Frankie AMPS 429

Has the dose settled yet?

How long would you leave your cat with rising BG's, allowing a dose to "settle"?

 

If you are following the Tight Regulation Protocol for Lantus and Levemir,

• doses are typically held 3 to 5 days and
• "The cat should be monitored closely on the first 3 days on Lantus/Levemir: do curves between the AM and PM-doses, e.g. AM pre-shot, +3 hours, +6 hours, +9 hours, PM pre-shot."

From your SS, it looks like you've increased the dose from 1.0 to 2.0 units after 48 hours and you have virtually no mid-cycle checks. There is no way to know whether your AMPS is a bounce from a lower BG level earlier in the cycle. Also, and again based on the dosing protocol, doses are raised in increments of 0.25 to 0.50 based on the nadir. Just to reiterate what members have mentioned previously, the longer acting insulins like Lantus and Levemir do not act the same way nor are they dosed in the same manner as their shorter acting cousins.

 

I did a +2 check and irrespective of the food spike he is now at 502. Since I started low, his numbers have been a straight line rocket up, when I have spot checked, each subsequent spot check has been higher then the previous one.

As you can see a sense of frustration here on my end, I am going to raise him till I see him drop. Which is exactly what insulin is supposed to do. Rebound here is laughable as one PS to the next spot check to the next PS has been higher. I loathe to let him sit at over 300 let alone 500. As you all would.

 

Frankie +2 502

Am I the only one here who thinks I am under dosing him.

There has been no curve ( I have yet to do a 12 hour curve) but based on his subsequent PS being lower then spot checks, which are lower then his next PS, his nadir would have been his previous PS. Meaning a curve of a straight line up.

What would you do about this?
After almost 5 years of PZI Vet, testing and doing curves, then having to swith to Lantus as Idexx no longer manufacuters PZI Vet, we have gone from PS on either end of a 12 hour cycle of 220 to 250 to over 500?

I asked a question in a previous post and still have yet to get a clear answer. How does one base a dose on a Nadir, when then Nadir is many hours before the next PS and if each Nadir reading you see is higher then the last, doesnt that indicate that you should raise the dose?."Settling", how could one allow a dose that so far has been ineffective at dropping the BG value, but on the contrary, the dose has only allowed more sugar to flow into his blood stream, go up along with no duration?

 

Re: Frankie +2 502

previous thread for Sunday March 7

viewtopic.php?f=9&t=8337&p=83119#p83119

hi there,

just so info doesnt get lost, in this forum each kitty gets one thread per day..I've linked your previous thread for today so others can view the info posted there as well. This keeps everything in one place, ok?

Hopefully someone will be by today to explain things for you, hang in there.

 

I don't know anything about the other insulin you were using but the number you get when you test just before shots is NOT the most important number when you are using Lantus.

The best way I can describe it is this. You could be giving too much insulin, too fast, and here is a visual for you.

Take a tennis ball in your hand and hold it above your head (this height can represent your high pink and red BG number).
Now, as hard as you can, I want you to POUND that ball into the ground.

What happens??? BOING! Right up high, even higher!!

So you have tested before the bounce, and then you test again when that ball is sky high and say HOLY MOLY, NEED MORE INSULIN!

nope, wrong.

That's why it's so very very important to see what's happening in the middle of Frankie's cycle. That Lantus does not start to kick in till a couple hours after the shot, then it's a slow downward movement for a few hours, and then the Lantus wears off and Frankie's numbers start to go back up again. If you measure just at shot times, you miss the middle important info, you miss if there is a HUGE bounce or not.

Please click on the link to my Shadoe's ss in my signature.
Take a look at the week days, when I am at work and I can't see squat.
I test when I leave for work and again when I get home.
As you can see, it's an incomplete picture.
Next, look at what I can see when I test more frequently on the weekends and even some evenings. I see stuff! I see what the insulin is doing and NOW I can decide if it's time to increase her dose.

Don't forget about that shed, that reservoir of insulin that MUST be filled before you will see some action, some change in Frankies numbers.
I don't drive but think of a spare gas tank that you keep for your car.
Imagine that you need to fill that tank before you can put gas in your car's tank and drive the car.
Now, it can take up to 6 cycles, 6 shots, 3 days, for Frankie's spare tank to fill up.
Once it's filled up and you give that 7th shot, Frankie's body says Whup, the spare's filled so you can use that Lantus on that 7th shot to bring Frankie's numbers down.
I hope you are good so far with the above.

