? Switched from Lantus to Prozinc and numbers are all over the place...

[Angela & Cleo]

Afternoon,
On Saturday 2/19/22 and Sunday 2/20/22 she did not eat, would not drink and had diarrhea. We took Cleo to the clinic on Sunday and they released her on Tuesday evening. I'm waiting for the full blood workup to be sent to me, but the fructosamine results came back "poor, 500-600 range".

We have been VERY unsuccessful with home testing (I haven't given up yet, still conditioning her but its moving along slowly) so we took the Vets advice and had the Libre implanted so we weren't shooting blind anymore. The Vet also switched her insulin from Lantus to Prozinc.
Cleo received 2 units of prozinc on 2/21/22 in the am, 2 units on 2/21/22 pm, and 2 units on 2/22/22 AM at the clinic. We took her home that evening.

If I'm being honest, I'm glad to have the Libre because it alerted us to a HYPO event yesterday which did not require another vet visit because my husband stayed home to handle it for the rest of the afternoon. THANK YOU FDMB HYPO KIT!

The 2/24/22 PMPS was 132. Vet advised us to not shoot, wait an hour and if BG was over 200 to give 1U. He also said to give her the 2U if BG was over 300. One hour later, BG was at 262 so we gave her 1U.
This morning, BG was 367 - gave 2 U but then this happened:

My SS has the imgs of the libre from 2/22-2/25. I have no idea what to do. I'm afraid and at a loss.
She hasn't been on the new insulin long enough to even do a curve to warrant dose reductions or increases. At this point we're dosing based on riding her waves. Any input/explanation/advice would be greatly appreciated.

https://www.felinediabetes.com/FDMB/threads/new-member-and-very-new-diagnosis.259062/

 

[FrostD]

When was her last Lantus dose? The 20th PM shot?

It is very unusual to go from Lantus to ProZinc. I see your notes. I don't think she was insulin resistant, just needed a higher dose. 2U is far too low a dose to call it "insulin resistant" yet. And without the home testing, we have no way of knowing how low she was actually going - fructosamine only shows the average over two weeks, but not how low. If it were me I'd go back to Lantus...

But I digress. Lantus is a depot insulin. So there was still leftover Lantus when they switched to ProZinc, honestly you're a bit lucky nothing worse happened.

Are you using U40 syringes with the ProZinc? They are red cap and would say U40 on the side of the barrel.

Since she dropped below 50 a few times, that is far too low. It's nice to have the Libre, but if it dies on you or she rips it off you'll be in trouble if you can't reliably home test. The Libre can read artificially low at those numbers, we usually recommend checking it with a handheld meter. I would reduce to 1.5U*

*We have two dosing methods. Since you have the Libre and she is on LC wet you can do either. MPM is more aggressive, reductions are 0.25U below 50 on human meter (68 on a pet meter like AlphaTrak). MPM allows for increases every 3-7 days depending on numbers, but requires more testing. (minimum 2 tests per cycle, more if they are in low numbers).
SLGS is more conservative, hold doses for a week then do a curve. reductions are 0.25U below 90 on either kind of meter. Since you cannot reliably home test yet, and there is risk of Libre dying or detaching, I would recommend SLGS. 40s is far too low for SLGS, hence the recommendation to reduce by 0.5U.

Right now I would not shoot below 200, unless someone here can advise. Stall without feeding, and ask for advice on the main forum.

It is likely the Lantus was still in play when she dropped that low the first few times, I just prefer to reduce a bit more, then go up later if necessary.

Tagging @Wendy&Neko . Thoughts? Depot drained by now? What to do with dose?

 

[Angela & Cleo]

When was her last Lantus dose? The 20th PM shot?
Last Dose of Lantus was on 2/19/22 AM. Cleo did not eat for pm 2/19 and did not eat for am 2/20. So we took her to the clinic in afternoon of 2/20. BG in clinic intake was over 600. They put her on IV fluids and insulin drip.

It is very unusual to go from Lantus to ProZinc. I see your notes. I don't think she was insulin resistant, just needed a higher dose. 2U is far too low a dose to call it "insulin resistant" yet. And without the home testing, we have no way of knowing how low she was actually going - fructosamine only shows the average over two weeks, but not how low. If it were me I'd go back to Lantus...
I'm inclined to agree with the switch back to Lantus but I'm skeptical to keep changing the insulin.

