Steph & Quintus & L & O
Member Since 2017
condo: http://www.felinediabetes.com/FDMB/...ps-173-2-83-3-53-green-day-ns-tonight.188907/
No juice!
Things are looking pretty good for Quintus this morning! After getting "0.1ui" yesterday morning and swimming with the sharks (but not so far out that I needed honey), he went up to 149 in the evening before feeding time (185 after having his food). Two hours later he was down to 119.
So, I'm going to not shoot this morning either, and continue monitoring to see how he does "on his own".
In my readings yesterday, off and on the board, I stumbled upon a bunch of stuff by Dr Hodgkins. I know her protocol isn't widely followed here and that it wasn't developed for Lantus, and that her sweeping affirmations about clinical hypo not being a possibility within the parameters of her protocol are refuted.
Now for some reflexion
I would like, however, to highlight a couple ideas I found worthwhile, and that echoed my "gut feeling" for what to do though they seem to go against how things are usually done in this community. I would therefore to curious to know more about the history and rationale for doing things "this way rather than that". I offer these reflexions with the caveat of my limited FD experience, and in that they are applied to what I've seen happen with Quintus, who is a recent diabetic secondary to pancreatitis ("Type 3" diabetes?).
The first is the idea of not "feeding the curve".
Quote (EH): "I am, as you all know, against using insulin to lower BG and then pumping a diabetic cat full of new glucose precursors (food) to get it back up; Cats roller-coaster enough without us MAKING them do so. "
from https://www.diabeticcatcare.com/DCCCOK/PearlsGleaned.htm
As I see things so far, a cat that gets "near hypo = lime green" numbers has more insulin in his system than needed for the sugar that is available. So there are two options to prevent that from happening: give more sugar, or give less insulin. Now, once the insulin is in the system, obviously you give me sugar. But giving more sugar (moreso for an animal that is not really designed to function with dietary sugar?) easily becomes "too much sugar" => higher numbers possible from both a bounce and exogenous glucose.
Both TR and SLGS, by the way, indicate that when "low" (as defined in each protocol/method) are reached, it is sign that "too much" insulin is being used, inviting a dose reduction.
For me it doesn't really make sense to be "pushing and pulling" at the same time to keep the numbers right. One gets a flatter line, but it's full of tension. A little off on one side or another and it gets skewed. In Quintus's case, he's always been a grazing free-feeder, and the idea of giving him the whole of his 12-hour ration in the space of three hours really didn't sit right with me. Of keeping to feed him honey on each cycle to prevent him from going too low, only to end up with him heading up afterwards either because he did indeed go too low for his comfort or get too much honey because I didn't want to be testing like crazy every 15 minutes. I'm aware that with experience a CG will know better how much HC to give. But still. It seems an awful lot of work to keep on giving what seems like "too high a dose of insulin" based on what the cat's physiological response is telling me.
In addition to that, here's something I've been wondering about. Doing this puts more control in the hands of the CG. It's reassuring to be in control, as it relieves anxiety. Control-oriented action is also a way to escape from grief (don't I know it). What part does that play in the way we choose to care for our kitties? The "pushing and pulling" method seems to me to be a high-control method that requires a lot from the CG, and so far I'm not convinced it's really better for the kitty than just... inching the dose down so kitty can stay in safe numbers without intervention.
Sharks and honey with Quintus
After dipping my toes in there on 29th evening despite having dropped the dose from 1ui to 0.5ui (many thanks to @Stacy & Asia for holding my hand through that stressful evening!) I decided it was not the way I wanted to go, and that my aim was to keep Quintus in the best numbers possible with the least intervention possible. I'd been stressing out for days to get food in him early in the cycle (he's a nice guy, if I bring his bowl to him and stick it under his chin, he eats) and now with the appearance of lime greens I was testing like crazy and adding honey to the mix.
The next morning (30th) he was "high enough" in the blues (and I knew there were still high doses in the depot -- that's when I started wondering about computing a rough "depot indicator", you can find that in a tab in the SS) that I shot 0.5ui again, and swam with the sharks again. I dropped the dose again to 0.25 that night, fed him early in the cycle, and don't know what happened because I didn't stay up, but he was at 70-80 the next morning (31st), down from blue two hours earlier.
I was hesitant even to shoot, but did a small 0.25 (0.2). I still had to put food in him early in the cycle and use some honey to keep him up. His numbers were up in the evening, and I banked on the fact it was bouncy/honey numbers, and didn't shoot (also because, new year's eve). He was already coming down in the evening, and the next morning he was at 170. A bit high, sure, but lower.
