4/24 Carter: AMPS 566, +4 587, +6 484, +8.25 543, PMPS 476

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Erica & Carter

Erica & Carter

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Yesterday's conversation.

Carter took a trip into the blues last night, only to bounce back with fury this morning at 566!

I had increased after 3 days due to his high numbers and following the TR rules from 1u to 1.5u. Today and tonight will be his 5th and 6th cycle. It says to increase again after 3 days (6 cycles) if Nadir is still not below 300.

So, that being said, providing he doesn't have an extremely low PS tomorrow or a under 300 Nadir today, tomorrow would I increase again .5u (2u total) and then try that increase for 3 days?

My one concern is that last night he dropped pretty low into the blues on that 1.5u, but he doesn't seem to be doing that for the AM cycle, just the PM cycle.
 
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What you're seeing on Carter's SS isn't a situation that's well explained in the protocol.

Carter is bouncing. When a kitty drops into low numbers, lower numbers than his body is currently used to (like Carter did), or the numbers drop quickly, the liver and pancreas dump a stored form of glucose and counterregulatory hormones into the blood stream. This is a protective function to safeguard against hypoglycemia. Unfortunately, because a kitty may be used to high(er) numbers due to diabetes, the liver and pancreas are overreacting and unnecessarily go into panic mode. As a result, the numbers spike upward into what we refer to as a "bounce." It can take as much as 3 days for a bounce to clear.

You can raise a dose during a bounce. However, you want to avoid increasing the dose if the bounce is breaking. When the bounce is clearing, numbers typically drop back down. If there is momentum from the bounce breaking and you increase on top of that, there may be a fair amount of momentum that drive the numbers low. Again, this isn't a horrible situation -- you just need to have the confidence to manage the low numbers. We generally suggest to newer members to wait until a bounce has cleared before raising the dose.

 
Sienne and Gabby (GA) said:
What you're seeing on Carter's SS isn't a situation that's well explained in the protocol.

Carter is bouncing. When a kitty drops into low numbers, lower numbers than his body is currently used to (like Carter did), or the numbers drop quickly, the liver and pancreas dump a stored form of glucose and counterregulatory hormones into the blood stream. This is a protective function to safeguard against hypoglycemia. Unfortunately, because a kitty may be used to high(er) numbers due to diabetes, the liver and pancreas are overreacting and unnecessarily go into panic mode. As a result, the numbers spike upward into what we refer to as a "bounce." It can take as much as 3 days for a bounce to clear.

You can raise a dose during a bounce. However, you want to avoid increasing the dose if the bounce is breaking. When the bounce is clearing, numbers typically drop back down. If there is momentum from the bounce breaking and you increase on top of that, there may be a fair amount of momentum that drive the numbers low. Again, this isn't a horrible situation -- you just need to have the confidence to manage the low numbers. We generally suggest to newer members to wait until a bounce has cleared before raising the dose.
Click to expand...

My concern is that he started off on too low of a dose (maybe not TOO low but he could have handled a higher starting dose, on the advise of others I started with 1u to be safe) so he is kind of stuck in a pemanent bounce, if you will? Because his body isn't adjusting, or maybe the depot isn't filling up?

I'm curious to why his PM cycle hits the blues but his AM cycle does not. I find it hard to read if he's bouncing versus New Dose Wonkiness?

I have an interview Monday morning so I won't really have much time to come online and ask thus why I was hoping to figure out what to do (in regards to increasing or not) ahead of time.

I don't think he will clear a bounce by tomorrow though... he always seems to be bouncing.
 
Do not ask me to explain this since I don't think there's an explanation (or I haven't been able to find one) but many cats do seem to experience lower numbers at night. (It's probably because they are trying to be contrary, are nocturnal, and want us to be awake and playing with them at night so they come up with a reason to keep us awake.) There is also "dawn phenomenon" which is part of the body's biorhythm that increases "stress" hormones as a means of preparing mammals for the day ahead and thereby raises BG levels.

