10/23 Tiggy AMPS 110 +4 128 - dose increase again sigh

[Wendy&Tiggy(GA)]

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Up down up down swinging around..... Maybe 38 isn't quite low enough for a dose decrease in the first place.

he seems fine though - still got diarrhea but seems happy and playful. Was knocking a blue ball of fur around my feet as I was trying to make his brekfis.

Wendy

PS Pikachu isn't doing so well today - seems to be in quite a bit of pain. Its expected I guess even with painkillers but I feel bad for the little fuzzy. She's eating ok though.

 

[Dale 'n' Chip]

We need the cut off point somewhere and I think 39 is good for the mandatory reduction.

However use a little common sense. Like don't take 2 reductions in a row when the 2nd is sure to fail. Or if there may be a good reason for another low number, take that into consideration. Chip gets a lot of 30's and I treat upper 30's a little differently than low 30's.

But the mandatory reduction is *mandatory* for a reason and really needs to be taken seriously. As Jill says if you don't want the reduction for some reason, then steer around it. I don't always get that done perfectly in practice, but I think it is the best approach if only to demonstrate that *you* control the numbers. Not the other way around. :smile:

One other thing to keep in mind is that "returning to the last good dose" is the one time you don't need patience. You can immediately return to the last good dose after as few as a few cycles if you get a bad feeling about it. About the worst thing that can happen (as long as you monitor) is he earns the reduction again right away.

 

[Wendy&Neko]

Out of curiosity, why are you increasing? He had an all green day yesterday and got a 56. That would seem a pretty good dose to me.

 

[Wendy&Tiggy(GA)]

I am following Tilley protocol so because I am still getting numbers over 200, and it's been 10cycles, he gets an increase... Right?

Wendy

 

[Dale 'n' Chip]

It wouldn't be an "increase" proper, just returning to the last good dose, 5.5U.

I think there is plenty of room to do that, you don't need to wait or count cycles in this case.

 

[Chris & China (GA)]

Just another country heard from...I'm not sure I'd go back to 5.5 just yet...maybe a fat 5.25?

The protocol says increase if nadirs are above 200, but below 300 go up .25 but I only see 2 "above 200's" in the last 10 cycles

Of course it also says if they are "less than 200" for 10 cycles you can go up .25

That's always been a little confusing to me...I guess they mean on the first example (below) you're holding the dose for more cycles before taking the increase again?

Increasing the dose:
Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

 

[Dale 'n' Chip]

...The protocol says increase if nadirs are above 200, but below 300 go up .25 but I only see 2 "above 200's" in the last 10 cycles

Of course it also says if they are "less than 200" for 10 cycles you can go up .25

That's always been a little confusing to me...I guess they mean on the first example (below) you're holding the dose for more cycles before taking the increase again?

Increasing the dose:
Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

True but what Tiggy is doing here is Tilly (Roomp/Rand) which is fundamentally different than the modified approach used by most here. :smile:

With Roomp/Rand you don't wait around on bounces, at least not longer than 7 days. Instead if they can't maintain numbers between 40 and 200 they get an increase. Or a reduction for a long term diabetic dropping below 40 of course. This is the same approach I'm using with Chip. nailbite_smile

If nadir blood glucose concentration < 200mg/dL but peak is >200mg/dL (11 mmol/L)

Increase every 5-7 days by 0.25-0.5 IU depending on if cat on low or high dose of insulin

 

[Chris & China (GA)]

OK thanks Dale!

There's always something to learn about this dance! ...this whole adventure seems to be one long learning curve...it's pretty steep at the beginning, but there's always more to learn

 

[Dale 'n' Chip]

The primary reason I got started down that path was because I didn't understand the modified protocol.

Of course Neko may convince me to try it someday yet. ;-)

 

[Wendy&Neko]

Good luck with your increase Wendy. I hope your bunny feels better soon. She's probably hurting from the surgery.

Chris - One difference is that in TR we dose based on the nadirs and try to ignore the bounces, whereas Tilly does consider all the numbers. It can be a little more aggressive protocol so not for everyone.

