10/3 Artemis AMPS 477 +4 326 +7 249 PMPS 338 +1 301

[MemberLeftDueToAbusiveMod]

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Checking back in for some advice on dosing.

Artemis seems to be having a paradoxical response at 2.75+ doses.

As you can see from the gray "notes" squares on my sheet, it has taken quite a bit of effort to be able to manage keeping Artemis totally on schedule and tracking with life being exceptionally challenging (health issues on my end) and facing new obstacles (changes to my own schedule/needs) to my ability to track as carefully as I'd like due to career. That period on the sheet may not be 100% accurate, but it is as close as it is going to get.

Somewhere between the 22nd and 25th he developed very stinky, loose stools that were a pleasure to travel with. This resolved within days of returning home on the 24th and providing a wider variety of food (he had been eating exclusively chicken and beef fancy feast pate for a while).

However, I'm not sure if numbers from (10/1) and (10/2) are reliable due to a food hiccup. I decided to splurge on a treat for him given my financial situation quickly changing.... didn't go well. I was surprised as he tolerated this Blue Wilderness food very well in the past. Was one of the best choices pre-2023. He ate the following two types and vomited after both:

10/2:
Crude Protein 10.5% min Crude Fat 9.0% min Crude Fiber1.5% max Moisture78.0% max Taurine0.1% min DHA*0.1% min. https://bluebuffalo.com/wet-cat-food/wilderness/kitten-chicken/

10/1:
Crude Protein 10.0% minCrude Fat 8.0% min Crude Fiber 1.5% max Moisture 78.0% max Taurine 0.10% min. https://bluebuffalo.com/wet-cat-food/wilderness/duck/

I'm touching base this week before traveling again for a 12-13 hour drive to take my mother to crucial medical procedures (hopefully our life doesn't change with the news of the results). Artemis will be coming as we don't have anyone who can dose and monitor his blood sugar. This trip should be much easier for tracking as no housing search or unpredictable work schedules will be getting in the way.

Then we move for work, another 2-3 day drive (20 hours total), sometime around the end of October/First of November. This will provide greater stability and less driving required for medical care, so just a little more chaos before the calm...

However, I'm concerned about how to ensure he gets his dosing at the right times on days I go to the office. I will routinely be gone for at least 10 hours and maybe up to 12 or 13. I'll also have to fly for work (up to 25% of the time, but probably less in reality) in the future. I can work from home at least two days a week. Aiming for 3.

I'm hoping I can get to the point where I'm safely able to blind shoot twice a day on days that someone is filling in for me with cat care. I might have some leeway with work hours in November and December due to holidays slowing things down, but after that all bets are off for travel and length of day. So, I'd say by January at the latest we need to be in a position where my help can simply inject and feed at scheduled times.

Anxious to hear thoughts on the current dosing and input on how to move forward given the goals and constraints.

 

[Marje and Gracie]

Artemis seems to be having a paradoxical response at 2.75+ doses

I’m not seeing that and I’m not really sure what you are seeing to make that conclusion so specifics are greatly appreciated. It looks to me like like he has a classic dive bounce scenario but you aren’t catching the lower (not necessarily low) BGs.

Certainly, vomiting can affect the BG in diabetic cats. The nutritional info on the foods isn’t helpful as they are the guaranteed analysis and to determine the % calories from carbs, we use dry matter basis or as-fed values. When looking at Dr. Lisa’s charts, which are older, both the Blue Wilderness foods are LC. Perhaps he has developed a sensitivity to an ingredient.

Honestly, no one here should or will give advice for blind shooting. We “typically” don’t do it; it’s not safe. I say typically because we have had some situations in the past where a CG has to be away for a short time and the petsitter can’t test. In that circumstance, the dose is cut way back.

But you are talking about something that might be frequent and cutting the dose way back to keep him safe also puts him in jeopardy of developing other health conditions like DKA.

Insofar as his current dose, he’s seen some BGs in the 100-200 range so you’ll want to hold the dose ten cycles from those first blue BGs. We don’t recommend dose increases when we can’t tell how low the current dose is going so with cycles where there is no testing after PMPS, we don’t know what his BG has been.

My suggestion is to switch to ProZinc insulin because it doesn’t have a depot and there is more latitude in shooting times even though it also works best when given every 12 hours. If you want to stick with Lantus, that’s your decision but I would not recommend shooting blind. Although it will make for some wonkiness, you’d be better off testing before every shot even if you had an occasional one that was late or a bit early. However, if the shot times are going to vary at least once a day, I’d seriously think about PZ.

 

[Diane Tyler's Mom GA]

@Twinkleboots
Hi Josh I was looking at your signature and it says
Glargine 7/22 (switched from Vetsulin)| TR
But on your spreadsheet you noted in the remarks section you switched to Glargine on 8-19
You might want to correct your signature to read 8-19
You have you are following TR method in your signature but on your spreadsheet up too you have SLGS
Which one are you following?

 

[MemberLeftDueToAbusiveMod]

I’m not seeing that and I’m not really sure what you are seeing to make that conclusion so specifics are greatly appreciated. It looks to me like like he has a classic dive bounce scenario but you aren’t catching the lower (not necessarily low) BGs.

He was regularly approaching 200s and sometimes 100s at 2-2.75. Since then he's been spending more time higher. I suspected he may be bouncing. What kind of specifics would be helpful?

Honestly, no one here should or will give advice for blind shooting. We “typically” don’t do it; it’s not safe. I say typically because we have had some situations in the past where a CG has to be away for a short time and the petsitter can’t test. In that circumstance, the dose is cut way back.

But you are talking about something that might be frequent and cutting the dose way back to keep him safe also puts him in jeopardy of developing other health conditions like DKA.

I anticipated someone would say something to this effect... As far as I know blind shooting twice daily is what people were doing for a long time with glargine... had a friend who did this for her diabetic cat in the 80s after getting the dose right for a good while. Lived a healthy, long and happy life. What is the actual risk of this if his diet is stable and reaction to dose is predictable? Is this something that is seriously going to happen, or is there just an extremely low risk tolerance? I have a high level of trust that if I were gone my cat sitter would be able to identify any kind of health issue (even better than me perhaps because she's very in-tune with cats - this one especially) and get him to emergency care.

