6/24 Henry PMPS 355

[John & Henry]

https://felinediabetes.com/FDMB/thr...-saga-amps-317-1-5-308-2-25-313-3-336.265025/

Alright, Mr. Henry was living in the red almost the whole last cycle. Last ketone check we were at .8, down from .9 the check before. I think the .25U R really helped with the 100 point drop, that quickly rebounded a couple hours later, but kept us from getting up to the 400s.

Fingers crossed for some blues and yellows this cycle. Maybe even a green or two. No more red!

Would love your input @Wendy&Neko

 

[Bron and Sheba (GA)]

Hi John, Wendy will be sound asleep for the next several hours. But you got the 100 point drop with the R which is what Wendy was looking for.
How are you feeling? you must be tired. You can’t keep going on like this without some sleep. You won’t be any good for anyone, least of all Henry.
Are you OK to monitor for the next 4 or 5 hours?
That is good that the ketones have stayed down.

 

[Bandit's Mom]

Hi John, is the PMPS 255 or 355? SS says 355 and title says 255 unless I'm seeing things wrong!

ETA: did you up the L dose to 2U?

 

[John & Henry]

Hi John, is the PMPS 255 or 355? SS says 355 and title says 255 unless I'm seeing things wrong!

ETA: did you up the L dose to 2U?

That was a typo sorry for the scare. It's 355. Yes, after all the red and the ketones I went with 2U L. I'd rather deal with potential hypo than ketones

 

[Bron and Sheba (GA)]

That was a typo sorry for the scare. It's 355. Yes, after all the red and the ketones I went with 2U L. I'd rather deal with potential hypo than ketones

John, that was really not a good idea to increase the dose of Lantus to 2 units. Please, please do not do increases on your own at the moment, especially when you are just starting R.
Henry dropped to 34 last night on 2 units and his dose was dropped to 1.75units. The 34 indicates that the dose was too high.
Hypos can be a lot harder to manage than you think.

 

[John & Henry]

Hi John, Wendy will be sound asleep for the next several hours. But you got the 100 point drop with the R which is what Wendy was looking for.
How are you feeling? you must be tired. You can’t keep going on like this without some sleep. You won’t be any good for anyone, least of all Henry.
Are you OK to monitor for the next 4 or 5 hours?
That is good that the ketones have stayed down.

Yes, I'll be OK. Got a couple hours this morning when he was running good. 45 minute "eyes closed" sessions in between readings (it takes me usually at least an hour to actually fall asleep, so, I'm not really "sleeping" per se). The libre is great for waking me up when things go south, and Henry sleeps right next to me, just I've just been scanning him periodically. The libre is basically useless in the reds tho. It just reads 400 or HI. I'm very happy about the ketones and the clear 100 point drop right after the R dose. Hopefully that will be good information going foward.

Do either of you know if certain brands of syringes are more or less prone to bubbles? I've been having a hell of a time with bubbles and dosing out that R. He may be getting a bit less than I intend.

 

[Bandit's Mom]

That was a typo sorry for the scare. It's 355. Yes, after all the red and the ketones I went with 2U L. I'd rather deal with potential hypo than ketones

I know the multiple DKAs have been scary but dosing is based on nadirs and not preshots or bounces. There is only so much you can do to prevent bouncing...unfortunately. And numbers will be flat and high in bounce cycles. Lantus is a depot insulin, so dosing based on a bounce cycle can cumulate and give you hell when the bounce clears. Especially with R in the mix as well.

Do either of you know if certain brands of syringes are more or less prone to bubbles? I've been having a hell of a time with bubbles and dosing out that R. He may be getting a bit less than I intend.

Which brand are you using? Try pressing the plunger hard and keeping it pressed and insert into the pen/vial and see if that draws less air? Sometimes it is a real pain in the ar$e to get the air bubble out.

