What is the vet's role in the TR protocol?

[Adrian and Chino]

Before I found this board, I took my cat to a vet who didn't want to increase his Lantus from 2 units BID, even though his nadirs were consistently in the 300s. I asked if I could go up at least half a unit, and he agreed to that. A week later, he tested over 600 two hours after his evening dose and I took him to an emergency clinic where the vet said I could go up to 3 or 3.5.

So I'm looking for a new vet, but I have a few questions:

1. Was your vet familiar with the TR protocol before you discussed it with them?
2. Did you get any resistance or disapproval?
3. Do you notify the vet of dose changes or hypo episodes?
4. How frequently do you see the vet for routine diabetes care?

Any other relevant information you can share would be appreciated. Thanks!

 

[Nan & Amber (GA)]

Hello and welcome!

Answers to your questions:

1. I don't know, I only used SLGS, but my vets were supportive of home testing and up-to-date on proper nutrition for diabetic cats, so .
2. No, they were great.
3. I would bring in my spreadsheet with all the numbers and they would make copies for their records. I did follow their recommendations on the first couple of dose changes, then I basically just did what I thought right (based on information here) and kept them informed. No (symptomatic) hypo episodes to report.
4. Before OTJ, we went in every month or so, but that was partly because of the unwelcome addition of pancreatitis to the mix-- without that, and without the OTJ, I think we would have just been on a once-every-six-months schedule after the initial period and settling on the course of treatment.


Others will be by soon who have more experience sussing out spreadsheet patterns than I do, but I do have a couple of comments in the meantime.

Observation: Chino seems to have a good response to Lantus (great job on getting a lot of tests in, by the way!) on some days, but also shows a pronounced tendency to bounce sky-high after he drops low. This isn't unusual in the early days, but it does make it harder to figure out what is going on and make dose decisions-- it takes a lot of data to figure out what a given high number "means".

Question: how was the initial dose of 1.0U decided on? Was it based on BG numbers at diagnosis, a vet curve, Chino's weight, some combination?

Beyond the question of the initial dose, my big concern in looking at the spreadsheet is that the decision to go from 1U->2U of Lantus was made before you had all those wonderful mid-cycle tests in, and therefore on the basis of very little data. You do have the data going forward, but that's a pretty big jump for a cat. I'm also wondering about the subsequent increases-- 0.5U may not seem like a big amount, but it can be for a cat-- that's why the protocols here recommend 0.25U increase amounts.

Overall, my impression is that there's a fair chance that the ideal dose for Chino has been missed on the trip up the dosing ladder-- maybe between 1.0 and 2.0U, maybe even lower than that. Others will weigh in with their opinions and recommendations as to the best path going forward, but in the meantime, just want to say welcome again, and great job on the testing!!!!

 

[Critter Mom]

Hi Adrian,

I recently posted about how the relationship between myself and our vet worked when I was using TRP with Saoirse. Here's the link:

http://www.felinediabetes.com/FDMB/...-i-have-5-year-old-twins.170428/#post-1856910

I think I am the first (and possibly the only) client at the practice to use TRP. I used the Roomp-Rand journal article attached below as part of my discussion with our main vet when starting Saoirse on TRP. Our main vet is very progressive and was willing to support my choice but at times he has told me that in the veterinary profession TRP is considered "very controversial." (Note: At our previous practice I would probably have got open hostility to TRP - but they hadn't any real clue about effective treatment for feline diabetes in general.)

My impression is that many vets here (including some specialists I've encountered) try to shoehorn caregivers into a treatment method where the cat is kept in somewhat hyperglycaemic numbers for part of the day so as to minimise chance of hypo. I sense that they are very wary of TRP but I do wonder whether part of that is due to the lack of people who home test and rely on vet curves, etc. for dose management and who, I can imagine, may end up in hospital with hypos far more frequently than a cat well-managed by a home testing caregiver. I feel that the default position of most vets is to assume that caregivers aren't willing or able to 'go the extra mile' to better manage their cats' insulin needs. I think they do not have enough respect for the fact that some caregivers are very capable of keeping their cats safely and tightly regulated using adequate home testing and trend tracking tools like the FDMB spreadsheet, and said caregivers are also more than capable of managing day to day dose adjustments following a well-defined, published protocol. TRP is not for everyone but I wish vets in general would be more supportive of caregivers willing and able to work with it.

