3/29 Max amps 101, reduced dose again

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Mindy & Max

Mindy & Max

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Friday: viewtopic.php?f=9&t=10263

Morning everyone!

We had a nice green weekend. :mrgreen: We held his dose at 1.25 to see how he did, and he did fantastic! Of course, I jinxed it when I talked to my mom Saturday night and said he was holding that dose really well. I was hoping for a few days of a "break" in having to worry about him dropping too low...but no dice. Sunday he started showing signs of needing another dosecrease, and Sunday night I gave him one because his pmps was only 68 (and I still had to pull out the HC later that evening). So....now we'll hold the 1U dose and see what happens. He was a little high this morning from the HC last night, but I'm expecting his pmps tonight to be around 80-90.

DH is home now, and the kids of course are sleeping a bit better. And one day this week I'll make DH do Max's BG test so I know he knows how to do it. He might be able to run home on his prep hour or right after school to check him on days we think he may be low. He needs to learn anyway--I'll be out of town for a few days next weekend, so he'll have to keep a close eye on him for me.
 
I'm not sure if you are following the dosing protocol. The research would suggest that doses are not reduced until numbers drop below 50. It looks like you are reducing if numbers are below 100. This sticky has the links to the formal dosing protocols as well as the overview.

I completely understand your giving what we term a "big chicken sh*t" (BCS) dose if you are concerned about Max's numbers during the day when you aren't there to monitor. However, I think you are reducing doses too quickly, like when you dropped from 2.0u to 1.25 in two cycles. I hope this dose sticks. I'd encourage you to not drop the dose further until you see whether the 1.0u is effective -- we hold doses for at least 3 cycles unless the numbers dictate a dose reduction by dropping to under 50.
 
I do have the dosing protocol printed and sitting on my counter at home right next to the testing supplies and the notepad I keep track of his numbers on.

I'll try to explain my reasoning for his dosing...hopefully it'll translate properly through a post. I know sometimes it's hard to follow my own brain path and explain it to others when speaking...it's harder when I'm typing.

I am aware of the "drop to under 50" rule for an immediate dose reduction, but If his ps number is low (which I believe most would say it is at 68 since 60 starts verging into possible hypo country), and I know my cat, and know that he WILL drop below 50, possibly much further than that, why can't I reduce the dose by .25U and save him from the hypo? The way his cycles usually work, he peaks at 3 or 4 hours after feeding/shot time, and his low is around +7-9, give or take. If he's low at +3, he's going to keep going lower. I don't feel it's necessary to let him keep dropping, and possibly suffer a rebound later. Does that make sense? And in the dosing protocol, under the section about raising the dose, it goes over what happens at the 2nd shot time after increasing--and has specific rules about shooting when the ps number is between 50 and 100. All three possible options include reducing the dose by 0.25-0.5U (I know this wasn't following an increase, but the reasoning still seems sound because making the cat go hypo isn't the goal).

I have gotten over my fear of shooting at an 80/90-ish ps number, and for the most part I'm okay with continuing current dosing when faced with that ps number...but many of the charts I've seen that have ps numbers around 60/70 show that the bean skipped that shot. I think skipping the shot entirely is probably more damaging than reducing for a few cycles to see how he handles it. I'm fully prepared to increase his dose back to 1.25U if he starts showing higher numbers again...but again, according to the dosing protocol, as long as he's staying between 50 and 200, the dose is supposed to be held. My vet is happy if he's staying under 150. If he starts showing a lot of blue ps numbers, however, I'll try pushing the dose back up to see what happens--provided I can be home to test and watch him.

I know that dosing isn't based on ps numbers, but rather on peaks and nadirs. Because I work, and I'm not superhuman and can't stay up all night, I don't have a ton of peak/nadir numbers on the chart. The ones I do have, tho, show that his ps numbers fall at about the mid-range of his cycle numbers (i.e. if is ps is 100, he's likely to cycle between 60 and 140 give or take a few points).

