Very late nadir

Status
Not open for further replies.
Charliemeow

Charliemeow

Very Active Member
I did a curve yesterday and found charlie's nadir was at his pmps. Does this mean something?

Amps:427, 4u
+2: 382
+4: 355 (food at +5)
+6: 325
+8: 345 (food at +9)
skipped +10 since he had risen between the +6 and +8 tests.
pmps: 298, 4u

Any thoughts? Ever seen this before? Thanks!! I also x-posted in health.
 
With PZI it can be a sign the dose is too high. What you want is a nice U-curve. An inverse curve or a slope down from one PS to the next can be from a dose too high. When I have seen that with Bix, often a dose lowering of 0.1 or 0.2 is the ticket to good #s. There can be other explanations though as well, and it looks like you have tried doses slightly lower already, and didn't get great results. Wish I had some better insight for you but I don't.

At the risk of getting slapped, and with the caveat that I have not been following along and I am sure others have been working hard to help you (I know, I deserve a double slap for the drive-by recommendations), if I were in your shoes I would be evaluating whether it might be time to try a different insulin. It looks to me like you have given a pretty good trial with doses lower than this and doses higher than this, and have not gotten good results. It also looks to me like you have had some mega-zoom when you have hit good numbers. You can overcome things like that with PZI if you can shoot early, like every 8 or 10 hours, but for most people that is next to impossible to manage. Happy to be corrected if I am off target, I don't mean to throw a wrench in things if you are on a good path at the moment.

I noticed you commented something about his pee smelling vinegary at times. Have you had it checked for urine pH? It sounds like it could be too acidic, which is uncommon, but can be a sign of some issues that should be treated. Might be nothing (sometimes their pee just smells funny), but if you haven't, I'd have the vet check the pH (or you can get reagent paper and test yourself if you want, though the paper can be hard to find - I can send you a link if you are interested).
 
Thanks Joanna! Gator also mentioned that the dose may be too high if the low point is the ps. I just feel a bit helpless cuz I've tried every dose twice now. I don't know if variable dosing would help, but I really don't know how to set up a good guideline for that. Gator mentioned that with variable dosing, you shouldn't go up or down more than .2u from one cycle to the next. Beyond that, though, I'm at a loss. I have certainly considered a switch to levemir. I just bought a new bottle of pz yesterday and dropped off charlie's ss with the vet. When she calls me to go over it, I'm going to mention that to her. But I have a feeling that I'll need to find a new vet in that case.

About the vinegary pee. I have done searches on the topic as it relates to fd, and found that it's actually a pretty common side effect of the diabetes. Now I know you can't trust everything you read on the Internet... But the good news is that his pee hadn't smelled that way in quite a while now. I'm totally open to hearing any more ideas you have. It's been really quiet around here lately, especially since Lori stepped back since she was my primary helper. So thanks so much for responding!
 
You may well need to consider a change in insulin because not all insulins are suiting to every cat. I know that of my two, Shadoe does much better on Levemir than Lantus, noticeably better, and Oliver does OK on both, but seems more relaxed on Levemir.

If you have been struggling with the dosing and the insulin, it may be worth a try to switch to Lev. I am sorry to hear that you may have to get a new vet but it's better to have a vet who will work with you and be flexible and willing to learn.
My vet office knows nothing of Lev or Lantus but was just fine with going along with my choice to switch.
 
I will crosspost my response in PZI as well. I don't see a sputtering pancreas. I do see a couple startling signs:

Odd drops and resistance building.

