? General question about TR guidelines

[stannarp]

I'm doing a bit of reading about TR to see if I can implement it for Hissey Whiskey, and am not sure whether I am being an idiot or not, but this para in the TR guidelines sticky just does not make sense to me (https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/):

Have also read this article, and the two guidelines on increasing just don't seem to correlate: http://www.tillydiabetes.net/en_6_protocol2.htm

I'm fully aware that I don't really understand the protocol, but that is why I am reading, and trying to figure it out before leaping headlong into it.

 

[Katherine&Ruby]

Hi Patricia! Here is your last post for continuity: https://www.felinediabetes.com/FDMB...214-dosing-advice-please.257559/#post-2899024

I was trying to access your spreadsheet so I could have some context for your question and it's apparently in your trash on your computer? @Bandit's Mom can you help her with this?

We give dosing advice based on how low it takes a cat. If your cat sees any numbers under 100 (in US numbers, not World), then you keep giving the cat the same dose for another 10 cycles or 5 days to see if any further adjustment is needed. Your last post seems to indicate that Whisky is in greens, so you would hold the same dose for 10 more cycles since the last time you saw a green number.

 

[stannarp]

Hi Patricia! Here is your last post for continuity: https://www.felinediabetes.com/FDMB...214-dosing-advice-please.257559/#post-2899024

I was trying to access your spreadsheet so I could have some context for your question and it's apparently in your trash on your computer? @Bandit's Mom can you help her with this?

We give dosing advice based on how low it takes a cat. If your cat sees any numbers under 100 (in US numbers, not World), then you keep giving the cat the same dose for another 10 cycles or 5 days to see if any further adjustment is needed. Your last post seems to indicate that Whisky is in greens, so you would hold the same dose for 10 more cycles since the last time you saw a green number.

Hi there, the spreadsheet should be sorted out now, the link in my sig was outdated as I've been trying to pull the data into a pivot chart to make more sense of it, so have been tinkering with the files, I've updated it now though.

In terms of numbers, she did have numbers under 100 on 0.25 but as I am using SLGS and have read many horror stories (and it was late hours when my brain goes numb) I panicked a bit and tried to bring her up.

I've PM'd @Bandit's Mom about a suggestion on the previous thread for this, as I don't want to clog up the forum with the finer questions I have (which currently feel endless), will add you the conversation.

 

[stannarp]

OK, had this as a conversation, for @Bandit's Mom and @Katherine&Ruby, but per suggestion, posting it here in case anyone else does a search and needs similar info...

"I am still reading and trying to figure out the TR sticky's.

Right now I feel that she's not doing as well when I bring her dose down from 0.25 to 0.10 (this is the second time I'm trying it), first time in Dec 2021.

In your message on this thread: https://felinediabetes.com/FDMB/thr...67-amps-11-9-214-dosing-advice-please.257559/, I just wanted to check about the highlighted bit:

How much more testing would be involved?

At the moment I try to do AM and PM PS for sure every day, and 2-4 between cycle tests in daylight hours.

Generally I am for a 'curve day' once a week or so.

How many tests per day should I be aiming for, in daylight hours and night?

I'm trying to test before sleep, and at weird times in the night, but it is a bit of a challenge.

There are obviously some days where I can only test 2 x a day."

 

[Katherine&Ruby]

Keep asking the questions! There is no harm in it and your cat will do better with your understanding.

I've been on the FDMB for over a year now, and the horror stories are few and far between though it's good for you to be aware of the pitfalls. TR is more aggressive than SLGS, mostly because we increase doses more quickly when the cat needs it. It is also as has been pointed out to you the best way to get your cat into remission. Testing as much as possible is encouraged, though not necessary. We ask for 4 tests per day at minimum, and at least one test at night. The reasoning is that we want to see trends over days.

It may help you to look at other member spreadsheets. If you look at Ruby's, you will see how often I test. I am not doing TR, so please don't copy the way I dose Ruby, as I am very experienced and she has other conditions that make dosing for her a little trickier. I have a full time, full on, brain-taxing job that does not allow me to stay up all night to test, so I do the best that I can to get at least one, maybe two tests in the PM cycle.

You will also see how low Ruby goes and how low I give insulin. With TR, you can give a shot whenever the number is above 50. There are great things about using Lantus--it does not onset or become effective until 2-3 hours after a shot. If the cat is at 55 at shot time, you can feed it some medium or higher carb food to get it into a higher number before Lantus kicks in. This is why you will often read us telling members to get a +2 test.

The green numbers seems scary but they really are not. You have to get comfortable with the cat being in numbers between 50 and 100 if remission is your goal.

