11/20 Portia AMPS 185 +4 232- increase dose today

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portiarita

Member Since 2013
Hello LL,
Its been a while since I last posted. Ive been quite tied up with work the last few days and havent been able to do any testing :(( The vet insisted I change Portia's dose of insulin. She wanted to change by 1 whole unit in the am and keep the pm as it is. Instead, I increased by 0.5U (so today she got 1.5U in the am and will get 1U in the pm). I was wondering how soon before I see any changes in her BG? Will it take a few cycles for the increased dose to kick in?

Also, what are your thoughts on unequal dosing (meaning 1.5U in the am and 1U in the pm)?


Thanks for your input

Rita
 
There seems to be a fundamental part of the way Lantus works that your vet may not fully appreciate. Lantus is a depot insulin. If you give unequal doses at AM and PM the result will be wonky numbers. The depot needs to stabilize. Every time you change the dose, it effects the depot. It can take 3 days for a change in the dose to stabilize. If you are changing the dose at every shot, this won't happen. You'd be better off increasing the dose to 1.25u twice a day. Portia would still be getting a total of a 0.5u increase but it would mean giving the same amount at each shot time.

Please, please, please test. Test both AM and PM. If you look over the Tight Regulation Protocol, you'll note that it recommends that you do not raise a dose by 0.5u if the nadirs are under 300. When the nadirs are under 300, the dose increase in 0.25u. Your vet requested that you double the recommended increase. As I noted above, increasing by 0.25u at AM and PM is what the TR Protocol would indicate.

You might want to share the journal article describing the TR Protocol with your vet if you haven't done so already.


Thanks for filling us in on what's been going on with Portia. I saw you're reply about her diet and pancreatitis. FYI - we link our thread's/condo's together. Your last condo is below.

Portia's 11/17 Condo
 

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Hi Sienne,
Thanks for responding. Its been a while since I last posted and I totally forgot to link my last post. Thanks for pointing it out and linking it :)

So here's the problem. According to the TR protocol, Portia should ideally be on a low carb diet. She is on a very high carb diet that cannot be changed at the moment due to her other medical conditions (as you know). So my question is, do the lantus dose increase suggestions apply strictly to her when her carb intake is so high? I though that it probably dint and that was why I thought a 0.5 increase may not be terrible. However, I do not like that she's on an uneven dosing right now. Just looking at her curves, she doesnt really appear to have a nadir and if it does dip, it tends to dip later on in the day (around +8-+12). I believe this is largely driven by her food intake. Let me know if Im interpreting her BG readings incorrectly. My vet had suggested the uneven dosing because of this. She eats 3/4 of her daily intake during the day and we're afraid that if we give her the same high dose at night she might go into hypo if she doesnt eat.

What would you recommend?Also, due to my tight work schedule and the fact that she's on appetite stimulants to help her eat, I cannot withdraw food after +6 as is recommended. I feel its cruel to induce her appetite and then hold food back. So Ive been letting her eat whenever she wants but Im trying to take the food away 2 hrs before AMPS and PMPS.

Please let me know if you think of a way around her problems.
Rita
 
I did send my vet the article a week back but I never heard back from her about it. Not sure if she read it or ignored it (?)

Rita
 
For a kitty that's on a very high carb diet and getting pred, Portia's numbers are pretty darn good. I know you want to change one variable at a time. Frankly, if you could change the carbs, I think you'd see a dramatic improvement in Portia's numbers. That said, given that you're seeing numbers that are largely below 300, I would not be overly aggressive with the dose.

Stepping back for a minute, I think you have 2 choices. You can follow TR with the understanding that you're not currently able to meet one of the criteria -- feeding low carb. However, it sounds like that could change. Whenever there's a kitty that has medical issues, the stance that is encouraged is to work the insulin around those issues. If Portia needs more insulin to offset the effect of the pred and/or the Z/A, then so be it. You just need to be aware that if the carb content of Portia's food changes, you will need to be vigilant because numbers could drop quickly. I see the advantage to TR being that it is inherently aggressive with regard to dose. You're evaluating the dose every 3 days. The TR Protocol also gives you a set of guidelines to follow with regard to dosing and those guidelines are based on research.