 

[John & Henry]

John, that was really not a good idea to increase the dose of Lantus to 2 units. Please, please do not do increases on your own at the moment, especially when you are just starting R.
Henry dropped to 34 last night on 2 units and his dose was dropped to 1.75units. The 34 indicates that the dose was too high.
Hypos can be a lot harder to manage than you think.

Yes he did, but when that 1U dose was given his BG was only 70 and it had dropped from 80. I know we thought it was going to shoot up at some point so I understand why you wanted to shoot at 70. I just see a big difference between shooting at 70 and shooting at 355. Maybe I made a bad choice tonight. I guess we'll find out soon. I just keep thinking back to the day he was given 2U and then proceeded to stayed in the 400s the whole cycle til he ended up in the hospital. I'm trying to avoid that repeat at all costs.

 

[John & Henry]

I know the multiple DKAs have been scary but dosing is based on nadirs and not preshots or bounces. There is only so much you can do to prevent bouncing...unfortunately. And numbers will be flat and high in bounce cycles. Lantus is a depot insulin, so dosing based on a bounce cycle can cumulate and give you hell when the bounce clears. Especially with R in the mix as well.


Which brand are you using? Try pressing the plunger hard and keeping it pressed and insert into the pen/vial and see if that draws less air? Sometimes it is a real pain in the ar$e to get the air bubble out.

I guess I just figured the vet had been giving him 2U (well, she actually gave him 3U at one point which probably caused a lot of this bouncing in the first place) and he's really had mostly 2U for 5 or 6 days now with the exception of last night and this morning. I see what you're saying tho. I guess we'll have to see how this cycle goes. I guess I'm just traumatized from the last 3 hospitalizations. I wish wendy would have had a second to look at his SS and give an opinion.

I'm using UltiCare VetRx 3/10 29g U-100 syringes. I've tried everything I can think of and can't get rid of every last damn bubble, it's near impossible. It's gotta have something to do with the brand. So he's probably getting less than we expect. I have been pushing the plunger and drawing very very slowly and it may help a little, but it's bubbles that seem to stick around the top of the syrine and you can't even really eject them out, they get like hung up on the plastic or something.

 

[Bron and Sheba (GA)]

Yes he did, but when that 1U dose was given his BG was only 70 and it had dropped from 80. I know we thought it was going to shoot up at some point so I understand why you wanted to shoot at 70. I just see a big difference between shooting at 70 and shooting at 355. Maybe I made a bad choice tonight. I guess we'll find out g.

John, the reason we shot at 70 was because he needed to get some insulin into him. Today was different. Lantus dosing is based on the nadir as Bhooma said, not the pre shot BG. You have given him the increase based on the pre shot and you have given 0.25 units of R as well

just keep thinking back to the day he was given 2U and then proceeded to stayed in the 400s the whole cycle til he ended up in the hospital. I'm trying to avoid that repeat at all costs

He was not eating well that cycle, and he was drinking a huge amount and the previous cycle had been skipped and he was unwell. This time he is eating well, he is getting sub Q fluids, no skipped doses and he is getting R. There is a big difference.
We can’t help you unless you help us help you. If you want to do something please ask us first.we will always discuss it with you. But if you go ahead and do increase without telling us, it is very hard to help you.
I know you are tired and that is the worst time to be making decisions on your own.
We only want what is best for Henry, believe me.

 

[Bron and Sheba (GA)]

I guess I'm just traumatized from the last 3 hospitalizations. I wish wendy would have had a second to look at his SS and give an opinion.

I totally get you are traumatised after three admissions. I would be too.
Let’s draw a line in the sand and move on.
Not sure when Wendy will be back online. But I’m sure she will be popping in here to see how Henry is going. And hopefully Sandy will as well.

