10/19/10 Squamee Dosing advise needed

[judy and squamee(GA)]

AMPS (at +11) 178 .8u
+4 93
+5 62
+6 69
+8 +158

I was uneasy about shooting this morning, but went ahead, and came home to check on her during the day. I Got her to eat a can of FF beef and additional sauce from other FF cans of beef between 4 and 6. I don't think I can stay up tonight to check her, I can probably stay up till +4. I am thinking to lower the dose, but by how much? to .6? or .7?

 

[Nancy and Cody]

Since Squamee has other medical issues, she may benefit from variable dosing. Gator would probably be best to help you with this since he had a sick kitty with a very variable appetite, which is similar to your situation.

you don't need anything fancy, but it needs to take a variety of factors into account for example:
START with a basic scale based on preshot- and these are just rough suggestions/examples- I have NOT studied her ss or her history, so evaluate whether you think this is safe for yourself and make adjustments.
over 360 .9u
300-360 .8u
250-300 .7u
200-250 .6u
175-200 and rising .5u

example of other factors:
then if she is not eating well, decrease slightly
if you are gone for the day, decrease slightly
if you are shooting early, decrease slightly
she's vomiting, decrease slightly
if you are shooting late, increase slightly
she's eating well and you are home, increase slightly

then watch for the nadirs, and adjust things as you see fit and as you collect more data.

 

[judy and squamee(GA)]

Thanks, Nancy, I appreciate the quick response. I decided to give .7.

 

[Gator & H (GA)]

VDS variable dosing explained in more detail

I echo just about everything Nancy said with the following modifications:

I think the "scale" should not be so set in stone based on a certain PS but more about where the PSes are headed/trending and where you want them to go. SO we enter into what I call "variable dosing." I tend to watch the trends of the PSes then adjust up or down the dose to try to get the next PS more in the territory that I want it. Meanwhile trying to take things slowly and not try to make the next PS exactly where I want it but to move it towards the area I want it. One can always move the next dose up a little more if the dose just given does not bring the next PS down by the amount desired. And I like to think of everything revolving around the dose [at the time] that I would expect to keep the PS steady. Then one can add a little more or less depending on the need.

I think the last note I wrote you was that .7 was bringing her PSes down slowly except for the odd morning. So here is what I *might* have done with some of your recent numbers and not any appetite differences or changes:

351 .7
312 .7
272 .7
242 .7
348 .8
247 .7
178 .65
259 .7

My thinking is that .7 seems to bring her down almost perfectly slowly [with the exception of some oddities]. .7 seems to bring her down maybe 30 points at a time? Maybe .65 might be the number to hold her steady? Bringing them down slowly is like betting at the roulette table - you bet with what's hot and not against the table: if a certain dose is taking you in the direction you want than stick with it and over time it will take you where you need to go. But when the table changes then you need to change your bet. Not sure if that's the best metaphor or not?

BUT, obviously the world is not perfect and S has a variable appetite and many other things that could raise or lower her numbers at the time. So you will have to take that into consideration which I cannot in my above sample since I'm not there to observe.

But basically if she is not eating much and the numbers are going down on a dose that would have normally held her PSes steady or brought them down, then you would need to start backing off on the dose a little. Then when the appetite kicks back in, and their numbers start to go back up then you have to follow them back up with the dosing but trying not to get too aggressive hopefully. As the appetite waxes or wanes so will that expected dose that you would expect to hold the PS steady from PS to PS. I always felt like I was 12 hours behind but even with that feeling things generally worked out OK.

And obviously you have to take the nadir into consideration so that you do not go too low.

Since I did not test at night I tended not to make any "risky" moves at night - or I might just play it safer at night if I were debating doses. Is any of this making sense? Please let me know if I can help clarify. I know I'm probably not doing the best job explaining things. Also You might want to search out "variable dosing" or "VDS" in the PZI forum and see if you find anything worth reading. I don't think I've really had anyone ask me super detailed questions though before about it.

And I encourage you to take what input of mine that works for you and do your own riff on it and toss out what does not work. Also do not hesitate to PM me if needed - but I am expected to be at the computer infrequently until perhaps the end of Oct.

