? 11/10 EDDIE AMPS 313, +3 252

[Jodey&Eddie&Blue]

Last night I gave Eddie 14u and this morning, I gave 15u. I realize doses are dependant not on AMPS or PMPS but with nadir. So, I'm asking (although it's only +3 and I'll test again at +6), does the trend still indicate going back to 14u (or staying at it) rather than keeping, again, to the 15u.

I realize I've been asking this question in roundabout ways--and probably much too repetitively-- and yet I'm still uncertain as to how to proceed with an actual day's readings, like today. My question is, aside from asking for help with the dose, what is it in the numbers that indicate the dose? I feel I'm also not asking that very clearly but I'm trying to establish how to make decisions about the dose/nadir relationship without repeating myself and clogging up the forum with the same thread over and over. I hope this makes sense.

Thank you and thank you for your patience.

 

[Katherine&Ruby]

Hi Jodey,

Here is your last thread for continuity (please cut and paste this into your first post of the day) and you should change the date in the thread title :https://www.felinediabetes.com/FDMB...ng-low-just-want-support.254094/#post-2863993

Here are the dosing methods available to follow: https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/

Since Eddie is on a high dose and you are doing a good job of testing, I would follow Tight Regulation or TR. This means that every time your cat goes below 68 on the AlphaTrak, you reduce the dose. You can post here every 6 cycles or 3 days after starting a new dose to ask for dosing advice and someone will help you. It can take 6 cycles for an insulin dose to show how it is working.

The reason why we look for nadirs versus preshot numbers is we want to see how low the insulin dose takes a cat. 15 was too much because you got that 67 yesterday. Sometimes with unregulated cats the nadir is the preshot number, so we use that to judge whether or not a cat needs to go up in dose or lower. We look at the lowest number to keep the cat safe. You want to get in as much insulin as safely as possible without overdoing it.

Please feel free to ask questions. I ask for dosing help all the time and I've been here for over a year. There is no such thing as a stupid or repetitive question. There is a steep learning curve here, and even experienced members read and re-read the stickies at the top of the forum. They will be of great value to you as you forge on ahead.

 

[Jodey&Eddie&Blue]

So, at +6, Eddie is in the blues again (169) and this is following 15u this morning.

This is my question. If 15u has brought him back into the blue (169) @ +6 (is this the nadir?), should he not continue with 15u tonight? Where I'm having difficulty understanding the dose/nadir relation is that he's at 169 based mostly of a number of days @ 15u, with the exception being the drop to 67 yesterday. Would +7 then be his nadir and not +6 as I'm suggesting here because two days prior he was at 74 at +7.

I think I've been reading nadir as +6 (6 hours between shots) when in fact it may be that Eddie's is at +7 and I notice I've hardly done any +7 tests recently. Does the nadir vary according to the dose (and whatever else may be happening that day? I guess I'm trying, perhaps naively, to find a pattern).

Thank you so much @PerfumedCatMom Forging ahead with your help.

 

[FrostD]

So, at +6, Eddie is in the blues again (169) and this is following 15u this morning.

This is my question. If 15u has brought him back into the blue (169) @ +6 (is this the nadir?), should he not continue with 15u tonight? Where I'm having difficulty understanding the dose/nadir relation is that he's at 169 based mostly of a number of days @ 15u, with the exception being the drop to 67 yesterday. Would +7 then be his nadir and not +6 as I'm suggesting here because two days prior he was at 74 at +7.

I think I've been reading nadir as +6 (6 hours between shots) when in fact it may be that Eddie's is at +7 and I notice I've hardly done any +7 tests recently. Does the nadir vary according to the dose (and whatever else may be happening that day? I guess I'm trying, perhaps naively, to find a pattern).

Thank you so much @PerfumedCatMom Forging ahead with your help.

So short answer - yes, most cats start to show a pattern after awhile, with a fairly predictable nadir within a two-ish hour window. That said, it can be different day to day. Insulin is a hormone, it doesn't work the same way every day, especially when it comes to acro cats since there is the tumor to contend with.

