Vet wants to increase dose from 2U to 3U

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Cindy & Pets

Cindy & Pets

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Yikes, at least everything else checked out fine. Found out that my Relion Ultima has been consistently reading about 50-60 points lower compared to the vets alpha trak. So at least that gives me some sort of conversion. But I'm very concerned about how to handle the 1U jump, we've been steadily increasing by .5U, so I'm not understanding her reasoning here. But this was after showing her a curve I did, and showing all this data, of which now she encourages home testing. Also that if this insulin isn't working, we'd switch to another. Just concerned about the price and what-not.

However, on to my question. The receptionist said I should just increase directly from 2U-3U, and not do a slow step up. What would you guys say? I was thinking, since I really don't want to stay up late at all, should I just ignore that and do 2.5U tonight and 3U tomorrow morning, do a curve, and then do another later in the week? I mean, her numbers are at least indicating an increase is in order, but....
 
Personally I don't think you are going to see any better numbers while on N, it just isn't a great insulin for a cat. Yes, Lantus, Levemir and ProZinc are more expensive upfront, but they all last a long time if properly handled and will give you a much better chance of getting her numbers down and keeping them down. Humulin N is just too quick in and out to do much good over the long haul...Just my 2 cents worth.

Mel, Maxwell, Musette, Autumn & The Fur Gang
 
Yeah, I was happy when she mentioned that we might in the end go to that, because if it means better numbers I'm happier with paying more than giving her more and more of the humulin N in hopes to controlling it that way. But she wanted some time to look at the curve and decided that. I'm going to be bringing it up again on next friday and voice my concerns about humulin N a bit more clearly. Until then though, I'm not sure how to handle her dosing suggestion.
 
One of the problems with N is the potential for a fast hard drop after the dose is given. An big increase could mean a drastic dive after the dose.. I think you are wise to question that much of an increase. And I think there is no need to dose that way. Until you can get another insulin, I would be cautious with the increases and monitor carefully.

One of our obnoxious sayings here is "you can't get the insulin out of the cat once it's given". Better higher numbers for a few days with cautious increases than a hypo.
 
Right, and I definitely don't want to have another scare with her going too low(the time she went down to 59). Especially since I may or may not be awake when she does. I'm also concerned since isn't 3U kind of high for a cat of any kind of insulin? I'm also more than happy to change since she's getting close to emptying her vial of humulin N, so it wouldn't be like I'd be wasting too much and it'd be better for her considering how much she seems to drop.
 
It's an "every cat is different". There are cats on 3 units, but most cats here are closer to one unit, plus or minus. It can be a process to get them there, with increases and decreases based on testing at home.

You can give a lower dose and then just tell your vet you were afraid of giving a higher dose. That's honest.
 
Alright, that sounds fair. I'll go up to the 3U, just not tonight as if she's to go hypo at all, I want to be in good mental condition(read: mentally and physically awake), but I'll at least want to know what she does on 2.5 tonight. Just mention when Tip is in next(only going once a week to the vet because of the last scare Tip had), maybe change insulins that day, if not, soon) that I took steps just to err on the side of caution. Got a plan. Thanks everyone. :)
 
My concern with the increase using Humulin is that I don't think it's going to show the vet numbers that she likes, and she'll keep telling you that you need to increase.
What is likely to happen is what Sue said. I think you will get fast and big drops. But the quick deep drops will cause "bounces" for the next test/shot, and the cycle just keeps repeating. The quick rise after the drop is just his body trying to save itself from a radically lower BG level. It's instinctive self-preservation. Her pancreas and liver react to the lower numbers, "glucose" gets dumped into the blood by her organs to correct the "low". You shoot more, it happens again and again. The real danger is that at some point, her body won't be able to self-correct, or it will just stop trying, in which case her BG plummets and there's nothing stopping it from going too low.
Telling you to increase your dose by 50% all at once is just not a good idea, no matter what insulin you are using. None of the protocols calls for radical increases or decreases in dose. We normally err on the side of caution and advise a .25u max increase per shot. Some will go as high as .5u per shot if the dose is already somewhat high. When I look at dose adjustments, I try to think "percentage of change" rather than # of units. And I would never tell someone to increase their dose by 50% all at once when the dose is higher than 1u already. There's just no way to predict what that much of an increase will do, and once the shot is in, you can't get it back out. All you can do is monitor closely and be prepared to deal with any emergency that happens.

