7 Nov | Girlie AMPS 367; +4=479; +6=531l PMPS 635; +2=565 Yikes!

[Girlie's mom]

Condo: http://www.felinediabetes.com/FDMB/...-664-not-doing-well-here.186367/#post-2069661

Dose increase last night to 1.25 Units, so NDW today. This is month 5 on Lantus. I just did a visual scroll through her SS, and the longest time she went without any blacks or reds was 10 days when she was on 0.10, but there was a fair bit of pink in there. Her nadirs (before this latest drama) were typically at AM+2 or +4 and still are, unless there's been food manipulation.

I do think the Zydax injections had a hand in her run of high numbers in August and after 10 October, but I would assume that the affect from that second injection on 10 October should be gone by now. Girlie did clear the 28 August injection highs within a week or so.

My civvie, Max, has jumped on the drama train. The mobile vet thinks it might be an abscess or perhaps a fractured jaw, so Max got lots of injections and was syringe fed on the good side. We'll see how he goes by tonight and if there's no improvement, then jaw x-rays tomorrow.

 

[Bronx's dad (GA)]

Uggh, you got a lot going on between Max & Girlie! Are you thinking of switching to Lev after the vial runs out?

 

[Stacy & Asia]

Hope you got a little bit of sleep last night and hope you're on the upside of your cold. Tell Max he doesn't need to be that dramatic to get a little extra attention! Hope he's feeling better soon. Paws crossed the new dose brings Girlie into some nicer numbers (and not too dramatically or fast, please, Girlie).

 

[Girlie's mom]

Uggh, you got a lot going on between Max & Girlie! Are you thinking of switching to Lev after the vial runs out?

I think Max just wanted to feel special, too...

I am thinking of switching to Levemir, although I know you're supposed to wait six months. There just doesn't seem to be anything in over 4 months of Lantus that shouts "we're improving!" or even "we're levelling out/having better duration."

I wonder about the pros and cons. I think you reduce the current Lantus dose when you switch to Levemir, and Girlie's just gone to 1.25 (hard to believe that at the beginning of October she was at 0.1 Unit); what would that put her at on Levemir, I wonder? I'm sure she would still bounce and dive - but perhaps it would level her out a bit. That and the later nadir would be my goal, at least.

How did you decide to make the switch to Levemir? Are there certain indications you should look for that tell you that Lantus isn't doing it? I might tag @Osha as well: I think you (?) mentioned that the switch helped Osha.

 

[Girlie's mom]

Hope you got a little bit of sleep last night and hope you're on the upside of your cold. Tell Max he doesn't need to be that dramatic to get a little extra attention! Hope he's feeling better soon. Paws crossed the new dose brings Girlie into some nicer numbers (and not too dramatically or fast, please, Girlie).

A little sleep, thank you! Not enough yet, but I'm hoping that tonight, maybe - as long as Max decides to get off the drama train, that is!

I hope you are doing well!

 

[Bronx's dad (GA)]

Rule of thumb is 70% of the Lantus dose to start, would be about 1u right now.

 

[Girlie's mom]

I'm surprised she's in such high numbers on cycle 2 of the 1.25 Units. With an increase, I usually see movement on Cycle 2. I wonder what's going on.

I remember reading that they can also go too high if the dose is too high: could that be possible? She had her best run of numbers 30 Sept to ca 3/4 October when she was on 0.1 units: she's gone steadily upwards since then. Hmmm...I have no clue!

 

[Bronx's dad (GA)]

Yeah, they say too high of a dose can look like it's too low of a dose. But I always assumed that meant the high BG #s are the result of bouncing because the high dose is causing low nadirs? But I could be completely wrong on that assumption.

 

[Marje and Gracie]

Darrah

Just because you need them.

The time change does make it a challenge but I’m glad you increased. I’m so sorry that everything is coming down on you so hard right now. All the family things you have going on are difficult enough even if Girlie was not diabetic.