Per the post linked above I was much happier managing my own dose adjustments for Saoirse. As my knowledge and experience increased I felt that my understanding of treating my cat with Lantus far outstripped anything the vets at our practice could offer. Once we got up and running on TRP I did not consult with the vets further about the diabetes side of things. Our main vet was perfectly happy that I knew what I was doing. I might chat about Saoirse's current status during consults about non-diabetes health matters and the vet might have a quick look at Saoirse's spreadsheet but nothing more than that.

I had no need to report any hypo episodes to the vet because once I started home testing and managing Saoirse's dosing myself she didn't have any!

(Had Saoirse ever experienced a mild symptomatic hypo I would have managed it at home and later informed the vet. If she had ever been at the slightest risk of experiencing a serious hypo episode I would have immediately taken her to the vets for emergency treatment.)

Our vets now consider me to be a very capable caregiver of a feline diabetic. Our main vet has a special interest in feline diabetes and he has taken a very keen interest in my treatment of Saoirse in line with TRP guidelines. He may not have completely agreed with some of my decisions in the first instance but has frequently reconsidered his position when he could see from her data that my choices were safe and effective. I have earned his respect. That said, hand on heart I don't see the practice running an ad campaign to encourage other clients to practice TRP any day soon. Had I not brought TRP to the table after learning about it here I doubt very much whether any vet at our practice would have suggested it as a treatment method.


Mogs
.

 

[Adrian and Chino]

I was living in Naples when he was diagnosed. His BG was above 400 mg/dl. I switched to Fancy Feast and brought him back 2 weeks later and they tested again: 422. So the vet said to start him on 1 unit twice daily. I asked for a prescription for an AlphaTrak 2, which he wrote, but told me not to test until 7 days later.

After a week, I was going to try for a curve, but it was Saturday and they closed at noon, so I called with the AMPS and +2 (429 and 524) and he increased the dose to 2 units. Again, he told me not to test until 7 days out, but I tested earlier to get a non-stressed value, since I moved to Tampa later that week. That's when I found the new vet who looked at my spreadsheet but didn't want to increase the dose at all. I asked if I could go up at least 2.5 units, and he agreed to that.

I went up to 3 after the emergency vet said I could increase to 3 or 3.5. I took him to the emergency clinic a week after going up to 2.5 because his +2 was over 600.

 

[Adrian and Chino]

Thanks, Mogs! I printed the article for the same purpose. You make some great points about caregivers who don't test vs. those who do.

Amber, is there a protocol for lowering the dose when the blood sugar is this high, in order to determine if a lower dose is more effective?

 

[Nan & Amber (GA)]

Amber, is there a protocol for lowering the dose when the blood sugar is this high, in order to determine if a lower dose is more effective?

Other more experienced folks can give you guidance on the best way to do that-- I wish I could, but I don't feel that I've been around long enough to give that kind of specific dosing advice. Mogs is one of the people who can give such advice and you should definitely listen to her on all things feline diabetes (even if she disagrees with me ), but since you are using Lantus I would also ask for spreadsheet interpretation and dose advice in the Lantus+Levemir forum-- it's very active and there are a whole host of extremely knowledgable caregivers there who can help.

 

[Critter Mom]

Amber, is there a protocol for lowering the dose when the blood sugar is this high, in order to determine if a lower dose is more effective?

