11/28 Pumbaa AMPS/131 +3/237 +8/323 PMPS/345

[Pumbaa]

NOTE: Pumbaa's SS is in reverse with the most current data at the top.

I gave Pumbaa one drop short of his 2.50U dose this morning, in an attempt to prevent these swings. But, since he was at 345 at his PMPS, he got the full 2.50U.

Pumbaa, Pumbaa, Pumbaa...I know you hate these drastic swings in your numbers as much as I do. I wish I could do more for you to prevent them, little guy!

As soon as this bounce clears, and he settles down again, I think it's time to take him up to 2.75U. (Barring his settling into flat blues and greens in the meantime.)

On the Lantus, he was getting good runs of blues and greens on 2.25U and 2.50U, and, even though the Levemir is supposed to be more potent than the Lantus, it might be possible that FD cats who are switched to Levemir after Lantus need more insulin to break through, due to developing insulin resistance. But cats who are started on Levemir may need much lower doses. Yes? No? Input on this is very welcome. It would make a great discussion.

I'm happy that we haven't seen a red number since 11/9/12, and I'm still very pleased that Pumbaa doesn't react negatively to his Levemir injections like he did to the Lantus. And, I can't tell you how much easier it is to dose the Levemir (much thinner in substance, almost no air bubbles, much less waste) than it was the Lantus. So, while I was praying that Levemir would prevent any and all swings in Pumbaa's BG numbers, the benefits outweigh the trouble of transitioning from one insulin to another. And Pumbaa really is much less of a SuperBall on Levemir than he was on Lantus. But ECID. I just wish more vets would give Levemir a try from the get-go, and that someone would do a study on FD cats started on each of the two L insulins for a comparison.

Suze

 

[Dale 'n' Chip]

I suspect you need to breakthough to a good working dose, and that may well be *much* higher than you saw on Lantus after all this time.

I'm glad you abandoned the idea of that "micro drop" chicken shot or whatever that was? I'm pretty sure that will only make the problem worse.

Likely better is consistent dosing (identical to the drop) and probably the digital calipers to make it that much easier.

The best (and probably only) way to stop the swings is by training the liver. Bringing the numbers down and keeping them down.

Always easier said than done of course. But maybe not impossible.

 

[Sheila & Beau GA & Jeddie GA]

Ramming down the BGs with more insulin is NOT the only way to stop the swings (a euphemism for rebound). The rebound is happening for one of several reasons: too fast a drop, too far of a drop, or too low of a drop - all as perceived by the cat's endocrine system (not the liver as is commonly believed around here due to the "liver training" jargon), thus telling the liver to release stored glucose.

Notice I said "perception". These drops don't have to be dangerous. They just have to be of a nature to set off the alarm bells. How do you prevent or lesson the rebound response? Reduce the dose. In the case where, say, the nadir is a safe one, but still causes rebound, I think the reduction needs to be a very small one.

Pumbaa did not drop too low, just low enough to cause the rebound bounce, which is what tonight's 300s are - the effect of last night's 58. He is not used to those numbers. Back off slightly to 2.35 and it might stop the swings and then the step back to 2.5u (if needed) may not set off alarms. He is very sensitive to insulin.

IMO, if you stay at 2.5u he might stop swinging, but he might not. If you actually raise the dose, he will continue swinging and probably intensive both the low and the high - and you will see a red number again.

 

[Dale 'n' Chip]

Ramming down the BGs with more insulin is NOT the only way to stop the swings (a euphemism for rebound). The rebound is happening for one of several reasons: too fast a drop, too far of a drop, or too low of a drop - all as perceived by the cat's endocrine system (not the liver as is commonly believed around here due to the "liver training" jargon), thus telling the liver to release stored glucose.

There certainly is another way to stop the swing, reduce the insulin until the body doesn't see it resulting in flat yellow. When I tried that with Chip all I got was the pink tinge on the ketone strips. Not what we want to see here. A self reinforcing spiral to nowhere.

I suspect the only safe way to do it in a case like this is not "Ramming" or "Bashing" anything but instead doing the organized, methodical, and proven Tilly approach. Or take him off human depot insulin. I have now looked at so many spreadsheets I really never want to see another. But I just don't ever see where reducing the dose for any cat with GT/IR (and almost certainly no pancreas at present) (and not obviously overdose) is ever safe or effective. What Pumbaa needs is more green, not less.

