Very confused now... What is going on with him?

I'm very confused today. Went to give copper his +5 reading and he was actually higher than his pmps. What is going on? Did i not give enough insulin this morning? Or am i giving too much? Just don't understand. He started going down a couple of days ago on the 2u. Then went down to 1.8u. Now he is up. What is going on???

Any insights would be helpful.

Thanks!

lori

 

Lori:
I can only tell you what worked for us (and folks here can tell you, Asher is not the typical kitty on insulin).

We found we had to be consistent and shoot the same dose for days (like a week or so) before we knew if we should change dose again or not. I think some kitties just need time to adjust to a dose. Also we needed to be real consistent with the food from day to day.

I know it is so hard to be patient but that is the only way we got anywhere. Just wanted to throw that out there FWIW.

 

Keep at a consistent dose even though it is going down?

 

Hi Lori,

Are you shooting different doses based on what number you get at shot time? Not right or wrong, I just need to understand your question better....
Is that why on Dec. 1st you shot 1.8 and 2.0?
Carl

 

Yes. Thought if the number @ amps or pmps is lower than you shoot lower?

 

Lori,
Two schools of thought on that. I know that before you came here, or when you first posted, that you were using a modified "sliding scale", and that Dr. P. was helping a lot. It's fine to do that. Some cats respond well to it, some don't.
If you are doing that, can you post the scale that you are using so that we can all understand how it is set up? It'll be easier to help with that if we understand it. There are 3 or 4 at least other PZI kitties using a scale for dosing.

Carl

 

Yes, some kitties do well on a sliding scale. I just wanted to throw out there what worked for us, in case the sliding scale isn’t giving you the results you want.

 

Dr. P really doesn't do sliding scales. She looks at all the data as a whole and based on what the kitty is doing in the last cycle she makes a decision. But based on what copper was doing at the time (a week ago) and my anxiety level, she came up with a modified scale. Basically >300 shoot 2u, and 250-300 Shoot 1.8, 200-250 1.5, 150-200 1.0. This was for Copper only based on what he was doing at the time. I don't think that every kitty is the same, so i wouldn't won't others to follow. I guess based on the numbers i'm seeing from the 1.8u, he doesn't respond. So i should stick with the 2u even though he drops his amps or pmps. This is scary for me since i'm so busy with my schedule and really can't be home for the critical nadir time. But i guess i just need to do it, because my kitty is just not responding. Very frustrating to me.
I just don't understand FD. you would think that 1.8 and 2u are not that much of a difference. But i guess in my kitty it does. I think? I'm just not experienced enough to know what to do when it does this.

lori

 

Lori,
This is okay, it's going to get easier for you, believe me. Like you said, it's confusing and you're still pretty new to it, and it is hard to make sense of the numbers when for whatever reason some times they don't "make sense".

But that's why we're here. To look at them when you ask us to and try to help you make some sense out of it.

So.....
The "higher in the middle" thing you have today. Doesn't look like it happens much at all for Copper. It could be nothing more than "an off day". It's only one day, so it isn't a big issue. The insulin isn't going to work the same way every day. Some days you like what you see, other days you're like "what the meow is up with that???" But that's "normal". Look in any of the PZI kitty threads. They all drive the beans crazy at times.

I think you can stick with the simple scale that Dr. Lisa communicated to you. And just continue to collect the data. Always test before the shots, you know that already. And get tests "in between" as you can. Any data you can put into the spreadsheet is going to be helpful.

This is just "one of those days" in the "sugar dance". If he continues reacting the same way, that'll tell us which way to go with his doses. You could still use a scale like that, we'd just help you figure out whether to adjust all the doses up or down depending on how he reacts to them.

Make more sense now?

Carl

 

Yes. Just don't understand why each day, each cycle, is so different. You'd think that if he was responding, that he would continue to do so instead of going back up. I just hate seeing him this way. I want his neuropathy to get better and i know the only way is for his sugar to go down and stay down. I really thought that when i finally got a dose that he responded to, that you just have to keep at it and he would improve. So confusing to me. Haven't changed anything from one day to the next. What a strange disease.

Thanks for being here. I really do feel alone in this and not sure i am making the right decisions for him to get well. I know Dr. P would always say to me, he didn't become a diabetic in one day and it will take time. I guess i'm learning i'm not a very patient person for this disease. I fear he will get worse. He is only 7yrs old and he has many years left of FD and i'm trying to imagine years of going through this if he is unregulated. Want him so much to get regulated and fast!

I will do his pmps tonight around 7pm and see where we are at. I'm almost afraid to see what it is going to be since his nadir was in the 300's. Crazy!