If this were me, I might hold the dose just a bit longer. The other factor that may have contributed to the blue numbers is that the depot is more fully in place. The depot is filling. Unless you have a cat with a very weird system (i.e., there is a metabolic problem and your cat's system is too acidic -- and this is very, very unlikely since I'm presuming your cat is healthy. Metabolic acidosis can be life threatening), the depot is forming. It just takes 5 - 7 days for this to happen. (Lantus is acidic. Your cat's blood isn't. As a result, when you inject Lantus, it forms crystals that deposit in the fat tissue and slowly release insulin. This mechanism is how the insulin depot works -- at least with Lantus.)

If it makes more sense for you to increase for the Monday PM shot, that's fine. It sounds like you will be less worried going into your interview if you wait to increase Carter's dose.

 
Hi, Erica! I just wanted to say that Carter hasn't been at this very long yet so while it may feel like he is always bouncing or getting stuck at a particualr dose, it is way too soon to thnnk that. He needs time to level off and adjust although I know those high numbers are NOT something you want to see. Rosie used to bounce all the time and sometimes the bounces were much higher or longer than others. If you look at the 2015 tab on her SS, you'll see what I mean. But now, she rarely bounces. It just took time for her to reach this point.

Best of luck!
 
Sienne and Gabby (GA) said:
Do not ask me to explain this since I don't think there's an explanation (or I haven't been able to find one) but many cats do seem to experience lower numbers at night. (It's probably because they are trying to be contrary, are nocturnal, and want us to be awake and playing with them at night so they come up with a reason to keep us awake.) There is also "dawn phenomenon" which is part of the body's biorhythm that increases "stress" hormones as a means of preparing mammals for the day ahead and thereby raises BG levels.

If this were me, I might hold the dose just a bit longer. The other factor that may have contributed to the blue numbers is that the depot is more fully in place. The depot is filling. Unless you have a cat with a very weird system (i.e., there is a metabolic problem and your cat's system is too acidic -- and this is very, very unlikely since I'm presuming your cat is healthy. Metabolic acidosis can be life threatening), the depot is forming. It just takes 5 - 7 days for this to happen. (Lantus is acidic. Your cat's blood isn't. As a result, when you inject Lantus, it forms crystals that deposit in the fat tissue and slowly release insulin. This mechanism is how the insulin depot works -- at least with Lantus.)

If it makes more sense for you to increase for the Monday PM shot, that's fine. It sounds like you will be less worried going into your interview if you wait to increase Carter's dose.
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So how do I tell the difference between a steady high curve and bouncing/staying high? I just want to make sure I'm following the TR rules for increasing but if he keeps bouncing I'm not sure when it's appropriate.

**The reason I'm trying to stay on an "increase" schedule I guess is that I'm currently unemployment and once I go back to work, I won't be here during the day for at least a couple days out of the week and that worries me. I would be too afraid to increase if I couldn't be here, but then I'd feel bad if he needed the increase.
 
Lydia & Rosie AKA &Basil said:
Hi, Erica! I just wanted to say that Carter hasn't been at this very long yet so while it may feel like he is always bouncing or getting stuck at a particualr dose, it is way too soon to thnnk that. He needs time to level off and adjust although I know those high numbers are NOT something you want to see. Rosie used to bounce all the time and sometimes the bounces were much higher or longer than others. If you look at the 2015 tab on her SS, you'll see what I mean. But now, she rarely bounces. It just took time for her to reach this point.

Best of luck!
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Thank you. I know lots of other kitties bounce, I just want to make sure I'm increasing/decreasing appropriately and with him always bouncing, it's hard to know if I'm suppose to follow the TR rule, if I'm not suppose to follow the TR rule because of bouncing. Just scared to make the wrong decision.
 