I guess what I'm asking for here is a real and pragmatic take on what it means to be single, working full time, AND trying to care for a diabetic cat - this is what the vets seem to get dumped on for. However, I can see why they give the advice they do - they understand people have to juggle a LOT just to survive. Taking care of the owner is also a factor in providing sustainable, adequate care to the pet.

Insofar as his current dose, he’s seen some BGs in the 100-200 range so you’ll want to hold the dose ten cycles from those first blue BGs. We don’t recommend dose increases when we can’t tell how low the current dose is going so with cycles where there is no testing after PMPS, we don’t know what his BG has been.

Understood, but he's spending an awful lot of time in the 300s and 400s still. That isn't what I'd consider approaching any form of remission. So what if he kisses the 200 mark or high 100s for like 30 minutes to an hour? What does that really mean? The fact of the matter is that a majority of the day he still has way too much glucose circulating in his bloodstream - THAT is dangerous too, is it not?

My suggestion is to switch to ProZinc insulin because it doesn’t have a depot and there is more latitude in shooting times even though it also works best when given every 12 hours. If you want to stick with Lantus, that’s your decision but I would not recommend shooting blind. Although it will make for some wonkiness, you’d be better off testing before every shot even if you had an occasional one that was late or a bit early. However, if the shot times are going to vary at least once a day, I’d seriously think about PZ.

PZ if the shot times are going to vary at least once a day - vary by how much? 30 minutes? 2 hours? What's the tolerance/threshold? I'm not saying every day it's going to be an hour or two late if we can't blind shoot - I'm going to be working from home hopefully 3 days a week but at least 2. Then weekends I stay home frequently.

Can you elaborate on PZ? Are there any other factors that make it more appealing? Also curious how not having a depot impacts the ability to have lenience with shooting times? Working people used glargine for years right? I doubt they were able to adhere to every 12 hours religiously and as far as I know (could be wrong) there wasn't an epedemic of cats dying from DKA, was there?

Thanks

 

[MemberLeftDueToAbusiveMod]

Which one are you following?

TR as far as I know, but I wasn't comfortable bumping up dose every 6 cycles because I was missing BG readings. So TR with food except for some occasional 9% carb ff pate.

 

[Marje and Gracie]

He was regularly approaching 200s and sometimes 100s at 2-2.75. Since then he's been spending more time higher. I suspected he may be bouncing. What kind of specifics would be helpful?

Yes bouncing. You said he was having a “paradoxical” response so I just was curious what made you say that.

As far as I know blind shooting twice daily is what people were doing for a long time with glargine... had a friend who did this for her diabetic cat in the 80s after getting the dose right for a good while. Lived a healthy, long and happy life. What is the actual risk of this if his diet is stable and reaction to dose is predictable?

I’m not sure how you would know that. This site was one of the first to use glargine in cats and we’ve never supported shooting blind. I can’t address your friend’s cat….id say she was lucky. But, too many times, I’ve seen members’ cats suddenly have a nonshootable number at PS. If they hadn’t tested and then shot, their cat would have hypoed. We also had a very long-term member here whose kitty had nice, flat predictable cycles on a lower dose for a very, very long time. She got complacent and things do change. She came home one day to find him in such a severe hypo that she had to help him cross. I can’t even count the number of times I, personally, have been up all night with someone very new to the forum who shot blind because the vet said the caregiver didn’t need to test. The person’s cat would be acting weird and the person would find us in a crisis. Some of those cats didn’t survive.

Not all cats will have different behavior if their BG is low. I caught my Gracie in the 20s more than once. I was very bonded to her and knew her well and I had no clue except for having done a routine test.

Just curious but if you had a diabetic child, would you give it insulin without testing first?

I guess what I'm asking for here is a real and pragmatic take on what it means to be single, working full time, AND trying to care for a diabetic cat - this is what the vets seem to get dumped on for. However, I can see why they give the advice they do - they understand people have to juggle a LOT just to survive. Taking care of the owner is also a factor in providing sustainable, adequate care to the pet.

Here is a helpful post written by a former moderator and one of our most experienced members on doing TR with a full-time job. Many, many members have done it and do it now and they always get a PS text.

Understood, but he's spending an awful lot of time in the 300s and 400s still. That isn't what I'd consider approaching any form of remission. So what if he kisses the 200 mark or high 100s for like 30 minutes to an hour? What does that really mean? The fact of the matter is that a majority of the day he still has way too much glucose circulating in his bloodstream - THAT is dangerous too, is it not?

But you don’t have enough data to know how much time he’s spending below 200. If you had two nighttime tests (after PS) every night, and he did not come below 200 in six cycles, I’d suggest you increase but my number one rule is I don’t suggest an increase if I don’t know how low the BG has gone. I can put some data together and “see” but if there is no data in a cycle, the old crystal ball doesn’t work.

PZ if the shot times are going to vary at least once a day - vary by how much? 30 minutes? 2 hours? What's the tolerance/threshold? I'm not saying every day it's going to be an hour or two late if we can't blind shoot - I'm going to be working from home hopefully 3 days a week but at least 2. Then weekends I stay home frequently.

You could, for example, shoot at +11 one cycle and +13 the next without too much disruption but you don’t want to do it every cycle. PZ is less expensive.
With a depot insulin, the shots are cumulative so one dose layers on to the previous. That doesn’t happen with PZ in the same way,

Working people used glargine for years right? I doubt they were able to adhere to every 12 hours religiously and as far as I know (could be wrong) there wasn't an epedemic of cats dying from DKA, was there?

There are two things to consider:
—he’s your cat and you hold the syringe and pay the vet bills
—in this forum, we just do not support blind shooting; we are always about safety first and shooting blind is not safe.

I feel you are trying to justify shooting blind by what you “might” have heard elsewhere but it only takes once to endanger your cat and one episode of DKA can not only have severe repercussions for the kitty but can predispose him to future episodes. If testing is not being done at the correct times (at least PS and nadir), the dose might not be properly adjusted.

 

[MemberLeftDueToAbusiveMod]

Yes bouncing. You said he was having a “paradoxical” response so I just was curious what made you say that.

