11-5 Nico AMPS - 563, +3 - 455, +6 -477, pmps -533, +4 -483

[Tyleete]

Yesterday
@Wendy&Neko Maddie was showing me Kai's spreadsheet, and she doesn't go crazy with the ear sticks. Is it possible to do this? To go the TR route with no more than 7 a day unless there's a scary reading? Cause she showed me how well Kai has done since switching. Though in truth, I really didn't see much of a difference in the use of insulin? I was seeing some TR ss that averaged 12-14 sticks per day even when there were no concerning looking numbers and that scared me.
Thanks!

 

[Lauren & Esse]

You might consider adding the blue question mark tag for a question to your thread title to have more folks get their eyes on this. But from reviewing what the TR protocol says about testing, I definitely think you could get away with 7 tests on lower activity days.

It says "Kitty should be monitored closely the first three days when starting Lantus or Levemir. Initially, blood glucose levels should at least be checked at pre-shot, +3, +6, and +9. More monitoring may be needed." -- so that would be just in the first couple days of starting Lantus. You're past that point already pretty much. The other thing it says, from when the protocol was developed, is "Owners measured blood glucose an average of 5 times daily" That's from the initial study, not from how we use the protocol now, but it's good background info.

A helpful concept to keep in mind is the value of the +2 number. Copying and pasting from my notes:

General Guideline regarding pre-shot number and +2 relationship.

If +2 is a lot more than the pre-shot, it's probably going to be an inactive cycle. You probably can head off to sleep or work.
If +2 is similar to pre-shot, it's likely to be a normal, active cycle Lantus cycle. You probably want to get a +4 and a +6. Leave out some extra food if you go to work.
If +2 is much less than pre-shot, it's likely to be a very active cycle, with possibly an early drop. More testing and monitoring required. Definitely leave out some extra food, maybe even some higher carb food, so your cat has something to eat if they drop really low.

Speaking for myself personally... If we weren't using a CGM, we'd test at pre-shot and then probably at +2 and +6 during the day. That +2 gives us an idea of how active the cycle will be that day, and the +6 tells us how low the nadir was. (That mid-cycle value could also be variable, say between +4 and +8, if we didn't know when the nadir usually is.)
And then obviously you're not going to get up in the middle of the night every single night to test, but what you can do is test first thing in the morning. +6 in the PM would be 3am for us, but we could test at +10 which would be right after we wake up. If that before-bed +2 said it would be an active cycle, grabbing that first thing in the morning test can be good data.

 

[Tyleete]

You might consider adding the blue question mark tag for a question to your thread title to have more folks get their eyes on this. But from reviewing what the TR protocol says about testing, I definitely think you could get away with 7 tests on lower activity days.

It says "Kitty should be monitored closely the first three days when starting Lantus or Levemir. Initially, blood glucose levels should at least be checked at pre-shot, +3, +6, and +9. More monitoring may be needed." -- so that would be just in the first couple days of starting Lantus. You're past that point already pretty much. The other thing it says, from when the protocol was developed, is "Owners measured blood glucose an average of 5 times daily" That's from the initial study, not from how we use the protocol now, but it's good background info.

A helpful concept to keep in mind is the value of the +2 number. Copying and pasting from my notes:


Speaking for myself personally... If we weren't using a CGM, we'd test at pre-shot and then probably at +2 and +6 during the day. That +2 gives us an idea of how active the cycle will be that day, and the +6 tells us how low the nadir was. (That mid-cycle value could also be variable, say between +4 and +8, if we didn't know when the nadir usually is.)
And then obviously you're not going to get up in the middle of the night every single night to test, but what you can do is test first thing in the morning. +6 in the PM would be 3am for us, but we could test at +10 which would be right after we wake up. If that before-bed +2 said it would be an active cycle, grabbing that first thing in the morning test can be good data.

