12/17 Pumbaa - surfed green all day...and I was steering

[Carl & Polly & Bob (GA)]

carl, we stole that concept from the PZI group several years ago!

That's pretty ironic, Jill. The prevailing advice on PZI since I joined is "DON'T shoot the bounce!". Don't adjust the dose based on the preshot number just because it's inflated by a bounce. IOW, ignore it, make believe it isn't there, because it's going to go away on its own.

Which I guess IS the same thing we tell people here? Ignore it, it's going to clear on its own? The question here is "to reduce, or not to reduce" on the bouncy number. The question there is "to increase or not to increased" based on the bouncy number.

Of course, with P insulins, adjusting the dose based on the numbers isn't restricted by a set number of cycles. You can tweak the dose every shot if you're able to manage that, and have the data to back it up. The sliding scale is pretty much what I did with Bob. And I probably did shoot a lot of bouncy numbers because his numbers were all over the place (and I didn't test for nadir much, due to ignorance).

Carl

 

[Dale 'n' Chip]

...Yes, cats can continue to bounce after reductions, and some cats continue to bounce until right before they go OTJ. Here is Alex's first spreadsheet, which Jill has labeled as pre-TR. This was when she was first working with Kirsten and learning about TR - shooting that low almost got her kicked off the board! Luna tried to drive us crazy by continuing to bounce on the tiniest dose of insulin. And then here is the famous Riggs, who bounced like crazy even when he wasn't receiving ANY insulin!

It is important, too, that while it would be nice if the path to OTJ was working up to a good breakthrough dose and then down to nothing, in truth most cats have to take a few attempts at getting there. Lucy went from 4.25u to 1u and then back up to 4.25 again before going OTJ. Many cats go up and down in dose for quite a while before one day they finally hit the moment that we call "The Snap" and they hit all blue/green. It happens overnight usually, and is a thing of beauty. Lucy finally snapped at 2.25u on her final trip down the dosing ladder.

So, how do you know if a reduction has failed? Primarily by nadirs - when any bounce has cleared, does the cat manage to get back down to a nice green nadir? If yes, hold the dose. If no, increase the dose. We do recommend waiting out the bounce because we've seen too many times that people increase too quickly and the cat ends up bottoming out.

Thanks Libby, very interesting.

Yes I did notice the difference in the advice and the difference between what people practice and what they *preach*. The more cautious advice failed Chip of course, as did the idea of dosing to the nadir. He gets about the same nadir on 2.0U, 2.25U. 2.5U and 3.0U, and holding those lower doses longer only left him in worse shape in the long run than increasing to the dose that meets the Tilly standard of dosing to the range 50-200. Of course I wasn't going to spin my wheels waiting around months longer for some miracle that probably wasn't going to happen. The higher dose called for by Tilly seemed to be what stopped his bouncing, so I wondered why so few here are encouraged to go with the straight protocol, and the higher doses called for when the peak glucose is over 200.

Chip has already been up and down the scale after I failed with the first round of reductions and had to take him almost all the way back up. That's why I'm taking it much slower this time down.

spends significant amounts of time in this range each day

So hitting green only once a week, or once every three days doesn't qualify? Typical bouncing and diving?

The way I qualified that standard with Chip was I wanted to see green every cycle, and until he reached that point it seemed like he was losing ground faster than he was gaining. Same thing if a reduction fails, I don't want to see Chip losing so much ground I have to go all the way back up again.

I guess what I don't see with Chip (and I know from being chained to the cat by choice) is the bottoming out. I do let him eat whenever he demands food, which for him is primarily when he's dropping, sort of his own version of carb manipulation: eating regular food. Which perhaps nullified unwanted reductions early on. After he started going below 50, I took a more active role with carbs.

I guess I figured one of the primary benefits of Tilly was to address that bouncing problem in a safe manner with the orderly increases, in addition to the more typical breaking resistance. But that doesn't seem like much of a focus on this forum.

 

[Pumbaa]

You'll notice that there are "qualifiers" in those quotes. There always are. I never used Lev or the protocol so I'd have to be an idiot to not make any advice conditional. If you notice, I said only after proving to yourself that it isn't working, then you tweak things. And obviously, there's things that bother you, like bouncing, that wouldn't concern me as much.

But please keep in mind that I was arguing that you follow the protocol to a T, in a discussion where I felt that the protocol indicated that you needed to reduce, while most of the discussion was about you increasing? So yeah, in this case I felt the protocol, as I understood it, need to be adhered to.

Carl,
I know you had qualifiers, and I know you're not an idiot! And I know that in that thread you stated specific reasons (based on protocol) that Pumbaa deserved a decrease and not an increase. And what did I do? I ignored you and my gut, and increased him anyway. Why did I do that? Because I was worried that my being too chickenshit to increase him was preventing Pumbaa from reaching the magic dose that would finally stop his bouncing and diving. Now, thanks to Libby, I know that there may not be a magic dose like that for Pumbaa, and he may, eventually, go OTJ bouncing all the way! So, from now on, when my little guy earns a decrease, he's going to get that decrease.

Suze

 

[Pumbaa]

I don't believe they should bounce when the reduction is successful. The protocol stresses that the cat must remain in normal numbers after any reduction. Or you return to the last good dose. Or you continue increasing until you reach a good dose. Normal numbers in this case are 50-200.