I gave him 0.1ui (best estimate) because I was there to monitor, and didn't want to risk his numbers going back up if the low numbers I'd seen recently were the higher doses still in the depot. Well, we still saw a shark or two, but I managed to stay away from the honey, and by +11 he was at 150. I decided to skip the shot that evening to see how he'd do on his own. And he seems to have done quite well, coming down to 85 this morning. So I'm still not shooting.
Which brings me to my second reflexion topic.
Giving insulin on low numbers
EH again, from the same source:
"I think giving insulin at low numbers can actually be counter productive. If you think about it, the liver, even once it is retrained and completely onboard with health and recovery of the diabetic, still has the job of keeping BG from going too low. If the cat is happily going along at 110, and it gets insulin from outside, it's no different than the cat having to run hard and long to get away from a coyote. In such a situation, the liver is supposed to get busy and get more glucose into circulation. So it does, in both situations. In other words, when we shoot at low numbers, we make the liver do something we really don't want it to do. I know this is weird, hearing me say that there are times when shooting is a bad thing (and not because of hypo, but because of the effect of doing so on the liver), but if you don't really need insulin, you want to just let the body be.
The rationale for not shooting at these near-normal levels is to see if the pancreas of the cat will handle the matter itself. You never know when the pancreas will feel "up to" handling these small rises, and if you shoot from outside, you certainly do obscure that observation. Additionally, if the pancreas and the liver are getting into sync with each other at such a time, giving insulin causes the liver to do exactly as it should if a fairly big burst of insulin shows up (our dosing, even when conservative, is always excessive compared to the much smaller, measured and frequent doses that come from the operating pancreas in response to the gradual rise in BG that happens in any animal. We are, after all, a very crude substitute for the operational pancreas under the best of circumstances). So, at some point, all of us want to find out what the cat itself can do."
I know the common way of doing things here is to keep on giving tiny doses of insulin before stopping, a real tapering off. And that there is this idea of a "strong remission". I'd really be interested in knowing what it's based on. (Again, my wariness of cognitive bias and taking into account human psychology in assessing how we care for our cats.)
I've seen yesterday morning that a tiny dose had an effect on Quintus. So... I'm not saying the doses are useless. But as EH argues in the paragraphs quoted above, I think it makes sense to see what the cat is capable of doing on its own. Particularly for a cat like Quintus who is a recent pancreatitis-enabled diabetic.
I also read this conversation that seems to go in the same direction as my intuition: http://www.felinediabetes.com/FDMB/threads/treating-hypos-with-glucose-might-be-bad.86621/
And this article, that I've yet to read in full and assess, seems to confirm my concern for "sending kitty low" repeatedly: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568263/
This leads me to wonder if there is not more risk in continuing to give low-dose insulin to a cat who can otherwise stay in largely healthy numbers on its own.
Also, trying to keep things in perspective: my initial objective with Quintus was to keep him under 360 for as many hours a day as possible, then 270 (20 and 15 mmol/l respectively). So at this stage, I thought it was really interesting to see how his pancreas is behaving "off juice", particularly as I a looking for a "less interventionist" way of managing his FD.
What now?
It's clearly too early to cry victory. This is just one morning and one evening with no shot. I'm keeping a close eye on his BG, and who knows, might shoot tonight. We'll see.
But boy, does it feel relaxing to not have to watch him like a hawk, worry about his numbers falling or rising too much, worry about getting food in him. I wrote a few days ago about how all-consuming treating this FD was becoming for me, that all my interactions with Quintus were becoming medical, and that I was at risk of losing not only my sanity but my relationship with my cat through all this, turning into 100% caregiver and not "human with a cat" anymore.
Quintus might very well be one of those lucky cats (again, considering his medical history) who will go into remission pretty much whatever the CG does. I'm willing to let him hang out in slightly higher numbers than TR would aim for, at least momentarily, if it means I can get some of my life and some of my cat back.
Also important: I really think this improvement we're seeing has to do with taking care of the underlying pancreatitis. We don't know for how long he's had pancreatitis, but his lipase numbers, though slightly elevated, were normal end June. They were through the roof end September, which led to diagnosis and all that followed.
The two ultrasounds showed issues with his gallbladder (jelly-like). He's been on two bouts of ursochol for it, with visible improvement (on ultrasound) between the first and the second. He's been on marbocyl the second time around. He had omeprazole in October and November (for the pancreatitis "relapse"). He's been on convenia since early November (the relapse). I resumed his Onsior (anti-inflammatory, NSAID) treatment on December 18th, after we interrupted it mid-November. I am certain the Onsior and Convenia both helped (and it's quite logic when you think of what pancreatitis does). I was hesitant whether to stop the Convenia now or give him another shot, which would be due end of this week, but I'm now pretty much decided to give him this last one -- if the antibiotic coverage provided by the Convenia has played a role in dealing with his pancreatitis and help his FD become less severe, I do not want to run the risk of interrupting it prematurely.
