Evie's numbers cont.

[AliceL]

Previous thread: https://www.felinediabetes.com/FDMB/threads/evies-numbers.299606/#post-3266692

She is having a bit of a higher run today after that low last night. It could be a bit of glycogenolysis but Evie doesn't usually tend towards bouncing. Not sure if the honey upset her stomach, I've seen no obvious inflammation signs but there is no way to track mild inflammation other than higher BG (which could also be a number of other things). She did have a slight runny eye this morning but it was clear so I think that it's maybe just her FHV and stress induced. She does get quite stressed out when her BG drops like that.

Keeping her BG quite stable with no sharp drops or peaks is the best thing for her.
I just wonder why she keeps having these sharp drops every now and then.
It makes it hard to decide what to do with her dose in future.

… although I have to say that in my own cat, when I gave him HC like corn syrup it frequently would just end up shooting him to the moon.

This could likely be the same in Evie's case with her sensitive stomach. Usually eating more of her LC food doesnt keep her BG elevated like this.

At least hopefully she didn’t get any inflammatory foods. I would hate for her to have to eat the stuff that’s not good for her when she’s doing so well!

No, just two drops of honey and her usual food. If the honey is propping her so much and resulting in higher runs on the next cycle anyway maybe it's still worth trying mid carb liquid snacks to try get her to surf. I have Churus lickable treats at 11% and 15% carb. It's chicken flavour so it might be better than honey re inflammation (she is allergic to fish and beef).

This is really difficult to predict. There are so many factors in play that it may not be a linear progression…. but we don’t know unless we see that she is always dropping at a particular rate that we can predict. I understand your concern.

I've had better results overall (surfing greens while also maintaining good numbers on next cycle) if I slow steep drops earlier in the cycle around +3.

 

[Suzanne & Darcy]

I've had better results overall (surfing greens while also maintaining good numbers on next cycle) if I slow steep drops earlier in the cycle around +3

Yes. I started to actually write this last night— that I thought the “homemade medium carb” should have been given a little earlier in the cycle — about the +3.5 to 4.5 mark. But that also could have backfired and just hijacked the whole cycle as it would have been purely a guess at those points. As it is, the cycle had a very good green and she didn’t drop below 71 (with your intervention.). The only way she will ever get used to being in the greens again like she was when she was in remission is for her to spend more time in them. She’s just taking longer this time instead of going so quickly as she did last time (earning reductions almost every day at times!)

 

[Suzanne & Darcy]

I saw your message about a steep drop at +2. I don’t see it. The difference between PMPS of 232 and 188 is a good one and to be expected at onset. I see she’s may have gone up a little at +3. I hope she just did that on her own and no extra carbs were given.

Did you decide it wasn’t a steep drop after all?

I see she’s in blue and has just now gone down a bit at +4. I hope she will continue down a bit more toward her nadir.

 

[AliceL]

No, I do think it was a steep drop from +0 to +2 as far as Evie's habits go.
I’m used to seeing an increase, flat or max -20mg between those times, ie, her main meal is buffering her more against the onset.
Last night was -40mg from +0 to +2, ie she was much more sensitive to the insulin on that cycle despite eating her main meal and her +1.5 snack.

I know she usually gains traction on the insulin between +3 and +5 when the rate of drop accelerates.
Taking the previous night’s cycle into consideration I moved her +3 feed to +2 to bolster that drop… so officially she didn’t have more food but the timing changed on one meal.

In hindsight, it was probably too much food loading early in the cycle which blunted the drop and is why we see a bump up at +3.
Afterward that food bump cleared, the drop resumed to around -30mg per hour thereafter resuming her usual feeding schedule.
She didn’t get a green but that rate of drop is similar to the previous night’s cycle.
Food timing matters to Evie’s curves and can be used to manipulate the results.

I think slow and gentle is the way to go here.
I don’t know why Evie’s numbers are higher on the day cycle after experiencing low numbers at night.
I know it looks like bouncing but I think stress is a consideration here - I am the one seeing her behavioral reaction during cycles and making connections to the results in the proceeding cycles. That observation can't be read off her spreadsheet. On the occasional nights she went lower but had reduced stress about it I see that her day cycle is much better.

I’ve been thinking of testing something a little unorthodox for a few cycles but wonder what you think about it.
Insulin hits her much harder at night so I’d like to try a slightly reduced dose at night, maybe just 1.2u.
At the same time revert to usual feed times which encourages those sharper drops, but reducing insulin will not make it so powerful.
I think doing this could reduce the nighttime cycle stress which will improve her daytime numbers.
A few cycles like that should also bring her to lower numbers on both cycles. I've seen evidence of that in previous patterns.

Alternatively, what would you do if Evie was your cat?
At the rate she drops (without surfing) at night I don't think I'm in a position to safely increase her dose, at least on the night cycle.

 

[Suzanne & Darcy]

@Marje and Gracie I would like to get your take on the situation here with Evie. You may have some helpful observations to share. I know you are pressed for time though so I don’t know how much you can catch up on the whole thread(s). Alice’s Evie had been in remission until this year. She has inflammation from certain foods so Alice is limited by the types of foods she can give and will use a drop or two of honey in the food when she wants to bring up Evie’s numbers. Evie is eating a single food now that seems to be non-inflammatory for her. Alice had started with MPM but switched to SLGS with reductions at 70.

Alice, I have seen quite a few cats who will have a higher daytime cycle after lower night time numbers.

