Simon - very labile BG. Dosing suggestions please

[Yvonne & Simon]

Hi all.

Just to update you on my newly diabetic kitty Simon (diag Mar 2021).

Here are a couple of my posts to give you the back story:
https://felinediabetes.com/FDMB/threads/re-toujeo-insulin-pens-libre.245467/
https://felinediabetes.com/FDMB/threads/new-member-lots-of-questions.245480/


Hx of IBD with recent course of budesonide which caused the diabetes. It has been discontinued, and he has now been started on Chlorambucil. It does have a side effect of inappetance which is concern for both me and the vet as he is a very fussy and poor eater, who REFUSES to transition to canned food (I can maybe get him to eat a tsp a day now).

Started on Toujeo insulin by the vet, changed to Lantus the following week.

Had eye infection which is finally clearing up with antibiotics. Has this been affecting his BGs???

Just started on the Chlorambucil - received third dose this morning (getting 2x/wk).

My issue is that his blood sugars have been very labile. Mostly high. My vet read me the riot act last week about them being too high, and wanted me to get much more aggressive about controlling them as she is concerned about glucose toxicity, and also really wants me to give him his very best shot at going into remission now that the steroid has been discontinued.

I admit that I have been very timid about increasing his insulin as I am quite fearful about causing him hypoglycemia, especially in V/O he is such a poor eater and the fact that his BG will occasionally just plummet really quickly.

I have tried my best to put him on a consistent dose on insulin and leave him there but when I get these sudden rapid shifts in his blood sugars they really freak me out and I want to back off. Vet thinks these are likely due to residual pancreatic function which erratically kicks in and out. She is much less worried about his having a low blood sugar than I am!

Case in point, increased his insulin to 2 U the other day, and it dropped his BG from 356 to 124 within 8 hrs. So I backed off a bit with his evening dose to 1.75 (felt ok with that as PMPS was already rising again by that point). Next morning (yesterday) his BGs were high (this seems to be his trend) so gave him 2, however instead of his usual PMPS being high, it was was dropping (different for him) so I again backed off to 1.75 last night.

This AMPS was 135 - the lowest it has ever been for him since this all started. Was really undecided what to do, so decided to play it safe and only give him 1 U. Will keep checking him today to make sure he is ok.

Sorry for the long winded story. But feel like I need help (or at least reassurance) here.
I want to try to get his insulin dose more consistent and to some degree feel like I am over-micromanaging him, but on the same token, all these weird jumps just freak me out, and make me want to back off. So I keep messing about with his dosing instead of keeping it consistent. I don't know if this is the right thing to do or not.
Argh!!!

Just wondering if anyone else has dealt with a scenario like this and what you did?
Am I correct in changing the dose each time in response or is that bad practice?
Do I just pick a dose and stick with it, despite what the BG say? Eg should I have gone ahead and given him a higher dose this AM, despite it having gone down so much for him?
Ugh.

Any advise, words of wisdom or even some reassurance would be much appreciated!

PS his spreadsheet is all updated.

 

[Diane Tyler's Mom GA]

I'll tag a few members for you Yvonne , you can always tag members that have helped you in the past also
@Wendy&Neko

@Sienne and Gabby (GA)





Thank you ladies

 

[Wendy&Neko]

Had eye infection which is finally clearing up with antibiotics. Has this been affecting his BGs???

Infection/inflammation can impact the BG. So can antibiotics if given in a solution with sugar.

Just started on the Chlorambucil - received third dose this morning (getting 2x/wk).

This isn't any published protocol for chlorambucil that I know of. The one slightly larger dose given every two week is much better in terms of inappetance. It took Neko 4-5 days to get over her chlorambucil related nausea. It wasn't until we went to the pulsed or every two weeks dosing that she got some relief for the nausea. Proper dosing of anti nausea meds is also key - many vets underdose it. I hope you are giving ondansetron, it's the best for chemo drugs.

Case in point, increased his insulin to 2 U the other day, and it dropped his BG from 356 to 124 within 8 hrs. So I backed off a bit with his evening dose to 1.75

We dose here based on the nadirs, or how low the dose is taking the cat. 124 is still a very safe number. You do want to eventually get nadirs below 100 so pancreatic healing can occur. With Lantus, you will have to learn to shoot full dose at lower numbers. If you post over on the Lantus/Basaglar/Levemir forum, we can help you do that. Shooting lower numbers with Lantus (provided you are around to monitor) provides much flatter cycles.

Jumping around in dose with a depot insulin is not helpful, the depot has no time to stabilize. We have a couple dosing methods in the Lantus forum - if you pick one, it'll give you a process to follow. And again, dosing based on how low the dose takes the cat, not the preshot values.

 

[Diane Tyler's Mom GA]

@Wendy&Neko
Thank you Wendy

 

[Yvonne & Simon]

Thanks for the info re the chlorambucil @Wendy&Neko
The vet prescribed me cerenia, so I have been giving that in the morning prior to my giving him the chlorambucil. So far he doesn't seem to be overtly nauseated but I have been giving it to him "just in case". I'll ask the vet about some ondansetron.

Re the antibiotics
He is getting Zeniquin tablets. I try to minimize any sort of liquid or bad tasting stuff that I give him orally as it just makes him that much harder to get to eat so I declined the liquid antibiotic version. He is very good about taking pills.