What I see is possible IAA. Here's a SS for you to look at and see if you see familiarity. This cat is on Lantus so keep in mind the action of the insulin is going to be different from PZI, but you can see in the early days where there was not enough insulin, and as the dose started to get higher, the odd drops started. http://spreadsheets.google.com/pub?key= ... utput=html

The reason I say possible IAA and am not (at this time) focusing solely on acro is the odd drops. IAA is known for that. You get the insulin to the point that it finally overwhelms the resistance, and either reduce or hold, and the IAA picks up strength again. If this turns out to be IAA, you will need to be very aggressive. The good news is, if it's IAA, it's a temporary condition, as long as you are consistently aggressive. If it's acro, you will need to be "cautiously aggressive" which means give lots of insulin to overwhelm THAT resistance, but also avoid green cycles. Read the sticky that Patti posted about high dose conditions to familiarize yourself with the difference between the two. Not all acro's are very high dose, so it's possible, but I feel if Charlie was an acro... or I should say.. to feel more inclined to push that acro test.. we wouldn't have seen that drop on the 9th. I do think you need those tests, but I am also keenly aware this is a terrible time of year to be budgeting, and that finances may not be available for it. I do also think you need a change in insulin. No one need suggest I am attacking PZI users because I am a former PZI user myself. I just think PZI is doing no good for Charlie or you right now.
 
I think the IAA test is inexpensive ($10 range?) but I could be wrong on that. I know there is detailed info on it around here somewhere - I will see if I can dig it up. If you can afford that, I think it would be well worth the cost. I don't know anything about insulin resistence, but certainly was puzzled by the oddball drops, so if experienced eyes see signs of that, to me it would be a no-brainer to get the test done and know for sure.
 
Here is the IAA info from the sticky (What We Know viewtopic.php?f=12&t=375) in the high dose forum. The links didn't cut & paste well, so use the link above to get to the actual post & scroll down a bit, and then the links should work from there. Looks like the test itself is $15, but will cost more I'm sure at the vets as it looks to have special shipping requirements.

Cats with Insulin Auto Antibodies (IAA)

http://petdiabetes.wikia.com/wiki/Insulin_antibodies
When insulin is injected into a diabetic cat, the body views it as a foreign substance and the immune system sets out to destroy the "invader" insulin, just as it would destroy cold and flu viruses. When this happens to injected insulin - most of it never reaches the bloodstream thus being unable to control blood glucose. Insulin doses may be increased but the immune system only goes into higher gear and continues to effectively destroy any additional injected insulin. Over time this becomes officially known as insulin resistance.

Sharyn and Fiona states: One article on humans suggests that changing insulin doesn't work. IAA is supposed to be self-limiting, meaning it goes away at some point. (See article link below) “We have a couple of anecdotal reports of kitties who, by continuing to raise the insulin doses, were able to overwhelm the antibodies, eventually lower the insulin doses and gain control of the BG’s.”

Currently 10/09 Sandy and Black Kitty seem to have done just that. At one point Black Kitty was needing 27 units of Lantus insulin/day. He is now OTJ. GREAT JOB BK!!!!

Link to have blood sent for IAA testing:
http://www.animalhealth.msu.edu/Bin/Cat ... st&Id=1494
A result > 20% is considered positive for IAA.


Further Information:

*Extreme insulin resistance (IAA)
http://www.faqs.org/faqs/diabetes/faq/p ... on-24.html

*Beta cell and insulin antibodies in treated and untreated diabetic cats
http://www.sciencedirect.com/science?_o ... ced2157334
 
The IAA test *is* inexpensive, but you still have to pay for the draw itself and the overnight shipping.. just keep that in the back of your mind when budgeting. :)
 
I have some mixed thoughts about a potential change to Lev which I'll try to address more completely maybe later. I'm not really for it or against it at this stage. But for right now I'd just like to point out that from a budget standpoint it is likely Lev would save you money which you could put towards some testing perhaps.

How much are 1500u of Lev [5 300u pens - it comes that way right]?

At 4u twice per day Charlie is about a 3000u per year cat. So that's about 2 sets of 5 per year?

3200u [8 bottles] of ProZinc [if you got it at a good price] is like $640.

You could take the the savings ad put that towards some testing.

Now other the other hand you might be able to stick with ProZinc or other PZI and reduce the amount he needs over time - if you got lucky. So the cost disparity would not be as great.

And there are other cheaper ways to do PZI too [like BCP] which would be another way to perhaps re-allocate funds.
 
If the insulin is not working and if the tests when done show there is insulin resistance, then a switch to Lantus or Levemir is likely what will be needed.

