sliding scale

for those of you who adjust your dose (almost) daily based on your BG, what is your scale? How long did it take you to figure out what dose to give?

I realize that ECID but I'm curious how much things vary for each of you.

Thanks!
Michele

i used to do sliding scale but to be honest, i got tired of "ok she's at this i'm gonna shoot this amount" and then "maybe i should have shot more" or "maybe i need to re-do her scale" and later "obviously that didn't work" and one day i decided to stick with a set dose and i'll be damned if her numbers didn't get better. and it was so much easier too

mind you, i was doing a 10/14 schedule 5 days a week and TID on the weekends with a sliding scale.

since going to a 10/14 schedule on a set dose 90% of the time (sometimes the little broad throws me a lower than normal number so i reduce dose a little), she has better numbers all the time.

when we did TID or sliding scale, unfortunately she was swinging all over the place. but that's my little broad, whom i think has treated me pretty well thru this disease......so far keeping things mostly uncomplicated

Can we call it VDS?

"Sliding Scale" means different things to different people. And in general it seems to have a pretty bad rap [particularly because of its connection to another kitty DM site]. I think from here on out I'll call our "Sliding Scale," "Variable Dosing Strategy" [VDS] - hope that does not sound too contagious?? To my knowledge I'm the only one here currently in PZI Land who does "SS"/"VDS." I'm not sure why I'm the only one who has found VDS to work OK. Most here do not like it.

I've always been tired of "hey I came home 1.5 hours late, do I account that in my dosing?" I might be a few years short on experience of folks here. But when I'm 1.5 hours late it does not matter that I'm +13.5. I just shoot the amount that I think is best.

Let me say that I think there is not any hard sliding scale, but a "scale" or "variable dosing strategy" that allows one to shoot whatever one likes depending on the sitch.

Every SS/VDS IMHO must be tailored to the cat and should be more of a moving average. Nothing hard.

Like tonight I got home from a dinner party two hours beyond what his normal shot should have been. I have no sweats about it since I shoot what he needs- that I have to be RIGHT on the dose in order for it to end up OK. This DM has made my life crazy enough and SS is just one way I use to make it less crazy [or maybe that's just a convenient thought].
Good news is that the dinner brought him back his total favorite - fois gras!!! He's a fois gras nut!!! So good to see him crazy over food [even if it is just a smear of fois gras since he has pancreatitis]. :smile:

Anyway, small variations have caused us big differences with ProZinc as where with PZI Vet we were able to get away with much larger dose variations. But maybe this is just because of our newness to ProZinc.

Most importantly, if one wants to pursue SS/VDS they need to have the data to back up their dosing decisions. And IMHO [since I have no experience with them] SS should not be tried with other longer lasting insulins like Lantus or Levemir.

And let me say that I've found that with H & ProZinc SS/VDS is a bit harder to balance. Most recently we have not varied much more than ±0.05u with an average of .85u!! [wow - that's a small variation] As time goes on and we get used to shooting more [higher doses than in the past] that variation may increase. In the past we varied ±0.2 to maybe ±0.4u with a max dose of ≈0.8u - so quite a larger variation.

One approach I like to take is, what do I expect the delta [change from PS to nadir] of a certain dose to be at a certain PS? In other words how far do I expect him to drop at a certain dose with a PS of X. Of course this changes with different conditions and it's really not fair to start with this type of strategy until you have the dose pretty much dialed in. Ideally one would like to be able to drop them slowly from PS to PS and then even out with a very slight let up in the dose. HA, yea but they are cats and generally give you surprises. But it's nice when they zoom off and you can give them a dose that brings them back down into getting things under control range. Ultimately, the ability to increase when needed and back off when needed [and not worry about +13.5 and wait and test and wait and test situations] is the best part of SS/VDS IMHO. BUT it is also important to know when to not overreact.

Maybe that is the big difference is that SS/VDS does not take time so much into consideration. Not to say that it totally does not become part of it, but that time is a very small player in the equation.

I don't know... it works enough for me.

Ask me more questions and I'll try to answer.

Back when PZI was the insulin of choice, there were a lot of folks using sliding scales. I encouraged them to develop their own, starting with 3 steps (high, medium, low) with refinements from there. 3 steps was all I ever needed for Lucy and those 3 steps had only a .1 unit difference. We also had what we called a BAM dose--or a slightly larger dose for those times when we were much later than normal with a shot and knew we had lost overlap.

Thanks for your replies! Very helpful!

VDS it is! ;-)

For us, 5am is ALWAYS the amps. I can count on that. However, the pmps may be anywhere from +12-+14. My schedule is such that I just can't count on being home from work. Also, spot-checking is, well, "spotty" at best. My kids have lots of activities in the evenings and on weekends... All of this makes it difficult to nail down the dose. With that said, I think that we are settling on 0.2-0.4 with a high of 0.6.

