Suggestions for Sabian

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patrick_777

patrick_777

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Hello,

Some of you are probably already familiar with my kitty, but I'm looking for some advice on where to go with Sabian's dosing.

Her levels seem to be all over the place the past few weeks, and I'm getting way too many people giving me some very contradictory advice. Some are telling me to go TID, others are saying raise the dose, and still others want me to lower the dose, or change insulin altogether (basically starting over), sometimes several of these at once.

My actual vet actually suggests that I stick at 0.8u where I was at last week and make tiny changes in treats and withhold any food in-between shots since she's very food-sensitive. She has a dental scheduled in two weeks and I'm hesitant changing much of anything at the moment, but I want to keep her from spiking hard during the midday hours, and diving hard at +2 to +4. It's getting very frustrating not knowing what to do or who to listen to, and even more frustrating hearing multiple contradictory opinions all at once. I've picked up on this pretty quickly, but I'm still uncertain of where to go. I'm unwilling to hand it over completely to my vet because he seems to be learning more and more about this as we go as well.

I know there is a lot of great knowledge here, but I also know that there are as many opinions as there are people.

Please take a look at my sheets and graphs and ask away if you need to know anything.

Thanks!
 
Welcome Patrick,

I have been watching your posts on Health and have been impressed with your testing and how much you have learned so fast.

It looks like .80 is working pretty well - most cycles. With .6, you got higher numbers. With the .8 you did get the long duration on 3/25 that made the pmps shot difficult.

What have you learned about how food impacts her numbers? Sometimes, when .8 is close, but .6 is too little, you can manipulate the numbers using really low carb or a mid low carb.

The other thing we lose sight of, when we are agonizing over numbers, is that Sabian is doing great. She is regulated! I know you want her in remission, but just don't lose track of how well you and she are doing.

I think maybe a skinny .8 The dental can really change this picture so you might consider being in a holding pattern till then. (Gosh, guess I sort of agree with your vet. That doesn't happen all that often.)
 
Hi Patrick,
I for one have a hard time reading your ss. And I really really want to. Is it necessary to have the time, the meal, actually anything other than the typical amps shot and + hours?
From what I could see there does not seem anything really terrible going on here.
Oh, also the black colored whatever information (think it's the sabien's weight on any given day)
TMI,
Could you, would you, reduce the info and coloring down to a typical SS.
I will be more than happy to really look it over and give my 2 cents if you like.
Lori
and tomtom too!
 
Too much information? That's a first. :o

If you go to the link labeled Sabian's Graph it's a simplified version made exclusively to chart the information graphically. The black lines separate the weeks. There's really only one or two added columns from the original template, but I will move the AMPS column closer to the hourly readings.
 
oh that will br great..now let me go look at the gragh. and sorry if the sheet confuzeled me. brb.
 
Hi Patrick! I agree that 0.8u seems to be working well, but it looks like on most days she does tend to zoom a bit right before the shot. Those types of kitties are usually good candidates for TID dosing if you want to go that route. You catch the zoom before it happens with TID. If you stay BID, I would stick with the 0.8u and hope that she gets more and more used to the dose, and eventually gives you a longer duration. I wouldn't up the dose. Those lows are low enough.
 
patrick, are you feeding h/c to those lower greens. like the +4 65?
 
Lori, very seldom unless noted. The 60s and 70s don't bother me anymore, but I watch her carefully during those times.

I think the lower numbers are causing a bit of a rebound in her PMPS though. She's usually pretty high in the PM after those lows.
 
She's also sensitive to food from what I can see. After feeding, usually within the hour she spikes hard, even low to no-carb food, which she's been on since dx.
 
sorry about the delay. i'm happy you are'nt feeding those lower greens. i thought maybe in an over-reaction it caused the pinks that followed. i really want to look over your chart again. there's like 7 people viewing it! brb
 
i'm looking to see why you steered away from 1u and lowered dose? check your pm's ok.
 
I can't get my mind around the SS right now, but just wanted to comment on the contradictory advice factor, as I have been there before and found it very frustrating. cat(2)_steam

It might help you to view the advice (with some possible exceptions) as a set of options. For instance TID, or alternately as-needed shooting, are tools that some have used with a lot of success. Your #s are good enough overall that I don't see a big need for something like that, but I think it's an option available to you if it's something you would want to attempt. Same deal IMO with a different insulin. Your #s are good so there's no compelling need that I see to switch, but if you are interested in trying a different insulin, it's always an option.