Off to lunch, but will keep you posted on how this day goes!
No juice!
Things are looking pretty good for Quintus this morning! After getting "0.1ui" yesterday morning and swimming with the sharks (but not so far out that I needed honey), he went up to 149 in the evening before feeding time (185 after having his food). Two hours later he was down to 119.
So, I'm going to not shoot this morning either, and continue monitoring to see how he does "on his own".
In my readings yesterday, off and on the board, I stumbled upon a bunch of stuff by Dr Hodgkins. I know her protocol isn't widely followed here and that it wasn't developed for Lantus, and that her sweeping affirmations about clinical hypo not being a possibility within the parameters of her protocol are refuted.
Now for some reflexion
I would like, however, to highlight a couple ideas I found worthwhile, and that echoed my "gut feeling" for what to do though they seem to go against how things are usually done in this community. I would therefore to curious to know more about the history and rationale for doing things "this way rather than that". I offer these reflexions with the caveat of my limited FD experience, and in that they are applied to what I've seen happen with Quintus, who is a recent diabetic secondary to pancreatitis ("Type 3" diabetes?).
The first is the idea of not "feeding the curve".
Quote (EH): "I am, as you all know, against using insulin to lower BG and then pumping a diabetic cat full of new glucose precursors (food) to get it back up; Cats roller-coaster enough without us MAKING them do so. "
from https://www.diabeticcatcare.com/DCCCOK/PearlsGleaned.htm
As I see things so far, a cat that gets "near hypo = lime green" numbers has more insulin in his system than needed for the sugar that is available. So there are two options to prevent that from happening: give more sugar, or give less insulin. Now, once the insulin is in the system, obviously you give me sugar. But giving more sugar (moreso for an animal that is not really designed to function with dietary sugar?) easily becomes "too much sugar" => higher numbers possible from both a bounce and exogenous glucose.
Both TR and SLGS, by the way, indicate that when "low" (as defined in each protocol/method) are reached, it is sign that "too much" insulin is being used, inviting a dose reduction.
For me it doesn't really make sense to be "pushing and pulling" at the same time to keep the numbers right. One gets a flatter line, but it's full of tension. A little off on one side or another and it gets skewed. In Quintus's case, he's always been a grazing free-feeder, and the idea of giving him the whole of his 12-hour ration in the space of three hours really didn't sit right with me. Of keeping to feed him honey on each cycle to prevent him from going too low, only to end up with him heading up afterwards either because he did indeed go too low for his comfort or get too much honey because I didn't want to be testing like crazy every 15 minutes. I'm aware that with experience a CG will know better how much HC to give. But still. It seems an awful lot of work to keep on giving what seems like "too high a dose of insulin" based on what the cat's physiological response is telling me.
In addition to that, here's something I've been wondering about. Doing this puts more control in the hands of the CG. It's reassuring to be in control, as it relieves anxiety. Control-oriented action is also a way to escape from grief (don't I know it). What part does that play in the way we choose to care for our kitties? The "pushing and pulling" method seems to me to be a high-control method that requires a lot from the CG, and so far I'm not convinced it's really better for the kitty than just... inching the dose down so kitty can stay in safe numbers without intervention.
Sharks and honey with Quintus
After dipping my toes in there on 29th evening despite having dropped the dose from 1ui to 0.5ui (many thanks to @Stacy & Asia for holding my hand through that stressful evening!) I decided it was not the way I wanted to go, and that my aim was to keep Quintus in the best numbers possible with the least intervention possible. I'd been stressing out for days to get food in him early in the cycle (he's a nice guy, if I bring his bowl to him and stick it under his chin, he eats) and now with the appearance of lime greens I was testing like crazy and adding honey to the mix.
The next morning (30th) he was "high enough" in the blues (and I knew there were still high doses in the depot -- that's when I started wondering about computing a rough "depot indicator", you can find that in a tab in the SS) that I shot 0.5ui again, and swam with the sharks again. I dropped the dose again to 0.25 that night, fed him early in the cycle, and don't know what happened because I didn't stay up, but he was at 70-80 the next morning (31st), down from blue two hours earlier.
I was hesitant even to shoot, but did a small 0.25 (0.2). I still had to put food in him early in the cycle and use some honey to keep him up. His numbers were up in the evening, and I banked on the fact it was bouncy/honey numbers, and didn't shoot (also because, new year's eve). He was already coming down in the evening, and the next morning he was at 170. A bit high, sure, but lower.
I gave him 0.1ui (best estimate) because I was there to monitor, and didn't want to risk his numbers going back up if the low numbers I'd seen recently were the higher doses still in the depot. Well, we still saw a shark or two, but I managed to stay away from the honey, and by +11 he was at 150. I decided to skip the shot that evening to see how he'd do on his own. And he seems to have done quite well, coming down to 85 this morning. So I'm still not shooting.