He is a really weird cat in that he is very private and doesn't like to be seen using the litter box or eating. So basically I have been monitoring his intake by seeing if there is a dent out of his food and by monitoring his weight daily. He pretty much refuses to eat in front of me which is frustrating. He literally just pecks a bit here and there. More at night than during the day.
I just offered him some canned c/d food which he took about a tsp of.

His blood sugar has now dropped to 86.
Seems like with the Lantus, he hits his lowest at +8 hrs, so I will be watching him VERY carefully.

I haven't posted over on the Lantus/Basaglar/Levemir forum as frankly I find that section to be incredibly confusing with all the numbers and acronyms!
I have looked at multiple posts there but so many of them didn't seem to be relevant to our situation as the ones I looked at all seemed to be referring to cats who had longer established histories of diabetes.

 

[Yvonne & Simon]

Ok, we are now down to 68. I am definitely starting to freak out.
And can't get him to eat anything.
Don't know if I should start corn syrup now before he drops much lower...

 

[Wendy&Neko]

Ondansetron is a pill - you get a prescription from your vet and fill it at a human pharmacy - you want the 4 mg size. Expensive, but worth it. Dosing is 2-3 times a day, half a pill is typical but depends on cat's weight. I predose 1 hour before chlorambucil in the evening and over the next couple days. Ondansetron targets different nausea receptors than does Cerenia, so they can be complimentary, but typically ondansetron is better for chemo drug nausea - actually, better generally for cats if not vomiting.

Is Simon getting any probiotics? Sometimes antibiotics kill off the good tummy flora and adding probiotics, two hours apart from antibiotic, can help that balance.

C/D is high carb food, will he take more of it? Is there any food he will eat? If so, add a drop of corn syrup or honey. Can you syringe a bit of food in him? Or put honey/syrup on his gums. He's still not dangerously low, but I don't like the direction with him not eating.

The LBL forum has a real mix of people. Experienced people who can help with dosing/low numbers, as well as plenty of new people that you can follow what their spreadsheets look like. Not disimilar from Simon's. Checked out the member's Joined date under their avatar to find the new ones. And over there we all remember what it is like to be new and try to be helpful. Also a lot more traffic and likelihood of getting help.

 

[Yvonne & Simon]

Ondansetron is a pill - you get a prescription from your vet and fill it at a human pharmacy - you want the 4 mg size. Expensive, but worth it. Dosing is 2-3 times a day, half a pill is typical but depends on cat's weight. I predose 1 hour before chlorambucil in the evening and over the next couple days. Ondansetron targets different nausea receptors than does Cerenia, so they can be complimentary, but typically ondansetron is better for chemo drug nausea - actually, better generally for cats if not vomiting.

I have a call into the vet now.

Is Simon getting any probiotics? Sometimes antibiotics kill off the good tummy flora and adding probiotics, two hours apart from antibiotic, can help that balance.

He gets a very small amount of Fortiflora. I sprinkle some on his canned food to entice him to eat the pittance amount of it that he deigns to eat. If I put a whole package on, he'll refuse to eat it.

C/D is high carb food, will he take more of it? Is there any food he will eat? If so, add a drop of corn syrup or honey. Can you syringe a bit of food in him? Or put honey/syrup on his gums. He's still not dangerously low, but I don't like the direction with him not eating.

He wouldn't eat any more of the cd. I decided not to press the matter as that typically is the one canned food that he'll take small amounts of, willingly. If I was going to force something on him, it will undoubtedly result in a food aversion afterwards, so decided I didn't want it to be with this one.
I had some recovery diet canned food (left over from a sick dog) which is really smooth so I mixed that with a bit of water and a 1 tsp of corn syrup and syringed that in.
I felt much better after getting that into him!
Checked his BG a half an hour after getting that into him and it had gone up to 112.

Although his BGs weren't that low, I am pretty sure that he was officially having a "reaction" as his eyes were quite crossed and "starey" and he had a really flat affect. Refused to eat anything including temptations which he'll typically take a few of, when he is refusing all else.

Just checked him again now. He is now up to 160. And he just ate a few temptations. So I am feeling better now. But I'll keep checking as he is usually at his lowest at +8 hrs. Ugh. Didn't like this, one little bit!

The LBL forum has a real mix of people. Experienced people who can help with dosing/low numbers, as well as plenty of new people that you can follow what their spreadsheets look like. Not disimilar from Simon's. Checked out the member's Joined date under their avatar to find the new ones. And over there we all remember what it is like to be new and try to be helpful. Also a lot more traffic and likelihood of getting help.

Thanks. I'll try to spend a bit more time on that. I just seem to find it very hard to follow.

 

[SashaV]

LBL forum is very confusing when it doesn't make sense. I had to wait a few days before I felt ready to jump in

First we write the date, name of the cat, then the AMPS or PMPS, AM or PM pre-shot. And as the day goes, you just type in his BG.
We always give the link to the previous day's thread, so it's easy to trace back.
Because we all do the same, the knowledgeable people can scan through and see if someone need help, if a cat in is a rush to get down, or consistently high and that sort of thing.
Try it out, we're really kind and you're more than welcome

 

[Wendy&Neko]

He gets a very small amount of Fortiflora.

Fortiflora isn't a very good probiotic, it only has one strain of flora. There are many other human ones out there that are suitable, like Renew Ultimate. My vet recommended Natural Factors Protec.

Since Simon normally eats dry food, you should probably lower the dose to 1.5 units. We don't want a cat on dry food going below 90. With the jumping around in dosing it's hard to say if this is the 2.0 units or the 1.75 units and it's depot that got him down to 68.