But Chip has bounced on a reduction, and you waited it out, and he came back down without your increasing his dose. See from 11/29 to 12/5 on your SS. I just don't think you gave the reduction on 12/5 long enough to settle in, from what I see in his history.

Suze

 

[Dale 'n' Chip]

Now, thanks to Libby, I know that there may not be a magic dose like that for Pumbaa, and he may, eventually, go OTJ bouncing all the way!

That's not the way I read it. :smile:

But It's clear we pick up on entirely different things in these world famous condo's.

Something here for everyone! ;-)

 

[Dale 'n' Chip]

I don't believe they should bounce when the reduction is successful. The protocol stresses that the cat must remain in normal numbers after any reduction. Or you return to the last good dose. Or you continue increasing until you reach a good dose. Normal numbers in this case are 50-200.

But Chip has bounced on a reduction, and you waited it out, and he came back down without your increasing his dose. See from 11/29 to 12/5 on your SS. I just don't think you gave the reduction on 12/5 long enough to settle in, from what I see in his history.

Suze

Yes he had that one short yellow bounce. My new rule is no pink after a reduction. Look at all Chip's numerous other failed reductions, and failed doses. You let that slip away and you (can) lose so much ground. End up having to go all the way back up. Lose months of time and effort, hundreds of test strips. All the blood sweat and tears. :sad:

You want to know were I learned too many of these things? From watching Pumbaa in real time. :smile:

 

[Pumbaa]

okey-dokey, here's my take. I know I won't address all of your points because I'm feeling a little scatterbrained today, but let's see how I do. :lol:

Won't quote everything here, but you did a GREAT job explaining things.

"Adjustments to dose are based on nadirs with only some consideration given to preshot numbers." "It doesn't say they have to be under 200 ALL the time, just as much as possible."

Yes! Since Pumbaa is a bouncer, I don't want to be dosing him based on his high numbers, I want to be dosing him based on his low numbers. I think that is what Carl has meant when he said to ignore the bounces. But others here have pointed to Pumbaa's high numbers, ignoring the lows, and suggested to increase. That's the problem I have been dealing with. Thank you again, Libby! You are getting through to me loud and clear! (((HUGS)))

Another thing to keep in mind if you are watching the people who give advice in condos - I freely admit that I give different advice to different people.

That makes sense. As does my receiving "increase the dose" advice from people who may not have looked at Pumbaa's history, and who saw his high numbers on the current dose, but didn't take into account that he was coming down from a bounce.

You made total sense, Libby! And what I quoted didn't do justice to your entire post, but I wanted to point out a few key factors. Thank you, again!

Suze

 

[Pumbaa]

a note about clearing bounces...
we're all familiar with the statement, "it can takes up to 72 hours for a bounce to clear." well, guess what? it *can* take longer than 72 hours to clear a bounce! look at tucker's spreadsheet for an example. it took 4 days for tucker to clear a bounce. i've always suspected it could happen, but have never seen such a clear-cut example. ECID. the longer i stick around here the clearer this point is driven home. :mrgreen:

about failed reductions...
it's all about nadirs. if kitty is remaining high, go back to the last good dose.

Good stuff on the inaccuracy of meters & test strips, and thank you very much for your time researching this information!

I tend to go with the idea that, if I am using the same meter for Pumbaa, and the same test strips, and his numbers appear to be within a normal range based on insulin and food, I won't question the results. But, when I get a number that appears to be out of a normal range, I will retest. Since I am using the same meter over and over, and the only variable is the test strips after I go through 50 of them, I feel I am basing Pumbaa's dosing on a constant, and whether it is absolutely correct or not is another matter. But it's like using a bathroom scale. My scale may be higher than the scale at my MD's office, but it's a constant for me from day to day.

But, a question about the failed reductions..."it's all about nadirs. if kitty is remaining high" after how long? After the bounce finally clears? Even if it takes over 72 hours?

Suze

 

[Carl & Polly & Bob (GA)]

But it's like using a bathroom scale. My scale may be higher than the scale at my MD's office, but it's a constant for me from day to day.

Good analogy. The specific numbers don't matter, just the trend, whether you're losing or gaining.

Carl

 

[Pumbaa]

The question here is "to reduce, or not to reduce" on the bouncy number. The question there is "to increase or not to increased" based on the bouncy number.

Libby enlightened us above, about basing dose changes on the nadirs (with some consideration given to PS numbers), and not on the highs that are caused by bounces. I'm a happy person tonight because what Libby stated agrees totally with what my brain has said is important!

Suze

 

[Pumbaa]

Good analogy. The specific numbers don't matter, just the trend, whether you're losing or gaining.

That's what I think. The specific numbers still matter, but they are based on your cat and your meter as long as you are testing the same cat on the same meter.

I might be wrong, but there are so many variables involved here, we have to stop making ourselves insane at some point, right?

Suze

 

[Carl & Polly & Bob (GA)]

I might be wrong, but there are so many variables involved here, we have to stop making ourselves insane at some point, right?

I'm pretty sure you've seen words to that effect come from my fingertips a few times.... :lol:

Carl

 

[Pumbaa]

I might be wrong, but there are so many variables involved here, we have to stop making ourselves insane at some point, right?