But I digress. Lantus is a depot insulin. So there was still leftover Lantus when they switched to ProZinc, honestly you're a bit lucky nothing worse happened.

Are you using U40 syringes with the ProZinc? They are red cap and would say U40 on the side of the barrel.
We are using U40 syringes.

Since she dropped below 50 a few times, that is far too low. It's nice to have the Libre, but if it dies on you or she rips it off you'll be in trouble if you can't reliably home test. The Libre can read artificially low at those numbers, we usually recommend checking it with a handheld meter. I would reduce to 1.5U*
We do have the AlphaTrak2 and are conditioning her to accept our touch on her ears. Its a slowwwww process with Cleo. We haven't given up, just didn't want her to keep shooting blind. Hence the Libre.

*We have two dosing methods. Since you have the Libre and she is on LC wet you can do either. MPM is more aggressive, reductions are 0.25U below 50 on human meter (68 on a pet meter like AlphaTrak). MPM allows for increases every 3-7 days depending on numbers, but requires more testing. (minimum 2 tests per cycle, more if they are in low numbers).
SLGS is more conservative, hold doses for a week then do a curve. reductions are 0.25U below 90 on either kind of meter. Since you cannot reliably home test yet, and there is risk of Libre dying or detaching, I would recommend SLGS. 40s is far too low for SLGS, hence the recommendation to reduce by 0.5U.

Right now I would not shoot below 200, unless someone here can advise. Stall without feeding, and ask for advice on the main forum.
Thank you for this. I am the type of person that needs some guidelines with this hormone. Just for clarity, if PMPS is anything over 200 give her 1.5Us?

It is likely the Lantus was still in play when she dropped that low the first few times, I just prefer to reduce a bit more, then go up later if necessary.

Tagging @Wendy&Neko . Thoughts? Depot drained by now? What to do with dose?[/QUOTE]

 

[FrostD]

Ok. Did they ever find a cause for her inappetence and diarrhea? Did they only keep her because of BG? Or were there other reasons? Has she had any ketones lately?

I don't like to keep changing insulin either, it's just Lantus usually ends up working the best. Shes gotten some good numbers from ProZinc, so no harm in giving it a try for awhile.

Yes, if above 200 at all give 1.5U. does not matter if it's 200 or 500, give 1.5U.

 

[Angela & Cleo]

Ok. Did they ever find a cause for her inappetence and diarrhea? Did they only keep her because of BG? Or were there other reasons? Has she had any ketones lately?

They kept her because they wanted to run all the tests to rule out pancreatitis etc. and put her on fluids since she hadn't eaten or drank anything in close to 2 days. They ran all the tests - ketones, urine analysis etc and everything but the BG came back in normal range. So no reason for inappetence and diarrhea other than BG.

I don't like to keep changing insulin either, it's just Lantus usually ends up working the best. Shes gotten some good numbers from ProZinc, so no harm in giving it a try for awhile.

Yes, if above 200 at all give 1.5U. does not matter if it's 200 or 500, give 1.5U.

Perfect, I was inclined to reduce to 1.5 but purely on mommy instincts. Thought it best to consult some experts
Should I be worried about the drastic drops and drastic increases?

 

[FrostD]

Perfect, I was inclined to reduce to 1.5 but purely on mommy instincts. Thought it best to consult some experts
Should I be worried about the drastic drops and drastic increases?

The drastic drop/rise is threefold - dose a bit too high, the way ProZinc works, and what we call bouncing. When they drop lower and/or faster than they're used to, their liver panics and dumps glycogen and counter regulatory hormones in response to the "threat" (real or perceived). So then the BG rockets back up. It can take 6 cycles to clear, but with the way ProZinc works it's usually 1-3 cycles. When they "break" the bounce, they can often drop lower than usual...often triggering another bounce.

The only way to "treat" bounces is (1) make sure the dose is good (not taking them too low), (2) feeding the curve to help slow the drop (we can talk about this in a bit, I'd have to come back to it later tonight), and (3) waiting for them to get used to the lower numbers and stop bouncing so much. Some cats do just stay a bit bouncy. And sometimes ProZinc ends up being too harsh of an insulin; in most cases it's a good insulin, but some cats just don't do well on it.