Please share the AAHA guidelines for insulin for cats with your vet.
Insulin therapy in the cat
The insulin preparations with the appropriate duration of action in most diabetic cats are glargine (U-100) or the veterinary-approved human protamine zinc insulin (PZI U-40). This panel does not recommend the veterinary-approved porcine zinc (lente) insulin suspension as the initial treatment for the cat, because its duration of action is short and control of clinical signs is poor. This insulin should be reserved for cats in which other insulin choices have not yielded satisfactory results.
Click to expand...
https://www.aahanet.org/PublicDocuments/AAHADiabetesGuidelines.pdf
That's the American Animal Hospital Association's words, not "ours". The "veterinary-approved porcine zinc (lente) insulin suspension" that they don't recommend for cats?
Brand Names and Other Names

This drug is registered for use in humans and dogs only.
Human formulations: Humulin® R (Lilly), Humulin® N (Lilly), Humulin® U Ultralente (Lilly), Novalin® N (Novo-Nordisk), Iletin® II NPH (Lilly), Regular Insulin (Novo-Nordisk), and various generic preparations. Please note that Humulin® L and U are going off the market fall 2005.
Veterinary formulations: Vetsulin™ (Intervet) (porcine insulin zinc suspension)
Click to expand...
http://www.petplace.com/drug-library/insulin-humulin-iletin-vetsulin/page1.aspx
You'll see the name "Humulin" there...

Carl
 
Wouldn't the curves help a little with convincing the vet away from just upping the dose? As she was actually extremely excited to see I had done a curve and actually told me to do another between now and next week, though I'm likely to do 2 of them, as it's the summer, so I have plenty of time and feel I need more numbers.

I agree though, increasing a whole unit just seemed absurd, because even the vet tech, when Tip was first diagnosed, said that small increases should be done, not large ones, and....well, I guess the receptionist(not the vet tech) decided differently? I'm not sure. I'm definitely not giving her the full dose tonight, at most 2.5U, but would you suggest I stay there tomorrow and see what her numbers do with a curve there and then increase based on that, or?

Forgot to mention, now that my vet and I are on the same page with testing, I am going to ask for a different insulin next time I go in, I've already decided on that. I figure 1 step at a time is the easiest. I've got the info bookmarked and whatnot, if need be, I'll print it, but she seems already open to changing it, especially how shocked she was to see Tips nadir seemed so early(from what I've learned here, humulin N does that) to her.
 
Couple of thoughts.
I would not increase from 2.5 at all without running a curve to see if an increase makes any sense. Also, I would not increase or decrease based on the results of just one curve (except in a case where the numbers go dangerously low, and then an immediate decrease is logical). One curve is not conclusive evidence of what a dose will do. Way too many "other things" influence a cat's BG on a daily basis. The only things we have any control over is how much food is in the dish, and how much insulin is in the needle. That gives us "some control" over BG, but by no means total control. I often refer to something that Dr. Lisa has posted here.... "look for repeatability before making any major decision". If something happens once, it's an event. If things repeat, it's a trend, and you make dosing decisions based on trends, not "events". If you up to 2.5, I would keep that dose for at least 3 days before going any higher. If you see the numbers decrease significantly mid-cycle due to the increase, then you decrease the dose immediately for safety's sake. That is the only "event" that I would react to immediately.

Carl
 
I see....hm. Alright. I'll give it a lot of thought from now until it's time for her insulin. Is it okay to base it off of the curve numbers and the pre-shot times, as based on the pre-shot times, the curve makes sense for what's going on, and today, the 1:30pm test at the vet made sense based on the time. I'll still give it all quite a bit of thought.
 
The number at the vet was taken at +6, right? If you look a couple days earlier, you'll see her nadir was prior to that, probably around +4. That's "normal" nadir for Humulin, which might last 8 hours in a cat. So that 306 the vet got, was probably Tip's number past nadir, on the way up rather than at its lowest point.
IMO, Tip had the best numbers on dose closer to 1u, 1.5 the most. I think that most of the numbers you have gotten since going up to 1.5 and higher have been "bouncy" numbers due to her BG going low someplace in the middle of her cycles (as I described above). I realize the vet doesn't agree with that, but that's just my interpretation of the numbers I can see.

Carl
 
Yeah, the number taken at the vets was at +6, that was my meter. For some reason, the comments aren't showing up properly, but the vets alpha trak had 364 as the number, if it matters any. And if it helps, last time she was at the vets, at +6 they were 334 for my meter and 383 for the vets alpha trak. What I'm wondering the most though, is if things got majorly screwed up around 4/19 because I had such bad luck that day. Even managed to accidentally break the plastic portion of a syringe, so I wound up just giving up for the day on her insulin and testing. I know I saw what I think to be good numbers before then? I'm not sure.
 
