? 1/30/2016 Conan AMPS 342, +2 296, +4 199, +5 236, +6 401, +7 481, +8 501 +9 440 - Increase dose?

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Jessica & Conan

Jessica & Conan

Member Since 2016
Yesterday

First a few hopefully not too dumb questions, but my post from yesterday was my first here ever, and I'm not entirely sure of the protocol. It contained a bunch of questions, and while I got a few great responses, I'd still love to have more input on those, which is why I put "Question" in the title for today as well - but am I supposed to repeat all the questions again here?

I was also in the middle of a discussion on the responses from yesterday. But I gather that nonetheless, the correct protocol is not to continue responding in yesterday's post but to start a new thread for today? Do I just put my responses to yesterday's comments here then?

I guess I'll just assume that's the case and do it, and someone will tell me if I'm wrong!

julie & punkin (ga) said:
Your description of his inappetance improving with the fluids makes me think of pancreatitis. Fluids is one of the treatments and pancreatitis is fairly common in diabetic cats. Take a look at the Primer on Pancreatitis and see if that sounds like it might be what's going on. I haven't heard of CKD being connected with inappetance, but it's possible.
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Thanks for the link. It looks like Conan doesn't quite fit the profile for pancreatitis. No vomiting, hypothermia, ataxia, shortness of breath... Yes to the lethargy, anorexia, and dehydration, but only for a day or two, and those symptoms are common to many things - and in fact, dehydration itself often leads to lack of desire to eat, and then lethargy and anorexia. I, unfortunately, have had 3-4 CKD/CRF cats, and loss of appetite is a very common symptom (as are vomiting and weight loss). Renal failure causes an increase in gastric acid, leading to nausea and inappetence, then dehydration, weight loss, etc.

But anyway, there have only been two of these non-eating episodes so far, and they have been very short lived. I'll have to continue to monitor and make sure the vet continues to check him.

Re: Conan's dosing and tight regulation (my main questions).

Since we've only been doing this for a few weeks, I don't think I am ready yet to consider or discuss with the vet the possibility of changing him to another insulin, though it's something to consider if we can't get the Lantus to work well enough with my schedule.

I would be interested to know if there is anyone else out there who is managing Lantus - with or without tight regulation - on a schedule that doesn't permit 12/12 dosing - 11/13 or even (as will more often be the case for me) more like 11.5/13.5, and how it is working out. It may be inevitable that the curve is not quite as smooth as it would be on 12/12, but can it be made to work?

Regarding tight regulation, I think my larger concern than the irregularity is that on M, W, and F, I can't take BG measurements between the morning dose and +7 or +8. I wonder if this makes it too risky. Again, anyone have thoughts about this? Could I attempt it, would I need to make some accommodations/modifications?

For now - is he bouncing? His "low" day, all day, was Monday. It's possible he was low overnight on Tuesday night since he was low on Wed. morning (though he was high on Wednesday day), and/or low overnight on Wednesday night, since he was low on Thurs morning, but he's been high since. So he's been "bouncing," if that's what he's doing, at least since Thurs morning, if not earlier. Is that possible? I will take curves today and tomorrow (today I can only do 10 hours) and then decide what to do - perhaps seek further advice here?

Does anyone else have thoughts, in light of Conan's spreadsheet - keeping in mind that it is based on AlphaTrak 2 meter - about my dosing? The full explanation is in yesterday's post (including my non-12/12 schedule, and feeding extra meals some days, and more details about Conan) but that's the gist of my question. I'd love to have any additional help/guidance/advice.

Chris & China said:
The Relion Confirm and Micro meters from WalMart are both very popular around here because they're cheap (about $15) and the strips are affordable ($35.88 per 100)
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Thanks Chris. Oddly, according tot the Walmart website, none of the Walmarts near me seem to carry the meters or strips (this seems like it can't be right, but that's what the website said). So I went ahead and ordered the Relion Micro from Walmart online, along with some strips. I haven't discussed it with my vet, but since I still have the AlphaTrak anyway (and plenty of strips) hopefully it won't be too much of an issue.

I'm assuming the Akray strips from ADW work in the Micro?

I welcome and greatly appreciate any advice or suggestions - I am still very new to this and am trying to find my way!
 
