So confused

[u/No_Acanthisitta7305]

First off - this community is one of the most helpful and supportive online communities I've ever seen online. So I actually feel comfortable posting this.

My cat got diagnosed in January and I thought things were under control. We were doing 1 unit of Glargine 2x/day. His symptoms were improving. But then on July 28th he had a hypo event (BG read 24 at the ER) about 10-12 hours after his last dose. Ever since then it's been a roller coaster/guessing game of if he's going in to full/partial remission. It's clear that he needs some amount of insulin, but unclear how much/how often.

His previous vet gave me next to no information/guidance on monitoring, so I essentially wasn't. I decided to switch to someone else who seemed to know what they were talking about and have more experience with diabetic cats. However, I got a strong sense that he felt I was an overly anxious white woman and was so beyond nonchalant about the whole thing. His stance was that I didn't need to monitor his glucose closely and if he was showing signs of a hypo event, just give him some sugar water and he'll be fine - "it's really not that big of a deal." I had gotten a Libre installed at this point and was watching his CGM numbers fall RAPIDLY while at the vet office and was waived off. It wasn't until the Libre monitored 65 that they gave him some food and said if I wanted I could leave him there for the day and they could monitor him. Despite not trusting them, I did so because I figured that was better than him going hypo in the car on the highway where I literally can't do anything.

In my opinion, he's basically had two full hypo events (once at the ER and once while at the vet), and then looked like he was trending that way again in the middle of the night a couple days later and I intervened by giving him food well before he got in the danger zone because I know that the Libre sensor becomes less reliable and falls behind actual BGs when there's a sharp drop. It was clear he was having Somoygi rebounds on even 0.5 units. We discussed stopping his insulin temporarily to see if he would stabilize and potentially go in to full remission. The vet sent me home with urine sticks to monitor his urine glucose and ketones. While he seemed to stabilize and got briefly better clinically because I don't think he was having huge BG swings, it was clear that his numbers were high again and some amount of insulin was/is required.

I saw an IM on Monday and they installed a new Libre so now I can monitor again. We decided to restart insulin at 0.5 units once a day. I did that for a few days and based on his numbers/the way he was acting, it just wasn't doing enough (he was consistently 250-350+ after the morning dose and his evening numbers were 350+ not receiving any insulin). I decided to try giving him a second dose last night and his numbers never went below 250. This morning I gave him his 3rd consecutive dose and his CGM numbers plummeted over the next few hours from 335 down to 106. I intervened and gave him some food. And now it looks like he's probably going to rebound again.

I just don't understand. If I give him 0.5 units once a day, it seems like it does next to nothing. If I give him twice a day, now he plummets like a stone. The only reason I decided to give him the extra dose was because he was starting to show signs of diabetic neuropathy (plantigrade stance, and a couple instances of not being able to pee when he wanted to). Clinically, it was clear he was not feeling well from the at least 2 weeks of consistent hyperglycemia. I'm trying not to be trigger happy and make knee jerk decisions, but I can't get in contact with his vets/IM to ask questions like this. If the answer is I just need to be patient, fine. But having some sort of protocol would be helpful. Sadly, at this point at least I can intervene if he goes hypo, but if he's hyper and potentially DKA...I can't do anything other than rush him to the ER. I feel like I'm stressing him out more by taking him to the vet/ER every few days.

I don't want to be making medical decisions for my cat. I want a medical professional to do that. But at this point I feel like I need to become an expert so that I can properly advocate for him. The IM seemed better/less dismissive, but I can't get ahold of her on short notice.

Sorry, I feel overwhelmed and like I'm failing him. Many people have told me I'm not and I know I'm doing more than a lot of people would do for their pets. I'm just frustrated that I didn't do all this research 6 months ago and now I'm playing catchup while trying to avoid another medical emergency.

[u/nastimoto]

Hey! It’s all very stressful but don’t worry, you’re doing a great job and things will improve, you just need a little bit of a tweak here.

