? 12/4 Does anyone have experience with Dr. Hodgkin's sliding scale TR protocol?

Sher (Teddy)

Sher (Teddy)

Member Since 2021
Teddy is a 13 yo neutered male tabby who was diagnosed with DM a year ago (excess thirst/urination/appetite with weight loss) who responded well to switch from dry food to Friskies pate LC canned food and glargine insulin, with reversal of his clinical symptoms. His vet has been very supportive of my desire to use the TR protocol published by Roomp & Rand (JFMS 2009). I have been testing at least 3 times a day per the parameters in Table 1 of the article, with more conservative dosing when I know I won’t be home to check more frequently. He has hypoglycemic nadirs out of the blue; all have been asymptomatic, even when down in the 20s. Then he rebounds to hyperglycemia in the 300s (3 times in the 400s). He shows transient rises with dose increases. He has never been regulated, and I worry about chronic rebound. Roomp says on http://www.tillydiabetes.net/ “Try to find a way to dose as consistently as possible, time-wise and dose-wise: sliding scales don't work. Don't skip shots.” She also says TR works for most cats, but not all. Is Teddy one of these cats? Has anyone had experience with the sliding scale protocol of Dr. Elizabeth Hodgkins as used on http://www.diabeticcatinternational.com/, where they promote using “the right amount of insulin at the right time”, even at 10 hour injection intervals?
 
Sher said:
Teddy is a 13 yo neutered male tabby who was diagnosed with DM a year ago (excess thirst/urination/appetite with weight loss) who responded well to switch from dry food to Friskies pate LC canned food and glargine insulin, with reversal of his clinical symptoms. His vet has been very supportive of my desire to use the TR protocol published by Roomp & Rand (JFMS 2009). I have been testing at least 3 times a day per the parameters in Table 1 of the article, with more conservative dosing when I know I won’t be home to check more frequently. He has hypoglycemic nadirs out of the blue; all have been asymptomatic, even when down in the 20s. Then he rebounds to hyperglycemia in the 300s (3 times in the 400s). He shows transient rises with dose increases. He has never been regulated, and I worry about dr. No chronic rebound. Roomp says on http://www.tillydiabetes.net/ “Try to find a way to dose as consistently as possible, time-wise and dose-wise: sliding scales don't work. Don't skip shots.” She also says TR works for most cats, but not all. Is Teddy one of these cats? Has anyone had experience with the sliding scale protocol of Dr. Elizabeth Hodgkins as used on http://www.diabeticcatinternational.com/, where they promote using “the right amount of insulin at the right time”, even at 10 hour injection intervals?
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Yes, we are familiar with it and that forum but we do not use that dosing method here. While it might work for some cats, it’s not a method we support for the L insulins. I also know of a couple members who have tried it but it did not work well for their cats.

Dr. Hodgkins originally designed the sliding scale for PZI and not Lantus or Levemir. It works well with anyone still using compounded PZI or Prozinc. That forum extended its use to Lantus. I often look at that forum and I don’t see them having the successes we have here.

You might be surprised to know that Teddy is considered to be well-regulated under the definitions established for regulation:
  • Not treated [blood glucose typically above 300 mg/dl (16.7 mmol/L), poor clinical signs]
  • Treated but not regulated [often above 300 (16.7) and rarely near 100 (5.6), poor clinical signs]
  • Regulated [generally below 300 (16.7) with glucose nadir near 100 (5.6), good clinical signs, no hypoglycemia]
  • Well regulated [generally below 200-250 (11.1-13.9) and often near 100 (5.6), no hypoglycemia]
  • Tightly regulated [generally below 150 (8.3) and usually in the 60-120 (3.3-6.7) range, no hypoglycemia, still receiving insulin]
  • Normalized [60-120 (3.3-6.7) except perhaps directly after meals -- usually not receiving insulin]
I don’t believe it’s the dosing method that is causing the issue but it’s the management of his FD. Apologies but you cannot hope to get a cat into tight regulation if you don’t manage the insulin correctly. “Some” of those things include:
  • Always getting 2-3 tests per cycle including night. If you are missing data at night, you are missing half your data.
  • As many cycles as possible, getting a +2 test. The +2 will tell you if it’s likely to be an active cycle where you will need to test more.
  • Managing the curve with food. If the +2 is much less than the PS or he’s clearing a bounce, he is likely to drop very low such as on 11/28. Those low numbers were completely avoidable.
  • Feeding only canned or balanced raw food. I see he is still getting dry food such as Meow Mix and another cat’s dry food; one of the requisites for TR is feeding only wet food, canned or balanced raw.
Just as an aside, I’m not sure where the info on the top right of his SS came from regarding ranges (I suspect from a FB group we are aware of) but the two regarding “normal” glucose are not what we use here. Also, I understand you might have a specific need for separating out the weeks but, for those of looking at his SS, we look for wives of action and it’s very hard to visualize that (and I have looked at literally thousands of SSs) with the numerous blank white lines in between the cycles. I’m not saying you have to change it…it’s his SS…but it doesn’t really serve a function, there are other ways to define the weeks and you can PM me if you need help, but it also breaks up the waves.

