1/13 Pearl AMPS 264; +1 300 - Confused

[Margaret and Pearl (GA)]

Good morning everyone,

Pearl is all over the map. I have a few questions, as I think I am getting confused by ALL THE BOUNCING.

(1) She seems to start each cycle with high PS numbers, and then drops very quickly (1-3 hours). Adding in low-carb food to slow it down won't help because she is already eating the low-carb food when this happens (she gets approx 50g Wellness Turkey/Duck 5% carb at PS and also at +2 or +3 of each cycle. She grazes so it takes her a couple hours to finish each meal). So...what do I do to slow down these drops? It seems whenever she drops she bounces (even if she doesn't hit her NADIR until +6). Do I need to add a teaspoon of HC or something to her PS meal so she doesn't drop as fast?

(2) Does her continuous bouncing indicate that I can't increase dose until she settles in? I am nervous she will NEVER settle in and just keep bouncing. I mean, is that possible for her to just keep bouncing? If so, how do you go about adjusting dose and experimenting with food amounts and times?

I would love any tips you can offer about her situation. The good news for me is that she spends more time in yellow and even sometimes gets a BLUE on the 1.5U dose, even though she still gets pinks with the bounces at times (no blues really on the 1.25U dose).

Link to yesterday's post: https://www.felinediabetes.com/FDMB/threads/1-12-pearl-amps-300-1-322.241385/#post-2717992

Thank you!!

 

[Bandit's Mom]

Hi Margaret, it is still early in Pearl's journey and she is bound to be extra bouncy. You could try feeding her a meal at +1 also but I would not worry about slowing the drops just yet. She should settle down with time. Some of the higher numbers you are seeing are her bouncing as well as her needing more insulin.

Bouncing has nothing to do with dosing. We dose based on nadirs. Bounces are upsetting - especially since they follow a streak of good numbers - but just ignore them. If you see good numbers on a dose, we usually ask that you hold the dose to see if the good numbers return after the bounce clears.

Your signature as well as your SS says you are following "Modified SLGS". Could you clarify on the SS what modification has been made? Are you increasing the dose every 4 days rather than 7?

 

[Margaret and Pearl (GA)]

Hi Margaret, it is still early in Pearl's journey and she is bound to be extra bouncy. You could try feeding her a meal at +1 also but I would not worry about slowing the drops just yet. She should settle down with time. Some of the higher numbers you are seeing are her bouncing as well as her needing more insulin.

Bouncing has nothing to do with dosing. We dose based on nadirs. Bounces are upsetting - especially since they follow a streak of good numbers - but just ignore them. If you see good numbers on a dose, we usually ask that you hold the dose to see if the good numbers return after the bounce clears.

Your signature as well as your SS says you are following "Modified SLGS". Could you clarify on the SS what modification has been made? Are you increasing the dose every 4 days rather than 7?

Hi and thanks for your message!

I wish I could clarify on "modified SLGS". I started off SLGS because my vet had told me NOT to monitor. But then I realized I was monitoring and home enough to do TR, and I would prefer that personally. Then, I got into a discussion here about the Pred she has to receive every 3 days and how it's hard to tell right at the moment what the effect of it is on her BGs, so I was advised to slow down my upping her dose, instead of doing every 3-4 days, wait until she levels out a bit THEN upp the dose. So I put "modified SLGS" in my signature so you all knew that I couldn't automatically upp every 3-4 days as on TR, due to Pre (even though I would like to stick as close to TR as possible, and I do not want to hold things 7 days for SLGS).

So I guess I am confused about all that too. I was planning to upp her dose tomorrow or Friday if you all feel she can handle it with the bouncing. I wasn't doing strict 4 or 7 day timeframes. I was trying to do 4 days if her numbers seemed stable with the Pred, and if not increase that a little as needed.

Does this make sense and help?

I appreciate your comment about ignoring the bounce. LOL Pearl's bounces hardly clear till she gets into a new one. So I don't know if the BLUE blobs here and there count as a good streak for holding the dose - I suspect not, and am ready to upp tomorrow (it's not good to upp a dose at night time right?)

Thank you!!

 

[Tomlin]

Good Morning,

Pre Insulin BG

This is going to be higher with most cats because the duration of action of the insulin has ended.

