? 13April2020/Maxi/This Morning PM+6:163/Questions re. R, Goal Glucose Numbers, Ketones

Hi Karen,

Looks like you are seeing some action tonight. From what I recall, R should be pretty much done it's course @+4 right? Then Lantus should start kicking in. Would be nice if Maxi would just surf along in blues for a bit.

Let's tag @Wendy&Neko and see if she's still up. I'm thinking Wendy is a bit of a night owl! lol
 
The 1.5 unit of R seems a bit much, it is taking him down more than 100 points over the four hours. This is also day 15 of cabergoline and cycle six of this Lantus dose, so depot is full. A lot possibly contributing to tonight’s action. I would hold the Lantus dose tomorrow. Cabergoline can start working day 10-14 ish. Time to exercise a little caution, just in case.
 
Wendy&Neko said:
The 1.5 unit of R seems a bit much, it is taking him down more than 100 points over the four hours. This is also day 15 of cabergoline and cycle six of this Lantus dose, so depot is full. A lot possibly contributing to tonight’s action. I would hold the Lantus dose tomorrow. Cabergoline can start working day 10-14 ish. Time to exercise a little caution, just in case.
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Thanks, Wendy.
You don't mean withhold Lantus tomorrow, right? You mean that I should not increase his Lantus up from 7.5 tomorrow, but I should give him Lantus in the AM and PM, right? Just want to confirm what you mean by 'hold the Lantus.'
 
Wendy&Neko said:
By the way, we ask that you just do one post a day, and keep the subject line updated as things change. Here is the link to your other post today http://www.feline diabetes.com/FDMB/threads/12april2020-maxi-questions.228245/

Maxi already answered some of your questions from that other post.:cool:
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I was not going to post again today (April 13), so this post is my 1-post allotment.

I am still hoping for answers to my questions, which I will copy here:

Is the only time to give R at AM and PM and AM+6 and PM+6?

200s are decent? Isn't the goal below 100?

Hasn't it been long enough for the cumulative effect to kick in? The layers of Lantus and R have not brought his numbers into a healthy range. Am I waiting for more accumulation to bring the numbers down? How long?

His AM+6 was just 274, so I didn't give him R because per the scale I should give R only if 275 or above. Is that a line not to be crossed? It seems to me that giving R at 274 would be a good idea since it's only a point away.

I just tested his ketones. I didn't put the strip in his urine stream; I caught some urine in a bowl and dipped the stick in. It shows "trace" ketones as far as I can tell. Photo attached. What should I do?

Thank you.
 

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At last, some blue :cool:

Regarding the “trace” ketone test reading and your question as to what to do, make sure he is well hydrated. Adding as much water as he will tolerate into his food helps. Do not let 24 hours pass without a ketone test. If he were my cat I would test for ketones once per cycle. Anything beyond “trace” warrants a call to the vet.

I agree with Wendy- do not increase Lantus dose tomorrow.
 
bambinaki said:
Thanks, Wendy.
You don't mean withhold Lantus tomorrow, right? You mean that I should not increase his Lantus up from 7.5 tomorrow, but I should give him Lantus in the AM and PM, right? Just want to confirm what you mean by 'hold the Lantus.'
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Karen, Wendy may well have gone to bed as it's pretty late where she lives.
I'm sure she means that you hold the same dose and don't increase the dose. By the look of things you have been increasing every three days and she doesn't want you to do that tomorrow.
 
Sandy and Black Kitty said:
At last, some blue :cool:

Regarding the “trace” ketone test reading and your question as to what to do, make sure he is well hydrated. Adding as much water as he will tolerate into his food helps. Do not let 24 hours pass without a ketone test. If he were my cat I would test for ketones once per cycle. Anything beyond “trace” warrants a call to the vet.

I agree with Wendy- do not increase Lantus dose tomorrow.
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Thanks, Sandy.
What's the treatment for more than trace ketones?
 
Bron and Sheba (GA) said:
Karen, Wendy may well have gone to bed as it's pretty late where she lives.
I'm sure she means that you hold the same dose and don't increase the dose. By the look of things you have been increasing every three days and she doesn't want you to do that tomorrow.
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Thanks, Bron.
 
Judy and Freckles said:
Hi Karen,

Looks like you are seeing some action tonight. From what I recall, R should be pretty much done it's course @+4 right? Then Lantus should start kicking in. Would be nice if Maxi would just surf along in blues for a bit.

Let's tag @Wendy&Neko and see if she's still up. I'm thinking Wendy is a bit of a night owl! lol
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Thanks, Judy.
 