What is her current feeding schedule?

And circling back - did she get any sort of diagnosis at the vet? Have you checked ketones lately?

 

[Wendy&Neko]

Thoughts? Depot drained by now? What to do with dose?

No idea on the depot, I see no Lantus data on the spreadsheet. If its been 5 days, it's probably gone. But again, the SS doesn't show the Lantus dose. Sorry, I've been here for 10 years now, and my brain is wired to read spreadsheets.

 

[Angela & Cleo]

The drastic drop/rise is threefold - dose a bit too high, the way ProZinc works, and what we call bouncing. When they drop lower and/or faster than they're used to, their liver panics and dumps glycogen and counter regulatory hormones in response to the "threat" (real or perceived). So then the BG rockets back up. It can take 6 cycles to clear, but with the way ProZinc works it's usually 1-3 cycles. When they "break" the bounce, they can often drop lower than usual...often triggering another bounce.

The only way to "treat" bounces is (1) make sure the dose is good (not taking them too low), (2) feeding the curve to help slow the drop (we can talk about this in a bit, I'd have to come back to it later tonight), and (3) waiting for them to get used to the lower numbers and stop bouncing so much. Some cats do just stay a bit bouncy. And sometimes ProZinc ends up being too harsh of an insulin; in most cases it's a good insulin, but some cats just don't do well on it.

What is her current feeding schedule?

And circling back - did she get any sort of diagnosis at the vet? Have you checked ketones lately?

She currently eats 100grams at breakfast at approx 7am EST and 100 grams at dinner at 7pm EST. We also give her a tsp or two throughout the day if she asks for it.
Apparently her blood work and urinalysis came back "perfect". No pancreatitis - I made sure to ask for it. No UTI. They did xrays and sonograms...everything perfect except for BG at 600. The best diagnosis they could give is that inappetance and diarrhea were a result of unregulated and fluctuating glucose levels. We are also testing her urine at home and no ketones. Wacky glucose though. One day glucose is 500++. The next day it is negative. Then its trace. Then back to 500++. Never any ketones. Vet also confirmed on Tuesday that there were NO blood ketones NOne in her urine either.

I've been reading up on the bounce etc. It makes perfect sense.
Pmps reading HI on libre. Took one with the alphatrak and it came back at 590. Some of that might have been stress because we held her down so we could test BG but either way very high. We fed and gave 1.5 units. An hour later, 8pm EST libre read 485. Going to scan her again in a few to see if she came down some more.

 

[FrostD]

So that's the interesting thing about urine BG. Renal threshold in cats in somewhere between 200-300. Above that's glucose spills into the urine. I saw it discussed somewhere here recently (I'd have a hard time finding a link) that anecdotally, if a cat was below renal threshold for at least a few hours, the urine strips came back negative. Then obviously once BG came back above for a few hours, it was in the urine.

I really wouldn't bother with urine BG testing, just ketones. The urine BG isn't a real time number

Entirely possible she just felt like crap that day, hopefully that's all it is.

 

[Angela & Cleo]

Cant access spreadsheet right now so posting here.
Pmps 590, fed 1/2 can and 1.5U insulin
+1 465
+2 392
Is a 70pt drop in an hour a concern?
Shes sleeping now on hubbys favorite chair. Going to scan her again in an hour.

ETA +3 298

 

[Angela & Cleo]

The strips I have test for both. And since Ive had a heck of time getting bg readings with a meter without torturing her...and probably raising her bg bc of it...the strips were the next best thing.

 

[Katherine&Ruby]

@Bandit's Mom Can you help Angela with accessing her spreadsheet?

 

[Wendy&Neko]

Renal threshold in cats in somewhere between 200-300

In some cats it's upper 100's.

 

[FrostD]

Cant access spreadsheet right now so posting here.
Pmps 590, fed 1/2 can and 1.5U insulin
+1 465
+2 392
Is a 70pt drop in an hour a concern?
Shes sleeping now on hubbys favorite chair. Going to scan her again in an hour.

ETA +3 298

The 70 pt isn't a concern at these numbers, just tells you to keep an eye out. The safe thing to do is assume she'll keep dropping at a similar rate, and base your test/scanning off that. You can see it was 100 pts between the +2/+3. From what I can tell she nadirs around +4/+5, but not a lot of data yet.