Let me take a stab at explaining. I like to look at the guidelines themselves, so here is the part of the TR protocol for increasing the dose phase, which is where you are right now. When a cat starts out, they are on the "increasing" phase and once they start hitting green numbers consistently, they are either holding the dose or begin the dose decreasing phase.

INCREASING THE DOSE:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
    • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
    • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
You always want to be asking the question, "how low can this dose cause my cat's blood sugar to go?" At this point, Carter is getting at least as low as 104 on the dose. With Lantus, the low decides what you do with the dose. So I'd look up at the guidelines above and think that the part I've blued/bolded above applies. The high numbers will pass, but your focus is on the low numbers. It's possible he even got into green numbers last night before he started rising again. It's not terribly important, and you shouldn't feel like you needed to have stayed up longer and checked. He had dropped about 80 points in the 2 hours before the 104 - cats don't drop at a consistent rate per hour, but comparing to the last test can give you an idea of how quickly they are dropping.

So with a nadir close to 100, I'd hold the dose longer rather than shorter, within the guidelines above. You want to see if holding the dose longer - in this case I'd hold 8-10 cycles - will let him get back into that range again. Sometimes the cat will, sometimes it won't.

After waiting 8-10 cycles, if he's not in green numbers you may want to increase. Since he is in the lower blue range, you'd increase by 0.25u. If he gets into green numbers within that 8-10 cycles, then you might want to continue holding the dose longer to see if he can do it again. The more they get into normal range, the more their body "remembers" it's normal and the more time they will spend there. It also will help the bouncing lessen and in many cats, it will eventually end.

One "trick" that can help - when Carter gets into green numbers, try giving him a couple of teaspoons of his regular low carb food. That can help a cat surf, ie, stay in green numbers longer.

You asked about why he's lower at night than day - that's really common. As Sienne mentioned above, I tend to blame Dawn Phenomenon, although it could be that the lower cycle triggers a little bounce that is resolved by the next evening. Sometimes you can't figure out the why - so you just go with what data you have to make decisions.

The goal of Tight Reg is to get the cat's body back into normal numbers and keep it there. When they are in normal range, the pancreas has the opportunity to heal if that is possible. Many newly diagnosed cats in that circumstance will have their pancreas heal and sputter back to life again, putting out insulin, and sometimes the cat can become diet-controlled and go off of insulin.

That doesn't happen to every cat. Sometimes there are other factors going on in their body that prevent it. The second benefit to getting a cat's body into normal numbers is that it protects the body from the damages of high blood sugar. That's really important - we've had cats live as long as 9 years on insulin.

Here is a thread "Where Can I Find?" that is a bit of an index to this group and can help you find information that has been given in various threads. In the lower part of the first post, there is a section called Special strategies that help some cats: Look under there for "Tight Reg Protocol, Myths Debunked" for comments about increasing on a bounce and shooting a dropping number. You might also find the "shooting low" post in the same section to be a little helpful. You're not getting the opportunity to shoot low yet, but you likely will before too long.

I think Carter is close to a good dose. Might be this one, he might need a little more insulin before you've got all green numbers, but he's starting to show potential by getting to blue 2 nights in a row on the 1.5u. He needed 3u on the N to get to green, and that can suggest he'll need a little more than he's got now, but sometimes those aren't exactly the same (comparing N and L doses.)

Hope some of that helps. Keep asking questions - the more you understand, the more you'll be able to help Carter.
 
julie & punkin (ga) said:
Let me take a stab at explaining. I like to look at the guidelines themselves, so here is the part of the TR protocol for increasing the dose phase, which is where you are right now. When a cat starts out, they are on the "increasing" phase and once they start hitting green numbers consistently, they are either holding the dose or begin the dose decreasing phase.