Thanks for the support!

lori

 

Lori,
You'll get past the "fear". And IMO, a lifetime of two shots a day can be measured in pretty good happy and healthy years. How long do human diabetics live with it? It will get to the point where he is regulated, and you won't "know" he's diabetic except when you test him. Or he might go into remission, but always be a diet-controlled diabetic. That's what Bob is. He's one bag of dry food away from going back on insulin. Something "could" happen with him that nobody can explain that causes a relapse. But he's about 12 now, and I plan on him being around for a while.

It is a confusing disease for sure. But you're giving him basically a hormone, not a drug. It doesn't do wonders, it just replaces something in his body that is missing right now. So the results you get are "inconsistent" because it isn't a drug. There's no "give him one pill, it does this, give him two pills it does that" like you would think is supposed to happen.
Are you giving him something like B-12 for the neuropathy?
Carl

 

Let's see what other people think, but I am wondering about reducing the dose to one unit and staying there a few cycles, testing religiously for ketones. It looks like you started at 1.25 and you have never gotten great numbers. I am wondering if he has been in rebound since the beginning. Today's curve was inverse with the highest number at nadir, which usually indicates too much insulin.

There are only 2 ways to go - up or down - in dose. You have tried up (and it may be that you just haven't hit the right dose over 2 units yet) but generally the numbers have been pretty blah.
You have gotten some blues on 2 units, so maybe you should do 2.25 and stay there a few cycles.

If you try the reduction, plan to be around to monitor and test urine and blood. If that doesn't work, then it's up.

 

If you reduce the dose, why do you have to monitor the urine more often than now. Is that because of the BG possibly going to to high?

My confusion is that he is responding on the 2u and then he is going in the 200's @amps and pmps. Is it ok to just stay on the 2u? Isn't there a chance he will go into hypo because of too much insulin then?

If he was in rebound all this time, why would he do well on the higher dose and not so good on the lower dose? I thought that if he was responding well then that is kind of where you need to be, not lower dose. If i were to go on the lower dose (1.25), how many cycles do i stay on it before i would know if working or not? Would he be high if not working right away?

Thanks
lori

 

It certainly is not a clear picture, Lori. I don't know if you have been reading Sev's posts on Health. He started around 1.25 and got horrid numbers. (much worse than Copper). We told him he could go up or down. His answer was "so it is just a craps shoot?". And it is. There is no manual because each cat reacts to the insulin differently.

You are right, you have gotten some decent nadirs in the 1.25- 2 unit dose range. That may mean that a tweak upward is what is needed - like 2.25

On the other hand, you have gotten a couple inverse cycles with the nadir higher than the preshots. This usually means your dose is too high. And since you have tried most doses between 1.25 and 2, the only lower dose is one unit. We say to test for ketones because they are caused by too little insulin, high numbers and not eating. And reducing the dose can give you higher numbers and less insulin. So we say only for a cycle or so, testing for ketones and monitoring blood levels.

It would be so nice to have a concrete answer. It may feel safest for you to just tweak the dose upward. That will be fine. And watch to see if there are any more inverse cycles or if the numbers come down.

And finally,yes. Dr. P is absolutely right. There is no hurrying this dance.

 

Forgot to answer the question about neuropathy. Yes i have been giving him the zobaline 3mg 3 times a day.

lori

 

This is what I see on your ss. Your first 4 days you had all mid 200 PS's while you were shooting 1.25u. Since moving the dose up to 2 units you are seeing some blue nadirs but your PS's are mostly in the 300's. And today you got an inverse curve which indicates that the dose is too high.

Both of the L's have changed their starting dose to .5u instead of 1u and I have thought we should do the same for PZI expecially since we have had so many micro dose kitties on PZI. Starting at too high of a dose you can miss the right dose.

You hold the syringe and are the only one who can decide what is best to do. Whatever you decide, up or down, we will support you.

If it were my kitty I would start over at 1 unit to make sure I didn't miss the right dose, just to make sure. If that doesn't improve the bg's then up we go, but with confidence.

If you do lower your dose, test for ketones daily, keep a good record in the comments section of food intake, behavior, the 5 P's, etc. and keep us posted.

Hang in there, this will get better.

 

Thanks for the input everyone! Just wanted to let you know that all the readings(freestyle meter) before i changed meters to current one(relion) were 100pts lower than they should of been. I did a comparison check on the alpha meter and alpha was always 100pts higher. Changed to the relion meter and tested it several times with the alpha meter and it compared within 30pts of each other. I then tested with the old one(freestyle) and that was 100pts lower. So the meter i was using in the beginning was NOT accurate. So all those numbers were 100pts higher than they really showed.

So the 1.25u did some movement, but not enough. So i choose to do the 1.5u tonight and will see what happens tonight and see what his amps is at. I will try to get the ketone testing, but not sure i will be able to catch him going. I will try.