I'm getting BG levels higher than before. Higher than when we began tracking. I would call it paradoxical because it doesn't seem controlled at all, I'm seeing higher PS numbers more frequently than when I started this process and when the glargine was given at lower doses. I'm considering backing down to 3.0 for tomorrow. Is this advisable here?

Not all cats will have different behavior if their BG is low. I caught my Gracie in the 20s more than once. I was very bonded to her and knew her well and I had no clue except for having done a routine test.

I caught artemis in the 20s earlier in July before I started tracking on this sheet and using the ReliOn meter that has memory. The honey did the trick and he recovered very quickly within an hour. He was symptomatic with vomiting, dilated pupils, and strange behavior. Was really sad to see but I was happy he responded well to the honey. I have also heard in other groups (TR, I believe) that the risk and threat of hypo is overstated; hence my question about the presence of any "extreme risk averseness" surrounding hypo. For practicality sake, I simply had to ask this question. Looking back into July when I started tracking on the SS he was having better numbers with Vetsulin than with glargine. He doesn't seem to be getting better numbers at all. Anywhere. Then looking back to 1.25-1.5 units of glargine he was having better numbers. Is it possible he has been diabetic for so long that his liver is going to fight it every step of the way and not relent? For an older cat, would possibly that put more stress and wear on his body than if he were not on insulin?

I'm not sure if my glargine went bad during the trip or what. Is that possible as well? It got left out for a few hours but the temps weren't over 75 outside. Carried it inside a plastic bottle that I put inside a thermos with ice in it on the trip, emptying and re-filling it at gas stations once or twice a day.

But you don’t have enough data to know how much time he’s spending below 200. If you had two nighttime tests (after PS) every night, and he did not come below 200 in six cycles, I’d suggest you increase but my number one rule is I don’t suggest an increase if I don’t know how low the BG has gone. I can put some data together and “see” but if there is no data in a cycle, the old crystal ball doesn’t work.

So not only is it AMPS and PMPS at a minimum, it's a +6 in the middle of the night or maybe more? I'm not sure what the duration of this level of monitoring is supposed to look like here (permanent?), but that isn't sustainable in my life. I don't know what full-time working person would say it is. I'm taking on high functioning career work as an engineer, not just clock 8 hours a day job. How about just getting him a CGM implanted for crying out loud?

You could, for example, shoot at +11 one cycle and +13 the next without too much disruption but you don’t want to do it every cycle.

In other words, a 2 hour spread/delta?

PZ is less expensive.
With a depot insulin, the shots are cumulative so one dose layers on to the previous. That doesn’t happen with PZ in the same way,

So, to my knowledge the depot insulin would be more stable due to this "layering" effect right? On an insulin curve, the "onset" dimension/trough point overlapping with another administration/release of insulin would only serve to flatten out the curve's peaks and create a flatter, more predictable curve across the duration, do you agree?

—in this forum, we just do not support blind shooting; we are always about safety first and shooting blind is not safe.

Well hopefully its ok that I'm asking questions to clarify and understand -clearly- for myself what the wholistic reasoning behind these instructions is. I'm not trying to argue, I'm trying to go through a decision-making process.

I feel you are trying to justify shooting blind by what you “might” have heard elsewhere but it only takes once to endanger your cat and one episode of DKA can not only have severe repercussions for the kitty but can predispose him to future episodes.

I think your feelings are providing you with inaccurate information then. I'm not trying to justify anything, per the above. This is just a blunt, no-BS fact finding effort to get to the answers I need in order to keep my Artemis as happy and healthy as possible for as long as possible. If I have to scrutinize the instructions and methods provided in any community support group or by any vet in order to do that, then I will. With all the different camps and opinions out there on feline health, I feel I'm within my full right to do that in order to advocate for my cat. If I don't fully understand it then I can't impliment it. Whatever I can find that I know will effectively treat Artemis and will actually be sustainable/work for me and allow me to maintain my own health/effectiveness is best for Artemis. I don't care what camp or forum that answer is coming from (If I did then it would be to Artemis' detriment), so I better get it straight as to what the whole picture looks like in terms of actual options and approaches. That's what I'm trying to do here, not justify blind shooting. My ability to implement *any* of this hinges on my ability to practice self care and make a *good* living as well. I *also* have special needs that need to be worked around and can cause conflict with some of the guidelines/advice given.

I'm interested to know more about PZ.

I still don't understand exactly why PZ would be a better choice for Artemis when referencing his blood glucose and considering my future constraints. I want to consider why I might switch. Can you elaborate further?

What is it about the action of PZ exactly what will be better?

What would that look like compared to glargine numbers we see on the chart? Compared to the Vetsulin numbers we see on the chart?

Can all of this be solved by placing a CGM?

Looking at Artemis numbers from July to now, it seems like he's MORE diabetic than when he started. His behavior and coat don't say that, but the numbers do. Is it at all possible that he was misdiagnosed? Only reason I'd say not is that before insulin, he was almost always famished and pestering for food. Extremely food driven and starving all the time no matter how much I fed him. He'd always eat more. It wasn't ALL the time, but he would go through bouts of it and sometimes they'd last a very long time. I was always feeding wet food after the first couple years. Usually good stuff, 9 lives as a college student but then blue wilderness, science diet d/d, or another similar higher quality brand of pate. Always pate.

 

[MemberLeftDueToAbusiveMod]

Here is a helpful post written by a former moderator and one of our most experienced members on doing TR with a full-time job. Many, many members have done it and do it now and they always get a PS text.

This is simply not realistic and I'm not sure how many people would actually be able to implement this in my situation. She says it right there in the first section that she's able to reliably get home at 12 hours post shot each and every day. No travel for this worker. This person is also able to sleep only 7 hours a day still function. Good for them. Not the case with me - I will get ill as I'm immunocompromised and very sensitive. But also notice that there was no routine NADIR testing other than "curve day". This is a part-time job on top of a full time job. It's not practical whatsoever for someone who also struggles themself and is doing good to just bring in the damn check to support sick self, sick family, sick cat. Whatever world Libby and Lucy live in sounds really relaxing and routine. I'd like that. That isn't my reality right now. Hopefully someday it will be. My only option to implement this kind of rigorous testing schedule sustainably would likely be a CGM. I have no idea how long I can expect these BG levels to continue bouncing, then (supposedly a "running" phase?) where they are being erratic and unpredictable while I chase them down stressing myself to no end.... losing sleep, getting sick, and sacrificing any bit of social life I might hope to have. All that isn't an option. I need to be able to let my help feed my cat and give him insulin without the need for the process of getting blood in the glucose monitor. Physical limitations preclude this individual from doing so regularly.