INCREASING THE DOSE:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
    • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
    • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
You always want to be asking the question, "how low can this dose cause my cat's blood sugar to go?" At this point, Carter is getting at least as low as 104 on the dose. With Lantus, the low decides what you do with the dose. So I'd look up at the guidelines above and think that the part I've blued/bolded above applies. The high numbers will pass, but your focus is on the low numbers. It's possible he even got into green numbers last night before he started rising again. It's not terribly important, and you shouldn't feel like you needed to have stayed up longer and checked. He had dropped about 80 points in the 2 hours before the 104 - cats don't drop at a consistent rate per hour, but comparing to the last test can give you an idea of how quickly they are dropping.

So with a nadir close to 100, I'd hold the dose longer rather than shorter, within the guidelines above. You want to see if holding the dose longer - in this case I'd hold 8-10 cycles - will let him get back into that range again. Sometimes the cat will, sometimes it won't.

After waiting 8-10 cycles, if he's not in green numbers you may want to increase. Since he is in the lower blue range, you'd increase by 0.25u. If he gets into green numbers within that 8-10 cycles, then you might want to continue holding the dose longer to see if he can do it again. The more they get into normal range, the more their body "remembers" it's normal and the more time they will spend there. It also will help the bouncing lessen and in many cats, it will eventually end.

One "trick" that can help - when Carter gets into green numbers, try giving him a couple of teaspoons of his regular low carb food. That can help a cat surf, ie, stay in green numbers longer.

You asked about why he's lower at night than day - that's really common. As Sienne mentioned above, I tend to blame Dawn Phenomenon, although it could be that the lower cycle triggers a little bounce that is resolved by the next evening. Sometimes you can't figure out the why - so you just go with what data you have to make decisions.

The goal of Tight Reg is to get the cat's body back into normal numbers and keep it there. When they are in normal range, the pancreas has the opportunity to heal if that is possible. Many newly diagnosed cats in that circumstance will have their pancreas heal and sputter back to life again, putting out insulin, and sometimes the cat can become diet-controlled and go off of insulin.

That doesn't happen to every cat. Sometimes there are other factors going on in their body that prevent it. The second benefit to getting a cat's body into normal numbers is that it protects the body from the damages of high blood sugar. That's really important - we've had cats live as long as 9 years on insulin.

Here is a thread "Where Can I Find?" that is a bit of an index to this group and can help you find information that has been given in various threads. In the lower part of the first post, there is a section called Special strategies that help some cats: Look under there for "Tight Reg Protocol, Myths Debunked" for comments about increasing on a bounce and shooting a dropping number. You might also find the "shooting low" post in the same section to be a little helpful. You're not getting the opportunity to shoot low yet, but you likely will before too long.

I think Carter is close to a good dose. Might be this one, he might need a little more insulin before you've got all green numbers, but he's starting to show potential by getting to blue 2 nights in a row on the 1.5u. He needed 3u on the N to get to green, and that can suggest he'll need a little more than he's got now, but sometimes those aren't exactly the same (comparing N and L doses.)

Hope some of that helps. Keep asking questions - the more you understand, the more you'll be able to help Carter.
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Thank you very much. So when hit hits the greens would I give him food in additon to the other feedings or encourage to eat what is available? They get 4x feedings on my autofeeder but sometimes they nibble on their "before bed" snack until it rotates at a certain time to prevent eating 2+ hours before the AMPS. This is assuming he hits the greens in the PM cycle rather than the AM cycle.

I think I understand a bit more now in regards to the Nadir. I was referencing the Nadir for the AM cycle, which as been high, rather than the PM cycle, which has been lower. So when it comes to the dose adjustment, do I base it off of whatever Nadir is the lowest then? What happens if I am only one to get one or the other so I don't know if one was indeed lower than the other for a particular day?
 