 

[Libby and Lucy]

oh boy, I am confused. :?

our modified protocol and the Tight Regulation Protocol (the one some of you are calling Tilly) are the SAME THING. Think of the modified protocol as a "best practices" document. You know, when you're at work and you have a process to do, and you think "if I just tweak this one little thing, the whole process works better for me." That's it, the modifications are tweaks, "best practices" based on what we have observed to work well in the majority of circumstances. Note that I say the majority of circumstances, not ALL circumstances. ;-) Some of the tweaks are more aggressive than the original protocol, and some are actually a bit less aggressive. The modifications were based on observations of the hundreds of cats that have gone through this board in the last 6-7 years. Admittedly, I have not been on the board very much lately, so perhaps this is not the way it has been taught recently.

Any protocol is simply a tool to help you get from Point A to Point B in a way that is likely to be successful. The protocols are a way to get most cats' numbers into a good range quickly, and they are also a tool to help the caregiver learn his/her own cat's responses to food, insulin, and other factors. Following the protocol is highly recommended for new caregivers because it works, and because it is a safe way to learn.

Once you are no longer new, you are going to find some tweaks that work better for your own cat. You'll be able to do this because you know your cat and his responses. These tweaks are not written down because a) they are individual to each cat, and b) really the only people who should be more aggressive than the written protocol are caregivers who are experienced enough to figure out those modifications on their own, and take responsibility for whatever happens. If someone has to advise you to deviate from the protocol, then you may not be ready to tweak just yet.

Example - Jazzy was well regulated in blue/green forever. When she started getting yellow I nudged her dose upward a bit, sometimes even when her nadirs were fine. Sometimes that worked out well, sometimes it proved to be a very bad idea. I did that not because some protocol says to, but because I thought it would work based on her past responses, and also I knew that if it proved to be a poor decision, I would do whatever it takes to keep her safe. Stay up all night, go to ER, whatever. If I make a poor decision for my cat, it's my responsibility to fix it. I'm not going to suggest something to someone else if my suggestion carries a strong likelihood of sending them to ER, though.

A more specific comment on dosing: just because the protocol says you *can* adjust the dose after a certain number of cycles doesn't mean you *have to* adjust the dose then. If I see a cat (new or old) with a nadir in the 50s, I'm going to think "hmmmm, I wonder what this kitty has planned for this dose." I'm going to want to wait and see. To me, it doesn't matter if it has been 6 cycles or 26 cycles, if I think there is still action left on a dose then I want to wait and see what it is. If I think we've seen all that we're going to see from that dose, then onward and upward. Some bouncy cats benefit from raising the dose aggressively to help them overcome the bounce, some bouncy cats benefit more from sitting still and letting things settle a bit. Some cats benefit from more carbs, some from less, etc. Experience will help you figure that out.

 

[Dale 'n' Chip]

Thanks for jumping in here Libby.

I guess if we are going to call them the SAME THING, perhaps we should clarify the important differences. Confusing to me was/is the talk here in Lantus Land about ignoring bounces and the Roomp/Rand goal of keeping the cat between 50 and 200. I consider that a fundamental difference; either keeping the cat below 200 or letting them bounce for long periods and ignoring it, without *much* consideration given to peak glucose.

I should probably also mention that the TR protocol I keep referring to is not the "modified version" that can be found as a sticky on this board - there are differences.

Kirsten Roomp said that a few years ago and ever since I stumbled onto that I've been curious about her thoughts on the significance of the differences. I keep meaning to ask Jill and yourself but there is always more pressing issues to discuss. :smile:

While you are here what are your thoughts on Tiggy? I keep pondering how much patience is needed and I keep thinking less since Tiggy seems to be one of those cats Kirsten refers to in several places (including the linked post) that may be more stable with "tighter" regulation. Apparently much like Chip. Give them just a little too much "zen" (because of the good nadir) and the dose apparently needs to go back up.

 

[Libby and Lucy]

This is getting off-topic with regards to Tiggy (sorry Wendy!), but I can't resist a good teaching/learning moment. :mrgreen:

Thanks for jumping in here Libby.