 

[MemberLeftDueToAbusiveMod]

@Wendy&Neko thinking of quitting TR back to SLGS. Go back down to 3. 0 or 2.75u. I what do you think?

Can I get your input on the above too?

 

[MemberLeftDueToAbusiveMod]

As of now, I'm deciding TR is not going to be happening for Artemis. I'm also going to give 3u instead of 3.25 today. I don't think this is the dose for him either. Back to SLGS and no more 6 cycle changes for him - I think he's been diabetic for a long time but the vets didn't catch it.

He has been drinking a LOT t the last day or two. His numbers are getting worse and his behavior is getting more lethargic and less engaged the past 24-48 hours. Eyes seem watery, glazed and squinty. He seems to have some neuropathy or poor coordination - hyperglycemia symptoms that he was diagnosed with essentially.

 

[MemberLeftDueToAbusiveMod]

@Marje and Gracie : https://felinediabetes.com/FDMB/threads/new-chronic-somogyi-rebound-myths-and-facts.281027/

If this is what is happening with his high numbers, what are guidelines for reducing dose per the following:
"Caregivers whose kitties have "High Dose" conditions may find the need to reduce in whole units or more."
on
https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/

 

[Marje and Gracie]

I'm getting BG levels higher than before. Higher than when we began tracking. I would call it paradoxical because it doesn't seem controlled at all, I'm seeing higher PS numbers more frequently than when I started this process and when the glargine was given at lower doses. I'm considering backing down to 3.0 for tomorrow. Is this advisable here?

First…I took the 911 down. That is only to be used for life-threatening emergencies. We don’t do rebound checks and reduce the dose when you have taken it up slowly and systematically. I am not seeing that he is overdosed at this point but data is your friend. The only way to know is to leave the dose and test more to catch his nadir.

He doesn't seem to be getting better numbers at all. Anywhere. Then looking back to 1.25-1.5 units of glargine he was having better numbers. Is it possible he has been diabetic for so long that his liver is going to fight it every step of the way and not relent? For an older cat, would possibly that put more stress and wear on his body than if he were not on insulin?

The answer to your question is “no” it won’t put more stress on him and if take him off insulin, he will die most likely from hyperglycemia and/or DKA and that is not something you want to see. His higher BG could be because he’s built up glucose toxicity but you have so much data missing that it’s not possible to tell. I don’t know whether the trip could have affected the insulin. I don’t know how old your pen is. The pens are made to be carried in a pocket or purse without refrigeration for 28 days but last longer with refrigeration.

So not only is it AMPS and PMPS at a minimum, it's a +6 in the middle of the night or maybe more? I'm not sure what the duration of this level of monitoring is supposed to look like here (permanent?), but that isn't sustainable in my life. I don't know what full-time working person would say it is. I'm taking on high functioning career work as an engineer, not just clock 8 hours a day job. How about just getting him a CGM implanted for crying out loud?

For someone working, we suggest always a PS, an out-the-door test, an in-the-door test, and at night, a +2 and before bed test. I worked full time when Gracie was diabetic in a high functioning career as a scientist for the federal government. Was I tired? Absolutely but I learned when I could get a before bed and go to sleep and I also learned when I had to test more at night to keep her safe. You have to figure out how to work it with your situation. I don’t know if a CGM will make it better or not. They have to be changed every two weeks, they can be glitchy. In your situation, if someone is shooting for you, it could be a help so they can see his BG before they shoot. I haven’t used one so I don’t know how often the data is sent to your phone.

So, to my knowledge the depot insulin would be more stable due to this "layering" effect right? On an insulin curve, the "onset" dimension/trough point overlapping with another administration/release of insulin would only serve to flatten out the curve's peaks and create a flatter, more predictable curve across the duration, do you agree?

Theoretically that is how the insulin would work in a cat that is tightly regulated but not in a cat who is not at his ideal dose and is still bouncing. You can’t force this. You have to realize that Artemis might always bounce.

I think your feelings are providing you with inaccurate information then. I'm not trying to justify anything, per the above. This is just a blunt, no-BS fact finding effort to get to the answers I need in order to keep my Artemis as happy and healthy as possible for as long as possible. If I have to scrutinize the instructions and methods provided in any community support group or by any vet in order to do that, then I will. With all the different camps and opinions out there on feline health, I feel I'm within my full right to do that in order to advocate for my cat. If I don't fully understand it then I can't impliment it. Whatever I can find that I know will effectively treat Artemis and will actually be sustainable/work for me and allow me to maintain my own health/effectiveness is best for Artemis. I don't care what camp or forum that answer is coming from (If I did then it would be to Artemis' detriment), so I better get it straight as to what the whole picture looks like in terms of actual options and approaches. That's what I'm trying to do here, not justify blind shooting. My ability to implement *any* of this hinges on my ability to practice self care and make a *good* living as well. I *also* have special needs that need to be worked around and can cause conflict with some of the guidelines/advice given.

Then my apologies. I’m not sure what to tell you but I understand; every single person here with a diabetic cat has had to make choices. Most work and have to make a living; many have their own health issues or family members with health issues. It’s a balancing act. Everyone sets their priorities and everyone’s are different. We can offer you support, guidance, and methods which will help you help him. But they aren’t going to work if you don’t follow them as they are written. Is there some flexibility? Yes, but not to the degree you have been doing. If you are an engineer, you know as I do as a scientist, that data is critical. If you don’t have it, you are basing actions and conclusions on nothing.

I'm interested to know more about PZ.

I still don't understand exactly why PZ would be a better choice for Artemis when referencing his blood glucose and considering my future constraints. I want to consider why I might switch. Can you elaborate further?