Long answer - Lantus is a depot insulin, so there's some insulin in "reserve" on any given day. The best analogy I've seen so far is a potted plant - the insulins like Vetsulin and ProZinc are like just watering the plant straight from a watering can twice a day. The depot insulins like Lantus and Levemir are like adding a sponge on top of the dirt - so even though you watered the plant, that sponge holds a little extra if it's needed. Flip side - if you get a downpour and the plant gets flooded, now you still have the sponge with even more water (what you may have seen called an overfull depot). So let's say the cat drops below 68 and earns a reduction, there's still insulin in the depot for a few more cycles, and that may affect numbers.

There is no way to know how much insulin is in the depot. Part of the reason we hold a dose for a certain number of days is to give the depot time to stabilize. So since Eddie was at 15, then down to 14, back up to 15, then 14 tonight - who knows where the depot is at, needs a few days at the dose to stabilize and see how he really does with a dose

 

[Katherine&Ruby]

So, at +6, Eddie is in the blues again (169) and this is following 15u this morning.

This is my question. If 15u has brought him back into the blue (169) @ +6 (is this the nadir?), should he not continue with 15u tonight? Where I'm having difficulty understanding the dose/nadir relation is that he's at 169 based mostly of a number of days @ 15u, with the exception being the drop to 67 yesterday. Would +7 then be his nadir and not +6 as I'm suggesting here because two days prior he was at 74 at +7.

I think I've been reading nadir as +6 (6 hours between shots) when in fact it may be that Eddie's is at +7 and I notice I've hardly done any +7 tests recently. Does the nadir vary according to the dose (and whatever else may be happening that day? I guess I'm trying, perhaps naively, to find a pattern).

Thank you so much @PerfumedCatMom Forging ahead with your help.

You hold doses for at least 6 cycles or three days to see how the cat is doing and where the nadirs fall, unless you get a number below 68 on an AlphaTrak (it's 50 on a human meter) and you reduce the next dose IMMEDIATELY. We don't react to static numbers, but to overall trends. Not really sure why you went back up to 15 units because that 67 you got yesterday tells us that 15 units was too much for him, and that's why you were advised to take the dose down to 14.

Please read the dosing link I sent to you and the sticky notes at the top of the forum list.

 

[Jodey&Eddie&Blue]

So short answer - yes, most cats start to show a pattern after awhile, with a fairly predictable nadir within a two-ish hour window. That said, it can be different day to day. Insulin is a hormone, it doesn't work the same way every day, especially when it comes to acro cats since there is the tumor to contend with.

Long answer - Lantus is a depot insulin, so there's some insulin in "reserve" on any given day. The best analogy I've seen so far is a potted plant - the insulins like Vetsulin and ProZinc are like just watering the plant straight from a watering can twice a day. The depot insulins like Lantus and Levemir are like adding a sponge on top of the dirt - so even though you watered the plant, that sponge holds a little extra if it's needed. Flip side - if you get a downpour and the plant gets flooded, now you still have the sponge with even more water (what you may have seen called an overfull depot). So let's say the cat drops below 68 and earns a reduction, there's still insulin in the depot for a few more cycles, and that may affect numbers.

There is no way to know how much insulin is in the depot. Part of the reason we hold a dose for a certain number of days is to give the depot time to stabilize. So since Eddie was at 15, then down to 14, back up to 15, then 14 tonight - who knows where the depot is at, needs a few days at the dose to stabilize and see how he really does with a dose

Eddie is indeed an acrocat, although he's had hypophysectomy and SRT. These are part of the variables since the SRT was only 7 months ago and I've been advised results can be expected around 9 months and up to 12 months. The more the tumour succumbs to the radiation, the less insulin Eddie will need, which is why I'm finding the latest numbers encouraging.

I'm going to test him again in about 45 minutes just so I can see if the numbers are going down or up at +7. He's only been on 14u once over the past 6 days (last night) and so I'm trying to determine, to use your analogy, whether or not we had a flood with the drop or what.

I didn't realize I was advised to stay at 14u. But now I see that's what was the case. I've been reading the stickies you linked and, wow, they require some slow, thoughtful reading. I'm getting there.

