02/18 BuddyM: +9 113 | AMPS 85 | +2 77

[Mariette]

Previously:
https://www.felinediabetes.com/FDMB/threads/02-16-buddym-amps-77-3-60-6-69.243232/#post-2742351

But we also had some discussion on Katherine's thread yesterday about Buddy and Ruby's similar numbers:
https://www.felinediabetes.com/FDMB/threads/2-17-ruby-pmps-88-1-5-80-3-69.243278/

I said that I don't feel like the insulin is doing very much for Buddy currently. @Marje and Gracie pointed to the better AMPS numbers. I didn't want to hijack Katherine's thread yestterday, so I'm hoping we can discuss here today.

We've previously established that the lower AMPS number was because of the food. I started giving Buddy a snack at 5am to try to bring that number down. He wasn't really interested in eating at that time at first but he's now consistently eating it all.

We even did a little experiment on 1/31 to confirm that the better AMPS number was because of the 5am snack and not the insulin:
https://felinediabetes.com/FDMB/threads/01-30-buddym-amps-83-2-71.242333/
https://www.felinediabetes.com/FDMB/threads/01-31-buddym-amps-133-2-73-4-63.242390/#post-2731122

I can do the experiment again, but I don't really see the value in doing it again. I know that the food sends the numbers down. We've also seen it for the +9 test. When I fed at +6 on 2/11 and 2/12 the +9 tests were lower.

Look at 1/13, the first day he didn't get any insulin... Food alone brought him down from 193 to 68 in 90 minutes.

This is why I believe that food is a much larger factor in Buddy's numbers than the insulin. And if I look at Buddy's numbers during the time he was off insulin, and now, they look the same if I disregard the AMPS number. When Buddy was off insulin I was not giving the 5am snack so we can not look at the AMPS number when comparing, because it will be an apples to oranges comparison.

I am a little concerned that havng increased the insulin in these small steps may have done more harm than good. I suspect that the body may just be adjusting to the extra insulin. The same way that when a cat is reducing on TR after staying in normal numbers for a week. When reducing in these tiny steps the body seems to just compensate. What if I have now done the same but in reverse. I have now succesfully gotten Buddy on insulin again, instead of off.

 

[Mariette]

I calculated the average of the Buddy's numbers for 1/14 to 1/17 when he wasn't getting any insulin, and also 2/14 - 2/17 when he's been receiving 0.25 units.
1/14 - 1/17 am cycle average is 65.7
2/14 - 2/17 am cycle average is 70.4

I'm not saying that the insulin is making his numbers higher, who knows he may have trended up if I wasn't giving him any. Just illustrating that his numbers are not better on the insulin.

 

[Sue and Luci]

From what I see on the SS, it looks like Buddy still depends on some help from you...otherwise his numbers wouldn't be those nice greens.

Kitties are strange and mysterious creatures as far as their insulin needs go. Remember they have an entire compliment of organs working in there to hopefully create insulin and deal with glucose and hormones...sometimes those organs work better than other times...and when they need help from you, they need it...when they're getting too much help from you the numbers will drop too low (meaning that their pancreas is doing it's job perfectly)...when it's not working so well, then it's time for you.

The problem with all of this is there's no gauge or other way to determine what's going on in there - we have to depend on the blood glucose tests that we all do frequently to tell us by way of the BG numbers what's going on.

I think you're doing an excellent job with Buddy...just hang on and keep doing what you're doing. When he's had enough help, he'll let you know.

 

[Mariette]

From what I see on the SS, it looks like Buddy still depends on some help from you...otherwise his numbers wouldn't be those nice greens.

Kitties are strange and mysterious creatures as far as their insulin needs go. Remember they have an entire compliment of organs working in there to hopefully create insulin and deal with glucose and hormones...sometimes those organs work better than other times...and when they need help from you, they need it...when they're getting too much help from you the numbers will drop too low (meaning that their pancreas is doing it's job perfectly)...when it's not working so well, then it's time for you.

The problem with all of this is there's no gauge or other way to determine what's going on in there - we have to depend on the blood glucose tests that we all do frequently to tell us by way of the BG numbers what's going on.

I think you're doing an excellent job with Buddy...just hang on and keep doing what you're doing. When he's had enough help, he'll let you know.

Thank you Sue! I try my best

By saying he's depending on help from me do you mean insulin wise?

