9/9, Atlas AMps 411, PMps 62, +1 81, +2 93, +3 156

Yesterday's condo with the big slide!

http://felinediabetes.com/FDMB/viewtopi ... =9&t=24425

Good morning! As you all know I have been trying to deal with "slidage." I am trying to follow the protocol and am confused as to some of the advice I have received. Namely not feeding on schedule? Withholding food and waiting, which seems contrary to what,

The protocol says:
you will face the problem of having a low pre-shot BG and wondering what dose you should give. Try reducing the dose the first few times to see what happens - in all likelihood the cat will have higher BGs as a result. A second alternative is to feed the cat, wait 1 to 2 hours, test again, and when the BGs start rising, give the normal dose. A third alternative is to split the dose: feed the cat, give most of the dose immediately and give the remainder 1 to 2 hours later when the BGs start rising.

So as a new Lantus user, I am easily confused by contradictions. Is the advice because folks can't tell the difference between a food spike and an actual rise? I am curious as to what caused the modification of the protocol in forum? What the experiences are that lead to a pacing hungry cat?

Re: 9/9, Atlas AMps 411

I'm a newbie and not good w/dosing, feeding advice just yet. Will defer to the more experienced folks here. Hopefully someone will come along to help you out with that question.


Just wanted to stop by and say good morning to you and Atlas. Cute name.

Re: 9/9, Atlas AMps 411

Good Morning back at you

It is a coffee talk kinda question.

And as it appears to me from Attie's chart, his panicky liver symptoms from being on N...

I think a good question. I am very grateful for the advice I received last night. Folks here know I can be a very black/white answer kinda person and vaguery will drive me bonkers! :shock:

Atlas, is his shelter name. It is really a reflection of his world the past 8 months or so. He has been through a lot.

I am hoping he can make this transition to Lantus and "shrug" off his past to a new happy, loving family and life soon.

Re: 9/9, Atlas AMps 411

Part of the misunderstanding might be due to the difference in what is considered a "low" BG reading....
The information form the University of Queensland stats if the Blood glucose at the time of the next injections is 50-100 you have those choices you mentioned above. From what I can gather from your SS, the original BG was 183 at PMS time, correct?
Once we have gathered information as to how our individual kitty responds to both the insulin and HC, we can make a decision to shoot a lower PS than we normally would see.

If we get a lower than normal Preshot, we do not feed and test in 15 minutes again to get an idea of where the BGs are going. If it is a lower number, we can wait to see if it will come up on its own without food. The ideal is to shoot the same amount of insulin 12/12 and that is what we aim for to maintain consistency.

The information you recorded lat night is useful for the future of course. If you do get a lower PS number, it would be good if you would post that number and update in 15 minutes. It would be good to know if you will be home for the next few hours and if you do have HC and plenty of test strips on hand. Should the number be <100 the above choices come into play. The data you have collected form all your BG tests will be important to help making the decision as to which choice is best for you at the time. When we have plenty of data, we can make an educated guess as to where the BGs will go with the full dose of insulin onboard. We will always get a +1 test and be prepared to about the cycle with HC gravy if the BGs are dipping too low at any time during the cycle.
Some kitties actually do have their nadir at or around PS time too which means there will always be a lower PS number. We know from our data that the kitty's numbers will begin to rise again so a delay in shooting is not necessary when we have the data. Make sense?

The most important thing is to test often to see how your kitty responds. You are gathering lots of good data and if/when you come to this situation again, if you would like to post the number and someone will advise you whether to shoot right away or to stall.
When we stall as i said yesterday, we move our next shot time back to where it will leave 12 hours between the previous shot. Therefore, stalling is not always the most practical way of dealing with low numbers. Sometimes, it is the best way though.

Re: 9/9, Atlas AMps 411

If you take a look at what a "perfect" curve would look like, a food spike would occur at +1 and BG values "should" return to pre-shot levels by +2. If you were to follow the Queensland guidelines, I suspect the idea is that you'd make the kitty happy by feeding and hopefully, the numbers would be coming up and you could shoot.

