11/12 Ebby AMPS 516 Dosecrease now?

[MelissaEbby]

Yesterday

I know I said I'd give it a few days, but I think I have to try more insulin tonight. Her numbers are not good. I'm at a loss as to why she's not coming down from the insulin. It's as if the insulin isn't working at all.

I will try to get a look at her teeth and make sure they are fine.

Another thought....If I did give the extra shot on 11/9, I would have filled a used syringe. Would this contaminate the pen? That's a lot of "ifs" because it's hard to say if I even did that or not.

 

[PeterDevonMocha]

HI guys .. no dosing advice from me, but fingers and toes and paws crossed that ebby comes down for you soon .. have a great day guys!

 

[Marje and Gracie]

I don't think it would have contaminated the pen if you just drew the dose per normal and didn't inject any insulin INTO the pen.

I think you have a failed reduction. Unless she comes flying down today, I'd increase her dose back to 1u tonight....or tomorrow if you prefer to do it during the day.

Paws crossed!!

 

[MelissaEbby]

Thanks for the visits and well wishes!

Marje, I will increase tonight. I hate having her sitting in high numbers so if that means I lose sleep, so be it. I sure hope we can get back on track. She's never been regulated, but at least we had been seeing a lot of green and blue. Now...I'm beginning to hate the color yellow. Thanks for the input!

Also, checked right side teeth...all looked ok. I'll check the right side when she flips over on the bed. She's been sneezing some. Maybe a cold could be causing this. We'll see if the extra juice helps.

 

[Marje and Gracie]

It's been seven cycles since she got the 48. Yes, she could possibly have gotten that double dose and so she might have gotten a little more of a whammy from the extra counterregulatory hormones from any extra insulin, AND sometimes cats will bounce longer than six cycles but she's pretty high and flat after 7 cycles.

Just watch her because that black number this morning could be a high before a break so she might clear the bounce quickly.

 

[Jill & Alex (GA)]

hi melissa. i'm late to your question and you've probably shot already tonight so i can't suggest holding the dose, but this is also an opportunity for a teaching moment.

the last entry on ebby's ss is AM+4. what happened the rest of the day? the reason why i'm asking is so far the numbers pretty much confirm having given two PM shots on 11/09.

see here's the thing with lantus overdoses... they can manifest themselves in several ways:

• the "extra" insulin can simply push the numbers up resulting in a non-event (too much insulin causes high numbers)

• otoh, there's a point where too much insulin will quickly drop kitty, make it difficult to bring the numbers up throughout the cycle, as well as markedly increasing duration

• sometimes the numbers will shoot up high, but towards the end of the cycle they'll start to drop dramatically and you'll see extended duration

when dealing with an overdose, real or imagined, i'm always rather nervous until i get a sense of how things will go. :?

i do think there's a real possibility ebby dropped lower than 48 on 11/08. this morning's 0.5u dose was only the 5th cycle on 0.75u. combine an expected bounce with a probable overdose and the most prudent thing to do is put some distance between the unusual circumstances and thoughts of an increase. protocol does not apply when the unusual circumstances aren't part of the protocol. it's better to err on the side of caution. these are the reasons both libby and i felt it was best to see if the high numbers cleared out on their own.

please monitor carefully over the next few cycles if you've increased the dose tonight. ebby can be quite the drama queen. she's demonstrated the ability to drop 200 - 300 points in the first few hours after her shot (even when her preshot number is in the 500s). :roll:

 

[MelissaEbby]

Hi Jill, Yes I'm just now seeing your post, so sorry, I did already shoot a 1 unit.

the last entry on ebby's ss is AM+4. what happened the rest of the day?

I don't have the tests to confirm it, but I'm pretty confident she stayed flat yellow. Ebby gets a lot of momentum from +1 to +5 and then she tends to stop dropping at which she either stays flat or skyrockets after +10. I have yet to get a spot check that shows a nadir after +6. Because of this, I feel pretty confident that if she is in the yellows or pinks at +4 I can take a little break from testing. Now, she MIGHT of hit a blue, but I really doubt she in any way came close to below 50, and I even doubt she got below 200.

the reason why i'm asking is so far the numbers pretty much confirm having given two PM shots on 11/09.

