11/28 - Gen, AMPS >400, PMPS >400

[Allie & Gen]

Yesterday

So after a chill AM cycle, Gen had a very alarming PM cycle that kept me up until almost 4AM and I have no idea why. I'm pretty freaked out and incredibly overtired, and could really use some input.

He went diving down again. He hadn't eaten much of his evening meal, but he was also showing in the "HI" (over 400) range when I gave him his shot. When he got down into the double digits after only a few hours, though, I decided I needed to make sure he ate something. He wasn't showing much interest in the salmon pate, so I tried a scoop of dry food which he also didn't seem too excited about. I still had a bag of Temptations so I offered him one, then put a second one into the dry food so he'd have to "chase" it, and he ate a bit more at that point.

For several hours he hovered around the 70s-80s. He set off the "urgent low glucose" alarm (<55) a couple of times, although the app data isn't showing numbers lower than the 60s now. When he finally climbed into the 100s I went to bed with the phone right by my head in case of more alarms.

He seemed to be feeling just fine the whole time. Very cuddly, very alert when the alarm went off.

This morning I find him back at "HI" again. I don't understand what's happening. (Also, nights like that would become a huge problem during the work week. I feel like death.)

He ate well and I'm certainly giving him his shot (in about 15 minutes), but??

 

[Mary & Jude]

Hi! It looks like he's bouncing. This can happen when the insulin starts to bring them into normal numbers that their body is not used to. Here is the definition of bouncing:

"Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles)."

Sometimes cats bounce a lot at the very beginning of treatment until they start feeling more comfortable in those lower numbers. But we also have some cats on the forum that are chronic bouncers.

 

[Allie & Gen]

Does bouncing go in both directions? I thought that meant going high after unaccustomed low numbers. I don't understand why he went so far down last night; right now, the fact that he came all the way up to the red is much less alarming to me than the steep drop. I'm worried about him going hypoglycemic while I'm asleep! (And I really need more sleep. )

 

[Allie & Gen]

So far today we're staying up high, just dipping into the upper 300s in between hours. I don't know. I took a nap, still pretty wiped out, which makes thinking through all this a little challenging.

That said, my rather excellent vet is back in the office today; she sent me a brief email and we should have a longer chat later. Going off what I had told her mid-day on Tuesday, she's thinking dietary changes instead of insulin. I sent her data to catch her up, so we'll see what she thinks after that.

 

[Mary & Jude]

A drop below 90 earns a dose reduction on SLGS. Here is the sticky explaining the dosing adjustments: Sticky - Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR)

The next dose down is a 0.1. Here is a sticky that shows what this looks like on the syringe: Sticky - Insulin Care & Syringe Info: Proper Handling, Drawing, Fine Dosing

I'm also going to tag @tiffmaxee and @Wendy&Neko for more experienced guidance.

 

[Staci & Ivy]

Yesterday

So after a chill AM cycle, Gen had a very alarming PM cycle that kept me up until almost 4AM and I have no idea why. I'm pretty freaked out and incredibly overtired, and could really use some input.

He went diving down again. He hadn't eaten much of his evening meal, but he was also showing in the "HI" (over 400) range when I gave him his shot. When he got down into the double digits after only a few hours, though, I decided I needed to make sure he ate something. He wasn't showing much interest in the salmon pate, so I tried a scoop of dry food which he also didn't seem too excited about. I still had a bag of Temptations so I offered him one, then put a second one into the dry food so he'd have to "chase" it, and he ate a bit more at that point.

For several hours he hovered around the 70s-80s. He set off the "urgent low glucose" alarm (<55) a couple of times, although the app data isn't showing numbers lower than the 60s now. When he finally climbed into the 100s I went to bed with the phone right by my head in case of more alarms.

He seemed to be feeling just fine the whole time. Very cuddly, very alert when the alarm went off.

This morning I find him back at "HI" again. I don't understand what's happening. (Also, nights like that would become a huge problem during the work week. I feel like death.)

He ate well and I'm certainly giving him his shot (in about 15 minutes), but??

View attachment 75338

Sorry you had such an exhausting night
I agree with Mary, looks like he is bouncing from those lows.
Ivy has similar cycles, I will attach her graph from last night, you can see her overnight dip and then she jumped up again this morning.

