Advice on clearing a bounce

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Sue484

Member Since 2015
Frankie is having a HUGE bounce after hitting a new low of 65 yesterday. I have therefore reduced his dose this morning by 0.25 as per the SLGS instructions. Is there anything I could or should be doing when he is heading for blues and greens that will lessen the bounce or help it clear quicker?
 
Three things, and just remember this is only my semi-informed opinion:

1) when confronted with a moderately low number like the one you got even on an alphatrack, you probably don't need high carb food. Just a low carb (preferably moist) meal is all you need and that's more for you than the cat.

2) when your cat came up over 100 (maybe above 130 on an alphatrack), you could have given his new (reduced) dose an hour or so late. when dealing with a drug like lantus or levemir it takes a few hours to kick in normally and onset is gradual. If you'd done that it would have affirmatively impacted the magnitude of the bounce if not preventing it.

3) i can't prove it, but it's my opinion when a cat gets better regulated, in general, they are less likely to show the bounce phenomenon. the "bounce" is really just a maladaptive extreme of a normal homeostatic mechanism. and as glucose regulation/metabolism becomes less broken, it's logical to believe those adaptive mechanisms get less broken also. this might make for an interesting study. just make sure your low carb food is really low carb. that's most important.

Take a look at my spreadsheet. Mine had a scary drop to 36 recently (human meter... probably 48 or 50 on an alphatrack equivalent). Now I did put a couple drops of honey under his tongue, then fed him his usual stuff. He came up to 104 about six hours later (135 or 140 on an alphatrack) and I just shot him with his (new reduced) usual dose. Everything was fine. No bounce I could see.

my 2 cents.
 
Three things, and just remember this is only my semi-informed opinion:

1) when confronted with a moderately low number like the one you got even on an alphatrack, you probably don't need high carb food. Just a low carb (preferably moist) meal is all you need and that's more for you than the cat.

2) when your cat came up over 100 (maybe above 130 on an alphatrack), you could have given his new (reduced) dose an hour or so late. when dealing with a drug like lantus or levemir it takes a few hours to kick in normally and onset is gradual. If you'd done that it would have affirmatively impacted the magnitude of the bounce if not preventing it.

3) i can't prove it, but it's my opinion when a cat gets better regulated, in general, they are less likely to show the bounce phenomenon. the "bounce" is really just a maladaptive extreme of a normal homeostatic mechanism. and as glucose regulation/metabolism becomes less broken, it's logical to believe those adaptive mechanisms get less broken also. this might make for an interesting study. just make sure your low carb food is really low carb. that's most important.

Take a look at my spreadsheet. Mine had a scary drop to 36 recently (human meter... probably 48 or 50 on an alphatrack equivalent). Now I did put a couple drops of honey under his tongue, then fed him his usual stuff. He came up to 104 about six hours later (135 or 140 on an alphatrack) and I just shot him with his (new reduced) usual dose. Everything was fine. No bounce I could see.

my 2 cents.
I'm sorry, but this isn't good information.

The basic principle is that better an hour too high than a minute too low. When numbers are below 68 on an AT meter, that is in too low territory. You feed HC food or syrup in a modest amount and then re-test in 15 - 30 min to see if the HC has begun to bring numbers up. You repeat the process if numbers are not returning to safe levels. Please take a look at the Shooting & Handling Low Numbers sticky. The latter portion of the post deals with managing low numbers. The cut-offs are based on a human meter but the principle is still applicable and is also applicable to SLGS although I wrote the section primarily for TR.

I generally discourage new members from adjusting shot times (if possible) until they have sufficient data accumulated on their cat. It's important to know when onset begins and nadir falls as well as to know how much duration you're getting from your insulin. Adjusting shot times rarely has an impact on a bounce. Cat's numbers will bounce until they don't. Shooting late acts like a dose reduction. If anything, you can hold the current dose for a cycle and then shoot the reduced dose the following cycle. We refer to this as "shooting though the bounce." The idea is that holding the current dose for the additional cycle may help the bounce to clear a bit more quickly.