 

[Bandit's Mom]

Yes he did, but when that 1U dose was given his BG was only 70 and it had dropped from 80. I know we thought it was going to shoot up at some point so I understand why you wanted to shoot at 70. I just see a big difference between shooting at 70 and shooting at 355. Maybe I made a bad choice tonight. I guess we'll find out soon. I just keep thinking back to the day he was given 2U and then proceeded to stayed in the 400s the whole cycle til he ended up in the hospital. I'm trying to avoid that repeat at all costs.

We all know and understand how traumatic this has been for you. 3 DKAs, almost back to back, would freak anybody out. We have to find a balance between DKA and hypo. Both are dangerous and potentially fatal and can send him back to the ER.

This seems rather illogical but a preshot is not always an indication of how the cycle will play out. We like to say "Shoot low to stay low" because Lantus is very good at giving beautiful flat cycles when you shoot a low preshot. You can have cycles where you start in the 400s or 500s and nadir below 50. Especially in bounce breaking cycles where there is additional downward momentum.

2U took him down to the 50s on 6/20 and if you had shot on the AM of 6/21, it's possible he might have dropped below 50 and earned a reduction. You will get a good idea of what a dose is doing when you shoot the same dose consistently for a few cycles and see how low he goes when a bounce clears. There is only so long you can prop a cat's numbers up with higher carbs when the dose is higher than it should be. If the depot gets overfull, it's like standing in front of a speeding train. There was a sticky somehere with an actual example of a CG who didn't take an earned reduction and spent a cycle strugging to bring the cat up from the 20s. A cycle like last night is also not something you want.

I wish wendy would have had a second to look at his SS and give an opinion.

Wendy usually checks in every day but unfortunately she's tied up this weekend. I'm sure she will peek in at some point, but might not be able to do so as often as she usually does.

I'm using UltiCare VetRx 3/10 29g U-100 syringes. I've tried everything I can think of and can't get rid of every last damn bubble, it's near impossible. It's gotta have something to do with the brand. So he's probably getting less than we expect. I have been pushing the plunger and drawing very very slowly and it may help a little, but it's bubbles that seem to stick around the top of the syrine and you can't even really eject them out, they get like hung up on the plastic or something.

I guess you must already have tried this, but do you flick the syringe with your finger to try and get the bubble to the bottom of the needle so that you can squeeze it out?

 

[John & Henry]

I guess the way I'm looking at it is we actually did a decrease because as I said, he had been at 2U for 5-6 days, now we're seeing high numbers and we would no doubt be in the 400s right now with more ketones if I had followed the advice to not to give the .25U R because wendy wasn't around. I get that R is different than what everyone is used to using and everyone is reluctant to give advice because they don't have experience with it and don't want to be responsible for a hypo event. I get it. I'm also not thrilled about getting blamed by the vet for not following her instructions, but I realize this is your area of expertise and I'm trying to defer almost everything to the knowledgeable people of this board. Henry's been hypo a couple times now, its been pretty easily dealt with. he's had no symptoms of hypo and if he did I'm less than 5 minutes away from an ER and dextrose and hypo is rarely fatal, but another DKA would be for him at this point. I also think both of these glucose meter are garbage. The nova may be better, but with the faulty batch of strips it seems I was using, who's to say he was even under 50 at all? we just don't know for sure. I feel like I'm trying as hard as I can to keep him alive, and I do appreciate everything you've done to help.

I'm also exhausted and don't want to argue as I can barely spell and I've been trying to type this short message for 20 minutes now.

 

[Bron and Sheba (GA)]

feel like I'm trying as hard as I can to keep him alive, and I do appreciate everything you've done to help.

You are doing everything possible to help Henry. And it’s wonderful to see someone love their kitty as much as you do!

I'm also exhausted and don't want to argue as I can barely spell and I've been trying to type this short message for 20 minutes now.

No one is arguing, we just want what is best for Henry. And I get that you are totally exhausted.
I am happy you gave the R tonight. Who said not to?
I am just concerned that the Lantus was increased.
However we are going to move on and I am hoping Henry has a really good cycle, eats well and the ketones stay down.
it must be time for +1?

