1/25 Rocky PMPS 366 +3 354 +7 334

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Re: 1/25 Rocky AMPS 389

in response to your last post, yes, everyone increases doses based upon the nadirs. i think if you look very carefully at those spreadsheets, however, you will find that people hold doses a minimum of 4 shots, most of the time 6, sometimes longer. I'm trying to think of who has been posting on Rocky's condo that you might have been looking at. Wendy's cat Neko has iaa and acromegaly, Sandy's cat BK had iaa and my cat, punkin, had acromegaly. The protocol wasn't developed for high dose conditions and it isn't completely applicable. High dose cats require some different strategies.

If those are the ss you are basing your decisions on, you are comparing apples and oranges, which can be a problem when we're talking about diabetic cats.

Experienced people will also tweak things to see what works with their cats. Before doing that, you must understand the action of the insulin - when it onsets in your cat, what the duration is, and know when the nadir is. If you can't answer those questions yet, you will be able to later, but you really want to understand how things work before you go off the protocol.

We tailor advice to fit the cat we're talking about. In your case, you've got a newly diagnosed cat who does not have a high dose condition. The protocol is applicable to Rocky and it is the safest way to make dosing decisions for him.
 
Re: 1/25 Rocky AMPS 389

Hi Julie,

I agree that it seems so far Rocky does not have a high dose protocol, however, he was prescribed 1.5u from the vet after spending over 10 days there. I feel comfortable resuming that dose.

It remains to be seen if that will be too much for Rocky. After looking at his SS, I'm not even sure that the 2.0u prescribed dosing was too much.

As much as I would like Rocky to be on less insulin it doesn't look like his pancreas or liver is functioning well enough to warrant that. I probably should have given a shot of at least 1.5u, on January 11, instead of nothing at all. It seems to me like that is what really has screwed up his numbers. He was still in the blues at 110mg that day, a good number. I think it was the vet who recommended no shot that night but I cannot remember.

Anyway, I don't think it's likely with Rocky's high to mid-300s since January 16, (including three 400s readings in there), that he is suddenly going to dip too low today. He's been 9 days in those high 300s and I do not like that.
 
Re: 1/25 Rocky AMPS 389

Tina: Take a deep breath. Kitties bounce. You got some low numbers, whether due to too little blood, bad strips, whatever, being a newbie you should not shoot those numbers. Please read and re-read the stickies. There is a lot of information there. Perhaps it will help you understand Lantus and the way it works. You can't rush the numbers. Tuffy was a high dose kitty on the vet's recommendation. Tuffy was a difficult manage. I followed the advice I received here and it works. it is a MARATHON NOT A SPRINT. Getting ketone tests is very important since he went DKA. Using fluids and R can be dangerous particularly if you need to leave and can't monitor.
 
Re: 1/25 Rocky AMPS 389 +2 397

None of your cats have blood glucose levels that are continuing to climb. This is what I am trying to point out to you guys. I feel like no one is hearing me.

You all say your cats are difficult to manage. When I look at your charts I just don't see the steady 300s like Rocky has, ever. It's not good for him.

If there is a spread sheet like that, where someone's cat is presenting consistently in the 300s for 9 days in a row like Rocky is doing, please point me to that cat's SS. I would like to look at it.

I do appreciate your help and guidance but so far nothing seems to be working.

As far as marathon vs sprint, I don't think it is sprinting to ask that Rocky's numbers at the very least be in the 200s. So far, that has not even happened.

I'm not blaming anyone here, I am just disappointed and afraid for him.

I don't think fluids are dangerous if you know how to give them. I don't need to pay a vet to give Rocky fluids. I don't think that the (6)tbs a day I give him is enough for the amount that he pees considering that he drinks BARELY any water. On many days he drinks no water at all.
 
Re: 1/25 Rocky AMPS 389 +2 397

Tina: Take a look at Tuffy's SS. Yes, after 2 1/2 years with the assistance of this board and their suggestions she went OTJ. You are not alone and we are listening, are you?

I'm sorry to disagree with you but fluids can be dangerous. Knowing how to give them and giving too much is the problem.
 
Re: 1/25 Rocky AMPS 389 +2 397

Take a look at Cobb's spreadsheet. You'll see weeks of him in the 300s and above, even after we switched to wet food.

Currently Cobb has not been diagnosed with any high dose condition, but you can see he's on 11.5units of Lantus twice a day. He's had a few dips into the green, but yes...he was in the 300+ for weeks. And before we switched his food he was in the 500-600+ range since he was diagnosed back in April. We got incredibly bad advice from our vet. And she had his dose jumping by 2 units at a time AND that there was no need to test for ketones...ever - incredibly dangerous. And yes, incredibly difficult to manage.

