? 1/20 Yum Safe to test 0.5uR in evenings?

[MJW]

Yum is getting .25R at AMPS+11 and PMPS+11.
She is getting a response, but her BG numbers are higher in the evening than during the day.
Is there any reason I shouldn't test .5uR as an evening dose?
What about .5uR as a morning dose? It's my impression people will say that would lower her too far (>100) below her basal L response.

I might be aggressive and push her to 9uL this evening and skip R for 2 cycles.
I am so worried the high numbers are ruining her kidneys. She clearly needs a higher Lantus dose.

 

[Jill & Alex (GA)]

Not so sure you want to hear from me because you already know where I stand on dose increases so I'd just like to make a couple of comments...

Hard to tell with the variables involved, but there's a possibility she's bouncing from that 654 @ AMPS to 389 @ AM +11 yesterday because that 389 was a new low for her.

I can't remember if it was @Wendy&Neko , @Marje and Gracie , or @Sandy and Black Kitty who said there was a certain amount of finesse involved when using R. It's so true. My biggest concern all along is not wanting to set Yum up to bounce like a yo-yo due to an attempt to pound down her numbers with rapid dose increases. I know it's frustrating, but the hardest part of this dance is learning when to sit on your hands. When she gets up to 10u bid, usually increases in increments of 1u are suggested... depending on the numbers. If I was in your shoes I'd stick with the program and test for ketones daily. You will get her numbers down.

I hope others will share their thoughts on a safe and practical dosing strategy. Maybe they'll have other ideas...

 

[MJW]

Not so sure you want to hear from me because you already know where I stand on dose increases so I'd just like to make a couple of comments...

Thank you for responding! And for all your advice!

Hard to tell with the variables involved, but there's a possibility she's bouncing from that 654 @ AMPS to 389 @ AM +11 yesterday because that 389 was a new low for her.

Yes, but she had the same highs the preceding night without such a dramatic low (and low day). For that reason, I think it might not be a bounce.
(1)It could be I need a different R shot offset for the PM shot than the AM shot (which is 1 hour). Is that a pattern that others have experienced?
(2)Is there a rule for max R dose for a given L dose?
(3)I will look at charts to see if people use different R doses AM and PM (as opposed to offsets). The scales charts are just based on BG. Yum's PM curves are always different from her AM curves.

I can't remember if it was @Wendy&Neko , @Marje and Gracie , or @Sandy and Black Kitty who said there was a certain amount of finesse involved when using R. It's so true. My biggest concern all along is not wanting to set Yum up to bounce like a yo-yo due to an attempt to pound down her numbers with rapid dose increases. I know it's frustrating, but the hardest part of this dance is learning when to sit on your hands. When she gets up to 10u bid, usually increases in increments of 1u are suggested... depending on the numbers. If I was in your shoes I'd stick with the program and test for ketones daily. You will get her numbers down.

The L dose increase rules do factor in the BG level and the current dose, but not on a smooth scale, only with step changes. If Yum was in yellows I would wait longer to see what an L dose would give me. Ditto if she was at 2 units. She is in reds and blacks at 8.5 units and she shows little or no improvement (and often worsening) with each dose increase. The pattern makes me think: (a) I am very very far from the correct dose; and (b) her disease is progressing faster than my dose increases. Sometimes it does look like a race, where I need to get ahead of some rising tide. I worry I am killing her by not increasing her more quickly. The high BG is damaging her organs, right?

R is very nuanced. I am very excited it got her into reds for 2 AM cycles, something 8.5uL would probably not have done. But I think I need to use the big hammer and raise her L again. Then tweak R as the depot fills.

Thanks again!

 

[Marje and Gracie]

Yes, but she had the same highs the preceding night without such a dramatic low (and low day). For that reason, I think it might not be a bounce.
(1)It could be I need a different R shot offset for the PM shot than the AM shot (which is 1 hour). Is that a pattern that others have experienced?
(2)Is there a rule for max R dose for a given L dose?
(3)I will look at charts to see if people use different R doses AM and PM (as opposed to offsets). The scales charts are just based on BG. Yum's PM curves are always different from her AM curves.

I agree with Jill and it does look like a bounce to me as well. I’m not sure I understand your comment that “she had the same highs the preceding night without such a dramatic low”. It’s the dramatic low that looks to me (and I believe Jill) that caused a bit of a bounce because of the way she headed up.

(1) It’s possible you might want to shoot p.m. R at a different time but I wouldn’t get so set in a time for either cycle. In other words, some cycles when she’s high, you might decide to shoot R at +6 or +7; others, it might be better to shoot at +10. You have to be flexible and base it on what the BG is telling you looking at the last cycle or two and also considering where she might be headed without the R.

(2) No there isn’t a rule that I am aware of but, I always erred on the side of caution and I would urge you to do so as well. Members, of high dose cats, who have used R got to the higher doses of R very slowly. They didn’t go from shooting 1uR to shooting 5uR. I believe someone mentioned Suki and Crystal but I’m not sure if they linked Crystal’s SS and Crystal’s SS #2 which is a good study for how Suki increased the R. However, Crystal was on 23u bid before Suki started using R at 0.25u.