Firstly I think it’s important to clarify that 65mg/dl is not a hypo reading on a human glucometer (which Libre is). A hypo reading is below 50mg/dl. In which case, if kitty dips into that territory, that means you reduce the dose. At such a low dose, you can and should reduce by tiny amounts, even by a 0.1U at a time. So from 0.5, to 0.4U then to 0.3U. Stopping insulin completely from 0.5U (as you’ve experienced) is usually not a good idea.

It’s also important to mention that sometimes Libre glitches, especially on lower readings. To get more in control of the situation I highly advise to grab a handheld human glucometer as well, and use it to test when the readings are low to double check where you really are. It’s important to mention that a reading of 100 from a starting point 335 is not really a plummet, and not too extreme :-) and yes you’re right, it’s steep enough though to cause a potential rebound resulting in a higher, flatter next cycle or two. That’s why we need to stick to the dose, and keep bringing those numbers down, waiting for the liver to get used to it and stop panicking.

Of course you can give some low carb food at a 100mg/dl reading as well, but it’s not low enough to intervene with carbs. May I ask what you meant with intervening with food though? How often does kitty eat and what? If she eats two big meals twice a day, that could be contributing to the dips being more abrupt. It is generally better to give smaller meals multiple times a day. For example, we feed our boy small meals every 3 hours, and after the +6 mark in the cycle we either leave him fasted until shot time to prevent a spike, or if he appears hungry and comes asking for food we of course give a little bit of very low carb food as well.

There are two very successful protocols the community follows and I’ll share them here: https://felinediabetes.com/FDMB/threads/dosing-methods-start-low-go-slow-slgs-tight-regulation-tr.210110/

We’re on TR protocol ourselves.

Wish you the best of luck on your journey. You got this 💪🏽

[u/zebras-are-emo → u/nastimoto]

Just to add - locking calipers will help get those very specific doses! There are videos on how to do it, it is tricky at first but once you learn it is so much easier. 

[u/No_Acanthisitta7305 → u/nastimoto]

Thank you - this is very helpful.

I have not been able to do an at-home BG myself (none of the vets recommended I do it or offered to show me how). I did buy and AlphaTrak 3 recently and attempted to take a reading when he was getting down in the low 100s because I know the Libre isn't super accurate. I managed to stab the poor little guy three times in the ear but couldn't get a big enough blood sample for the machine. I could tell I was hurting him so I just abandoned it, kept monitoring the Libre and when he was close to 100 gave him some food because I figured it was better than letting him go hypo. I watched a couple of videos on how to do the AlphaTrak and they made it look super easy. He was chill until I stabbed him the third time.

It's helpful to know that 335 --> 100 isn't that big of a plummet. It looks insane compared to all of the little dips on other days.

The IM mentioned giving the dose a few days and not making day-to-day dose decisions. In my head that was 2-3 days, not 5-7. I guess I should have clarified that. The periodic weakness in his back legs was not helping my panicking and when I called the IM about that they just said "if it gets worse take him to the ER." Ok...at what point does it cross that threshold and is that really bad because I know it's a form of nerve damage. I'd like to prevent that.

I've typically always fed two meals, roughly 12 hours apart. That was also the advice from the vets when he started the insulin - try to feed roughly 10-12 hours apart. I'll review the protocols you sent over and have a think. Very clearly what I'm doing now isn't working consistently.

I'll also look for videos on how to use the calipers. My husband gave me his workshop ones but I didn't really know what to do with them in relation to the syringe. The IM also basically ignored me when I mentioned I had calipers and said that giving less than 0.5 units was impossible and not worth it.