There are some cats who are fortunate & experience a longer duration of action vs a more average duration of Lantus. For those cats, you will often see flat or lower numbers pre insulin but then a rise for a few hours after the insulin is given because the duration of action of the previous dose has finally ended & the onset of action of the new injection has not started yet.

While there is reference to a “depot” I have been made aware ((by a prominent endo/DM specialist/insulin researcher) that Lantus does not create the equivalent or true depot in cats that it does in humans. I mention this because some will tend to think “I have a depot built up so that should be keeping them steady”. Not so.

Do I need to add a teaspoon of HC or something to her PS meal so she doesn't drop as fast?

This involves some trial & error, especially given that Pearl has some IBD. When a cat has IBD, how and what is actually metabolized within the GI tract (such as carbs) becomes a crap shoot to some extent. So, in actuality, a higher carb food may in fact work better for Pearl OR even a different formulation of moderate carb food may work better.
Again, some of this is simply trial & error to find out what works best for your specific cat .

Does her continuous bouncing indicate that I can't increase dose until she settles in?

Not at all. However, you continue to dose base on the NADIR vs those higher BGs you are seeing as Pearls body adjusts to new BG levels & you continue to do so as per the protocol if you are using TR OR the guidelines set up for SLGS with @Marje and Gracie suggestion that you can try using the modification of 70 instead of 90 to reduce the dose.

I am nervous she will NEVER settle in and just keep bouncing. I mean, is that possible for her to just keep bouncing?

There are actually cats on FDMB who have been described as “bouncy” & who literally bounced throughout their process all the way to remission.

Some cats bodies are more sensitive to changes to BG & will respond to the changes. However, keep in mind that not every high BG that follows lower BGs is a bounce. There is a complex process involved in the body & in addition to responses to new, lower BGs, the fact is there are also times when long acting insulin does not act the same way day to day, food is metabolized differently etc.

So, there are some variables at play in addition to the bouncing that is often referenced when higher BGs show up. Sometimes, there is not a definite explanation ! More often than not, time and patience & just continuing the process results in more steady BGs vs what you are seeing now.

Ultimately, the old saying “Stay the Course” fits well with DM regulation

 

[Margaret and Pearl (GA)]

This involves some trial & error, especially given that Pearl has some IBD. When a cat has IBD, how and what is actually metabolized within the GI tract (such as carbs) becomes a crap shoot to some extent. So, in actuality, a higher carb food may in fact work better for Pearl OR even a different formulation of moderate carb food may work better.
Again, some of this is simply trial & error to find out what works best for your specific cat .



Not at all. However, you continue to dose base on the NADIR vs those higher BGs you are seeing as Pearls body adjusts to new BG levels & you continue to do so as per the protocol if you are using TR OR the guidelines set up for SLGS with @Marje and Gracie suggestion that you can try using the modification of 70 instead of 90 to reduce the dose.

Hi Amy and good morning!
I have no idea how to try to fold in a bit higher carb (I have some 13% she loves I could try), but I can figure out a plan of attack and give it a shot.

I am actually confused about what I decided for modified-SLGS because of the Pred on board (every 3rd day). I'd like to stick to the TR dosing schedule as much as possible, and definitley do NOT want to HAVE to be extended out 7 days for a wait. Can I do soemthing in between 4 and 7 days? Or should I really try to stick with one or the other?

And if I AM going to upp her dose tomorrow (after the 8th cycle tonight), I wonder when I should start tinkering with the food a bit. Any thoughts on that?

The poitn you make about the IBD is interesting, and I have no idea how her food absorption is so maybe i do need to work on adding a bit more carb.

When you say "try using the modification of 70 instead of 90" what does the 70 and the 90 mean?

Thanks!!
Margaret

 

[Tomlin]

Good Morning!

For 100% safety reasons, FDMB does not mix and match the TR protocol & always follows the guidelines set out in the protocol. Again, this is because it is an aggressive protocol already, so to modify it randomly is potentially a risk to a cat & no one wants that .

SLGS is actually a set of guidelines (vs set protocol) with safety in mind. At times, there have been some limited adjustments made to it by more experienced members for some specific situations or by members as they get more trend info for their specific cat.