To answer your questions:

• The vets gave a pretty high dose of Rapid and they gave it at a time in the cycle that was a little odd. We start at 0.1u. As an example, in yesterday’s cycle, I’d have had you test again at +7 (if you had been home) and give it if she was on the rise. If you hadn’t been home, we’d have given it at +9 to stop her from going any higher. It would just be waning as she onset from the next L shot, giving her a lower starting point.
• The skill in giving R is to give it at a time right when the numbers zoom up and only give a tiny amount, to start with. If you give it at the wrong time or give too much, it can start a dive bounce cycle.
• Levemir is a fantastic insulin and I, personally, prefer it. I think it is absolutely fine if you want to switch her but there is no guarantee that she won’t bounce. Gracie definitely improved but she still bounced.
• We would start the Lev dose at 70% of the Lantus dose and if the BG doesn’t drop quickly, as some cats’ will upon switching, we would fast track her back up.
• I actually did feel it was a bit like starting over because I had to learn her cycles all over again. Onset is about +4 and nadir anywhere from +8 to +12 or even after if the kitty gets good duration (Gracie could often get 15 hours). You will have to adjust her feeding times, most likely.
• I found R to be a great compliment to Levemir so we would still have that in our back pocket.
• NDW can hit at any time in the first 24+ hours.
• You’ve been taking the dose up very slowly and in small increments and you’ve tested a lot. She hasn’t been green in over six cycles so she’s had time to clear any bounces and come back down. Her dose is t too high but I don’t k ow what has caused her to hang out in these numbers.

I have seen SSs like hers and we just take the dose up per the TR protocol and/or use R u til we hit a breakthrough dose. It is hard to see what is specifically causing her to pop up like she is at the time she she does.

I worked full time the first year Gracie was diabetic but my husband always helped immensely and was here with her when I was at work. After the first year, I went part time due to exhaustion. I worked in the office one day a week and the rest at home. I would have had to treat her entirely differently and been much less aggressive without my husband sharing the responsibility equally.

Let me know if you want to switch insulins. We won’t know if it will help her until you try....it has made a big difference for some cats; for some, like Gracie, it offered a definite improvement; others, there was little difference. If it were me, and I could figure out how I could work with a different cycle, I would switch.

 

[Girlie's mom]

Darrah

Just because you need them.

The time change does make it a challenge but I’m glad you increased. I’m so sorry that everything is coming down on you so hard right now. All the family things you have going on are difficult enough even if Girlie was not diabetic.

To answer your questions:

• The vets gave a pretty high dose of Rapid and they gave it at a time in the cycle that was a little odd. We start at 0.1u. As an example, in yesterday’s cycle, I’d have had you test again at +7 (if you had been home) and give it if she was on the rise. If you hadn’t been home, we’d have given it at +9 to stop her from going any higher. It would just be waning as she onset from the next L shot, giving her a lower starting point.
• The skill in giving R is to give it at a time right when the numbers zoom up and only give a tiny amount, to start with. If you give it at the wrong time or give too much, it can start a dive bounce cycle.
• Levemir is a fantastic insulin and I, personally, prefer it. I think it is absolutely fine if you want to switch her but there is no guarantee that she won’t bounce. Gracie definitely improved but she still bounced.
• We would start the Lev dose at 70% of the Lantus dose and if the BG doesn’t drop quickly, as some cats’ will upon switching, we would fast track her back up.
• I actually did feel it was a bit like starting over because I had to learn her cycles all over again. Onset is about +4 and nadir anywhere from +8 to +12 or even after if the kitty gets good duration (Gracie could often get 15 hours). You will have to adjust her feeding times, most likely.
• I found R to be a great compliment to Levemir so we would still have that in our back pocket.
• NDW can hit at any time in the first 24+ hours.
• You’ve been taking the dose up very slowly and in small increments and you’ve tested a lot. She hasn’t been green in over six cycles so she’s had time to clear any bounces and come back down. Her dose is t too high but I don’t k ow what has caused her to hang out in these numbers.

I have seen SSs like hers and we just take the dose up per the TR protocol and/or use R u til we hit a breakthrough dose. It is hard to see what is specifically causing her to pop up like she is at the time she she does.

I worked full time the first year Gracie was diabetic but my husband always helped immensely and was here with her when I was at work. After the first year, I went part time due to exhaustion. I worked in the office one day a week and the rest at home. I would have had to treat her entirely differently and been much less aggressive without my husband sharing the responsibility equally.

Let me know if you want to switch insulins. We won’t know if it will help her until you try....it has made a big difference for some cats; for some, like Gracie, it offered a definite improvement; others, there was little difference. If it were me, and I could figure out how I could work with a different cycle, I would switch.