I guess I don't totally see this but am open to an explanation. All I see is pretty flat yellow with her typical red and black preshots. Are you referring to the flat yellow indicating the double dose, or the high preshots? I kind of see the opposite, that the numbers confirm NOT having given two PM shots. Now, I might be more convinced of an overdose had I seen a red or black directly following the possible double dose, but the next two preshots after the evening of 11/09 were flat yellow.

sometimes the numbers will shoot up high, but towards the end of the cycle they'll start to drop dramatically and you'll see extended duration

I guess this could have happened. I don't have tests that late in the cycle to show either way. I was told there was a possibility of extended duration but I didn't understand this to mean she would come up and back down later in the cycle. I wish I had gotten some spot checks if that were the case, but I didn't interpret extended duration to mean a later nadir, rather just "extended duration" after the nadir....so this is good to know.

the "extra" insulin can simply push the numbers up resulting in a non-event (too much insulin causes high numbers)

Just curious on how this happens. So say she did get extra insulin on 11/09.... I give her the shot....a double dose is now in her system....but she shows very little drop from the insulin. How then would her body know she had too much insulin if there was never a drop in BG to indicate to her body she had too much? Maybe this is getting to complex but just can't quite wrap my mind around that. Without a drop in BG what exactly would trigger counterregulatory hormones?

protocol does not apply when the unusual circumstances aren't part of the protocol. it's better to err on the side of caution. these are the reasons both libby and i felt it was best to see if the high numbers cleared out on their own.

I hope you don't think I was disregarding any advice you and Libby gave me to hold off on the increase. In my mind I held off for two more cycles (last night and this morning) and she was still not doing well. I was told to wait on increasing but it was a little unclear how long I should wait and so I posted the question about increasing tonight. I guess I thought since I didn't get a no it was ok. I can't tell who has read the post or not so thought maybe you or Libby had seen it. Maybe I should have PM you to clarify yesterday's advice to hold, so sorry about that. But tonight would have been 72 hours since the possible double dose. She has been sitting flat and high, and she is not doing well. She obviously feels lousy and looks lousy. These are the reasons I felt ok with going ahead with the increase.

So talking about overdose:
It's a little weird to me that flat yellows would indicate an overdose, but yet Ebby's everyday typical patterns don't (supposedly) indicate overdose. On Ebby's second cycle of Lantus she hit 56 at +5 on .50 units. On a lot of days she can drop well over 50% by +3. And she's bouncing all the time. All of these things have made me wonder if I've been overdosing her this whole time. And I've read and read about bouncing and understand the concept, so I do what I've been doing and follow the protocol, and refrain from re-bound checks, but I still worry that she's been overdosed the entire time.

please monitor carefully over the next few cycles if you've increased the dose tonight. ebby can be quite the drama queen. she's demonstrated the ability to drop 200 - 300 points in the first few hours after her shot (even when her preshot number is in the 500s).

Thanks Jill, I appreciate your feedback and concern. I'll monitor closely....except sometimes those spot checks at +8 or +9 are just not possible. Like tonight...I will have to go to bed once Ebby reaches her typical nadir. I am almost always sleep deprived and at some point have to trust Ebby will be ok. :roll:

 

[Libby and Lucy]

Melissa,

I'm at work so can't post much right now, but I wanted to say don't ever worry about "disregarding" anyone's advice. The advice given here is just meant to show you your options, and show you some things we have seen over the years, to help you make decisions. You are the one who knows your cat, so as long as you are considering the options and making decisions that make sense to you, that's really all we want to see. I love seeing people think things through and making their own decisions, even when their decisions don't exactly match mine. :smile:

One thing that stands out to me, though, is that flat/yellow really isn't all that "normal" for Ebby anymore. It could be a failed reduction, or it could be something else. Jill and I both prefer to err on the side of caution when a possible overdose is in the picture, just to be safe. But, you said that Ebby does not seem to be feeling well, and that is important too. You're doing the right thing, just be sure to monitor.