So... Gator&H... do you have a "no-shoot" line? Well, of course you do, but do you frequently reach it? Have you been able to determine where the overlap disappears? What I'm fearing is that Soccer's #'s are steadily dropping because we have some long-standing overlap. Eventually (days??) the dose will get low enough that the overlap will wear off. Then he'll spike. Do you see that?

Michele

MicheleS said:

So... Gator&H... do you have a "no-shoot" line? Well, of course you do, but do you frequently reach it? Have you been able to determine where the overlap disappears? What I'm fearing is that Soccer's #'s are steadily dropping because we have some long-standing overlap. Eventually (days??) the dose will get low enough that the overlap will wear off. Then he'll spike. Do you see that?

Click to expand...

Hmm a no shoot line? Yea, there have been infrequent times I did not shoot. This was generally when he was under 90 or 100 for a PS. When that was going on I had him "tightly regulated" and we were giving doses as low as 0.1u. Occasionally we would skip a dose just because there was no way to reliably get a much smaller dose in him. Once you get the hang of it you will have a feel for what the expected drop of a certain dose with a PS of X should be. As well as you'll get a feel for how they react when you back off on your dosing quickly. There have been times I've given a much reduced dose and all it did was prevent him from zooming off as quick. And sometimes that's been the intention - which allows them to get back into a territory that you feel more comfortable with.

As for overlap, I never really noticed it with PZI Vet [some notice it and some don't]. As for ProZinc, I'm not really sure yet ow I feel about it and overlap. Right now I'm treating it as though there is no overlap but that does not mean H does not get it with ProZinc. Either that or I just pretend it doesn't exist [LOL - that probably qualifies as a bad PZI habit]. But basically overlap is an ECID thing. I'm not sure I understand the rest of your question about overlap. Hopefully the dose will go low enough that you won't have to give insulin :smile: Maybe others would like to chime in but I do not think that a lower dose should have less overlap if that's what you are saying. Maybe others would disagree with me? It's an interesting thought. I don't know, [maybe for my own convenience] I've bought hard into the idea that H does not have overlap. When H was in the "tight regulation" zone and we were giving very small doses [0.1u - 0.3U] we really did not experience any "spikes." It was all pretty smooth and wonderful sailing.

If this is a route that you choose to go, it does take some time to build up the old experience bank. Things can [but don't always] get a little shifty. I have had very infrequent times where H would go into the low 300s for PS. But I was able to get him back into the OK zone quickly.

Ultimately, I've found our VDS to be pretty intuitive.

I hear you about the schedule thing. I hope you are able to find a way to make this process as efficient for yourself as possible. I try as hard as I can to keep things in the ±1 hour zone for each shot. So each shot runs 12 hours ±1 hour from the last shot time. Occasionally [as happened last night] things do not work out perfect - as is life.

i'm from the old days of '07 but honestly i don't understand the concept of not using a sliding scale. (cindy aside, she's been at it forever and knows her cat)
if we're not willing to adjust dose why are we even testing and keeping track of #'s?
why shoot the same dose into a 370 as you would a 180?
like i said i'm old school so i don't understand not shooting according to #, even if it is different every time.

Hi, Michelle. Back when Moochie was on PZI Vet we used a fixed dose until I knew what the dose was doing for her. She started out with very high BG levels - normally in the 400s and more often in the 500s. Bearing in mind that Moochie is STILL a dry foodie because she won't switch and it's too risky to try to force her (chronic pancreatitis and hunger strike at will kitty) she needs higher doses than most kitties who made the food switch.

Anyway, I was never able to shoot more than on a 12/12 - 10/14 schedule, like Cindy, due to my work. I did use a sliding scale ultimately for her and it was what finally broke through those high numbers.

This is the sliding scale that I ultimately used for her back then - after much tweaking. It is Moochi'e 2007 sliding scale. It is NOT a recommendation for anyone else but an example only.

150 and under – Do Not Shoot
150 – 200 1U
200 – 250 1.5U
250 – 300 2U
300 – 400 2.5U
400 – 500 3U
500+ !

Moochie did go OTJ for a few months after I started using this scale. When she went back on insulin after a bad CP flare I no longer used it. Her BG levels were never that high again and since she is not a micro dose kitty that scale, by default, became defunct for her so I went back to shooting a fixed dose because her insulin needs had obviously changed from the first time around.