My Oliver tested positive for acro and IAA. If you look at his ss, you will see how much trouble we had in the beginning, and then how aggressive we were with dosing until we reached a point where the IAA was likely squashed. Now his doses are different and there is almost nil need for R, so we likely broke down the IAA. If he were not also acro, I suspect he would be OTJ now.

I don't see the point in staying with an insulin that is not working, and likely would not work easily if tests were to be positive.

I had issues getting my vet office to send out the blood draw for the 2 tests; I had to print out the sheets for the tests from MSU site, take them to the vet and say call to get info. While the tests themselves are quite cheap, the cost will end up being what your vet charges for the draw and packing, and the FEDEX charges to deliver to the MSU lab. You can always ask your vet for an estimate what the total cost will be. For sure get both tests done because they are totalling around $50 for the acro and IAA.

It will all depend on the vet though I would still lean towards insulin change.
 
Gator & H (GA) said:
I have some mixed thoughts about a potential change to Lev which I'll try to address more completely maybe later. I'm not really for it or against it at this stage. But for right now I'd just like to point out that from a budget standpoint it is likely Lev would save you money which you could put towards some testing perhaps.

How much are 1500u of Lev [5 300u pens - it comes that way right]?

At 4u twice per day Charlie is about a 3000u per year cat. So that's about 2 sets of 5 per year?

3200u [8 bottles] of ProZinc [if you got it at a good price] is like $640.

You could take the the savings ad put that towards some testing.

Now other the other hand you might be able to stick with ProZinc or other PZI and reduce the amount he needs over time - if you got lucky. So the cost disparity would not be as great.

And there are other cheaper ways to do PZI too [like BCP] which would be another way to perhaps re-allocate funds.
Click to expand...

Comparing doses between insulins is not going to be productive at this point. The reason they are not comparable is because the doses are not going to remain the same. They will go up or down depending on the cat's response to insulin and depending on the reason for the resistance, and if it, or when it, is overcome.. Re: your cost question, I buy vials for $86 at RiteAid locally and 5 packs of Levemir pens (1500u total) are $125 shipped from Canada. I use vials because Leo's doses are so high, but if they were lower, I would use the pens from Canada. That works out to $.086/u for the lev vials, $0.083/u per lev pen pack. If it costs a pzi user $640 for 3200u of insulin, your cost is $0.20 per unit?

The reason we are recommending Levemir or Lantus is because none of the PZI's, (BCP, VET or even a locally compounded version, nor Prozinc) offers the duration necessary to overcome insulin resistance, without resorting to TID dosing. THAT will jam the costs up, as well as the effort and time spent.
 
Carolyn and Spot said:
The reason we are recommending Levemir or Lantus is because none of the PZI's, (BCP, VET or even a locally compounded version, nor Prozinc) offers the duration necessary to overcome insulin resistance, without resorting to TID dosing.
Click to expand...
I was not suggesting any reasons for why you are doing what you are doing. What I AM suggesting are ways that Claudia might be able to work a budget towards getting the testing done which I think you would agree would be useful. Clearly the dose will change. I was making some very broad cost comparisons as a means to further the potential budgeting/testing idea. At my first/rough glance at Charlie's numbers, I don't think Charlie has shown that he needs TID either at this point but I would have to look closer.

Anyway, I not in the mood to have any arguments on the merits of changing insulin. That was not what Claudia even posted about. Everyone knows that there are other insulins out there. That's no well kept secret. And there are whole groups on this board that will be happy to talk about the benefits of those insulins. What is not well understood is that it is frequently advised to stick with other insulins longer than a few months even in the face of a lot of difficulty. So look guys I think your point was well made that you think she should change insulins. I think you guys have already advocated for that before? Point taken.

Perhaps Carolyn you might address how you were able to achieve success with PZI and how you might apply that to Charlie's current sitch?
 
