Brutus is Diabetic - Insulin question

[Carol Teitler]

Brutus is a very large, 13 yr. old, male cat who developed diabetes about 1-1/2 years ago. We worked him up to 11 units of insulin (daily injection) before the levels in his urine were neutral...until last week when his urine showed glucose and we upped to 12 units. This is all under the care of a veterinarian. We noticed a change in his drinking habits and had a fructosamine test performed about a month ago which showed the levels to be "high normal." A test performed 6 months prior showed normal levels. It has only been three days since the increase but we retested his urine and it was neutral. However, he still is drinking excessively, which indicates to me that he is probably still at "high normal" levels. My question is, is it safe to keep him at this "high normal" level or should the insulin be gradually increased until the level is lower? I know the dangers of too much insulin but it seems to me that the dangers of these high levels may be just as bad.

[Traci]

You need to be testing the blood glucose, not necessarily the urine glucose!

Get him back in for a BG quick check or a new BG curve. Do NOT give more or less insulin until you've had more than one curve done or a consistent fructosamine level. Also, if he's gaining more weight, he has to utilize that much more insulin, did your vet discuss his diet and exercise with you?

What are you feeding him?

What is the type of insulin you're giving? I assume once a day?

Has your vet ruled out urinary tract infection? (this could be causing higher than normal urine glucose)

Has the vet ruled out secondary renal disease?

If your vet isn't addressing these things, please see a new vet who will be more comitted to more appropriate testing and regulating Brutus' insulin, ASAP.

[Carol Teitler]

Traci, sorry I didn't make myself clear. Brutus was in for a fructosamine test and a complete blood work-up about a month ago. blood work all came back normal. His fructosamine test showed high normal. We did not change his insulin injection (PZI Vet) (1Xday) at that time because his urine was not showing any glucose at all. He is not gaining nor losing weight. I test his urine occasionally, more often when we notice a problem. I tested last Friday and it showed between 25% and 50% on the glucose chart. I spoke with the vet and he said to up the insulin by 1 unit, wait a week, and test again. After we get him neutral, we will do a follow up fructosamine in about 2 months. My question was, is "High Normal" dangerous? Thanks again for your help! Carol

[Traci]

Please don't rely on urine strips to accurately determine glucose levels. It is best to spot-check blood glucose when you suspect a problem. If you're checking glucose in the morning, for example, try checking it in the afternoon during "mid" insulin peak time, the results could actually be more accurate. But, again, this checking SHOULD be done with a blood glucose check, NOT a urine glucose check (unless there is a signifcant level in the urine, in which UTI or other problems need to be addressed and BOTH blood and urine glucose should be checked together).

A high normal on fructosamine is not necessarily a bad thing, particularly if it is consistent. But, the fructosamine should be checked around two weeks after the last increase or decrease of insulin, no longer than that. This is really the only way to determine consistency.

The increased water consumption IS concerning, but is he also urinating large amounts and more often? If so, recheck the blood glucose, immediately. The blood glucose should be checked weekly until the results are within normal range (including each time the insulin is increased), then two weeks after a normal result, recheck the fructosamine.

Again, what are you feeding him?

Are you giving insulin before, during or directly after his meal? Are you feeding him on a schedule or are you free-feeding him? Did your vet discuss the significance in these?

Has he always been on PZI? Has your vet ever considered glargine?

Is your vet addressing the weight issue? When was the last time he gained or lost?

Has Brutus developed any other signs of illness or changes in behavior? Any stress in the environment?

Has his thyroid function been tested? I understand you said he had a full bloodwork panel done, but was thyroid function testing included? (this is a seperate test).

[Carol Teitler]

Traci, again, thanks for all your help! It's wonderful to have someone to count on for great advice! Brutus has always been a very large (size, not weight) cat and has been at the same weight for years. He is on Prescription Diet MD and has been for several years. He never loses any weight but doesn't gain either. We tried RD but he didn't take to it and it didn't do his weight any good either. He gets fed twice daily, 1/2 can and 1/4 cup dry each time. We do give him treats in between, but very few and mostly "LEAN TREATS" bought from the vet. I give him his shot right before he eats his morning meal but he has food available during the night, as well. His appetite has always been very good but the increased water consumption has me concerned. He doesn't finish the dry food but the meat is always gone (which is usual for him). He does urinate large amounts, which isn't really abnormal for him, but an increase since he has been drinking more. He drinks about a total of 1 to 1-1/2 cups of water in a 24-hour period. Other than his constantly meowing at us during the day for a treat, his behavior is normal. We moved into a new house but that was a year ago so, no, there is no stress in the environment. He's an extremely friendly, social cat and loves when people visit. The only stress he has is when we take him to the vet. The vet said his thyroid was normal. I will mention to the vet about the suggested change in insulin. Thanks for everything!!
Carol

[Traci]

Can I just ask if you're confident in your vet when treating feline diabetes?