 

[Jill & Alex (GA)]

ditto to libby's remarks! love, love, love to see you thinking things through. :mrgreen:

like libby, i'm working. i only work 3 days a week, but they're 10 - 12 hour days. i'll try to get to your questions when i have some down time. if not, it'll have to be later tonight.

have a good day!

 

[MelissaEbby]

Hi Jill, definitely no hurry. It is a work day for me today too, :sad: so I'll be out of the house after 4:00 pm.

One thing that stands out to me, though, is that flat/yellow really isn't all that "normal" for Ebby anymore.

This is a good point, although I started to feel her numbers getting a little weird around 11/1. Part of me thinks they have just steadily gotten worse since then and these past few days have been a product of some lost regulation or glucose toxicity. But you're very right- flat and yellow are not characteristics most associated with Ebby...and throw a possible overdose in the mix, and we're left with an extra variable in trying to figure out why her numbers look the way they do.

 

[Jill & Alex (GA)]

the last entry on ebby's ss is AM+4. what happened the rest of the day?

I don't have the tests to confirm it, but I'm pretty confident she stayed flat yellow. Ebby gets a lot of momentum from +1 to +5 and then she tends to stop dropping at which she either stays flat or skyrockets after +10. I have yet to get a spot check that shows a nadir after +6. Because of this, I feel pretty confident that if she is in the yellows or pinks at +4 I can take a little break from testing. Now, she MIGHT of hit a blue, but I really doubt she in any way came close to below 50, and I even doubt she got below 200.

it's hard to tell. something has either changed causing those flat yellow cycles libby mentioned above or a double dose given the other night is causing them. something is skewing the data over the last few days.

the reason why i'm asking is so far the numbers pretty much confirm having given two PM shots on 11/09.

I guess I don't totally see this but am open to an explanation. All I see is pretty flat yellow with her typical red and black preshots. Are you referring to the flat yellow indicating the double dose, or the high preshots? I kind of see the opposite, that the numbers confirm NOT having given two PM shots. Now, I might be more convinced of an overdose had I seen a red or black directly following the possible double dose, but the next two preshots after the evening of 11/09 were flat yellow.

for the most part, the past few days following the suspected over dose have been far from typical for ebby. she hasn't been having flat yellow cycles of late... so what's changed? although having said that, i suspect the red & black AM preshots the last 3 mornings may have been preceded by a drop into lower numbers. that part is typical of ebby. ;-) the timing of this sudden change and the form it's taken lead me to think it's likely she did receive a second dose. more can be found about too much insulin causing high numbers below.

the AM cycle today is very similar to yesterday. it'll be interesting to see what happens tonight and if she ends up with another high preshot number in the morning.

sometimes the numbers will shoot up high, but towards the end of the cycle they'll start to drop dramatically and you'll see extended duration

I guess this could have happened. I don't have tests that late in the cycle to show either way. I was told there was a possibility of extended duration but I didn't understand this to mean she would come up and back down later in the cycle. I wish I had gotten some spot checks if that were the case, but I didn't interpret extended duration to mean a later nadir, rather just "extended duration" after the nadir....so this is good to know.

most caregivers aren't aware of all the possibilities... including caregivers of long term diabetic kitties. i noticed it hadn't been mentioned by anyone the other night and i wasn't surprised. it doesn't happen often enough for most to have seen it happening first hand. probably the only reason i'm aware of the different scenarios is i've stuck around for the last 7.5 years offering suggestions and advice. i couldn't tell you how many spreadsheets libby and i have studied. spotting these things has come directly from experience. libby and i don't post much anymore, but for years we've spent hours and hours offering suggestions and advice in this group everyday. anyone can offer suggestions based on the TR protocol, but very, very few have a good handle on interpreting spreadsheets... spotting the patterns... reading the "invisible" numbers on a spreadsheet.

the "extra" insulin can simply push the numbers up resulting in a non-event (too much insulin causes high numbers)

Just curious on how this happens. So say she did get extra insulin on 11/09.... I give her the shot....a double dose is now in her system....but she shows very little drop from the insulin. How then would her body know she had too much insulin if there was never a drop in BG to indicate to her body she had too much? Maybe this is getting to complex but just can't quite wrap my mind around that. Without a drop in BG what exactly would trigger counterregulatory hormones?