So yes, there are cats who spend time in those upper numbers. Because Rocky has a prior DKA episode, you need to be extra vigilant and constantly test for ketones, whatever it takes to achieve that. That does not mean you should ignore the tested and proven protocol and increase before it is warranted. 4 cycles is safe because it gives enough time for a bounce to clear and for you to be sure you are not increasing in a bounce. That could kill him quickly if you increased during a bounce and he hypo'd. You do not want a high dose kitty.

You're right, 1.5u might not be Rocky's optimal dose. But twice he dipped incredibly low when he was on 1 unit, so a slower approach is advisable until you have enough data to make those decisions. You have to understand that the dose is based on the lowest number, not the highest. Lantus is good at creating a flat curve, not an inverted bell curve. Flat curves are good because that means the BG is not bouncing all over the place.

The reason you see Sandy, Wendy and Julie make immediate adjustments is because they had a lot of data to back up those decisions. You don't have that data just yet. Be patient and you will. Sandy and Wendy made quick adjustments because their cats had IAA and they had to push through the antibodies, which means very aggressive dosing. But they had a diagnosis to back up that course of treatment. Rocky does not. Cobb will likely be diagnosed with IAA or acro, I'm sure. But he hasn't yet so you don't see me making an immediate adjustment when he hits a 300+ number. I wait at least 4 cycles - which is also incredibly aggressive dosing, especially for not having a high dose diagnosis.

It took us over a month after joining to get some consistent 200s, so yes it could be too much to ask that Rocky's BG stay in the 200s while you search for the optimal dose. The marathon/sprint analogy bothered me at first too...but you see we've stuck it out through several miles and are now, finally seeing lower numbers.

This is not something that will fix itself overnight. Lantus is not that insulin.

I understand you are frustrated and feel like no one is listening to you. That simply isn't true. I would guess many of those advising feel like their advice is not being accepted. The people advising you have a lot of experience and their concern is for Rocky's safety.
 
Re: 1/25 Rocky AMPS 389

Good morning ~O) :cool:

Picking up from after I dropped of last night:
Tina & Rocky said:
If he were in the hospital right now, they would definitely be giving him the higher dose in the morning. They don't wait for cycles to bring down those numbers.
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He is not in the hospital. You and Rocky are here, where folks who live, breath and successfully navigate the treatment of FD 24/7 offer first hand experience, directly from the battle front.
Tina & Rocky said:
In addition Sandy, I noticed that you moved the time you gave the shot a lot. I'm not saying that is good or bad, I am just noticing it
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If you take a look at my signature line, you will notice IAA 84%, which is a diagnosed condition of extreme insulin resistance resulting from the formation of insulin antibodies. He was the first LL kitty to test for it; no one had blazed a trail before him and there was no protocol to guide us.
Tina & Rocky said:
None of your cats have blood glucose levels that are continuing to climb.
Click to expand...
Tina & Rocky said:
When I look at your charts I just don't see the steady 300s like Rocky has, ever.
Click to expand...
Tina & Rocky said:
If there is a spread sheet like that, where someone's cat is presenting consistently in the 300s for 9 days in a row like Rocky is doing, please point me to that cat's SS. I would like to look at it.
Click to expand...
When you looked at BKs SS, you noticed that I moved shot times, Go back and have a look at the first 5 months or so and try and find even a yellow. It was 6 months before we saw a number in the double digits Relentless immovable pink in the face of massive amounts of injected insulns for months on end and the hopelessness of it all - something I'm intimately familiar with.

I also know the fear all to well. however, in spite of the hopelessness, in spite of the fear and in spite of being in uncharted waters without a map or even a compass, with the help of the folks in LL we navigated through it.
All the way to the falls. :cool:

eta - Barbara makes an important point that I will add my voice to-
Barbara and tuffy said:
You are not alone and we are listening, are you?
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Re: 1/25 Rocky AMPS 389 +2 397

Tina, yes, Rocky's numbers have been higher than any of us would like, and we DO understand he's had an episode of DKA so it's important to remember that when dealing with him...however:

He has not been steady in the 300's for 9 days without doing anything or without considering where he's been. On the 16th he was too low to shoot, and on the 17th he dropped down to 113. When we were SURE he wasn't still bouncing, he was increased to 1 unit. EVERY time you increase, you just HAVE to be patient to see what that dose will do. We very rarely suggest someone increase after only 4 cycles, and usually if we do, it's because the cat has been in even higher numbers for longer periods and we're trying to get "on top" of it, but we ONLY suggest it when the caregiver has been following the protocol exactly and it hasn't been working..and their cats are still in very high numbers (400+) with no signs of bouncing.