I’m curious to see what your vet says, if they feel only a diet change can work.

When Ivy was diagnosed we tried just a diet tweak (she never ate dry, but we went to a 6% wet food which I cook for her).

Didn’t work for us (diet only) and we began insulin. Here we are.
Hope you can get some rest today

 

[Tyleete]

My cat has swung crazy like that a couple times. And it is extremely terrifying. Heck, mine's still not adjusted, but his swings seem less defined as before thankfully.
It says explained in the same basic way as above to me. When their bodies hit new lows, their internals kind of freak out like.... What the heck is this!?! Backup backup!
That's what a bounce is. The body throwing everything at it to 'fix' the problem. Adjustments is dosage help this. Hang in there.

 

[Allie & Gen]

Well, on Tuesday I was wondering about dropping the insulin, at least for now, and making dietary changes instead. This was after his hypoglycemic crisis (where he came back up on IV therapy, and then dove a second time, in the hospital thankfully so they could respond immediately), and then the very next time we tried insulin and halved his dose, he dove again and wasn't coming back up at all until I skipped his shot and fed HC food. But I've had him on insulin since then, having changed my mind because the high numbers had me worried and I wasn't able to talk to my vet.

I've learned a number of things over the last few days that I want to discuss with her, including the ways in which periodontal infection affects diabetes, the existence of the depot (I had no idea, in spite of past experience). And ... I have a new suspicion that I seriously screwed up the dosage I was giving him last week and am still not reporting it correctly. Which is both humiliating and horror/guilt-inducing and it's hard to talk about. I'm trying to sort it out in my head.

 

[Tyleete]

Well, on Tuesday I was wondering about dropping the insulin, at least for now, and making dietary changes instead. This was after his hypoglycemic crisis (where he came back up on IV therapy, and then dove a second time, in the hospital thankfully so they could respond immediately), and then the very next time we tried insulin and halved his dose, he dove again and wasn't coming back up at all until I skipped his shot and fed HC food. But I've had him on insulin since then, having changed my mind because the high numbers had me worried and I wasn't able to talk to my vet.

I've learned a number of things over the last few days that I want to discuss with her, including the ways in which periodontal infection affects diabetes, the existence of the depot (I had no idea, in spite of past experience). And ... I have a new suspicion that I seriously screwed up the dosage I was giving him last week and am still not reporting it correctly. Which is both humiliating and horror/guilt-inducing and it's hard to talk about. I'm trying to sort it out in my head.

I'm sorry you're having such issues. It's probably hard to tell yourself this, but try.
You're doing the best you can.
And no one here will judge you for any kind of misstep. Everyone has them to one extent or another, and we really do the best we can with what we have.
There is SO much to read and try to wrap your head around. I've asked so many hypothetical questions, I've driven most buggy.ggy.t that's just me. I want to be so prepared for what could come, that sometimes I miss what's right there. It's just my nature.
So please try not to beat yourself up needlessly.
As for not trying insulin, I think I'd only feel safe trying that if my cats original numbers were in low 300's or less and she was eating a med-high carb food beforehand. But that's just me personally. I had 1 girl go into remission very quickly. But she went onlyonly a with less 1% carbs (and it's dry) and her numbers weren't very high.

 

[Mary & Jude]

Well, on Tuesday I was wondering about dropping the insulin, at least for now, and making dietary changes instead. This was after his hypoglycemic crisis (where he came back up on IV therapy, and then dove a second time, in the hospital thankfully so they could respond immediately), and then the very next time we tried insulin and halved his dose, he dove again and wasn't coming back up at all until I skipped his shot and fed HC food. But I've had him on insulin since then, having changed my mind because the high numbers had me worried and I wasn't able to talk to my vet.

I've learned a number of things over the last few days that I want to discuss with her, including the ways in which periodontal infection affects diabetes, the existence of the depot (I had no idea, in spite of past experience). And ... I have a new suspicion that I seriously screwed up the dosage I was giving him last week and am still not reporting it correctly. Which is both humiliating and horror/guilt-inducing and it's hard to talk about. I'm trying to sort it out in my head.

What are your concerns about the dosage and maybe we can help sort it out with you? Listen, people make mistakes often with their cats. The most important aspect is that you are trying your best to help him.