 

[Katherine&Ruby]

On January 7, you lowered the dose to .1. That was the right thing to do with SLGS. If you were following TR, you would not have reduced the dose and you would keep shooting .25 for another 10 cycles after you saw the green numbers on January 6. Make sense?

 

[Little Man's mom (GA)]

Hi Patricia! Been awhile since we chatted. You have been doing a great job with whiskey!

Katherine is right and I've found many of the ppl on here following tr have full time jobs. Much busier than me!

Feel free to look over my spreadsheet. When I started becoming more aggressive with dosing we started getting better and better numbers. I still get nervous especially when shooting lower numbers as we are finally seeing really great numbers over here in my world. Everyone here is so kind and there is so much info that even if someone cant get to you right away you can keep whiskey safe. I'm sure you have all the info you need internally (but it sure is nice to have a kind word and encouragement from the members)

I've only read through one really scary hypo story on this board. It seems to me most hypos are asymptomatic and with HC food and karo/honey everything is fine.

Having said that yes the low numbers are scary and much easier to be on the other side telling someone itll be ok. It's just a conditioning you have to go through really. Once you see the better numbers and how much happier your baby is they can be quite addictive!

 

[stannarp]

Keep asking the questions! There is no harm in it and your cat will do better with your understanding.

I've been on the FDMB for over a year now, and the horror stories are few and far between though it's good for you to be aware of the pitfalls. TR is more aggressive than SLGS, mostly because we increase doses more quickly when the cat needs it. It is also as has been pointed out to you the best way to get your cat into remission. Testing as much as possible is encouraged, though not necessary. We ask for 4 tests per day at minimum, and at least one test at night. The reasoning is that we want to see trends over days.

It may help you to look at other member spreadsheets. If you look at Ruby's, you will see how often I test. I am not doing TR, so please don't copy the way I dose Ruby, as I am very experienced and she has other conditions that make dosing for her a little trickier. I have a full time, full on, brain-taxing job that does not allow me to stay up all night to test, so I do the best that I can to get at least one, maybe two tests in the PM cycle.

You will also see how low Ruby goes and how low I give insulin. With TR, you can give a shot whenever the number is above 50. There are great things about using Lantus--it does not onset or become effective until 2-3 hours after a shot. If the cat is at 55 at shot time, you can feed it some medium or higher carb food to get it into a higher number before Lantus kicks in. This is why you will often read us telling members to get a +2 test.

The green numbers seems scary but they really are not. You have to get comfortable with the cat being in numbers between 50 and 100 if remission is your goal.

I mostly see the horror stories on FB, although from what I can see a fair number of those are related to mistakes, and quite a few are averted by pre shot testing.

The remission thing is the main reason I am considering TR, I really feel that she can get into remission if I try - or to rephrase that, I would like to give her the chance of remission BY trying.

The 4 tests per day won't be a problem, but the night one (at least anything post +3 at night) will be difficult; I work from home, but my work is also pretty insane; and I tend to fade quite early and need my full 8 hours to function optimally. The night she went into the greens was tough, as I saw her go the lowest I have ever seen at +3, and knowing her nadir is only at +6 I knew I had to stay up with the HC food, etc thing to make sure she didn't dip much lower.

Thanks for the idea to look at Ruby's spreadsheet, yes, I can see you do shoot at relatively low numbers.

I'm going to give her a try TR starting tomorrow morning at 0.25, and hopefully when I start seeing those low greens it will be in daylight hours (for me) so I will be in a better position to concentrate and not panic about them (fortunately I have the makings of a hypo kit) all where I know to find it!

 

[stannarp]

Hi Patricia! Been awhile since we chatted. You have been doing a great job with whiskey!

Katherine is right and I've found many of the ppl on here following tr have full time jobs. Much busier than me!

Feel free to look over my spreadsheet. When I started becoming more aggressive with dosing we started getting better and better numbers. I still get nervous especially when shooting lower numbers as we are finally seeing really great numbers over here in my world. Everyone here is so kind and there is so much info that even if someone cant get to you right away you can keep whiskey safe. I'm sure you have all the info you need internally (but it sure is nice to have a kind word and encouragement from the members)

I've only read through one really scary hypo story on this board. It seems to me most hypos are asymptomatic and with HC food and karo/honey everything is fine.

Having said that yes the low numbers are scary and much easier to be on the other side telling someone itll be ok. It's just a conditioning you have to go through really. Once you see the better numbers and how much happier your baby is they can be quite addictive!