The modification to Queensland came before I arrived here so I'm going to speculate. First, not all cats' numbers will rise after even a 2-hour delay. If you look at the next statement in the protocol, it's recommended that you shoot a reduced dose if this is the case. The impact on the shed, then, is you are giving less insulin as well as giving a late shot which has effect of a dose reduction. There is a big net effect on the shed as well as throwing you off schedule for the next shot.

The protocol also concludes:

Roomp & Rand said:

In general for most cats, the best results in phase 2 occur when insulin dose is as consistent as possible, giving the full normal dose at the regular injection time.

Click to expand...

At a personal level, I work with research treatment protocols (for humans) all the time. Once the actual research concludes, the protocols are published. The people in the trenches made adaptations to those protocols, often for practical purposes like the real life consideration of your schedule. It's my assumption that the modifications to the Queensland protocol reflect these kinds of considerations.

Re: 9/9, Atlas AMps 411

You’re overlooking the next sentence in that paragraph:
However, in most cats none of these alternatives have shown themselves to work as well as consistent dosing. You will have to learn how your cat reacts to Lantus/Levemir before you determine the best way to deal with this problem. http://www.tillydiabetes.net/en_6_protocol2.htm

You have choices in how to deal with low preshot numbers. She also emphasizes that you have to learn how your cat reacts to the insulin, and I would also add that you need to learn how your cat reacts to food. Then you’ll know what works for your cat.

What we have found (as mentioned in the sentence I quoted) is that the best option for most cats is to just shoot and feed on time at almost any preshot number (I wouldn’t shoot 40’s, and I would probably stall before shooting 50’s the first time, but otherwise I would shoot and monitor). Most people do want to experiment with other options before they believe us. :smile: I figure why not shoot, if I have time to stall the shot for an hour, then in the same amount of time I could just shoot and get a +1. If the +1 drops, feed the cycle to control the numbers. My schedule stays in place AND I’ve given the cat a chance to prove whether he/she needs a dose reduction.

The protocol is listing one option as to feed and wait 1-2 hours before retesting. By then, the food spike will have mostly cleared and the fact that you fed will be irrelevant. However, you are now 1-2 hours off schedule! That’s a lot to make up. What we usually do if we need to stall is don’t feed (to avoid food spike) and test in 15-30 minutes. If you’re only stalling 15-30 minutes, then the food spike definitely clouds the issue, until you know how carb sensitive your cat is. Some cats get very little rise from food, but we’ve seen cats here who can get 100 points or more from a low carb meal. Normally a cat won’t starve in ½ hour, despite what they would have you believe… Personally, I don’t like stalling and I don’t like seeing people stall. I would rather shoot and monitor. Stalling can take hours and then the schedule is a mess to fix and the shed is out of whack.

If your cat is a late nadir cat, then you have to get used to shooting lower numbers. You’re aiming for nadirs in the 50-80 range, and if his nadir is +12 then you can expect his +12 to be in the 50-80 range. In that case, you know he’s going to keep going up for several hours before the shot kicks in. I’m not sure yet that Atlas IS late nadir, because most of these cycles that look like late nadir cycles really look more like cycles where he is clearing a bounce late in the cycle. More data will help us figure that out as we go along.

Re: 9/9, Atlas AMps 411

THANKS!

To all who responded to my inquiry and question. I knew you would give me the inside scoop and rationale for the choices and advice on how to apply them.

Libby, I think you're right about the "just shoot," especially in Atlas's case. We delayed and now I have high numbers, late morning shot, plus the shed messed up today. And yes, I noted that the delay with food, in the protocol, would have the food spike already cleared.

So the in forum modification rationale is really leaning towards accomplishing the dose timing and consistency. So...

If you're going to wait to see if the numbers come up...in 15 minutes/half hour...then feed and shoot. What are you going to do if they don't ...? Feed and shoot anyway? So why wait in the first place, unless of course the numbers are in hypo ranges...then you'd be feeding anyway.