Regarding Tight Regulation: I don't think the issue with following TR is not being able to get mid cycle tests. There's a sticky note that discusses following TR if you work/go to school full time. My concern is your not being able to follow a close to 12-hour schedule. Here are my thoughts as to why. Lantus and Levemir are depot-types of insulin. This is what gives them their duration and gentle method of action. What also happens is that because of the depot, an early shot acts like a dose increase and a late shot acts like a dose reduction. Further, if you make back-to-back changes in dose (which is what happens functionally if you are shifting the shot time), the depot doesn't have time to stabilize and the result is wonky numbers. (Typically, you give any dose change 3 days/6 cycles to settle before making any subsequent change unless the numbers indicate a reduction is warranted.) If your schedule was only 30 min off course it wouldn't be an issue; 1.5 hours can make a difference.

Bouncing: I think it's entirely possible that Conan is bouncing. It looks like he bounced on Monday. Cleared the bounce and then likely bounced again on Thursday. If he's staying in higher ranges, you may want to get spot checks rather than get full curves. However, you're seeing a decent sized drop by +2 this morning. For many cats, you'd expect the +2 to be similar to your pre-shot test value. A +2 that's considerably lower than the pre-shot number can be a notice to keep on your toes since it may be an active cycle. In other words, it's possible that the bounce may be breaking.

In general, if you want to stick with Lantus, you may need to be more conservative with your dosing in light of your schedule. SLGS is a less aggressive approach and accommodates greater flexibility. TR is pretty merciless in that regard. A great deal will depend on your ability to get tests on those days when you need to shoot early if you are committed to following TR.

 
Thanks very much Sienne. I am in no way committed to following TR - I was just pondering the possibility, and whether, if it offers benefits to Conan, there would be any way for me to do it. But if my non-12/12 schedule - which I just can't find any way around, as I have other animals (horses in this case) that have to be accommodated as well and whose schedules, at this point in my life, allow no additional flexibility on those days - makes TR risky, I'm happy to go with SLGS, especially if it is more forgiving. And since the very days on which I need to shoot early - the 5am breakfast days - are the ones on which I am not able to test after shooting (which I assume means giving the insulin shot? I am still new too the lingo!) until +8 or so, it sounds like TR might indeed potentially be too risky for me.

So it looks like I am going to stick with SLGS for now.

I really appreciate your extra input on bouncing. I have no idea what is typical - e.g., that +2 is typically similar to pre-shot - so this is where I'm very grateful for the input of those with more experience. The fact that his +4 number is even lower - 199, lowest it's been since Thurs morning - seems to support the bouncing theory, and the idea that the bounce is breaking. So I'll continue with my curve today, and possibly another tomorrow, and see how it looks. Hopefully this will give me more input with regard to how, or whether, to modify based on the SLGS protocol. Can I expect bounces to continue to happen, or once it "breaks," is that generally it for a given dose? (Or does it vary wildly, since cats are wildly fickle?!)

For a reasonably well regulated cat, how would one expect a small mid-cycle meal to expect BG levels? If I understand correctly then with Lantus, such mid-cycle feeding, if not excessive, shouldn't have a great effect, but I'm not sure I do understand correctly!
 
So today's curve is not finished, only just hit 8 hours, but Conan's numbers have just been flying straight up since hour 4 - an increase of 200 between hours 4 and 6, and another hundred between hours 6 and 8, and now he's over 500, whereas at hour 4 it was looking like his "bounce" of the past few days might be breaking. Could this be another bounce? But in that case, how do you ever know what to do - if the breaking of a bounce itself causes a bounce?

None of this is really making any sense to me, and I have no idea what to do. Based on today's curve - assuming the trend stays the same for the next few hours - I'd increase his dose by .25 using SLGS. But could it be that the wild swings could be caused by his dose being too high? Is it possible that what I should do is try lowering it from 1 unit to .75? Or just change nothing and continue being patient, even though he's been on this dose for 16 days?

It makes me very unhappy to see numbers over 500 at hour 8...
 
What this looks like to me is that Conan isn't used to seeing lower numbers (e.g., under 200). That's really not uncommon in newly diagnosed cats. Even though Conan was on the cusp of blue, once he got there, he bounced. The more time he spends in closer to normal numbers, the bouncing should calm down.

