? 1/22 Yum: Should I try for pinks with R?

[MJW]

Previous condo: http://www.felinediabetes.com/FDMB/...o-test-0-5ur-in-evenings.189910/#post-2115403

I stopped R Saturday evening when I upped Yum's Lantus dose to 9u.
She had some reds in her second cycle of 9u: because she finally responded to an L dose increase or because of the previous R intervention? I don't know.

I started the R again last night on her third cycle of 9uL.

Does her chart indicate I could try for pinks with R increases or do I have to be content with reds?

When people say R should give me a 100 point drop: is that with respect to AMPS/PMPS or with respect to where she is on cycles w/o R?

She had her blood draw this morning for the MSU IAA and Acro tests. They expect results on Friday.

Thanks!

 

[Mandy & Rex (GA)]

She had her blood draw this morning for the MSU IAA and Acro tests. They expect results on Friday.

Good luck with the results!!

 

[Jill & Alex (GA)]

Happy to hear blood has been drawn for the IAA and Acro tests! It will be helpful to know if we're dealing with one or the other or both.

First off, let me say I get your wanting to pull Yum's numbers down as soon as possibly. I really do. Incorporating the use of R is an awesome tool which will help you get there sooner rather than later. However, and I can't stress this enough... it has to be done safely and methodically or it's all going to catch up with you.

• Don't increase the Lantus dose before 6 consecutive cycles have been completed when you're using R (not 5). Use one method or the other to treat aggressively, but not both.

• You acknowledged a bounce on 1/20. Here we are, six cycles later (remember we're looking at "waves of action"). It's due to break. Will it be today or tonight? Who knows? We don't have recent data to compare. Giving R as a bounce is breaking can be dangerous because it can accelerate the drop. You already gave R at PM+11 last night which will affect today's cycle. I think it would be prudent to hold off on R until you know if the bounce broke. We probably won't know that til much later... maybe or maybe not til PMPS time. If we can't tell if the bounce broke by PMPS time, I certainly wouldn't R the PM cycle for fear she'd drop while I was sleeping. Will it matter? Who knows? At this point, you're still in data gathering mode and learning when to use or not use R. It's all part of the process. Gathering the data now will go a long way in making educated and informed decisions in the future. These lessons are not steps you want to skip.

From a personal perspective, pulling Yum's numbers down aggressively involves a process. We're trying to teach to help you make decisions on your own for Yum. Going against the grain and then disappearing even for a day has made me very nervous about helping you with using R. I'll be very honest with you, I've reached the point where I'm equally concerned about helping you as I am about not helping you and what could happen to Yum as a result. I'm very uncomfortable.

I hope others are available today to weigh in because it's good for you to hear other's thoughts. However, both Marje and Wendy have a lot going on at the moment. Not sure if they'll be around today.


Just my thoughts...

 

[Sandy and Black Kitty]

She had her blood draw this morning for the MSU IAA and Acro tests. They expect results on Friday.

Fabulous!

Does her chart indicate I could try for pinks with R increases or do I have to be content with reds?

Easy does it. Pink will come. Take a step back and look at the ss overall for the past couple weeks.
Red is taking up more and more real estate on the ss which is good. Beating BG down to pink from black with R will likely trigger a bounce back to black.

I know it’s hard to sit on your hands. Hang in there.
Friday will be here before we know it and you will know what you are dealing with. In the meantime please check daily for ketones.

 

[MJW]

Response to @Jill & Alex (GA)

Well, I guess that’s an emphatic “No!” to my question re pushing R to give Yum pinks.

On 1/21 @Wendy&Neko wrote LuvinthisPig "I agree with Sandy, time for the L increase. Nothing beats getting to a good Lantus dose.“

On 1/20 @Marje and Gracie wrote me "Here’s the point I think you are missing. Lantus and Levemir are not the "big hammers”. They don’t have the ability to yank numbers down. If you go back and look at Crystal’s SSs, you’ll see that she got up to 60u Lev bid and Suki just couldn’t continue to go through that much insulin every day so she started using the R at higher doses and it worked beautifully. Now....I am absolutely not suggesting you start using R like that. What I’m trying to show is that L is not the "big hammer" you think it is.”
[Suki held L fixed and increased R.]

I was just wondering which insulin I should emphasize. I guess I will continue using R to slightly lower Yum’s cycles and count on getting to a good L dose ASAP.