The third point above is correct. As a cat gets used to spending more time in normal BG range, bounces are less frequent and/or less extreme. A bounce isn't, however, a "maladaptive extreme" -- it's a safety mechanism of our normally redundant homeostatic system. Your cat has become acclimated to being in higher numbers. As a result, when numbers drop fast or drop low, the liver and pancreas respond to what is interpreted as an emergency -- they panic! A stored form of glucose along with counterregulatory hormones are released and numbers spike back up. It's a protection from hypoglycemia. It's an annoying response but a normal one. You just need to wait the process out.
 
1) The feline system is quite capable of manufacturing carbs from protein. For that matter we are too. But that's the way a cat lives in the wild. We have big molars suited for crushing/grinding nuts. They have hypertophied canines perfectly suited for killing prey and tearing flesh. They're obligate carnivores. Maybe you need candy bars to survive, maybe the commercial kibble makers love to sell this (high profit margins from cheap food), but your cat needs this like a hole in the head. The irony is eating candy bars probably helped your cat become diabetic in the first place. A mouse or a lizard is 2% dry matter carbs maximum. 65 on an alphatrack translates roughly to 48-50 on a human meter. Yes, this is a tiny bit low, but not a "panic value". Per the protocol, in a maintenance phase of TR, this isn't even a reason to immediately cut the dose unless you see this number 3 times on separate days. You handle this your way, I'll handle it mine. If my cat will eat some fancy feast classic +/- fortiflora blended in a nutribullet, in the absence of symptoms, that's plenty. If he's in the 30's (as happened recently) a couple drops of honey under the tongue and the nutribullet fancy feast is what I do. If he won't eat, then honey. This is by no means animal cruelty or even "incorrect" conceptually. My cat was just fine and he didn't "bounce", not even 10 points, and he had never documented numbers that low. Look at his prior numbers, this particular episode, my notes about what I did, and the aftermath in my SS.

Mr. Sluggo does not need candy bars! He likes low-carb so much he'll hunt his own, given the chance.

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2) Delaying the shot for an hour while feeding a meal was specifically mentioned as an option in the protocol. If you have to head off to work, or whatever, it may be impractical. But it is a reasonable and accepted approach to the problem. Read the protocol carefully. Then read it again, before you call this bad information.

3) Perhaps I was misunderstood when I stated "maladaptive extreme". Yes, it is a normal homeostatic mechanism for the liver to release glucose from glycogen in response to glucagon. However, it is maladaptive when that mechanism takes the blood sugar to 500 or 600. Of course, when you're finished feeding your cat candy bars while the liver is already doing its thing that may be the end-result, and as I mentioned when glucose regulation and metabolism gets fixed from the insulin end of things, the glucagon end of things likely improves as well. It's just under control of different cells in the same organ (alpha cells, not beta cells in the pancreas). Perhaps when the pancreas heals, all of it does not just beta cells.

blood glucose regulation
 
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Sandman:

I'm inordinately familiar with the German Lantus board version of the TR protocol as well as the modifications that we use. I've been dealing with Gabby's FD for almost 6 years and spend a good deal of time volunteering here. If you wish to run your cat in numbers below 50, that's your decision. I would respectfully ask that you not advise others to do so. We use below 50 (on a human meter) as a margin of safety given that there is measurement error inherent in any meter and any strip. Frankly, this is a better safe than sorry approach. I will not encourage anyone to allow their cat to sit in numbers below 50 because there is no guarantee how easy or hard it will be to get those numbers back into a safe range. I suspect you are familiar with the statement, "First, do no harm." Please do not encourage the potential for harm to befall someone else's cat.


 
I did NOT run my cat in numbers below 50 and have not. Look at my SS. With what I did Mr. Sluggo was documented out of those number within 30 minutes and there isn't another number on the sheet like what you've described. And there was no subsequent bounce. I did get him in remission once back in 2012 initially with prozinc TR, attempted when he relapsed with the same thing, and when things weren't going the right direction, recognized it and made the switch to lantus. Who can say what the future holds, but so far, if I do say so myself, it's blue skies and green lights.