This has probably been suggested, but some have had good success with feeding in the early hours of the cycle to moderate the drop (even going with mid-carb food for sharp droppers - doesn't sound like she would need that though). That way they can stay with a dose that gives them good duration, and not risk a nadir that is too low. If you haven't already tried something like that, you might want to do some experimenting and see if you can find a food timing scheme that gets the curve more how you want it.

W/o having looked at the #s too closely, I'm curious about the couple nights recently where you shot 0.6 and then got a really nice PS the next morning. I'm not really sure what to make of it, as on other cycles 0.6 looks too low. Was there any different pattern those nights, maybe a different eating pattern?
 
ok, i just noticed in reading your notes that the amps is not the first number you get in the morning....you should put that first number in the evening section as +11.5 or such so we can all easily see the sudden rise.
as joanna said still deciphering ss.
 
lori and tom said:
ok, i just noticed in reading your notes that the amps is not the first number you get in the morning....you should put that first number in the evening section as +11.5 or such so we can all easily see the sudden rise.
as joanna said still deciphering ss.
Click to expand...

The AMPS actually is the first number I get. Sometimes if it's too low to shoot, I've been feeding first before shooting because she spikes with food and I was waiting for the number to rise before pushing insulin.

There are relatively few times for that though, and each one is noted. The PS is typically 5 minutes or so before shooting, and I shoot her while she eats.
 
still it's good to have the un-spiked number actually on the chart...you'll find it helps peeps to understand the whole picture.
 
see what kelly wrote about zooming right before the shot? were those, all of them, some of them..food spikes?
 
That's why I usually put it on there. 03/01 is the only day I've held the shot in the AM due to too low a number. I'm trying to figure out why she varies so much on the PM than the AM and the only things I can figure is that a) she's sleeping more at night, and b) I'm feeding treats with testing. The treats are individually tiny, but add them up throughout the day and they are probably what is causing her PMs to deviate.
 
yes, looks like it happens alot but not always. nice thing about pz is you can dose as needed so why not dose higher for her evening shot and lower for her morning shot. that would seem reasonable.
 
well that was a fast 100 point drop in 2 hours this evening.
 
Sue and Oliver said:
Patrick,

Are the treats lo carb?
Click to expand...

They are now, since about a week ago. I was using a few kibbles of Purina DM, but now I've switched over to freeze-dried chicken. I have a bag of Nature's Variety Raw Instinct (7% cal/carbs) coming in the mail in a day or so, so I'll be able to use those too. She's been weird about the chicken today though...she loved it yesterday, but today she literally runs from it. :roll:

Lori, she regularly has 100+ drops. Several times, she's dived 150 to 200+ in just a few hours... :shock:
 
lori and tom said:
yes, looks like it happens alot but not always. nice thing about pz is you can dose as needed so why not dose higher for her evening shot and lower for her morning shot. that would seem reasonable.
Click to expand...

I didn't think you were supposed to do that. Is it because it comes out of the system faster or doesn't build up like the other insulins?
 
I know one of your frustrations, Patrick, is that you get lots of differing suggestions. One of the reasons is that you CAN do different things with PZI. If you have data, and you certainly do, you can experiment. PZi has no shed so we usually figure you can shoot what you get at ps. There are some cats who seem to do best with the same dose every day for several cycles to let the dose settle. Other cats don't respond this way. (take a look at Donnac' SS. We don't seem to ever be able to predict what Asher will do.)

For better or worse, in some cats, PZI seems to be a "do it yourself" insulin. There's no set protocol, only guidelines that all operate with ECID.

What we tend to do is offer suggestions, let the bean consider and the try what they feel safe and best about.

I tend to be more conservative than others. Not more right- just more conservative.
 
patrick, as many human diabetics do i am usually in favor of shooting the number with pro zinc. it just makes sense. you absolutley can not do that with lantus or levemir. they don't work that way. but with pro zinc (pz) you can. the only trouble you may encounter is yet lower amps. the other thing you may try if possible is changing your shot times. for whatever reason seems kitty may get a boost of either pancreatic action...or on the other paw, 0 pancreatic action at different times of the day. don't know when your shooting...i should cause you have it in your ss...but maybe bo like 10pm/10am or anything 3-4 hours different than what you have now.

make any sense?

yes opinions vary. that is the juice of knowledge from which you get to learn. medicine is often an art.
 