Lastly, it’s important to know not all cats become tightly regulated no matter what you do. None of us three moderators had tightly regulated cats all the time, although one kitty was acro. If you do the best you can to manage the insulin and feeding correctly, then it’s up to Teddy’s body and he just might always be well-regulated.

I hope that helps. Please let me know your questions.
 
Thank you very much!! Very helpful indeed!! For clarification, the dry Meow Mix is his rescue food when he goes hypo; he is otherwise exclusively fed canned Purina Pate, open fed. I am planning to switch to a homemade diet with the EZComplete fur Cats supplement referenced in a forum on this website. I am hoping that manipulating his diet further may help.
 
Sher said:
Thank you very much!! Very helpful indeed!! For clarification, the dry Meow Mix is his rescue food when he goes hypo; he is otherwise exclusively fed canned Purina Pate, open fed. I am planning to switch to a homemade diet with the EZComplete fur Cats supplement referenced in a forum on this website. I am hoping that manipulating his diet further may help.
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I agree with Elise and here’s why: dry food is not the best option for bringing low numbers up. It can take a little longer to respond to low numbers and then it stays in the system longer, affecting the BG longer.

The best option is as Elise suggested….higher carb canned foods.
 
Thank you all for your kind suggestions. I have wavered between wanting to be aggressive and being completely frightened I would kill my cat with an OD of insulin - I guess that shows in his spreadsheet! I even took him to work with me on Monday 2/22 to make sure he didn't croak! Some of the gaps are me needing a break; he is just fine with testing. I really appreciate your thoughtfulness.
 
The only other piece of information I would add to Wendy's explanation of Hodgekin's method of tight regulation is that it can be quite dangerous if you follow it to the letter. She eschews the use of high carb food to raise low numbers. Frankly, cat's have died from hypoglycemia following that guideline.

We also use a slightly modified version of the Roomp & Rand protocol I'd encourage you to read over the sticky note on our dosing methods and please ask questions so we can clarify if you have questions.
 
Thank you so much! I set myself up for an unrealistic expectation of a quick remission given that Vet said Teddy had a good chance with early initiation of therapy after symptom onset and use of glargine insulin. At the one year mark of therapy at the beginning of this week, I became very down. I feel it is my fault if he doesn't remit. I am not a user of social media but knew I needed to reach our for help. I really appreciate the support and the suggestions!! I will work on my gaps and stick with it.
 
FD is crazy hard to figure out and so many vets aren’t well trained in how to approach it. Try and post daily even if you have nothing to say. In that case just link your previous post. That way more eyes will be on your spreadsheet daily.
 
Please don't kick yourself! There is no way to predict whether a cat will go into remission. I used to become so distressed when I would see cats were here for what seemed like a minute go into remission and I was struggling to keep Gabby in good numbers. I know in her case and like for many others, I had no way to know how long Gabby had been diabetic. She didn't show the typical symptoms. You have been doing your research and reading which is a great deal more than many people do. Perhaps even more importantly, you are fighting for Teddy. There are any number of caregivers who would give up -- their vet may say their cat's lifespan will be a year, that treating diabetes is difficult, and all sorts of nonsense coupled with it would just be better to euthanize their cat. You've not done any of that and instead, you're working to give Teddy the best quality of life and as much love as possible. And frankly, I suspect that's all Teddy cares about!

Given that you have an IBD kitty, I would be cautious with using gravy-based food to raise your cats BG level. Most gravy based foods contain gluten. It could upset your cat's GI track. Gabby was gluten sensitive. I would use a drop or two of either honey or corn syrup (Karo) to steer her BG numbers.
 
Thank you so much for the support. Means so much!! Karo gets so sticky on the whiskas!! But yes, it's in the toolbox, just dang messy.
 
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