 

[Jodey&Eddie&Blue]

Well, it would appear that the nadir was at +6 169, as we are now at +7 and he's gone up to 198.

Here is really where my absolute inexperience comes in. Because he's only had one shot at 14u in all of these days--and his BG is now rising--why should he be on 14u instead of 15u?

I feel like a dunderhead in asking this question but the way I'm looking at the spreadsheet suggests that after the anomalous 67 yesterday, his BG started to rise (I gave a teaspoon of low carb food) and was higher before (pmps) and after the shot and into the night (up to 2:30 am) which was my (mistaken?) rationale for giving 15u this morning.

Believe me, I'm starting to annoy myself so thank you @PerfumedCatMom and, possibly, @Wendy&Neko for any patience you can spare.

 

[Katherine&Ruby]

Well, it would appear that the nadir was at +6 169, as we are now at +7 and he's gone up to 198.

Here is really where my absolute inexperience comes in. Because he's only had one shot at 14u in all of these days--and his BG is now rising--why should he be on 14u instead of 15u?

I feel like a dunderhead in asking this question but the way I'm looking at the spreadsheet suggests that after the anomalous 67 yesterday, his BG started to rise (I gave a teaspoon of low carb food) and was higher before (pmps) and after the shot and into the night (up to 2:30 am) which was my (mistaken?) rationale for giving 15u this morning.

Believe me, I'm starting to annoy myself so thank you @PerfumedCatMom and, possibly, @Wendy&Neko for any patience you can spare.

First of all, please go to the top right of this screen and go to Thread Tools and edit the thread title so that it has today's date. That will help us help you.

Secondly, Lantus is a DEPOT insulin. That means that it gets stored in the subcutaneous fat and gets released slowly, as @FrostD explained. It takes time for this depot to build up in the body, so you have no idea how a dose is doing if you change the dose all the time. The experience of the FDMB shows that it takes 6 cycles or 3 days for changes in the dosing to take effect. HOWEVER, if you reduce the dose and numbers are climbing after 2 or 3 cycles, you can call it a FAILED REDUCTION and take the dose back up to 15. The thing is that you want your cat off insulin, not on it forever, especially if he is responding to SRT. So you really want to give those dose reductions a chance, and see if that 14 unit dose takes your cat as low as the 15 unit one did.

Does this make sense?

 

[Jodey&Eddie&Blue]

First of all, please go to the top right of this screen and go to Thread Tools and edit the thread title so that it has today's date. That will help us help you.

Secondly, Lantus is a DEPOT insulin. That means that it gets stored in the subcutaneous fat and gets released slowly, as @FrostD explained. It takes time for this depot to build up in the body, so you have no idea how a dose is doing if you change the dose all the time. The experience of the FDMB shows that it takes 6 cycles or 3 days for changes in the dosing to take effect. HOWEVER, if you reduce the dose and numbers are climbing after 2 or 3 cycles, you can call it a FAILED REDUCTION and take the dose back up to 15. The thing is that you want your cat off insulin, not on it forever, especially if he is responding to SRT. So you really want to give those dose reductions a chance, and see if that 14 unit dose takes your cat as low as the 15 unit one did.

Does this make sense?

Does this makes sense. OMG, yes, finally, I think I understand ("gives head a shake"). Thank you.

 

[FrostD]

Because he's only had one shot at 14u in all of these days--and his BG is now rising--why should he be on 14u instead of 15u?
@PerfumedCatMom and, possibly, @Wendy&Neko for any patience you can spare.

Because it could be an off day, he could be bouncing a little, we just don't know. If you hold the 14U for a few days (as Katherine pointed to in the sticky) and he doesn't see green, you can call it a failed reduction and go right back up.

The 67 could have been anomalous, or not. You could have just as easily given 15U again and he ended up in a hypo situation, there's no way to know how it would go. For safety's sake it's better to reduce for a few cycles then go back up if needed.

 

[Jodey&Eddie&Blue]

Because it could be an off day, he could be bouncing a little, we just don't know. If you hold the 14U for a few days (as Katherine pointed to in the sticky) and he doesn't see green, you can call it a failed reduction and go right back up.