I guess if we are going to call them the SAME THING, perhaps we should clarify the important differences. Confusing to me was/is the talk here in Lantus Land about ignoring bounces and the Roomp/Rand goal of keeping the cat between 50 and 200. I consider that a fundamental difference; either keeping the cat below 200 or letting them bounce for years on end and ignoring it, without *much* consideration given to peak glucose.

I think it's important to distinguish between what the protocols say and what has become practice in LL. ;-) Often they are not the same thing, sometimes for good reason and sometimes I'm not sure. :lol: I think what happens is that somebody sees something that is suggested to someone, sees that it works for that cat (or their own), then suggests it to others without always understanding WHY it worked in that situation. Then all of a sudden it has become a "rule." VERY often these days when I visit a condo, I see something mentioned that leaves me scratching my head.

New cats *should* ignore bounces, for the most part. Early on in the dance, if a cat is spending time in the 70s then they are probably also spending a lot of time in the 300s. You don't want to let those highs distract you from the overall picture. If a cat has been "bouncing around for years on end," then we need to be looking for reasons why the cat is still bouncing and figuring out how to make the bouncing diminish. Too much insulin? Too little insulin? Food issue, duration issue, something else? That solution probably does not lie within any protocol, though the foundation for the solution probably does.

Notice that when Kirsten mentions the goal of 50-200, she includes that in Phase 3/Holding the Dose. In Phase 2, she says to stop increasing the dose when the cat starts to spend significant amounts of time in the 50-80 range. She doesn't even mention 200 here, just the nadir. In Phase 3, assuming that a cat is pretty much stabilized on a dose, then "periodic slight adjustments are necessary in many cases" in order to maintain the ideal range.

Of course, you also need to use common sense. At one point Lucy was spending almost all of every cycle in green, but shooting up to pink for preshot. Jill and Jojo told me to be patient, that she was only pink for a few hours each day, and that the rest of the time she was healing.

I should probably also mention that the TR protocol I keep referring to is not the "modified version" that can be found as a sticky on this board - there are differences.

Kirsten Roomp said that a few years ago and ever since I stumbled onto that I've been curious about her thoughts on the significance of the differences. I keep meaning to ask Jill and yourself but there is always more pressing issues to discuss. :smile:

Jill can probably address this better than I can. IIRC, the biggest thing is letting cats go below 40. She says to keep the cat above 50, and in our modifications we allow for 30s in some cases. We also tend to look for a lower ideal range - Kirsten says 200, but we tend to push for more like 120-150. The Tight Regulation Protocol doesn't really allow for dose shaves, and we open the door for them for some cats.

While you are here what are your thoughts on Tiggy? I keep pondering how much patience is needed and I keep thinking less since Tiggy seems to be one of that cats Kirsten refers to in several places (including the linked post) that may be more stable with "tighter" regulation. Apparently much like Chip. Give them just a little too much "zen" (because of the good nadir) and the dose apparently needs to go back up.

I don't want to comment on dosing until I have had a chance to study, so I'm going to put off answering this question for now. Sorry! Will try to come back after work.

eta: I see now that you linked the published version of the TR protocol in one post. That one does mention increasing if peaks are over 200. Since you said "Tilly," I was looking at tillydiabetes.net. Same, but different. ;-)

 

[Chris & China (GA)]

I have nothing useful to add to the discussion other than I sure am glad I asked about the differences in how Wendy & Tiggy were dosing, and the modified TR protocol "most" of us use

This is becoming a very educational thread!!

Thanks for the explanations everyone!

 

[Dale 'n' Chip]

...Notice that when Kirsten mentions the goal of 50-200, she includes that in Phase 3/Holding the Dose. In Phase 2, she says to stop increasing the dose when the cat starts to spend significant amounts of time in the 50-80 range. She doesn't even mention 200 here, just the nadir. In Phase 3, assuming that a cat is pretty much stabilized on a dose, then "periodic slight adjustments are necessary in many cases" in order to maintain the ideal range.

Of course, you also need to use common sense. At one point Lucy was spending almost all of every cycle in green, but shooting up to pink for preshot. Jill and Jojo told me to be patient, that she was only pink for a few hours each day, and that the rest of the time she was healing.