The other alternative is the Start Low Go Slow (SLGS) approach. With SLGS, you change the dose after 5 - 7 days. However, the change in dose remain 0.25u with Lantus. It's possible that this may be a better fit for your work schedule. The other difference is that with TR, the dose is reduced when numbers drop below 50 whereas with SLGS, doses are changed if numbers drop below 90.

Regardless of which method of dosing you use, you will need to test religiously at pre-shot and at least once during each cycle with the exception of when you're at work. It's especially important to get the PM tests if you're gone for the day. Testing is critical with TR because dose changes are closer together than with SLGS. With either strategy, dose changes are based on nadir. Again, with either TR or SLGS, it's the numbers that dictate whether doses are raised or lowered not what the kitty is eating. Like I said, for a kitty that's getting a whopping amount of carbs, her numbers are very good.
 
Hi Rita, I hope you can get Portia into some nicer numbers soon. I stopped in for a couple of reasons. My vet wanted me to do different dosing at night and that's what we did when were were originally on Caninulin. But she has experience only with Caninsulin and other fast acting insulins. There it makes sense, especially with people not testing, to do a lower dose at night so you can safely sleep. However, as Sienne says, that's not how Lantus works. Often the dose you are shooting now can impact the next cycle. Consistency is best.

The other thing I had to comment on was the Rayne Clinical Nutrition pet food. It peaked my interest because one of the proteins my furkids eat is kangaroo. I've only every seen kangaroo in pet foods in Canada, and it turns out Rayne is manufactured not very far from me. There are many paperwork issues with meat crossing the border to the US. I don't know of any Canadian pet food manufacturers that sell to the US. The website says they provide food for pets in Canada. If you can get it, I've yet to see a cat turn down kangaroo.
 
Hi Wendy and Sienne,
Thanks for stopping in. Im very confused as to what to do now. My vet is really good and has been amazing with Portia and Im hesitant to directly disobey her dosing instructions. But they clash with the TR protocol. So ugh.. I don know. I guess what Ill do is do the uneven dosing for 3 days. Ill be able to test more often in the coming week. See how she does. If her numbers are all over the place, then Ill talk to my vet, bring up the TR protocol with her (again) and see what she says. Its so important that I stay on her good side because Im going to need her to do me many favors in the coming year when I move to Peru. I need her to know that I can follow instruction and that she can trust me.

Thanks for commenting on Rayne Wendy. I looked on their website and they do ship to the US. I really want to try them. The nutritional profile of the Kangaroo diet looks really good. I just dont know how good they are. If you hear anything about them, please let me know. I know another person on the Feline pacreatitis group who might be trying them soon so maybe she'll have some input as well.

Thanks for your help. I hope its ok if I continue posting in the TR forum even though her food and dosing doesnt match the protocol. If you guys would rather I post in the general forum, I can do that as well.

Thanks again.
Rita
 
I think that given your situation, a good goal might just be keeping Portia in decent numbers, rather than trying to follow the TR protocol. There's nothing wrong with that and it might be safer. The goal of TR is to push a cat's BGs into normal, non-diabetic numbers (less than 100 most of the time) so that the cat's pancreas can heal and begin producing insulin again. i wouldn't rule that out with Portia, and the best chances for that happening are sooner rather than later following diagnosis.

however, with her eating high carb 34% food all the time i'm not sure how that would work if she had low numbers (less than 50) and you were trying to bring her up. it's not something i have experience in, although perhaps someone else can comment on it.