And in the end, ECID. Max had just gotten off a month of prednisone when he was diagnosed, and so many have told me he would most likely go into remission, and that it probably wouldn't take long for that to happen. While I didn't expect him to progress this fast, I'm not entirely shocked to see it when I know other cats have gone OTJ within 1-3 weeks of starting insulin and a low-carb diet. Do I want to be reducing his dose every few days? No way--I'd get more sleep if it weren't working out this way, but I have to follow Max's lead.
 
I just wanted to stop by and take a look at your Max - he's a handsome boy. Glad everything is going well for you.
 
The not shooting at that low of a number is the correct choice, I think what Sienne is getting at is that should be a one shot adjustment and the next shot should go back to the dose you were at to hold the dose for 7 days unless you hit a 50. I completely understand where you are at with knowing the cat, Smokey came down from those high doses pretty quickly and we did cut out .5 short in order to get on schedule with the vet.

The problem you could run into if you take him down too fast is it can make his pancreas work harder when the supporting insulin is taken away too fast. The harder we make it work while on insulin, the bigger chance we have on having the OTJ fail and Max would end back on insulin. I know when life is hectic, getting to the OTJ as fast as possible seems like the goal, but getting there too fast could hurt your chances of OTJ. Max's numbers look really good right now, but he isn't hitting any really low numbers, so that tells me (and I am new at this, but a bit obsessive about getting educated), but that tells me that he is still using the insulin to bring him down and the pacreas isn't kicking in as much as it could be (otherwise you could be seeing low numbers at over 1u).

Reducing a dose on a low PS number is a good thing when you know Max will drop too fast. But putting the dose back on schedule will give him the help he needs to heal and a much better chance at staying OTJ forever.
 
Is this the section of the Queensland/Rand protocol you're referencing?

If blood glucose at the time of the next insulin injection 50-100mg/dl (2.8-5.6 mmol/L) Initially test which of the alternate methods is best suited to the individual cat:

a. Feed cat and reduce the dose by 0.25-0.5 IU depending on if cat on low or high dose of insulin
b. Feed the cat, wait 1-2 hours and when the glucose concentration increases to >100 mg/dL give the normal dose. If the glucose concentration does not increase within 1-2 hours, reduce the dose by 0.25 IU or 0.5 IU (as above).
c. Split the dose: feed cat, and give most of dose immediately and then give the remainder 1 to 2 hours later, when the glucose concentration has increased to >100 mg/dL.

If all these methods lead to increased blood glucose concentrations, give the full dose if pre-insulin blood glucose concentration is 50-100 mg/dL and observe
closely for signs of hypoglycemia. In general for most cats, the best results in phase 2 occur when insulin dose is as consistent as possible, giving the full normal dose at the regular injection time.
Click to expand...

I would also point out that we don't use alternative "c." I think at small doses it would be exceptionally hard to split the dose. We approach a low pre-shot BG in a slightly different manner: don't feed and stall for 15 - 20 min. and retest to see if numbers are surfing or rising. Repeat this if necessary for up to 2 hrs; shoot a reduced (BCS) dose; or skip the shot.

If this is, in fact what you were referring to, I think Melanie is correct. You need to return to your pre-reduction dose. The above section of the protocol doesn't imply a permanent dose reduction. It is a guide for what to do if you have a low PS number. Melanie is also right in that by giving the pancreas as much support as possible for as long as possible you maximize the potential for OTJ and staying in remission.

The other point that I think is important to remember is made is the last sentence:
In general for most cats, the best results in phase 2 occur when insulin dose is as consistent as possible, giving the full normal dose at the regular injection time.
Click to expand...
The SS that D linked is a great example of how to shoot low to stay low. I can understand your being apprehensive until you've had a chance to be able to be at home and monitor though. I don't know that I would want to try shooting low for the first time and walking out the door.

I'm wondering if we can find an option you will be comfortable with that will also be good for Max.
 
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