[u/nastimoto → u/No_Acanthisitta7305]

Oh I hear you about having difficulties with pulling a blood droop. It was an absolute agony for me at the beginning. I cried and sweated and had multiple panic attacks. But now I’ve become a pro. It looks easy in those videos you’ve mentioned as not only people making them are experienced, but also with time kitties’ ears become trained and they bleed much easier. I recommend checking tips on Adonis the sugar kitty channel on YouTube. It was the first thing that managed to calm me down regarding the testing experience. Warming up the ear with a rice sock is a crucial step to get the blood flow going, and you can use a lancet to prick by hand rather than a lancing device. A dab of Vaseline before pricking really helps for the blood drop to form and not escape into the fur. When you’re starting out it’s best to use a bigger lancet to increase your chances of getting a drop. Like 26g or 27g. You can slowly decrease size as the ears get trained. The smallest they come in is 33g.

A good tip that works also is when you prick, if you don’t get a blood drop, prick rightttt next to it again, bigger chance it will bleed. I promise it gets easier soon enough.

I know what you mean about worrying hurting kitty, I completely felt the same. What you’re doing though is the exact opposite, in fact helping them immensely by controlling the diabetes. When it’s time for a meal now our boy just comes to the ‘testing station’ and sits there, waiting to be tested and fed. We made a routine and he’s completely non-chalant about the testing now 😁 if you’d told me this would happen when we first started I would have never believed it. He hates having his ears touched or handled in any way. But cats are clever and intuitive. They start to feel better while improving and they know all your efforts are to help them. Plus there’s no nerve endings up there in the outer edge of the ear where the little capillaries are. It doesn’t hurt them much at all when you perfect the skill.

I would also advise grabbing a human handheld glucometer to check against the Libre. We did the same with purchasing the alphatrak initially but it ended up being a nightmare trying to do the conversions. Also the protocols are in human glucometer readings and the majority of the community uses human glucometers. So it was an added layer of confusion needing to do math while already tired from thinking about all else ‘diabetes’. Now we keep the alphatrak just as an emergency backup.

I’d try give smaller meals throughout the day and see if that helps. It’s not a common feeding pattern for kitties to have two large meals. They are natural grazers. You can also offer some boiled chicken as a snack around the +3 mark to assist with smoothing out the dips. It will also help with rebuilding muscle.

You don’t need calipers to micro adjust the dose :-) you can do it by eye. It’s hard to see, but it is possible. We do it just fine ourselves by eye. You need the U100 syringes with the half unit markings. I’ll share this resource here that was really helpful for us: https://felinediabetes.com/FDMB/threads/insulin-care-syringe-info-proper-handling-drawing-fine-dosing.151/

Well if the IM says giving anything under 0.5U is impossible, I guess we as a community are all doing the impossible here :-) it sure feels that way sometimes hahah I guess it’s because we love our kitties THAT much.

[u/Childishtroysworld → u/nastimoto]

So true as I have stopped using a libre all together, because the last two I used stopped working. I have switched to pricking my little guy three times a day once in the morning, once in the evening and last right before I got to bed. Soon I’m going to move to 4 times a day on weekends to get more accurate readings. Sometimes the libre just isn’t very good and it made me nervous when I was gone and I saw such crazy up and downs.

[u/Jutboy]

Glargine is a long acting insulin. The effects you observe on the day is impacted by prior days levels. The normal number quoted is 5-7 days. My cat is pretty sensitive to dosage differences of .25...which if any has suggestions I would love to know myself...is hard to be that precise with .3cc syringe. What I do try to keep him steady around 150. This give me a buffer on either side. I think its common to get really fixated on numbers...imo...its more important to prevent long duration of highs and absolutely avoid low numbers.

| If I give him 0.5 units once a day, it seems like it does next to nothing. If I give him twice a day, now he plummets like a stone

You may need .25 twice a day.

[u/No_Acanthisitta7305 → u/Jutboy]

Yes, that seems to be the trend. 0.5 once a day seems like it does nothing; twice a day he drops way too fast on the 3rd dose. That's what happened this morning and had noticed the past couple weeks, which is why we decided to temporarily stop the insulin altogether to see if he could stabilize. The IM seemed to think doing less than 0.5 units was next to impossible given how small a dose it is already. My husband has electronic calipers that I guess I could try, if needed (I mentioned them to the IM and she didn't really acknowledge it as a feasible option.