Now, when you increase a dose with Lantus, you need to 'top up' that spare tank. That's just the way it is. That spare tank MUST hold an amount equal to your shot size.
So a dose increase means we have to fill 'er up again.

You had Frankie on the dose of 1uLantus for a short time and I suspect that his spare tank was not filled yet, so the Lantus was not being used to bring down his numbers at all.
When you increased too soon to a bigger dose of 2u Lantus, you are back to filling up that spare tank again.

For the above reason, you MUST hold that dose for the 6 shots to give Frankie a chance to fill his spare tank and then what shots follow will be put to use to bring his numbers down.

The more data you can collect and put onto your ss, the better you will know how Frankie is reacting to the insulin. It is vital that you know how LOW Frankie is going in the middle of the cycles because you do NOT want him going so low that he can't recover.
Not wanting to scare you, but some kitties go VERY low and then bounce right back up. It is important to know what your kitty does and treat those lows if they are happening.

Start low, go slow. It works.
If you want to see him drop, you have to check at the right times, and that's at mid cycle.
Think of the letters "U" or "V"; looking at the two ends won't tell you a thing.

I think once you start to test as you can in time alllowed, even +3 +6 +9, or whatever you can get, you will start to see that Frankie is INDEED going much lower, but his dose may be too high or he is bouncing back up to the higher numbers.

Seriously, I know where you're coming from and have gone through high numbers that just don't want to go down, so I and everyone else here know how you are feeling.
You must go slow because Frankie's organs need to learn that the lower numbers are the right numbers. Some kitties learn quickly; others, not so quickly.

Last, the numbers are NOT the most important or only thing to consider.
You need to focus on the WHOLE CAT and see how Frankie is acting. Watch him as time passes after each shot. You will see how he changes. Watch his habits and his appetite. Look for the old Frankie to come back; things he used to do before but just stopped. Watch for those things to return. Watch his appetite and how it changes. Watch and listen for how he carries himself, how he purrs and when.

No cat is just a number, so watch all of Frankie.
And remember this: Nobody rushes a cat. The cat will progress when the cat is good and ready, so you just get yourself comfy and wait it out.
Frankie's in charge now, always has been, and always will be. :lol:

 

see what I mean? lol!

and a link for the 2nd thread for Frankie today:
viewtopic.php?f=9&t=8347


as u can see, you're gonna get AWESOME info on both threads and some of it is gonna get lost, and that INFO is the most IMPORTANT thing!

 

Thanks
Jay

 

I was the one who told you to forget everything you know about PZI when you first came on here the other day--
We were on humilin N & also had to forget everything here-
This is an example of a typical curve, but also what to expect from the numbers over the course of a cycle-
A dose takes 3 days to settle into Frankie's body--then you can talk to dosing helpers about changing the dose-OK?
Here it is & this will help understanding I hope:
Example of a typical curve:
+0 - PreShot number.
+1 - Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number.
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 - Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (may dip around +10 or +11).
+12 - PreShot number

 

Oh Gosh, Jay. I can only imagine how frustrating this must be needing to change gears. It was hard enough for me to understand everything without switching insulins. And Im still learning, every moment of the day.

I think some folks in this condo and your previous one, did a very good job of explaining the basic concept of lantus. Sometimes its just taking that leap of faith and believing in those around here, along with giving it time in order to see Frankie's patterns and progress. That is H A R D!!!!!

I will agree that if you continue to increase the dose as you did recently, you will be doing more harm than good - both with BG's and the overall health of your cat. You certainly care about Frankie, that is obvious. I hope that by reading the stickies maybe over and over, listening to others, reviewing other cat's spreadsheets, and watching Frankie, you will see what is best for him.

I cant remember who said it in your last condo, but they mentioned that Lantus is not like an inhaler where you take a puff or two and can suddenly breath better. It's more like the maintenance meds that gently help you thru the day.

I really wish you the best of luck. Keep asking questions, and folks will keep trying to answer them and support you how ever they can.

Oh- and definately look at some other spread sheets. You will see the bounces (which can sometimes last up to 72 hrs!ack!). In my cat's case, it seems a whole vial of insulin would not keep that bounce down!