As for what the protocol says, refer to table 3A here:

lantus_TR_protocol

[URL='http://www.felinediabetes.com/Roomp_Rand_2008%20dosing_testing%20protocol.pdf']
You're saying if a cat shows any number below 50 they get an immediate dosage reduction? Many do say that, though it's a departure from the above. I'll consider doing that going forward. I'm sure the reason for that provision in the protocol is the possibility the cat will then fly out of control and you'll need to backtrack. What would you say are the odds of that?

I do appreciate your contribution to the community. I am grateful for all you do here. And as regards, "do no harm"... yes, I am familiar with that one.
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1) The feline system is quite capable of manufacturing carbs from protein.

This may be true of healthy cats, but with diabetic cats, all bets are off. Every cat responds differently to treatment and carbs, and every cat is diabetic for different reasons. (FWIW, my cat was eating a low-carb/high protein diet when she was diagnosed...no candy bars here.) Some cats bounce forever, some suddenly stop bouncing, some stay nicely regulated for a while then go back to bouncing. There is no "one size fits all" with regards to any aspect of FD and its treatment.

As Sienne said, you are playing with fire by not using the appropriate tools (such as high carb food) when a cat is skating on the edge of dangerously low numbers. While we are very much about tight regulation and healthy numbers, safety must absolutely come first. The protocols we follow here adhere to that concept - safety first.
 
You do what you want. I found reversion to high carb food unnecessary with a prozinc TR regimen back in 2012, and going by what the R/R study says it's likely even less necessary when using a long-acting insulin like lantus. For unknown reasons clinical hypoglycemic episodes were even less common with lantus than shorter acting insulins. For that matter some vets feel being more aggressive with lantus in early TR is less harmful than hypoglycemia.

>
How to increase the chance of remission
Our study in diabetic cats (Marshall et al, awaiting publication) found better glycaemic control and higher remission rates when newly diagnosed diabetic cats were treated with glargine compared to lente or PZI insulins. This study also showed that, regardless of insulin type, good glycaemic control soon after diagnosis (within 3 weeks) increases the chance of achieving remission.

For reasons that are presently unknown, glargine treated cats appear to tolerate slight overdosing with insulin very well. For this reason, it is suggested that for the first 4-6 weeks of therapy, insulin be slightly overdosed and cats monitored carefully. Slightly overdosing with glargine increases the risk of hypoglycemia but usually results in achieving early good glycemic control which reverses glucose toxicity and results in a non-insulin dependant state. The benefits of remission far outweighs the risks of hypoglycaemia.

To maximise glycaemic control and hence the chance of remission

  • select glargine as initial insulin
  • administer glargine TWICE daily rather than once daily
  • slightly overdose with insulin for the first 4-6 weeks
  • use a low carbohydrate diet
  • restrict calories if overweight and encourage physical activity<
So, it's a trade-off.

http://www.thecatclinic.com.au/info-for-vets/using-glargine-in-diabetic-cats-2/
 
I have to agree with Sienne and it's also based on my lengthy experience here and having looked at hundreds of SSs and also having sat up most of the night with members whose cats were in low numbers.

First of all, you cannot extrapolate across the board what a number on a human meter will equate to on an AT. We've had lots of members, including me, run comparisons and they are all over the place. One can compare one's own human meter and one's own AT but I wouldn't go any further than that. I have a tab on Gracie's SS if you would like to see the comparisons. Based on that info, I would never make the assumptions you make regarding meter comparisons.