The 67 could have been anomalous, or not. You could have just as easily given 15U again and he ended up in a hypo situation, there's no way to know how it would go. For safety's sake it's better to reduce for a few cycles then go back up if needed.

The light is starting to penetrate my inexperience. This makes perfect sense and I don't know why I couldn't see it before but I think I got it. Thank you.

 

[JL and Chip]

I know it’s hard, but sometimes we need to “sit on our hands” and trust the protocol, and not allow ourselves to analyze every last number and cycle. It’s easy to react to a high number and want to change something to “fix it now!” but that’s not how feline diabetes works. It’s not as simple as “my car is a quart low on oil” so you just add more. The data we collect is all part of a big picture, not a standalone thing.

Tubby was an acrocat too, my third diabetic. Every one of them was different, but what was the same was that I’d have to talk to myself when I saw a high number and take a deep breath. My instinct was always to tweak. That has served me well with other medical issues in my crew, but with diabetes we need to “stay the course.” Otherwise we just end up chasing our tails and adding confusion.

The lightbulb doesn’t turn on overnight, but it will. Just tell yourself that your job now is to collect BG data, follow the proven protocol (feel free to read it over and over and ask questions), sit on your hands when you have the urge to change something just because of a high number, and stay the course. You’ll get there. We’ll help you.

Acro is a huge challenge, but we’ve have plenty of acros here. Tubby had SRT also. You’re not alone in this journey. Glad you found us. Take a deep breath.

 

[Wendy&Neko]

I'm back home. Happy Thanksgiving to you Jodey. And thank you Katherine and Melissa for stepping in.

I've been advised results can be expected around 9 months and up to 12 months.

Neko reacted after two weeks. Correction, less than two weeks. She started earning back to back reduction on the car ride home from Colorado. ECID - every cat is different, and acrocats even more so. When a cat starts to react to SRT, they can do so in a rather dramatic fashion. That can mean back to back reductions, larger reductions than normal - or not. ECID again. One reduction from Eddie does not yet indicate he's reacting to SRT, but I would be on alert. If he does something like this again and soon on a lower dose, then I'd lead to that conclusion. Or it could be just that he's breaking through some glucose toxicity, which can mean a few reductions in a row. In either case, he should go back to 14 units and hold the dose until any bounce is over, unless he goes low again.

See where I'm going with this? There are no absolute answers for why every BG test is what it is. If you read the Sticky Note What is the Insulin Depot?, you'll see there are many reasons for varying numbers. So as the others suggest, just follow the protocol for now. Look at how low a particular dose is taking Eddie. If the answer is "too low or below 68", then we lower the dose so he stays above 68 on your AT. When Neko's dose started going into freefall, I actually raised the reduction point temporarily, and took reductions earlier than I might have otherwise. That was to give me an even further safety margin. Larger doses come with larger depots, and it can take 6+ cycles to drain that larger depot. If that larger depot (pre-reduction) takes him too low, then you could be battling lower numbers for a while. There are techniques we can help you with to drain the depot (skips, reduced doses), and we can talk about that if it ever comes to that point. It is the 15 unit depot that is probably helping reduce the bounce somewhat.

Nadirs can also vary. Bounce breaking cycles tend to have later nadirs. Sometimes reduction cycles have earlier nadirs. Neko's nadir on Lantus varied from +3.5 to +13, though most often +7 to +9. Some cats are more predictable than that.

 

[Jodey&Eddie&Blue]

I know it’s hard, but sometimes we need to “sit on our hands” and trust the protocol, and not allow ourselves to analyze every last number and cycle. It’s easy to react to a high number and want to change something to “fix it now!” but that’s not how feline diabetes works. It’s not as simple as “my car is a quart low on oil” so you just add more. The data we collect is all part of a big picture, not a standalone thing.

Tubby was an acrocat too, my third diabetic. Every one of them was different, but what was the same was that I’d have to talk to myself when I saw a high number and take a deep breath. My instinct was always to tweak. That has served me well with other medical issues in my crew, but with diabetes we need to “stay the course.” Otherwise we just end up chasing our tails and adding confusion.