Hi Patrick,
I have thought about your question and this would be my best response .... you need to think of the list like you do the library, so much information and so much knowledge but who do you listen to? yourself.

You ... know Sabian ..... you do. What feels right? how does he respond to X, to Y? ..... you live with him, you know him, as Sue said it's not all numbers and charts, how is your cat doing? you are almost OTJ! can't you see that? you have gotten really good advice but ultimately it is your decision. I would do anything to have a cat like Sabian .....

I am recently back to pzi after trying Lantus, unfortunately my Payne is a very, very difficult diabetic and when we switched, she crashed. Not because of the insulin but because the insulin doesn't do what I need for Payne. ProZinc is most forgiving ..... I am one of the ones who uses it t.i.d. and it so works for us, would it work for you? don't know, all I can tell you is for us it stopped the big highs. You need to step back and look at the whole picture.

I have gotten the best advice I ever could have wanted from this list, it has literally saved Payne's life. But what it has done is not confuse me, it has empowered me! I feel confident to try different things but if they don't work, to go back. To be confident in my decisions, even the bad one's because they have gotten me to the good ones ..... and Payne is still alive and that has astounded many.

It's all up to you Patrick, the list is here for every emergency, for which I am thankful but it is here for just what you are doing, asking everyone what they think. I think to dismiss that knowledge as everyone is giving you different advice, is to say the night/day you hypo'd that no one was holding your hand ......
Nancy and Payne (thankful for everyone on this list who has helped us)
 
Hi Patrick,
I very much understand the frustration and irritation you feel. This is a disease which mobilizes those feelings. You are a very quick study, learned a great deal in a short time, and want to be able to do it "right" and control the numbers. I have been in your shoes and found that it was impossible to achieve (had 2 bouts with Squamee with diabetes, the first time she went OTJ in a short time, the second time I never even got her regulated). THe numbers are influenced by SO many factors; all kinds of health conditions, food, environment, exercise, stress, etc. etc. etc. And each cat is different, and each cat can also change over time. In my experience, the best you can do is keep testing as a way to be safe, and make educated guesses based on the data. If it works, great, if not, try something else.

But keep in mind that you are doing a terrific job, that Sabian is very lucky to have someone as dedicated as you, and the numbers you are seeing a really quite good---I think you are underestimating what you have achieved. If you had not been testing and so devoted, but had just followed your vet's original advice, your cat would probably be dead by now. Instead Sabian is in a good range, and who knows, with the dental you may find things get easier (I hope that for you!).
Keep up the good work! Eventually I think you will learn enough to teach us a thing or 2.
 
Just got a semi-disturbing call from the vet. Sabian's blood-work came back in today and he called to let me know that everything looked fine, except the fructosamine. It was at 517. I will get a full workup tomorrow with the lab's normal ranges as well.

He said this was considered poorly regulated, and after reading through some of the articles here, that appears to be the case. I honestly don't remember what the DX fructosamine level was back in Jan/Feb, but doesn't that measure basically an average level over 7-10 days?

I just ran a control test on my meter and it came up dead center in the range for the control solution.

We're going in tomorrow morning (preshot) to compare readings from the same blood draw. It's a good bet she's going to be cranky tomorrow...she hates the carrier.

angry(2)_cat
 
My understanding is that more than 500 is a diabetic result. Under 500 is not diabetic. So that would mean Sabian is a borderline diabetic, which she is. She is regulated but still requires insulin. The fructosamine is an average of her levels over the past 2 weeks or so - the 116s and the 350s. I would disagree that the results mean she is poorly regulated.

Here is an interesting thread on fructosamine numbers: http://www.felinediabetes.com/phorum5/r ... 2,report=1

If I were you, I would do some research on fructosamine levels before you meet with your vet. I would trust your numbers at home and the evidence that she is feeling better, not filling the litter box, eating well etc.
 
Whoops--the link did not work so well. I copied some of the info. (if you use the link, you can do a search there for fructosamine to find the article.)





Diagnosis of Diabetes Mellitus Using Fructosamine (Glycosylated Proteins)

Fructosamine measurement also may be used to diagnose and monitor diabetes mellitus in dogs and cats. It is a highly sensitive and specific laboratory test to distinguish hyperglycemic, non-diabetic patients from diabetics with chronic hyperglycemia.1 Fructosamines are stable complexes of carbohydrates and proteins that are produced by an irreversible, nonenzymatic glycosylation of protein (Figs. 3 and 4).11 Glucose has a greater affinity for albumin in dogs and for globulins in cats.9 Determination of fructosamine concentration in the blood is performed using an adapted, commercially available, automated, colorimetric nitroblue tetrazolium technique. This laboratory test is fast, reproducible, inexpensive, easily automated, requires minimal labor, and provides greater precision than other tests.8

Figure 3. With normoglycemia, a relatively small amount of serum protein is glycosylated. Figure 4. With persistent hyperglycemia, increased protein glycosylation occurs.