If so, why do you think he needs insulin support from the spreadsheet? I really appreciate all eyes and insights!

Like I noted his am cycle average from 1/14 - 1/17 without insulin was actually slightly lower than 2/14 - 2/17. So I don't see what the 0.25 is bringing to the table. Of course it's impossible to judge what he would be right no without the insulin, but both you and Marje seem to think he needs insulin and I'd like to understand why. What am I not seeing?

 

[Mariette]

Wanted to add that just because he's not throwing lime greens I'm not convinced that it means he needs at least that dose. I increased with tiny amounts. Pretty much a drop a week. And I'm suspecting that because it's such tiny increases his body is just adjusting to it. The same way that a cat adjusts to very slow lowering of a dose. I suspect that Buddy has simply adjusted to the very slow increase in insulin.

 

[Marje and Gracie]

Thank you, Mariette, for the discussion and info.

Buddy’s AMBGs off insulin were much higher. There are several days, when you started giving insulin, that his AMBG was much improved without a +9 feeding. I’m going off the info you have in Remarks or in the +9 cell for a snack.

I’m going to tease you here a bit because I didn’t recommend you increase to 0.25u. I was surprised when you did it.

One telltale sign of getting insulin when they don’t need it as they have inverted curves. An inverted curve would be where Buddy’s nadir is higher than his preshots. I’m not seeing that here.

IMHO, and under TR, I’d leave him at this dose for a week unless he drops below 50 (then you’d reduce). If he stays in these numbers for a week (amd you’re almost there) and doesn’t creep up, I’d reduce the dose back to 0.1u and see where he goes from there.

How does that sound? I, personally, would not recommend that you just stop insulin but, instead, you just follow the TR protocol back down and let’s see how he does.

Note for readers: there are other things that can cause an inverted curve so for all those reading this, don’t assume if your cat has inverted curves, it doesn’t need insulin. Inverted curves can also be caused by not enough insulin and bounces so it’s best to have an experienced SS reader advise you if you see inverted curves.

 

[Mariette]

Thank you, Mariette, for the discussion and info.

Buddy’s AMBGs off insulin were much higher. There are several days, when you started giving insulin, that his AMBG was much improved without a +9 feeding. I’m going off the info you have in Remarks or in the +9 cell for a snack.

Hi Marje!
Can you give me a date or two that you're looking at please for the better AMPS numbers?

I’m going to tease you here a bit because I didn’t recommend you increase to 0.25u. I was surprised when you did it.

I increased him to 0.25 because the 0.1 dose wasn't changing his numbers. And I really want to bring his morning numbers down. Without food if at all possible!

I am totally not putting any of these decisions on you I decided every step of the way when I wanted to increase and he's my responsibility alone. I never felt that I have given over the responsibility of his treatment or doses. I just want to be able to make as informed decisions as possible. So that's why I always try to understand a differing position as thoroughly as possible. So that I know when there's something I'm not seeing or thinking of.

If insulin will bring the morning numbers down I'm all for it. So I'm just really bummed that it hasn't had that effect. And that's why yesterday I was contemplating maybe increasing him to 0.5. But I am concerned that with these tiny increases I have just made him tolerant of the insulin in a very gradual way. Because I can't explain why else his numbers aren't responding.

 

[Mariette]

As for the inverted curve... I think if Buddy was receiving food only two times a day - at AMPS and PMPS times his curves may be inverted. But he's currently getting food every two to three hours during the day which affects his numbers during the cycle.

 

[Mariette]

And in case it wasn't clear.. I'm not advocating for getting him off insulin. I am working from home at the moment and I'm able to be here and monitor him at the moment. So if I ever have the opportunity to get him better it's now. All I want is the best chance of remission for him. And as far as I understand with his current high morning numbers that is not really possible.
But also if what I'm doing currently is not improving his chances I need to change what I'm doing. Whether that is increasing the dose in bigger increments so he doesn't just adjust to it, or whether it's getting him on a different feeding schedule.
Unfortunately to me it doesn't look like I've made any progress over the past month. The AMPS number is better, yes, but as soon as I withold food at 5am I am sure it's going to go back up.

 

[Marje and Gracie]

Can you give me a date or two that you're looking at please for the better AMPS numbers?

2/4 and 2/5 he did not appear to have +9 meals.