I'm pretty sure you've seen words to that effect come from my fingertips a few times.... :lol:

Carl

Oh yeah! And, from my fingertips, too many times to count. *LOL*
I'm just trying to stay sane dealing with work and life and Pumbaa. This is a constant struggle with all that I deal with in my life right now. Not that anyone else has any less to deal with than I do, but it's so hard when you are one person dealing with a diabetic cat and so many other things that need attending to. I feel for everyone in the same boat that I am in. (((HUGS)))

Suze

 

[Dale 'n' Chip]

about meters...

The Contour is a consistent and reliable meter and apparently the human glucometer used by Roomp/Rand to set the glucose thresholds for Tilly TR.

yes, it was. however, a little known fact... or at least discussed on the fdmb... is over the last few years the test strip manufacturers have been changing the methodologies used in their test strips to test blood glucose. the changes have been made to weed out properties in the blood which could affect the readings shown on the meters (make the result appear higher) in order to get a "true" BG reading.

i've been doing some research on the subject, but (1) so much of this is over my head, (2) it's hard to find much on the internet on the subject, and (3) getting info from strip manufacturers has been like pulling teeth. i've included the little bit of information i could find on the tab labeled Strip Comp on alex's ss.

based on a limited amount of research, as well as the allowable +/- 20% variation in meters, the fact that you can take 2 readings moments apart and get different results, not to mention differences between any 2 meters will be much greater at high numbers... my conclusion is there aren't any meters which reflect 100% accuracy. and trying to compare them is a bit like repeatedly hitting your head against a brick wall. even the manufacturer of alphatrack test strips recently changed the methodology used from GDH-PQQ to GDH-FAD. incidentally, the new GDH-FAD methodology used in the alphatracks is the same methodology used in the freestyle "butterfly" strips which has been totally discredited by some members of this board. :shock: :shock: :shock:

100% accuracy no longer matters to me. what i look at is ranges... and conclude alex is "somewhere" in that range. i'm good if she's running in the normal range. i don't like ultra lows as much as i don't like high numbers. i try to make adjustments accordingly instead of getting hung up on particular numbers.
just some thoughts...

I saw strip comp before, noticed the Arkray Vital usually tested lower than the others. Wish the Bayer Contour was included. As far as I know the contour strips are pretty mature/older process. Strips are made in Japan, takes a big drop but gives very similar results time after time. Errors out with the wrong sized drop, but I believe it is more consistently *accurate* than my other meters. Guess it was good enough for Roomp and Rand.

Generally all that matters is using the same meter and looking at trends. Unless of course you are taking a reduction on every 49. If it is really 55 or 59 that is a big difference when it comes to a reduction. That's about the only time I see when the actual number really matters. Especially if the reductions tend to fail. Okay maybe my standards for reductions are high. But hey I notice you skipping reductions with Alex and cranking the juice when you know she needs it. All of course with lots of data to support what you are doing. That is absolutely the only way I do it with Chip. :smile:

 

[Jill & Alex (GA)]

I saw strip comp before, noticed the Arkray Vital usually tested lower than the others. Wish the Bayer Contour was included. As far as I know the contour strips are pretty mature/older process. Strips are made in Japan, takes a big drop but gives very similar results time after time. Errors out with the wrong sized drop, but I believe it is more consistently *accurate* than my other meters. Guess it was good enough for Roomp and Rand.

i've wondered if Bayer has changed the methodology used to read blood glucose since the roomp/rand study... or if it's the same as when the study was done. and who knows if the strips we use here are the same as what's available in europe.

the only reason i've given any thought to it is because the USA Country-Specific Glucose Monitor List has the methodology currently used by Bayer for the Contour strips as glucose dehydrogenase with flavin-adenine dinucleotide (GDH-FAD). this is the same "new" methodology used for the FreeStyle meters that everyone's complaining about. the test strips for the new alphatrak 2 also use GDH-FAD.

Generally all that matters is using the same meter and looking at trends. Unless of course you are taking a reduction on every 49. If it is really 55 or 59 that is a big difference when it comes to a reduction. That's about the only time I see when the actual number really matters. Especially if the reductions tend to fail. Okay maybe my standards for reductions are high. But hey I notice you skipping reductions with Alex and cranking the juice when you know she needs it. All of course with lots of data to support what you are doing. That is absolutely the only way I do it with Chip. :smile:

i agree with you completely about using the same meter and looking at trends.

yes, i've skipped reductions and i have cranked up the juice when necessary. The TR protocol has given me the basics, but i really haven't followed it to the letter for quite some time. i do have data to support the decisions made, but there can also be variables worth considering once you really "know your cat".

with alex, these variables include, but are not limited to an ultra sensitivity to % of carbs, specific amounts fed and when they're fed, illnesses (cholangiohepatitis/triaditis, renal & liver disease, pancreatitis, and allergies), being prone to developing ketones, and having pinned down her renal threshold through the use of diastix to be generally around 150 - 180 (probably a little closer to 180). this is a cat who cannot afford to reside in high numbers for any length of time. i've also been exposed to a more aggressive approach for using lantus and levemir... a method which imo, requires vet supervision/cooperation because it's too aggressive to be used in an internet setting.

oh, and i'll make a public confession...
i don't agonize over measuring doses accurately. i told marje quite some time ago that she'd be appalled at how quickly i draw a dose. i simply eyeball the amount of the dose. sometimes it might be a little light... sometimes it might be a tad bit heavy... and i know it, but i don't re-draw the dose. i'll often skip a reduction if i suspect the dose was heavy. i also shoot early and late... often. if alex earns a reduction on an early shot i may or may not take it depending on how she's trending. on the reverse side of things, i'll often hold doses for a longer period of time than most before attempting a reduction for "good behavior".

i have to consider the big picture with alex when making dose adjustments... something most of us come to eventually through observation and data collection.