I think Roomp/Rand mentions 200 in about every phase.

Phase 2: Increasing the dose: If nadir blood glucose concentration < 200mg/dL but peak is >200mg/dL (11 mmol/L) Increase...
Phase 3: Holding the dose: If nadir or peak blood glucose concentration > 200mg/dL (11 mmol/L) Increase...
Phase 4: Reducing the dose: If peak blood glucose concentration > 200mg/dL (11 mmol/L) Immediately increase insulin dose to last effective dose!

I suspected that is a feature of Roomp/Rand; to "dose" depot insulin in an innovative (but perfectly safe) way to "breakthrough" and suppress bouncing. The reason I got onto that notion in the first place was because when I was floundering around outside of Lantus Land, the few I was talking to told me the way to stop bouncing was through reboots, rebound checks, or otherwise persistently lowering the dose. Didn't work very obviously. My last ditch phone-a-friend lifeline was Julia. I asked her about the modified protocol in the stickies. She told me not to worry about it, instead to use Roomp/Rand as she had successfully with Bandit and two other cats she took OTJ. The most important thing Julia said at that time was that the overall goal was to keep the cat between 50 and 200. :idea: Prior to that point I had been attempting to ignore bounces and dose to the nadir without much (any?) luck. Of course Chip was not newly diagnosed by that time.

I didn't realize there was no shaving in Roomp/Rand except at the end of phase 4? They do seem to mention 40-50 in several places, even a variation on split dosing. I guess it's never a bad idea to review the published protocol again and often. ;-)

I totally agree that those newly diagnosed should not focus on bouncing. But I've always wondered about those who seem to stick with that long term under cover of the modified protocol. And if a reason for bouncing might be too much juice (I don't mean an undetected low or a wild swing) that makes me wonder about Chip? His bounces when he loses it are exceptionally harsh. Wonder if there is any *safe* zen approach that may be effective with Chip to get the dose down? Safe as in no ketones, glucose toxicity, and/or increased resistance. And of course back on topic, I wonder the same thing about Tiggy. :smile:

 

[Libby and Lucy]

I think Roomp/Rand mentions 200 in about every phase.

Phase 2: Increasing the dose: If nadir blood glucose concentration < 200mg/dL but peak is >200mg/dL (11 mmol/L) Increase...
Phase 3: Holding the dose: If nadir or peak blood glucose concentration > 200mg/dL (11 mmol/L) Increase...
Phase 4: Reducing the dose: If peak blood glucose concentration > 200mg/dL (11 mmol/L) Immediately increase insulin dose to last effective dose!

ok, I reread that version of the TR protocol. :smile:

Essentially we are all saying the same thing:
If nadirs are over 200, increase every 3 days
If nadirs are under 200, slow down. Increase only every 5-7 days when needed. The main difference is that they say if highs are over 200, keep increasing. We slow down a bit more at that point.
If the cat goes below 50, reduce.

My thought is that increases with lower nadirs need to be handled carefully and only by someone who has enough experience to know that it is ok for their cat. With a cat like Lucy, the cycles when she had pink preshots were the cycles when she was most likely to drop low. She liked to visit pink, but she didn't stay there! Sometimes it was hard to stay ahead of her numbers even without a dose change. I think if I had increased just because of a pink preshot, then the momentum of dropping from pink combined with the momentum of a dose increase could have been disastrous. Fine for a cat like Jazzy, not for a cat like Lucy. Know which type of cat you have. ;-)

I suspected that is a feature of Roomp/Rand; to "dose" depot insulin in an innovative (but perfectly safe) way to "breakthrough" and suppress bouncing.

Could be, but I'm not sure I can go along with the "perfectly safe" due to Lucy's example. I wonder if this was one of Rand's contributions to the protocol. It hearkens back to her previous protocols. Maybe I'm overly cautious, but in my opinion some very effective approaches aren't all that appropriate for treating over the Internet.

The reason I got onto that notion in the first place was because when I was floundering around outside of Lantus Land, the few I was talking to told me the way to stop bouncing was through reboots, rebound checks, or otherwise persistently lowering the dose. Didn't work very obviously.

