Help understanding BG numbers (continuation)

Liberty has been in the blues all day, for the past two days. Did not give shot last night with 150 PMPS. Thinking it might be the same tonight. So possibly two nights NS. Not sure what to make of that. I think it's a good thing? But a little odd because I was expecting higher numbers today because of the NS last night. Thoughts?
 
I think the skipped shots aren’t really good for his overall progress… perhaps a half dose tonight would have been better. What I do like though is seeing no pink or red for the last few days. It looks like he may need to go back up in dose to get better numbers, but for now let’s see how he looks after 7 days on this new dose. Things can change.
 
I thought about giving a token dose, but was maybe too conservative. Are we wanting blues and greens rather than just blues? I’ll be interested to see what the morning numbers are.
 
Suzanne & Darcy said:
I think the skipped shots aren’t really good for his overall progress… perhaps a half dose tonight would have been better. What I do like though is seeing no pink or red for the last few days. It looks like he may need to go back up in dose to get better numbers, but for now let’s see how he looks after 7 days on this new dose. Things can change.
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When you say he might need to go back up in dose to get better numbers, I'm a bit confused. Would the numbers he's been at the past two days not be good? In my mind I was interpreting the flat curve to mean insulin and food were working well together (he's eating small feedings after AMPS, +2, +4, +6, PMPS). Do we want to see more of a curve? I haven't been able to tell what his nadir is yet. Also wondering- at diagnosis we switched his food immediately to low carb (after many years on high carb dry RX urinary diet). Could the change to low carb wet diet now be positively affecting his numbers? Maybe it took a bit to start seeing an impact?
Like you said, things can change (and probably will, lol!) and sometimes I overthink things!;)
 
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Ok, shot 0.5u last night. Today AMPS was 120, stalled w/o feeding, got 92 so NS. 68 at +2. Giving LC FF to see if that affects numbers. But with that 68 he’s earned another reduction, so that’s down to 0.25u.

Hope I’m doing this right! Any input would be helpful if possible.:)
 
Suzanne & Darcy said:
I think the skipped shots aren’t really good for his overall progress… perhaps a half dose tonight would have been better. What I do like though is seeing no pink or red for the last few days. It looks like he may need to go back up in dose to get better numbers, but for now let’s see how he looks after 7 days on this new dose. Things can change.
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So, today he earned a reduction with the 68 at +2. That means his dose would be 0.25 (at 8pm). Looking like his PMPS will be low (138 at +11), so I'm pondering what to do (depending on the number). I'll stall and retest if it's low. Hard to know at this point when to stick with "below 150 don't shoot" protocol.
Thoughts?
 
Just looked at his spreadsheet. No difference between 133 and 130 so he was stable during the stall and not dropping. I will be very interested to see how Liberty does tonight and tomorrow morning. He is doing really well. I’m happy.
 
He is going higher tonight than we would like. If you want to try for remission then we will have to be able to shoot lower numbers. We can talk about it later. Hopefully, Liberty has his own ideas about going down in dose.
 
Yes, definitely want to do whatever I can to help make that happen! I’m ok with shooting lower numbers with some guidance. I’ve been hesitant to do it on my own. I welcome your help.
 
I reduced today's dose to 0.25 because of the BG 68 yesterday. And I see how his numbers were starting to creep up without any shots yesterday. I actually wondered about continuing with the 0.5 dose today, but went ahead with that reduction because of the 68.
 
So here’s my question…

Liberty earned a dose reduction of 0.25 yesterday. That brought his dose today down to 0.25. His numbers this morning are below 90. A reduction of 0.25 would bring me down to zero… hmmm, what to do?
 
JulieL said:
So here’s my question…

Liberty earned a dose reduction of 0.25 yesterday. That brought his dose today down to 0.25. His numbers this morning are below 90. A reduction of 0.25 would bring me down to zero… hmmm, what to do?
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There are other doses besides .25. There is a .10 dose and a drop dose. However, I think it looks (right now) like he could still benefit from the insulin support. If he were my cat, I would keep him at .25 units. I would follow the Modified ProZinc Method (MPM) where reductions are earned if the cat drops below 50. He would not have earned a reduction today according to MPM. This would allow his BG to drop into a more normal range (of a non-diabetic cat.) Our target nadirs would be 50-120.
 
JulieL said:
I usually plan to shoot at 8pm, so I usually do PMPS about 7:45pm
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Do you wait after you feed him to shoot? There's no need to wait with ProZinc, you can shoot at the same time he's eating if you want to. But since you have a system that's working for you, don't worry about it. I just wouldn't wait too long after he eats to shoot (and it sounds like you don't.)
 
You would need to change from SLGS to MPM on your spreadsheet and should add MPM to your signature, after where is says ProZinc and before it says ReliOn (on your signature.)
 