 

[Dale 'n' Chip]

...the only reason i've given any thought to it is because the USA Country-Specific Glucose Monitor List has the methodology currently used by Bayer for the Contour strips as glucose dehydrogenase with flavin-adenine dinucleotide (GDH-FAD). this is the same "new" methodology used for the FreeStyle meters that everyone's complaining about. the test strips for the new alphatrak 2 also use GDH-FAD.

That's scary.

But the problem with the butterfly strip manifests as almost no pink to speak of and no red or black at all. These Contour strips do register all colors and seem to fit what is going on clinically. From low to high. But it's actually good to periodically have reference backup readings from something else. As long as you don't drive yourself crazy comparing.

I'm almost alarmed by the variability I see from the Arkray Vital and Relion Prime (I have and use both versions) different readings might be off by 100 to 150 points, much more than 20%, and the instructions have different warnings about both too big and too small blood drop size causing invalid/unreliable readings. Since I'm already well practiced in making consistent drop size for the contour, I do the same for the Vital/Prime and I believe it helps produce more reliable readings. But still, I'd hate to be without the contour when I want to double check something that just doesn't fit.

with alex, these variables include, but are not limited to an ultra sensitivity to % of carbs, specific amounts fed and when they're fed, illnesses (cholangiohepatitis/triaditis, renal & liver disease, pancreatitis, and allergies), being prone to developing ketones, and having pinned down her renal threshold through the use of diastix to be generally around 150 - 180 (probably a little closer to 180). this is a cat who cannot afford to reside in high numbers for any length of time. i've also been exposed to a more aggressive approach for using lantus and levemir... a method which imo, requires vet supervision/cooperation because it's too aggressive to be used in an internet setting.

oh, and i'll make a public confession...
i don't agonize over measuring doses accurately. i told marje quite some time ago that she'd be appalled at how quickly i draw a dose. i simply eyeball the amount of the dose. sometimes it might be a little light... sometimes it might be a tad bit heavy... and i know it, but i don't re-draw the dose. i'll often skip a reduction if i suspect the dose was heavy. i also shoot early and late... often. if alex earns a reduction on an early shot i may or may not take it depending on how she's trending. on the reverse side of things, i'll often hold doses for a longer period of time than most before attempting a reduction for "good behavior".

i have to consider the big picture with alex when making dose adjustments... something most of us come to eventually through observation and data collection.

It's amazing what you have been able to do with Alex over the years. You've got her down and you've got it down. But still learning as you go.

That seems like a low renal threshold, but that just speaks for tighter regulation. And it also speaks for the accuracy of the meter used to arrive at those values. I'm definitely starting to appreciate the benefits of tighter regulation for Chip, I started out just wanting blue for him, and blue does seem to fall below his renal threshold from what I can tell, but I haven't pinned it down yet with the dip sticks. And hey I'd better do that while I still have Contour test strips to work with. But there are other benefits to the tighter green including leveraging the increased sensitivity to help the reductions stick. Of course I see that as another argument against the bouncing, since he does tend to go flat pink and stay there. His bounces seem to pretty quickly undo his progress.

You really might want to try Marje's revolutionary technology with dose measurement. Chip is very sensitive to the slightest changes in dose with Levemir. Using the Terumo syringes and Pittburgh digital calipers, I feel my doses are accurate to the the half drop. For any dose or percentage you'd ever want. I can nudge in 8 or more flavors for every quarter unit. The problem becomes what do we name all those different doses. But this accuracy is even more important as the doses get smaller.

You likely don't need to change a thing but it doesn't cost more at all to get much more control of your doses. Takes less than a minute to draw a perfect dose, where I used to agonize over the printing on the syringes. And if you knew how off they actually are, you wouldn't want to dose that way. Levemir certainly likes the exact same dose time after time after time, as long as you pay attention not to stagnate into a rut. I believe Levemir is more prone to stagnation than Lantus.

I noticed some of your tricks with shot times. I did the round the clock shot times (stalling an hour every 3rd cycle or so as needed) as way to stagger the accumulating nadirs and delay those unwanted reductions a bit longer. Now I'm shooting lower and preserving the shot time. But it may require more steering since Chip does drop lower as the nadirs perhaps concentrate deeper in one place. But I'm getting better with the steering as well. It is amazing some of the things I was able to learn pretty much on my own, but even more amazing all that goes on here. :thumbup

 

[Pumbaa]

oh, and i'll make a public confession...
i don't agonize over measuring doses accurately. i told marje quite some time ago that she'd be appalled at how quickly i draw a dose. i simply eyeball the amount of the dose. sometimes it might be a little light... sometimes it might be a tad bit heavy... and i know it, but i don't re-draw the dose. i'll often skip a reduction if i suspect the dose was heavy. i also shoot early and late... often. if alex earns a reduction on an early shot i may or may not take it depending on how she's trending. on the reverse side of things, i'll often hold doses for a longer period of time than most before attempting a reduction for "good behavior".