 

[Allie & Gen]

No, my inclination is to stick with the insulin. I don't really know what Gen's numbers were in 2021, but he went into remission when he was on a relatively med/high-carb diet (which I did not realize) and a dose of 1u for three months. He's older now and has other health factors, but I think insulin is still the way to go. I was just bewildered by the reactions he had last week and at the start of this week, and I'm developing a theory that it was because I was overdosing him, significantly.

I'd done all this before! Administering insulin is pretty easy for me, especially compared to manual BG tests or oral syringes! I felt confident going into treatment this time, like I was on familiar ground after a difficult few months with a false cancer diagnosis and a postponed oral surgery and a lot of other life stuff. But I think I actually remembered how to measure the dose on the syringe completely wrong. I think that when I thought I was giving him 1U, I was giving him 5.

If that's the case, he'd been on that dose for 7 cycles when the hypoglycemic crisis happened. And I told the ER vet I'd been giving him 1U. She was very confused and worried when his BG dove a second time in the hospital, well after the scheduled time for his next shot. She thought the insulin should have been mostly out of his system by then. But ... if he'd been on a much higher dose for days, the depot might explain that, right? Not such a medical mystery after all.

My vet was also so confused about what had happened, which is why we were really cautious. We put on the Libre but waited out the weekend (hoping to get useful data) before starting a lower dose. (He was sky high the whole time.) So Monday we had another appointment and she told me to go to 0.5U. But I, still not suspecting my own error, would have given him 2.5U instead. The result: he took a dive all night long, I woke up Tuesday to find he'd gone from >400 to 61 and panicked. I got his numbers back up, but then my vet was out sick, and I had to decide what to do on my own (with the lovely advice and help from this board). So I decided on a reduction, but I also decided to skip his evening shot (no shots on Tuesday) because I wanted to be able to be awake and monitoring him closely.

So on Wednesday morning I gave him what I thought was .24U, but was probably actually a slightly fat 1U. Which is what he's been on for the the last not-quite-4.5 cycles.

No wonder it's been such chaos.

I'm trying to get past thinking "I almost killed my baby boy because of a stupid mistake" and think rationally about this, but it's a little challenging!

Given all of the above, I'd be very grateful for anyone's thoughts on the state of my poor boy's system at this point. I'm still not sure I understand why he took a big dive again last night (albeit one he came back up from, like a really deep cycle, not an all-night plunge like Monday night into Tuesday).

And yeah. I need to talk to my vet, because she's operating on incorrect information.

Here's where I'd start swearing, but it feels like manners around here are too nice for my potty mouth.

 

[Tyleete]

I'm a beginner, but this are my thoughts....
It's going to take a little to get him situated after a larger than planned dose. Being as it's a depot insulin, even changing it right away, it's not going to be instant. The pros can explain that more on time frame you might be looking at.
But 7 cycles isn't the end of things and you realized the mistake before it was too late, and that's what matters now.
You know what helps me get past the passing of a cat? I tell myself to find what I could've done wrong or different and learn from it. So it won't be for nothing. You've got the benefit of your precious one still being with you and can learn from it. So as long as you learn from a mistake, you're good.

 

[Allie & Gen]

Just to be clear, if I have this right now, it went like this:

• 7 cycles on 5U --> hypoglycemic crisis
• 9 "cycles" (4.5 days) of no insulin
• 1 cycle of 2.5U --> scary drop
• 2 "cycles" (1 day) of no insulin
• 4 cycles of 1U - he's in the middle of his 5th

I have emailed my vet this information, and I am going to go take some deep breaths and eat something. I really screwed up (and have paid for it), but Eugenides seems to be doing reasonably well now; I just don't know how much insulin he may still have in his system or how best to proceed with dosing.

My poor, beloved boy. I wish there were a way to apologize to a cat. Not that it would feel like enough just to say "sorry."

 

[Mary & Jude]

No, my inclination is to stick with the insulin. I don't really know what Gen's numbers were in 2021, but he went into remission when he was on a relatively med/high-carb diet (which I did not realize) and a dose of 1u for three months. He's older now and has other health factors, but I think insulin is still the way to go. I was just bewildered by the reactions he had last week and at the start of this week, and I'm developing a theory that it was because I was overdosing him, significantly.