Thanks so much @Rainbow Conti, I am going to try TR starting tomorrow - although my work is hectic and full time, I am in the fortunate position of working from home most of the time, so monitoring is easier for me than most in daylight hours - it is the long nights that freak me out, I need to get rest to deal with the insanity of my work, and also have to monitor myself to make sure I don't get over exhausted (I have ME and keeping it under control is a tightrope for me).

As above, I think I owe her the chance of remission by trying TR at least - my fear is doing something wrong that may result in harming her, but that is my issue not hers, and I need to get over that.

 

[Katherine&Ruby]

I'm going to give her a try TR starting tomorrow morning at 0.25

That's a good call. I looked at Whiskey's numbers and he could use a little more juice. Keep in mind that a dose increase is not instantaneous--it will take 6-10 cycles for you to see how the new dose is doing. I suggest you post more regularly here if you can, even if nothing is going on of note. It's helpful for us to get the "whole cat" report, how he is eating, drinking, using the litter box. A cat is more than his numbers.

 

[Little Man's mom (GA)]

Thanks so much @Rainbow Conti, I am going to try TR starting tomorrow - although my work is hectic and full time, I am in the fortunate position of working from home most of the time, so monitoring is easier for me than most in daylight hours - it is the long nights that freak me out, I need to get rest to deal with the insanity of my work, and also have to monitor myself to make sure I don't get over exhausted (I have ME and keeping it under control is a tightrope for me).

As above, I think I owe her the chance of remission by trying TR at least - my fear is doing something wrong that may result in harming her, but that is my issue not hers, and I need to get over that.

I have lupus and fully understand caring yourself as well!

I decided on TR for same reason I owe LM the chance. I will admit the nights can be longer sometimes but generally once you hit nadir its sleepytime. I have discovered how carb sensitive my boy is and am able to most of time figure out what is needed to keep him up and surfing. Testing helps an great deal to know when and how it all affects bg. Just like anything else data is crucial to management of fd.

 

[stannarp]

I have lupus and fully understand caring yourself as well!

I decided on TR for same reason I owe LM the chance. I will admit the nights can be longer sometimes but generally once you hit nadir its sleepytime. I have discovered how carb sensitive my boy is and am able to most of time figure out what is needed to keep him up and surfing. Testing helps an great deal to know when and how it all affects bg. Just like anything else data is crucial to management of fd.

Hats off to you for managing lupus and a diabetic cat! I am fortunate that the ME is generally in 'remission', but I know what causes it to flare up, stress and lack of sleep combined with not exercising are prime reasons to create a flare up.

I might start moving her earlier in terms of her shot times, so that I can get closer to nadir time for the pre bed test, that might make it a bit less stressful (I am an early waker anyway).

Fortunately I am a bit of a data and spreadsheet junkie, so the spreadsheet and intense data are right up my alley - I am sort of having fun trying to make it into a privot chart and table which will give me more meaningful data, LOL!

In terms of the previous comment about dose increases, I at least have data for how she does on 0.25 so I have an idea what to expect, but I will take on board the 6-10 cycles; but at least I also have some data about how much HC food to give her and how long it affects her.

Thing that amazes me about cats and inuslin is how little is required (at least in my Hissey Whisk) to make a huge difference in their lives!

 

[tiffmaxee]

Hi Patricia. I’m just waking up and haven’t had my coffee but wanted to respond. I’ve read what the others have written and see you are going to try TR. The problems with SLGS for a cat with such a good chance of remission are the high reduction number and that if you have to reduce the dose you have to wait a week to go back up. Then the cat starts to need more and more insulin as they get used to higher bg. With TR, if a reduction fails, you go right back to the last good dose once you have given the reduction time to see if it will stick. We can help with that.

Start a post every day, even if nothing to say or ask. On that case only the link to the previous condo will be needed. It gets eyes on your condo.

If at any time you find you can’t test more be it day or night, you can always abort the cycle by feeding hc. Just use wet hc because dry is forbidden on TR because it sticks with them too long.

I see the numbers the last few days were influenced by contraband dry so that’s an example. Cats are quick and smart and I know she snuck in to get it. I just point it out to further clarify about what kind of hc to feed.

See how TR works for you. There are things we can do if you see it’s too much of a challenge. It’s important to first try it as written. Good luck.

 

[Marje and Gracie]

I'm doing a bit of reading about TR to see if I can implement it for Hissey Whiskey, and am not sure whether I am being an idiot or not, but this para in the TR guidelines sticky just does not make sense to me (https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/):
View attachment 63350
Have also read this article, and the two guidelines on increasing just don't seem to correlate: http://www.tillydiabetes.net/en_6_protocol2.htm

I'm fully aware that I don't really understand the protocol, but that is why I am reading, and trying to figure it out before leaping headlong into it.