I was hoping for a much more exciting confession, like you're really Bill Gates in disguise and will pay for all of our cats' insulin for the rest of their lives! haha_smiley

While I don't agonize over the dosing, and don't have calipers like some people use, I waste insulin regularly, and always overdraw by about .5U, to make up for any air bubbles I can't see in the syringe, and to also allow me to adjust the dose in the syringe accordingly, after the pen is no longer in the picture. So for me, drawing the dose (plus some) and perfecting the dose are two different tasks.

Before I draw in the insulin, I pump the syringe a couple of times and depress it like I would depress it while injecting Pumbaa. I look to see where the plunger top aligns with the zero line (above, middle, below) and then use that as my basis for fine-tuning the insulin in the syringe. I also tap the syringe to get any and all air bubbles to the top, then pull the plunger down slightly to create a larger air bubble at the top, tap some more so that all air bubbles are merged into one, then depress the plunger slowly until I am at the correct dose.

I doubt that I ever give a heavy dose, but every once in a while I know the dose is slightly light due to an air bubble that wouldn't go away, or because I depressed too much out. But, when the doses have been light, I doubt that it has been more than a drop or two. Had I thought it was more than that, I would have eaten my losses and started a new syringe. But, that's just me.

I've been using the Terumo syringes for a few months now (dosing both Lantus and Levemir), and have to say that the Terumo's are very Levemir friendly, but that is because Levemir is so much thinner in viscosity than Lantus. To me, that's another plus to the Levemir...that it's so much easier to fill the syringe with!

As for late/early shooting times, I try to be consistent, but we're all human, and the cats aren't always cooperative either. If Pumbaa is late with a test/shoot by over 1/2 hour, I will try and adjust back in 15 minute increments. Again, that is just me, because I figure his numbers will be affected if I don't do this, and don't want to have to remember that a "dose decrease" number might have been caused by an early shot.

You obviously have a grip on all of this and know Alex and how she responds, and that is all that counts!

Suze

 

[Jill & Alex (GA)]

carl, we stole that concept from the PZI group several years ago!

That's pretty ironic, Jill. The prevailing advice on PZI since I joined is "DON'T shoot the bounce!". Don't adjust the dose based on the preshot number just because it's inflated by a bounce. IOW, ignore it, make believe it isn't there, because it's going to go away on its own.

Which I guess IS the same thing we tell people here? Ignore it, it's going to clear on its own? The question here is "to reduce, or not to reduce" on the bouncy number. The question there is "to increase or not to increased" based on the bouncy number.

Of course, with P insulins, adjusting the dose based on the numbers isn't restricted by a set number of cycles. You can tweak the dose every shot if you're able to manage that, and have the data to back it up. The sliding scale is pretty much what I did with Bob. And I probably did shoot a lot of bouncy numbers because his numbers were all over the place (and I didn't test for nadir much, due to ignorance).

yes, it is ironic. when i first arrived on the FDMB, the bulk of people using tight regulation used pzi. TR has all but disappeared in the pzi group today. it's really too bad... for kitties and caregivers alike. there's a whole lot of info available both in the pzi group and in the TR Forum on the "old" board if you ever want to revive the interest in TR with the P insulins.

in this forum we usually suggest newbies take a reduction when it is earned. we don't suggest shooting through the bounce until we feel the caregiver is ready, willing, and able to take that step.

 

[Jill & Alex (GA)]

You really might want to try Marje's revolutionary technology with dose measurement. Chip is very sensitive to the slightest changes in dose with Levemir. Using the Terumo syringes and Pittburgh digital calipers, I feel my doses are accurate to the the half drop. For any dose or percentage you'd ever want. I can nudge in 8 or more flavors for every quarter unit. The problem becomes what do we name all those different doses. But this accuracy is even more important as the doses get smaller.

You likely don't need to change a thing but it doesn't cost more at all to get much more control of your doses. Takes less than a minute to draw a perfect dose, where I used to agonize over the printing on the syringes. And if you knew how off they actually are, you wouldn't want to dose that way. Levemir certainly likes the exact same dose time after time after time, as long as you pay attention not to stagnate into a rut. I believe Levemir is more prone to stagnation than Lantus.


I noticed some of your tricks with shot times. I did the round the clock shot times (stalling an hour every 3rd cycle or so as needed) as way to stagger the accumulating nadirs and delay those unwanted reductions a bit longer. Now I'm shooting lower and preserving the shot time. But it may require more steering since Chip does drop lower as the nadirs perhaps concentrate deeper in one place. But I'm getting better with the steering as well. It is amazing some of the things I was able to learn pretty much on my own, but even more amazing all that goes on here. :thumbup

i really haven't found it necessary to be as precise as calipers allow. if there should come a day when i feel differently i'll be sure to order a caliper. most cats (including alex) do not seem to respond to dose increases measured in drops as much as they do with dose reductions. reductions is where i've seen drops make a huge difference, but mostly with longer term kitties who have not held reductions. newly diagnosed kitties are very tolerant to our inaccuracies and ineptness.