You can also *try* to study our old ProZinc SS to see how we did it. I generally was happy to keep the PS's under 200 and very happy to keep them under 150-160. https://spreadsheets.google.com/ccc?key ... XYwVFJ4M0E
Since I was one of the first ProZinc users here I tried to make the SS as informative as possible to others and included weights and some appetite notes so others might be able to follow my decision making process.

 

[judy and squamee(GA)]

Thanks, Gator. As usual, most helpful.
Am struggling with pilling her. She has refused the pill pockets (she nicely waited till Monday night when we returned from our weekend away---so she didn't spoil my weekend!), and I am back to putting the phenobarb down her throat, but I sometimes find tiny bits of it on the floor. I am syringing the gabapentin into her mouth, and not sure how much she gets. I am looking for a pharmacy that compounds phenobarb--the one we got the gabapentin from does not. THe vet has me holding the dose of both of them stable while we observe her dopey-ness. I am not sure what he plans to do about increasing the dose, have to talk to him at the end of the week. I have the impression that the phenobarb is more effective than the gabapentin, tho I am not sure why I think that. At present, she is able to eat, but struggles with the mouth symptoms after she is eating for awhile. Keeps remindiing me of people with ill-fitting dentures, but I guess the dental specialist would have picked it up if there was something structurally wrong with her jaw.

 

[Gator & H (GA)]

most helpful

lol I hope so. I know the video sort of makes sense to me, I just hope I'm telling the story right.

Am struggling with pilling her.

I have no idea the struggle you guys must be facing. All I can do is sit in my armchair here and say to try to get that thing in there and wash it down with some water if possible. I can only imagine how frustrating it must be. I'd just say keep at it and see if you both might be able to get better at it. I think I mentioned before that I get on my knees on the floor and kind of sit on my feet that are closed in a V shape. Then slide kitty into the open side of the V with kitties head pointing out the open side of the V. That will trap them and allow more efficient use of the hands. Sometimes I'll set up my pills and syringe with water in a spot on the floor, then grab kitty and take them to that spot.

I think you had mentioned you had tried the old crushing and putting in the food trick. And I think you mentioned that you think the water chaser is bad for her symptoms -- grrr. Sure would be good if you could work out the water chaser - that would ensure the pills went down.

If you have a total crazy cat on your hands there are cat straight jackets or immobilization jackets. But one can basically achieve the same objective with a large towel by wrapping it around them and their legs with just the head sticking out. I can only imagine what that would do to the old BGs though. :roll:

Are you on your own or have a helper available to you?

THe vet has me holding the dose of both of them stable while we observe her dopey-ness.

I agree with this to a point. I think Nancy even said something about the gab taking a little while to show it's effects. It is like the buprenorphine - even in humans the opiate "high" wears off but they will remain effective at killing the pain. So *perhaps* from a building up a 'tolerance' standpoint it may be beneficial to continue a dose that initially makes 'em a hair dopey. On the other hand, I just had the recent experience of opiate nausea I would not wish that on any kitty. As much as is within reason, I'm an advocate of trying the drugs we give our kitties just to understand what they may be facing since they can't talk.

Keeps remindiing me of people with ill-fitting dentures, but I guess the dental specialist would have picked it up if there was something structurally wrong with her jaw.

F was grinding his teeth until we just got the extraction done. :roll: F is doing a little better with the eating now [but still has some major issues going on sadly].

What is the Facial Syndrome you guys are dealing with? Can you provide me some reading on it?

 

[Gator & H (GA)]

Darned 4am thoughts! Hope this one was worth getting out of warm bed for...

Forgot to mention that one of my more important tenants to variable dosing is that things tend to work on a moving average of maybe 10 days or whatever interval works best. So basically the older the data the less relevant it becomes or the less it should be factored into your current decision making. Just because kitty went down Z on a dose of X with a PS of Y two months ago, really shouldn't have much of nothing to do with a dosing decision today. It really is about the current trending.

And I think as long on one can stay relatively conservative and make small[er] dosing changes [particularly when the BGs go up] then the danger of making dosing decisions are lessened. I would always recommend that a bean be aggressive about lowering the dose if they felt necessary. Ultimately, if dropping the dose aggressively does not work as planned then that experience can be cataloged for later.

Hope that video makes more than 4am sense?