What is it about the action of PZ exactly what will be better?

What would that look like compared to glargine numbers we see on the chart? Compared to the Vetsulin numbers we see on the chart?

Can all of this be solved by placing a CGM?

The best thing for you to do is go to the PZ insulin support group on the board and read through all the stickys there and then ask questions. I can’t tell you what his BG will look like on PZ. Every cat is different. It just allows more flexibility in shooting but it doesn’t mean you don’t have to test. It is also a 12-hour duration insulin when used correctly. I’m going to ask Suzanne to pop by as she has used PZ. Will it be better for Artemis? I don’t know. There are some members who swear by PZ and love it and whose cats have gone into remission. Others switch to a depot insulin. I’ve already addressed the CGM.

This is simply not realistic and I'm not sure how many people would actually be able to implement this in my situation. She says it right there in the first section that she's able to reliably get home at 12 hours post shot each and every day. No travel for this worker. This person is also able to sleep only 7 hours a day still function. Good for them. Not the case with me - I will get ill as I'm immunocompromised and very sensitive. But also notice that there was no routine NADIR testing other than "curve day". This is a part-time job on top of a full time job. It's not practical whatsoever for someone who also struggles themself and is doing good to just bring in the damn check to support sick self, sick family, sick cat. Whatever world Libby and Lucy live in sounds really relaxing and routine. I'd like that. That isn't my reality right now. Hopefully someday it will be. My only option to implement this kind of rigorous testing schedule sustainably would likely be a CGM. I have no idea how long I can expect these BG levels to continue bouncing, then (supposedly a "running" phase?) where they are being erratic and unpredictable while I chase them down stressing myself to no end.... losing sleep, getting sick, and sacrificing any bit of social life I might hope to have. All that isn't an option. I need to be able to let my help feed my cat and give him insulin without the need for the process of getting blood in the glucose monitor. Physical limitations preclude this individual from doing so regularly.

well, that is judgmental because you don’t know Libby or what her life was like with a diabetic cat. While I am empathetic to your issues, we have had so many members over the years with the same ones. We’ve had members who were teachers and had long days and they used Libby’s post to help them. A moderator is a clinical Ph.D. at a teaching hospital and she had very long days but made it work. She couldn’t just walk off from seeing patients to test her cat. Other members, including me, travelled for work or to care for sick parents or both.


I’ve given you an idea of the kind of testing you would need to do and you have to figure out how that might work for you. This is your kitty and you obviously want to be responsible for his well-being so you are the one that will have to align it with your schedule. I’m just letting you know that shooting blind is dangerous and you can’t make the dosing adjustments he might need without data.

As of now, I'm deciding TR is not going to be happening for Artemis. I'm also going to give 3u instead of 3.25 today. I don't think this is the dose for him either. Back to SLGS and no more 6 cycle changes for him - I think he's been diabetic for a long time but the vets didn't catch it.

He has been drinking a LOT t the last day or two. His numbers are getting worse and his behavior is getting more lethargic and less engaged the past 24-48 hours. Eyes seem watery, glazed and squinty. He seems to have some neuropathy or poor coordination - hyperglycemia symptoms that he was diagnosed with essentially.

I’m not sure why you think SLGS will benefit him. It means he stays at higher doses longer. And if you feel he has hyperglycemia symptoms, why are you dropping his dose? He’s drinking more because his BG is higher. Does he need more insulin? It’s difficult to tell at this point but likely he does. Are you testing his ketones every day?

It looks like your dates are messed up on the SS because today is just 10/5 and you show a full day’s data. But you have an entire PM cycle on what you show as 10/4 (which would be last night) with no data.

My best advice to you is to take a deep breath, hold the dose, take a couple cycles to get some good data so we can see what he’s doing but it looks like he will need more insulin. If he has neuropathy, he needs methyl B12.

 

[Marje and Gracie]

@Marje and Gracie : https://felinediabetes.com/FDMB/threads/new-chronic-somogyi-rebound-myths-and-facts.281027/

If this is what is happening with his high numbers, what are guidelines for reducing dose per the following:
"Caregivers whose kitties have "High Dose" conditions may find the need to reduce in whole units or more."
on
https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/

This doesn’t apply to him. A cat with a high dose condition is one who is over 6u twice a day and has been diagnosed with IAA or acromegaly. We reduce those cats in larger increments because their dose is so high. We don’t test for high dose conditions until the dose is 6u twice a day.

 

[MemberLeftDueToAbusiveMod]

And if you feel he has hyperglycemia symptoms, why are you dropping his dose?

Why would I think SLGS would benefit him? I think it's pretty clear it would benefit him and I both. It is clear because these high numbers are from the bounce and I can tell he isn't tolerating this dose right now very well. He needs to go slower as he's a very sensitive cat. ECID, right?

So yeah. It will benefit him if the dose is dropped and things are taken more slowly for this sensitive 15 year old cat!... and hopefully he can stop bouncing so high for a while then increase as needed after more data - just as you suggested earlier. I believe the increase after only 6 cycles was a bad move. I think 6 cycles is just too few for Artemis. Going go back to weekly adjustments to avoid rework and complication. TR isn't going to be working for this cat, IMO. The low carb diet part, fine with both him and I. Seems he's an SLGS kind of guy in nature. Extremely sensitive in many ways. Doubt insulin and bg is any different in that regard.

Are you pushing for TR for him and I? Why?

It looks like your dates are messed up on the SS because today is just 10/5 and you show a full day’s data. But you have an entire PM cycle on what you show as 10/4 (which would be last night) with no data.

Probably is. I'll fix it. I thank you for pointing it out.

My best advice to you is to take a deep breath, hold the dose, take a couple cycles to get some good data so we can see what he’s doing but it looks like he will need more insulin. If he has neuropathy, he needs methyl B12.

Thanks for your advice. I am not comfortable continuing the 3.25u right now. Found a whisker that had fallen out on my desk where his perch is next to my computer workstation. That was the last straw. With the upheaval coming up I'm not OK with him constantly bouncing high in combination with prolonged travel and time away from home. I think it's still less stress for him than just boarding for $20 a day which I can do, but wouldn't do more than a day or two.

