7/7 - Shakespeare - ADVICE PLEASE

Hi EVeryone
Well I am starting to wonder if I am raising too fast
Can someone please look at his SS
It appears that there is a pattern
I am starting to think that maybe I should reduce to 2 units

I upped his and he is now at 3 units
but he saw more yellow and blue at 2 units
any advice would be greatly appreciated
Thanks

Could you say a bit more about the pattern you're seeing?

I'm really not worried about there being a problem given that you've been systematic in your dose increases and you've not yet seen any consistent blues or greens.

I wouldn't reduce. You're testing enough that you would know if he was dropping too low and bouncing. I don't see any signs that this dose is too much - you've increased the dose according to protocol, so you can be confident that the dose is ok. I will say that I don't always agree with going all the way back down to 1u when changing insulins, but one good thing about doing that is that now you can know for sure that you have increased carefully and you're not over dose. The protocol eliminates a lot of the guesswork and gives you confidence in what you're doing (at least it did for me).

From looking back at your spreadsheet, it looks like Shakes had his best numbers on Prozinc when he was over 3 units, the insulin just wasn't lasting long enough. Most cats end up on a little higher Levemir dose than Prozinc so I wouldn't worry yet. I know it's tough sometimes when you see other cats turning around on lower doses. Lucy's breakthrough was 4.25 units and I remember how hard it was to keep going up and up. One thing I've learned around here is that the size of the dose isn't that important. We see the whole gamut. The important thing is to find the right dose for your cat, whether that is 0.25u or 5u or more. They can get regulated or even go OTJ from any of those doses, if that is what is meant to happen.

A couple of other things I have noticed about Lantus and Levemir - often it looks like the insulin is doing absolutely nothing, dose increase after dose increase. The numbers stay the same and people think "why isn't this working?" But then one day all of a sudden there is a breakthrough. All of a sudden you'll see green everywhere (and it will drive you crazy because usually you won't have seen it coming!). Hang in there! I would just keep increasing every 6 cycles until things start to change. He'll get there.

Being newer than you are, Denise, I don't have the expertise to offer. What Libby said makes sense, though, the protocol does take the guess-work out. For me, there have been some conflicts in my mind ProZinc vs Levemir. I have to remind myself they are very different in some ways and just kind of push what I learned about ProZinc to the side.

Hoping you hit on the right dose soon -

Libby (& Hershey, too!)

Thanks for the input, but here is my thinking,
since I raised to 3 units yesterday he is not acting right
his pmps tonight is 529
+3=444
+5 = 424
I am not liking this at all.
at least on the lower dose he was in the 300's
now he is staying in the 400's

I will see how this plays out and what his amps is
I hope it is not another 500, and if it is I think I might reduce to 2.5 to see if that can bring him down
some. He was acting so good on 2 and 2.5 units.

I certainly see your frustration and you know we'll support you doing what you feel is best for Shakes. I hope you find some answers SOON!

i agree with libby - and it's also possible you may be seeing some New Dose Wonkiness. it's not uncommon for a cat to have increased numbers with a dose increase. i have found that it can take more than a day for punkin's to settle down sometimes. as long as you're following the protocol for increases, you don't have to worry about it being too much. you would have evidence (lower numbers) if it were. for whatever reason, shakespeare just looks like he hasn't found the right dose yet.

i have a cat with acro, and i remind myself regularly (and everyone else) what libby said - the important number is the blood glucose, not the dose size. you just want to give them what they need. that 529 is painfully difficult to see, but if you persevere shakespeare will get past it and you will see better numbers. that's for certain. 3 units is really not that much for many cats.

and hi! i think i've seen you on the PZI forum, but not here yet. nice to meet you and shakespeare. cat_pet_icon

Hi Denise! You know I share your frustration, but I think Libby/Hershey hit it on the head. We kind of have to put out of our mind the whole Prozinc experience. This is a new dance, new music, new steps. Fortunately we're a little more comfortable in our dancing shoes this time around!