I'd done all this before! Administering insulin is pretty easy for me, especially compared to manual BG tests or oral syringes! I felt confident going into treatment this time, like I was on familiar ground after a difficult few months with a false cancer diagnosis and a postponed oral surgery and a lot of other life stuff. But I think I actually remembered how to measure the dose on the syringe completely wrong. I think that when I thought I was giving him 1U, I was giving him 5.

If that's the case, he'd been on that dose for 7 cycles when the hypoglycemic crisis happened. And I told the ER vet I'd been giving him 1U. She was very confused and worried when his BG dove a second time in the hospital, well after the scheduled time for his next shot. She thought the insulin should have been mostly out of his system by then. But ... if he'd been on a much higher dose for days, the depot might explain that, right? Not such a medical mystery after all.

My vet was also so confused about what had happened, which is why we were really cautious. We put on the Libre but waited out the weekend (hoping to get useful data) before starting a lower dose. (He was sky high the whole time.) So Monday we had another appointment and she told me to go to 0.5U. But I, still not suspecting my own error, would have given him 2.5U instead. The result: he took a dive all night long, I woke up Tuesday to find he'd gone from >400 to 61 and panicked. I got his numbers back up, but then my vet was out sick, and I had to decide what to do on my own (with the lovely advice and help from this board). So I decided on a reduction, but I also decided to skip his evening shot (no shots on Tuesday) because I wanted to be able to be awake and monitoring him closely.

So on Wednesday morning I gave him what I thought was .24U, but was probably actually a slightly fat 1U. Which is what he's been on for the the last not-quite-4.5 cycles.

No wonder it's been such chaos.

I'm trying to get past thinking "I almost killed my baby boy because of a stupid mistake" and think rationally about this, but it's a little challenging!

Given all of the above, I'd be very grateful for anyone's thoughts on the state of my poor boy's system at this point. I'm still not sure I understand why he took a big dive again last night (albeit one he came back up from, like a really deep cycle, not an all-night plunge like Monday night into Tuesday).

And yeah. I need to talk to my vet, because she's operating on incorrect information.

Here's where I'd start swearing, but it feels like manners around here are too nice for my potty mouth.

You will find no judgment here; this is a place where we want to help both you and Gen. We've all made mistakes before. I'm just glad that you figured out your mistake. Gen is fortunate to have you; it is clear you want the very best for him.

Other than the dosing advice you've requested, do you feel completely comfortable with your decisions on dosing now? If you want to run anything by us--like photos of syringes, with dose measures, etc.--we'll be glad to double check you just to make sure everything looks right.

I do hope that someone will pop in soon to address the concerns you mentioned. Being that it's Thanksgiving weekend, we seem to be rather short-handed on the board. I'm going to tag a couple of other more experienced folks for you: @Bandit's Mom @Sienne and Gabby (GA)

 

[Allie & Gen]

I'm a beginner, but this are my thoughts....
It's going to take a little to get him situated after a larger than planned dose. Being as it's a depot insulin, even changing it right away, it's not going to be instant. The pros can explain that more on time frame you might be looking at.
But 7 cycles isn't the end of things and you realized the mistake before it was too late, and that's what matters now.
You know what helps me get past the passing of a cat? I tell myself to find what I could've done wrong or different and learn from it. So it won't be for nothing. You've got the benefit of your precious one still being with you and can learn from it. So as long as you learn from a mistake, you're good.

Thank you. That's kind. Eugenides is my first cat, and I had wanted one very much all my life. We've been together ten years and he is my family. So, I am more grateful than I can say that he's not a casualty of an easily avoided mistake.

You will find no judgment here; this is a place where we want to help both you and Gen. We've all made mistakes before. I'm just glad that you figured out your mistake. Gen is fortunate to have you; it is clear you want the very best for him.

Other than the dosing advice you've requested, do you feel completely comfortable with your decisions on dosing now? If you want to run anything by us--like photos of syringes, with dose measures, etc.--we'll be glad to double check you just to make sure everything looks right.