A single measure of fructosamine indicates the average glucose concentration over the previous 1-2 weeks.5 Fructosamine measurement may be used to assist in the diagnosis of diabetes mellitus as well as to monitor the effectiveness of insulin therapy in diabetic patients. There is very little evidence that fructosamine values are significantly influenced by acute or transient hyperglycemia. Thus, fructosamine concentration may be used to assist in the diagnosis and monitoring of diabetic patients without interference from transient hyperglycemia.5 This is especially beneficial in cats that are highly affected by stress-induced hyperglycemia.9 Quantitative measurement of fructosamine depends on the level and duration of serum glucose concentration and the rate of turnover of specific plasma proteins in the patient.3 In dogs, the half-life of albumin is approximately 8 days.2 Therefore, fructosamine values will change faster than glycosylated hemoglobin values in response to changes in blood glucose concentration.

Reference Intervals for Fructosamine in Dogs and Cats

Reference intervals for fructosamine concentration have been proposed in many publications since this test was introduced for use in diabetic veterinary patients, and these reference intervals vary greatly from manuscript to manuscript. This variation in fructosamine reference intervals is most likely due to different populations of animals, different methods of performing the assay, different statistical procedures, and different environmental conditions and feeding protocols.11 For example, the clinical pathology laboratory used by the University of Georgia Veterinary Medical Teaching Hospital uses fructosamine reference intervals of 175-400 µmol/L in cats and 258-343 µmol/L in dogs. It is important to know that reference intervals are variable between laboratories and that each laboratory should establish their own reference intervals. Reference intervals are not affected by the age or sex of the animal.1,11

Limitations of Fructosamine Measurement in Monitoring of Glycemic Control

While fructosamine levels provide a useful tool for the evaluation of overall control of diabetes mellitus and long-term glucose regulation, this test is unable to detect short-term or transient abnormalities in blood glucose values. For instance, a patient may have an average blood glucose level within the reference interval over a period of 1-2 weeks preceding the test, but still have transient daily episodes of hypoglycemia and/or hyperglycemia. Serial measurements of blood and/or urine glucose are necessary for the detection of these short-term alterations, and are useful in establishing an initial protocol for the feeding and medication of a diabetic patient. Fructosamine levels are more useful for the evaluation of longer-term control, as well as owner compliance with the administration of insulin.
 
Somewhere there is a conversion chart for Fructosamine, sorry I don't have the bookmark - the #s are definitely not the same as the #s we see, the Fruct will read a lot higher. I wouldn't worry about it too much, like others said. Symptoms to me are the most important, BGs #s we get regularly are next, vague tests like Fruct and curves at the vet are a dim third.

Another tool is the glucose pee stix - far from a solid measure, but you can get from that some sense of how much glucose is spilling into their urine. From what I understand, the renal threshold is sort of the dividing line between where their body is getting gradual damage vs. not too much. If there is no glucose in the urine you are good to go, vs. a lot means pretty unregulated. Of course it's not much help with dosing & stuff, but can give you a sense of how close or far you are from the ideal of no glucose. I'm not an expert at all on any of that, so I wouldn't swear by it, but I think that's what I've read. I don't know that too many people bother testing that since we're pretty #s-happy around here :mrgreen: , but just wanted to mention it if you are looking for additional measures of how she is doing.
 
Here's the same question, three different ways...I can't really find a definitive answer to this, or maybe I'm just not reading it correctly.

Is the fructosamine measurement basically an average of the BG levels?

As in, are they defined by the same measurement, or are they different?

Another way of asking is this: If her fructosamine is 517, does that mean her BGs have ranged from say 200 to 800 within the past few weeks?

I presume they are different altogether, but I'm just not that certain.
 
I would take your meter to the vet visit and compare it to your vet's on the same sample of blood taken from the ear, Patrick. I am thinking you are worried that your numbers at home aren't accurate. Is that right?
 
Actually quite the opposite. My vet is worried about that. I'm just trying to cover all the bases. The reason we're going in tomorrow is for that exact reason actually.