Suzanne & Darcy said:
There are other doses besides .25. There is a .10 dose and a drop dose. However, I think it looks (right now) like he could still benefit from the insulin support. If he were my cat, I would keep him at .25 units. I would follow the Modified ProZinc Method (MPM) where reductions are earned if the cat drops below 50. He would not have earned a reduction today according to MPM. This would allow his BG to drop into a more normal range (of a non-diabetic cat.) Our target nadirs would be 50-120.
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I've been wondering about the MPM. My syringes are U-40 0.5ml with half units. I'm not sure I can get a much smaller dose than 0.25 with accuracy.
 
Suzanne & Darcy said:
Do you wait after you feed him to shoot? There's no need to wait with ProZinc, you can shoot at the same time he's eating if you want to. But since you have a system that's working for you, don't worry about it. I just wouldn't wait too long after he eats to shoot (and it sounds like you don't.)
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I mainly wait to make sure he's going to actually eat. As you know, its been challenging getting the calories in him.
 
JulieL said:
I mainly wait to make sure he's going to actually eat. As you know, its been challenging getting the calories in him.
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Yes, and this does make sense. Do you think he's gained any weight? Do you have a baby scale at home? I have a baby scale and track my cat's weights pretty closely (and also use it to weigh kittens to make sure they're gaining appropriately.)
 
Suzanne & Darcy said:
Yes, and this does make sense. Do you think he's gained any weight? Do you have a baby scale at home? I have a baby scale and track my cat's weights pretty closely (and also use it to weigh kittens to make sure they're gaining appropriately.)
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I haven't weighed him, but I don't think he's gained. I'll get a rough idea by weighing myself with and without him just for a guideline.
 
Recently, he seems to be nadiring very early. Can you get him to eat another teaspoon of food at +1? If he won't do it, that's okay, but maybe he would be willing.
 
Maybe I do a skinny 0.25? Or just go with 0.25. And frequent monitoring through the night? With MPM is there a low number that would trigger action?
 
Target BG 50-120.

But right now, I would not reduce his dose. According to MPM, his dose would not be reduced. He had a great cycle on .25 units. Very excellent greens today (what we call the "healing greens" where his pancreas can heal.) We don't want to rush the process too much. If he is going to go into remission, we want to ensure a lasting remission. Some cats can go fast through this phase and some cats will take longer.
 
His numbers overall have been a lot better since February 14. Just look at the dramatic color change. Something good is happening with Liberty :-) and see how his preshots have been a lot lower to begin with... it's a lot easier to get down to a green number when you didn't start out in yellow, pink or red, right?
 
I know I'm testing a lot, but I'm trying to gather as much data as I can. I'm fortunate that I have been able to stay home basically 24/7 to monitor him. I will say, my family for the most part is supportive, but it's been challenging because they rely on me to help with the grandkids and that has been difficult right now.
 
Suzanne & Darcy said:
His numbers overall have been a lot better since February 14. Just look at the dramatic color change. Something good is happening with Liberty :) and see how his preshots have been a lot lower to begin with... it's a lot easier to get down to a green number when you didn't start out in yellow, pink or red, right?
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I'll have to read the MPM protocol again to get used to the new thresholds. I've gotten so used to PS 200+, and below 150 NS. Remind me, is there a NS number with MPM I need to know?
 
Here's part of the MPM that you should read.

Modified ProZinc Method

Changing the Dose: (general guidelines)
  • After the initial adjustment period, subsequent doses should be held for 3-6 cycles and data collected to determine next steps. Changing doses faster than that, or trying to use a sliding scale, nearly always results in bouncing and wild unpredictable variations in blood glucose, or BG getting stuck high and flat as if nothing is happening. Small steady dose changes work best.
  • PZ typically lasts 10-14 hours in most cats, and one cycle affects the next, so when changing dose, it can take a few cycles before you really see the impact of the change. It’s not uncommon for the first cycle after a dose increase to be a little higher. If this happens, try not to get discouraged. Wait a couple of cycles, collect data, and see what the BG does.
  • Conversely, if you decrease the dose when you shouldn’t, it’s not uncommon to see a good first cycle because there is still some impact from the previous higher dose. Subsequently, the following cycles may result in the numbers starting to rise. If this happens, move back up to the previous higher dose.
  • Dose changes are made based on the nadir, and the amount of drop between the pre-shot number and the nadir. Doses are not based on pre-shot numbers so do not increase the dose without seeing mid-cycle numbers.
  • Pre-shot numbers are important so that you know the cat’s BG is high enough to safely inject, and so you can monitor the change between the PS and nadir; however, again, they do not determine the dose by themselves. Adjusting the dose based on PS numbers alone frequently leads to overdosing, underdosing, and bouncing.
  • In general, dose changes are made in increments of 0.25u. In sensitive cats, it may be necessary to make even smaller changes.
  • Precision in drawing the dose of PZ is very important. Insulin is powerful and even slight variations can make a difference.
  • If a cat is having nadirs above 200, then dose changes of 0.5u are recommended.
  • Occasionally we see cats who need the dose held longer than the recommended 3-6 cycles because they are very prone to diving BG numbers or bouncing. Collecting data and learning your cat’s patterns are essential to determining if your cat might be in this category.
  • Conversely, holding the dose for too long can lead to glucose toxicity - when the blood glucose gets “stuck” and even increasing seems to do nothing. If this happens, seek advice on next steps.
Increasing the dose: (numbers based on using a US human meter):