How is neuropathy related to b12? Is that how diabetes creates neuropathy? Depleting b12?

How would he be assessed for b12 deficiency? Blood work? Any other confirming tests or indicators?

This doesn’t apply to him. A cat with a high dose condition is one who is over 6u twice a day and has been diagnosed with IAA or acromegaly

What incriment to decrease with for Artemis then? He needs to reset at a healthier baseline for a few days. I'm not going to keep him at 3.25u.

 

[Wendy&Neko]

thinking of quitting TR back to SLGS. Go back down to 3. 0 or 2.75u. I what do you think?

You are not collecting enough data to follow TR, or SLGS for that matter. The minimum requirement is to get preshot tests, and Marje has explained above why. If you could add in preshot tests, then you could follow SLGS. If you cannot get a preshot test plus at least one other each cycle, then SLGS would be the dosing method to follow. A CGM would definitely be an option, but you'd still have to use a hand held meter to test the lows, as we have seen many cases here where the Libre tests a lot lower than the hand held. The choice of TR or SLGS is yours, provided you can follow the minimum requirements for the dosing method. People who can test enough for TR or SLGS have their own personal reasons for selecting one method over the other, and depends on their lifestyle and goals for their cat.

Instead of reducing the dose, how about getting a few days worth of more data at 3.25 units. Then evaluating what to do. So far, I don't see a reason to reduce the dose. With SLGS, you reduce if they go under 90, 101 is the lowest you've seen. The PMPS following you did see a really high number for preshot. Those higher numbers you are seeing might be as a result of the insulin dose finally able to get his numbers lower than he's used to.

Found a whisker that had fallen out on my desk where his perch is next to my computer workstation. That was the last straw

Cat's do shed whiskers, it's not uncommon.

 

[Marje and Gracie]

Why would I think SLGS would benefit him? I think it's pretty clear it would benefit him and I both. It is clear because these high numbers are from the bounce and I can tell he isn't tolerating this dose right now very well. He needs to go slower as he's a very sensitive cat. ECID, right?

Cats bounce on SLGS. He hasn’t been on this dose long enough and there isn’t enough data even for me, with 13+ years of experience, to tell you if he’s tolerating it or not. If you take the dose down, he “might” stop bouncing but he was bouncing when the dose was lower before. You are also risking increased glucose toxicity. All I can do is give you the best advice I can. If you don’t want to take it, so be it. I wish I had a dime for everyone who told me their cat was sensitive; heck, I even said it about Gracie at first and guess what? She wasn’t. It was all me.

I’m not pushing TR. It’s shown to get cats better regulated sooner and gives a much better chance of remission. Your decision.

I hate to tell you but every cat loses whiskers. It’s no big deal. My young, healthy cat loses them. It’s not a stress or health thing.

Neuropathy is caused by weakening of the nerves and methyB12 helps with that but it won’t correct it if he is hyperglycemia. He has to also be somewhat regulated but it will help a bit. It won’t hurt that’s for certain. No test but if he’s walking plantigrade, then it’s neuropathy and I’d give him methylB12. We can link a brand for you if you like but VitaCost has one.

What incriment to decrease with for Artemis then? He needs to reset at a healthier baseline for a few days. I'm not going to keep him at 3.25u.

I can’t recommend a decrease but if it’s something you want to do, best to read SLGS if that’s the way you are going.

 

[Sienne and Gabby (GA)]

I'm that clinical PhD that Marje referred to. To suggest that my hours were long would have been an understatement. I also tested to the point that I refer to myself as a "testaholic." Aside from the fact that I like data, Gabby was notorious for fast, early drops in her numbers that were completely unpredictable. To that point, she could start a cycle in the 400s, drop into the 40s, and her next pre-shot was in the 400s. If I had neglected getting tests close to nadir, I would have been increasing the dose and no doubt, overdosing my cat.

And again, to underscore, Artemis is your cat. How you decide to manage his diabetes is up to you. Whatever you decide, you have to take responsibility. I've been here longer than Marje. All we can do is offer advice based on our experience both with our own cats, with seeing literally hundreds of other cats and their spreadsheets, and basing our suggestions on a good deal of reading. I have access to both medical and veterinary libraries. We've also benefited from discussions with the German Lantus board where the data for the Tight Regulation Protocol was collected. We are not a group of crazy cat people trolling the internet. We want everyone's cat to be a success story. We are also committed to members keeping their cat safe.

 

[MemberLeftDueToAbusiveMod]

You are not collecting enough data to follow TR, or SLGS for that matter. The minimum requirement is to get preshot tests, and Marje has explained above why

Where am I not getting preshot tests?? How is it I'm not getting enough data when I'm doing all preshot tests and multiple other tests. If you'd please look at my spreadsheet you'd see that.

A CGM would definitely be an option, but you'd still have to use a hand held meter to test the lows, as we have seen many cases here where the Libre tests a lot lower than the hand held.

But the cgm measures interstitial levels which are a more accurate reflection of active insulin right? Is the only reason you use the hand held because it's capable of measuring a higher value and therefore perceived as more conservative? Or does the blood value from the ear play a stronger role that I'm not aware of?

In all the literature I've researched on cgm, they eliminate the need for these punctures that you say are still required. Why is that? And why in the world would a person invest in a cgm when there's really no benefit according to your rationale?

The choice of TR or SLGS is yours, provided you can follow the minimum requirements for the dosing method. People who can test enough for TR or SLGS have their own personal reasons for selecting one method over the other, and depends on their lifestyle and goals for their cat.

I'm sure it's more than just lifestyle that dictates the decision.. It's how they survive as human beings in this world and feed themselves and their family. As I've stated before numerous times, the only way I can afford to care for my cat in the ways he deserves is to work which requires me to be outside the house multiple days a week for at least ten hours a day. I do not have the privilege to be able to stay home all day to monitor constantly which is the only solution that's ever provided. Artemis is not replaceable, I am doing what I can to figure out how to get him proper care within my constraints.

It seems my circumstance is much different from the general population on this forum, which I have tried to explain over and over again on this forum. Please, understand that my only hope of providing for my cat, feeding him and I, and keeping roof over our heads (which we recently did not have) IS TO WORK AT THE JOBS I HAVE EXPERIENCE IN. These all require on site time each week. My job carries significant responsibilities as well.