I had an R scale for Gracie but, for example, if she was at a number that my R scale would normally call for 0.1u, depending on what her cycles were looking like, I might err on the side of caution and only shoot a drop. The only time I got a little heavier handed with R was the last week she was alive and was hitting numbers that were totally insane for her and, as I said, Jill and Libby helped me with that. I’d have probably never shot 0.4u R on my own with her although it was the right thing to do.

(3) It’s good to look at other SSs but remember that using R, like using an L insulin, is really ECID. I would not suggest you copy anyone else’s R dosing scale. You need to determine that for Yum.

I know you started a new vial of lantus recently and that can last you a while but, in the meantime, I’d like to suggest that you consider switching to levemir when it’s time for a new vial. For one, Lev does not sting and Lantus can at higher doses. In fact, Lantus stung Gracie even at 1.25u but that is also ECID. Take a look at Doodle’s SS, 2016 tab, and how much better he immediately looked after switching to Levemir. It doesn’t always happen and sometimes, it takes weeks to see improvement (it did for Gracie) but it’s worth consideration.

I think I need to use the big hammer and raise her L again.

Here’s the point I think you are missing. Lantus and Levemir are not the "big hammers”. They don’t have the ability to yank numbers down. If you go back and look at Crystal’s SSs, you’ll see that she got up to 60u Lev bid and Suki just couldn’t continue to go through that much insulin every day so she started using the R at higher doses and it worked beautifully. Now....I am absolutely not suggesting you start using R like that. What I’m trying to show is that L is not the "big hammer" you think it is.

 

[Stacy & Asia]

I know it's hard to be patient with increases when you're seeing those numbers and thinking of the internal damage happening.

But I choose to (and you don't have to) believe the people stepping up to help you have so much experience in these areas (high dose kitties, R, lots of ugly numbers) that they are giving you the best and most aggressive advice possible while keeping Yum safe. I believe they would follow this advice if given for their own kitties (and probably have and did). Would that there were some formula to follow that could measure something and tell you exactly the proper dose that is effective at any given time, until then, collective experience of the many that came before you and all of the kitties they have seen in a similar boat will have to do. Remember, we are on your team, everybody has the same goal, to get Yum better and keep her safe while doing so.

It sucks! Period. You have every right to be upset with the situation and vent all you want about how tight your patience pants are, but Yum is making progress (I think it's harder to see it when it's your own kitty and it's subtle) and hopefully very soon these numbers will be behind you and Yum will be on a path to much better health. Tons of hugs and patience and healing vines from us until then.

 

[Marje and Gracie]

BTW, I forgot to mention that if she were mine, I’d leave the dose tonight and then “consider” raising it to 9u in the morning depending on how she looks. If she’s still stuck in high numbers and you elected to not give R in the p.m. cycle, than it would be reasonable to raise the L dose in the morning. But also consider how the cycle might look like it will play out. Lots to think about when R is in the mix and you want to increase the L dose.

 

[MJW]

I agree with Jill and it does look like a bounce to me as well.

Yeah. You and Jill are right. Looks like she is bouncing.

(1) It’s possible you might want to shoot p.m. R at a different time but I wouldn’t get so set in a time for either cycle. ....
(3) It’s good to look at other SSs but remember that using R, like using an L insulin, is really ECID. I would not suggest you copy anyone else’s R dosing scale. You need to determine that for Yum.

Thanks for these other examples.

I know you started a new vial of lantus recently and that can last you a while but, in the meantime, I’d like to suggest that you consider switching to levemir when it’s time for a new vial. For one, Lev does not sting and Lantus can at higher doses. In fact, Lantus stung Gracie even at 1.25u but that is also ECID. Take a look at Doodle’s SS, 2016 tab, and how much better he immediately looked after switching to Levemir. It doesn’t always happen and sometimes, it takes weeks to see improvement (it did for Gracie) but it’s worth consideration.

Another new thing for the list.

Here’s the point I think you are missing. Lantus and Levemir are not the "big hammers”. They don’t have the ability to yank numbers down. If you go back and look at Crystal’s SSs, you’ll see that she got up to 60u Lev bid and just couldn’t continue to go through that much insulin every day so she started using the R at higher doses and it worked beautifully. Now....I am absolutely not suggesting you start using R like that. What I’m trying to show is that L was not the big hammer you think it is.

Wow. Maybe I am really looking at this wrong. I was thinking I was just chasing a magic dose of Lantus, like I did last year. Lately I've felt it was a moving target (constantly increasing), but still it was the solution. I will have to rethink this and look at Crystal's spreadsheet. Lots to think about.

Thank you for spending the time on a long response. Yum and I are grateful.

 

[MJW]

BTW, I forgot to mention that if she were mine, I’d leave the dose tonight and then “consider” raising it to 9u in the morning depending on how she looks. If she’s still stuck in high numbers and you elected to not give R in the p.m. cycle, than it would be reasonable to raise the L dose in the morning. But also consider how the cycle might look like it will play out. Lots to think about when R is in the mix and you want to increase the L dose.

Got this too late. I was using what I thought was the big hammer.

 

[Marje and Gracie]

Got this too late. I was using what I thought was the big hammer.

Uh.....but we discussed a few days ago slowing down those L increases while you were using R.......