Going down to 113 when his body was USED to higher numbers caused him to bounce, so for the next 72 hours, we would NOT want to increase him because IF the bounce breaks AND you also increase, you're just setting him up to go too low (and possibly have to feed a lot of high carb to bring him back up which would screw up his numbers again) as well as set him up to bounce AGAIN. The problem with bouncing is we don't have a crystal ball. We have no way of knowing when they might come crashing back down. We do know it can take up to 72 hours though, so the safe choice is to wait and make sure.

If you increase the dose when they might be bouncing, let's say the bounce broke and sent him back to 113..AND you increased the dose that same cycle...do you understand why that's a bad idea? It won't help Rocky to FORCE him down into lower numbers too fast. It will just cause him to bounce again.

The protocol we're trying to teach you is VERY effective, and Rocky has only been on it for 2 weeks. (and those first seven days, his dose was changed, skipped, changed, skipped EIGHT times). Lantus NEEDS consistency to work correctly and safely.

Now that you've increased to 1.5, please just have faith that we won't forget you, won't do anything to hurt Rocky, and will always be keeping our collective eyes on him. You're never going to find the tens of thousands of hours of REAL LIFE experience you're going to find here. Hold it for at LEAST 4 cycles, and then let us see where it's taken him. We might suggest increasing after that, but we may also ask you to hold on for another cycle or two. There are reasons for the decisions that are being made, and they're ALL intended to help Rocky...as well as keeping him safe and with the realization that you're terribly concerned about the DKA.

Please understand we DO understand your concerns, and everyone here will do their best to help you, but you're going to need to trust that we're doing the best we can for you and Rocky.
 
Re: 1/25 Rocky AMPS 389 +2 397

Tina
You are all increasing the dose when your cat goes up.
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No, we aren't. We are following the protocol and I think you might think the above because you are not understanding the protocol, the insulin, or how to read a spreadsheet. Julie explained how she, Sandy, and Wendy dose and why. If you've looked at Gracie's SS, you will not see a time that I raised her dose after three cycles. If you see me raising on a higher PS, it's because she is on levemir and her nadir is around her PS so I am raising doses based on her nadir and also taking into account the several previous cycles.

I suggested R because it is a tool to use but, frankly, at this time, after you increased the dose today when several of us suggested that you don't, I don't think you are ready to use R. I apologize for being so candid but it can be a great tool or a dangerous one and if I'm going to help someone use it, I have to firmly believe they will listen to those experienced with using it. I just don't want to take that responsibility when I feel you don't understand how lantus works. So, IMHO, I think we should table the discussion of you using R and I am sincerely sorry I brought it up to you last night. A couple of us thought it might be an option but, this morning, I do not think it is right now.

Yes, Rocky is in your care, and I do always encourage CGs to read the information offered, study their cat's SS, and make an educated decision based on all of that. All of us are just interested in helping you based on years and years of collective experience and a protocol based on scientific research. All of us have experienced prolonged high numbers at one time or another. And we all support a CG taking the info we provide and, knowing their cat and understanding the insulin, making a decision; it isn't that we think a CG is obligated to take our suggestions. They aren't. But our suggestions are also based on safety and that will always be the first thing.
 
Re: 1/25 Rocky AMPS 389 +2 397

I am not giving Rocky the Clavamox any longer.

I took him off of it, with the vets advice. We talked on Jan 22, and she told me to keep him on it for only a few more days and then stop. We are going to start him on a different antibiotic called "Fluconazole." It is an anti-fungal and also helps stops yeast build-up inside of the body. It will most likely help him recover from the ring worm, and maybe it will kill any yeast bacteria he might have growing inside of his stomach. Maybe it's yeast in his stomach that makes him always burp after he eats? :roll:

He was prescribed this new medicine on Jan. 22, but at first I thought I would skip it and instead just give him the bath and then the next day do the lime-sulfur dip. But with Rocky's continued high blood glucose numbers, maybe he still has some type of internal infection that is not going away. I will get the prescription filled today and he will receive his first dose tonight.

http://www.petmd.com/pet-medication/fluconazole
 
Re: 1/25 Rocky AMPS 389 +2 397 +4 357

Marje,

I think it was you who advised me last night, based on Rocky's current cycles, that it was OK to increase him to 1.75u. I choose to increase him to only 1.5u, which was the dose he was prescribed when he left the hospital. I think it was Sandy who said to hold steady at the 1.25u and try the Humulin R.

Marje wrote: Certainly you can try 1.5u first if you like. I was just looking at his nadirs now and applying the TR protocol. But if you are uncomfortable increasing that much to 1.75u, it's ok.
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I think I am getting a few mixed messages here.. Just so everyone knows, I am not communicating with any of you in private emails. Not asking anyone for their personal advise without the group consensus. We're all just sharing here about Rocky and his numbers/treatment plan, on the public forum.