Thanks again! We shall see what happens......to be continued


lori

 

Oliver would never pee with an audience. We put him in a room with a clean litter box filled with aquarium gravel. You can also use beans or shredded paper. They can't stand to see a clean LB and usually will go. The pee won't soak in and you can swoop in and get a test.

 

Questions:

How soon will I see the ketones in the urine if the insulin is too low? Does it usually take a couple of cycles to show up? Does the ketones show up in the urine if the dose is too high also?

Copper has always been a good eater, so don't have to worry about that.

Will try the gravel if i can't catch him going. He prefers to go outside in the yard during the day so can't get it then. Will try to stick him in the box and put a bowl underhim once the flow of urine starts. That is what i've done the last two times and it seems to work. It's just hard to get it even in the box because he is a low squatter when it comes to peeing. I think it's from his neruopathy. We shall try.....

Thanks SOooooo much!

lori

 

You would just plan to do a ketone test once daily, or if you saw any unusual behaviors like lethargy or dehydration. If you go a positive test at the lower dose, you would increase it.

 

Lori,
I'm with Sue and Robin on what they've said tonight regarding dose. It could be that a reduction is needed, and those inverse numbers are due to a dose that is too high. But like Robin also said, no matter which way you go, we're here to try to help. I like to put it "We advise, you decide". If Copper were my kitty, I would do what I thought was right. I am sure you will do the same, because you love him, and want only to make him better. Totally understand that. Bob is my Kitty. The final call was always mine.

The scale you are using... Something like that is perfectly fine, and there are cats here who are dose that way. Robin has set up several "sliding scales", one for each kitty. Customized for you cat based on prior dosing and BG numbers. I'm pretty sure she would be willing to do the same thing for Copper, so that option is out there.

Do you have a copy of the original blood lab report from the vet when Copper was dx'd? Or can you get a copy? Sometimes there are numbers there that make no sense individually, but might mean something "total picture" wise. If so, maybe there is something there that can help explain what it going on with the numbers. There's a lot more than just the BG that figures into this.

Carl

 

Original vet that dx of FD did not do any blood work or urine. Didn't even suggest it. Said that he could go on humilin-N and/or offered that he changed his diet to DM wet and dry. Said that was the only insulin to take. Changed the diet first and started reading up on internet about FD. Went to another vet for 2nd opinion. They did BG, but no bloodwork or urine. Said to put copper on 2u of prozinc 2xday. Didn't feel that was right either. That's when i found the diabetic care group that did TR and then found you all. I haven't found another vet yet because not much offered in this area. Will try to take him to another vet soon. I think he is just too fragile right now to go in car ride +30min to vet. I'm sure that would just stress him out too much more and his BG would be sky high.

Went down to 1.5u dose tonight. Will try to set alarm and get back up for +5 or +6 reading. Got a daughter with the stomach flu right now so have to get up and check her too. She had a temp of 104 earlier tonight. Thank God for motrin. Fever down. So moch going on right now. Why does it all happen at one time?......

To be continued... Shall see tonight how he does and check his amps reading in morning. hoping it will be lower and not higher.

Lori

 

I am going to break my rule here and comment on dosage. I would be raising it. I understand the issue of possible rebound but, generally speaking, I see it worried about far too much.

I often see more worrying about rebound than ongoing glucose toxicity.

Yes, we have to be patient but not so patient that we keep watching the patient drown in sugar.

I also do not see rebound as a failure or a mis-step.

Also, we need to consider the issue of warranted or unwarranted rebound. If warranted? ( a number truly too low or the drop too fast)..... Lower the dose. If unwarranted? (a cat over-reacting to a safe number) Stay the course and push through it. Don't just look at a high number and assume warranted rebound.

I am more aggressive than most. I want the cat rescued from glucose toxicity but it has been hard with Copper's case because of his mom's intense fear of insulin.

 

I will certainly defer to your dosing advice over ours, Dr. P.

I think we were wondering particularly about the inverse cycles and whether they were an indicator of too much insulin and thought it would be worth a trial.

 

I agree with Sue and defer to Dr. P's advise.

I just thought it was worth exploring the inverse curve.

 

[quoteI just thought it was worth exploring the inverse curve.
Rob & Harley [/quote]

And you guys could very well be right and that a lower dosage is needed.

We would all have the answer (raise or lower) if we had continuous BG readings where we could see an obvious low that may have triggered rebound.

I want to stress that I think you guys do a fabulous job on this board. If I did not feel that way, i would not send people here. And....I am loathe to post comments to encourage more aggressive recommendations by folks just trying to help out in their spare time on an internet board so please don't take my comments as trying to necessarily push for a more aggressive approach. The fact that the mantra of "better weeks too high than a minute too low" is followed here has kept thousands of cats safe throughout the years.