Secondly, every cat responds differently to carbs just as people have different responses to different macro- and micro-nutrients. My philosophy is to use the lowest carb food that gets the job done but, for some cats, that might be a high carb food if numbers are low. I see no benefit in allowing my cat to surf in the 40s because there is no cushion and she has been flat even in the 60s and then dropped to the 20s (these are all human meter BGs). Know thy cat. Your cat might do fine with your regimen but until a new member knows their cat, we are going to be cautious based on our knowledge. Lantus and levemir insulins have a cumulative nature so one shot builds upon the preceding. When the depot gets full, a CG could be dealing with low numbers for an extended time. I know...I've done it. I'm not waiting six hours for my cat to come out of the 30s. As a doctor, you should know that hypoglycemia has many effects on the body and that includes the brain. We don't have any way to connect our cats to monitors at lower numbers to see what effects the low blood sugar is actually having when they are showing no clinical signs of hypoglycemia. Safety first.

Thirdly, numbers might shoot up for a variety of reasons including the response of the liver, feeding high carb food, lack of duration. If numbers skyrocket from green or blue to pink or higher within a very short span of time (hour or so), it is likely due to lack of duration. I've also had Gracie fairly tightly regulated for long periods of time with minimal bouncing...and then she starts the bouncing again.

Lastly, some cats do much better on a 10% of calories from carbs food as opposed to a very low carb food such as 0-1%. My kitty did not do well on the lowest carb foods. She does much better with foods in the 4-10% range. ECID.

I did NOT run my cat in numbers below 50 and have not. Look at my SS.
I did and I don't know how you can make the above statement, on the night you got a 36, you didn't retest for six hours. Knowing what I know about FD, he could have run below 50 for several hours. The honey you gave him likely wore off within an hour or two. It's possible that he came up on his own with the FF because he was past mid-cycle but his depot was very full...so he might have stayed low for quite some time before coming up.
 
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I did and I don't know how you can make the above statement, on the night you got a 36, you didn't retest for six hours.

Excuse me. Look at the notes section of the chart from that evening.

62 @ 6.25. 63 @ 6.75. 73 @ 7.25

I documented rising numbers for an hour and a half (an hour and a quarter past his usual nadir).

In no way was I cavalier about how I handled that one.
 
You do what you want. I found reversion to high carb food unnecessary with a prozinc TR regimen back in 2012, and going by what the R/R study says it's likely even less necessary when using a long-acting insulin like lantus. For unknown reasons clinical hypoglycemic episodes were even less common with lantus than shorter acting insulins. For that matter some vets feel being more aggressive with lantus in early TR is less harmful than hypoglycemia.

This last sentence is particular is untrue, and extremely dangerous. We HAVE lost cats on lantus to hypoglycemia, and we have seen cats became permanently brain damaged due to hyp0glycemia in this group. Just because it is considered a gentle and slow-acting insulin does NOT guarantee safety from hypo.

Remember that "TR" stands for Tight REGULATION". Remission is the icing on the cake, but the protocol is about safe REGULATION, and it is not a guarantee of remission. Being more aggressive than would allow for safety will not force remission if remission is just not meant to be.
 
Frankie is having a HUGE bounce after hitting a new low of 65 yesterday. I have therefore reduced his dose this morning by 0.25 as per the SLGS instructions. Is there anything I could or should be doing when he is heading for blues and greens that will lessen the bounce or help it clear quicker?
Hi there :cool:

What you are seeing is the combined effects of the 'bounce' and the skipped shot.
If you can swing it, get some +2 tests in. That way you can get a feel for what kind of cycle it may be and use food to slow the drop if needed.
Hang in there - it's a lot to learn :cool:


@Sandman - Sue is not following TR.
While we know a whole lot about FD, we don't know what we don't know.
Each cat is different. It takes time for a caregiver to get to 'know thy cat' , which is the foundation for successful, safe treatment.

 
This last sentence is particular is untrue, and extremely dangerous.

No, that last sentence is not untrue at all and I provided you both a reference and a web link showing you that.