I don't think she is bouncing. Of course I could be wrong, but her curves haven't changed significantly to my eyes.

The lowest Yum has gone in the last 2 weeks was 389 (+-20%), and that was just one outlier sample. I think the likelihood of her going lower than 68 due to the dose changes I am making is almost nil or extremely small. The R curves are mostly less than 100 points below the no-R curves.
I'm not changing R and L at the same time.
I ran 2 cycles at 9uL without R, to make up for the 5 cycles at 8.5u. (I see LuvinthisPig starts R up at the second cycle.)
If Yum wasn't red and black I would be more conservative.
I'm testing the poor thing every few hours. In the past year I have never seen anything suggesting she goes low in the middle of the night. ECID. That's something I like about Lantus more than Levemir: it has earlier nadirs.
I know anything could happen and she could crash on me at 3 AM and I will have to live with it.

Thank you for all your advice. I follow most of it. Yum's life depends on it.

 

[MJW]

Fabulous!
Easy does it. Pink will come. Take a step back and look at the ss overall for the past couple weeks.
Red is taking up more and more real estate on the ss which is good. Beating BG down to pink from black with R will likely trigger a bounce back to black.

I know it’s hard to sit on your hands. Hang in there.
Friday will be here before we know it and you will know what you are dealing with. In the meantime please check daily for ketones.

Yes, who knew I would look on a sea of reds as progress. She just lies around though, waiting to beg food from me if I go into the kitchen. She is eager for all her ear pricks, because I feed her after each one.

Her SS has only improved since I started R. Before that it was a sea of black.

 

[Wendy&Neko]

First of all, great news that the high dose tests are going forward. Knowing what you are dealing with makes it easier to decide what to do next. Don't worry if one or other of the test results do not come in on Friday. I know some people were seeing a delay with getting the IAA results back the end of next year. I didn't get my results back until the Saturday and Sunday. Just because the results are ready at MSU, doesn't mean it gets to you right away.

Second, Pig and Yum are different cats. Remember ECID? It's even more true for high dose cats. Sarah's vet didn't send in the blood for the IAA testing (in spite of being asked), but at least we know we are dealing with acromegaly. "High dose" condition cats need for insulin varies hugely. I've seen an acro cat on 2.25 U of Lantus, and also one on 106 units of Levemir with R thrown in for good measure. We don't know where Yum will end up yet or even if she has IAA or acromegaly.

I'm not going to add to the broken record of being cautious with timing on increases. You didn't pay attention when I said it before, might as well save my breath. Just remember that Yum doesn't have a say in this. It's your decision to fast track against the voices of experience, but she's the one that will suffer the consequences.

OK, to answer your questions in the first post. No, you don't aim for a particular number the R. Think of R as a helper tool. Lantus/Lev is the tool that will eventually get Yum to better numbers, R provides an assist. It gives the Lantus better numbers to start working with and takes the edge off the high numbers. As we've said before, you want the R to lower the numbers no more 100 points, to avoid setting off a bounce. That's not from preshot, but from when you inject R to the end of the R duration.

In the past year I have never seen anything suggesting she goes low in the middle of the night. ECID.

Not only ECID, but Yum isn't the same cat she was last year. Never assume their patterns will stay the same. And in my experience, patterns in high numbers can be quite different than those in lower numbers. Right now Yum is mostly just high and flat. And as Jill said, I can sympathize on wanting to do anything to get out of those high numbers. I also know what it's like to see a mostly regulated cat suddenly veer off track. Been there, done that. I had to learn to do other things, get out the house, exercise, or do what I could to burn off stress and get my mind out of hover mode.

One last thing, I see her numbers sliding down towards the end of the cycle, looks like bounce breaking to me.

 

[MJW]

She came up to 586 at +11. I gave her .25uR.

 

[MJW]

OK, to answer your questions in the first post. No, you don't aim for a particular number the R. Think of R as a helper tool. Lantus/Lev is the tool that will eventually get Yum to better numbers, R provides an assist. It gives the Lantus better numbers to start working with and takes the edge off the high numbers. As we've said before, you want the R to lower the numbers no more 100 points, to avoid setting off a bounce. That's not from preshot, but from when you inject R to the end of the R duration.

Thanks for these clarifications!