 

[John & Henry]

I guess you must already have tried this, but do you flick the syringe with your finger to try and get the bubble to the bottom of the needle so that you can squeeze it out?

Yes and although it takes some effort I can usually always get the bottom bubbles. Its the bubbles that get caught on top that are the problems. You'd think they would get ejected out when I push, but it's like they're stuck on the plastic or something and no amount of flicking or trying to eject them till get rid of them. It's gotta be the brand of syringe. These syringes are also not uniform. Some of them the plunger goes all the way to the zero line, some of them it's back as far (or further) than where the plunger should be for a .1U dose. It's very frustrating and makes gauging small doses very difficult. The trick that wendy talked about with just doing it over and over on to a piece of paper to try and get a uniform drop is the best I can do, but it's still not easy at all.

 

[John & Henry]

I am hoping Henry has a really good cycle, eats well and the ketones stay down.
it must be time for +1?

Yeah we're almost to +2 actually. The libre was still reading HI half an hour ago. let me poke him. He's had 4+ full cans of food today so yeah, I'd say he's been eating well.

 

[Bron and Sheba (GA)]

I'd say he's been eating well

That’s great.

 

[John & Henry]

So we're not down much 335 @ +2

 

[Bron and Sheba (GA)]

So we're not down much 335 @ +2

But it is going in the right direction.
Can you get some sleep for 1 hour?

 

[John & Henry]

But it is going in the right direction.
Can you get some sleep for 1 hour?

sleep? probably not, but just lying in bed with my eyes closed helps. I'll be back and check him in an hour.

 

[Bron and Sheba (GA)]

sleep? probably not, but just lying in bed with my eyes closed helps. I'll be back and check him in an hour.

Do try because you have not slept for ages.

 

[John & Henry]

We're at 298 on the nova for +3. The libre is actually updating again and its at 370 and will start screaming at me if it gets low. I'll be back in another hour since everything isn't crazy right now

 

[Suzanne & Darcy]

We're at 298 on the nova for +3. The libre is actually updating again and its at 370 and will start screaming at me if it gets low. I'll be back in another hour since everything isn't crazy right now

Yellow!

 

[Tina Marie (GA) and Jan]

John, it is beautiful to witness your love for Henry (precious), your quick learning on his behalf, and your very good attitude along the way. I hurt for you over the expense, and your lack of rest.

I am glad you pushed for using R. You also accomplished giving subQ fluid (a big yes on those 20g Terumo needles @Suzanne & Darcy / and maybe somebody else, mentioned). They slide in easily with the long sharp, slender opening at the tip. I could give 100 ml in just over 2 minutes.

I deeply "feel" for Henry, as I have taken insulin for 43 years (currently Levemir and Humalog, which is faster acting than R). I know what highs and lows feel like, and I remember DKA too when I was 18. One of the first cats I gave insulin, was a beautiful black boy named Henry Having a scale for R is very helpful, after you discover just what works, which you are in the process of doing.

Big hugs and peace you are a great cat daddy!

 

[John & Henry]

Yellow!

....and back to red 336 @ +4 the Libre is reading HI again. I really don't understand what is going on here. So strange. Situations like these are why I was suspecting my Lantus had gone bad or something. Well, looks like we don't need to be afraid of hypo anymore. The libre should beep at me if it drops anywhere near scary terrority. Can I try to actually sleep for a few hours and I'll try and catch a +8 or something? Hopefully it doesn't go back up too much. /sigh

 

[John & Henry]

John, it is beautiful to witness your love for Henry (precious), your quick learning on his behalf, and your very good attitude along the way. I hurt for you over the expense, and your lack of rest.

I am glad you pushed for using R. You also accomplished giving subQ fluid (a big yes on those 20g Terumo needles @Suzanne & Darcy / and maybe somebody else, mentioned). They slide in easily with the long sharp, slender opening at the tip. I could give 100 ml in just over 2 minutes.