Thank you for that info. I actually did a screen cap of your +2's to help me better understand it. I'm trying so hard to learn this all at the same time as another illness for another cat. I spend hours every day online trying to read and soak up as much info as I can.
The thing that confuses me, is there really doesn't seem to be much in the way of difference in looking at the ss between the dosing of go slow and TR? I see the subtle changes in dosing in both types, but the end result usually much better in the TR. So what am I missing?
I have read the TR piece twice, and still no closer to understanding. I know you can raise and lower easier at will. But the idea of me being a novice and trying to judge what he needs like that is a bit terrifying. And I like(currently/using a pet meter. I know it's thought of as a scam, but the reading that science claims glucose is measured differently in species and then having that item that's meant for that particular species just makes sense to me. I've been using both my pet meter & a Relion I bought, and as he's in the upper numbers, there's a large difference. Sometimes a good 100pts. But the color chart for what his pet meter is reading is always either in the red or black. Whereas if human meter, reds and pinks. But I can't help think pet one is more accurate by far. Seriously. Over 100pts difference some times.
I'm just confused, and buggy, and want to know everything right now so that I may get him started on his path to feeling better.

 

[Lauren & Esse]

I totally get it, it's extremely overwhelming at first.

The thing that confuses me, is there really doesn't seem to be much in the way of difference in looking at the ss between the dosing of go slow and TR? I see the subtle changes in dosing in both types, but the end result usually much better in the TR. So what am I missing?

There are a few differences, maybe I can try and summarize them as I understand it:

With SLGS: You make dose increases about once a week based on one cycle's glucose curve. You make dose decreases whenever kitty hits below 90 (on a human meter).
With TR: You make dose increases in as little as 3 days, based on the nadirs you saw over those three days. You make decreases whenever kitty hits below 50 (on a human meter).

SLGS is more conservative, so it's a better option for new caregivers or for people who are not able to monitor kitty as closely. TR is more aggressive, so it's better suited for folks who have a little more experience (or who can consult frequently with experienced members) and who are able to monitor kitty more closely.

TR also requires that kitty be on an all-wet low-carb diet. SLGS does not have that requirement, so folks who feed dry food who are weaning kitty off dry food can use that method.

...but the end result usually much better in the TR. So what am I missing?

The more time kitty spends in 'green' (50-100 on a human meter) numbers, the more healing their pancreas is able to do. TR allows kitty to spend more time under 100, whereas SLGS has you reduce insulin at 90. In terms of ultimate outcome, it seems to me that SLGS helps cats get their diabetes symptoms under control in a very low-risk way, where TR allows you to more aggressively pursue remission/getting off insulin. Different strategies for different goals.

But the idea of me being a novice and trying to judge what he needs like that is a bit terrifying.

To be clear--the dosing protocol guidelines help us all make decisions, but the experienced folks on the board can and should also help. You can always post to say "based on TR protocol and our last 3 days, it looks like we're ready to increase again. What do you think?" and tag it as a question and see what people think.

But I can't help think pet one is more accurate by far. Seriously. Over 100pts difference some times.

They have different reference ranges, as you know, so they will never show the same number. Pet meters read 'higher,' but the scale is exponential. Higher numbers will be much higher on a pet meter, low numbers will be only a little higher.
Ultimately, you can and should use whatever meter you feel more comfortable with. The guides here were written before pet meters were widely available, and many members prefer the human ones anyway because of the cost and ease of obtaining the strips. (It's comforting to know you can just run out to the drugstore if you're running low.) So that's the 'default,' and we have the evidence that kitties can be treated accurately using one. BUT if you like the pet meter better, that's also fine! It's up to you, no one is going to force you to switch.

 

[Tyleete]

I totally get it, it's extremely overwhelming at first.

There are a few differences, maybe I can try and summarize them as I understand it:

With SLGS: You make dose increases about once a week based on one cycle's glucose curve. You make dose decreases whenever kitty hits below 90 (on a human meter).
With TR: You make dose increases in as little as 3 days, based on the nadirs you saw over those three days. You make decreases whenever kitty hits below 50 (on a human meter).

SLGS is more conservative, so it's a better option for new caregivers or for people who are not able to monitor kitty as closely. TR is more aggressive, so it's better suited for folks who have a little more experience (or who can consult frequently with experienced members) and who are able to monitor kitty more closely.

TR also requires that kitty be on an all-wet low-carb diet. SLGS does not have that requirement, so folks who feed dry food who are weaning kitty off dry food can use that method.

The more time kitty spends in 'green' (50-100 on a human meter) numbers, the more healing their pancreas is able to do. TR allows kitty to spend more time under 100, whereas SLGS has you reduce insulin at 90. In terms of ultimate outcome, it seems to me that SLGS helps cats get their diabetes symptoms under control in a very low-risk way, where TR allows you to more aggressively pursue remission/getting off insulin. Different strategies for different goals.