Questions to ask before increasing the dose:
  • When does the current dose reach it's peak (nadir)?
  • How low has the current dose taken kitty over the last 72 - 96 hours?
  • What? You don't know when your kitty reaches nadir on this dose?
  • You don't know how low the current dose is taking your kitty?
Nadir checks will provide the answer! It's your job to find out how low the current dose is dropping kitty before increasing the dose.

Once you know your kitty's nadir over the last several days/nights, you'll know if an increase is needed. If you don't know how low the current dose is taking your cat you run the risk of your cat becoming over dose as well as experiencing a hypoglycemic event... not what any of us wants to happen. So, please recognize the importance of getting those nadir checks (day & night) BEFORE you increase the dose.
  • If nadirs are 100-200, increase the dose by 0.25 unit.
    • hold the new dose for 3-6 cycles unless the BG drops below 50. If the BG drops below 50, decrease the dose by 0.25u on the next cycle.
    • if your cat is new to nadirs under 200, you may notice that she/he feels a little sluggish and sleepy when first getting into healthier numbers. This is normal and will get better in time.
  • If nadirs are more than 200, increase the dose by 0.5u. Dose increases should be made every 3-6 cycles and should continue to increase until nadir numbers begin to come down.
  • If nadirs are 50-100, hold the dose for additional cycles.
    • If the nadirs start to rise, then increase the dose by 0.25u.
    • If nadirs stay in green numbers (50-99), continue to hold the dose.
  • If nadirs are under 50 on a human meter or under 68 on a pet meter, decrease the dose on the next cycle.
Reducing the dose:
  • If your cat is in the first 3-6 months of diagnosis, reduce the dose by 0.25u anytime you see a BG below 50 on a human meter or 68 on a pet meter.
  • If your cat is between six months to a year of diagnosis, look at the overall picture of your data to determine if a 0.25u reduction is warranted on a single number below 50.
    • Prozinc can be a little volatile at times, and there will be the occasional random drop. If you have a consistent body of mid-cycle tests that indicate the low number is unusual, you may consider holding the dose and continuing to monitor or you may choose to just shave a little off the dose.
    • If the low number appears to indicate a general downward trend of numbers, then it may indicate that you should indeed lower the dose.
    • If your cat is more than a year since diagnosis, a single number between 40-50 should not mean a full 0.25u reduction. You may shave a little off the next dose, or just hold the dose and continue to monitor.
    • Additional numbers between 40-50 in the days following would indicate the dose should be reduced.
    • Any cat, regardless of time since diagnosis should receive a reduction if there is a number below 40.
  • Caregivers whose kitties have "High Dose" conditions may find the need to reduce in whole units or more.
  • If an attempted reduction fails, go right back up to the last good dose as soon as you see kitty's numbers trending upwards. You don't have to hold the reduced dose for a certain number of cycles before taking the dose right back up. The guidelines listed under the topic "Increasing the dose" do not apply to a failed reduction. Please use common sense in this situation. The "last good dose" is not the dose that just dropped kitty into the 20s or 30s. You want to resume momentum by finding an in-between the dose.
How to handle a low pre-shot number:
  • Sometimes your kitty will surprise you with a lower than normal PS number (but above 50). When that happens you have four choices:
    • Skip the dose: If the number is below 200, and your kitty is newly diagnosed (less than three months), your best option is to skip unless your kitty has ketones or is post-DKA (see below) and you should post here or in the Health Forum for help.
    • As you gain more experience and data, your goal is to gradually learn to shoot lower and lower numbers (never below 50). You can use other options below as you are learning to shoot below 200. Ultimately, with data, experience, and knowing your cat, you should be able to shoot PSs above 50 provided you are available and able to monitor.
      • If your cat has been diabetic for awhile and the PS is much lower than normal, you may still need to skip if you have to leave the house for many hours and can’t monitor, but in general we don’t recommend skipping if your cat has a good body of data, so see the other options.
    • Stall: Do not feed your kitty but wait 30 minutes and test again. (Note: we generally stall without feeding because food will falsely cause the BG to rise. It’s important to not shoot a food spike
    • If after stalling the number is rising into safer ranges, you can then give the full-dose shot. You can stall as long as you need to (in 30 minute increments), but keep in mind that the next shot needs to be 12 hours later, so be mindful of your new shot time. If it’s getting too late, try the next option.
    • Reduce the dose: How much to reduce can be a tough decision. Some of it will depend on how well you know your cat, how confident you are in testing, if you’ll be around to monitor, etc. This is a good time to ask for advice. If no one is around and it’s your first time, reduce the dose by 50%. If you have been at this awhile and know your cat’s reactions well, you can do a smaller reduction. If your cat is below 150, do not give a dose at all unless you can get regular BG tests throughout the cycle.
    • Give the regular dose: this is recommended if you are able to monitor closely and/or if your cat is a long-term diabetic (more than a year) and you have a lot of data to know it’s safe. Long-term diabetics with solid data can often safely shoot below 150 (and should if possible to do so safely).
If the BG is in the 40s at PS:
  • Stall without feeding for 20 minutes and recheck the BG.
  • If they are hanging in the 40s for a while, or if they are still dropping, it is ok to feed a tsp or two of LC and retest. This is very tricky. You want to avoid feeding too much while you’re waiting for them to go over 50, because you don’t want to artificially inflate the number with food.
    • Example: if kitty is 43 and you feed a whole meal, or feed some HC, and the number bumps up to 52, is that the cat’s natural end-of-cycle rise, or is it food spike? What if it is food spike? Then if you shoot the 52, when the food wears off he might drop back to the 40’s (and when insulin kicks in a couple of hours later, you might have a problem). If the 52 is the cat’s natural rise, then he will probably keep rising for the next few hours until insulin kicks in. If you can’t tell whether the number is food spike or natural rise, it’s safest to wait. Your data will help you here. Study the spreadsheet. How much food spike does the cat usually get? How many hours after the shot does the insulin’s onset usually occur in this cat? At what number is the cat likely to be when onset occurs? If the cat does drop, how easy/hard is it to regain control of the numbers? How carb sensitive is he?
  • Test often (every 15-20 minutes, or at most every 30 minutes). You want to catch the rise the minute it starts. With most of our cats, once they start to rise they will really zoom. You want to get the insulin in as soon as possible, because it will be another 2-3 hours before the insulin kicks in and you don’t want to let the cycle get too far ahead of you.
If the BG is in the 30s at PS:
  • Feed a small amount of HC food/syrup and a drop of syrup/honey and skip the shot, testing 20 mins after the meal to ensure the BG is coming up.
  • Be sure, even when you skip, to continue testing regularly until the BG is at a safe number and remains there more than two hours after eating.
Perhaps the most important guideline in shooting low is that any time you shoot your lowest ever number, you should get a +1 and +2 to give you an idea of how the cycle will go. If the +1 is not higher than PS, or if +2 is much lower than PS, that means “pay attention” over the next few hours. Those tests will also help you become even more data ready for the next time you are presented with a low preshot reading.