Right?

Re: 9/9, Atlas AMps 411

You've got the gist of it!

Take a look at Gabby's SS for a couple of examples. On 9/7, I shot low, I was monitoring carefully and brought Gabby's numbers up with HC after she earned the reduction. On 8/29, I shot low and she surfed. On 8/25, rather low numbers and skipped the shot -- too much insulin in the shed. I can't think of the last time I stalled in order to shoot. That said, I have a lot of data! Having the data to make these decisions is essential.

Re: 9/9, Atlas AMps 411

Whew!!! Thanks!

I can be slow and picky on understanding things, but now at least I understand it.

You guys are really, really great! ;-)

Re: 9/9, Atlas AMps 411

Blue said:

If you're going to wait to see if the numbers come up...in 15 minutes/half hour...then feed and shoot. What are you going to do if they don't ...? Feed and shoot anyway? So why wait in the first place, unless of course the numbers are in hypo ranges...then you'd be feeding anyway.

Click to expand...

Exactly! Why wait? I strongly believe that Lucy's breakthrough (after 17 months) came because I started shooting consistently at +12 no matter what. Granted, she never presented me with 40's at shot time or I would have had to stall. Some people can shoot 40's but that's only when they have a ton of data showing that their cat has a late nadir.

Re: 9/9, Atlas AMps 411, +4 399, +6 274, +8 246,

Oh my it can all be so confusing sometimes....

All better now though!

Re: 9/9, Atlas AMps 411, +4 399, +6 274, +8 246,

hi blue! i don't think i've had a chance to stop by your condo to say hello and welcome. looks like you're getting some great answers to the questions you're asking! routinely shooting on the 12s is hard to get used to. when alex started on lantus in 2006, we weren't doing that much. no one was. by the time she went back on insulin in 2009, we had learned so much more about using lantus and levemir. when she hasn't been sick (liver & kidney issues), i've been able to use food to manage her curves. we shoot full doses 12/12 on preshot numbers 50 or over. it's worked out very well...

Re: 9/9, Atlas AMps 411, +4 399, +6 274, +8 246,

Lantus is really a unique insulin to use.

I guess I would say, it really isn't even a normal long acting insulin.

So why the "storage shed?" I understand how it exists, but for even humans...why a storage shed? Is it making up for insulin...just in case. Kinda like the liver when it dumps glucose?

Sort of like the relationship should be between insulin and glucose?

Re: 9/9, Atlas AMps 411, +4 399, +6 274, +8 246, + 10 134

I'm not stressing...I'm not stressing...

Looky it is blue again...it is blue...

Re: 9/9, Atlas AMps 411, +4 399, +6 274, +8 246, + 10 134

no need to stress. go look at your ss. waiting til blue atlas was on the rise last night didn't work out too well.
remember not only will you feed him at shot time (which will most likely cause the numbers to rise), but it'll be a couple hours before onset (more time for the numbers to rise). when the insulin kicks in, blue's atlas's numbers will be higher...

sorry about the edit. can't even get the kitty's name right!

Re: 9/9, Atlas AMps 411, PMps looks like...100!

Looks like we're having dinner at the 100 Club!

Re: 9/9, Atlas AMps 411, PMps looks like...100!

Blue...I thought you shot last night at 8:30 or so....isn't that your new PMPS time for today?
Or, did you not move your morning shot back to allow for the 12 hours between the delayed shot last night?

Re: 9/9, Atlas AMps 411, PMps looks like...100!

nice shooting!

Good question, Pat. It's not a problem to shoot at +10 when he's in the 400's, but normally if you delay a shot then the next one is due 12 hours after that. Just a piece of information for next time. :smile: Shooting at +10 can set you up for some extra overlap if you're not careful. In the 400's, extra overlap can be your friend sometimes, as long as you are able to monitor.

Re: 9/9, Atlas AMps 411, PMps looks like...100!

