to get home in time to sleep though, so that'll hopefully be better on me.

I've been checking my meter at the vets. Mine has been consistently reading about 50-60 points under their alpha trak if too much blood isn't applied to the strip.

Alright, that's good. It was one of the things I was worried about. I wasn't sure of the probably less asked differences of hormones and medicines.

Yeah, the lots of changing, that was at the beginning of it all. She's overall looking alright, and is occasionally annoyingly bothersome, like how she used to be, she's always had dandruff, or, at least, it's always been noticeable. No more than usual though.

I can propose that idea to the vet, I'm likely to switch insulin anyways because I can only hold that type of dosing until late august, when I go back to classes. I do have that option, vet even suggested it in passing but said she doesn't want to if it isn't needed because it's expensive. Well, seems it's needed.

@ Sue: Alright, glad that it's likely not something wrong with Tip, but the insulin. I hope so too. I'm especially not so adverse to switching because 1. my vet gave me the first bottle free and 2. There's not enough left in the vial to really say "Oh, I'm wasting all this insulin." Tip is more important anyways. Yeah, I've noticed that by graphing some of the curves, what worried the most though, was how it seems like, dose increase or not, her numbers aren't seeming to budge at all.

@ Hope: Alright, I'm really hoping I get the vet, rather than someone else so I can discuss all this on the 29th. It would've been on this friday, but I'm to go to my dads house, and I was concerned about if I should just not give the insulin, or teach my cousin, who will be here, or ask my mom to come out(she has a diabetic cat, so I've also been relying strongly on her for help, she's also diabetic herself, her cat went in to remission on diet change).
 
Hey - I'm in Columbus, just northwest of you (OK, maybe a 30 minute drive - but since I drive rescue transports, that's a trivial amount of time to me!) This week and weekend is a bit crazy, but I could stop by Memorial Day or the weekend after that, if you'd like some moral support.

If you think the vet is approachable, I would encourage you to print out these pdfs ... with copies for the vet techs, since they don't seem to understand either!

Glargine & BG control-Roomp & Rand_2009-JFMS

AAHA Feline Diabetes Treatment Guidelines

You might also suggest the vet consult with OSU, as obviously, the vet is out of date using a shorter acting insulin with a cat. It might be fine for a dog, but cat's metabolism is about twice as fast.
 
Sorry about that, fell asleep from benedryl, turns out I'm allergic to pokeweed, no more de-weeding the garden for me!

I might be messaging you in the future to take up on the offer of moral support, thanks. :)

She's definitely approachable, I'll read, as I'm interested in reading them myself, and print them out once I'm less groggy. Definitely for the vet techs though. @_@ One of them was the one who said I could reuse needles, yuk! I guess at least they're all friendly....

Oh, speaking of needle safety and such, I've got to go to my dads, and I'm not too happy about not giving Tip her insulin, would it be safe to teach my cousin how to give her her shots and then suck up the right amount and stick them in the fridge to assure she gets the right amount? If not, I can just pull out some of them and mark them with medical tape.

Alright, might be a good idea. I'm thinking she's bouncing a lot of ideas off of the dog-only vet there, and that's why some of them might not be so great ideas.
 
Sayania said:
@akbahsMum: I can propose that idea to the vet, I'm likely to switch insulin anyways because I can only hold that type of dosing until late august, when I go back to classes. I do have that option, vet even suggested it in passing but said she doesn't want to if it isn't needed because it's expensive. Well, seems it's needed.
Click to expand...

I guess this might be your response to the idea of three shots a day? If so, for the record, when I saw Hope's comment about that I agreed with her. I'm hoping you can get a different insulin, I have read how different insulins work differently on different cats, and maybe there is a different one that works for your cat.
For example, here http://www.sugarpet.net/mycurves.html you can see differences between insulins (and dosages) reflected in blood curves for the same cat.
 
Oh wow, I didn't expect those kinds of differences. I'm hoping I can as well. In fact, I'm actually refusing to allow another increase. My gut is saying that bad things will happen if I do, because....I don't know, with the pets, it's just always right. So yes, something will happen that won't involve upping her dose, preferable changing insulin.

But....I do have an off-topic question, is it okay to draw up humulin N up early? I figure if so, that might be a good solution. I know my mom has said I can, and a friends diabetic mom has, but I wanted to check with one more source before I do. If anything, I can just mark them with medical tape if it wouldn't be safe to just draw it up early.
 
Looking for info about drawing up early and having the injections ready to go for your visiting cat carers, I found this:
*an extra note about handling your insulin...
"Store refrigerated at 2-8ºC (35-46º F). Protect from light. Store in the upright position. Following withdrawal of the first dose use the product within 28 days. Discard unused material."
When in doubt and if numbers start to climb, think about replacing your insulin. Insulin poop out has been known to happen before 28 days and also after and is worth thinking on if numbers are going up and nothing else has changed.
Click to expand...
viewtopic.php?f=19&t=302

Does this relate to your insulin, is it getting old? As you were asking originally...

I also found this
viewtopic.php?f=19&t=303
Doesn't say anything about predrawing but lots of useful info about Humulin, useful if you stay with it that is.

Edited to fix links. *Why* does the front come off the link and break it, when you submit a post with a link to a fdmb thread????
 