everyone is entitled to their own opinion based on their own cat's response, but i happen to disagree with your belief, "I believe Levemir is more prone to stagnation than Lantus." imo, kitties can and do "stagnate" on all three of the most popular insulins used today (prozinc, lantus, & levemir). glucose toxicity can set in very quickly... within days. jmo.

i often shot around the clock when alex was on insulin the first time (pre tight regulation), but that was then and this is now. life changes. my life has changed. most, but not all, of the early and late shots you see on alex's ss for the last couple of years reflect real life rather than tricks of the trade. i'm so not a morning person and have a very active social life. i've also come to realize i have a cat with diabetes, but feline diabetes does not represent the total sum of my life. :mrgreen:

i also believe in the KISS method.
i think there's been a tendency over the last few years to make treating feline diabetes too hard...

 

[Dale 'n' Chip]

I want to start by saying thanks again to Jill and Libby for stopping back here to grace us with their wisdom and experience. And I say that because I have *one more* very important related question for both of you, which I will get to in a minute. We all appreciate the time you put in here, and with that in mind I will attempt to prioritize the most important questions (hey the Horse is still thirsty) since I still have a few more I've wanted to ask for some time. And if anyone else has any ideas please jump in here. :smile:

...i really haven't found it necessary to be as precise as calipers allow. if there should come a day when i feel differently i'll be sure to order a caliper. most cats (including alex) do not seem to respond to dose increases measured in drops as much as they do with dose reductions. reductions is where i've seen drops make a huge difference, but mostly with longer term kitties who have not held reductions. newly diagnosed kitties are very tolerant to our inaccuracies and ineptness.

everyone is entitled to their own opinion based on their own cat's response, but i happen to disagree with your belief, "I believe Levemir is more prone to stagnation than Lantus." imo, kitties can and do "stagnate" on all three of the most popular insulins used today (prozinc, lantus, & levemir). glucose toxicity can set in very quickly... within days. jmo.

I worded that entirely wrong about stagnation. What I should have said is when one holds the wrong dose too long (and by wrong I mean the slightest bit too low for that particular point in time) Levemir may be prone to stagnation, GT and IR. Perhaps because it has such a flat response with some cats, it doesn't seem to jump start itself. I didn't want to in any way suggest that isn't a problem (a big problem) with Lantus or Prozinc.

But Levemir may need an aggressive approach when flat pink sets in, or when there is absolutely no response in the first two or three days. Same thing just as much applies to Lantus or Prozinc. Chip's SS is a perfect example of little or no response to Levemir for 4 long weeks spent diligently marching up the scale, increasing every 6 cycles. In the very beginning with Lantus, Chip dropped almost to a reduction on day 4, even immediately after what I assume was prior resistance problems from about 2 months of improperly dosed NPH.

I agree, measuring doses with drops is only for decreases. I'd rather not nudge upward with Chip unless returning to the last good dose. If he needs an increase, I take the full 0.25U (or 0.5U) and then nudge my way back down, if what he needs may be in between. I suspect (don't know for sure) that there may be times when nudging upward with Lantus may work for some people in some situations, when fine tuning the dose. I fear nudging Levemir "up" is just a way to ensure Chip may need go even higher than otherwise, related to that intangible stagnation factor. Not that it isn't perhaps just as true with all three recommended insulins.

And of course with a good dose, I want to hold that forever and a day, or until Chip earns a decrease. This is where I suspect Marje's innovations in dose measurement may have another benefit, in increased stability from having consistent doses. At least I suspect it works better that way for Chip, since I have enough problems with furshots, life getting in the way, and other variables outside my control. It's now easy enough to at least control the dose.

i'm so not a morning person and have a very active social life. i've also come to realize i have a cat with diabetes, but feline diabetes does not represent the total sum of my life. :mrgreen:

i also believe in the KISS method.
i think there's been a tendency over the last few years to make treating feline diabetes too hard...

That's something I must learn. But maybe only because I got off to a bad start and am still recovering. Right now I just don't want to make any more mistakes. So hopefully I'm asking all the right questions. ;-)

So my big question is about nadirs. When we are dosing to the nadir, exactly what qualifies? Or should I say how often? When I was holding longer an obviously stagnant dose of Lantus (looking back) Chip was basically flat pink (pink or red every day) however he still made his blue nadir at least once every 6 cycles when he cleared the bounce. And he also made some good greens during that dose about every 7 or 10 days. So were those nadirs? I thought I was using the zen approach of waiting for the numbers to come. But apparently the only thing that showed up was increased resistance and glucose toxicity. And then Levemir.

Does having a solid streak of greens once every 3 or 5 days followed by bounces of a rainbow of non-normal colors qualify as a reduction which is holding, or needing to be settled more?

Are peeks or even streaks of green every 4th or 8th day (maybe dipping just below 50) in the sea of yellow/pink with perhaps a touch of blue indicative of a dose that needs to settle longer?

Just how often do we need to see that green, or do we need to make the good nadir in order to still be on track in most cases?

 

[Pumbaa]

i also believe in the KISS method.
i think there's been a tendency over the last few years to make treating feline diabetes too hard...

Do I ever agree with that!