Which brings me to my second reflexion topic.
Giving insulin on low numbers
EH again, from the same source:
"I think giving insulin at low numbers can actually be counter productive. If you think about it, the liver, even once it is retrained and completely onboard with health and recovery of the diabetic, still has the job of keeping BG from going too low. If the cat is happily going along at 110, and it gets insulin from outside, it's no different than the cat having to run hard and long to get away from a coyote. In such a situation, the liver is supposed to get busy and get more glucose into circulation. So it does, in both situations. In other words, when we shoot at low numbers, we make the liver do something we really don't want it to do. I know this is weird, hearing me say that there are times when shooting is a bad thing (and not because of hypo, but because of the effect of doing so on the liver), but if you don't really need insulin, you want to just let the body be.
The rationale for not shooting at these near-normal levels is to see if the pancreas of the cat will handle the matter itself. You never know when the pancreas will feel "up to" handling these small rises, and if you shoot from outside, you certainly do obscure that observation. Additionally, if the pancreas and the liver are getting into sync with each other at such a time, giving insulin causes the liver to do exactly as it should if a fairly big burst of insulin shows up (our dosing, even when conservative, is always excessive compared to the much smaller, measured and frequent doses that come from the operating pancreas in response to the gradual rise in BG that happens in any animal. We are, after all, a very crude substitute for the operational pancreas under the best of circumstances). So, at some point, all of us want to find out what the cat itself can do."
I know the common way of doing things here is to keep on giving tiny doses of insulin before stopping, a real tapering off. And that there is this idea of a "strong remission". I'd really be interested in knowing what it's based on. (Again, my wariness of cognitive bias and taking into account human psychology in assessing how we care for our cats.)
I've seen yesterday morning that a tiny dose had an effect on Quintus. So... I'm not saying the doses are useless. But as EH argues in the paragraphs quoted above, I think it makes sense to see what the cat is capable of doing on its own. Particularly for a cat like Quintus who is a recent pancreatitis-enabled diabetic.
I also read this conversation that seems to go in the same direction as my intuition: http://www.felinediabetes.com/FDMB/threads/treating-hypos-with-glucose-might-be-bad.86621/
And this article, that I've yet to read in full and assess, seems to confirm my concern for "sending kitty low" repeatedly: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568263/
This leads me to wonder if there is not more risk in continuing to give low-dose insulin to a cat who can otherwise stay in largely healthy numbers on its own.
Also, trying to keep things in perspective: my initial objective with Quintus was to keep him under 360 for as many hours a day as possible, then 270 (20 and 15 mmol/l respectively). So at this stage, I thought it was really interesting to see how his pancreas is behaving "off juice", particularly as I a looking for a "less interventionist" way of managing his FD.
What now?
It's clearly too early to cry victory. This is just one morning and one evening with no shot. I'm keeping a close eye on his BG, and who knows, might shoot tonight. We'll see.
But boy, does it feel relaxing to not have to watch him like a hawk, worry about his numbers falling or rising too much, worry about getting food in him. I wrote a few days ago about how all-consuming treating this FD was becoming for me, that all my interactions with Quintus were becoming medical, and that I was at risk of losing not only my sanity but my relationship with my cat through all this, turning into 100% caregiver and not "human with a cat" anymore.
Quintus might very well be one of those lucky cats (again, considering his medical history) who will go into remission pretty much whatever the CG does. I'm willing to let him hang out in slightly higher numbers than TR would aim for, at least momentarily, if it means I can get some of my life and some of my cat back.
Also important: I really think this improvement we're seeing has to do with taking care of the underlying pancreatitis. We don't know for how long he's had pancreatitis, but his lipase numbers, though slightly elevated, were normal end June. They were through the roof end September, which led to diagnosis and all that followed.
The two ultrasounds showed issues with his gallbladder (jelly-like). He's been on two bouts of ursochol for it, with visible improvement (on ultrasound) between the first and the second. He's been on marbocyl the second time around. He had omeprazole in October and November (for the pancreatitis "relapse"). He's been on convenia since early November (the relapse). I resumed his Onsior (anti-inflammatory, NSAID) treatment on December 18th, after we interrupted it mid-November. I am certain the Onsior and Convenia both helped (and it's quite logic when you think of what pancreatitis does). I was hesitant whether to stop the Convenia now or give him another shot, which would be due end of this week, but I'm now pretty much decided to give him this last one -- if the antibiotic coverage provided by the Convenia has played a role in dealing with his pancreatitis and help his FD become less severe, I do not want to run the risk of interrupting it prematurely.
Off to lunch, but will keep you posted on how this day goes!
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