Sometimes there are circumstances such as ketones present, an unusually low preshot number, a caregiver leaving the cat with a sitter, relatively high flat curves, loss of appetite, infection, a schedule change, ability to monitor, etc. which may call for adjustments to these guidelines. Please ask for guidance if any of these or other circumstances present themselves or are of concern. If ketones are present or your kitty is post-DKA, it is best to not skip shots but please post for assistance.

A few other things:
  • Sometimes the dose will require fine tuning by adding just a little more or a little less to the dose. We call this giving a Fat (a little more) or a Skinny (a little less) dose. This is helpful when your cat is very close to being in normal numbers. On your spreadsheet you can show it by putting the number of units followed by F or S. For example, if a cat gets 2u but the caregiver gives just a little more than that, the spreadsheet would show “2F” .
  • Find a pet sitter you can trust. This can be tough, but there are going to be times when you’re going to need help whether because something comes up in your schedule or because you suddenly need to leave town or spend the night in a hospital (heaven forbid!). Finding a pet sitter now and getting them trained before you need them will go a long way towards your peace of mind. If you don’t have a friend or neighbor who can help, try services like Rover or check with nearby vet offices to see if they have a vet tech who also does pet sitting, or if they do boarding. While nothing compares to your love and care, it is essential that you have a plan for backup should it become necessary.
  • Take care of yourself. This can be stressful, especially at the beginning. I promise, it will get easier in time. If you are just starting on this journey it may be hard to imagine right now, but in a few weeks, this will all be as routine as brushing your teeth. Make sure you are taking care of yourself. Visit friends. Get your sleep. Do what you need to do to keep up your own energy, health, and sanity. And know that there is a broad community here to support you.
 
I will reread it all (several times). I actually have it printed out already with SLGS protocol. As far as testing through the night, suggestions ? Obviously if he's dropping I need to monitor closely. But if all is looking good what do you suggest for frequency of testing?
 
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