5/20 Miss Meows AMPS 230, +2 267, +4 254, +6.5 242, +8.5 292, PMPS 275

[missMeows]

Happy Hump day!

Yesterday

So it looks like she is keeping to the yellows and blues again. Fiancé is doing a curve today for me since today is the day that her dose should really kick in. I would also usually increase this evening, but TR protocol states to wait 10 cycles before increasing if you see greens. Does that mean the first time we see green (which was 5/6). Or does the fact we saw green on 5/17 also mean I should wait another day (this morning is her 8th cycle)? Or is it 10 cycles from the time of the green?

Thanks so much! Hope everyone's kitties are purring and eating... and behaving. Unlike mine who thinks that the kitchen counter is now part of her realm

 

[Marje and Gracie]

I haven't had a chance to welcome you, Gabrielle, Miss Meows, and DF to our group so a hearty welcome!

From the modified TR protocol we see here:

• when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.

I'd aim for holding the dose longer and seeing if she can settle more into it as one shot builds up one the previous. Following the above, you'd hold for ten cycles after seeing "nadirs" under 100. If she doesn't see another nadir under 100 in the next few cycles, discounting bounces, I'd increase.

Have a great day.

 

[Sienne and Gabby (GA)]

Actually, the TR protocol indicates that if nadirs are below 200 (blues and greens) but the peak (highest point in the cycle) are over 200, you would increase every 5 - 7 days.

The information that is in the TR Protocol sticky note needs to be updated. If you look at the recent article that Jill attached to that post, there are some subtle changes in the protocol. If you don't want to download the article, it's summarized on the website from the German Lantus forum.

 

[missMeows]

I haven't had a chance to welcome you, Gabrielle, Miss Meows, and DF to our group so a hearty welcome!

Thank you!!!

Marje and Sienne,
Thanks for all the info and advise! I'm a bit confused now though. So according to the new TR guidelines, I should always wait 5 - 7 days since she sometimes has blue nadirs. Does this now take the place of the rule with green nadirs? I've read the pdf and the link and no where does it mention that part anymore.

Thanks again!

 

[Marje and Gracie]

Actually, the TR protocol indicates that if nadirs are below 200 (blues and greens) but the peak (highest point in the cycle) are over 200, you would increase every 5 - 7 days.

The information that is in the TR Protocol sticky note needs to be updated. If you look at the recent article that Jill attached to that post, there are some subtle changes in the protocol. If you don't want to download the article, it's summarized on the website from the German Lantus forum.

I was quoting the modified TR protocol that we are using here. If the revised Roomp/Rand protocol is being used, then Sienne provided that info.

I know it's confusing to have the Roomp/Rand TR protocol and also the modified TR protocol that many members here use. I'd just suggest reading over them both and deciding which might be a better fit, the modified is a bit more aggressive but it's the one I, personally, like to use for Gracie. Not to say I don't read and reread the TR protocol as presented on Tilly's webpage and the original and revised R/R TR protocol. But I typically will quote from the modified.

 

[missMeows]

I was quoting the modified TR protocol that we are using here. If the revised Roomp/Rand protocol is being used, then Sienne provided that info.

Oh my! I didn't realize there were two forms of the TR protocol! Oye

So if I'm understanding this correctly, if I go with the R/R TR protocol - I wait 5-7 days for increases, ignoring her greens. If I go with the modified TR protocol - I wait 10 cycles from her last greens (technically 5/18) before I increase.

If that is correct, my last question would be, do I always wait 10 cycles from when we start to see green nadirs on a dose? Or is this a "if you're new to seeing green" type of thing? Actually I lied.. another question to follow that one up. Say I saw greens today (most unlikely unfortunately), would it then be 10 cycles again from there?

Sorry with all the questions, for some reason this whole concept of "what to do with greens" has been difficult for me to wrap my head around.

Thanks again for your help!

 

[Marje and Gracie]

If that is correct, my last question would be, do I always wait 10 cycles from when we start to see green nadirs on a dose? Or is this a "if you're new to seeing green" type of thing? Actually I lied.. another question to follow that one up. Say I saw greens today (most unlikely unfortunately), would it then be 10 cycles again from there?

This is the one place in the modified TR protocol where I think it is s little more conservative regarding new members starting to see nadirs below 100. So, yes...that is a "new to seeing green" so once you are a little more experienced with seeing green and handling low numbers, then you can see what works best for Miss Meow. For example, I know Gracie is a bit of a slow responder at times to increases. If she shows me green in the first six cycles, I hold the dose at least 11 cycles to see if she can settle in a bit more. Again, this is what I've noticed in Gracie and shoudl not be used for other cats unless they have a similar pattern.

Once you are more accustomed to nadirs under 200, you could follow the modified TR protocol and hold the dose 6-10 consecutive cycles to see what she's doing. You'll learn her patterns and we can help you with that as well.