The one adjustment that was mentioned by @Marje and Gracie specific to Pearl is to lower the BG point at which you would need to lower the insulin dose and use a BG of 70 vs a BG of 90. SLGS guideline is normally 90.

The caveat with changing the # of days for changing insulin is that the # of days is more about information gathering in order to see the trends more clearly. If you are following TR, there is a required minimum # of BG tests you are doing every single day to get the information which then allows you to gather more trend info more quickly & then make safe decisions regarding dosing. When you are unable to to get the necessary amount of BG tests done daily as per the TR protocol, the safest solution is to add more days in order to be able to obtain the info needed to make safe dosing decisions, aka following a guideline like SLGS offers.

I hope this makes sense! The emphasis is on data,
Obtaining more BGs to be able to try to see what is going on—try to see the trends across a period of time. This is the best way to adjust insulin—have to have data .

 

[Margaret and Pearl (GA)]

Good Morning!

For 100% safety reasons, FDMB does not mix and match the TR protocol & always follows the guidelines set out in the protocol. Again, this is because it is an aggressive protocol already, so to modify it randomly is potentially a risk to a cat & no one wants that .

SLGS is actually a set of guidelines (vs set protocol) with safety in mind. At times, there have been some limited adjustments made to it by more experienced members for some specific situations or by members as they get more trend info for their specific cat.

The one adjustment that was mentioned by @Marje and Gracie specific to Pearl is to lower the BG point at which you would need to lower the insulin dose and use a BG of 70 vs a BG of 90. SLGS guideline is normally 90.

The caveat with changing the # of days for changing insulin is that the # of days is more about information gathering in order to see the trends more clearly. If you are following TR, there is a required minimum # of BG tests you are doing every single day to get the information which then allows you to gather more trend info more quickly & then make safe decisions regarding dosing. When you are unable to to get the necessary amount of BG tests done daily as per the TR protocol, the safest solution is to add more days in order to be able to obtain the info needed to make safe dosing decisions, aka following a guideline like SLGS offers.

I hope this makes sense! The emphasis is on data,
Obtaining more BGs to be able to try to see what is going on—try to see the trends across a period of time. This is the best way to adjust insulin—have to have data .

|
Thank you! Some of it makes sense - so as you know, I test A LOT. So in that sense, I am primed for TR well. In that sense, I am doing TR - yes? If I make dose adjustments every 4-ish days, this is still TR yes? Would my method only become SLGS if I reduced the number of BG checks in a day?

Also, the # of days to hold a dose - even if I held on for like 5 days, could still be called TR? When would it become SLGS?

I am so sorry for these basic questions, I got myself all mixed up. Reading the documents do not help, because according to the documents I am TR - but can I still be TR if I don't religiously upp the dose every 6 cycles? Can it go 8 or 10 cycles?

THANK YOU AMY!!!!

 

[Tomlin]

The issue is there is no “ish” or wiggle room for TR in the sense of having 3 or 4 days during the week that you are able to do testing needed but then a few days you can’t get the info & decide to hold the dose until you can follow TR for a few days.
Again, the protocol is very rigid for a reason. It is to keep cats safe given that it is an aggressive dosing method.

Based on my understanding, the only way you are following TR is if you are able to follow the protocol to the letter—-and that is 24/7 vs “most” or “many” days. Does that make sense? Again, while it may not seem like a big deal, the reason for the rigidity is safety.

 

[Margaret and Pearl (GA)]

The issue is there is no “ish” or wiggle room for TR in the sense of having 3 or 4 days during the week that you are able to do testing needed but then a few days you can’t get the info & decide to hold the dose until you can follow TR for a few days.
Again, the protocol is very rigid for a reason. It is to keep cats safe given that it is an aggressive dosing method.

Based on my understanding, the only way you are following TR is if you are able to follow the protocol to the letter—-and that is 24/7 vs “most” or “many” days. Does that make sense? Again, while it may not seem like a big deal, the reason for the rigidity is safety.

Oh, if that is the definition, I am set for TR! I work from home, and as a Lymie I am quarantined and rarely leave the house. So, there is zero chance I will miss taking her BGs! Yay!

 

[Tomlin]

Well there is the “half full” attitude to the Lymie situation .....TR for Pearl .