i wish i knew the answer. what we do know through observation and experience (when using any insulin) is an over dose or too much insulin doesn't necessarily mean you'll see a drop into lower numbers. often times administering too much insulin will cause consistently high numbers. heck, we've had kitties come to the fdmb on a 10u dose and as far as the caregiver knows their kitty has never bottomed out like one would expect. i've often suspected this reaction may have some kind of connection/similarity with the phenomenon kirsten mentions in the TR Protocol in regard to increasing the dose... as written on the tillydiabetes web site: "Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations." but I don't know. it's purely conjecture on my part.

protocol does not apply when the unusual circumstances aren't part of the protocol. it's better to err on the side of caution. these are the reasons both libby and i felt it was best to see if the high numbers cleared out on their own.

I hope you don't think I was disregarding any advice you and Libby gave me to hold off on the increase. In my mind I held off for two more cycles (last night and this morning) and she was still not doing well. I was told to wait on increasing but it was a little unclear how long I should wait and so I posted the question about increasing tonight. I guess I thought since I didn't get a no it was ok. I can't tell who has read the post or not so thought maybe you or Libby had seen it. Maybe I should have PM you to clarify yesterday's advice to hold, so sorry about that. But tonight would have been 72 hours since the possible double dose. She has been sitting flat and high, and she is not doing well. She obviously feels lousy and looks lousy. These are the reasons I felt ok with going ahead with the increase.

no problem! you made a call on the information you had available to you. i would have done the same given the circumstances. neither libby or i were saying ebby didn't need an increase. all we were encouraging was allowing extra time for the effects of a possible over dose as well as the bounce clear out of her system before increasing... because those effects were clouding the picture.

safety is the #1 priority on the fdmb. putting some distance between the possible over dose and increasing the dose just makes sense.

So talking about overdose:
It's a little weird to me that flat yellows would indicate an overdose, but yet Ebby's everyday typical patterns don't (supposedly) indicate overdose. On Ebby's second cycle of Lantus she hit 56 at +5 on .50 units. On a lot of days she can drop well over 50% by +3. And she's bouncing all the time. All of these things have made me wonder if I've been overdosing her this whole time. And I've read and read about bouncing and understand the concept, so I do what I've been doing and follow the protocol, and refrain from re-bound checks, but I still worry that she's been overdosed the entire time.

fwiw, i'm not seeing that she's been overdosed all along. to me, ebby just looks like a bouncy kitty. we have lots of them around here!

please monitor carefully over the next few cycles if you've increased the dose tonight. ebby can be quite the drama queen. she's demonstrated the ability to drop 200 - 300 points in the first few hours after her shot (even when her preshot number is in the 500s).

Thanks Jill, I appreciate your feedback and concern. I'll monitor closely....except sometimes those spot checks at +8 or +9 are just not possible. Like tonight...I will have to go to bed once Ebby reaches her typical nadir. I am almost always sleep deprived and at some point have to trust Ebby will be ok. :roll:

i know how hard it can be to get those late spot checks at night. it took me quite awhile to be able to wake up, grab a test, and go right back to sleep. there's actually been occasions when i felt like i hit a wall that i've given reduced doses, skipped a shot, or given late AM shots so i could sleep in in the morning (i am sooooooooooo not a morning person). if there's one thing i've learned is it's just as important to take care of yourself as it is to take care of your cat. :mrgreen:

hope this helps...

 

[MelissaEbby]

hope this helps...

Thanks Jill, it does help. I appreciate your info and advice. I've been thinking about all of this so much my mind is a little over-worked right now, and not knowing whether or not I did give the extra shot drives me crazy. But...I guess we just move on and try to regain some regulation again. I'm also going to stop feeding the Weruva food for now. It's listed at 3% but I'm beginning to question that. I noticed I started feeding this around 11/2 which was when I mentioned things started to feel off. Can't say this is a factor, but figure I should remove it for now just in case it's causing any problems. Ebby is not flat today....in fact a steep drop to green....so maybe we're back to some normalcy. :roll: Thanks again.

 

[Jill & Alex (GA)]

you're welcome!