 

Perhaps looking at another SS would help. Take a look at Mousie/Cindy's SS. Cindy was a very long term PZI user who recently made the switch to Lantus. She works a crazy schedule which makes mid-cycle checks impossible during the work week. But, take a look at the good things that are happening for Mousie. After holding that 5 day settling in period where the shed is being built, Mousie is beginning to see some numbers in the green. Mousie's SS

We're really trying to not torture you or Frankie! Really! What we don't want to see happen is for you to keep raising his dose out of frustration with high numbers and once the shed is filled, you have a hypo crisis on your hands. We really don't want to see Frankie in high numbers for longer than is warranted but we are trying to balance his safety in light of the big picture. The protocol, while seemingly slow and plodding, really does work for the vast majority of cats.

 

Its not from frustration, that I have raised the dose, Its to get a dose, that will do what insulin is supposed to do, That is to bring his BG level down, slowly to a Nadir, then get some duration, so I can play with the overlap, and keep him within a range that is neither too detrimental (over 300 consistently is, isnt it) nor one that would do him any harm. IE Hypo Incident.

Some more background, until I got really aggressive with finding a dose 4 1/2 years ago, he was sitting very high at his PS's both AM and PM and high at his Nadir.

The assumption, I think that everyone here is making is that, Frankie was newly dx'd. Far from the case. As Cindy. my personal schedule is about the same. I do know however, that the quicker I can find a dose that will bring him down gradually and maintain a safe range of BG levels, from PS to Naidr to PS the better off he will be and the better off I will be. In other words. finding a dose that allows us to go on "cruise control". PS/Feed/Shoot and go on with my life outside of Frankie, to PS/Feed and Shoot. All without worrying whether he is going to have an adverse reaction with the dose (hypo)

 

I think that is everyone's goal!!!!

But you do understand that raising the dose too quickly on Lantus will do exactly what you are trying to prevent? It wont allow the insulin to do what it is suppose to do.

I dont know much about the other insulins. I do think Lantus could work for you and Frankie. But Im wondering if maybe there is a faster acting one that you would find easier to go back to? maybe stupid question, sorry.

I read your first post, and realize you are not new to the whole FD thing! You have definately been around the block. Im sure you have a great deal of knowledge you could contribute to us. :mrgreen:

Best of Luck to you and Frankie. I really hope things can work out, however you go about it.

 

I really do understand that you are not new to insulin use or FD. The concern is that how Lantus is used is different than shorter acting insulin due to it's pharmacology. Approaching it like PZI is not recommended. There is a time for an aggressive approach - it's just not now. It is far too easy to miss what may be an optimal dose by what amounts to 4 times the typical increase. You also need to take the shed into consideration.

What you do is your choice. All we can do is point you to what the research literature informs us and what we have seen from experience. Please take a look at those materials. It may be, as Carolyn suggested, that Lantus is not suited to how you conceptualize insulin use or your lifestyle.

 

hi jay. i've merged both your threads into one to keep all the info together for today. please continue posting on this thread today. tomorrow... start another thread.

i'm also going to do something i don't like to do and that is... post and run. i have to leave the house in a couple minutes and won't be back til late tonight. lantus (and levemir, too) are different than pzi. lantus has a cumulative effect.... meaning one dose builds upon the next and can effect the next 3-5 days. dose-hopping does not work well. increasing the dose in increments of 0.25u or 0.5u is the way to go. when you increase in increments of 1u, it's like shooting yourself in the foot. by the time lantus has accumulated enough to do anything... you'll be over dose. you know what happens when a kitty is over dose. too much insulin can cause the numbers to rise and then plummet unexpectedly... or stay high.

look at alex's lantus spreadsheet from 2006 (link in my signature). this was back in the days when we didn't know how to use lantus as effectively as we do now. i floundered about for quite awhile before it all came together. then take a look at alex's 2009 levemir spreadsheet (link in signature). levemir works in a similar fashion to lantus. we use the same protocol. her 2009 levemir spreadsheet is a good example of fast tracking kitty into normal numbers by an experienced user. this is the technique i suggest you follow since you are not new to feline diabetes. please study the spreadsheet. notice how even one drop of insulin can and does make a difference. i also want you to notice how the numbers got worse before they got better. THIS IS NORMAL.

please, forget everything you ever knew about pzi. instead, concentrate on the dosing protocols used for lantus and levemir found here: http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=1581.

i'll check back here later. have a good day...

 

Then what is?. Quite frankly dealing with a diabetic who cant tell me that he feels terrible, who cant test himself and cant dose himself is not suited to my lifestyle. Unlike some here, I dont have the luxury of sitting home all day. I know that most dont do that.

If not Lanthus and PZI Vet is not longer being manufactured..what then?