The delay for the next shot and the upsetting your schedule is the reasons that people do not like to stall at shot time if they can avoid it....it takes days to get back on your previous schedule as I said in my post yesterday...
I hope you will update with a +1 ....and maybe do a +2 and +3 tonight too or until you see the numbers rising nicely. Sound good?

Re: 9/9, Atlas AMps 411, PMps looks like...100!

Naw...we're still waiting for the official PMps...which hasn't happened yet, but we're still falling going into it. We're now down to a 73. I was kinda excited to see these numbers.

I need Attie to be on that 7pm slot. We shot last night at 8:15, I backed it up to 7:45am and was thinking a 7:15 or 7:30 tonight.

Like I originally posted this morning...yesterday messed things up! Hence, my bazillion questions regarding rationale.

So last night he actually got a low dose and this morning a slightly higher dose, without actually changing the dose. I do get that.

Re: 9/9, Atlas AMps 411, PMps looks like...100!

Libby and Lucy said:

nice shooting!

Good question, Pat. It's not a problem to shoot at +10 when he's in the 400's, but normally if you delay a shot then the next one is due 12 hours after that. Just a piece of information for next time. :smile: Shooting at +10 can set you up for some extra overlap if you're not careful. In the 400's, extra overlap can be your friend sometimes, as long as you are able to monitor.

Click to expand...

I didn't think shooting this morning a little earlier, off of last night was a big deal. He was in the 400's most of the evening into the morning. And no I didn't shoot 2 whole hours early either. He's throwing these numbers very late in the cycle and I bet I get a big bounce tonight, even if a shot right now!

As someone else pointed out to me in his chart...when he starts to rise...you already lost him.

Re: 9/9, Atlas AMps 411, PMps looks like...100!

ok, makes sense. I was thinking that you shot 2 hours early because your AMPS post this morning was early and it sounded like you had already shot.

Play it by ear tonight. If he's still dropping then I would wait until +12 to shoot, and make up the rest of the time some other time (maybe in the morning).

Re: 9/9, Atlas AMps 411, PMps looks like...100!

Well 7:30 here and he is at 62.

15 minutes more will put us at 12 from this mornings shot.

Shed question

Blue said:

Lantus is really a unique insulin to use.

I guess I would say, it really isn't even a normal long acting insulin.

So why the "storage shed?" I understand how it exists, but for even humans...why a storage shed? Is it making up for insulin...just in case. Kinda like the liver when it dumps glucose?

Sort of like the relationship should be between insulin and glucose?

Click to expand...

Pharmacologically speaking, Lantus isn't unique. There are any number of drugs that are depot drugs. It is what allows certain medications to be long-acting. There are some medications which last as long as 3 months (e.g., depo-provera). The depot doesn't "make up" for insulin. Lantus, when injected, forms crystals. The crystals gradually dissolve rather than enter the bloodstream all at once, like the shorter-acting types of insulin. In the case of Lantus, the pool/depot that forms under the skin is what allows for overlap between doses.

Re: 9/9, Atlas AMps 411, PMps looks like...100!

looks like you shot, so see you at +1. Nice shooting. :mrgreen:

Re: 9/9, Atlas AMps 411, PMps 62, +1 81

Not too big of a rise for a +1. This will be interesting to see if the lantus onset holds things down in 3 or 4 hours from now. I am truly expecting a huge bounce though.

Re: 9/9, Atlas AMps 411, PMps 62, +1 81

good, can you get a +2?

Re: 9/9, Atlas AMps 411, PMps 62, +1 81

Planning on it.

Re: 9/9, Atlas AMps 411, PMps 62, +1 81

good luck Atlas!

binks

Re: 9/9, Atlas AMps 411, PMps 62, +1 81, +2 93

Plus 2 is a 93. Attie seems lethargic though.

Re: 9/9, Atlas AMps 411, PMps 62, +1 81, +2 93

how about a couple of tsp of low carb food to try to get him surfing?

Yep... even with a little bit of food...

We're off to the races for the night.

I'll be setting the alarm clock though for about 3 or 4 am ...to check

there's the bounce. I'm glad you shot on time!