Fortunately, so far, there are not cycles with the Pred where the dosing is causing issues once the Pred is not impacting the BG. This is the only thing you will need to watch for as Pearls BG decreases lower IF she is still getting the Pred.

 

[Margaret and Pearl (GA)]

Well there is the “half full” attitude to the Lymie situation .....TR for Pearl .

LOL, I've learned to live with it. I've had Lyme most of my life (just diagnosed in 2015, and I'm in my 40s!), and in the past 6 years my world has gotten extremely limited (I was out of work for a year and bedridden in 2015). Nothing has been the same since the 2015 crash. I do a lot of crafts and enjoy my cats and hobbies - that is enough of a full life for me! And my work is gracious in allowing me to work from home most of the time.

 

[tiffmaxee]

Good Morning,



While there is reference to a “depot” I have been made aware ((by a prominent endo/DM specialist/insulin researcher) that Lantus does not create the equivalent or true depot in cats that it does in humans. I mention this because some will tend to think “I have a depot built up so that should be keeping them steady”. Not so.

This is not what the FDMB believes. There is a sticky on depot drugs that you can read here.

https://felinediabetes.com/FDMB/threads/what-is-the-insulin-depot.150/

 

[Tomlin]

@tiffmaxee

I am aware of this info, have read it & unfortunately, the endos have found that it does not act the same way in cats as it does in humans.

I am a big believer in asking questions, specifically to the leading vet endos who study & oftentimes help with the development of the treatment of DM. The understanding changes with time & this may be one of those areas that need to be revisited. Sometimes, what once was thought to be a certain way, with time, research & experience, the understanding and info changes.

 

[Marje and Gracie]

While there is reference to a “depot” I have been made aware ((by a prominent endo/DM specialist/insulin researcher) that Lantus does not create the equivalent or true depot in cats that it does in humans. I mention this because some will tend to think “I have a depot built up so that should be keeping them steady”. Not so.

One person does not a scientific conclusion make. If you want to provide scientific research that has been peer reviewed, we will look at it, but this is a misleading statement that is incongruent with all of the information we have. Saying “the endos” is inconsequential and, honestly, I’ve seen some info from some “endos” that was grossly lacking in knowledge of what we see with FD. So....I’m asking that you not make these statements without providing peer reviewed research. Thank you.

 

[Marje and Gracie]

if you are using TR OR the guidelines set up for SLGS with @Marje and Gracie suggestion that you can try using the modification of 70 instead of 90 to reduce the dose.

I never made this recommendation for Pearl. Just because we use it for one cat does not mean it’s appropriate for every cat. I haven’t had a chance to study Pearl’s SS yet.

 

[Tomlin]

One person does not a scientific conclusion make. If you want to provide scientific research that has been peer reviewed, we will look at it, but this is a misleading statement that is incongruent with all of the information we have. Saying “the endos” is inconsequential and, honestly, I’ve seen some info from some “endos” that was grossly lacking in knowledge of what we see with FD. So....I’m asking that you not make these statements without providing peer reviewed research. Thank you.

Most often, I do just that—source the info & the source is not always limited to this site & I think that is a good thing. I do not think info that is “incongruent” with what is offered here should immediately be deemed as “misleading” or result in such a response or posture vs a “hmmmm....” let’s ask some questions, investigate

 

[Tomlin]

I never made this recommendation for Pearl. Just because we use it for one cat does not mean it’s appropriate for every cat. I haven’t had a chance to study Pearl’s SS yet.

This is definitely my error—someone cue some coffee! You were tagged for a different member/cat & made this suggestion a few days ago. I deeply apologize for the confusion & the intent was definitely not to tell a member who was not offered the option directly by you, that it was an option. Again, SO sorry for the mix up ....both to you & Katherine . Fortunately, she is sticking with TR .

 

[Marje and Gracie]

This is definitely my error—someone cue some coffee! You were tagged for a different member/cat & made this suggestion a few days ago. I deeply apologize for the confusion & the intent was definitely not to tell a member who was not offered the option directly by you, that it was an option. Again, SO sorry for the mix up ....both to you & Katherine . Fortunately, she is sticking with TR .

Thank you. I appreciate it.