The full time worker method linked above shows no +6 measurements regularly except for the weekend curves,right? So how is it that I'm that far off with the testing when I'm doing ps tests all the time? The future of those ps tests is what's in question, leading me to think about a cgm.

So far, I don't see a reason to reduce the dose. With SLGS, you reduce if they go under 90, 101 is the lowest you've seen. The PMPS following you did see a really high number for preshot. Those higher numbers you are seeing might be as a result of the insulin dose finally able to get his numbers lower than he's used to.

The reason is the CLINICAL SIGNS ie: behavior and health symptoms as well as continuously higher bg levels. Right? Why do I care if his bg dips for 30 minutes or so to normal numbers if over the half the rest of the time he's over 3-400?

I understand where you're coming from with strictly following the relatively short guide materials, but I'm not comfortable with the clinical signs and symptoms I'm seeing.

Marje also suggested I didn't have enough nadir data to go up earlier, so I interpret that as it's possible I went up too fast, no? So makes sense to back track and get him stable again before going back up in my rationale.

Cat's do shed whiskers, it's not uncommon.

Never seen this before with Artemis. Not once.


......


BOTTOM LINE:
1. I am following the minimum requirements you just claimed I am not following. I always get preshot.

2. I am not going to be home all hours of the day especially right in the middle of my work day for a midpoint, or at night while I'm sleeping for another midpoint. I have to make a living to survive in this world! Or should I quit my job? No one seems to absorb this fact. I'm basically being asked to sacrifice my job, my own struggling health (by losing much needed sleep hours), or my cat. Everyone must be independently wealth or taken care of by a spouse or work at home with a flexible workload. Not my case.

3. I seem to repeatedly getting answers that fall outside my previously stated constraints. There has to be workarounds and equivalencies in a diabetes management approach. Even a CGM isn't good enough to ameliorate my need for occasionally reoccurring travel and the possibility of 12+ hour days on days I go to the job site.

 

[Wendy&Neko]

Where am I not getting preshot tests??

Going back just the last two weeks, 9/23 AM and PM, 9/24 AM and PM, 9/25 PM (that was due to deliberate skip, please put Skip in the PMPS so we know it wasn't a missing entry, 9/26 AM, 9/30 AM, 10/1 AM, 10/4 PM. By my count, 8 in the last two weeks, not including the skipped dose. There were more before then. Remember, we can only go by the data you put in the spreadsheet. To me it looks like skipped preshots.

But the cgm measures interstitial levels which are a more accurate reflection of active insulin right?

You want blood sugar, which the CGM does not test, or is delayed from blood readings. People put a CGM on because it means less manual testing and more data. In cats, we have seen that the CGM registers lower values, specifically in lower numbers. Which is why I said it's good to use a manual test to verify, or otherwise you could be taking a reduction before you should. For those people, however, the CGM values are good most of the time. And allow you to be away/sleep more, knowing you can see what the cat did. Some people also find them really handy if they are going away on vacation.

I'm sure it's more than just lifestyle that dictates the decision.

Yes, some people need more sleep or have medical conditions precluding more testing, some people work odd hours, there are all sorts of reason lumped into "lifestyle". That's why it's a personal decision. Sometimes we have strategies that can help people, sometimes not. We've had lots of people work full time and follow TR, but it doesn't always work, depending on the job and how the cat uses insulin. SLGS is more the option for those people. And by the way, it doesn't always have to be midpoint data you get. With an early in the cycle test +2 to +3, that can give us a clue what is happening in the cycle.

Marje also suggested I didn't have enough nadir data to go up earlier, so I interpret that as it's possible I went up too fast, no?

I think Marje said the same thing I did. You haven't been on this dose long enough is what she said. You do not have enough data on 3.25 units to say how low this is taking Artemis. Dropping the dose if the dose is too little or just right, will just make him high and flat, which has it's own consequences. Let's see what 3.25 units is doing first (unless he drops below 90).

 

[MemberLeftDueToAbusiveMod]

I think Marje said the same thing I did. You haven't been on this dose long enough is what she said.

You do not have enough data on 3.25 units to say how low this is taking Artemis.

I'm referring to this post,

We don’t recommend dose increases when we can’t tell how low the current dose is going so with cycles where there is no testing after PMPS, we don’t know what his BG has been.

....which was later both contradicted and validated at the same time between all responses. Perhaps both are true. However, if both are true and you arrived in this situation because you feel you went up in error, then it would be sensible and reasonable to presume you should go back to the last best point? Or are you saying that I'm in gridlock at this dose until I routinely get afternoon/nightly nadirs at +6 and earn reductions back down to this dose, which I already stated I can't get without cgm? Why wouldn't I just go back to the last good place that I was at if that's actually the only option and it can't happen any time in the next month?

And by the way, it doesn't always have to be midpoint data you get. With an early in the cycle test +2 to +3, that can give us a clue what is happening in the cycle.

I'm getting these numbers...... Relatively routinely besides the trip.

 

[MemberLeftDueToAbusiveMod]

For those people, however, the CGM values are good most of the time. And allow you to be away/sleep more, knowing you can see what the cat did. Some people also find them really handy if they are going away on vacation.

OK. Then a cgm will sufficiently fix the issue. This is really as simple as all this needed to be. Thank you.

What styles are recommended? Are any smaller and less prone to irritation and disturbance?

 

[Marje and Gracie]

....which was later both contradicted and validated at the same time between all responses. Perhaps both are true. However, if both are true and you arrived in this situation because you feel you went up in error, then it would be sensible and reasonable to presume you should go back to the last best point? Or are you saying that I'm in gridlock at this dose until I routinely get afternoon/nightly nadirs at +6 and earn reductions back down to this dose, which I already stated I can't get without cgm? Why wouldn't I just go back to the last good place that I was at if that's actually the only option and it can't happen any time in the next month?

Honestly, I have no idea what your point is.

