12/10 Tessa AMPS 322 +2 370 +9 291 PMPS 324 - Vet wants to decrease dose

[tessa's mom]

Previous thread: https://felinediabetes.com/FDMB/thr...-2-3-53-vet-wants-us-to-pause-insulin.271666/

I am really kicking myself that we ran to the vet yesterday because the vet is really trying to push us to decrease her dose. The vet is saying that Tessa may have had pancreatitis and the insulin helped heal her pancreas so we can reduce her dose. She wants us to do 1 unit for the rest of the weekend (I already gave her 1.5 units this morning but I think my husband mistakenly said that we gave her 1 unit today) and then call them Monday morning with her numbers. They seem really worried about hypoglycemia after yesterday but she never even dropped below 50 so I don't know why they're so concerned, I guess because of the really fast drop and then her vomiting?

I'm trying to follow TR so obviously decreasing her dose is not what I want to do. I'm just not sure how to handle the vet if we keep with the 1.5 units all weekend.

I think it would be really weird if Tessa had had pancreatitis because the food we were giving her prior to her diagnosis was a prescription diet that is commonly given FOR pancreatitis (she was given that food for GI issues though) and she's been off that food since November 28th. Wouldn't you expect the pancreatitis to get worse and not better if you went off the prescription food?

So what do you all think? Should I stick with 1.5 units or go with the vet's recommendation of 1 unit for the rest of the weekend?

I'm kicking around the idea of doing what the vet asks and then when her numbers are sky high, I'll have some leverage and I can talk about making dose changes on my own. I was thinking I could send over the journal article (I found a PDF copy of the full article so I'd send that) that details the basic TR protocol and ask if we can follow that. Then I don't have to lie to the vet and constantly ask for their permission to change her dosage.

Thoughts?

 

[Cali S]

I haven’t been at this for too long, but I will say what I’ve been told here is that you are the one holding the needle. You don’t need their permission to change dosage.

If I were in your shoes I’d share the TR paper with your vet and say that you’re following a published protocol with a high rate of success. My vet told me she didn’t have the time to read it *rolls eyes*

I smile and nod at my vet’s dosing advice and then follow TR. Published results hold a lot of weight with me!

 

[tessa's mom]

I haven’t been at this for too long, but I will say what I’ve been told here is that you are the one holding the needle. You don’t need their permission to change dosage.

If I were in your shoes I’d share the TR paper with your vet and say that you’re following a published protocol with a high rate of success. My vet told me she didn’t have the time to read it *rolls eyes*

I smile and nod at my vet’s dosing advice and then follow TR. Published results hold a lot of weight with me!

I'm just so bad at confrontation and I don't know what I'd do if the vet got upset with me for changing the dose on my own. I have terrible anxiety as it is. I think I'll email the paper today so the vet has some time to read it over the weekend and we can go from there. We still have over 8 hours to decide how much insulin we give her tonight so I have some time to think on it.

 

[tessa's mom]

Email sent, now we wait...

 

[Bandit's Mom]

I am unable to understand why the vet thinks Tessa is getting too much insulin? Is it on the basis of the greens yesterday morning? She didn't even drop below 50 to indicate that 1.75U was too much for her. We have had caregivers try a dose "reset" at the suggestion of vets or another diabetes group on FB that loves resets and it invariably fails leaving the cat in higher numbers with glucose toxicity and the caregiver has to chase a good dose to break into good numbers. There is no reason to think that Tessa has bypassed a good dose. You have been increasing in multiples of 0.25U and getting enough tests to know how low she is going at each dose.

There are cats who have gone down in dosing at breakthrough speed after breaking through glucose toxicity or a change of diet or they just flip a switch and decide they want to be regulated, but in all these cases there is clear evidence that they want to be at a much lower dose. I am not seeing that with Tessa...yet. It's possible she will get there.

You could always try going down in dose and see whether she holds the reduction. Who knows? She just might to prove us all wrong (they love doing that). If she doesn't you can go back up in dose.

 

[tessa's mom]

I am unable to understand why the vet thinks Tessa is getting too much insulin? Is it on the basis of the greens yesterday morning? She didn't even drop below 50 to indicate that 1.75U was too much for her. We have had caregivers try a dose "reset" at the suggestion of vets or another diabetes group on FB that loves resets rolleyes and it invariably fails leaving the cat in higher numbers with glucose toxicity and the caregiver has to chase a good dose to break into good numbers. There is no reason to think that Tessa has bypassed a good dose. You have been increasing in multiples of 0.25U and getting enough tests to know how low she is going at each dose.

There are cats who have gone down in dosing at breakthrough speed after breaking through glucose toxicity or a change of diet or they just flip a switch and decide they want to be regulated, but in all these cases there is clear evidence that they want to be at a much lower dose. I am not seeing that with Tessa...yet. It's possible she will get there.

You could always try going down in dose and see whether she holds the reduction. Who knows? She just might to prove us all wrong (they love doing that). If she doesn't you can go back up in dose.

I believe the vet is following the AAHA guidelines which consider a nadir below 80 to be worthy of concern (I do wonder if the vet is taking into consideration that a Libre monitor is going to read lower than a pet calibrated monitor).