I deeply "feel" for Henry, as I have taken insulin for 43 years (currently Levemir and Humalog, which is faster acting than R). I know what highs and lows feel like, and I remember DKA too when I was 18. One of the first cats I gave insulin, was a beautiful black boy named Henry Having a scale for R is very helpful, after you discover just what works, which you are in the process of doing.

Big hugs and peace you are a great cat daddy!

Thank you for the thing words Tina. I'll have to look into those needles. I'm glad Henry's a good boy I was afraid he wasn't going to like it after seeing those needles. I'm sorry you've had to experience this. I actually lost a (human) friend to DKA a little over a year ago. Diabetes is such a devastating disease. I hope your able to manage everything ok? Another diabetic Henry, eh? I've seen 3 different Henry's (including mine) here on the Lantus board alone. Must be a popular name for diabetic cats.

Thanks again for all the encouragement

 

[Bron and Sheba (GA)]

....and back to red 336 @ +4 the Libre is reading HI again. I really don't understand what is going on here. So strange. Situations like these are why I was suspecting my Lantus had gone bad or something. Well, looks like we don't need to be afraid of hypo anymore. The libre should beep at me if it drops anywhere near scary terrority. Can I try to actually sleep for a few hours and I'll try and catch a +8 or something? Hopefully it doesn't go back up too much. /sigh

Yes, I think you can get some sleep. Were you thinking of giving R again at +6? We need to see what the +6 is first.
He is bouncing at the moment from the run of low greens yesterday. That is why you are seeing the higher numbers.
Have you got a urine sample to test for ketones at all?
I’m not commenting on the R dose moving forward at all, I’ll leave that to Wendy and Sandy, but with the Lantus dose, I think you should go back to 1.75 units in the morning, because when he breaks the bounce he could drop low and we know that 2 units took him down to 37.

 

[John & Henry]

Yes, I think you can get some sleep. Were you thinking of giving R again at +6? We need to see what the +6 is first.
He is bouncing at the moment from the run of low greens yesterday. That is why you are seeing the higher numbers.
Have you got a urine sample to test for ketones at all?
I’m not commenting on the R dose moving forward at all, I’ll leave that to Wendy and Sandy, but with the Lantus dose, I think you should go back to 1.75 units in the morning, because when he breaks the bounce he could drop low and we know that 2 units took him down to 37.

Yes, I was actually just thinking that right after I got up about doing the R at +6 so I'll be back then for .25U.

edit: should conditions continue to permit. Have not been able to catch a urine ketone yet.

 

[Bron and Sheba (GA)]

Yes, I was actually just thinking that right after I got up about doing the R at +6 so I'll be back then for .25U.

edit: should conditions continue to permit. Have not been able to catch a urine ketone yet.

Get some sleep between now and +6

 

[Bron and Sheba (GA)]

I’m heading to bed now John. I’ll ask @Bandit's Mom to help you.
See you tomorrow. I hope you can grab some sleep.
You are doing a great job under difficult circumstances Henry is one lucky kitty to have you.

 

[Suzanne & Darcy]

I was sorry to see he is back in pink - although it’s not a huge change from the 298. It’s so frustrating to see so little change from AMPS.

 

[alio]

Hi John, I've only partly been following Henry's story, but I just wanted to pop in and say what you are doing for Henry is very heroic, I can only imagine how stressed and exhausted you are. Henry is very lucky to have you!

With the bubbles in the syringe, I too struggled with that for a while. What worked for me (most of the time):
* hold the syringe with the needle up and flick the bubbles to the top
* still holding it upright, draw in more air to make a big gap of air at the top
* still holding it upright, slowly depress the plunger til the air is gone

It seems counter-intuitive, but, for whatever reason, the big air bubble likes to stay together when it gets expelled, whereas the tiny ones just seem to get stuck up the top.