Since I no longer use PZI for her, rather Levemir, I have no need to consider sliding scales again but they can work.

in regards to what lori had to say and this is just me and my cat so please remember that what is most important is figuring out what works for you and your cat.

what i figured out for us and why i don't use a sliding scale anymore is that Mousie's BG levels are strongly influenced by her surroundings.

back in the day if i got a 300+ number and shot more insulin according to the sliding scale i was using at the time (remember, Dr. Hodgkins was our vet so of course we started out with sliding scale), it resulted in an even higher number come next shot time. drove me nuts wondering what the hell was going on and why her numbers were always so high.

one day i got sick of all the calculating and decided quality over quantity and decided to try a set dose. lo and behold Mousie's numbers were 100% better within days of going that route.

if Mousie gets seriously scared by something (doorbell, another kitty getting too close, me picking her up, santa ana winds slamming patio tables up against the house, etc.....) her numbers literally skyrocket. for instance, yesterday she gave me a 300+ number at pmps. i still shot only 1.2u. why? because not too long before, she was walking across the living room towards the front door. suddenly Yoda appeared barrelling down the stairs and BOO! she was right in Mousie's face before Mousie had a chance to realize what happened. Mousie freaked out, hissed, swatted, and yelled and ran for safety under the kitchen table. poor Yoda poofed up as big as she could get and skedaddled right back up the stairs and into the bedroom. that will take Mousie from a 100+ number to a 300+ number in minutes.

if i shot more because she was 300+, when she calms down, her BG comes down some on it's own, and then the insulin brings her down even further, she ends up going back to skyhigh next pre-shot. rebound. if i stick with the 1.2u no matter what, she'll return to her cool steady under 180 24 hours a day self.

i do want to add though that i do adjust down if she gives me a lower than normal preshot and i'm leaving. :smile:

also, and why i don't say too much in regards to what others should do with their cats is that i personally feel Mousie is not like the majority of kitties here. She was diagnosed young (4.5 yrs old), never obese, does not have any of the other complications that can go along with diabetes, and personally, based on my direct experience with feline diabetes, think she's made it pretty darn easy for me. there is a very good chance she is type 1, not type 2, so to me that kinda makes her dance a little different. i do not have remission specifically as a goal. if it happens, great, if not, no biggie. thus, steady as she goes for us.

for others, i have no problem with sliding scale and have seen it work in lots of kitties. if you have the time to put into it, heck yeah, go for it. :smile:

Well geez, Cindy, with Mousie reacting that way it would make a sliding scale a mess, wouldn't it? :lol: Sorry to laugh but I am laughing with you, not at you . That's kind of why I am with you on the not giving dosing advice much thouh. Although Moochie doesn't have much stress related BG inflation in her life she does the dry food so what works for her is often way too much insulin for many. Makes it difficult to suggest dose increments for me.

As far as why 1 unit works the same on a 300 as it does on a 180 I can't even begin to explain but in the last year (roughly) of Moochie on PZI it did. She was on 1.5U and mostly had preshots below 250 until the last couple of months when she had a periodic PS of 300-ish. For the most part the 1.5U dropped her to the same level and her next PS was lower. When it stopped doing that for her I made the switch.

Again, I only posted Moochie's 2007 scale as an example. Moochie does best with 0.5U changes as necessary and anything below 1U doesn't touch her glucose levels.

Re: sliding scale & Liver Training??

A week or so ago we were talking about holding the dose for liver training. So do you only use the sliding scale after you have the liver trained? Or how do the two "methods" work together? Or maybe they don't? I admit, I'm confused.

ele i wish i knew about liver training but i don't know anything about it. i would suggest that you just take a good long study of her #'s and see if you can detect a pattern.
for example, you shoot a 1.8 into a 120, does she tend to have a much higher bg next shot time. if you see this pattern make a mental note. if you shoot 1.8 into a 320 is she more evened out or perchance lower next shot time.
it's really a case by case study.
i don't know about skipping a dose altogether....scary with your #'s but i would certainly study what you've got. that's what i'm doing with tom. i hope to one day see a clue.

Ele, I'm with Lori here. I don't get the "liver training" because all I was worried about was getting Moochie's BGs down to a less dangerous level and the sliding scale was my last resort.

Again, I don't follow everybody everyday so please forgive my possibly stupid question. Michele, please forgive my digression from your original question too. From what I see in your spreadsheet you were getting a better response when you were shooting 2.2U than you have since you dropped the dose and started working your way back up. I understand why you shot a lower dose on the 31st of January in the evening but I don't know why you stayed at the reduced dose the next morning. That seems to me to be where Blackie's numbers started climbing again.

I would seriously not consider a sliding scale yet.

ele, check out 1/14/10 and see what i mean as your pm shot took what looks to be a rebound. judging from the afternoon #'s i don't see that pm shot needing to be so high IMHO