Suze

 

[Marje and Gracie]

I haven't been drawing doses even 1/3 of the time that Jill has and I don't trust my dosing accuracy. Add onto that that Mike also shoots sometimes and so we need to be sure we have consistency between us. Ad then the kicker is that Gracie is really sensitive to small changes that I can't eyeball. Thus the calipers.

Wild I love to keep it simple? Oh yes. But I've also checked out the Monojects and Terumos with a micropipettor and I can tell you that sometimes the dose from syringe to syringe of the same lot number "can" vary as much as 0.5u. That doesn't occur that often but I did find it to be pretty typical for them to vary by 0.25u. There was a learning curve with the calipers but it was quick and I can draw a dose pretty quickly now. And I can also fine tune her doses more. But, as Dale said, then I gotta think of names for them.

 

[Jill & Alex (GA)]

But Levemir may need an aggressive approach when flat pink sets in, or when there is absolutely no response in the first two or three days. Same thing just as much applies to Lantus or Prozinc. Chip's SS is a perfect example of little or no response to Levemir for 4 long weeks spent diligently marching up the scale, increasing every 6 cycles. In the very beginning with Lantus, Chip dropped almost to a reduction on day 4, even immediately after what I assume was prior resistance problems from about 2 months of improperly dosed NPH.

i don't remember the circumstances surrounding your decision to start lev at 0.5u bid, but the initial lev starting dose was set too low. 1.5u lantus was only dipping chip into occasional greens. i don't understand the logic in dropping the initial starting dose of lev to 0.5 unit, but that's water under the bridge at this point.

when switching from lantus to lev we *usually* (if kitty has been brought up the lantus dosing scale honestly) suggest an initial starting dose of lev at approximately 70% of the prior lantus dose. dropping the dose too much when switching between insulin opens the door to ketones developing and glucose toxicity setting in. once glucose toxicity sets in insulin requirements will have to be increased until there's a break through. imho, this is a waste of time, insulin, and energy... not to mention the wear and tear on the cat who's remaining in high numbers far too long.

dr. lisa makes some interesting comments about dosing/glucose toxicity/kitties drowning in sugar in this thread: Very confused now... What is going on with him?. it's a thread worth reading!

And of course with a good dose, I want to hold that forever and a day, or until Chip earns a decrease. This is where I suspect Marje's innovations in dose measurement may have another benefit, in increased stability from having consistent doses. At least I suspect it works better that way for Chip, since I have enough problems with furshots, life getting in the way, and other variables outside my control. It's now easy enough to at least control the dose.

i agree. calipers will offer consistency.

So my big question is about nadirs. When we are dosing to the nadir, exactly what qualifies? Or should I say how often? When I was holding longer an obviously stagnant dose of Lantus (looking back) Chip was basically flat pink (pink or red every day) however he still made his blue nadir at least once every 6 cycles when he cleared the bounce. And he also made some good greens during that dose about every 7 or 10 days. So were those nadirs? I thought I was using the zen approach of waiting for the numbers to come. But apparently the only thing that showed up was increased resistance and glucose toxicity. And then Levemir.

it's really almost pointless to discuss what went wrong with chip's time on lantus. it's done. over with. and you can't go back and change anything. however, the blues and occasional greens you saw... sure. they were nadirs. in a nutshell, some increases weren't enough and generally doses were held too long... which allowed glucose toxicity to set in. battling glucose toxicity can literally add weeks or even months to get back to the point of seeing some green.

Does having a solid streak of greens once every 3 or 5 days followed by bounces of a rainbow of non-normal colors qualify as a reduction which is holding, or needing to be settled more?

if kitty clears the bounce and comes right back down to green, then yes, the reduction is holding. "settling time" after a reduction has no place in my vocabulary. :mrgreen:

newly diagnosed kitties will often bounce right into remission, but for the most part we want to work towards dropping kitty into normal numbers (overall, less than 100) for as many hours as possible everyday. that's when an experienced caregiver may want to use food to manipulate the curve in an effort to maintain (or even increase) the dose as described here: http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=23446&p=234616#p234616.

Are peeks or even streaks of green every 4th or 8th day (maybe dipping just below 50) in the sea of yellow/pink with perhaps a touch of blue indicative of a dose that needs to settle longer?

it can be. i'd certainly give an increased dose some time to work if i were dealing with a newly diagnosed kitty. however, i don't think i'd wait around for a dose increase to settle if i was dealing with a long term diabetic or a kitty who has returned from the falls. perhaps it's an assumption on my part, but i would think a kitty returning from the Falls or a long term diabetic has fewer *good* beta cells left to work with. i wouldn't want to waste any time waiting for a dose to settle. waiting too long only results in the dreaded glucose toxicity setting in... or ketones developing in a ketone prone cat.

Just how often do we need to see that green, or do we need to make the good nadir in order to still be on track in most cases?

the $64,000 question. :lol:
a lot would depend on at what point in the journey the particular is at. see the thing is, i don't necessarily think seeing green determines if a cat is on track or not. to me, being on track means we're seeing a nice progression on the spreadsheet... which will eventually show more and more green. when that forward momentum is lost... i see that as a problem. however, it's important to realize lost momentum is not always the result of lousy dosing. a cat can lose momentum for a multitude of reasons... many of which are beyond our control.


hope this helps a little...