Aha - I knew it! Your dear husband was your secret weapon... And thank you for the hugs: I know everyone has been (or still is!) where I am now, and it's hard for all of us, this sugar dance: but so rewarding when we see some improvement. She is SO much better than she was at the end of June when she was diagnosed.

I think I might well try Levemir. I'll ask the vet to prescribe some. From what I've heard, Australian vets don't like to prescribe the fast-acting insulins, but I'll see. I still have two weeks where I'm only working 1/2 days at the office, so this would be an ideal time to do the switch. If I wait another month or two, the only time I'll be able to monitor her closely will be on weekends, which will slow progress.

Thanks for all of the explanations. I have a lot of questions, though! I'm sure experienced Levemir users like @Bronx's dad and @Osha could chime in with their thoughts, as well.

1. As far as adjusting the feeding schedule and the late nadirs: I assume she'd still get her shots at 6 am and 6 pm, for example: when you say I'd have to adjust her feeding schedule, would I have to give her a PS meal and then delay feeding until onset?
2. If nadir is at +12, how does that work with the (say) 6 pm shot time? The doses would overlap then, yes?
   
3. I can start as early as 7:00 am at work and as late as 10:00 if need be, and if I keep my job here (we'll find out by end of the year; that's also up in the air: joy!), I'm close enough to be able to get home for lunch, but possibly not every day.
4. Would she need to stop Lantus cold for several days first before starting the Levemir, or could it just start when her next shot is due?
5. My biggest hope is that the Levemir might stop the dramatic deep dives early in her cycle that then lead to the equally dramatic high, high bounces. Once Girlie starts at a decent blue or even yellow number, she's much better, but trying to get her down from the high blacks or reds without causing a deep dive and yet another bounce is really, really tricky - as you can see. But I guess I'd have to see if Levemir could help with that.

Re the vets: they have to know a lot, and they aren't experts in diabetes. My mobile vet today hadn't even heard of Levemir: she only uses Lantus or a fast-acting one. But that's okay: they don't present themselves as experts in diabetes, but they are good general vets.

 

[Girlie's mom]

• NDW can hit at any time in the first 24+ hours.
• You’ve been taking the dose up very slowly and in small increments and you’ve tested a lot. She hasn’t been green in over six cycles so she’s had time to clear any bounces and come back down. Her dose is t too high but I don’t k ow what has caused her to hang out in these numbers.

I have seen SSs like hers and we just take the dose up per the TR protocol and/or use R u til we hit a breakthrough dose. It is hard to see what is specifically causing her to pop up like she is at the time she she does.

When I look at her and think back, I think that the Zydax definitely played a role: something about their mix of Pentosan just doesn't work for Girlie. It might be just coincidental, but I'm not going to test it out just to be sure.

From 17 October to 1 Nov (start of stall the fud dive experiment) she started AM in high blacks, then dove dramatically, then bounced back up to black. It's the high black starting numbers that are her achilles heel. She'll deep dive anyway: that's her thing: but it's just awful when she does that from the highest numbers.

I think I'm going to at least try to start with lower cal food (lower than the 6%). I know she will drop on that: she'll get out of black. The problem is, will she stay out of black?

I'm having great trouble trying to figure out how to be proactive rather than reactive: when I look at her SS, I just seem to guess wrong and give food that's too high in carbs. If you could look at 1 Nov on in the US numbers and see anything that I've missed - what I've done wrong, what I seem to have done right - that would be enormously helpful. I just see her dive regardless: the dive is just pushed off until later in the day.

I know it's better to be proactive than reactive, but I just can't figure the proactive part out. If I start out at 6% (which has done well for her in the past and brought her down to greens), and then REact when she dives - I'm not sure which is better for her (or worse).

Thank you, again, Marje, for taking the time to help me and so many others. It is very much appreciated!

 

[Girlie's mom]

And another question! Often, I can tell Girlie is diving from her behaviour or her attitude towards food (e.g. she actively seeks food for a change), but when I test her, the BG doesn't show a drop. Does anyone know how long it takes for a drop in levels to show up in the blood? More times than I can count I have tested her at +1.5 because I know she's diving, but the monitor says otherwise; then at +2, sure enough, she's down way over 50 points and more towards 100 points. Should I listen to the signs she's giving me at times like this if it's typically a time she has taken a steep dive before, do you think, and perhaps try a food that has higher carbs?

 

[Girlie's mom]

Wow: she is NOT moving! Try a new colour, baby girl...you can do it!