N. I will use that..but its two hours in duration, sever drops and rises. Very harsh.

 

hi there

I just wanted to let u know, your replies are showing up mixed in with other's replies in the quotes, if u could space them out(your own reply) a bit or highlight where u are replying, it makes it a bit easier and quicker to read your own replies.

You could also post your own reply a bit lower, or rather under the quotes so it keeps them separate.
Just trying to help ya so others can view the posts more clearly.

How is Frankie doing today? Behaving like a good kitty?

 

Frankie is behaving well. Its me that isnt.

I dont want to see him sleep in his water bowl, due to my ineffectiveness at finding a dose for him quickly. As it stands, his numbers are thru the roof and its only a matter of time that will happen, if I cant get them down.

jay

 

Re: Frankie PMPS 468

Here we are

at + 8 from his am ps...he was 468...and rising,

Gave him 2 units (no drop nor duration)
PMPS 468
+2 476
+4 469
+6 197 Finally some movement in the right direction
+8 228,
+10 302
AMPS 302 12:30 AM 2.units

now that he has peaked and is rising, the question I am pondering is this, give him a reduced dose, now, along with more food, or wait. I'm thinking out loud in this post. I dont want him to go too high and he is on his way up. The previous dose gave him no duration. He is over my "top BG", give him 1 unit and test that dose, to see if at 228 how far it will bring him down, or to leave him alone (his ear has been overpoked today 16 readings) and let him relax. Sooner or later, I will have to find out what effect a smaller dose will have on him at lower BG. The next question is, do I or can I stay up all night to make sure he is out of harms way by not going too low. We are both really tired as its been a long day.

Aggressive, yes, for sure. The sooner we get the testing of an appropriate dose out of the way the better.

He only rose 30 points between +6 and +8, food is long gone, I'm going to wait another 2 hours, and then make a decision as to another dose.

I know "no dose hopping" but I do want to keep him safe on the bottom too (60 at the bottom, 220 at the top. I did learn that when he is over 400 that 2 units will get him down to a reasonable level (I hope he does go lower. I will be up all night if necessary to find out, it wont be the first time that I puledl an all niter with him, hopefully the last)

As Yogi Berra once said, "It aint over till its over" It will be over when I find that dose that will keep him at a high of 220 and a Nadir of 60. Any tighter then that would require me to be home during the week which isnt possible. I took a week off to deal with this swtich, and will be going back to work on 31/5.
Jay

 

my cat was OTJ for almost 3 years before i switched to levemir. so there's really no comparison to be made as far as a base line dose.

i agree with you. dropping to 1u bid of lantus from 3u bid of pzi would be ineffective.

again, i agree with you. if frankie was getting 3u bid of pzi, the initial starting dose of lantus was set too low. his starting dose probably should have been set at 2u or possibly even 2.5u bid. since you're seeing some action tonight, i would stick with 2u bid for 6 shot cycles (3 days) unless he has a high flat curve. if that happens, i would raise the dose by no more than 0.5u after 4 shot cycles (48 hours).

you have to remember the "cumulative" effect of lantus. one dose does build on the next. generally speaking, you'll see better results after a few days on a dose. if you don't, it's time to raise the dose.

--- if nadirs are greater than 200, but less than 300 increase by 0.25 unit.
--- if nadirs are greater than 300, increase by 0.5 unit.
--- if nadirs are less than 200, hold the dose for 3-5 days. let that cumulative action build up.

make sense?

 

Thanks
Yes.. I think I understand but then again I'm not an expert, allthough I do know Frankie better then anyone.

I didnt give him a dose at +10 and given that I had dosed him at 2 units at +8 dropping with a very high PS. I was considering shooting lower with a slightly reduced dose. 1.75 units with food going in. I am having trouble keeping my eyes open as we started this process at 6 AM this morning. I know that hypos, typically happen within the first 4 hours after a dose. I do want to be up to make sure he is ok. I'm not sure I can make it, which is why I was considering a slightly reduced dose.

His nadir was, 197 at +6 at 2 units. So, based on this protocol I should keep him at 2.0 units for the next few cycles. Right.

How does one measure a 1/4 of unit. As it is, I am using U100 syringes with 1/2 unit markings. Heck, there has been so little insulin going into the syringe that I am not even sure he is getting the dose (each dose I have given him, I thought was a fur shot)

Just so you know, PZI Vet is a U40 insuling and converting to a U100 syringe required a dose of what appeared to be 8 units hash mark. That dose I could feel going in when I was using it. This is tough. Tiny specs of insulin are being used comparatively speaking

Its time for a +10 poke.