 

[tiffmaxee]

Most often, I do just that—source the info & the source is not always limited to this site & I think that is a good thing. I do not think info that is “incongruent” with what is offered here should immediately be deemed as “misleading” or result in such a response or posture vs a “hmmmm....” let’s ask some questions, investigate

Experts often disagree. I don’t believe one should choose to believe one over many others just because it’s more recent. I know that you know about the link I listed. It was for Margaret to read. I didn’t see any link for the researcher you are mentioning. Please provide.

 

[Tomlin]

Thank you. I appreciate it.

Again...so sorry about that! Thank you for catching it .

 

[Marje and Gracie]

Most often, I do just that—source the info & the source is not always limited to this site & I think that is a good thing. I do not think info that is “incongruent” with what is offered here should immediately be deemed as “misleading” or result in such a response or posture vs a “hmmmm....” let’s ask some questions, investigate

I never said it was misleading. The only posture I’m taking is concern with making invalidated comments. We use a lot of other sources here...if you read through the posts on the Health Index, you’ll see many outside sources referenced. We are not opposed to that at all. Knowledge is power. You know the research upon which the TR protocol, that we use here, is based and so if you are going to state on this board that it’s incorrect, then provide the research. Otherwise, we have to ask you to please remove your comment. From one scientist to another, that is a simple request.

 

[Marje and Gracie]

Good morning everyone,

Pearl is all over the map. I have a few questions, as I think I am getting confused by ALL THE BOUNCING.

(1) She seems to start each cycle with high PS numbers, and then drops very quickly (1-3 hours). Adding in low-carb food to slow it down won't help because she is already eating the low-carb food when this happens (she gets approx 50g Wellness Turkey/Duck 5% carb at PS and also at +2 or +3 of each cycle. She grazes so it takes her a couple hours to finish each meal). So...what do I do to slow down these drops? It seems whenever she drops she bounces (even if she doesn't hit her NADIR until +6). Do I need to add a teaspoon of HC or something to her PS meal so she doesn't drop as fast?

(2) Does her continuous bouncing indicate that I can't increase dose until she settles in? I am nervous she will NEVER settle in and just keep bouncing. I mean, is that possible for her to just keep bouncing? If so, how do you go about adjusting dose and experimenting with food amounts and times?

I would love any tips you can offer about her situation. The good news for me is that she spends more time in yellow and even sometimes gets a BLUE on the 1.5U dose, even though she still gets pinks with the bounces at times (no blues really on the 1.25U dose).

Link to yesterday's post: https://www.felinediabetes.com/FDMB/threads/1-12-pearl-amps-300-1-322.241385/#post-2717992

Thank you!!

I haven’t had a chance to look closely at her SS but I wanted to provide you with some general info.

In response to question 1, my Gracie was a diver. How did I get it under control when she started it? I tested at +1. If she was headed down by +1, I upped the carbs a bit to slow the drop. I’m not saying feed HC...I’m saying find a higher LC or even a MC (I used 13% no gravy) and stop the dive. You want to flatten her out to prevent the dive. I found doing this just a couple cycles with Gracie would stop that diving.

In response to question 2, you might find this helpful.

If you are giving pred for IBD, have you talked to your vet about budesonide which has less effect on the BG?

 

[Tomlin]

Experts often disagree. I don’t believe one should choose to believe one over many others just because it’s more recent. I know that you know about the link I listed. It was for Margaret to read. I didn’t see any link for the researcher you are mentioning. Please provide.

What is provided on this site is taken from human literature about depots &
“Practical experience on FDMB shows that as a generalization”

I agree with the fact that they acknowledge there is a “generalization” based on some practical experience. I am not discounting the years of practical experience, especially when it comes to TR.

However, even with respect to this sites info on the depot they make a point & reference

Furthermore, the degree of absorption of any dose, both between individuals and in the same individual, can vary from day to day by as much as 25 to 50 percent, leading to unexplained fluctuations in glucose control. This effect is greatest with longer-acting insulin and least with rapid-acting insulin.

In the end, even in humans there is some unpredictability & issues when it comes to the depot

Sometimes there are references to the depot & it is good for people to understand some of the limitations with it, especially in cats but also in humans .

@Margaret (and Pearl) -definitely read the yellow stickies at top of the forum . All good info & helpful.

I want to personally take a moment and apologize for any confusion caused for you & also for the back & forth that took place on your thread today .