First, let me explain we use a modified TR protocol here so it isn’t exactly like Tilly’s. It is based upon the TR Protocol as discussed in Management of Diabetic Cats with Long Lasting Insulin by Roomp and Rand (the link is in the New to the Group Sticky) which is a rewrite of the original TR Protocol (Tilly’s) by those authors published in the Journal of Feline Medicine and Surgery. We have modified the TR Protocol slightly based on anecdotal evidence and experience within this forum. It is more slightly aggressive than the Roomp and Rand TR Protocol.

In regard to the section you quoted and asked about, and remember we are talking about consecutive cycles,

• If the cat is new to nadirs under 200, hold the dose 8-10 cycles after the first nadir below 200.
• For any cat on TR protocol, when the caregiver starts to see nadirs (more than one), hold the dose ten cycles.

Another way to explain this is using an example:
Let's say a very newly diagnosed kitty starts out on a dose increase and by cycle six (assume all cycles are consecutive), starts to see nadirs between 100-200 for the first time. Hold the dose ten cycles after the first nadir below 200. Maybe the kitty is on that dose for 12 cycles and then sees a nadir below 100. If it's just one, I'd increase. But if they start churning out hours of BGs below 100 and they do it both cycles, I'd hold the dose longer and likely another ten cycles after they start pumping out nadirs below 100. What's the rush?

I will add a caveat and that’s for very experienced CGs who have lots of data and know their cat. They might be seeing consecutive cycles of BGs below 100 at a dose and then the BG pops up above 100 after, as an example, seven cycles. That CG might choose to increase the dose to get the cat back into BGs below 100.

Does that help?

 

[stannarp]

Hi Patricia. I’m just waking up and haven’t had my coffee but wanted to respond. I’ve read what the others have written and see you are going to try TR. The problems with SLGS for a cat with such a good chance of remission are the high reduction number and that if you have to reduce the dose you have to wait a week to go back up. Then the cat starts to need more and more insulin as they get used to higher bg. With TR, if a reduction fails, you go right back to the last good dose once you have given the reduction time to see if it will stick. We can help with that.

Start a post every day, even if nothing to say or ask. On that case only the link to the previous condo will be needed. It gets eyes on your condo.

If at any time you find you can’t test more be it day or night, you can always abort the cycle by feeding hc. Just use wet hc because dry is forbidden on TR because it sticks with them too long.

I see the numbers the last few days were influenced by contraband dry so that’s an example. Cats are quick and smart and I know she snuck in to get it. I just point it out to further clarify about what kind of hc to feed.

See how TR works for you. There are things we can do if you see it’s too much of a challenge. It’s important to first try it as written. Good luck.

Thanks so much, yes, I am seeing from the other spreadsheets I've been looking at that giving HC does help keep them from hitting too many low's - I have HC gravy pouches, just one or two for emergencies, but will get a few to keep as a regular backup.

In terms of being quick and smart, I didn't realise just how quick and smart madam is - I usually give George his contraband behind closed doors and then put it waaaay out of reach, just that one time there was a small bit left and I knew he'd come back for it, so I put it in easy reach of me - and apparently Whiskey!

 

[stannarp]

First, let me explain we use a modified TR protocol here so it isn’t exactly like Tilly’s. It is based upon the TR Protocol as discussed in Management of Diabetic Cats with Long Lasting Insulin by Roomp and Rand (the link is in the New to the Group Sticky) which is a rewrite of the original TR Protocol (Tilly’s) by those authors published in the Journal of Feline Medicine and Surgery. We have modified the TR Protocol slightly based on anecdotal evidence and experience within this forum. It is more slightly aggressive than the Roomp and Rand TR Protocol.

In regard to the section you quoted and asked about, and remember we are talking about consecutive cycles,

• If the cat is new to nadirs under 200, hold the dose 8-10 cycles after the first nadir below 200.
• For any cat on TR protocol, when the caregiver starts to see nadirs (more than one), hold the dose ten cycles.

Another way to explain this is using an example:
Let's say a very newly diagnosed kitty starts out on a dose increase and by cycle six (assume all cycles are consecutive), starts to see nadirs between 100-200 for the first time. Hold the dose ten cycles after the first nadir below 200. Maybe the kitty is on that dose for 12 cycles and then sees a nadir below 100. If it's just one, I'd increase. But if they start churning out hours of BGs below 100 and they do it both cycles, I'd hold the dose longer and likely another ten cycles after they start pumping out nadirs below 100. What's the rush?