I am going to buy the Humulin for Rocky at Walmart pharmacy tonight if they are open when I get home. Sandy said it lasts a long time. If I'm too busy this afternoon, and don't manage to buy it tonight, I will buy it tomorrow. I wouldn't give it to Rocky without the supervision of someone from this group. Please don't worry about that.
 
Re: 1/25 Rocky AMPS 389 +2 397 +4 357

From your condo yesterday:

Marje and Gracie said:
I would give him one more cycle at 1.25u and if he doesn't come down any into yellow numbers, I' d increase to 1.75u.
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Marje was in consensus with everyone by saying to hold another cycle at 1.25u. That would have been this morning's dose when you increased it, because her advice was given after you gave Rocky his shot last night. She said, after today's cycle, you could try 1.75u if you didn't see any improvement into the yellows. That recommendation falls within the protocol to increase by .5 if nadirs were not under 300. The frequency of increasing is the issue, not the amount right now.
 
Re: 1/25 Rocky AMPS 389 +2 397 +4 357

Suzanne is correct....and thank you, Suzanne.

This is what Sandy said yesterday:
I'm glad you didn't increase the Lantus dose. Lantus can't be rushed. Go 4 cycles with this dose and then re-evaluate
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She didn't recommend a dose.

I urge you to go back and carefully read what everyone has said. I do think you will find we all encouraged you to hold the dose four cycles. My recommendation to go up 0.5u to 1.75u was based on the TR protocol and is consistent with our recommendations to other CGs when their cats SSs looked like Rockys.

eta: my statement that you could try 1.5u was not based on increasing this morning. You didn't want to do 1.75u and so I agreed it was fine if you wanted to try 1.5u. I was referring to the dose; not when you increased it.
 
Re: 1/25 Rocky AMPS 389 +2 397 +4 357

Ah, OK.. I thought the suggestion was to increase the dose at the next shot time.
 
Re: 1/25 Rocky AMPS 389 +2 397 +4 357

Tina:

I suspect it feels like we're ganging up on you. That's not the intent. Let me provide some context. The Tight Regulation Protocol, by its very nature, is aggressive. If you compare it to the Start Low Go Slow approach where doses are increased every 5 - 7 days and decreased occur when numbers drop below 90, TR is very aggressive. SLGS was the way most people here dosed their cats until the research on TR was published. From what some of the members who have been here longer than me have said, TR was met with tremendous resistance. The value of TR is that it is geared to getting cats regulated or into remission as quickly AND as safely as possible. That means that doses are increased systematically giving each dose enough time for the insulin depot to stabilize and for you to evaluate the effectiveness of the dose.

When you speed up the increases by raising the dose with fewer than 4 cycles, you could potentially put Rocky at risk because you are being more aggressive than an already aggressive approach. Doing so, despite all of the jumping up and down to get your attention that folks have been doing communicates your worry about Rocky, which is completely understandable, but it also communicates that either you aren't hearing what experienced Lantus users are saying (or you don't care which is OK) or you haven't had time to develop an understanding of how Lantus works. No one here wants to see Rocky remain in high numbers. My goal, and I suspect everyone's goal, is to help you get Rocky into better numbers as quickly AND as safely as possible. At a personal level, I'm not willing to sacrifice safety for speed.

You said that Rocky is different that the cats here. You wanted to see spreadsheets. The SSs below are just a few recent ones. All of these cats are OTJ. None of them are high dose cats.
One of the things you will see is that these cats got to a dose and the numbers snapped into place. Overly aggressive dosing won't necessarily get you to that point more quickly. It could put Rocky over what is a good dose and set up a lot of bouncing or also put him in higher numbers. I realize the latter point is counterintuitive but it does happen.

While none of us want to see Rocky in high numbers, we especially don't want to see his numbers crash. I can't by any means tell you that this will happen. However, you need to see the big picture and understand the risks. You hold the syringe. It's our job to do our best to help you look at the pros and the cons even if we're yelling, "No!"

As to this latter point, I agree with Marje. I do not think you are in a good place to try Humulin R. While this can be a very effective tool, it is potentially lethal. It is a very potent form of insulin and it works quickly. An itchy trigger finger with R can kill your cat. Using it with the respect it deserves can be very helpful. R is most effectively used in conjunction with Lantus. In Rocky's case, R would be used to slightly lower numbers so the Lantus can "grab on" and do a better job. That also means you need to be able to adjust the Lantus dose in an effective manner. A less than conservative use of R can set off a huge amount of bouncing.

I'm probably saying things you don't want to hear. As I said, my goal is to help you get Rocky's numbers into a better range as quickly AND as safely as possible.
 
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