NOW—back to the MOST important subject on this condo——PEARL (and you of course!!)

Have a great day & best with the BGs today!!!

 

[Marje and Gracie]

What is provided on this site is taken from human literature about depots &
“Practical experience on FDMB shows that as a generalization”

I agree with the fact that they acknowledge there is a “generalization” based on some practical experience. I am not discounting the years of practical experience, especially when it comes to TR.

However, even with respect to this sites info on the depot they make a point & reference

Furthermore, the degree of absorption of any dose, both between individuals and in the same individual, can vary from day to day by as much as 25 to 50 percent, leading to unexplained fluctuations in glucose control. This effect is greatest with longer-acting insulin and least with rapid-acting insulin.

In the end, even in humans there is some unpredictability & issues when it comes to the depot

Sometimes there are references to the depot & it is good for people to understand some of the limitations with it, especially in cats but also in humans .

@Margaret (and Pearl) -definitely read the yellow stickies at top of the forum . All good info & helpful.

I want to personally take a moment and apologize for any confusion caused for you & also for the back & forth that took place on your thread today .

NOW—back to the MOST important subject on this condo——PEARL (and you of course!!)

Have a great day & best with the BGs today!!!

Thanks, Amy. I would argue there is a difference between depot and absorption of a specific shot. But I won’t discuss it here in deference to Margaret.

I do appreciate your comments about condo hijacking and potentially making it confusing for Margaret and other newer members so I’d suggest you gather your materials and post on Think Tank. Tag experienced members and get a discussion going there. Informed discourse is always welcome.

Thanks, again.

 

[Margaret and Pearl (GA)]

I haven’t had a chance to look closely at her SS but I wanted to provide you with some general info.

In response to question 1, my Gracie was a diver. How did I get it under control when she started it? I tested at +1. If she was headed down by +1, I upped the carbs a bit to slow the drop. I’m not saying feed HC...I’m saying find a higher LC or even a MC (I used 13% no gravy) and stop the dive. You want to flatten her out to prevent the dive. I found doing this just a couple cycles with Gracie would stop that diving.

If you are giving pred for IBD, have you talked to your vet about budesonide which has less effect on the BG?

Hi Marje,

Thanks for your reply and for your advice about the MC food - I have decided on that very course of action at +1, and appreciate the confirmation. She likes the Wellness venison blend which is 13%!

Re: the Pred. Pearl gets it for asthma not IBD, and it's a long story about her need for it. She is a pretty significant asthmatic, and I historically use the Pred for flares (she is already on Flovent 250mcg, etc and etc), but she has had a lot of trauma in her life losing her friends this year and her asthma/pneumonia bouts have increased significantly, which is why she is on the Pred now and why I have been having a tough time getting her off of it in the past 3 months. But I am still trying to get as low as we can go, weaning. Every time so far I've gotten her OFF we have had to go back ON, but maybe this time will be the ticket! Whew, a lot of information!

 

[tiffmaxee]

The information helps us help you. Never worry about that or asking questions, as many as you have, as often as needed. Max got pancreatitis after watching his buddy lose her battle with lymphoma so that can definitely effect their health.

 

[Sienne and Gabby (GA)]

@Tomlin
In the spirit of the discussion, if the vet you mentioned does have research, we'd love to see it. The value of research is that it may very well be that the vet is correct and we need to give new information due consideration. I have access to veterinary and medical libraries so there's no issue with getting hold of journal articles. Personally, I'm quite curious as to how much the pharmacology of glargine would differ for cats vs humans (other than a cat's metabolism being faster) that would lead the endocrinologist to draw the conclusion he did.

 

[Tomlin]

@Sienne and Gabby (GA)

As stated earlier, I do not want to hijack this thread. If you read my comment made on this thread there is not reference to a specific or particular publication/research article nor is there just one endo who has shared this info with me. Again, I did not state there was no depot, I said that there isn’t a true depot as there tends to be with most humans.
Instead of a convo or a question to understand (which could be taken to think tank) there was the series of pretty interesting responses .

I will not be responding further to these messages left on this thread as it was agreed upon that it was more appropriate for a think tank discussion vs a members thread. I also want to hold true to
my agreement & not hijack this thread! Thank you!

Back to Pearl please