There's an expiration date on the Humulin N vile. It doesn't get "old", per say, before the expiration...it can however be mixed improperly. Here's something I posted in a previous thread:

Barn Cats R Us said:
I roll the vile gently in a horizontal position about 10 times, then I gently invert the bottle back and forth (tilt it upside-down, then right-side-up...like a rocking boat) about 10 more times. Then I gently roll it a couple more times, then I draw the insulin immediately into the syringe. If you walk away from your mixed vile, even for a minute, you should re-mix it before drawing your dose.

The problem with mixing cloudy insulin is...if it's not mixed completely when you draw just one dose...you've now changed the concentration of the rest of the vile. If the vile is consistently mixed poorly...the remainder of the vile could be considerably weaker, or stronger, than intended.

Cloudy insulin, that isn't consistently mixed well...is like a box of chocolates...you never know what you're gonna get!
Click to expand...

There is nothing "wrong" with your kitty. What you are seeing right now is short duration. Humulin N is an intermediate acting insulin. As opposed to the long acting insulins, most widely used for felines on a twice a day (BID) basis, Humulin N (in most cases) needs three times per day (TID) dosing. If this is something you are able to do, or for some reason would rather do, as opposed to BID dosing with a long acting insulin, you would need to drop her dose back down considerably, and start over on a TID basis. You also need to test for ketones.

I have never drawn Humulin in advance, but I‘ve heard of humans who do this. The pre-filled syringes, however, still need to be rolled & remixed, before injection.

Hope this helps.

Deb

Question: What is the [21] on your 5/21/12 pre-shot BG?
 
There is a lubricant on the inside of the syringes. As the insulin sits in the syringe, it may become contaminated by this lubricant, so we do not recommend you pre-draw the syringes.

It would be better to take some colored water and draw an example syringe to show how much to give.
Or put tape on the syringes to mark the dose.

And have her show you she knows how to do it - my friend overdosed Spitzer because he couldn't read some new syringes and gave 10 units instead of 1. Needless to say, poor Spitzer spent the next 24 hours at the emergency vet on a dextrose drip and eating like crazy to keep up with the insulin!

(he said "I'll drive you to the vet". I thought "d*mn right you'll drive me to the vet - you may have killed my cat!")
 
I'll both draw up colored water and mark the syringes with the tape to show how much to give. I'll also show him tonight, my biggest concern, besides giving the wrong dose, is if he'll wake up at the right time, but I could always give a call, he's a fairly light sleeper.

@ Barn Cats R Us: That very well could be my problem. I'm never sure if I'm mixing it enough, so I'll follow this on her evening dose and do a nadir test. Thanks. :) And it isn't expired yet, says another year.
 
Just wanted to update everyone that it appears as though I wasn't mixing it enough when her numbers went up, I could've swore I was, but now I'm making sure. I was so surprised that her number was 352 this morning when my cousin(her caregiver while I'm gone) that I HAD to retest, sure enough, when I tested her, she was at 343. I guess this shows just how important it is to make sure it's mixed enough. Question about that though, does this mean I need to get a new vial? Or should I be safe so long as her numbers don't start to go wonky?

Also, I had great fun giving my cousin a hard time to make sure he knows what to do in a hypo situation(karo/honey, regular vet if between office hours, emergency vet if not, bill me later so that he isn't stuck with the bill, etc), as well as regular care, I did however forget to put down what to do if she doesn't eat, and I will be printing out A LOT from this site as reference if he forgets. :) He's good at remembering and following instructions though, so I'm not that worried anymore.
 
Test, feed, shoot ... only if she eats!

If vomiting or diarrhea, pull out hypo instructions, and follow them.
 
Sayania said:
I guess this shows just how important it is to make sure it's mixed enough. Question about that though, does this mean I need to get a new vial? Or should I be safe so long as her numbers don't start to go wonky?
Click to expand...
If you feel you've been drawing improperly mixed doses...that leaves the rest of the vile in question. If you have a Walmart near you, Humulin N is typically $25 a vile. Since you think you'll be switching to a long acting insulin soon, if that doesn't "break the bank" (the $25 that is), it's probably best to get a new vile just to put your mind at ease. You can hold onto the current vile for emergencies...in case you drop the new vile...or something of that nature.

Deb

PS: What is your feeding schedule? Are you able to enter your feedings in the comment section of your spreadsheet? Use your "plus hours" as opposed to times. Example: 1/4 can "name of food" @ AMPS + 1/4 can @ AM+2.
 
Sorry for taking so long to respond, dealing with yet another familial situation has taken up a lot of my time. Everything is all sorted out now though.

Yeah, I should be able to add that to the comment section. In regards to the vial, I should hopefully be able to. Money is tight right now though, and I do want to save up so that I can make the switch to a better insulin for her come tuesday. So I'll double check that, and if I've got the room, I'll run out there later today to avoid needing to question it, if not, then I guess I'll just need to be extra careful with it until tuesday. I'm going to run off to update my SS now, unfortunately some of the times are weird as I learned my cousin didn't exactly care for any of the cats(no food or anything), so Tips numbers are off due to either getting her insulin and such early to not getting it at all.
 
Status
Not open for further replies.
Back
Top