First, Brutus may not have proper glucose control, and the only way to determine any accuracy is with blood glucose checks (not just fructosamine, but a glucose check in the clinic, it only takes a few minutes, try making an afternoon appointment as opposed to early morning, see if there is a significant difference). Those should be repeated every one to two weeks until the blood glucose is within normal range. If the blood glucose is too high, then perhaps the increase in insulin should only be a 1/2 unit for that week or two weeks, then recheck blood glucose. Current recommendations suggest increasing by 1/2 units rather than a whole unit works for some cats, but it's the blood glucose checks that really determine this approach. After an increase in insulin and if the glucose appears more normal, then two-three weeks after, a fructosamine can be checked for more accuracy and consistency.

I'm not saying he doesn't need an insulin increase, I'm saying blood glucose checks every one to two weeks is a better indicator than urine strips. A half unit increase may also work, but the vet has to use blood glucose checks to determine the efficiacy of a half unit increase.

The increased drinking/urination is concerning and may be indicative of poor glucose control. Has your vet ever considered using glargine instead? Have him check the Sept issue of Veterinary Medicine for current recommendations and more information on glargine. Not saying you should rock the boat by changing insulin, but it's an option. If your vet is thoroughly experienced in treating feline diabetes, it might be worth looking into. If he isn't very experienced though, I'd seek a second opinion and discuss testing more effectively, maybe talk about the glargine.

True, the stress of a vet visit can cause blood glucose to rise, but your vet can figure a percentage of the results and account for stress glucose. An afternoon appointment might be better, just for this reason, and because a reading might be more accurate mid-day as opposed to morning.

Lastly, do be sure your vet is confident that no renal disease or UTI or thyroid condition or any other condition is causing problems with diabetes.

[Carol Teitler]

Traci, I am currently using a new vet. The original diagnosis was made by the vet in another state and Brutus was being treated by him until 1 year ago when we relocated. Both vets seem to be handling this the same way. I will definitely question him on what you suggest. We have no qualms about taking Brutus to a specialist if need be. Thanks again. And, by the way, he seems to be better yesterday and today. Hopefully, we have the situation under control but we'll see how it goes by the end of the week.

[Traci]

I truly think it's best to check blood glucose levels first, weekly or every two weeks after an insulin increase. Then when the blood glucose becomes normal, wait two-three weeks and get a fructosamine level done. If the fructosamine is too high, back to the drawing board with blood glucose checks.

I know it can get costly over the weeks, but the blood glucose checks are relatively cheap (and can be done quickly)...ideally you should only have to monitor the fructosamine every few months or sooner when you suspect problems, but remember the blood glucose checks should be the vital part of the insulin regulation.

Of course, do keep an eagle eye on the drinking/urination, and notify your vet at once if they are increased....there is always the potential of UTI or increased glucose in the urine as a result of a urinary tract infection...you also want to always pay attention to ketones in the urine, etc.

If all goes well, in another 6 months to a year, consider retesting renal values too so that you're always one step ahead. Thyroid function should be tested yearly, or sooner if unusual health or behavior symptoms develop.

Keep us posted, K?

[Carol Teitler]

Absolutely! Hopefully, I'll have some really good news to write about. I was just reading up about home testing for blood glucose levels. Don't think I can handle that by myself. I'm considering calling a "mobile vet" service to take the blood in the house and thereby avoid the trauma of the trip for Brutus. Will let you know how I make out and thanks again!!!
Carol

[Carol Teitler]

Latest update...Brutus had blood glucose check (2 times) and both were high -- first test over 300 and second high 200's. Vet increased insulin again. Had a complete urine analysis done and everything was perfect. Waiting one week to see how he does before I call vet. As of today, 3 days post increase, I really don't see much of a difference in his habits/behavior. Will see what develops.......