being unable to test at all in the evening cycle would make me nervous. if that's what it needs to be - and i'm not being judgmental about it, just saying that if you aren't ever able to get pm cycle tests, realistically, keeping her safe means keeping her blood sugar a little bit higher. many cats run lower at night. we all have stuff we have to work around - i'm just thinking i wouldn't want to encourage you to dose her in a way to push her blood sugar down knowing that you might not be able to catch her to pull them up.

so . . . i think i would be more conservative on the dosing. i think the SLGS guidelines that Sienne gave you is a good option. that includes .25u dose changes and leaving doses alone for a week to settle, then doing a curve. so perhaps that's more reasonable for these circumstances. we do have other people following those guidelines. if something changes and you want to try going to a lowcarb food and seeing if she's ok with it, then i think we could revisit the situation, and if you think you could get pm cycle tests, same thing. until then, i'd feel more comfortable helping you with the SLGS guidelines.

as far as the dosing goes, i agree 100% with sienne. when you change the dose of lantus, it's a bit like throwing a stone in a pond. there are ripples - it takes a few days for the dose to settle in, which is why we re-evaluate dose increases every 3-5 days or so. if you are changing the dose every 12 hours i think you'll have wonky numbers and it will be hard to see what's going on. one of the benefits of Lantus is that one can get blood sugar fairly stabilized in cats so they don't have a lot of fluctuations, and if the dosing keeps getting changed you're not going to see that. i'd encourage you to feel empowered to gather information and do what you think is right with your cat. Your vet may not have a lot of diabetic cat experience - i asked at my 3 vet practice and they had exactly 2 diabetic cats, mine and one other. and honestly, that wasn't their specialty and i got some advice that actually could've killed punkin. the people here picked up on the error and fortunately, he was ok. at that point, i began taking my dosing advice from here and followed the published Tight Regulation Protocol.

ultimately, these are your choices. Portia is your cat. i know any of us will help you and support you in whatever way is most helpful to you. we're just trying to give you the information, as best as we know, that will help you make decisions.

btw, at the end of your last post i was asking if you're doing the other things that help with pancreatitis - bupe for pain, sub-q fluids and vitamin B12.
 
hehe i take so long to write posts . . . both wendy and you had posted in the meantime.

it's absolutely ok to post here. the people here really understand lantus and we do have several people not following TR - so don't worry about that part.

we just want to help you as best as we can.

intriguing idea about the kangaroo!
 
Hi Julie,
Thanks for your input. I completely understand what youre saying. Im going to do the uneven dosing for 3 days just to please my vet. As you guys predict, her numbers will probably be all over the place and then I can talk to her about changing to fit the TR. Im afraid if I just go to her with nothing to substantiate my claim, she may not agree and I really cant afford to have a disagreement with her now. And when I say nothing to substanitate my claim I mean no offense to the group. I trust you guys completely which is why Im on here but like most vets, I dont know how mine feels about anecdotal data from internet support groups. I dont want her to dismiss it for that reason.

Sorry about not responding to your previous post. I completely forgot. I've had a crazy few days (hence the lax testing :(.
Portia does get pain medication (buprinex) twice a day. She doesnt get Sub Q fluids but I add 75-100ml of water into her canned food everyday so hopefully that's enough to keep her hydrated. Based on how her gums feel, I dont think she is dehydrated. Im not giving her B12 because her cobalmine levels were normal. Now granted we ran that test about a year ago and perhaps its time we run it again. Unfortunately, this diabetes diagnosis has set me back by about $600 and Im so short for money right now that I cant afford to run the B12 and folate test (which is fairly expensive). So, that will probably have to wait for a few months.

Wish us good luck. Im so torn and feel like Im caught between a rock and a hard place.