The times this hasn't worked for me, is when there is insulin somehow above or on the side of the big air bubble, but, you can normally flick it into place. Sometimes it takes a couple of tries of redrawing more air.

 

[John & Henry]

So holding steady still at +6 333 Ketones back up to 1.1 Just gave what I hope was .25U R (the plunger barely moved when I pressed it, so hopefully there was enough R in there to do something. Will check BG in an hour. Thank you for the tips @alio will practice later. back to bed for an hour

 

[Sandy and Black Kitty]

It’s critical you understand that what makes Lantus long lasting is that it’s slow acting. The reason Lantus dosing decisions are not made based on pre shot value is that Lantus onset, unique to every cat, is generally +2-+3 ish and is the number you are actually shooting at.

The effects of Lantus are commutative and can sneak up on you. That’s why it’s important to string together the recommended number of consecutive cycles at the same dose

 

[John & Henry]

So the R seemed to have minimal effect, we''re at 306 @ +7. I'll be back for +8 reading. Will respond to some of you than later today, just sooo tired right now Thank you for the comments. <yawn>

 

[Liz & Minnie]

Hi John, just caught up on Henry's latest hijinks. Glad you are getting some sleep, and please don't feel that you have to respond to this.

I would also return to 1.75u L next cycle and keep following your R dosing rules. Don't be tricked by how little the plunger moves with the R!!

Generally per the rules for increases under TR and assuming his nadir remains in the 200s you will keep at 1.75u for 6 cycles before increasing to 2u.

<100 - hold for at least 10 cycles before increasing
<200 - hold for 6-10 cycles, incr 0.25u
200-300 - hold for 6 cycles, incr 0.25u​

I think you re-set the count so next 1.75u shot is cycle 1 - can someone else confirm this?

Also - to help your peace of mind, not for dosing guidance - I looked back at my s/s from when Minnie was hospitalized last year with back to back DKAs and the feeding tube. Don't look at the dosing, but in April 2021 you can see how she went green almost every time they sent her home followed by several cycles of pinks and she still had some ketones.

If you can get some urine ketone tests too that might help your peace of mind too (I never managed to catch her pee, I just kept not much litter in the tray so there were puddles I could dip into) because for Minnie at least, even when the novamax is showing ketones increasing up in the 1+ range it showed as negative or maybe trace with the urine test. It didn't change how I managed her at all but it helped me to 'not panic'.

You have the tools to fight the ketones - food, fluids and R - and hopefully he is still eating well. You just need to get a decent few hours of sleep!

 

[Suzanne & Darcy]

Sorry the R has seemed have minimal effect. We don’t really know where he might be without it. I’m concerned about when this bounce may start to break at the same time as having 2 units of Lantus and .25 R. Well, rest up now! Hopefully he will come down slowly from the high numbers and not do anything too dramatic.
I would give fluids again today(see my tips on Terumo needles/fluid warming, etc. from the previous thread.). Also - the higher you hang the bag, the faster it will flow. Only 60 mL should not take long at all.

 

[FrostD]

Since it is the weekend and not everyone is always around in time - my two cents for tonight (and the next few cycles) is to definitely wait for R advice as long as you can. There is a possibility he will break the bounce, and experienced eyes may be able to help pinpoint that trend early enough. Given the 2U this morning + past data + his onsets of L and R, the R at shot time could add some serious fuel to the fire of a bounce break if it happens.

If nobody is around to advise, I would go more conservative on the R and possibly even skip. Then if by midcycle he's not showing signs of a break, can rethink it then and hopefully buys you some time for someone to come around.

@Liz & Minnie how did you handle not knowing if a bounce was coming? Skip the R at L shot time and re evaluate mid cycle?

 

[Sandy and Black Kitty]

To best manage this situation you need to find a Lantus dose that you can shoot consistently. Then you need to spot time of onset, nadir and duration. Keep in mind these are not fixed- they can and do shift. You then need to look for the R onset, nadir and duration. with that information you will be able to judge the best timing for R.