Here it is one more time:

using glargine in diabetic cats

PS: don't you think this is a philosophical difference, perhaps best moved someplace else?? I think exposure to different viewpoints is perhaps a good thing for a newby. It's the basis for residency education in a medical specialty and if you're a good resident trying to survive your residency with sanity you say to yourself, "today I'll do it dr. xxxx's way". Then when you get out, you maybe have a variety of perspectives. But at this point, doesn't this belong elsewhere? And one other thing... I say an interchange of ideas is perhaps helped by an atmosphere of civility and respect. As JS Mill once said, liberty is good because it helps truth triumph over falsity. And such statements as "this information is incorrect!" is just not helpful. When you go to take your anesthesia oral boards, for example, there really AREN'T any right or wrong answers. Whether you pass or fail depends very much on whether you defend your answers and how well (other things as well, like whether you get thrown early and can't recover your wits, adaptability, etc., etc.). And that's all I have left to say. I have a headache, haven't taken my morning BP meds, I'm sure it's high now and life is just too short. AND it's time for a mid-cycle number on Mr. Sluggo!
 
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No, that last sentence is not untrue at all and I provided you both a reference and a web link showing you that.

Here it is one more time:

using glargine in diabetic cats

PS: don't you think this is a philosophical difference, perhaps best moved someplace else??

Links on websites and what can happen in reality are two different things. We have seen cats on lantus die from hypoglycemia here. At the same time, we have had cats in this group who run in higher numbers who are healthy and happy and very much alive. I'm all about a well-regulated cat running in good numbers, but safety has to come first.
 
Sandman...My apologies. His full SS did not show up on my iPad. I suggest you record his numbers on his SS in the appropriate blocks. That's where the numbers should be.

I also just want you to know you aren't the only one with an advanced degree with education in physiology (human or feline). We aren't just a bunch of crazy cat people. We have access to medical and veterinary research and also work to keep ourselves current on feline diabetes.
 
@Sandman : Sue is following the START LOW, GO SLOW METHOD (SLGS).

Please make yourself aware there are several methods to achieve regulation out there.
How to increase the chance of remission
Our study in diabetic cats (Marshall et al, awaiting publication) found better glycaemic control and higher remission rates when newly diagnosed diabetic cats were treated with glargine compared to lente or PZI insulins. This study also showed that, regardless of insulin type, good glycaemic control soon after diagnosis (within 3 weeks) increases the chance of achieving remission.

For reasons that are presently unknown, glargine treated cats appear to tolerate slight overdosing with insulin very well. For this reason, it is suggested that for the first 4-6 weeks of therapy, insulin be slightly overdosed and cats monitored carefully. Slightly overdosing with glargine increases the risk of hypoglycemia but usually results in achieving early good glycemic control which reverses glucose toxicity and results in a non-insulin dependant state. The benefits of remission far outweighs the risks of hypoglycaemia.

To maximise glycaemic control and hence the chance of remission


    • select glargine as initial insulin
    • administer glargine TWICE daily rather than once daily
    • slightly overdose with insulin for the first 4-6 weeks
    • use a low carbohydrate diet
    • restrict calories if overweight and encourage physical activity<

There's a lot of things on the Internet. Some of it is good. Some outdated. Some personal choice. The above is dated info and the FDMB's Lantus & Levemir ISG chose to move past it several years ago in favor of more recent studies.

Please familiarize yourself with this protocol before offering advice/suggestions to those following it. By not knowing the SLGS protocol and it's ins and outs... all you're doing is confusing Sue and others.

FYI: This is the TR protocol which is also followed in this group:

management of diabetic cats.pdf

There's also a sticky available with the protocol as well as a slightly modified version:
LANTUS & LEVEMIR - TIGHT REGULATION PROTOCOL



Sue, my apologies for your thread being being hi-jacked. The information, suggestions, and advice Sienne, Amy, Sandy and Marje have offered is appropriate for those following the SLGS Method.
 

Attachments

Healthy debate is always good, but it can certainly be confusing to a newbie.
Just a suggestion, @Sue484 -- I have a few very experienced favourites whose advice I seek and follow, they have helped so much, using the SLGS and TR protocols here. These people have sat up half the night, coaching me along when I've run into issues. Maybe you can find a few who you feel intuitively you can trust and work with them.
 
@Sue484 - I follow the TR protocol, so I can't speak to SLGS method, however, Skooter LOVED to bounce in early days of his diagnosis.

The piece of advice that I got (and trust me I hated it LOL) was patience. Patience is the key with this lovely sugar dance we are all participating in. I am not a very patient person myself, though I have been forced to become one in relation to his diabetes :rolleyes:

The other two pieces of advice that I got that I liked (because it was a little bit easier to do :smuggrin:) LEARN thy cat (which eventually will turn into KNOW they cat) --- I asked TONS of questions in the beginning, looking at other spreadsheets and comparing them to Skooter's and trying to make sense out of everything and don't just look at the numbers -WCR Whole Cat Report -- how are they acting? eating? playing? etc....that can sometimes can tell you just as much about how your cat is doing as the number on the meter.

The protocols that we use here are tested and work. People may do variations of that, but when it comes to needing help, everyone here will be basing that help on the protocols that we follow ---- when you start to go too far from those protocols it becomes difficult and dangerous for people to give you advice as everyone is in uncharted territory at that point.

Skooter was up to 5.5 uints twice a day when he started....we are currently at 0.50 twice a day and working on getting a reduction (total antijinx) soon....why? Because we followed the amazing advice of those people here who know and understand not only the different protocols, but how to read and interpret spreadsheets, etc......
 
I work with autistic children. There is a saying:

0cfd9cc86b7c597ecb04e6d8a960dde9.jpg


That also applies to diabetic cats. The saying here on FDMB is "ECID" or "Every Cat is Different." Anyone's first priority should be to learn about their own cat - being able to analyze someone else's cat's situation takes a great deal of experience with Feline Diabetes.

Sue, nice job handling the low numbers last night. :bighug: The more time Frankie spends in normal numbers, the faster he'll begin to clear his bounces. In the meantime, enjoy testing less often if he's running high.
 
>
How to increase the chance of remission
Our study in diabetic cats (Marshall et al, awaiting publication) found better glycaemic control and higher remission rates when newly diagnosed diabetic cats were treated with glargine compared to lente or PZI insulins. This study also showed that, regardless of insulin type, good glycaemic control soon after diagnosis (within 3 weeks) increases the chance of achieving remission.

For reasons that are presently unknown, glargine treated cats appear to tolerate slight overdosing with insulin very well. For this reason, it is suggested that for the first 4-6 weeks of therapy, insulin be slightly overdosed and cats monitored carefully. Slightly overdosing with glargine increases the risk of hypoglycemia but usually results in achieving early good glycemic control which reverses glucose toxicity and results in a non-insulin dependant state. The benefits of remission far outweighs the risks of hypoglycaemia.

Hi Sandman @Sandman

I think when you have been interpreting the above information, you have been doing so from a starting point of FDMB tight regulation, instead of a starting point of what most vets prescribe, which is a dose that keeps the cat well above an ideal or healing nadir (nadir of 5mml to 9 mmol OR US 90 to 162) for people who DO NOT test BSL. Vets do this because they need to ensure the cat does not drop low enough to cause problems that aren't being monitored. I know my vet is very uncomfortable once the BSL drops below about 6 or 7 (108 to 126)

I have had a phone consultation with Rhett Marshall and I can assure you he does not advocate very low BSLs. He said to me when we were discussing the dose of Sheba's insulin to go up slowing and as long as I was monitoring the BSL by testing multiple times during the day, I would be able to keep Sheba safe. He encourages his clients to home test and to learn to select the correct dose themselves.
On his website for people who are home monitoring he says to reduce the dose if the BSL is 4 to 6 (72 to 108) and to not give insulin, and to ring the clinic if the BSL is less than 4 (72). Those figures are not close to a hypo
So I think you may have been misinterpreting his meaning.
 
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