The lightbulb doesn’t turn on overnight, but it will. Just tell yourself that your job now is to collect BG data, follow the proven protocol (feel free to read it over and over and ask questions), sit on your hands when you have the urge to change something just because of a high number, and stay the course. You’ll get there. We’ll help you.

Acro is a huge challenge, but we’ve have plenty of acros here. Tubby had SRT also. You’re not alone in this journey. Glad you found us. Take a deep breath.

"Sit on our hands": what a good way living with an acrocat and diabetes. Thank you. I feel I should make this my motto for the next while.

Eddie being an acrocat is complicated by the fact that his brother, Blue, a silver tabby, is also an acrocat. Blue has had surgery, fractionated radiotherapy and lastly SRT in November 2020. Blue finally went into remission in mid-August and it's a wonderful thing. Eddie has been compromised because of the fact he twice had wound dehiscence and debridement (Dec. 2020). The tumour was too large to remove entirely by surgery so we went for SRT in February and he has had a full dance card of complications, not the least of which was diabetes insipidus and now "just" DM. I realize I've been hypervigilant with him because he's had such a terrible time. The issue may be that the surgery injured his hypothalamus and he became reactive, hissing and growling all the tie. One vet even put him on Trazadone for months until I said enough and weaned him off. These past few weeks have been so good for Eddie. These colours on his spreadsheet are encouraging so I'm just a bit jumpy as I've been so worried about him. But I do see improvement and I'm grateful.

I'm also grateful that I found you! I feel the support and, believe me, even when I'm forgetting to sit on my hands, your support is golden.

We are at 14u. BG pmps=14.0.

Goodnight and thank you again.

 

[Jodey&Eddie&Blue]

I'm back home. Happy Thanksgiving to you Jodey. And thank you Katherine and Melissa for stepping in.


Neko reacted after two weeks. Correction, less than two weeks. She started earning back to back reduction on the car ride home from Colorado. ECID - every cat is different, and acrocats even more so. When a cat starts to react to SRT, they can do so in a rather dramatic fashion. That can mean back to back reductions, larger reductions than normal - or not. ECID again. One reduction from Eddie does not yet indicate he's reacting to SRT, but I would be on alert. If he does something like this again and soon on a lower dose, then I'd lead to that conclusion. Or it could be just that he's breaking through some glucose toxicity, which can mean a few reductions in a row. In either case, he should go back to 14 units and hold the dose until any bounce is over, unless he goes low again.

See where I'm going with this? There are no absolute answers for why every BG test is what it is. If you read the Sticky Note What is the Insulin Depot?, you'll see there are many reasons for varying numbers. So as the others suggest, just follow the protocol for now. Look at how low a particular dose is taking Eddie. If the answer is "too low or below 68", then we lower the dose so he stays above 68 on your AT. When Neko's dose started going into freefall, I actually raised the reduction point temporarily, and took reductions earlier than I might have otherwise. That was to give me an even further safety margin. Larger doses come with larger depots, and it can take 6+ cycles to drain that larger depot. If that larger depot (pre-reduction) takes him too low, then you could be battling lower numbers for a while. There are techniques we can help you with to drain the depot (skips, reduced doses), and we can talk about that if it ever comes to that point. It is the 15 unit depot that is probably helping reduce the bounce somewhat.

Nadirs can also vary. Bounce breaking cycles tend to have later nadirs. Sometimes reduction cycles have earlier nadirs. Neko's nadir on Lantus varied from +3.5 to +13, though most often +7 to +9. Some cats are more predictable than that.

After SRT in November, 2020, Blue, Eddie's brother, dropped from 8u/BiD to 2u. He was on that until August and then almost went hypo. I took him to emerg and they gave him fluids, etc. and after that he went into remission, so yes, to the drama. Eddie's story is different, of course, but we are making progress. He is not as reactive as he was. He is starting, finally, to look like himself and that is everything.

Thank you so much for being there. We are on 14u. Goodnight.