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Erica & Carter said:
so he is kind of stuck in a pemanent bounce, if you will? Because his body isn't adjusting, or maybe the depot isn't filling up?
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Hi Erica, (I wrote the following while Julie was posting her excellent explanations, but just want to set it down to get some feedback from others who understand the whole process of the depot better than I do):

As I understand it, it takes about a week for the depot to form. When you switched to Lantus you gave 1 unit for 6 cycles (3 days) and then went up to 1.5 units. So the depot at the 1-unit level didn't have enough time to form (the depot always reflects the number of units). Now your dose is 1.5 units and you are on the 5th cycle (2 1/2 days). The 1.5 units produced some blue numbers that, as Sienne said, caused the present bounce. I don't think New Dose Wonkiness applies when the use of an insulin is just being started.
Someone please correct me if I'm wrong, but It looks to me like the depot is trying to catch up with the dose increases. I would agree with Sienne that you should wait at least until Monday night and see what happens before increasing the dose. In adjusting doses, it is always important to give a new dose time to settle in (to establish it's depot).

Good luck with your job search,

Ella & Rusty
 
Ella & Rusty & Stu(GA) said:
Hi Erica, (I wrote the following while Julie was posting her excellent explanations, but just want to set it down to get some feedback from others who understand the whole process of the depot better than I do):

As I understand it, it takes about a week for the depot to form. When you switched to Lantus you gave 1 unit for 6 cycles (3 days) and then went up to 1.5 units. So the depot at the 1-unit level didn't have enough time to form (the depot always reflects the number of units). Now your dose is 1.5 units and you are on the 5th cycle (2 1/2 days). The 1.5 units produced some blue numbers that, as Sienne said, caused the present bounce. I don't think New Dose Wonkiness applies when the use of an insulin is just being started.
Someone please correct me if I'm wrong, but It looks to me like the depot is trying to catch up with the dose increases. I would agree with Sienne that you should wait at least until Monday night and see what happens before increasing the dose. In adjusting doses, it is always important to give a new dose time to settle in (to establish it's depot).

Good luck with your job search,

Ella & Rusty
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Gotcha. I think I was advised to increase based on the fact that he was probably under-dosed and therefore continuing to be high and was a good candidate for the "Waiting 6 cycles" rule. I hadn't seen any blues with the 1u so it's good that the 1.5u showed some progress in that regard. I won't increase, I'll wait for at least 8-10 cycles an reassess from there unless he is stuck in the blacks or something.

He's just a big boy so I figured he MIGHT possibly end up receiving more Lantus than the normal cat, at least when he first starts. But I'd feel more comfortable increasing on day(s) when I'll be home, but if I get hired tomorrow, my schedule is going to change a lot and that worries me just because since his diagnosis I was working very minimally/trying to find a new job. It worries me most because he's not close to be regulated enough for me to feel comfortable leaving him at home, even if he wasn't in dangerous numbers. Idk, seems silly, sometimes I feel like I'm the diabetic one lol lately all I do is think about feline diabetes.
 
I think you said it beautifully, Ella. When you increase the dose, the depot has to "grow" to catch up - that's the reason for holding the dose at least 3 days.

You have a good idea of the nadir - it doesn't matter WHEN it occurs on a dose, just that on THIS dose, the nadirs are xyz, so then you look at the chart and see what it suggests. It doesn't have to be the nadir in the morning or the evening - it's just answering the question "how low can this dose make my cat's blood sugar drop?" Most people focus on the high numbers and want to increase the dose because of those, but that is a difference with a depot insulin - the low numbers rule the dose decisions. Doesn't matter when the lows occur, just that they do.

You want to hold doses a minimum of 3 days unless the cat earns a reduction in those 3 days. Then you reduce the dose with the next shot and hold the reduction until you decide if it was a good move or not.

Reductions are a whole other beast, so if he earns a reduction by dropping below 50 on a human glucometer, post again and we can go through what you're looking for when you reduce the dose.

If he's already nibbling and has food available, then there's not much point in giving more food. Some cats are fed on a schedule and suck up the whole meal the second it's put down, so feeding a little extra food if they get into greens at that point can be helpful. This is one of those ECID (every cat is different) things, so it's a bit of trial and error to see what works for Carter.

