Re: 1/30 Eddie AMPS = 295, +6 = 164
HI Jen,
Sue sent me a message and asked me to take a look at you and Eddie's numbers and some of the questions she thought I might be able to take a shot at answering.
I went back through your last few daily threads and you do ask some really good questions!
Question: My understanding basically is that the cat's body is seeking homeostasis between insulin and glucose. So, that's what bouncing is...when the liver releases glucose and other stuff to prevent what the cat's body perceives as not enough glucose. I'm guessing physiologically, that's why Eddie seems to settle in the yellows? His pancreas and liver feel like this is a "healthy" middle ground?
First off, I love seeing bounces, believe it or not. They usually say two things to me -
1 - the insulin did a good job that cycle in bringing the numbers down to "normal" in most cases.
2 - the built in self-defenses (what we call liver panic) are working just the way nature intended.
To me, those are both great things to see.
As far as my way of thinking, about bounces, dosing, how long it takes a dose to settle, or how long until a bounce clears... well, it's probably different than what other people might think. And my experiences with Bob were the most important factor in my way of thinking, keeping in mind that every cat is different. I mostly look at everything PZI related with a "Bob filter", so keep that in mind.
As far as the liver goes, I don't think the liver is at all interested in maintaining a healthy middle ground. If things get to the point where the liver is going to panic, and release glucose into the bloodstream, then I don't think there's any degree of control - it's an all or nothing kind of thing. Like "holy crap the BG is too low, bombs away!" and then the BG skyrockets back up, higher than we might like to see.
I see a couple of cycles on Eddie's spreadsheet that I think illustrate lows that caused a big bounce, and the high numbers that followed.
1/15 PM cycle. Eddie didn't drop too far from PMPS, but he went down to the 50s. And next AMPS was 390. To me, that's a perfect example of a bounce. And that morning, IMHO, you did the right thing. You recognized the 390 for what it was - a "low induced high" from the night before. And you actually shot less insulin than you had the night before when his PMPS was a yellow number. And his nadir that day was nice at 170. You
could have shot more, but I would have done the same thing. At PMPS, you got a 289. And that night, another green nadir, which is just what you wanted. And next morning, what does Eddie do? Gives you another bounce with a 436. At that point, his numbers sort of got yuckier going forward.
OK, here's my take on that sequence.
The first bounce, you gave less insulin, and he still gave you a nice nadir, and a nice PMPS. The way I see that is "the bounce cleared, and cleared very quickly". By PMPS it was gone. And that next PM cycle, he showed you that by giving you another green nadir (after two doses that were lower than the one that caused the first bounce).
Since then. Eddie has only given you one green nadir over two weeks. And until yesterday, all of his doses have been lower than the one that caused the first green nadir/bounce combination (1.6u). Not saying that's "bad", it's just what the data tells me.
OK, here's where we get to the "how long does it take for a dose to settle" theory. A lot of people will disagree with me, but my theory is "hardly any time at all with PZI". Because of the "in and out" nature of PZI, I am not a big believer that much "dose settling" goes on at all. Some cats, and again ECID, take longer than other cats to "clear a bounce". No matter what insulin you are using. Because it's the low number that causes the bounce, not the type of insulin. Low BG is low BG, period. To me, on the cycles I detailed above, Eddie cleared a couple of bounces in two cycles or less. And that's not saying that he will always clear them quickly. Some may last a couple of days, some will only last a few hours.
In hindsight, I really only have good data from about 1/20 forward, since I think I was changing doses too frequently and without considering bounces before that. I think going forward, if there are high(er) flat cycles, I'm going to assume they are bounces and hold for a 8 cycles to see if the bounce stops. If not, I will assume he's stuck and likely dosecrease. If he goes a bit lower numbers mid-cycle on the dosecrease, will hold that for probably around 6 to 8 cycles before considering another dosecrease. At least that's the plan for now! I explained my plan to Eddie, but we'll see if he decides to go along with it!
What I don't agree with there is two things. One, I don't think you were changing doses too frequently. My theory on dose is that it can be changed every shot if you choose to manage FD that way with PZI. You just have to have a strategy with a goal in mind when you look at the preshot number you're given. The other thing I differ from many with is the length of time it takes for a bounce to clear. You can't put a definite time frame on it because ECID, and because it's not just glucose that the liver "dumps" into the bloodstream. There are "counter-regulatory hormones" that are involved, and hormones are hormones, how predictable are they? To me, that's the difficult part - how long are the high numbers because of a bounce, and at what point to you determine that they are instead being caused by a dose that is too low? I don't know if anyone is
that adept at making that determination and that's the part that makes this so hard. And it is what makes the SS data so valuable. And I think you said it very well a couple of days ago:
I guess the million dollar question is how long to wait for a bounce to clear and at what point does it make sense to stop waiting for it to clear, and assume it's "stuck," requiring an increase.
Here's my general "strategy" on using PZI -
First off, pick a target "nadir". It can be a blue number, a green number, doesn't matter. Just a number you feel you'd hope to see at nadir.
Then look at the preshot number, and the cycle or two that led you to that PS number. This is where you have to evaluate things.
Was the preshot the end product of a bounce? Do the last couple of cycles show you a number that is likely to have caused one? Is this a bounce from days ago that just hasn't cleared? Because those factors will determine what your dose could be. If they look to be from a bounce, and Eddie looks like he clears a bounce quickly in general, then you would base the dose on that. If the past couple of cycles or days just show higher flat numbers, and you can't see where he went low enough to bounce, and most importantly,
if you can monitor the upcoming cycle, then you might shoot a higher dose. My overall goal is to try for green nadirs, and if a kitty bounces, oh well, they bounce. I have not seen a cat on any insulin over almost 3 years that hasn't bounced, so IMO, there's no avoiding them. And because they are destined to happen, I don't stress over them (easy for me to say, I don't have a diabetic cat on a trampoline).
Protocols - protocols are awesome. They give you a set of guidelines to follow that tell you "if this happens, here's your next step". And the TR protocol for Lantus/Lev has been used by thousands of people and a whole bunch of kitties have gone off the juice because of that. Unfortunately, there isn't a published protocol for Prozinc. There is the Hodgkins' TR protocol which was originally written for use of an insulin that is no longer sold, and it has been modified and used with Prozinc by some people. I always found it too aggressive and labor intensive to ever consider trying it, but that's me. The thing I try to keep in mind I guess is that while caregivers can follow a protocol, cats don't. They can't read, and they aren't really big on following rules of any kind. ;-)
Carl