Not only ECID, but Yum isn't the same cat she was last year. Never assume their patterns will stay the same. And in my experience, patterns in high numbers can be quite different than those in lower numbers. Right now Yum is mostly just high and flat. And as Jill said, I can sympathize on wanting to do anything to get out of those high numbers. I also know what it's like to see a mostly regulated cat suddenly veer off track. Been there, done that. I had to learn to do other things, get out the house, exercise, or do what I could to burn off stress and get my mind out of hover mode.

She is my obsession.

One last thing, I see her numbers sliding down towards the end of the cycle, looks like bounce breaking to me.

Since she came up, I hope it was okay to do the R.

 

[Marje and Gracie]

Since she came up, I hope it was okay to do the R

The current cycle that you shot R in is the sixth after the pink. It’s possible she popped up to 586 as the high before the break although she’s done this several cycles since she started the bounce.

I hope we didn’t confuse you about the roles of R and L. It might not sound like it but Wendy and I are saying the same thing. I indicated L is not the “big hammer” and Wendy said that L is the tool that will eventually get you to the right dose. But neither L nor R will get you there fast especially if there is some glucose toxicity in the mix.

Wendy’s and Jill’s points are well taken. I am also uncomfortable assisting with R if I feel the CG is getting way too ahead of the “process” and isn’t using it and L together safely and isn’t posting daily. The three of us have limited time right now and I have a list of whom I check in on. Yum’s condo is the first I look for. If you haven’t posted, I check her SS.

But if you have already decided what way you want to go with dosing and you haven’t posted, then our experience and wisdom are all for naught. While we don’t know yet if this is IAA or acro, if either or both are in the mix, things can change suddenly. If it’s IAA and it breaks, it can be a wild ride. If it’s acro and the tumor wanes, it can also be a little wild. If you use R and L together more judiciously, you are less likely to be left with too large of a depot and potentially quickly dropping numbers....whether it’s from IAA breaking, an acro tumor waning, or just hitting the breakthrough dose.

I’m hoping you will get some answers this week.

 

[MJW]

I am planning on shooting .25uR again tomorrow morning at PMPS+11 and 9uL at AMPS, if there are no contraindications.
Then I will either
(a)take her to 9.5uL tomorrow evening and skip R for 2 cycles
(b)or do a 7th cycle at 9uL with .25R and then increase to 9.5uL the following morning and just skip R for 1 cycle.

I will probably do (a) since that advances Lantus most quickly (6 cycles).
However, if her insulin requirement suddenly crashed, I guess it would be better to be at a low Lantus dose than a high Lantus dose.

 

[MJW]

I didn't realize I was supposed to post Yum's R progress every day, especially when I wasn't increasing R. Sorry. I am so pleased there are eyes on her, people who care.

 

[MJW]

Yum's chin is a bit swollen. I remarked on it to the vet during her exam last August. The vet thought it was just a slight skin infection. Lately I have blamed it on the fact that her chin is usually wet because she drinks so much water. I guess a swollen chin could be a sign of acromegaly.

 

[Marje and Gracie]

Yum's chin is a bit swollen. I remarked on it to the vet during her exam last August. The vet thought it was just a slight skin infection. Lately I have blamed it on the fact that her chin is usually wet because she drinks so much water. I guess a swollen chin could be a sign of acromegaly.

Does it have any little sores on it or black flecks that could be feline acne? Could she have gotten bitten by a spider?

I didn't realize I was supposed to post Yum's R progress every day, especially when I wasn't increasing R. Sorry. I am so pleased there are eyes on her, people who care.

There is no “requirement”. We can’t make you. But, sometimes we see something in a pattern and need to let you know. But if you are off the board that day, even if we post it in a previous condo, we don’t know if you will see it or get the information we want to give you.

I would suggest doing (a) as long as you don’t see any surprises between now and then.

 

[MJW]

Does it have any little sores on it or black flecks that could be feline acne? Could she have gotten bitten by a spider?

No.

I would suggest doing (a) as long as you don’t see any surprises between now and then.

(a) it is.
She hasn't shown much response to R this evening. No reds so far.
She is so hungry and thirsty.

 

[Marje and Gracie]

She hasn't shown much response to R this evening

Sometimes this happens with R. We’ve all experienced it.

 

[Sandy and Black Kitty]

She hasn't shown much response to R this evening. No reds so far.

It may appear there is not much response however, she had a nice stretch of red with a good part of it under 450 during the AM cycle. Although it appears to be not much of a response it’s possible the R may have actually put a ceiling over a bounce.