I increased him to 0.25 because the 0.1 dose wasn't changing his numbers. And I really want to bring his morning numbers down. Without food if at all possible!

My only thought is that the TR protocol wouldn’t have called for an increase. I know you want to get that AMPS down without feeding but a very wise mentor here told me once, “don’t chase the numbers”. She also told me, “Patience, Grasshopper”.

I am totally not putting any of these decisions on you I decided every step of the way when I wanted to increase and he's my responsibility alone. I never felt that I have given over the responsibility of his treatment or doses. I just want to be able to make as informed decisions as possible. So that's why I always try to understand a differing position as thoroughly as possible. So that I know when there's something I'm not seeing or thinking of.

Very wise and I was really just teasing. There was no harm done but also no improvement as you have observed.

As for the inverted curve... I think if Buddy was receiving food only two times a day - at AMPS and PMPS times his curves may be inverted. But he's currently getting food every two to three hours during the day which affects his numbers during the cycle.

Hmmmm ...that’s not a statement even I would make.

And in case it wasn't clear.. I'm not advocating for getting him off insulin. I am working from home at the moment and I'm able to be here and monitor him at the moment. So if I ever have the opportunity to get him better it's now. All I want is the best chance of remission for him. And as far as I understand with his current high morning numbers that is not really possible.
But also if what I'm doing currently is not improving his chances I need to change what I'm doing. Whether that is increasing the dose in bigger increments so he doesn't just adjust to it, or whether it's getting him on a different feeding schedule.
Unfortunately to me it doesn't look like I've made any progress over the past month. The AMPS number is better, yes, but as soon as I withold food at 5am I am sure it's going to go back up.

I understand but, honestly, if his only issue was blue AMPS just a little over 100, and he earns a reduction by one of the methods, it’s worth it to see if he can hold it. Sometimes they surprise us and the BG comes down when insulin is removed. Look at Sandy’s SS.

 

[Mariette]

2/4 and 2/5 he did not appear to have +9 meals.

He did. Apologies - I know my remarks section looks very disorganized, but it makes sense to me
2/4: He had 0.2 can Wellness beef at 5am.
2/5: 0.3 can Tiki venison at 5am.

If he showed a green preshot number for me without eating I would be elated. That's why I'd be surprised if I could have had one slip by me.

Hmmmm ...that’s not a statement even I would make.

Don't quite understand. I'm not saying he would have any kind of curve without the food. But rather that it's hard to say. The food alters the numbers clearly. But I have no idea what the specifications are for the inverted curve. That's the first time I've heard about it. How does one evaluate what the curve looks like taking into account that food alters the numbers?

Hmm looking at Sandy's spreadsheet. I'm not seeing the same stubborn high AM preshot as Buddy. It was just one day right?!

Thank you so much for explaining stuff to me Marje, and sticking with us. I wonder if it's just as frustrating for you as for me that the AM numbers aren't coming down by themselves.

Wondering if I should try to introduce the food at +6 again. If I'm going to be reducing his dose instead of raising it I doubt the morning numbers will come down.

Unfortunately I have to run out for an unexpected errand tonight and I have to give him the shot 30 minutes early. We'll adjust tomorrow to get back on schedule slowly, but I didn't want to shift 30 minutes in one go.

Thanks again for your time and advice!

 

[Marje and Gracie]

Don't quite understand. I'm not saying he would have any kind of curve without the food. But rather that it's hard to say. The food alters the numbers clearly. But I have no idea what the specifications are for the inverted curve. That's the first time I've heard about it. How does one evaluate what the curve looks like taking into account that food alters the numbers?

I’m just saying that with all the years I’ve been here and all the patterns, etc, I’ve seen, I wouldn’t make the conclusion that his curve would be inverted if he was only fed at AMPS and PMPS. You are correct that it’s hard to say. But since most feed their cats during the cycle, unless you are feeding a lot of HC constantly to bring the nadir up, you don’t have to worry too much about the food.

For tightly regulated kitties like Buddy who is getting a small dose of insulin, the insulin is pushing the BG down and feeding LC, unless he’s super carb sensitive, cannot counteract that drop. That would mean you wouldn’t see an inverted curve attributable to food.