Gator & H (GA) said:
Carolyn and Spot said:
The reason we are recommending Levemir or Lantus is because none of the PZI's, (BCP, VET or even a locally compounded version, nor Prozinc) offers the duration necessary to overcome insulin resistance, without resorting to TID dosing.
Click to expand...
I was not suggesting any reasons for why you are doing what you are doing. What I AM suggesting are ways that Claudia might be able to work a budget towards getting the testing done which I think you would agree would be useful. Clearly the dose will change. I was making some very broad cost comparisons as a means to further the potential budgeting/testing idea. At my first/rough glance at Charlie's numbers, I don't think Charlie has shown that he needs TID either at this point but I would have to look closer.

Anyway, I not in the mood to have any arguments on the merits of changing insulin. That was not what Claudia even posted about. Everyone knows that there are other insulins out there. That's no well kept secret. And there are whole groups on this board that will be happy to talk about the benefits of those insulins. What is not well understood is that it is frequently advised to stick with other insulins longer than a few months even in the face of a lot of difficulty. So look guys I think your point was well made that you think she should change insulins. I think you guys have already advocated for that before? Point taken.

Perhaps Carolyn you might address how you were able to achieve success with PZI and how you might apply that to Charlie's current sitch?
Click to expand...

Sure thing Justin. I do not know why you consider this an argument and do not understand your complete lack of respect for those who came before you. I have used pzi in 2 cats. The third cat, Roxanne was otj in 4 doses of pzi. Spot went on and off the juice many times as a steroid induced diabetic with pancreatitis. Pzi worked fine. Oscar was not so lucky. We did TID, QID, YDC and BID. He was resistant. I changed him to lantus after trying everything I could. We had instant success, he was happier and his insulin needs were reduced dramatically. Tragically he could not overcome the heart disease I never knew he had and I lost him. I knew I would never put leo on pzi because I knew he was a high dose cat when I got him.

High dose and resistant cats need duration. Time is not on your side. You must get in there and get ahead of it before it gets so far ahead that it takes months to catch up or makes the cat sick.

As I said before, you certainly have no cause to disrespect my years of experience with multiple cats, and I am quite certain that during your research you came across my posts about 8000 times. That is because I used to live on the pzi board too. I know more about pzi than you want to think I know and I have far more experience with high dose and resistant cats as well. I see your defensiveness about the L insulins, and I know it's sad to lose posters, but you have to always keep in the very front of your mind that it is always about the cat. If an insulin is not working, you do a disservice to the owner and to the cat to prolong the recommendations to stick with what is not working. Bcp is not going to help here, VET is not going to help here and prozinc is not going to help here. None of them are long term insulins and that is what is needed, so I can not recommend their use. I can help her use them, but I would be remiss if I did not point out there was something better to use.

Edited: typo
 
Anyone who spends any time in here knows that I really don't care to 'lose' users to other insulins and that I actively recommend other insulins. This is where you've shot yourself in the foot. The only disrespect is that shown to yourself.
 
Gator & H (GA) said:
Anyone who spends any time in here knows that I really don't care to 'lose' users to other insulins and that I actively recommend other insulins. This is where you've shot yourself in the foot. The only disrespect is that shown to yourself.
Click to expand...

I find it interesting that you are lamenting an argument on this thread, where there is none, save that caused by you. I also find it interesting that you have so far failed to directly answer a single one of my posts in a manner that is not dismissive and insulting. I do find it amusing, but it serves no purpose and is off topic.

What Claudia asked was "Any thoughts?". I posted my thoughts. To her. About her cat. You are turning this simple and innocent question into a barroom brawl. I do have experience here. You may question that all you like, but the bottom line is that I, and the other high dose moms, can help her. Do you wish to prevent that?
 
I have considered changing insulins. I obviously will have to if the cost of pz gets to be more than an l insulin. Or if he ends up acro or resistant. We'll get those tests done here soon. But for now, I just bought a new bottle of pz, so at the very least I'll use that up. His numbers have been blah. They could be, and have been, worse...but they could be so much better. I appreciate everybody's input. Thank you all.
 
Actually I'm currently using my freestyle lite back-up meter cuz I ran out of relion strips a while ago. I did see about that recall, though. Thanks!
 
Status
Not open for further replies.
Back
Top