R is a double edged sword. It’s easy to become trapped on “the R roller coaster”. It goes something like this-

You see a high number and grab the R to shoot it down. If the drop is too fast and or too far, the counter regulatory hormones are released and up the numbers go. So you grab the R…

before you know it you’re trapped in a self perpetuating loop of endless ups and downs.

 

[Suzanne & Darcy]

[QUOTE="FrostD, post: 2968065, member: 30207"
There is a possibility he will break the bounce, and experienced eyes may be hopefully buys you some time for someone to come around.

Melissa, I don't know that there's anyone around here who is better at predicting when a bounce break is coming than you. I've seen you do some good spotting in that department. Anyway, maybe you should share your methods with John and alert him to what he should be looking for But I agree with what you've said here, that's what I was trying to express concern about in my post above.

 

[FrostD]

[QUOTE="FrostD, post: 2968065, member: 30207"
There is a possibility he will break the bounce, and experienced eyes may be hopefully buys you some time for someone to come around.

Melissa, I don't know that there's anyone around here who is better at predicting when a bounce break is coming than you. I've seen you do some good spotting in that department. Anyway, maybe you should share your methods with John and alert him to what he should be looking for But I agree with what you've said here, that's what I was trying to express concern about in my post above.

In much better with ProZinc and Vetsulin

Last night I mentioned that about the only trend I could pull was that the cycle before the break Henry tends to dip into yellow, then come back up and stay flat pink the rest of the time. Now of course it's all a little fuzzy with hospitalizations and doses but that's best I can do.

@John & Henry I see he was pretty flat coming into AMPS and you still have 0.25U R at 319...Wendy's advice was 0.1U in that range so please do be watchful. I don't think he'll break the bounce that quickly on you, but if he starts to slide down towards midcycle - I strongly suggest no R unless one of the experts says otherwise.

 

[Suzanne & Darcy]

Here's my data dump on bounce clearing: If you see a bounce happening, with numbers high and maybe wobbling around a bit or just high and flat -- and sometimes it seems like there's just little to no response to the insulin -- then there some ways to spot a bounce breaking. If you see cycle where they are sliding down the entire cycle, that's a sign of a breaking bounce. However, sometimes a cat will do an unexpected rise in the cycle before the bounce break. I've heard Wendy call this the "high before the low." Of course, you will eventually learn how long it takes Henry to clear his bounces and be aware of it. Every cat is different in this respect.

 

[John & Henry]

So a got a few hours sleep in between tests last night & feeling better, (I did dream about feline diabetes the whole time tho!). I'm still extremely concerned with the current situation. The ketones crept up overnight, reading 1.1 @ PMPS +6. Atleast they didn't increase anymore at AMPS and stayed at 1.1. While the R at PMPS +6 seemed to do very little in regard to bringing the BG down much, maybe it helped fight off the ketones from rising anymore? His eating has been ravenous and he's suddenly been very interested in drinking this morning. We've seen this happen before with high BG & ketones-- he starts pounding the water, hopefully this isn't a sign of bad things to come. I went back to the 1.75U L dose based on everyone's suggestions. I do hope to not regret it and have it lead to higher BG/Ketones. Last hospitalization he started getting sick when ketones hit 1.9. EDIT: interestingly even though the nova didn't register much of a change after the +6 R shot, the libre stopped reading HI or 400 and has been showing in the high 300s ever since. Again, I'm questioning the accuracy of both of these meters.

R is a double edged sword. It’s easy to become trapped on “the R roller coaster”. It goes something like this-

You see a high number and grab the R to shoot it down. If the drop is too fast and or too far, the counter regulatory hormones are released and up the numbers go. So you grab the R…

before you know it you’re trapped in a self perpetuating loop of endless ups and downs.