Here's the AAHA page on monitoring: https://www.aaha.org/aaha-guidelines/diabetes-management/diabetes-algorithms/monitoring/

And following that chart it says to follow their hypoglycemia protocol: https://www.aaha.org/aaha-guidelines/diabetes-management/diabetes-algorithms/hypoglycemia/

I think that's where the vet is getting the idea to reduce the insulin.

In the email I sent earlier, I included Tessa's full Libre graph from yesterday and what she has so far today and specified that we gave her insulin this morning and her numbers are still high. I'm hoping that changes her mind on the suggestion to decrease the dose.

 

[Wendy&Neko]

Diet is not so much a factor in Feline pancreatitis, but is for dogs.

That AAHA guidelines might be referring to 80 on an AT, not a human meter. We have seen lots of Libre’s read lower than human meters in lower numbers.

 

[tessa's mom]

Diet is not so much a factor in Feline pancreatitis, but is for dogs.

That AAHA guidelines might be referring to 80 on an AT, not a human meter. We have seen lots of Libre’s read lower than human meters in lower numbers.

I did test Tessa manually yesterday while I was waiting for my husband to pick her up and bring her to the vet. The ReliOn meter said 72 at 9:37am and the Libre said 70 at 9:45am so this Libre sensor at least seems pretty accurate. Her BG was 92 at just after 10am as measured by the vet's equipment and the Libre measured 81 at 10am so there is a small difference there.

 

[tessa's mom]

I know this was probably a bad idea but we ultimately decided to split the difference on what the vet wanted and what we wanted and we gave her 1.25 units this evening. We'll decide in the morning what we're going to do, either stay at 1.25 or go back up to 1.5.

Also sorry I need so much hand holding, I promise I'll get better at this soon! Thank you to the kind folks who help me out, you're amazing!

 

[Bandit's Mom]

No need to apologize. We are here to help.

Lantus is a depot insulin, so you want to hold any dose long enough for the depot to adjust and for you to know how Tessa is doing on a dose. Unlike in and out insulins which only affect one cycle, the Lantus depot can affect 4-6 cycles after a reduction. So what you will see tonight and tomorrow is still the 1.5U depot at work.

 

[tessa's mom]

No need to apologize. We are here to help.

Lantus is a depot insulin, so you want to hold any dose long enough for the depot to adjust and for you to know how Tessa is doing on a dose. Unlike in and out insulins which only affect one cycle, the Lantus depot can affect 4-6 cycles after a reduction. So what you will see tonight and tomorrow is still the 1.5U depot at work.

Thank you!

I wish I had realized that the dose adjustment effects were delayed that long, I would have just kept with the 1.5 and dealt with the vet consequences later. By the time Monday rolls around, we'll barely be seeing the effects of dropping the dose and it's going to color the vet's view of how well the "reduction" went. Ugh all of this is so confusing and frustrating.

 

[Bandit's Mom]

I wish I had realized that the dose adjustment effects were delayed that long, I would have just kept with the 1.5 and dealt with the vet consequences later. By the time Monday rolls around, we'll barely be seeing the effects of dropping the dose and it's going to color the vet's view of how well the "reduction" went. Ugh all of this is so confusing and frustrating.

If you hold 1.25U, by Monday you will know what the dose is doing for her (4th cycle of the reduced dose). You don't want to keep changing doses every day/cycle because it "confuses" the depot and you don't know what dose is actually working for her.

 

[tessa's mom]

If you hold 1.25U, by Monday you will know what the dose is doing for her (4th cycle of the reduced dose). You don't want to keep changing doses every day/cycle because it "confuses" the depot and you don't know what dose is actually working for her.

Thank you! I'll stick with 1.25 over the weekend and probably go back to 1.5 on Monday morning. It feels like we're wasting precious time doing this dumb reduction but live and learn I guess.

 

[Bandit's Mom]

Thank you! I'll stick with 1.25 over the weekend and probably go back to 1.5 on Monday morning.

You want to hold 1.25U at least 4 cycles, so that would mean Monday AM cycle as well.

 

[tessa's mom]

You want to hold 1.25U at least 4 cycles, so that would mean Monday AM cycle as well.

I just realized that when I went to update her spreadsheet and was counting the cycles lol.

 

[Sienne and Gabby (GA)]

I did test Tessa manually yesterday while I was waiting for my husband to pick her up and bring her to the vet. The ReliOn meter said 72 at 9:37am and the Libre said 70 at 9:45am so this Libre sensor at least seems pretty accurate. Her BG was 92 at just after 10am as measured by the vet's equipment and the Libre measured 81 at 10am so there is a small difference there.

The Relion and Libre should be close to one another -- they are both human meters. If the vet did an in-office test, I'd be very surprised if they used a serum chemistry analyzer unless the vet was running an entire blood panel in the office. The vet may have been using a glucometer. The cut-offs in the AAHA information may be based on a serum chemistry analyzer and those numbers are more similar to what you get when you use a pet-specific meter.

 

[tessa's mom]

The Relion and Libre should be close to one another -- they are both human meters. If the vet did an in-office test, I'd be very surprised if they used a serum chemistry analyzer unless the vet was running an entire blood panel in the office. The vet may have been using a glucometer. The cut-offs in the AAHA information may be based on a serum chemistry analyzer and those numbers are more similar to what you get when you use a pet-specific meter.

I'm not sure what they did. The line item says blood glucose - in house and the price was $40. They did not charge an office visit fee (which is usually more than $40) though so maybe that charge was in lieu of the normal office visit fee.