 

[Jill & Alex (GA)]

I haven't been drawing doses even 1/3 of the time that Jill has and I don't trust my dosing accuracy. Add onto that that Mike also shoots sometimes and so we need to be sure we have consistency between us. Ad then the kicker is that Gracie is really sensitive to small changes that I can't eyeball. Thus the calipers.

Wild I love to keep it simple? Oh yes. But I've also checked out the Monojects and Terumos with a micropipettor and I can tell you that sometimes the dose from syringe to syringe of the same lot number "can" vary as much as 0.5u. That doesn't occur that often but I did find it to be pretty typical for them to vary by 0.25u. There was a learning curve with the calipers but it was quick and I can draw a dose pretty quickly now. And I can also fine tune her doses more. But, as Dale said, then I gotta think of names for them.

you must be typing on your iPad again. :lol:

you're either giving me too much credit or short-changing yourself. if you subtract all the time alex has been off insulin since diagnosis, i've only been shooting 11 months longer than you have. :mrgreen:

i whole-heartedly agree calipers lend themselves to consistent dosing. no doubt about it, but when i was referring to the KISS method as a personal preference, i was speaking to treating feline diabetes as a whole. as far as measuring doses go... my issue is with caregivers agonizing over minute changes. as dr. lisa said in this thread: "...I just hate to see people ripping their hair out over the dosage of insulin".


post copied here:

Something that Dr. Lisa said several weeks ago keeps tugging at my brain.

Given that there are MANY things going on in the body that influence the BG level, it is my opinion that we all get too caught up in thinking that the dosage we give is so critical down to the 0.1 or 0.2 unit….and that the *only* reason a hypo occurs is because of an overdose. Exogenous insulin is only one piece of the puzzle. This is why there is always going to be a risk of hypo because what if the pancreas just decides to wake up that day and join the party…adding to the exogenous insulin? What if some infection/inflammation subsided….or stress was reduced….or the patient lost some body fat…..any of which would render the patient more insulin sensitive?

I have been so busy lately and have not been following Copper's saga but I want to reiterate the above because I often see folks on this board getting so caught up in the insulin dosage (down to overdone minutia....driving themselves crazy....) as if that is the only issue...and as if 0.1 (not even measurable...) or 0.2 units (highly doubtful that this level is accurately measured...) is the end all...be all...'deal breaker' for the cat's situation when it simply is only one TINY (at that level of change) piece of a very complicated puzzle.

Believe me, I completely 'get' the frustration involved with managing any diabetic cat - especially one like Copper - but I just hate to see people ripping their hair out over the dosage of insulin....down to impossible-to-accurately-measure increments of 0.1 or 0.2 units when there are SO many other factors involved in the glucose curve making that level of dosage change pretty darn moot. Yes, it would be great if we really had *that* much control over the disease process but we don't.

(Lori - I am hoping that the last statement will take pressure off of you - not add to it. Copper's body is in charge and we are just along for the ride...doing the best that we can with the ability to affect only a few pieces of the puzzle....ie....diet, insulin, constipation, body weight - in the case of an overweight cat.)

Serum glucose, at any single time point during the glucose curve, represents the sum effects in the *rate* and *amount* and *timing* of:

*Exogenous insulin absorption

*Endogenous insulin production

*Intracellular uptake of exogenous and endogenous insulin

*Insulin degradation and elimination - different for exogenous vs endogenous

*Intestinal glucose absorption

*Endogenous glucose production

*Tissue glucose uptake and utilization

and then throw in the amount of exogenous insulin....excess body fat....inflammation....subclinical infection....etc...etc....

....and then add in Copper's recent bouts with constipation (stress => increased BG) which prompted an email to Lori to get Miralax (or generic PEG 3350) into him asap before he ended up needing an enema at her vet's office...which is not easy for her to get to and I hated the thought of Copper having to go through all of this. (Dosage Rx was to start with 1/8-1/4 tsp AM and PM - mixed into food - and dose upwards to effect.)

When you consider all of the above, to me, at least, I can't get caught up in agonizing over minute dosage changes...so dear Lori....please stop driving yourself nuts over such small dosage increments.

Carl - it is great that you take the time to really think these cases through and I know that Lori deeply appreciates the time you, and everyone else here, have spent on Copper's case. He is not an easy one, that is for sure.



there are simply too many uncontrollable variables on a day-to-day basis to get all caught up in a difference of 0.1 unit.
just my thoughts and opinion...

 

[Marje and Gracie]

Great points, Jill, and I agree with all of them. I know that on any given cycle, insulin absorption can vary by up to 50%. By using the calipers, I'm just trying to take that one thing.....dosing accuracy.....out of the mix. If I know I am giving her the same dose with each shot, instead of possible variations of up to .25u, then I am at least addressing that. The rest of it is up to her.

The other thing is that I have said, and others have said, many times "one dose is too much and the next lower one is too little". Now I know that I can consistently get in between those; and again...that's just addressing the consistency. The rest is still up to Gracie and all the other factors that you mentioned and which are enormously valid and important.

you're either giving me too much credit or short-changing yourself.

:lol: :lol: :lol: :lol: :lol: Probably neither. I can't accurately eyeball one foot much less .25u :lol: :lol: :lol: :lol: :lol: