Increasing the dose again

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I'd actually go back up to 1.75u. Looks like 2.0u was the last good dose that was getting her consistently into greens - when she got green at 1.5u that was the 5th cycle after the dose reduction from 2.0u, and I'd guess that the larger depot may have still been at play and helping to lower her blood sugar.

That's what I'm thinking anyway. It's really common for dose reductions taken too close together to end up being a failed reduction. I think hers were too close together. You want to consider that when you decrease the dose, that larger dose's depot will still be giving out some for as many as 6 additional cycles after you decrease the dose. Does that make sense? If it's more than 5-6 cycles since the last dose decrease, then I'd be more confident that a dose decrease is really needed. If the 40's happen in the first couple of cycles after a dose reduction, I probably wouldn't take another one yet and just consider that it was probably the depot action.

Looking at the green disappearing over the past week or so, you can see that there was a lot of green at 2.0u and right after you decreased the dose, but then as the depot dwindled, the green also dwindled.

You could make a case for just going back to 1.5u as well, although I'd lean to the 1.75u. Maybe it depends on how you're feeling.
 
julie & punkin (ga) said:
I'd actually go back up to 1.75u. Looks like 2.0u was the last good dose that was getting her consistently into greens - when she got green at 1.5u that was the 5th cycle after the dose reduction from 2.0u, and I'd guess that the larger depot may have still been at play and helping to lower her blood sugar.

That's what I'm thinking anyway. It's really common for dose reductions taken too close together to end up being a failed reduction. I think hers were too close together. You want to consider that when you decrease the dose, that larger dose's depot will still be giving out some for as many as 6 additional cycles after you decrease the dose. Does that make sense? If it's more than 5-6 cycles since the last dose decrease, then I'd be more confident that a dose decrease is really needed. If the 40's happen in the first couple of cycles after a dose reduction, I probably wouldn't take another one yet and just consider that it was probably the depot action.

Looking at the green disappearing over the past week or so, you can see that there was a lot of green at 2.0u and right after you decreased the dose, but then as the depot dwindled, the green also dwindled.

You could make a case for just going back to 1.5u as well, although I'd lean to the 1.75u. Maybe it depends on how you're feeling.
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Thank you Julie. I will go with the 1.5 unit dose I think but not wait too long to increase again if needed. I took the decreases because our vet wants us to stick to the protocol as written and it says to immediately reduce the dose if blood glucose is under 2.8/50. One thing I can't find in the protocol by Roomp/Rand is how long to hold the decreased dose. In one part it says immediately increase to last effective dose but that refers to phase 4 of the protocol where insulin is being phased out when glucose levels have consistently been in the normal range for at least a week and then they rise with a decrease in dose. Thank you again. I really appreciate your opinion and support too.
 
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Voula said:
One thing I can't find in the protocol by Roomp/Rand is how long to hold the decreased dose. In one part it says immediately increase to last effective dose but that refers to phase 4 of the protocol where insulin is being phased out when glucose levels have consistently been in the normal range for at least a week and then they rise with a decrease in dose.
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The idea with a dose decrease is that the green numbers that caused the drop under 50, and therefore the decrease in dose, will continue after the dose decrease. So if you're having long hours of green at, just for example, 2u, and then the cat drops under 50, and you decrease to 1.75u, those same long stretches of green should continue.

If you decrease the dose and the numbers trend upward, ie, you stop seeing those nice long stretches of green, then you should immediately go back up to the last good dose. There is no length of time to wait, except if there is a bounce and you want to see what the cat clears the bounce and gets to before deciding if you should increase back up.

Here's some more on failed reductions.

This part: where insulin is being phased out when glucose levels have consistently been in the normal range for at least a week and then they rise with a decrease in dose.

is a separate issue. That's in the section on decreasing the dose, and what it says is that a cat can either "earn" a reduction by dipping below 50, or by having all of their tests between 50-120 (human) for the past 7 days.

I wouldn't worry about the phase part.

I think where your vet is perhaps confused, is that one needs to consider the depot's effect when deciding if you should decrease the dose or not, like I described earlier. But even if you weren't thinking about the depot and you decreased the dose, as soon as you saw a "regular" cycle, not a bounce cycle, and the nadirs were no longer in green numbers, you would then call it a Failed reduction and go right back to the last good dose.

Does that make sense? I don't see you deviating from the protocol. It's meant as a place to start, however, while you get to know your cat's own patterns. People do deviate from the protocol once they've learned the basics, in order to do what their cat needs. The basic idea of the protocol is to try to get a cat tightly regulated, between 50-120, so their body is protected, and if it's possible for the pancreas to heal and begin putting out insulin again.
 
julie & punkin (ga) said:
The idea with a dose decrease is that the green numbers that caused the drop under 50, and therefore the decrease in dose, will continue after the dose decrease. So if you're having long hours of green at, just for example, 2u, and then the cat drops under 50, and you decrease to 1.75u, those same long stretches of green should continue.

If you decrease the dose and the numbers trend upward, ie, you stop seeing those nice long stretches of green, then you should immediately go back up to the last good dose. There is no length of time to wait, except if there is a bounce and you want to see what the cat clears the bounce and gets to before deciding if you should increase back up.

Here's some more on failed reductions.

This part: where insulin is being phased out when glucose levels have consistently been in the normal range for at least a week and then they rise with a decrease in dose.

is a separate issue. That's in the section on decreasing the dose, and what it says is that a cat can either "earn" a reduction by dipping below 50, or by having all of their tests between 50-120 (human) for the past 7 days.

I wouldn't worry about the phase part.

I think where your vet is perhaps confused, is that one needs to consider the depot's effect when deciding if you should decrease the dose or not, like I described earlier. But even if you weren't thinking about the depot and you decreased the dose, as soon as you saw a "regular" cycle, not a bounce cycle, and the nadirs were no longer in green numbers, you would then call it a Failed reduction and go right back to the last good dose.

Does that make sense? I don't see you deviating from the protocol. It's meant as a place to start, however, while you get to know your cat's own patterns. People do deviate from the protocol once they've learned the basics, in order to do what their cat needs. The basic idea of the protocol is to try to get a cat tightly regulated, between 50-120, so their body is protected, and if it's possible for the pancreas to heal and begin putting out insulin again.
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Thank you Julie. That all makes sense. I think I have been holding dose reductions too long so I thank you for clarifying what is done. I can see with the reduction from 1.5 units to 1.25 units that we did have some bouncing so on that basis I could have increased the dose a day or so earlier than I did when the bouncing cleared but all is well as we are having a really nice flat green cycle at the moment so the increase to 1.5 units is working for now. I understand about the depot effect and taking that into account with deciding on whether to reduce a dose. I understand our vet wanting us to stick to the protocol as written and I think in parts the protocol could be clearer in what to do in some situations. But either way even if we discount the depot I need to increase the dose more quickly from reductions in dose that aren't working when I see a regular cycle again after a bounce. I will bookmark your post and save it to my computer to reference again. Thank you again. :bighug:
 
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