I do hope that someone will pop in soon to address the concerns you mentioned. Being that it's Thanksgiving weekend, we seem to be rather short-handed on the board. I'm going to tag a couple of other more experienced folks for you: @Bandit's Mom @Sienne and Gabby (GA)

Thank you so much for your kindness. I do very much want the best for Gen. Right now it feels as though he deserves much better than me, but I'm what he's got, so I'd better keep going.

I'm completely comfortable with my ability to use a syringe and measure the correct dose; the error seems very obvious indeed in retrospect, all I really needed was a look at the images in the sticky post about "Insulin Care & Syringe Info" (which I hadn't looked at before, because I thought I knew what I was doing).

I would certainly accept dosing advice in terms of how much to use going forward, or any insight into what repercussions from the higher doses (and gaps in administration) might continue to have. I'm reading over the post about the depot; maybe this bit is relevant to last night?

A dose reduction will usually result in a need for less stored insulin. The excess may be released into the bloodstream faster than usual, especially if several dose reductions are done back-to-back.

I am inclined to think that holding the current 1U dose might be for the best, to see if there are irregularities still working themselves out, but I'm not sure, and I know that I am going to have to start leaving him alone again for at least 8 hours/day, 4 days a week, starting Monday. (I'm allowed to work from home on Wednesdays.) That gives me something of a deadline to have him reasonably stable, if at all possible. Trouble with my job means trouble with funding his care, after all.

 

[Allie & Gen]

I guess one of the things (probably the most immediate thing) I'm stuck on is: do I hold this dose?

With SLGS, I should have reduced this morning after he dropped past 90 last night, but with him back up over 400 that felt strange. I didn't reduce. And he's staying awfully high today.

Since I started him on this dose (a slightly fat 1U, which I thought was 0.25U because of the error described above):
Cycle #1 - pinks/yellows, nadir = 266 (AMPS + 5), never went back to 400 or above
Cycle #2 - mostly pink, early nadir = 288 (AMPS + 4), back up above 400 by +9
Cycle #3 - took longer to drop below 400, pinks/yellows with more yellows this time, nadir = 211 (+5), back up to above 400 by +11
Cycle #4 - giant dip through every color. nadir = 64 (+6.25)(!!!), dropped steeply, spent 5 hours in blues/greens, rose steeply up to 400 by +11
Cycle #5 - current cycle. took more than 2 hours to drop below 400, reds/pinks with a dip into yellow. (Libre apps are having some connectivity issues right now.)

In other words, he's been fairly high with last night being a very dramatically different, and I don't know if that's to do with the overdosing last week/lower but still overdose Monday night, or something else.

 

[Mary & Jude]

Eddis, are you able to hand test Gen or is he Libre-only?

In terms of the dose decision, keep in mind that it can take about 6 cycles for the depot to build and/or readjust. So he's been on the 1 unit now for five cycles. The fact that he experienced a number lower than 90 is a significant factor to consider (under SLGS) because the 1-unit dose's depot is nearly built now, and if he is hitting lower numbers on it, then you need to pay attention to those nadirs. The nadirs can tell us if the kitty is getting too much insulin. One thing you might consider is switching to TR, which has a lower reduction number (50 for newly diagnosed kitties), and which allows you to hold the dose longer. Under TR you have to test at least two times per cycle (including the preshot), and you're certainly doing that with the Libre. Also, under TR, they are not allowed to eat kibble.

Again: the dosing sticky: Sticky - Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR)

 

[Allie & Gen]

He's Libre-only right now. I have a handheld monitor, lancets, and (newly-purchased) strips, but he had an intensely adverse reaction to home monitoring when we tried in 2021, until I eventually stopped (my vet and I were in agreement) because it was causing him huge amounts of stress and I wasn't able to get enough blood to get a usable reading. My plan is to try and get us to occasional testing, but I think it needs a very slow, careful approach? He reacts very negatively to just about any attempt to interfere with him physically (trying to give him a liquid antibiotic with a plastic syringe was a full panicky freakout, and he would NOT let me get his mouth open to put honey on his gums when I tried Tuesday morning, though thankfully that wasn't ultimately necessary).

Plus I'm all alone here, and in spite of being underweight, he's a big cat. I can't restrain him well on my own for any length of time, even if that seemed like a great idea (stress, etc). So for right now, I don't think a usable test is possible for us. I'd be willing to try if necessary but I'm worried about causing more harm than good, if that makes sense.