Maxi's AMPS is 300, so I gave him 1.25 R.
This is not per the scale.
Here's the R scale:
PS 350 or higher: 1.75
PS 300 - 349: 1.5
PS 275 - 299: 0.75

Per the scale, I should have given him 1.5, but because of what happened last night, and because of Wendy's thinking 1.5 was a lot, and because 300 is right at the lower edge, I gave a bit less. I don't know if what I ended up with was closer to 1.25 or 1.5, but I aimed for 1.25.

I also wonder why the scale goes from 1.5 down to 0.75 and not 1.25 or 1...?

Thank you
 
Some very nice blues last night.

For ketones, it's giving extra water, making sure they eat enough and getting enough insulin. Be on the look out for possible infection or illness brewing. Trace ketones bear watching anything higher, vet should be consulted with.

If getting urine to test is difficult, there are blood ketone meters. Use just like glucose meter. Strips are super expensive though.
 
Olive & Paula said:
Some very nice blues last night.

For ketones, it's giving extra water, making sure they eat enough and getting enough insulin. Be on the look out for possible infection or illness brewing. Trace ketones bear watching anything higher, vet should be consulted with.

If getting urine to test is difficult, there are blood ketone meters. Use just like glucose meter. Strips are super expensive though.
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I do add as much water as I think he'll accept to his food and have 3 water bowls around the abode.

I will look into getting a ketone meter. Is there a recommended brand?
 
There are only 2 that I know of.

Precision X

Nova Max Plus.

I use Nova Max because it takes the smallest blood drop. Ollie doesn't bleed well even after all these years. Sample blood size is same as the AlphaTrac and the discontinued Relion Micro Meter (which I still use). Nova Max Plus is also a glucose meter (different strips). So it's a back up for me. I do find using it for glucose is temperamental. But for ketones it's great, no issues. You only get 10 ketone strips per bottle and they are expensive no matter which brand you go with.
 
Olive & Paula said:
There are only 2 that I know of.

Precision X

Nova Max Plus.

I use Nova Max because it takes the smallest blood drop. Ollie doesn't bleed well even after all these years. Sample blood size is same as the AlphaTrac and the discontinued Relion Micro Meter (which I still use). Nova Max Plus is also a glucose meter (different strips). So it's a back up for me. I do find using it for glucose is temperamental. But for ketones it's great, no issues. You only get 10 ketone strips per bottle and they are expensive no matter which brand you go with.
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Thanks, Paula
 
bambinaki said:
Is the only time to give R at AM and PM and AM+6 and PM+6?
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There is some wiggle room. What were you proposing?
bambinaki said:
200s are decent? Isn't the goal below 100?
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Since you have a cat with acromegaly, it's not so important to be in the range where the pancreas can heal (below 100). It's entirely possible his pancreas is working fine. A better goal for you is to try to get his numbers under renal threshold to avoid organ damage. For me, I found nadirs in the 70's gave me overall numbers under renal threshold. That is ECID, so you have to find out what works for Maxi. As far as 200's being decent - it depends where his renal threshold is, and they are way better than pinks and reds!
bambinaki said:
Hasn't it been long enough for the cumulative effect to kick in? The layers of Lantus and R have not brought his numbers into a healthy range. Am I waiting for more accumulation to bring the numbers down? How long?
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No, the reason I said to press pause on this dose is because of the possible cabergoline effect. If it is going to impact his numbers in a good way, it happens at around this time frame. Never underestimate the power of the larger Lantus depot. Adding R is a safety mechanism because you can just remove R to get a lower dose. But you also have to follow the R guidelines on not dropping the BG too much with it. I have seen some huge and fast dose need changes with cabergoline. That is all good, but since we don't know for sure what is happening, I am being cautious. Safety first is our mantra.
 
There is some wiggle room. What were you proposing?

For example, if his AM or PM PS number or his +6 number is not high enough for R, but some time later it gets higher and into the range for giving R, would it be right to give R at that time even if it's not AM or PM PS or +6?

Since you have a cat with acromegaly, it's not so important to be in the range where the pancreas can heal (below 100). It's entirely possible his pancreas is working fine. A better goal for you is to try to get his numbers under renal threshold to avoid organ damage. For me, I found nadirs in the 70's gave me overall numbers under renal threshold. That is ECID, so you have to find out what works for Maxi. As far as 200's being decent - it depends where his renal threshold is, and they are way better than pinks and reds!

To determine his renal threshold, I need Diastix, right?

No, the reason I said to press pause on this dose is because of the possible cabergoline effect. If it is going to impact his numbers in a good way, it happens at around this time frame. Never underestimate the power of the larger Lantus depot. Adding R is a safety mechanism because you can just remove R to get a lower dose. But you also have to follow the R guidelines on not dropping the BG too much with it. I have seen some huge and fast dose need changes with cabergoline. That is all good, but since we don't know for sure what is happening, I am being cautious. Safety first is our mantra.[/QUOTE]

Let's say his AM+6 is 274, and I don't give him R because per the scale I should give R only if 275 or above. Is that a line not to be crossed? It seems to me that giving R at 274 would be a good idea since it's only a point away.

Why does the R scale go from 1.5 down to 0.75 and not 1.25 or 1?
 
bambinaki said:
What were you proposing?
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I am looking for a concrete example. What is "some time later"? Yesterday it was just as well you didn't give R at that time.

Renal threshold is either ketodiastix, or I would test Neko just before she went for urinalysis. Ballpark it's probably mid to high blues to low yellows.
 
Wendy&Neko said:
I am looking for a concrete example. What is "some time later"? Yesterday it was just as well you didn't give R at that time.

Like on April 6, when his PMPS was 252 (too low to give R), but 2 hours later it was 277 (high enough to give R).

Renal threshold is either ketodiastix, or I would test Neko just before she went for urinalysis. Ballpark it's probably mid to high blues to low yellows.
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These strips (please see attached photo) are not what I need to determine renal threshold?

Thank you!
 

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bambinaki said:
These strips (please see attached photo) are not what I need to determine renal threshold?

Thank you!
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No. To determine renal threshold you need to find out when glucose isn't spilling into urine. I know Ollie spills urine when glucose is at least 223 But does not spill at 151. So she needs to stay below the 223. Don't know when she spills between the 2 yet. These numbers were by lab results.
 
Olive & Paula said:
No. To determine renal threshold you need to find out when glucose isn't spilling into urine. I know Ollie spills urine when glucose is at least 223 But does not spill at 151. So she needs to stay below the 223. Don't know when she spills between the 2 yet. These numbers were by lab results.
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Thanks, Paula. I wasn't sure if the strips in the photo test for glucose in urine because I think some strips test for both ketones and glucose. I would like to test Maxi's urine at home to determine his renal threshold.
 
bambinaki said:
Why does the R scale go from 1.5 down to 0.75 and not 1.25 or 1?
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The R scale is not locked in stone. You want an R dose such that the blood sugar numbers do not go down more than 100 points over the time the R is active, typically 4 hours. That is to reduce the chance of bouncing. With using R, you start with a particular dose, then you experiment several times to see what the action is, then adjust if needed. And be cautious about adjustments, making small changes at a time. From tonight's numbers, that 0.75 units R is spot on. :cool:

You also asked about shooting at 274 vs 275. It is somewhat situation dependent. I would shoot a bit lower if I knew for sure Neko was skyrocketing into a bounce.
 
Wendy&Neko said:
The R scale is not locked in stone. You want an R dose such that the blood sugar numbers do not go down more than 100 points over the time the R is active, typically 4 hours. That is to reduce the chance of bouncing. With using R, you start with a particular dose, then you experiment several times to see what the action is, then adjust if needed. And be cautious about adjustments, making small changes at a time. From tonight's numbers, that 0.75 units R is spot on. :cool:

You also asked about shooting at 274 vs 275. It is somewhat situation dependent. I would shoot a bit lower if I knew for sure Neko was skyrocketing into a bounce.
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Thank you, Wendy.

  • Why does the R scale go from 1.5 down to 0.75 and not 1.25 or 1? The scale starts at the upper end at 1.75; then the next level is 1.5, a 0.25 decrease; then the next level is 0.75, a 0.75 decrease. The first decrease is by 33%, but the second decrease is double, 66%. Why are the steps down (or up if you look at it that way) irregular?

  • If his AM or PM PS number or his +6 number is not high enough for R, but some time later it gets higher and into the range for giving R, would it be right to give R at that time even if it's not AM or PM PS or +6? In other words, if he doesn't get R at an AMPS, a PMPS, or a +6, but his glucose goes to a level 2 or 3 hours after AMPS, PMPS, or +6, should I give him R? For example, on April 6, when his PMPS was 252 (too low to give R), but 2 hours later it was 277 (high enough to give R according to the scale), would it have been right at that time, at +2, since he hadn't had R for 8 hours, to give him R?

  • Maxi has been at 7.5 units of Lantus for 8 cycles. Will you let me know when/if to increase the Lantus?
 
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Wendy&Neko said:
Because that is the number that works, as evidence by tonight.

Are you saying that is the number that is known to work in cats? Or in Maxi?
The scale was provided to me before the evidence it worked the one time with Maxi. I'd just like to know the thinking behind the irregularity of the scale.

How much later is the question.
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Wendy&Neko said:
Because that is the number that works, as evidence by tonight.

How much later is the question.
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As I said (maybe I edited it in after you posted this question), let's say 2 or 3 hours later as on April 6.

Thank you
 
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