To be clear--the dosing protocol guidelines help us all make decisions, but the experienced folks on the board can and should also help. You can always post to say "based on TR protocol and our last 3 days, it looks like we're ready to increase again. What do you think?" and tag it as a question and see what people think.


They have different reference ranges, as you know, so they will never show the same number. Pet meters read 'higher,' but the scale is exponential. Higher numbers will be much higher on a pet meter, low numbers will be only a little higher.
Ultimately, you can and should use whatever meter you feel more comfortable with. The guides here were written before pet meters were widely available, and many members prefer the human ones anyway because of the cost and ease of obtaining the strips. (It's comforting to know you can just run out to the drugstore if you're running low.) So that's the 'default,' and we have the evidence that kitties can be treated accurately using one. BUT if you like the pet meter better, that's also fine! It's up to you, no one is going to force you to switch.

Ok! I think I'm ready to try for it! I have read the TR thread twice already though, and it's a bit confusing. Any tips? What would I have to do to start?
I do stay home full time. Handicap. Yeah me! So I can watch over him closely. Have my hypo toolkit.
I do wonder though, why the 2 different numbers when decreasing? 90 on the slow go and 50 on TR? Thanks for explaining so much for me.

 

[Wendy&Neko]

Is it possible to do this? To go the TR route with no more than 7 a day unless there's a scary reading?

Take a look at my spreadsheet for Neko. I was testing a little more frequently at the beginning of 2016 cause she had just had some treatment for her acromegaly - a condition that caused her diabetes, and her dose was dropping fairly quickly. But mostly I was testing 5-6 times a day. By that point of course, I had a pretty good idea how Neko's the insulin and the best times to test her.

have read the TR thread twice already though, and it's a bit confusing. Any tips? What would I have to do to start?

First tip, start getting a second test in the PM after PMPS, every night. Always test either +2 or later, or whatever your before bed time is. You are missing half the data. It's possible for a kitty to drop low at night then bounce during the day. Neko did that once for 3 months in a row! Also after a acromegaly treatment and she was earning dose reductions with those night time drops. If all I'd seen was her daytime bounce data, I would have thought she needed an increase in dose, instead of decreases.

To start TR, update the spreadsheet on the top line to put TR for the dosing method, and change your signature to add TR. That and getting those night time tests. I strongly suspect Nico needs a 0.5 unit increase. TR allows 0.5 unit increases if not seeing anything under 300, and after six cycles. You've been at this dose long enough, TR says 5-7 days for the initial dose. However, I really want to see that second PM test tonight before you switch, so we can make sure it's safe.

 

[Tyleete]

Take a look at my spreadsheet for Neko. I was testing a little more frequently at the beginning of 2016 cause she had just had some treatment for her acromegaly - a condition that caused her diabetes, and her dose was dropping fairly quickly. But mostly I was testing 5-6 times a day. By that point of course, I had a pretty good idea how Neko's the insulin and the best times to test her.


First tip, start getting a second test in the PM after PMPS, every night. Always test either +2 or later, or whatever your before bed time is. You are missing half the data. It's possible for a kitty to drop low at night then bounce during the day. Neko did that once for 3 months in a row! Also after a acromegaly treatment and she was earning dose reductions with those night time drops. If all I'd seen was her daytime bounce data, I would have thought she needed an increase in dose, instead of decreases.

To start TR, update the spreadsheet on the top line to put TR for the dosing method, and change your signature to add TR. That and getting those night time tests. I strongly suspect Nico needs a 0.5 unit increase. TR allows 0.5 unit increases if not seeing anything under 300, and after six cycles. You've been at this dose long enough, TR says 5-7 days for the initial dose. However, I really want to see that second PM test tonight before you switch, so we can make sure it's safe.

OK! I feel actually better and excited at the idea of trying to move things along. I was going to start to taking tests at night again. Is there a time that is best by the +4? Unless he's going too low, I don't really want to stay up past that if I can help it. How many nights do I need a latte evening test to show where to go from here?

 

[Tyleete]

And I'll read through your ss from 2016 like your said after my shower when I sit down for the night. I read Maddie's last night instead of a book.

 

[Tyleete]

Pm +4 = 483
It's like the shots are barely doing anything for him.