Spreadsheet says 2U this morning, did you go back up to 2U? I would stay at 1.5U for a 2-3 days just to give her time to settle and see how the 1.5U does. Then if she needs it, we'd go to 1.75U

 

[Angela & Cleo]

The 70 pt isn't a concern at these numbers, just tells you to keep an eye out. The safe thing to do is assume she'll keep dropping at a similar rate, and base your test/scanning off that. You can see it was 100 pts between the +2/+3. From what I can tell she nadirs around +4/+5, but not a lot of data yet.

Spreadsheet says 2U this morning, did you go back up to 2U? I would stay at 1.5U for a 2-3 days just to give her time to settle and see how the 1.5U does. Then if she needs it, we'd go to 1.75U

Thank you so much for keeping an eye on me. I am so appreciative. I freaked out with HI reading on the Libre and freaked out even more when I couldn't get an ear prick and forgot about the 1.5U in lieu of the 2. After injection I remembered and have been kicking myself since. I also texted with the Vet earlier today and surprisingly he was very receptive to feeding the curve to slow the drop ( Initially we were told only 2 meals/day 12 hrs apart) but because she is high a lot of the time he wants to keep the 2Us for a few more days.
He said giving Cleo a tsp of LC wet food with 1 tsp water at +3 was great and was what he thinks kept her in the 200-300 range for 7 hrs.
He said he needs to see 2U for 6 days to get an idea of best dose since the switch from Lantus to Prozinc. He also confirmed that Lantus depot is gone by now.
I should mention that Vet is getting Libre readings directly on his phone and will text me to assess her behavior/symptoms. He is very involved in Cleos care.
Vet is leaning towards Somogyi syndrome and thinks that is why fructosamine keeps coming back "poor" even when she was on Lantus.
Are there any sticky notes or threads about "feeding the curve" I can familiarize myself with?

 

[jillnc1]

I would love to learn more about feeding schedules and as you say "feeding the curve". I feel I have home testing and giving the shots down, but coordinating the feeding schedule for best results is something I would like to hear more about. My kitty does have chronic pancreatitis. Thanks

 

[Angela & Cleo]

I would love to learn more about feeding schedules and as you say "feeding the curve". I feel I have home testing and giving the shots down, but coordinating the feeding schedule for best results is something I would like to hear more about. My kitty does have chronic pancreatitis. Thanks

Poor Kitty w/ pancreatitis
I wish I had home testing down. Home testing has been an exhausting and stressful process. It takes two humans and a humane cat chokehold to get one drop. We couldnt keep shooting blind so she is now on the libre. Still trying to home test though...I refuse to give up.
Will let you know if/when I find anything about feeding the curve.

 

[FrostD]

I would love to learn more about feeding schedules and as you say "feeding the curve". I feel I have home testing and giving the shots down, but coordinating the feeding schedule for best results is something I would like to hear more about. My kitty does have chronic pancreatitis. Thanks

Can you create a post for you and tag me in it please? It will likely be later tonight by the time I can come around, but I can definitely look!

 

[Angela & Cleo]

Can you create a post for you and tag me in it please? It will likely be later tonight by the time I can come around, but I can definitely look!

Will do! @jillnc1 do you want me to tag you too?

 

[jillnc1]

Poor Kitty w/ pancreatitis
I wish I had home testing down. Home testing has been an exhausting and stressful process. It takes two humans and a humane cat chokehold to get one drop. We couldnt keep shooting blind so she is now on the libre. Still trying to home test though...I refuse to give up.
Will let you know if/when I find anything about feeding the curve.

I am blessed that Mac is trooper when it comes to testing. very surprised but happy. On the other hand his brother (who sadly passed away this past January) would never have tolerated all my poking and prodding.

Best Wishes!

 

[jillnc1]

Will do! @jillnc1 do you want me to tag you too?

Yes please! and thank you!