+10 302.food and 2 units are in. Now to work on getting some duration and to get him "dosab;e" at a reasonable hour. This has been the longest duration 10 hours, that we have gotten so far. Clearly the previous dose was gone.

I'll fill you in as to where he is at. My best guess is that he only rose 30 points between +6 and +8 with food long gone. He should be (nuless the dose totally tanked out on him) around 280 to 300 at which point I will give him another 2 units, and then try to get some sleep

 

whoa! am i understanding you correctly? you shot 2u at +10 and you're planning on giving him another 2u before you go to sleep? i hope i've misunderstood what you said.

lantus is a 12/12 insulin. there are some circumstances when you might want to shoot a little earlier than that, but for the most part shoot every 12 hours or as close to it as your schedule allows. please do not give any more insulin tonight (if that's what you meant). your AM shot time is 12 hours from tonight's shot.

remember, lantus dosing is all about nadirs... and lantus likes consistency in dosing and schedule.

 

He got his dose, thats it for the moment. You misunderstood. I am aggressive yes, but thats a bit too much even for me.

I'd love to see 14 to 16 hours of duration, if not longer. Many times with PZI Vet, I had to skip cycles as we tended to get very long durations particularly when I dosed him close to or at the ideal time to catch overlap.

Although 12/12 would certainly make my life/schedule much easier. We are dealing with cats though, and since when do they make our lives easier? Just fuller with love and affection, but certainly not easy.

When we get to that point ( see above) with a dose, then its on cruise control and I have no fear that his Nadir will be too low, or that he will drop way to fast, too early in the cycle. That latter is what we all want to avoid.

He hardly ate. In under 24 hours he has eaten far more then he usually does as its been a long time since we dosed at TID ( is that 3x per day?)

Again with such little insulin in the syringe, I think I missed and gave him a fur shot yet again. I have to get used to the plunger being so close to the bottom of the syringe with a short slide as opposed to the long slide of the plunger as recently as this past Friday morning.

By the way. later on today 3/7 can I post a "new topic" or do I have to continue this thread?

Jay

 

He got his dose, thats it for the moment. You misunderstood. I am aggressive yes, but thats a bit too much even for me.

oh good. you scared me for a moment.

I'd love to see 14 to 16 hours of duration, if not longer. Many times with PZI Vet, I had to skip cycles as we tended to get very long durations particularly when I dosed him close to or at the ideal time to catch overlap.

i know it's difficult, but have patience. i know it's even more difficult to have patience when your cat did well on another insulin. you WILL get there. lantus doesn't like to be rushed. you're already ahead of the game because your experience will allow you to be a little more aggressive than the average newbie coming through here.

Although 12/12 would certainly make my life/schedule much easier. We are dealing with cats though, and since when do they make our lives easier? Just fuller with love and affection, but certainly not easy.

lol! how true! although, as soon as you get frankie to an ideal dose, your life will be made easier using lantus.

When we get to that point ( see above) with a dose, then its on cruise control and I have no fear that his Nadir will be too low, or that he will drop way to fast, too early in the cycle. That latter is what we all want to avoid.

yep. we're on the same page.

He hardly ate. In under 24 hours he has eaten far more then he usually does as its been a long time since we dosed at TID ( is that 3x per day?)

he may eat more when his numbers are higher. less as they come down. my alex always did.
yes, TID pertains to shooting 3 times a day.

Again with such little insulin in the syringe, I think I missed and gave him a fur shot yet again. I have to get used to the plunger being so close to the bottom of the syringe with a short slide as opposed to the long slide of the plunger as recently as this past Friday morning.

ddon't worry. you'll get used to it.

By the way. later on today 3/7 can I post a "new topic" or do I have to continue this thread?

you can start a new topic with frankie's AMPS. one thread per day per cat. there's so many kitties in this group. it helps keep things organized.
hope you get some sleep tonight...

 

Good morning ( It should be by the time you read this_

Sleep. whats that?

I got 3 1/2 hours and wanted to get up prior to +6 to check on him.

As I said earlier, cats, make our loves fuller with lover but easier...not a chance.

Cats Rule

Thanks for sticking with me last night.
Jay

 

Do you have the reverse of this protocol as it only speaks to "increasing the dose" not decreasing the dose as the Nadirs get lower and lower.

Jay