At any rate there is one thing that's clear, if you look at the extensive 8 months of copious testing on the spreadsheet, reducing the dose to "stop the swing" or holding longer under dose has clearly never brought Pumbaa any closer to regulation. It has certainly been tried and repeatedly. I'm not pretending like I have any sure answers but it seems obvious to me what hasn't worked for Pumbaa.

Looks like about the only thing left to try is getting serious about Tilly and staying on track.

He's seeing green, it just needs to go from 2 hours to 17 hours to 24/7. :mrgreen:

 

[Pumbaa]

Pumbaa's longest run in the greens was on Lantus, 2.50U at PM 8/10 through the morning of 8/11. Unfortunately, the morning of 8/11 his AMPS was 78, I gave a BCS of 1.50U, and he bounced at the end of the morning cycle. He cleared that quickly and went green again the morning of 8/12, but then I skipped his PM shot because his PMPS was 52.

In hindsight to the above, I should not have given a BCS of 1.50U and I should not have skipped the shot. Actually, looking at those days in August, there are a lot of things I would have done differently -- if he would have been on Levemir at that time instead of Lantus. And I say that because so far on the Levemir, Pumbaa may go low, but he doesn't dive like he did on the Lantus.

I need to spend some time looking at Pumbaa's history, and how and when he reacted to dose decreases. This morning was his 9th cycle at 2.50U. I'm thinking I'm going to hold him here a while longer, to make sure he's cleared that bounce yesterday, and doesn't bounce off of another bounce. Other than the bounce yesterday, he looks to me like he's trying to settle in to blues and healthy greens.

 

[Sheila & Beau GA & Jeddie GA]

I am NOT talking about reducing the dose until the body doesn't see it. I am talking about taking (shaving as Suze put it) a tiny amount off to make the lows maybe 20-30 points higher and not cause rebound. Once he is used to that, then the top numbers should start to come down. and IF the dose needs to go back to 2.5u, it won't cause so much response.

Suze, I agree on not increasing right now. He may still swing from the overnight greens, but perhaps if you just sit tight here, they will be lower swings.

 

[Carl & Polly & Bob (GA)]

Interesting debate on "to TR or not to TR".

Sheila is correct:

The rebound is happening for one of several reasons: too fast a drop, too far of a drop, or too low of a drop - all as perceived by the cat's endocrine system (not the liver as is commonly believed around here due to the "liver training" jargon), thus telling the liver to release stored glucose.

The jargon blames the liver, but the liver is just the final culprit in the chain. It's actually (bouncing) instigated by the pancreas, which does all sorts of stuff besides produce insulin. It all starts on the Islets of Langerhans...

Blood Sugar Levels Fall

The alpha cells in the islets of Langerhans of the pancreas product glucagon. Glucagon is “antagonistic” to insulin, basically having the opposite effect on the organs of the body. Glucagon increases the conversion of stored glycogen into glucose in the liver and muscles thereby increasing blood sugar levels.
Glucagon also increases the uptake of amino acids and glycerol into the liver so that more glucose can be synthesized.

Glucagon and Insulin
Glucagon increases the amount of glucose in the blood by accelerating the rate at which the liver converts stored glycogen into glucose and releases it into the blood. Insulin decreases the amount of glucose in the blood by transporting glucose from the blood and into the muscle cells. It also stimulates the conversion of glucose back into glycogen so that it can be stored.

http://bloodsugardiabetic.com/diabetestreatment/insulin/how-the-body-regulates-blood-sugar/ It's a site that explains human diabetes, but a great place to discover how all this junk works together.

What I'm reading here is that there are two ways to make the bounces stop?
Wait them out until the body stops doing the rebound thing.
Or cut the dose to eliminate the low numbers that are causing this instinctive reaction of the body to "low" BG numbers.
The first method is "TR Protocol", the 2nd isn't.
Protocol has you up the dose, to cause the lows that will result in probably bounces, but eventually in dose reductions.
The other way has you flatten the curves, avoid the lows (and hopefully the bounces), with the goal being that eventually all the numbers will continue to come down resulting in a flat but lower curve. I'm assuming at some point you would get to a point where you feel the dose can be further lowered with no negative impact on the overall BG numbers? Is there a "trigger" that indicates you should reduce (like the "under 50" reading of the TR protocol)?