The other considerations is the prednisolone. Steroid have an influence on BG. You're going to have to keep that in the back of your mind. The goal in Conan's case is to work the insulin around his pred. It may be that he'll need a bit more insulin in order to offset the effect of the steroids but we don't know that yet. For now, be patient (that's one of the major things Lantus will teach you) and don't get discouraged due to the bouncing. It's normal, albeit very annoying.

 
Conan's diabetes is, as far as we know, entirely steroid-induced. He's been on prednisolone for over two years - since September 2013. His dosing is regular - 2.5mg in the am with meals, 1.25mg pm with meals - so hopefully the effect on BG will be regular as well.

What I am still not sure about is whether I am supposed to assume he is bouncing/adjusting to lower numbers (though he doesn't seem to be spending very much time in more normal ranges - a few hours a day?) and just continue to stick with it, or whether it is advisable to adhere to the SLGS protocol, which is telling me that I should increase the dosage by .25 - after all, as directed by SLGS, I'm doing a curve after (more than) a week on a given dose, and the nadir of the curve is definitely over 150. SLGS tells me that in this case I should increase by .25.

If I don't, on the assumption that this is just bouncing and I should wait it out, then there's not much point in saying I'm following the protocol - I'm just kind adjusting by the seat of my pants, based on what I'm guessing (with help and advice) the numbers mean. If I'm not going to use the protocol as my guidance, I would love some sort of sense about how long to stick with this dose even in the face of high levels on the hope/assumption that his body is just adjusting.
 
Not health care for me - horse care! My schedule is dictated on certain days by the needs of my other, non-feline "fur-kids" - my horses (it's a complex situation involving coordination of the schedules of number of other people and a very long drive for me, and really has no wiggle room). And horses are even more schedule-bound than cats.

My schedule is reasonably fixed - it's just that it is different on M, W, and F than it is on the other days. On those three days the cats must get their morning meal at 5am, and I leave immediately thereafter and do not return home until 1. On other days, cats' morning meal is 7-8 and my daily schedule is much more flexible.
 
First thought - you can take a break from testing tonight. He looks like he's in another bounce from today's blues.

Second thought - can you feed your cats and give Conan his shot at 5am on the T-Th-Sat-Sun days?
 
Theoretically I could feed etc at 5 am on the other days - there's no structural obstacle in my schedule. But it would seriously flatten me, and I doubt I could sustain it over the long term. My cats are very important to me, but so is my own mental and physical health, and waking at 4:30 7 days a week indefinitely ( it takes a good half an hour for me to feed and medicate 4 cats), in light of my overall schedule and the other demands on me, might just be beyond my commitment level, whatever that might say about me as a cat mom... I feel exhausted and discouraged just thinking about attempting it.
 
Ok, I really really need help now understanding this.

Sure I can stop taking readings tonight - but when do I start again? When do bounces end? Is it normal to keep bouncing and bouncing repeatedly? This seems really strange to me -

And why am I assuming that this is yet another bounce, and continuing on this dose, rather than following the SLGS protocol and increasing Conan's dose by .25 based on the results of today's curve?

If I continue to see an occasional blue or yellow number, followed immediately by reds, do I just continue to assume these are bounces and make no dose changes - even though meanwhile he is spending the vast majority of the time in potentially damaging BG levels? When do I stop blaming it on "bounce" and start following the actual terms of the protocol?

Shouldn't bouncing stop at some point?

I'm more confused than ever and have no idea what to do. Please, can anyone help me understand? Am I asking the wrong questions?
 
Bounces happen for 3 reasons: (or any mix of all 3)

1. dropping too low
2. dropping too fast
3. dropping into numbers the cat's body isn't used to being at anymore (most of our cats go for quite awhile with high BG before they're diagnosed and their body gets used to living at those higher numbers, so even dropping into what might be a "normal" number can cause a bounce)

It looks like Conan dropped quickly this morning (from 342 to 296 in 2 hours is a fast drop) and he dropped to 199 (which his body may not be used to anymore) so he's bouncing due to reasons 2 and 3

As for when to test again, since he is running high tonight, you can take a break and just resume testing in the morning at AMPS time

Bounces can last up to 6 cycles so we just have to wait them out, but yes, generally speaking, as their body spends more time in lower numbers, it should "re-learn" that it's OK to be there and the bounces shouldn't be as high and shouldn't last as long
 
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