When I shifted, I felt like we weren't getting anywhere. Then one night I'm posting on FB/Acro saying "do I shoot the full dose? I've never shot a yellow preshot before" (pretty much). It was scary shooting a full dose into it, but he was just fine! We're here, we're testing, and sometimes we have to wait through some lower doses, but when we start seeing some good activity (or in Grayson's case - ANY movement), we do the happy dance!!!
dancing_cat dancing_cat dancing_cat dancing_cat

Shakespeare is just trying to remind you that "Rome wasn't built in a day!" He'll settle into the dose when he's good & ready to do so... and unfortunately for you, that doesn't always match your plan! In the mean time, enjoy that he's doing as well as he is! If you need a reminder, just look back to his old SS. It gives us a totally new perspective! ;-)

Denise

I also know this is hard to understand and to see. A couple things come to mind.

Libby did a great condo about the insulin depot of lantus and levemir. Here is the link in case you want to read it because it has some references that might apply to Shakes: Lantus and Levemir: What is the Insulin Depot?

But this is one part that I find most interesting and explains alot to me:

Another interesting note from the Boulder Medical Center:

Furthermore, the degree of absorption of any dose, both between individuals and in the same individual, can vary from day to day by as much as 25 to 50 percent, leading to unexplained fluctuations in glucose control. This effect is greatest with longer-acting insulin and least with rapid-acting insulin.

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For a long time, I know Mike and I were controlled by what Gracie's numbers were and we spent the day trying to figure out why, why, why? Now, I just try to take it in stride and not drive myself crazy asking for an answer that no one knows....except maybe Gracie and she ain't talking ;-)

It may not help but we all do know how you feel. :YMHUG:

I know it's hard to look at high numbers. There are some cats who just insist on staying higher than usual until their breakthrough. Thing is, they will all have a breakthrough at some point. I've been here over 4 years and have studied a lot of spreadsheets, and I can tell you that dropping the dose on a cat who has followed protocol on the way up rarely works. What usually happens is that you'll drop the dose down, then have to work your way back up. In the meantime, glucose toxicity starts to build and you will likely end up at an even higher dose than you are already at. The best course of action is to just keep going up until you find the breakthrough, then the cat will often earn a series of reductions. In fact, Kirsten even mentions "rebound checks" (reducing the dose) on Tilly's diabetes website:

Be aware that experimental studies in human diabetics over the last 15-20 have rejected the existence of the Somogyi effect (sometimes also called rebound). In cats, no studies have ever been done which properly demonstrate that such a phenomenon exists. Therefore, adjust the dose as described above, focusing on the nadir: don't do so-called rebound checks, as they only lead to unnecessary (and unhealthy!) hyperglycemia.

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As Julie mentioned, we also often see what we not-so-affectionately call New Dose Wonkiness, which is basically higher blood glucose numbers for a couple of days after a dose increase. Kirsten also mentions this in her protocol:

Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations.

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It is annoying for sure, but also very, very common. When you increase the dose, you'll usually see higher numbers the next day, sometimes the next two days, then the numbers will settle down or not. If not, then you increase the dose after 3 days and see if the next dose works better.

I almost forgot to make my other point, which is that even though 300s are better than 500s, I would hate to see you settle for 300s. I would try to get him under renal threshhold at least, and there is no reason why he can't get there. You don't have to aim for green unless you want to, but yellow and blue are nicer than pink.

Hi Denise,
I want to echo what Libby and Lu said earlier. When a kitty switches from prozinc to one of the "L" insulins, I think the hardest part on the bean is to understand that you have to forget a lot of what you learned, and try to think differently.
You saw in PZI that some cats, with inverse curves, or high and flat cycles, whose doses were reduced then saw an improvement on a lower dose, right?
Well, from what I have seen, and learned, Lantus and Lev don't work the same way. I know your instincts are telling you that if you reduce, you might see lower numbers for Shakes, like you may have seen when he was on prozinc. Lots of L users have said it doesn't work that way, and IMO, they have the experience to know.
The best thing you have going for you right now is that there's a protocol to follow. You have a dose, you stick with it for a specific number of cycles, and you increase if the numbers don't improve. The only time you ever have to think "decrease" is if you see numbers that are low enough to warrant a decrease according to the protocol. The other thing you have in your corner is a whole lot of very experienced people helping you out, and they aren't going to steer you wrong.
Shakes is going to do better, Denise. You just need to be patient and let the insulin and the guidelines get him there.

Chin up, kiddo,
Carl