Sheila, obviously "your" way works, because you've seen it work with your kitties. But I guess what I don't "get" is what indicates that a reduction in dose should be done once all the rebound/bouncing is under control? How do things "get better" so that you can reduce the dose, or know to reduce the dose?

But all that protocol business aside, it seems to me that the important part of this puzzle is what Suze wants to or can deal with. She can't put her health and her career at risk trying to deal with Pumbaa deep sea diving, and bouncing to the moon. She can't stay healthy and focused sleeping a hour at a time on the sofa like she's a cat. What is the magic answer that will help Suze help Pumbaa while maintaining her health and sanity?

Last question (for now anyway) - If the goal is to make the lows 20-30 points higher, can that be done by keeping the dose the same while instead changing the food, carb content, or timing of meals? It just seems to me that tweaking with food is "easier"??? than tweaking with calipers.

Carl

 

[hmjohnston]

Okay... I feel so BLOND now it isn't funny- well, maybe it is :lol: .

I am so glad you are understanding this and that, currently, Sneakers doesn't have this problem. She has others, but not this one :roll:

Come on Pumbaa- be nice for Mommy.

 

[Sheila & Beau GA & Jeddie GA]

Wait them out until the body stops doing the rebound thing.

I don't think that would work. It's either increase to drive down the high numbers - and hope the cat won't hypo, or decrease the dose to stop the lows and rebounds, then raise more slowly so that rebound is not initiated.

I'm assuming at some point you would get to a point where you feel the dose can be further lowered with no negative impact on the overall BG numbers? Is there a "trigger" that indicates you should reduce (like the "under 50" reading of the TR protocol)?

Sheila, obviously "your" way works, because you've seen it work with your kitties. But I guess what I don't "get" is what indicates that a reduction in dose should be done once all the rebound/bouncing is under control? How do things "get better" so that you can reduce the dose, or know to reduce the dose?

Same thing: a low number earns a decrease. Generally that's a below 50 number, but I have reduced Cami on PS's that are below 80 or something. I'm not adhering to anything set in store, it's more instinct.

But all that protocol business aside, it seems to me that the important part of this puzzle is what Suze wants to or can deal with. She can't put her health and her career at risk trying to deal with Pumbaa deep sea diving, and bouncing to the moon. She can't stay healthy and focused sleeping a hour at a time on the sofa like she's a cat. What is the magic answer that will help Suze help Pumbaa while maintaining her health and sanity?

That is why I have been advocating so strongly for taking a less aggressive approach than strict TR. I don't believe there is only one way to do things. What I see with Pumbaa AND Suze is that aggressive dosing won't work for the reasons you state and because Pumbaa is very sensitive to insulin. The "magic" answer has to come from Suze as she is the one living the life and holding the syringe.

Last question (for now anyway) - If the goal is to make the lows 20-30 points higher, can that be done by keeping the dose the same while instead changing the food, carb content, or timing of meals? It just seems to me that tweaking with food is "easier"??? than tweaking with calipers.

I think that using food would be more cumbersome - it would require figuring out how much of what food timed to certain BG patterns would stop the drop in time. That would require a lot of testing and figuring, which I think Suze wants to avoid. I think, if it works, shaving a drop off the dose is easier. Using the drop method to take off .1u or .15u should be enough. We have already seen that a deeper reduction is too much for Pumbaa. This is part of Pumbaa's makeup and not all cats would respond the same - Cami, for instance. She responded well to a 50% dose reduction.

 

[Pumbaa]

Carl, good information (thank you) and good discussion and questions! And thank you for thinking of what will make me less crazy. What I "want" more than anything is Pumbaa to hit steady blues and greens, and give his poor pancreas a chance to heal, and for him to stop the swinging wildly every day. (I also wanted to win the lottery, but that winning ticket in Arizona was not mine. *sigh*)

It's kind of funny, because once Sheila and Mel pointed out my insanity "cat-napping" on the sofa to get late-night readings, I raised Pumbaa's dose, which he needed, which is now causing late-night greens.