Just saw your last post above - take a look at the sticky on how to work full time while following Tight Reg. It just means that your autofeeder is very valuable, and that getting pm cycle tests every evening become even more important.
 
If only his BS matched his blue eyes. :p
 

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Sienne and Gabby (GA) said:
FWIW, I worked full time throughout Gabby's diabetes. It's feasible to do this you just need to learn how your cat responds to insulin.
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I just think it will be an adjustment. I'm pretty much the only one I trust with it. I'll have to teach my spouse numbers how everything works because she is home on the weekends and if I'm at work, she will need to know how to handle everything if I can't be reached.
 
It's definitely helpful if everyone who lives with the kitty knows how to test, shoot and deal with low numbers. You can no doubt teach her, and hopefully she can reach you via text if she needs help. Some people share the log-in information so everyone can post here if they need advice and can't reach the experienced partner.
 
julie & punkin (ga) said:
It's definitely helpful if everyone who lives with the kitty knows how to test, shoot and deal with low numbers. You can no doubt teach her, and hopefully she can reach you via text if she needs help. Some people share the log-in information so everyone can post here if they need advice and can't reach the experienced partner.
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Agreed. She can test and shoot but she doesn't know how to read the numbers which is super important.
 
Can you teach her to put them in the spreadsheet - the colors definitely help understand what one is seeing.

Our son took care of Punkin for a few days while we took a trip and I gave him some parameters to help guide him for shooting, then said if numbers were lower than xyz to text or call me.
 
Erica & Carter said:
I had increased after 3 days due to his high numbers and following the TR rules from 1u to 1.5u
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Hi Erica ~ I was reading through your thread and noticed that you are increasing dose by .50. We recommend increases and decrease by .25 units. That way you won't go past the right dose. Maybe there is a reason you are increasing by 1/2 units that I am not aware of but the protocol calls for .25 increases and decreases. When the units per shots get over 5 or 6 units then the increases can be by .50 units but, that is not the case with Carter.
 
Bobbie And Bubba said:
Hi Erica ~ I was reading through your thread and noticed that you are increasing dose by .50. We recommend increases and decrease by .25 units. That way you won't go past the right dose. Maybe there is a reason you are increasing by 1/2 units that I am not aware of but the protocol calls for .25 increases and decreases. When the units per shots get over 5 or 6 units then the increases can be by .50 units but, that is not the case with Carter.
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Hey,

I was under the impression I was following this:


GENERAL GUIDELINES:
  • Hold the initial starting dose for 5 - 7 days (10 - 14 consecutive cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 consecutive cycles).
  • Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction (See: Reducing the dose...).
  • Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.

INCREASING THE DOSE:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
    • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
    • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
I've really just been asking and following the advise of others. @Chris & China I think can confirm that I had asked about upping to .5u in a previous thread and got the o-k from some members because his nadirs were greater than 300.
 
I couple of people mentioned he might be under-dosed so .5 would be the better increase. But he's been bouncing so it's hard to tell what the appropriate dose is at this point.
 
Bobbie And Bubba said:
Hi Erica ~ I was reading through your thread and noticed that you are increasing dose by .50. We recommend increases and decrease by .25 units. That way you won't go past the right dose. Maybe there is a reason you are increasing by 1/2 units that I am not aware of but the protocol calls for .25 increases and decreases. When the units per shots get over 5 or 6 units then the increases can be by .50 units but, that is not the case with Carter.
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Bobbie, it's always good for people to recheck things! Don't apologize for bringing this up - better for it to be brought up than for someone to accidentally increase by too much. That's one good thing about a peer-reviewed forum, what people get told gets rechecked. It's perfectly possible for people to make errors, so it never hurts to recheck things. It helps us all learn.

And yes, now things have changed because dear little Carter has peeked at the blue floor, so he's back to 0.25u increases for now.

Good luck tomorrow!
 
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