 

[judy and squamee(GA)]

Gator, you are being so terrific about trying to do everything you can to help me and explain things to me!!! I am really touched. But you mentioned a video? I am at a loss--what am I missing? I am not aware of you sending any info about a video.
How do you do the water syringe when you are pilling? If you are holding the cat's mouth shut to keep them from spitting the pill out, how can you pick up the syringe and put it in the mouth? GIving the pill this AM went pretty well (if it actually went down) and tonight was hell. She spit it up 4 times and I gave up. An hour later I burrito-ed her and put clothespins down the scruff of her neck and my husband held her and I got the pill down her, and I THINK she swallowed it. THe problem is that she vigorously shakes her head around when I am trying to put the pill in her mouth. I am asking the vet tomorrow to order me compounded liquid suspension of phenobarb from a pharmacy in Oregon.
Her jaw problem was terrible tonight. She kept trying to eat and drink and could not. About and hour and a half later, she was able to eat. I don't know if it is the meds or the episode just passes. THere is a site for Feline Orofacial Pain Syndrome , it is at www.felineorofacialpain.com

 

[judy and squamee(GA)]

Gator, I forgot to ask how F. is doing. Squamee had 2 teeth extracted when all this started (this round, that is), but it didn't seem to have much of an effect on her.

 

[Gator & H (GA)]

The "Video?" lol You started with the "video." I wrote you a very detailed description of something, as I have a tendency to do, and I think you said "thanks for the video" or something like that. I thought it was an apt description for my detailed sometimes imagery of the how-tos. Plus I have have a thing for "video." Like "X person was all up in my video" [like when a person is being annoying on a personal level].... anyway. And I kind of see it as 'video' when I write too.

Good to hear you have a helper.

Water/Syringe:
They should have about 3ml of water after any pill. It should hopefully be done as slowly as possible so they hopefully do not aspirate water into their lungs. I like using a 3ml syringe and fill it with water. You can ask a pharmacist for a 3 ml syringe. Some compounding pharmacies have good ones for syringing cats. One type is called "luer lock" which has threads and the other is luer slip which does not have threads. I like the luer slip ones for syringing. I hate the eye droppers type. After the pill I syringe it in. I'm right handed so [for a difficult kitty] I set up the pill and the syringe on my right of where I will set up on my knees. You should not need to hold the mouth closed if you get the pill down far enough. When the pill gets down far enough they generally have a hard time getting it back up. The water just makes sure it goes all the way down. And makes sure they do not have the chance to work on getting it back up. I have large fingers [even for a man], I always feel bad about working my big fingers in a little kitty mouth. My point is that I'm almost positive your fingers are smaller than mine so don't feel so bad about getting them down in that little kitty mouth. Remember how I talked about the swipe from the side rather than the poke down the middle? When I do it my finger lines up like a fish hook from the side and not a pointer, pointing straight down their gullet. Things have to go quick or you will drop the pill and all sorts of things go wrong. It's kind of a sports psychology thing - envision yourself doing it with success before you do it. Envision exactly how it will go - all of your movements, all of her movements. Then it will almost be muscle memory even though you really don't have the muscle memory. Sounds a little crazy I know. From my experience it is pretty much a one person job since it goes so quick. I make it sound easy and I know it is not for you guys.

Maybe there are some piling videos that you could sample to see if saw any good tips?

Water is ultra non-toxic so maybe you can just practice with the water?

Good to hear you are willing to take a break when things get too frustrating. I have a tendency to lose perspective. :roll:

Those real videos of FOPS are horrible. :YMHUG: OMG this must be so hard for you. Wow. I just wish I could come over there, wave my wand and make it go away for her. The powerlessness we feel with some of our kitties issues...man.

The trigger is eating? Feeding tubes are no fun and require maybe 3-5 feedings per day. Not sure if that is a reasonable route. Are there any 'experts' on FOPS here in the US?

I know I've mentioned Cornell to you before and I know it is not close. However, they do have a fairly unique service where you can consult with them by phone for a fairly low price. I can find more info for you on that if needed. I mention them so much because they are known for their focus on kitties. There happens to be a sad story about one of their originating vets who loved kitties so much dying in a traffic accident when he swerved to get out of the way of a cat in the road. *sigh*

Do you have a copy of her oral radiographs [x-rays]? [mental note to get copies (most are doing "e" these days) of ALL imaging (x-rays, ultra sounds, MRI, CAT etc.) ]. Then you might be able to send via "e" to a phone consult with Cornell Board Certified dentist maybe? I don't know - maybe I'm just talkin' crazy talk. On a personal level, I'd just like to see you guys get a second opinion on the work that has been done on her mouth. But I know you have your own battles to fight.