It usually doesn't, in a cat that has been brought up the dosing scale honestly. To be fair, with my two adopted kitties I did drop their doses back when I got them. I had reasons - limited testing with their foster mamas, no data on their past dose changes, change in insulin from a compounded PZI (unsure of how potent it was) to Levemir, change in diet, relocation to a new home... I already suspected Jazzy was acro, so I knew I would need to fast-track her dose back up and I did. With KK, I had no idea, and the lower dose proved to be a good thing. I was prepared to fast track again if necessary.

I didn't realize there was no shaving in Roomp/Rand except at the end of phase 4? They do seem to mention 40-50 in several places, even a variation on split dosing. I guess it's never a bad idea to review the published protocol again and often. ;-)

40-50 yes, but to them <40 is to be avoided. Here, for some cats <40 is a goal. I'm not sure how I feel about that (even though that is what I did with Lucy), but that guideline came about because it does seem that most long-time diabetics need to earn reductions more convincingly before they will hold.

I totally agree that those newly diagnosed should not focus on bouncing. But I've always wondered about those who seem to stick with that long term under cover of the modified protocol.

I wonder about that too.

And if a reason for bouncing might be too much juice (I don't mean an undetected low or a wild swing) that makes me wonder about Chip? His bounces when he loses it are exceptionally harsh.

When I think about "too much," there is always a tradeoff somewhere. There is a reason you are giving the amount that you are giving. What is the reason, and what is the tradeoff? (and realize that I'm not talking about the dose being a lot too much, usually just a bit). For example, you may be increasing because of highs over 200 even though nadirs are good. So, you increase because you don't like the 200, but that might create even faster drops or lower numbers, creating another bounce, etc. Look at KK's last few weeks - his problem was more a lack of duration than of the insulin not being enough. The insulin brought him down just fine, it just couldn't keep him there. Increasing the dose didn't help because the amount of the dose wasn't the issue. The best solution for KK would probably have been to shoot a lower dose TID. That is a killer schedule! I couldn't do that, so I had to make do with what I *could* do (and then he snapped anyway, thank goodness). For a while I was able to feed higher carbs to keep him from dropping so much, allowing me to safely keep his insulin dose higher. After a while, though, his absorption issues made the food ineffective at controlling his numbers. It is what it is.

 

[Dale 'n' Chip]

...When I think about "too much," there is always a tradeoff somewhere. There is a reason you are giving the amount that you are giving. What is the reason, and what is the tradeoff? (and realize that I'm not talking about the dose being a lot too much, usually just a bit). For example, you may be increasing because of highs over 200 even though nadirs are good. So, you increase because you don't like the 200, but that might create even faster drops or lower numbers, creating another bounce, etc.

The original reason I kept going up (once I finally saw green on Levemir) was because I was trying keep Chip between 50 and 200. That did work but of course he failed the reductions miserably. The reason I do it now is because he seems to be more stable when I keep him lower. I didn't figure out how that worked until I started watching closely what Jill does with Alex. As for the trade offs, I do wonder. I understand why Jill needs to keep Alex below 150 at all times. But Chip is a young theoretically healthy cat. I'm not sure he really needs it so much as it's the only thing that has been remotely stable with Levemir. So I just keep chasing the numbers instead of risking ketones, or waiting out yucky high numbers. Already tried that. It's clear to me the source of his bounces is usually the Levemir. But it's also the thing that can suppress them.

Chip's liver is apparently trained to 30's so he doesn't often bounce from the nadirs. And he seldom drops too fast. Instead his bounces seem to come from the insulin itself, more like what I recognize as NDW. So I fully understand the irresistible urge to rebound check. But of course I also know too well how it nearly always ends UP.

I always suspected the more aggressive aspects of Roomp/Rand were Kirsten, I like the way she sums it up on the Tilly page. And I saw things somewhere from Dr. Rand still referencing Somogyi (with other insulins) and it appeared to be somewhat recent. But that's all speculation, we'd need to ask them.

Guess we can get back to the *related* topic of Tiggy. ;-)