On 4/21, at 1 unit, you got a 59 twice, at +3. That's a wonderful level .... except, of course, the Humulin N then wears off very quickly in your cat (+_3 for a nadir!) and the glucose pops right back up and more.

What I'm seeing on Tips spreadsheet makes me wonder if you haven't already exceeded his optimal dose and so his liver is compensating every time you give a higher dose, by dumping out glucose. I'd be quite hesitant to raise his dose; I'd be more inclined to redistribute it. Would you be able to do TID dosing? That is every 8 hours, uses more test strips and time, but is about the only way you are going to get better numbers using Humulin N, which only lasts 6-8 hours in a cat. You may want to remind the vet - cat's metabolism is TWICE as fast as a dog!!!
 
Well, during the summer(like now) I'm able to do that, but not during semesters due to work and classes which starts back up in late august.
What I'm wondering about 4/21, could it have been effected by the wonky dosing at the time? Because things aren't adding up between the tests then, and the tests now. Wouldn't I still see some indication at around +3-+4 that she's gone too low? I'm also, probably unfortunately, very concerned about straying too far away from the vets advice. Obviously using common sense and deviating when what the vet says violates that, but this has got me spinning in circles so much.
 
It is hard to get your vet's advice and then advice that differs, especially from people on the internet. :-D I think vets tend to know less about feline diabetes because they have to treat lots of different species with lots of different diseases. It is hard to stay current on everything. And they may only see a few diabetic cats a year - many of whom have owners who put them to sleep or just dose without any testing. It is often surprising for a vet to get a cat parent who wants to take an active role in their kitty's care.

We "see" dozens of new diabetics every week and literally thousands of people who have used our protocol (wet low carb, mild and long lasting insulin and hometesting) have their cats regulated or go into remission. We know it works! That is why we bombard you with advice and are so "pushy"

Do your reading and research. See what your vet says. Go with your gut. But meanwhile, keep your kitty safe. Learn how to test at home (no vet should have an objection to that) so you can monitor the levels and dosages.
 
Heh, yeah, I was extremely surprised to see just how excited my vet was to hear I had did a curve. It's just....wow, and then she asked me to do another? I was happy about that one. I also remember when Tip was first diagnosed how the vet didn't give an option to be put to sleep, just that it's manageable and to come in about 2 days later to learn how to give her insulin. So I imagine that's a plus. Only one danger I see in one ace she gets her insulin, is there's a vet that specializes in dogs(and one that specializes in cats, but she's usually extremely busy, so I don't get her often) and has a lot of diabetic patients and she asks for information from him on it.

Back on topic though, yeah it's really hard, especially when both of them make sense based on what I'm seeing, but both seem to be on opposite ends. I did wind up going with my gut, and the numbers I've been seeing as well as her weight. Based on her weight...her diabetes is out of control, that's what tipped me off that something was wrong before she was diagnosed. Considering she went from 9bs 11oz to 9lbs 7oz in only a week, I figured she did need the increase, I also remember how 'low' her numbers were back when she was on 2.5U before I was able to hometest a lot, if at all. So 3 might be a bit too much, but that the 59 on the 1 was probably an isolated case based on how sporadic the dosing was at the time, as was the Hi as she had gotten in to some chocolate. Still do want to get on a better insulin though, I never did like seeing her drop 100+ points in one go.
 
The thing you have to understand with diabetes is that too high a dose will keep numbers just as high as too low a dose. Looking at Tip's spreadsheet, you were seeing better numbers on lower doses. This is an indication that the dose could already be too high. Adding more insulin to already too high dose is adding fuel to the fire--it's going to make her blood sugar worse, not better. Giving too much insulin is not only dangerous in terms of hypoglycemia, it's counterproductive because the liver is dumping glucose into her blood stream to compensate. Finding the right insulin dose is kind of like playing a game on the Price is Right--in order to win, you have to get as close as possible to the right number without going over.

As others have mentioned, you are not likely to see good results with Humulin-N because it is not a good insulin for cats. This is a good insulin for dogs, but not cats. The sooner you switch insulins, the sooner you'll be able to get Tip's blood glucose under control so that she can start getting better instead of worse. Please print this document out and bring it to your vet: http://www.uq.edu.au/ccah/docs/diabetesinfo/link2.pdf. Note where it says "Lente is the 3rd insulin of choice and NPH the 4th of choice insulin for control of diabetes mellitus in cats, behind glargine or detemir (1st choice) and PZI (2nd choice), Lente and NPH result in lower remission rates compared to longer acting insulins."
 
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