My trust level of vets is in the negative territory - maybe it's just a personal thing. I have many angry tirades I could go on about vets which won't do you guys any good. :evil:

F is doing better - eating more. He's got IBD and was having the sh*ts for a week. We started metronidazole and that seems to have gotten a grip on things (for now). He is so thin and weak from the spinal nerve degeneration. I've had to re-learn a bit doing SubQ on him since he is so thin. Most cats have a layer of fat beneath their skin - he does not so I have to make sure when I tent that nothing but skin is in the tent. *sigh* He is still doing a little bit of the head moving around and trying to grind his teeth when he eats but it is better and he has been visibly feeling better since the last extraction.

 

[judy and squamee(GA)]

Hi Gator,
Have , at the moment, suspended the pilling. I got liquid suspensions for both meds---but she is fighting that too, and this morning after the meds, had a long thread of white colored drool hanging from her mouth---so I don't know how much she got and I am not too optimistic about what will be tonight. (and these are EXPENSIVE!).
I was thinking about your description of pilling--I know I do not put the pill far enough down her throat, but she is so vigorously shaking her head, I don't know how I can. And it's not clear to me how you hold the pill. Doesn't it take 2 fingers? I hold her head with my right hand, and hold the pill with the thumb and pointer of my left hand, and then use my middle finger of left hand to pry her mouth open. That means I am putting 2 fingers in her mouth. I am not clear how you do the fish hook---altho I get the idea of the swipe from side to side rather than just down her throat---but I am holding onto the pill with the 2 fingers, how do I swipe?

I have ordered a "pill-shooter" online ---maybe that will help.

I so appreciate your looking at those videos of FOPS. And I have to tell you, those are mild compared to what she does---it doesn't show you so much how she paws at the sides of her face. It is just awful to see.
THank you for your magic wand wishes---I have the same wish for F--and am glad to hear he is doing better--he is SO lucky to have someone as dedicated to him as you are!

I have thought about second opinions, and looking for experts, and contacting Cornell and hate to tell you that what ultimately stops me from proceeding is the expense. I have discussed it with my vet, who was willing to make a referral to a neurologist, but he said the course they would follow would be a CAT scan and MRI (which is what the dental specialist had said ) and those would cost more than a thousand dollars. Also, since she had a seizure a few weeks ago, that complicates the scenario. He said it might be a brain tumor or cancer---and I am not willing or able to go forward with brain surgery or chemo, so I came to a halt. (just to be clear--the FOPS is not a diagnosis, it is a syndrome, that is, a description of a group of clinical symptoms. Assuming it is a form of trigeminal neuralgia, they do not know what has effected the nerve. And to make this more awful, I know a person who had trigeminal neuralgia and tells me it was unbelievably excruciating.)
I do not have her dental records (altho I had asked them to send them to me) but have not pursued that, since I have no current plans to go for a consultation. So I am stuck in this miserable place, unable to really go forward, and trying to make her as comfortable as possible.

 

[Gator & H (GA)]

I think I also forgot to mention that with my "variable dosing" I did not take time into account too much. So if I was late or early shooting [most usually not more than ±1 hour and almost always not more than ±2 hours] I really did not factor that into the dose too much and I did not record that into my SS. Again it was much more focused on what the PS was and where I wanted it to go. Also, some here will wait or shoot early if they want to adjust how that particular dose might work out and that is something I never did. Waiting or shooting early is more for those that do consistent dosing variants. But who knows, you may even work your own hybrid.

I also thought I would mention that some here [including myself] might consider some of my techniques in the "bad habits" territory. For instance letting my shot time slip around I think is not the best practice in theory - but ultimately it worked out OK for us and what our goals were.

For better or worse, much of how I did things was self taught and not part of the regular program here. Back when we started I was home testing but going by the dose the vet said to go with. I caught him with a PS of 100, withheld that dose then just started dosing on my own without getting dosing help here [partly because we had other bad habits going on too] - trail by fire style. It was crazy nerve racking. @-) Luckily, H cooperated and made things go pretty quick.