This is a good explanation. So the counter regulatory hormones are released from a fast drop and not just a low drop? How much of a fast drop? I've read 100 is ideal. What about going from 450 to 250 in a couple hours, is that too fast? I do like how you explain why (counter regulatory hormones), sometimes I have a hard time accepting things deemed to be canonical without an explanation as to why. Especially in non-standard situations like Henry's.

but if he starts to slide down towards midcycle - I strongly suggest no R unless one of the experts says otherwise.

I'm totally on board with line of thought. I'd be thrilled with some yellows at this point.

Now of course it's all a little fuzzy with hospitalizations

So one thing that really concerns me with not explicitly following the vets instructions is what happens if he needs to be hospitalized again? Do I tell her what his doses have been? Do I include that information in my reports to her? She got really annoyed when we did the increase from 1U L to 1.25U L even though it actually improved the situation at the time and probably should have been higher. If he goes DKA again and I say "Yeah, I've only been giving him half the R dose you prescribed and 1.75U instead of the 2U you wanted " she likely isn't going to be happy about that. At this point shes made 3 major errors and I don't really want to have burden of guilt shifted back on me. When she called me out on the increase to 1.25U L before she said, "How can you even dose that? 1/4 units aren't even a thing"

I'll be responding to other comments too, but I just wanted to get this posted.

 

[Liz & Minnie]

@Liz & Minnie how did you handle not knowing if a bounce was coming? Skip the R at L shot time and re evaluate mid cycle?

I still can't spot when a bounce is going to break!

When I was in a similar situation to John last year, I started the R under the vet's instructions (0.5 or 1u) and then was told here afterwards that the vet had me giving too much R . I'm looking back again at last year, I think I just followed the rules pretty much based on BG reading at PS and and ~+6 (I'm using Levemir, not Lantus). I couldn't even spot her nadir at that point. I do remember posting and asking others for advice/if they thought the bounce was breaking. @Marina & Chico is also very good at analyzing s/s data.

Shorter answer - if the BG was high enough and the ketones high (fresh out of DKA), I think I gave the R at L shot time in the absence of other guidance. Knowing that you only want a drop of 100 over 4 hours means that if there was a steep drop after hour 1 or 2, I could give higher carb food.

This is all just me answering the question about how I handled it. Not giving advice. I can rarely spot bounces breaking (Minnie right now being a case in point, I have no idea what's going on)

 

[Liz & Minnie]

Nice +1!

 

[Suzanne & Darcy]

I hope he won't drop more than about another 50 in the next hour. Keep a close eye on him for sure. I was excited to see yellow though. Are you feeding him now, or what?

 

[FrostD]

"fast" really depends on the cat. Typically, if they drop about 1.5-2 color ranges in the sheet that's enough to do it...some are more sensitive than others.

As for the vet...I would explain the long hypo you had (which I think you already did) and you took an L reduction from that because that's just not sustainable. As for the R, that's up to you. You can tell her you did some reading and wanted to start a little more conservative. I personally don't think she needs to know that many details in the event of a hospitalization because the R doesn't have much bearing aside from when it was last given - they'll do their own thing in the hospital anyway

 

[FrostD]

Ok +1 tells me very likely no R midcycle and that you might be looking at a bounce break on this cycle...hoping for a long slow slide down once the R is out of the way.

That, or this is the cycle before he clears.

If the +1 to +2 drop is more than about 50 points I'd consider mixing some LC and MC...Liz and Suzanne, thoughts?

 

[Suzanne & Darcy]

Ok +1 tells me very likely no R midcycle and that you might be looking at a bounce break on this cycle...hoping for a long slow slide down once the R is out of the way.

That, or this is the cycle before he clears.

If the +1 to +2 drop is more than about 50 points I'd consider mixing some LC and MC...Liz and Suzanne, thoughts?

I agree with this!

 

[Liz & Minnie]

Yes, same thought! You want him to drop but not too much too fast.

And (paws crossed) if he is still in the yellows by mid-cycle, you wouldn't give R anyway if you're following the rules.