I will add a caveat and that’s for very experienced CGs who have lots of data and know their cat. They might be seeing consecutive cycles of BGs below 100 at a dose and then the BG pops up above 100 after, as an example, seven cycles. That CG might choose to increase the dose to get the cat back into BGs below 100.

Does that help?

Thanks, yes it does help; I was hoping to put it into a concise format with numbers, which is what makes sense to me; but I understand now that it is a bit more 'touchy feely', so I will adjust.

Also taking @Bandit's Mom's advice about trying to post daily to keep the data more on the forum on board.

Her nadirs at the moment are mostly in the 100's, upper at the moment because she also managed to get a sneak of our other cat's kibble (he has to get kibble as he is an old man with no canines and doesn't manage well on wet food because he cannot pick it up).

 

[Marje and Gracie]

Thanks, yes it does help; I was hoping to put it into a concise format with numbers, which is what makes sense to me; but I understand now that it is a bit more 'touchy feely', so I will adjust.

Also taking @Bandit's Mom's advice about trying to post daily to keep the data more on the forum on board.

Her nadirs at the moment are mostly in the 100's, upper at the moment because she also managed to get a sneak of our other cat's kibble (he has to get kibble as he is an old man with no canines and doesn't manage well on wet food because he cannot pick it up).

Actually, it isn’t touchy feely at all. It’s very straightforward And it does have numbers:

• Starting out, nadirs between 100-200, hold the dose ten cycles after the first blue nadir
• Hold the dose ten cycles after nadirs below 100.

 

[Jodey&Eddie&Blue]

Hi Patricia! Been awhile since we chatted. You have been doing a great job with whiskey!

Katherine is right and I've found many of the ppl on here following tr have full time jobs. Much busier than me!

Feel free to look over my spreadsheet. When I started becoming more aggressive with dosing we started getting better and better numbers. I still get nervous especially when shooting lower numbers as we are finally seeing really great numbers over here in my world. Everyone here is so kind and there is so much info that even if someone cant get to you right away you can keep whiskey safe. I'm sure you have all the info you need internally (but it sure is nice to have a kind word and encouragement from the members)

I've only read through one really scary hypo story on this board. It seems to me most hypos are asymptomatic and with HC food and karo/honey everything is fine.

Having said that yes the low numbers are scary and much easier to be on the other side telling someone itll be ok. It's just a conditioning you have to go through really. Once you see the better numbers and how much happier your baby is they can be quite addictive!

I can certainly attest to the rigours and effectiveness of TR as it is supported by members of this forum. Eddie is down from 15u about six months ago to 6.5u (see spreadsheet but don't copy. Eddie also has had surgery and SRT for acromegaly). I have one of those day-jobs that requires presence and clarity of mind and while I truly find doing tests and feeding into the night challenging to say the least, I know we wouldn't be at 6.5u (and possibly dropping further) without TR and the help from folks here. It is a wonderful feeling when you get a low green to know someone here has your back.

 

[stannarp]

Actually, it isn’t touchy feely at all. It’s very straightforward And it does have numbers:

• Starting out, nadirs between 100-200, hold the dose ten cycles after the first blue nadir
• Hold the dose ten cycles after nadirs below 100.

Thanks that helps - what I mean by touchy feely is that it is a lot more 'hands on' and 'know thy cat', i.e. the rules are relatively straightforward, but also situational. Guess the same can be said for SLGS ;-)

 

[stannarp]

I can certainly attest to the rigours and effectiveness of TR as it is supported by members of this forum. Eddie is down from 15u about six months ago to 6.5u (see spreadsheet but don't copy. Eddie also has had surgery and SRT for acromegaly). I have one of those day-jobs that requires presence and clarity of mind and while I truly find doing tests and feeding into the night challenging to say the least, I know we wouldn't be at 6.5u (and possibly dropping further) without TR and the help from folks here. It is a wonderful feeling when you get a low green to know someone here has your back.

It also helps to know that there are others with crazy jobs that have managed with TR - that is one of my biggest worries is balancing looking after Whisk and getting her as healthy as I can (given where she was when we adopted her) with keeping myself healthy enough to keep mind body and soul together to maintain my work and keep looking after her and everyone else!

But, def helps to know that there are people advising - and from my perspective also helps to know that for many of them my midnight hours are their daylight hours, as I am waaaaaay south of the equator !

EDITED - I see what you mean by don't copy - WOW, 6.5u!

 

[Marje and Gracie]

Thanks that helps - what I mean by touchy feely is that it is a lot more 'hands on' and 'know thy cat', i.e. the rules are relatively straightforward, but also situational. Guess the same can be said for SLGS ;-)

Yes, you are correct. It is definitely “know thy cat” but you are also correct that the same applies to SLGS.