Given that circumstances led to things going a bit awry on the dosing front, Adrian, I think the best way forward for you is to post straight away on the Lantus and Levemir ISG board for help. There are some very highly experienced Lantus users participating in the group and they would be best placed to help you with sorting out a 'reset' for Chino; it can be a little bit fiddly but they eat, sleep and breathe L insulins over there and they'll be able to guide you through it. (Love your little guy's picture! )

Here's a link straight to the L&L board:

http://www.felinediabetes.com/FDMB/forums/lantus-glargine-levemir-detemir.9/


Mogs
.

 

[Larry and Kitties]

1. Was your vet familiar with the TR protocol before you discussed it with them?

No. I do all the dosing/dose changes myself with no input from my vets. When I started I did periodically send the results that the Touch meter generated after downloading to my computer. After a short period of time the vet said do not send any more.

2. Did you get any resistance or disapproval?

The vets did not have any problem with myself determining dose.

3. Do you notify the vet of dose changes or hypo episodes?

No for dose changes. I have not had any hypos except for a newly adopted after her first shot. That was even before her first visit to the vet. I did take Mittens to the ER. I suspect that Mitten was continuously being overdosed.

4. How frequently do you see the vet for routine diabetes care?

Outside of a specific problem I try to g take them to the vet between 1 and 1 1/2 years.

Regarding Chino, except for 12/29 PM and 12/30 AM the curve is essentially flat. That typically indicates the dose is too high. Did Chino eat normally before those two periods?

 

[Adrian and Chino]

Yes. There were 2 times where he didn't finish his morning meal, but those are noted in the Comments. He did eat his entire meal the night he dropped to the 100s.

 

[Adrian and Chino]

Question: how was the initial dose of 1.0U decided on? Was it based on BG numbers at diagnosis, a vet curve, Chino's weight, some combination?

Not entirely sure of the vet's rationale, but it looks like the dose is consistent with Table 2 of the "Management of Diabetic Cats with Long-acting Insulin" article:

Begin with 0.5 IU/kg if the blood glucose is >360 mg/dL (>20 mmol/L) or
0.25/kg of ideal weight if blood glucose is lower. Do not increase in the
first week unless minimum response to insulin occurs, but decrease if
necessary. Monitor response to therapy for first 3 d. If no monitoring
occurs in the first week, begin with 1 IU per cat BID.

He weighed about 12 pounds when he started insulin, so if 0.5 IU/kg had been followed instead, he would've been started on ~2.75 units.

 

[Bronx's dad (GA)]

1. Was your vet familiar with the TR protocol before you discussed it with them?
2. Did you get any resistance or disapproval?
3. Do you notify the vet of dose changes or hypo episodes?
4. How frequently do you see the vet for routine diabetes care?

1. Was your vet familiar with the TR protocol before you discussed it with them? 1st vet no, sent me to a internal medicine vet who was since the 1st vet's SLGS gradual increases from 1.5 to 2 to 2.5 did not move the #s one bit.
2. Did you get any resistance or disapproval? got no resistance, we even discussed using R if the #s don't come down.
3. Do you notify the vet of dose changes or hypo episodes? he knows I am on TR, no hypo episodes to discuss.
4. How frequently do you see the vet for routine diabetes care? hardy ever thanks to the great info from here and performing home testing of ketones & BG.

 

[Nan & Amber (GA)]

Yes. There were 2 times where he didn't finish his morning meal, but those are noted in the Comments. He did eat his entire meal the night he dropped to the 100s.

Interesting. I'll be watching to see what the L+L pros have to say about these patterns.

As for the 1U starting dose: it's not an unreasonable place to start for a 12-lb cat, I do wish there were more info on how Chino was responding to it, though. My cat is a 16-pounder, and the 0.5U she got for her first dose dropped her from mid-200's (300's at the vet) down to 84 , so you never can tell how a given cat is going to behave.

 

[tiffmaxee]

I think it depends on your vet. My vet quickly was on board once he saw I knew what I was doing and showed my spreadsheet to his students. He said I managed a diabetic better than anyone in his over 30 years in practice. Other vets aren't on board and people just listen to their recommendations and follow TR.