 

[FrostD]

Thank you so much for keeping an eye on me. I am so appreciative. I freaked out with HI reading on the Libre and freaked out even more when I couldn't get an ear prick and forgot about the 1.5U in lieu of the 2. After injection I remembered and have been kicking myself since. I also texted with the Vet earlier today and surprisingly he was very receptive to feeding the curve to slow the drop ( Initially we were told only 2 meals/day 12 hrs apart) but because she is high a lot of the time he wants to keep the 2Us for a few more days.
He said giving Cleo a tsp of LC wet food with 1 tsp water at +3 was great and was what he thinks kept her in the 200-300 range for 7 hrs.
He said he needs to see 2U for 6 days to get an idea of best dose since the switch from Lantus to Prozinc. He also confirmed that Lantus depot is gone by now.
I should mention that Vet is getting Libre readings directly on his phone and will text me to assess her behavior/symptoms. He is very involved in Cleos care.
Vet is leaning towards Somogyi syndrome and thinks that is why fructosamine keeps coming back "poor" even when she was on Lantus.
Are there any sticky notes or threads about "feeding the curve" I can familiarize myself with?

So about somogyi...that's a sensitive subject here. I'm going to copy and paste a statement from a moderator @Wendy&Neko (post can be found here):
Symogyi has been proven to very rarely exist, almost never on cats who's dose started low, had safe increases, and caregiver is monitoring. More detail in this paper proving that: Rebound hyperglycaemia in diabetic cats.pdf

In her case, and Wendy cna correct me if I'm off target, it is possible because her dose is too high
(hence the 40s and possibly lower you're getting from the Libre).

But I entirely disagree with him that you need to keep the 2U for 6 days. She has shown time and again that dose is too high, no ifs ands or buts about it (minus the possibility of Libre reading artificially low, but right now it's all we have). For dose we don't care about the high preshots, it's nadir that matters. I've been at this for 2 years now, those low numbers are not to be messed with, I get palpitations every time I see it.

There is a post about feeding the curve I believe, I'm just having trouble finding it. I'll dig more later when I have time. But it's a bit of trial and error -you want to feed snacks in the beginning part of the cycle to slow the drops, keeping in mind it takes about 30 mins for food to kick in. For some cats, the regular LC is fine. Some cats need higher-LC (like 7-9%), and some drastic cats may need MC.

For Cleo, I'd like to see a few more days of data because her patterns have been a bit different each cycle. Looking at yesterday night, she was dropping 100 points an hour the first 3 hours, so some hourly LC snacks would have been a good experiment (or if you did that, it means she needs a bit more carbs). Today, hard to tell because of the HI readings, but +2 to +4 we're sizable drops.

 

[FrostD]

Will do! @jillnc1 do you want me to tag you too?

This reply was for Jill lol

 

[Angela & Cleo]

There is a post about feeding the curve I believe, I'm just having trouble finding it. I'll dig more later when I have time. But it's a bit of trial and error -you want to feed snacks in the beginning part of the cycle to slow the drops, keeping in mind it takes about 30 mins for food to kick in. For some cats, the regular LC is fine. Some cats need higher-LC (like 7-9%), and some drastic cats may need MC

For Cleo, I'd like to see a few more days of data because her patterns have been a bit different each cycle. Looking at yesterday night, she was dropping 100 points an hour the first 3 hours, so some hourly LC snacks would have been a good experiment (or if you did that, it means she needs a bit more carbs). Today, hard to tell because of the HI readings, but +2 to +4 we're sizable drops.

I LOVE ALL THIS LOVE!!!!!
I did give 1 tsp of LC wet food at PMPS +3 and it seemed to slow the severe drop.
I know Somogyi is a sensitive topic, even the Vet was hesistant to say it. He said its rare but a possibility based on Cleo's drastic drops and increases and HYPO scare. But just as you said, he wants more data.
I will keep updating SS and give her 1.5U this evening unless you say otherwise

 

[FrostD]

Ok good. Some vets just call everything somogyi and it gets a little frustrating for us (heck this whole thing can be delicate...internet strangers disagreeing with vet advice). I'm glad he's involved though, so many vets just turn people lose and say oh we'll touch base in a month or three.

As long as (1) preshot is above 200, and (2) she isn't going below 100, I would give 1.5U for a total of 3 days. Then we can re evaluate. Please continue to note any feeding schedule experiments you do in the Remarks column like you've been doing.

If she goes below 100 at any point tag me so I can take a look and see if anything needs changed