Questions on your ss.
When in the blue & then yellow pmps, in the evening on 17th of Jan. Why reduce the insulin? I would think if he's getting higher in need, you'd increase. Went from 3.5 to 3. And to 2.5 the next morning even though nerd still in blue. Then to 2 at next pm shot. What is bcs? 2u bcs? I saw it said he wasn't eating. Why cj this if not eating right? No sugar created from food?
My cat was said to have nadir at only +4. So does most of the testing need to happen then or before it?
And what is 'Post SRT'? Then you started adding 'F' after units. What is that?
Are you not feeding several meals throughout the day? It only looked like breakfast and dinner in the notes.
Was the not eating due to the other illness you spoke of, or the diabetes. I just wanted to know I case it's what I should be looking out for. Currently my little man eats like a starved child. No matter how much I give him, he always wants more.
And I am sorry for your loss.

 

[Wendy&Neko]

When in the blue & then yellow pmps, in the evening on 17th of Jan. Why reduce the insulin? I would think if he's getting higher in need, you'd increase. Went from 3.5 to 3. And to 2.5 the next morning even though nerd still in blue. Then to 2 at next pm shot. What is bcs? 2u bcs? I saw it said he wasn't eating. Why cj this if not eating right? No sugar created from food?
And what is 'Post SRT'? Then you started adding 'F' after units. What is that?
Are you not feeding several meals throughout the day? It only looked like breakfast and dinner in the notes.
Was the not eating due to the other illness you spoke of, or the diabetes.

A little background. Neko (a girl) had a condition called acromegaly, which is caused by a benign pituitary tumour. It sends out excess growth hormone, which in turn causes the diabetes, and some other side effects. In November 2015, she had stereotactic radiation therapy (SRT) on her pituitary gland. The radiation targets just the tumour with the goal that it neuters the tumour cells meaning they don't reproduce and eventually die off. When they die off, less growth hormone is produced and her insulin needs go down. Sometimes quickly. End of November 2016, she was getting 7 units of insulin, one and half months later down to 3.5 units and I knew her dose would continue down. There are some cases where the "rules" of TR need to be broken for safety. Treating secondary conditions that cause insulin resistance are in those cases.

We have a saying "know thy cat". When you have a special case like treated acromegaly, that is even more important. One of the "rules" that I implemented when Neko was going down dose after SRT was to change the reduction point to 70 instead of 50.

On the 15th of January she had hit 31, then two days later wasn't eating well. Neko loved her food, this was very unusual. From my experience with the previous time she had SRT 3 years earlier, I knew I had to be very cautious. I had also been debating taking a 0.5 unit reduction when she hit that 31, so decided I should have done that instead of a 0.25 units reduction so reduced by 0.25 units again.

A BCS is a big chicken sh*t dose. Done for caution. The F dose was for Fat. I had calipers so could do 0.125 unit changes. Neko was sensitive to small changes at the smaller doses. Most cats are fine with 0.25 unit changes.

I was feeding at PS, +1, +2, +3 and +9, though only PM+9 about half the time. I just split her regular meal into half at PM time, and the rest divided into the other meals. I didn't document that cause it's what I always did.

Not sure exactly what was causing Neko to be nauseous and not to eat at that point. She did have CKD so that could have been part of it. That May she was also diagnosed with heart disease and small cell lymphoma, both of which can also cause nausea and loss of appetite.

My cat was said to have nadir at only +4. So does most of the testing need to happen then or before it?

I don't think we have enough data yet to say when Nico's nadir is. We need to wait until his overall numbers get down to see where it ends up. Also, nadirs can change from cycle to cycle. In general, numbers do go up after nadir so you don't need to test after that. In early days, you do need to do more testing before nadir. You want to find out when his onset is as well (when the insulin starts to take effect). Some cats do a big drop at onset, which can cause bounces. Those early tests can also give you clues as to whether the cycle will be an active one needing more testing. Not tonight for Nico though.

 

[Tyleete]

I just thought whatever he was doing after the am shot, he'd be doing the same after the pm shot. In the past when I'd do +2,c3, or 4 test, it always looked the same as earlier in the day. It's why I stopped bothering.
So where to from here?
Oh, and someone had figured his nadir to be the +4 on the Prozinc. Where I got that. His numbers always dropped after that.