After reading through the stuff posted by Judy above and a lot of other technical stuff I could find on the fructosamine conversions, it sounds about accurate. Depending on the reference interval, a fructosamine level of 500-530 is somewhere around an average 330 BG. Looking back on my data, I can see several places she's jumped high like that, and with her food spikes, she may have jumped when I didn't catch it.

I'm working on some standard deviations right now with all those BG readings and trying to figure out her trends but I'm trying to keep myself from predicting any futures on it.
 
Good. Glad you are feeling confident. The other stuff not to discount is her overall health and whether it has improved. It certainly seems to have!
 
Well now. I just got her back from the vet where we compared BG numbers using both meters.

He was using a Glucopet meter and I was using my Relion Micro.

His reading from the same draw of blood: 257
Mine: 174

I guess this means all of my data is skewed, which would explain the fructosamine level still being 510 with a reference interval of 191-349.

I'm about to go out of my mind with this.
 
AlphaTrak and ReliOn generally read differently. (I am not sure about the Glucopet) There is a good thread on Think Tank comparing the animal meters with the human ones: viewtopic.php?f=22&t=38300

I think the general consensus is that, even if the numbers are not the same, you would be dosing the same for both numbers. Regardless of the numbers from the vet or your spreadsheet, Sabian is generally a regulated kitty.
 
I'm so aggravated with this stuff right now, I just want to throw everything out the window...including the cats.
 
Breathe, Patrick, breathe. Remember the big picture - Sabian could have died on 6 units back in the beginning. You are keeping her safe and healthy.
 
patrick i got your pm... i bow to you...you have accomplished what few of us have accomplished before you. it's waves will spread far beyond just your sabien.
bowing,
lori
and tomtom
 
Can't blame you for being aggravated. I learned through this process that I'm a more linear person than I realized and always wanted to find a nice consistent pattern, which I came to realize with feline diabetes doesn't always happen. Anyway, I'm just throwing this next part out as my past experience in comparing my meter readings with the vet, not to add to the aggravation level. A while back, I tested my cat Max at home right before his vet appointment with my meter (Walmart ReliOn Micro) and got a 140 (no insulin and no food since the vet tests like a pre shot). We then drove a 1/2 mile to the vet and tested Max in the office less than 10 min later and got a 127. The vet's test wasn't a meter reading but a blood draw and machine test. To me the two #'s are within the range of the meter and show they test pretty close (course this was just one test and not scientific). Just wondering, maybe comparing apples to oranges, human meter to pet meter, is what caused more variance. Again, not to give more suggestions that will give you more data that raises more questions, but maybe try comparing your meter to another human meter if you're concerned there's a problem with your meter. I did that too (borrowed one) cause I just wanted to see and got similar #'s (not the same). I don't know if there is any one answer to the meter question. Don't forget the progress Sabian has made already, although sometimes a good grunt of frustration can work wonders.
 
"Acceptable" meter variation can be up to 20% if I recall correctly, so it helps IMO not to put excessive weight on specific #s. The guidelines we use on the site (for instance that desireable nadirs are in the 50 - 80 range) are based on using human meters, not pet meters. So while the human meter may run lower than the pet meter, it's sort of built into the protocols to accomodate.

One thing I often recommend is to test a civie with your meter if you can. If you have a non-sugarcat who tests at 42 (have seen that here), then you can be pretty comfortable that if you see 42 with your sugarcat (and no hypo symptoms) it's not something to worry about. That can help when you are figuring out what doses you want to shoot. If your civie tests at 50 and your sug-cat is running nadirs of 90, then you might want to raise your dose a hair.

The meter questions can be frustrating, but if you can differentiate and feel comfortable with the 3 zones - scary low #s, good non-diabetic #s, and #s that are diabetic, it can be easier to view it that way. Avoid the scary lows and get your cat in the non-diabetic #s (as best you can assess, that's where the civie test comes in handy), and don't worry too much about the particular #s you are seeing, exactly how well regulated they are, etc.

My other suggestion is to focus on QOL. If your cat seems happy and is doing pretty well, then enjoy your time together, and do the best you can to manage the diabetes without letting it take over your life (ok, I'm a total hypocrite here, but whatever! :razz: overthinkers, overtesters, overworriers UNITE!!!! LOL). Even the cutting-edge vets and scientists haven't found any quick & easy answers, so of course it is a steep learning curve and lots of hair-pulling-out moments for the rest of us!!!
 
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