Rita
 
((((rita))))

most of us have been in your shoes. this feline diabetes is pretty - well, not fun. and expensive. although people here have all kinds of ways to minimize the costs.

i left my vet of 20ish years with punkin's diabetes. i really liked him and i thought he was a good vet and a good person. he's taken care of a dozen pets for us. so i really do understand.

many people here just nod their heads at the vet's dosing advice and then do what they want. you certainly don't have to provide a spreadsheet so she'll never need to know what you're doing - but i'm compulsively honest and i know i'd answer straight if i was asked.

everything about FD is hard at the beginning. it gets easier - in every way, as you learn more and get more experience.

i don't know if we ran a B12 test on punkin when he had pancreatitis. it's an accepted way to treat it and the Vit b12 itself is pretty cheap. we got injectible. there's some info on it in marje's post on pancreatitis (bottom of the NEw to the Group sticky). i thought it made a big difference in punkin - he perked right up with it. if you read the info on it and it's something you want to try, i wouldn't think you'd need to run a blood test for it, but i'm not certain. i don't think we did.
 
oh yeah, and you KNOW vets love it when you say you're getting advice off an internet group! :lol: :lol: :lol: i think the internet is the bane of professionals. it lets us all get the professional studies that used to be found in books in specialty libraries. i can imagine how aggravating that would be.
 
Like Julie and Wendy said, it's absolutely fine to post here. All that I would ask is that we're all clear on what you're doing. We don't want to push you into anything you're not comfortable with or that runs counter to your goals for Portia. If you absolutely can't test at night, then it will make sense to have Portia stay in slightly higher numbers. (Is it at all possible to get a test before you go to bed at night?) If that's the case, I'd think about trying to keep Portia's numbers below about 240 so she stays below renal threshold.

As for your vet, I completely understand. While there are LOTS of vets who are great at what they do, many of them are not terribly well versed at diabetes management. I don't want to put you in a position where you are second guessing your vet or alienating her. Of course, there are many people who never show their vet their kitty's SS. By the same token, if it means having the data to show the vet (or us) that something is or isn't working, that's a reasonable approach.
 
Hey guys,
Thank you all for the amazing feed back and support. So here's the plan for the next 3 or so days:

1. Do the uneven dosing as suggested by the vet.
2. Check Pre-shots and atleast 1 time point in between the shots during the am and pm cycle.
3. I will get a +5-+6 shot in the pm cycle every night
4. After 6 consecutive cycles of the uneven dosing, run a curve to see where her levels are at.

At that point, you guys can tell me what you think. As I mentioned, her vet actually wanted me to do 2U in the am and IU in the pm. Im not doing that for now but will revisit this after 3 days.

Does this make sense?

Julie, I dont think my vet will prescribed B12 without checking her cobalamine first. She said Portia dint need it if her levels were normal.However, I will ask her about it since Portia's been down the last week or so.

Rita
 
Hi Rita,

I wanted to comment a little bit on diets and protocols. Sienne is right, the Tight Regulation Protocol is based on a cat receiving a low carb wet food diet. My last kitty, KK, was eating some dry food and a higher carb wet food due to some other issues. I'm a big believer in Tight Regulation, but did not feel it was safe to follow the protocol to the letter when his diet was not appropriate for it. What I decided to do was to mostly follow the TR protocol, but I just didn't let him go as low. The protocol calls for giving a reduction if the cat cat goes under 50, but I did reductions if he started getting close to 60. I also did not increase as aggressively once he was getting green numbers. It's not perfect, but I felt that gave me enough wiggle room to be able to keep him safe and in good numbers with a less than ideal diet.

Dealing with the vet can be tough. With Lucy, I did a fair amount of fibbing to my vet. I did send her numbers, just not all of them. Once Lucy was very well regulated, then I showed off her spreadsheet. :mrgreen: When I got Jazzy, and later KK, the vet remembered that and left me alone about their dosing.
 
Hi Libby,
Thanks for the input. I think I may follow what you did for your cat and try to get her to into the blues and stay there. I have a problem lying to the vet. Not in principle but just in execution!! Ill probably have to start doing that soon if her numbers become wonky and the vet wont change the dosing. We'll just have to wait a few days and see.
Thanks
Rita
 
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