Simple:
--Wendy and I think you should hold the 3.25 dose for a few more cycles and get both PSs, an out-the-door, in-the-door, and evening a +2 and before bed. No, you won’t be able to get nadirs and we understand why you can’t. If the in-the-door test is PMPS, that’s fine. With even that much more testing consistently, we can get an idea in a few days if he needs more insulin or not.
--We don’t recommend rebound checks which is dropping the dose back when there is no evidence that it needs to be.

We haven’t contradicted ourselves. While I wouldn’t be surprised if he needs more insulin, I wouldn’t recommend it (neither would Wendy or Sienne) without knowing how low the current dose is taking him. That doesn’t mean you have to get the absolute lowest point but we are very, very good at telling what a ballpark lower number might be if we have a bit more data. Therefore, we won’t recommend and increase or a decrease at this time.

What styles are recommended? Are any smaller and less prone to irritation and disturbance?

The only one I am aware of which members use is the Freestyle Libre.

 

[MemberLeftDueToAbusiveMod]

Honestly, I have no idea what your point is

If I arrived at 3.25 in error and didn't have enough data to go up, by your previous comments I understand that I shouldn't be there in the first place. Therefore, I should go back to the last place I had good enough data to substantiate being at.

On the other hand, you say I can't reduce dose unless I've got more data in places that I can't get data.

This is gridlock in my situation.

Hope that clears things up. I was distracted when I was responding there.

Now I understand you're saying that I should stay at the 3.25 and get some more days of testing under my belt, with PS and evening plus two with whatever other data I can get in morning before work and evening read before the PS if I'm home before pmps time. Correct?

 

[Marje and Gracie]

Now I understand you're saying that I should stay at the 3.25 and get some more days of testing under my belt, with PS and evening plus two with whatever other data I can get in morning before work and evening read before the PS if I'm home before pmps time. Correct?

Yes.

We have a lot of new members who come here and the vet has been raising the dose by 1u every week quite often with little to no testing. Unless it is patently obvious the kitty is overdosed, we approach it the same way as we are suggesting for Artemis: hold the dose and collect some data.

 

[MemberLeftDueToAbusiveMod]

Unless it is patently obvious the kitty is overdosed, we approach it the same way as we are suggesting for Artemis: hold the dose and collect some data.

Ok, my plan is to hold dose at 3.25u and test every 3 hours since I work from home today and will be home for the weekend.

What woukd you consider patently obvious overdosing?

 

[Marje and Gracie]

Ok, my plan is to hold dose at 3.25u and test every 3 hours since I work from home today and will be home for the weekend.

What woukd you consider patently obvious overdosing?

One that comes to mind, the vet had advised increases of 1u every week and when the caregiver came here, the cat was in 10u bid. The BG was very high (black) and he was inky testing PS. Once we got him testing more, there were precipitous drops way below what was safe.

I do not see that in Artemis’s SS for data available. Thanks for being willing to hold the dose and test a bit more so we can help you sort it out.

I would also recommend you post a new condo every day per forum rules and please remember to link the previous condo. Thank you.

 

[MemberLeftDueToAbusiveMod]

I worked full time when Gracie was diabetic in a high functioning career as a scientist for the federal government.

Oh that's really cool. I'm also a federal employee. I'm an engineer for the Department of Defense. I do fire protection engineering and mechanical engineering design, review, testing, and supervision of work. I supervise the work of many individuals and am responsible for life life safety and protection of our assets. Peoples lives depend on my ability to make taking care of my diabetic cat as low impact as possible to my life and own personal health challenges. I'm coming back to this field and must ensure my mind is clear and my health issues in check.

So, that being said maybe there's just a little difference between whining about being tired and actually needing to ensure that this doesn't interfere with my critical professional responsibilities. My health challenges and sleep requirement are more impactful than just "being tired" as you state. That equivalence is actually quite devalidating and one of the most frustrating parts of living with my set of exposures and my conditions. I also care for a family member with health challenges on a daily basis. So let's not get into "they were able to do it, so why can't you?". Not going to help. I only ask for practical advice and clear communication on where the border between must and should is located. Flexibility wherever it exists will need to be identified. I would appreciate it if points of flexibilty were clearly presented to me without having to go through all of this. It should be obvious by now that I am not going to be one of those people who can implement the protocol perfectly.

 

[MemberLeftDueToAbusiveMod]

I would also recommend you post a new condo every day per forum rules

Is this absolutely necessary? Flexible with should or must? Its just one more hoop to jump through when it's already a struggle.

 

[Marje and Gracie]

Is this absolutely necessary? Flexible with should or must? Its just one more hoop to jump through when it's already a struggle.

It’s a must. We have many members here and limited volunteers so if everyone did whatever they wanted, we would not be able to keep track. It’s been the policy her since long before any of us were here and it works.

 

[Marje and Gracie]

Oh that's really cool. I'm also a federal employee. I'm an engineer for the Department of Defense. I do fire protection engineering and mechanical engineering design, review, testing, and supervision of work. I supervise the work of many individuals and am responsible for life life safety and protection of our assets. Peoples lives depend on my ability to make taking care of my diabetic cat as low impact as possible to my life and own personal health challenges. I'm coming back to this field and must ensure my mind is clear and my health issues in check.

So, that being said maybe there's just a little difference between whining about being tired and actually needing to ensure that this doesn't interfere with my critical professional responsibilities. My health challenges and sleep requirement are more impactful than just "being tired" as you state. That equivalence is actually quite devalidating and one of the most frustrating parts of living with my set of exposures and my conditions. I also care for a family member with health challenges on a daily basis. So let's not get into "they were able to do it, so why can't you?". Not going to help. I only ask for practical advice and clear communication on where the border between must and should is located. Flexibility wherever it exists will need to be identified. I would appreciate it if points of flexibilty were clearly presented to me without having to go through all of this. It should be obvious by now that I am not going to be one of those people who can implement the protocol perfectly.

I actually find this offensive. Again, you are making judgments about others’ lives when you don’t know the challenges any of them have in regard to their jobs, their health, their family members’ health. I’m not going to go to anyone else’s challenges but suffice it to say that we’ve seen many with more than what you have explained as yours.

We will offer you suggestions when you reach out or, if you post every day, when we see something that might help. Few can follow the methods perfectly because life happens. We are pretty good with “out-of-the-box” thinking when we have the data we need to keep cats safe.