But that said, I hate watching cats drown in glucose and be subjected to weeks...months of toxicity.

With Copper's case, as stated, there is no clear-cut reason to lower the dosage. Sure, we have some high PS's but no obviously low numbers to tell us that there is any warranted rebound. And, yes, I have stared at 11/23 until blue in the face but I can't let one day make me continue to worry about rebound.

Also note Lori's notes about how much better Copper has felt when on a higher dose of 2 units. That is a critical part of the picture - how the patient is feeling.

Again, I do not see rebound as a failure. I prefer to push the dosage up and then IF I see clear signs of warranted rebound, then I can adjust.

I would be increasing Copper's dosage to 2.5 units and holding for ~6 cycles (shots). That is another thing about me...I don't believe that it takes insulin so long to "settle" and will often go up after only 3 or 4 doses (yes...even with Lantus....) if I am seeing no response. If seeing some response, I am more apt to wait a bit longer before going up.

We are ALL at a disadvantage because we don't have continuous BG values. I am no smarter than you guys. You are just as smart as me and if we ALL had a BG reading of every minute of every day, we would all know what to do with those numbers.

The bummer is that we don't know where the patient is at every minute of every day and so we just have to go with the data that we have.

As I was discussing with Lori on the phone, the people who are home testing obviously can push their cats out of glucose toxicity more safely than those who are not testing.

And...of course....if the human is going to be around to watch the cat, it is safer to go up on the dosage. That is why you all are careful to check to see if the human is going to be around or not.

I could type for a long time but have to run.

Again, you guys do a GREAT job here and the diabetic cats of the world are incredibly lucky to have you GENEROUSLY donating your free time to their health. You have saved a lot of lives and increased the quality of life of many deserving furry critters. No doubt about that at all.

 

Dr. Lisa,
First off, I just want to say thanks for coming back and saying all of that.
I wanted to highlight one thing you said....

I spend a good bit of time in Health dealing with "newbies" who have just arrived. That doesn't make me special or anything, it's just where I feel that I fit in best and can help with the more common "newbie" issues.

One thing I try to pay attention to is when people mention what they are "seeing" with kitty. I posted something along those lines today, trying to remind folks that their eyes can be just as valuable tool in this "dance" as the meters and the spreadsheets. And that sometimes, especially in the beginning, we get so focused on the data and the process that we miss the "experience" of dealing with FD. In Lori's case, she said it, I missed it, but I wanted to say "thank you" for refreshing our memories. Of course, Carl the novelist takes 10 minutes to say what took you 10 seconds! But thanks for that.

And thanks also for mentioning "glucose toxicity". It gives me and everyone else something to read up on and learn about.

Carl

 

Many of my posts are very short..and may sound curt...because I am either on that darn iPad (a true pain in the butt to type on...especially on a message board where scrolling is hard...) or I just have so little time.

You shine well with the newbie hand-holding as do Sue and Rob and many others here. Ya'll are saints in my book. So much time spent helping others. Maybe one day we will all be rewarded for typing our fingers to bloody stubs for no pay?

I have noted that in many of your posts.

We are ALL guilty of that. We only have so much time in our day....

This is the beauty of peer review. You guys are my peers and are just as apt to catch something that I missed as the other way around.

This is the crux of diabetes. The longer a body is asked to drown in sugar, the more damage is done to the body...every part of the body...including the nerves for neuropathy.

This is why I don't jump on drowning the body in the high doses of B-12 that I often see used since there really is no proof that I know of that says it helps that much...if at all. The key is to rescue the nerves from glucose toxicity asap.

 

Hey y'all....
I was just rereading this, mostly the part about "warranted" rebound....

But what if the AMPS on 11/23, which sticks out like a really sore thumb on the SS....what if it was just one wonky meter reading. What if it wasn't a 455, but maybe a pink gone bad? It would make the cycle and a lot more of the SS make sense.
What if it was just a mid 300 with a better than normal response to that 2u dose? If that were the case, we would be calling 11/23 a great day. What if it wasn't a big ole bounce over the previously days blues....those blues weren't THAT low....
Just thinkin out loud.
Carl

 

Especially when you read Lori's comments about how Copper appeared to be feeling that morning, and that the 400+ surprised her....
just sayin

 

and this is a good read on glucose toxicity...

http://petdiabetes.wikia.com/wiki/Glucose_toxicity

 

This is an example of why I loathe labeling a cat X based on ONE lab value. ie....I get hundreds of people writing to me every year in a panic because their cat has been Dx'd with CKD based on only ONE blood panel. Makes me crazy....

Look for repeatability before panicking or making any important decision.

 

I'm bumping this....it makes it easier to find for "copy---->paste" use.

Carl