I'll consider switching to TR, but I was planning to wean him off the kibble slowly. He's always had both wet and dry, but he's consistently more enthusiastic about the dry, and that was all I could get him to eat last night when the numbers were so low. Also, I'm not home to feed small meals during the day for more than half a week, so I'd need an autofeeder. So many variables, so much that could go wrong.

I'm sorry, even without the stupid syringe mistake (I still can't believe it, but I'm trying not to focus on that) ... I feel like I must be making this overcomplicated. I'm under some pressure because of my stupid job and its on-site requirements. (Also I still haven't talked to my vet; she said she'd be calling me but the office closes in half an hour and now I can't get through to anyone there by phone. It's a small office and they get pretty overbooked sometimes, but augh.)

I feel like such a whiner. Thank you for your patience with me.

 

[Allie & Gen]

Having reviewed the dosing post again, I think I need to stick to SLGS for now because of all the variables I'm dealing with (diet not right for TR, periodontal disease, I'm not home during the day 4 days/week). I think?

What I'm stuck on is really this: his numbers dropped below 90 yesterday, which would mean a decrease. But at the same time, his numbers have been so high otherwise since we've started this dose. His nadirs have all been in the 200s, otherwise (look like this cycle's was 290). Reducing just seems counterintuitive. But I can't explain last night, which seems so out of nowhere in context. Maybe the highs right now are him bouncing even though they seem to match the first three cycles. It really is pretty confusing to me, and admittedly realizing the big mistake I made today has thrown me enormously.

I have about two hours to decide: reduce, or hold? I know too high is better than too low. SLGS doesn't have failed reductions, right? So I'd hold the reduced dose for a week, even if he's just up in the red and pink the whole time?

I appreciate your input so much, @Mary & Jude . I hope that's been clear at least, even while I flail around. What a day.

 

[Staci & Ivy]

He's Libre-only right now. I have a handheld monitor, lancets, and (newly-purchased) strips, but he had an intensely adverse reaction to home monitoring when we tried in 2021, until I eventually stopped (my vet and I were in agreement) because it was causing him huge amounts of stress and I wasn't able to get enough blood to get a usable reading. My plan is to try and get us to occasional testing, but I think it needs a very slow, careful approach? He reacts very negatively to just about any attempt to interfere with him physically (trying to give him a liquid antibiotic with a plastic syringe was a full panicky freakout, and he would NOT let me get his mouth open to put honey on his gums when I tried Tuesday morning, though thankfully that wasn't ultimately necessary).

Plus I'm all alone here, and in spite of being underweight, he's a big cat. I can't restrain him well on my own for any length of time, even if that seemed like a great idea (stress, etc). So for right now, I don't think a usable test is possible for us. I'd be willing to try if necessary but I'm worried about causing more harm than good, if that makes sense.

I'll consider switching to TR, but I was planning to wean him off the kibble slowly. He's always had both wet and dry, but he's consistently more enthusiastic about the dry, and that was all I could get him to eat last night when the numbers were so low. Also, I'm not home to feed small meals during the day for more than half a week, so I'd need an autofeeder. So many variables, so much that could go wrong.

I'm sorry, even without the stupid syringe mistake (I still can't believe it, but I'm trying not to focus on that) ... I feel like I must be making this overcomplicated. I'm under some pressure because of my stupid job and its on-site requirements. (Also I still haven't talked to my vet; she said she'd be calling me but the office closes in half an hour and now I can't get through to anyone there by phone. It's a small office and they get pretty overbooked sometimes, but augh.)

I feel like such a whiner. Thank you for your patience with me.

I’m sorry it’s been so rough. But so glad you figured out the mistake!
And he’s doing ok, whew.

As for the dose, since you’re following SLGS, (since you’re feeding dry food) if he goes under 90 you reduce by .25 units.
So his next dose will be 0.75 units, (down from 1 unit).

As a reminder, when he bounced up high, we ignore those numbers since dosing decisions are made by watching how LOW a dose takes your cat (nadirs).

Make sense?
Congratulations on the reduction!