 

[AliceL]

Just want to add - I did reduce slightly to 1.2u this evening to test my stress theory.
So far she is having quite a good cycle with numbers lower than last night but she is super chilled too - sleeping and relaxed most of the evening which is a stark contrast to her antsy, begging-for-food behaviour over the last two evenings. I even had to prompt her a few times to get up and eat her +5 snack - she is not fussed at all this evening.
I think it has a lot to do with the rate of drop and less about the actual number.
It will be interesting to see how her day cycle is tomorrow, I'm going to revert to 1.4u for AM.

 

[Suzanne & Darcy]

I see you also changed the feeding back to +3 and +5 instead of front loading the cycle as much. What do you think causes her coughing fits? How long do they last? I hope she doesn’t have asthma.

 

[AliceL]

I see you also changed the feeding back to +3 and +5 instead of front loading the cycle as much.

Exactly. It's almost a repeat of two nights ago when she fell quite sharply to 71, except on 1.2u she is much more relaxed during the cycle.

They are brief and infrequent bouts of coughing which seem to be related to the FHV which is respiratory.
The coughing occurs more frequently when she has a few high sugar cycles (like the last two day cycles).
It goes away completely when her sugar levels are better, or even when her cycles hang around in blue numbers.
She had coughing on and off as well in 2023 when she last had diabetes, but no coughing whatsoever while in remission.
She's been checked for chronic asthma before, the vet says it's all part of her systemic inflammation issues which present in various flareups - allergies, IBD, stomatitis etc

 

[Suzanne & Darcy]

I was thinking that not giving her quite so much food in the beginning allowed her to drop into slightly better numbers tonight. I was hoping for a green.

 

[Marje and Gracie]

@Marje and Gracie I would like to get your take on the situation here with Evie. You may have some helpful observations to share. I know you are pressed for time though so I don’t know how much you can catch up on the whole thread(s). Alice’s Evie had been in remission until this year. She has inflammation from certain foods so Alice is limited by the types of foods she can give and will use a drop or two of honey in the food when she wants to bring up Evie’s numbers. Evie is eating a single food now that seems to be non-inflammatory for her. Alice had started with MPM but switched to SLGS with reductions at 70.

Alice, I have seen quite a few cats who will have a higher daytime cycle after lower night time numbers.

Thanks, Suzanne. Happy to offer some thoughts.

@AliceL

A couple things I’d like to address. First, I think it is great you are watching her behaviors and looking at where she is with her BG, trying to interpret her SS, and figure out the best way to manage her curve with food. That’s really important.

Some of my other observations:
1. I don’t understand your comment about her numbers being higher due to glycogenolysis. Glycogenolysis is a normal process everyone experiences as it is just breaking down of glycogen to release as glucose in the blood. It’s a vital process for us all.
2. Evie is experiencing some bouncing, for example, the a.m. cycle of 4/22.
3. Remember every meter can have a 20% variance between readings so there is absolutely no difference between a 232 and a 188. That is very flat and not a drop. Overall, I am seeing a fairly flat trend in her BGs with, by and large, normal curves where her PSs are higher, she comes down to nadir, in general, around +5, and then she rises as the insulin wanes. She just needs to lower the overall curve.
4. I don’t see any sharp or steep drops anywhere on her SS although 109 to 71 in 30 minutes is a bit fast but, believe me, I’ve seen so much worse even in my own kitty A sharp or steep drop is one in which the BG is falling more than 50 mg/dL per hour consistently after considering the 20% variance.
5. It’s a good idea to front load cycles for most cats so a little more food at PS, +1, and +2 when onset occurs softens the drop quite often. I’m a fan of not using any more carbs than you need to keep her safe and I’m not seeing a reason to be using carbs with these numbers. On the PM cycle of 4/22, there is no difference between +2 and +3. Again, she’s flat.
6. From experience, shooting a lower dose once a day is not a good idea. You’ve already had her in remission and the best way to get her back is to be more aggressive, not less. I don’t mean be dangerously aggressive, but I, personally think she would be better off with MPM instead of SLGS. And BTW, if you are using 70 as your reduction point, you aren’t doing SLGS; you are custom dosing. The reduction point for SLGS is 90.

The one thing I can’t tell is her duration because you aren’t testing later in the cycle after +6/+7. When we look at a SS, we need to clearly see onset, nadir, and duration but with no late cycle tests, we don’t know how fast she is rising after +6/+7. If she starts rising really fast, you are shortening duration by feeding her after +6. That sets her up for a higher PS. It’s usually best to not feed after nadir but if her tummy hurts and you have to, you want to feed absolutely as low carb food as she can tolerate. I used to just boil chicken breast to feed Gracie after nadir if she was hungry. I don’t know if this is something Evie would tolerate but it could help duration and give you longer times in better numbers.

We’ve also found through many years of data that reductions and increases are usually done better by 0.25u and not shaving here and there and SLGS certainly does not include shaving doses. If you are truly doing SLGS, she would have earned a reduction to 1.15u on the evening of 4/22. If you are custom dosing, it’s best to put it in your signature block and on her SS but then it is harder to have members advise you because they aren’t sure what your custom dosing actually is.

It seems you are with her quite a bit and you might want to reconsider MPM and stick to it as it’s written. It would probably also be helpful for you to get her on a dose like 1.25u so you can easily raise and decrease by 0.25u for increases and reductions.

I understand you are with her and can see her behavior and how she reacts but I’ve been here 15 years and helped hundreds of cats. I am seeing a fairly flat SS and a kitty that could be doing a bit better and generating some nice, long green flat cycles if you use the appropriate method of regulation. Because she’s been in remission, the goal really should be to get her back there as quickly as possible.

These are just my opinion based on experience but, as we always say, you hold the needle.

Please let me know if you have any questions or how I can help.

 

[AliceL]

Thank you for your in-depth answer @Marje and Gracie
I need a few days break from all of this as I am utterly exhausted.
I will consider all your points and come back to you soon.