 

[Osha]

I personally love Levemir. It helped my diving/bouncing kitty to flatten out. On Lantus she could start at pink and be lime green in 4 hours. I don't have this experience with levemir. She nadirs late and is much more flat. I think her nadir is anywhere from +9 to +12. I feel comfortable shooting and going to work with Levemir. I can shoot in the 50's now without having a panic attack. It is a new learning process, but since you aren't learning everything about diabetes, it was easier than when I first started.

I could not change her feeding schedule. Osha broke her teeth dragging her feeder around the house so that isn't an option for me. In fact, since my new job in September, she gets food a bit earlier than she used to. So, if I am uncomfortable when I leave the house, I just give her an extra can of food right as I leave.

For me and Osha, Levemir was definitely the right choice.

 

[LizzieInTexas]

Thanks for the acupuncture info on my condo yesterday. It will definitely be something I discuss with Dr. P tomorrow.

I know how frustrating this whole dance can be. Especially when you are not seeing "progresss" but you are, sure it is slow, but it is still progress and like you said, vet was impressed on how she was doing.

The 6th year anniversary of my dad's death was 10/31. And my Aunts is upcoming on 11/14 (4 years). She was like a 2nd mom to me after my mom passed in 1985. I miss her so much. I hope you can get some rest. Things always seem worse when we are tired.

 

[Alicia & Maggie (GA)]

I hope Max doesn't have a broken jaw! Ouch!! I hope Levemir is the answer for Girlie. And here's a for you.

 

[Marje and Gracie]

As far as adjusting the feeding schedule and the late nadirs: I assume she'd still get her shots at 6 am and 6 pm, for example: when you say I'd have to adjust her feeding schedule, would I have to give her a PS meal and then delay feeding until onset?

Correct, you don’t change the shot time. Feeding is ECID. She would eat at PS but then it depends on her curve. We fed Gracie at PS,+2,+3, +6,+7 during the day and PS, +2, +3, +4, +5 at night. But that’s what worked for her. Amanda hasn’t been able to move Osha’s feeding times but that is rare. Since Gracie was all about food, she was fine with changes but Girlie, being older, might not adjust as well so do what you can.

If nadir is at +12, how does that work with the (say) 6 pm shot time? The doses would overlap then, yes?

We always hope for overlap. You might find that the nadir is at +12 and that requires you to learn to shoot low (above 50). That’s what I see as one of the beauties of Levemir.

I can start as early as 7:00 am at work and as late as 10:00 if need be, and if I keep my job here (we'll find out by end of the year; that's also up in the air: joy!), I'm close enough to be able to get home for lunch, but possibly not every day.

If you shoot at 6 a.m. and she nadirs at +8, that would be 2 p.m. That also puts her nighttime nadir fairly early in the morning.
Just keep these things in mind as you decide.

Would she need to stop Lantus cold for several days first before starting the Levemir, or could it just start when her next shot is due?

No. You will shoot lantus one cycle and then levemir the next. That’s why we drop the dose back initially.....because you are dealing with a depot insulin.

My biggest hope is that the Levemir might stop the dramatic deep dives early in her cycle that then lead to the equally dramatic high, high bounces. Once Girlie starts at a decent blue or even yellow number, she's much better, but trying to get her down from the high blacks or reds without causing a deep dive and yet another bounce is really, really tricky - as you can see. But I guess I'd have to see if Levemir could help with that.

It’s possible. Gracie did occasionally dive on Lev and I would go back to testing at +1 and being proactive for the dive to get it nipped in the bud. But she didn’t do it very often.

I think I'm going to at least try to start with lower cal food (lower than the 6%). I know she will drop on that: she'll get out of black. The problem is, will she stay out of black?

You can try this, certainly, but remember she will likely dive. But experimentation is the key to finding out the solution. The night of Oct 31 would have been when she was due to finally clear the bounce from the blues six cycles before. I have seen bounces take longer than six cycles to clear. Her Nov 1 cycle looks like a bounce clearing one to me and those are always going to be active cycles. It’s hard to not be reactive on those days. You did the best you could.

What I believe is she goes so high because she’s losing duration and bouncing. Then the only way to get back to blue or green is to clear the bounce and that almost always results in a very active cycle. You can see that when she starts much lower, like today, she stays flatter.

 

[Alicia & Maggie (GA)]

Darrah, I'm nosy... What kind of work do you do?