His shot times are 7 am/7 pm, so I don't have a problem getting a PM +5 at midnight, or even a PM +6 at 1 am, since I don't have to get up in the morning until 6:45. If I'm really tired I can always nap on the sofa between his PM +3 and the +5 or +6. But I still can't totally shake that paranoia from his Lantus days when he would just dive below 50 unexpectedly, even though on the Levemir I've only caught him below 50 once, and even though I know that he goes and eats more, instinctively, when his numbers are low. The other factor is that, if I don't get late-night readings, I won't know how low he's dropping for data to aid in dosing decisions. Looking at his SS: if I only got a PM +3 or +4 lately, I wouldn't know that he's been dropping down into the greens at night, and I might have already raised him to 2.75U which probably would have caused red and black numbers to appear.

I like the idea of controlling the lows with food, and I kinda/sorta do that, like last night when he hit 66 at +6...I put some Stella & Chewy's on his food to entice him to eat more. Either he had an early nadir last night or the eating at +6 worked, because at +7 he was up to 82. I almost didn't get a +9 reading because Pumbaa was sleeping soundly next to me in his "nest", but the alarm was already set and it woke me up, so I figured I'd rather be safe than sorry. But I don't know how I'd control the lows by giving him slightly higher carbed food, since they free-feed all day, and I can't predict at the main feeding time (PS time) which direction he's going to go in. You would think that a lower PS number would mean a lower nadir, but that's not the case with Pumbaa. *LOL* (Contrary little bugger!) Also, it doesn't appear that Pumbaa is so sensitive to carbs that a few percentage points make a difference.

Have I mentioned lately how awesome you all are for trying to help me figure out Pumbaa and how to "fix" him? (((HUGS))) to you all. I really mean that!

Suze

 

[Carl & Polly & Bob (GA)]

You would think that a lower PS number would mean a lower nadir, but that's not the case with Pumbaa. *LOL* (Contrary little bugger

Ah, but not so. You're thinking like a pzi bean and not a lev bean. With prozinc, I would agree with that logic. If you start lower and shoot the same, you'd expect to nadir lower. But, the perfect L curve is a flat line, isn't it? Level BGs all day and all night. It's why "shoot low to stay low" works. If the Lev is working right, you wouldn't necessarily see a lower nadir just because the preshot was lower. If the dose is right, the curve would be flatter and progressively getting lower as the healing happens.
Carl

 

[Pumbaa]

Carl, I thought even with L insulins, and in a "perfect world", that the preshot number reflected that the insulin was wearing off after 12 hours, and was expected to be higher than nadir, where the insulin is at peak performance. That's why the inverse curve is discussed as being normal, correct?

Maybe the curve flattens out as the cat gets closer to having a healed pancreas, but Pumbaa hasn't hit that point yet, and most of what I have read about the curves was about cats not regulated yet.

Here is where board member Blue described a typical curve for L insulins: http://felinediabetes.com/FDMB/viewtopic.php?f=28&t=55696&p=603248&hilit=third+eyelid#p617289

Example of a typical curve:
+0 - PreShot number.
+1 – Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number.
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 – Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (may dip around +10 or +11).
+12 - PreShot number.

Suze

 

[Sheila & Beau GA & Jeddie GA]

The nadir with lev tends to be later about +8, but can be as late as +12 or 13 (that is, a nadir at +1 is from the previous dose not the one given an hour earlier).

Of course, ECID. We each have to find the cycle our kitty works on.

Also, in the case like today where he climbed from the lower PS, I suspect that was the "bounce" taking over

 

[Carl & Polly & Bob (GA)]

Suze,
That typical curve is always shown to new members and is typical for new sugarkitties, and like Sheila said, Lev cats tend to nadir later. But from all the cases I've watched, the longer you use an L the flatter things get. Look at any SS of a cat on its way off the juice with blue or green preshots, and you'll see much flatness.
As far as an inverse curve, a lot of people seem to think it means too high of a dose, but I feel it's usually saying "not enough". That's if it repeats, of course. Anything that happens out of the blue, or just once (with the exception of a "hypo" of course), I tend to ignore and advise not to change anything.
Carl

 

[Pumbaa]

But from all the cases I've watched, the longer you use an L the flatter things get.

I don't think Pumbaa got this memo. :lol:

Oops....sorry...I didn't mean inverse curve as in a bell-shaped curve with higher numbers mid cycle.

 

[Pumbaa]

Sheila, yes, normally on the Levemir Pumbaa's nadir is anywhere from +6 to +10.

Unfortunately, he's playing yo-yo again, last night and this morning.