 

[Staci & Ivy]

Having reviewed the dosing post again, I think I need to stick to SLGS for now because of all the variables I'm dealing with (diet not right for TR, periodontal disease, I'm not home during the day 4 days/week). I think?

What I'm stuck on is really this: his numbers dropped below 90 yesterday, which would mean a decrease. But at the same time, his numbers have been so high otherwise since we've started this dose. His nadirs have all been in the 200s, otherwise (look like this cycle's was 290). Reducing just seems counterintuitive. But I can't explain last night, which seems so out of nowhere in context. Maybe the highs right now are him bouncing even though they seem to match the first three cycles. It really is pretty confusing to me, and admittedly realizing the big mistake I made today has thrown me enormously.

I have about two hours to decide: reduce, or hold? I know too high is better than too low. SLGS doesn't have failed reductions, right? So I'd hold the reduced dose for a week, even if he's just up in the red and pink the whole time?

I appreciate your input so much, @Mary & Jude . I hope that's been clear at least, even while I flail around. What a day.

Any time he goes under 90 with SLGS you will need to reduce by 0.25 units (post here with questions and get clarification).

His depot is all wonky from all of the ups and downs. It needs to stabilize.
You don’t hold a dose for a week if he drops under 90.

You do hold a dose for a week with SLGS (as long as no drops under 90). Then you would evaluate his nadirs that week to see how low the dose it taking him.
(Easy to see on the Libre).

 

[Allie & Gen]

I’m sorry it’s been so rough. But so glad you figured out the mistake!
And he’s doing ok, whew.

As for the dose, since you’re following SLGS, (since you’re feeding dry food) if he goes under 90 you reduce by .25 units.
So his next dose will be 0.75 units, (down from 1 unit).

As a reminder, when he bounced up high, we ignore those numbers since dosing decisions are made by watching how LOW a dose takes your cat (nadirs).

Make sense?
Congratulations on the reduction!

Thanks - hard to feel like I deserve congratulations right now, but Gen pretty much always deserves praise, so I'll take it.

I know we look at the nadirs, I suppose I just didn't expect them to be so drastically different! But I don't know why I think I should have expectations here, I'm new to these protocols.

Any time he goes under 90 with SLGS you will need to reduce by 0.25 units (post here with questions and get clarification).

His depot is all wonky from all of the ups and downs. It needs to stabilize.
You don’t hold a dose for a week if he drops under 90.

You do hold a dose for a week with SLGS (as long as no drops under 90). Then you would evaluate his nadirs that week to see how low the dose it taking him.
(Easy to see on the Libre).

Okay, yes, I've got it. Sorry, I think I hit a limit on how much I was able to take in. I napped, but I'm probably still pretty overtired!

What a couple of weeks this has been. It was already a doozy of a year. Time to shake it off and stop fretting/clinging to the app quite so continuously, I think. Is that ever a problem for you? Obsessing too much about the minutiae of each cycle?

 

[Staci & Ivy]

Thanks - hard to feel like I deserve congratulations right now, but Gen pretty much always deserves praise, so I'll take it.

I know we look at the nadirs, I suppose I just didn't expect them to be so drastically different! But I don't know why I think I should have expectations here, I'm new to these protocols.


Okay, yes, I've got it. Sorry, I think I hit a limit on how much I was able to take in. I napped, but I'm probably still pretty overtired!

What a couple of weeks this has been. It was already a doozy of a year. Time to shake it off and stop fretting/clinging to the app quite so continuously, I think. Is that ever a problem for you? Obsessing too much about the minutiae of each cycle?

Don’t apologize at all. We understand fully the overwhelming situation and it’s why we old timers are here. To pay it forward.

We were you not that long ago. And by the way, I’m still learning every single day by sticking around here. I’ve been here three years, and I learn something new every day by talking, discussing, reading and asking more questions.

The more you ask, and the more you post, the more you’ll learn, so hang in there and keep doing what you’re doing.
It’s because you kept talking to us that you probably realized what happened and you were able to correct the situation quickly.

 

[Allie & Gen]

Thank you, @Staci & Ivy .