I linked Sandy’s SS so you could see there are situations where the BG is what we would normally think as too high to start an OTJ trial. But the pattern indicated to me he was “bouncing off the insulin” so I suggested Liz stop insulin and see what happened. What I expected to happen, did happen. The lesson here is we need to be careful about giving Buddy more insulin at this time and not be tempted to increase when he’s pretty much below 120 all the time and below 100 the majority of the time.

dy. It was just one day right?!

Thank you so much for explaining stuff to me Marje, and sticking with us. I wonder if it's just as frustrating for you as for me that the AM numbers aren't coming down by themselves.

You’re welcome. If nothing else, it might help you to bounce ideas and thoughts off me. I believe we need to be patient but also there is the chance that he’s going to need this bit of insulin for a while. I try not to get frustrated. We just give things time and make adjustments when we need to. It’s easier for me because he’s not my cat I was not known for patience, at first, when dealing with Gracie’s diabetes although I eventually learned.

Wondering if I should try to introduce the food at +6 again. If I'm going to be reducing his dose instead of raising it I doubt the morning numbers will come down.

That’s up to you but the point is not to feed every three hours just to try & get the BG down.

 

[Mariette]

I’m just saying that with all the years I’ve been here and all the patterns, etc, I’ve seen, I wouldn’t make the conclusion that his curve would be inverted if he was only fed at AMPS and PMPS. You are correct that it’s hard to say. But since most feed their cats during the cycle, I less you are feeding a lot of HC constantly to bring the nadir up, you don’t have to worry too much about the food.

Foe tightly regulated kitties like Buddy who is getting a small dose of insulin, the insulin is pushing the BG down and feeding LC, unless he’s super carb sensitive, cannot counteract that drop. That would mean you wouldn’t see an inverted curve attributable to food.

I linked Sandy’s SS so you could see there are situations where the BG is what we would normally think as too high to start an OTJ trial. But the pattern indicated to me he was “bouncing off the insulin” so I suggested Liz stop insulin and see what happened. What I expected to happen, did happen. The lesson here is we need to be careful about giving Buddy more insulin at this time and not be tempted to increase when he’s pretty much below 120 all the time and below 100 the majority of the time.



You’re welcome. If nothing else, it might help you to bounce ideas and thoughts at me. I believe we need to be patient but also there is the chance that he’s going to need a bit of insulin for a while. I try not to get frustrated. It just give things time and make adjustments when we need to. It’s easier for me because he’s not my cat I was not known for patience at first when dealing with Gracie’s diabetes although I eventually learned.



That’s up to you but the point is not to feed every three hours just to get the BG down.

You're right that I'm losing my patience a bit. It's tough for me to keep doing the same thing when I don't think it's working. I know you think the numbers have improved over the past month, but I still don't see it!

I think we can try to scale the insulin back again and see how that goes. I do think that if I start to increase again that I should do it in bigger steps. Maybe jump straight to 0.25. I'm still a bit suspicious about his numbers not changing with the increases.

I have changed back to my old Brandzig syringes by the way. It was good to hear that you also had a tough time with the Monoject hubs. I honestly think that it may have screwed up some of my doses. It really is impossible to completely get rid of all air bubbles with those syringes.

So right now I'm planning for one more day on 0.25, and then reduce back to 0.1.

Thank you Marje!

 

[Marje and Gracie]

You're right that I'm losing my patience a bit. It's tough for me to keep doing the same thing when I don't think it's working. I know you think the numbers have improved over the past month, but I still don't see it!

I think we can try to scale the insulin back again and see how that goes. I do think that if I start to increase again that I should do it in bigger steps. Maybe jump straight to 0.25. I'm still a bit suspicious about his numbers not changing with the increases.

I have changed back to my old Brandzig syringes by the way. It was good to hear that you also had a tough time with the Monoject hubs. I honestly think that it may have screwed up some of my doses. It really is impossible to completely get rid of all air bubbles with those syringes.

So right now I'm planning for one more day on 0.25, and then reduce back to 0.1.

Thank you Marje!

You’re welcome. If he starts seeing more blue, we need to get the dose right back up.

Do you dose with calipers?

 

[Mariette]

You’re welcome. If he starts seeing more blue, we need to get the dose right back up.

Do you dose with calipers?

I have calipers but I actually find it easier to eyeball the distance from the top of the plunger. Lining up the calipers against the cylindrical syringe is so fidgety and prone to error for me.