Also I finally finally talked to my vet, which meant we discussed a bunch of the things I've learned being here. Which was great! She was on board with the reduction plan but suggested we do 0.5U instead of 0.75U. Which I'm going to do. She's spent time with Gen, and we have a really good working relationship (I know a lot of folks here have less than stellar experiences with their vets, and I've had some too, but this one's really a gem). She's been interested in learning from what I pick up here, too. It's good to have multiple trustworthy perspectives and collaborative approaches to care.

We're also discussing next steps around addressing Gen's dental issues with an eye towards considering how they put pressure on his diabetes.

 

[Mary & Jude]

Good luck with the decrease!

 

[Sienne and Gabby (GA)]

The other factor that no one mentioned is that a cat can be exquisitely sensitive to insulin after a hypoglycemic episode. I suspect that was what was going on with Gen. There's also not enough data on your spreadsheet (in terms of days) to know how your cat "typically" responds to insulin or dose changes. As others have noted, the other thing you were dealing with were bounces.

I agree that the numbers on your spreadsheet aren't pretty. Please remember that with either SLGS or TR you change doses in 0.25u increments. The drop from 1.0u to 0.5u may be why you're seeing higher numbers.

The dental issues may also be contributing to the high numbers. We've seen lots of cats fall out of remission due to dental concerns. If your vet insists that Gen needs to be better regulated before doing anything dental, you may want to consult with a veterinary dentist. Keep in mind that human diabetics get dental work done. Unless there is some other medical reason for anesthesia to be a problem, the dental issues aren't helping you to get Gen into lower numbers.

 

[Allie & Gen]

The other factor that no one mentioned is that a cat can be exquisitely sensitive to insulin after a hypoglycemic episode. I suspect that was what was going on with Gen. There's also not enough data on your spreadsheet (in terms of days) to know how your cat "typically" responds to insulin or dose changes. As others have noted, the other thing you were dealing with were bounces.

I agree that the numbers on your spreadsheet aren't pretty. Please remember that with either SLGS or TR you change doses in 0.25u increments. The drop from 1.0u to 0.5u may be why you're seeing higher numbers.

The dental issues may also be contributing to the high numbers. We've seen lots of cats fall out of remission due to dental concerns. If your vet insists that Gen needs to be better regulated before doing anything dental, you may want to consult with a veterinary dentist. Keep in mind that human diabetics get dental work done. Unless there is some other medical reason for anesthesia to be a problem, the dental issues aren't helping you to get Gen into lower numbers.

I actually spoke to a doctor friend about Gen too, and she mentioned the sensitivity issue, though it's true that I haven't found any reference to it here in the forum or anywhere else re: diabetic cats. I wasn't entirely sure if it was a human thing. I appreciate you bringing it up.

I have to admit, in addition to my vet's advice, part of the reason I decided to go with the reduction I did is that I do not currently have access to syringes with half-unit markings and I was worried about varying too much between doses. My confidence about dosing has taken something of a hit. That said, given that his numbers continue to be so high, I'm thinking about a 0.25 increase to 0.75 after all, even though it's not strictly how the protocol works.

I'm aware of the likely contribution of the dental issues. In fact, it was a veterinary dentist who refused to work on Gen two weeks ago after doing a preliminary blood test. I went to them based on a referral from a vet from my usual practice, who is not my usual vet, but was filling in because of a medical leave - now that my usual vet is back, she went over everything and will likely be able to take care of Gen's dental work in-house, which won't involve the kind of delays that are involved in getting onto the specialist's schedule. She's also not insisting that we get his BG to some perfectly stable place, but we are trying to improve it a little.

I am doing my best to make the right decisions and balance my own limitations. My financial and employment circumstances are restrictive; as I'm going to have to return to my office full-time four days/week starting tomorrow, my first concern has been to make sure Gen isn't likely to have another hypoglycemic crisis in my absence. There is no one who can step in to help with his care. I don't have access to a car, so in an emergency I have to get back to my apartment (20 minutes give or take) then call a rideshare, plus the 30-ish minute drive to the emergency vet (located in a congested part of downtown Boston; depending on time of day the ride could be longer still). I'm trying to take all these factors into account.

I truly appreciate all this input, thank you. However, I am fairly overwhelmed. I want to be receptive to all the knowledge and expertise around here and I don't want to come off as though I'm ignoring it or pushing back, but please understand that I'm also struggling with a lot of complexity.