I would start the count from the cycle you first saw green. If you see green again today, I wouldn't restart the count.

I should also correct one thing I said above. We followed the modified TR protocol with Gracie. Now, we use it as a guideline but we also have enough data and knowledge of her that she has her own special Gracie protocol

 

[Jill & Alex (GA)]

Actually, the TR protocol indicates that if nadirs are below 200 (blues and greens) but the peak (highest point in the cycle) are over 200, you would increase every 5 - 7 days.

Yes, Sienne. You are correct quoting the Roomp/Rand version of the TR Protocol. Marje is also correct when quoting the modified version of the protocol.

The information that is in the TR Protocol sticky note needs to be updated.

No, the TR Protocol sticky does not need updating in regard to the modified version. The TR Protocol Sticky specifically states and has since 2013:

"Many Lantus and Levemir users in this forum have been successful following a somewhat modified version of this Tight Regulation Protocol for the last few years. These "general" guidelines are based on anecdotal evidence and personal experiences of laypersons frequenting the forum.
(Revised 10/28/2013)"

I'm not sure how to make it any clearer. Suggestions?

If you look at the recent article that Jill attached to that post, there are some subtle changes in the protocol.

There have always been some subtle differences between the Roomp/Rand protocol and the modified version. I've tried to make that very clear in the protocol sticky from day one.


Gabrielle, I'm sorry for the confusion as well as hi-jacking your thread. I have to get back to work, but I will check back later to see if your questions have been answered.


ETA: Marje is quick and she types faster than me! LOL!

 

[missMeows]

Gabrielle, I'm sorry for the confusion as well as hi-jacking your thread. I have to get back to work, but I will check back later to see if your questions have been answered.

No worries at all! Any extra voices of experience is always welcome on my thread I suppose when I read the sticky and it said "For the most part, the guidelines/suggestions made in this forum are for those who wish to follow this particular protocol or a slightly modified version." I thought that meant you were quoting the original protocol and others with more experience modify it as they deem necessary. Just how Marje states

We followed the modified TR protocol with Gracie. Now, we use it as a guideline but we also have enough data and knowledge of her that she has her own special Gracie protocol

I thought that's what everyone was doing, just not with the already modified version, but the original version. Just a misinterpretation on my part.

This is the one place in the modified TR protocol where I think it is s little more conservative regarding new members starting to see nadirs below 100. So, yes...that is a "new to seeing green" so once you are a little more experienced with seeing green and handling low numbers, then you can see what works best for Miss Meow. For example, I know Gracie is a bit of a slow responder at times to increases. If she shows me green in the first six cycles, I hold the dose at least 11 cycles to see if she can settle in a bit more. Again, this is what I've noticed in Gracie and shoudl not be used for other cats unless they have a similar pattern.

Once you are more accustomed to nadirs under 200, you could follow the modified TR protocol and hold the dose 6-10 consecutive cycles to see what she's doing. You'll learn her patterns and we can help you with that as well.

I would start the count from the cycle you first saw green. If you see green again today, I wouldn't restart the count.

This has been all so wonderfully helpful in helping my understand this concept. Thank you so much! I think I'll stick with the modified TR and now wait another two days to see where this dose takes us.

Thank you all for your help. Big hugs all around

 

[Marje and Gracie]

I thought that's what everyone was doing, just not with the already modified version, but the original version. Just a misinterpretation on my part.

This has been a topic of discussion for some time. I think members start out trying very hard to stick to the TR protocol or the modified TR Protocol. It's a great place to start and gives you a framework you can refer back to time and time again. But as life demands and as we get to know our kitties, everyone tweaks it. That's why Jill stresses it is a "guideline". Following it to the last crossed "t" and dotted "i" requires a lot of diligence, patience, time, etc. yes, it can be done. But I think most members, once they get through the steep learning curve and start to feel more comfortable with the numbers and the process, begin to tweak a bit to fit into their life and their knowledge of their kitty.

This has been all so wonderfully helpful in helping my understand this concept. Thank you so much! I think I'll stick with the modified TR and now wait another two days to see where this dose takes us.

Sounds great. One thing that I had such a difficult time learning as a new member was patience. I was the worst! I found it to be so hard to see Gracie in higher numbers with a dip to good ones and then back up. It took me a very long time to learn the value of holding doses when she bounced even when we were seeing green nadirs. I still occasionally get an itchy trigger finger but I've been doing much better at holding doses when it's indicated and it's paid off.

 

[Sienne and Gabby (GA)]

(Marje really did have a hard time learning patience!)

 

[missMeows]

One thing that I had such a difficult time learning as a new member was patience. I was the worst! I found it to be so hard to see Gracie in higher numbers with a dip to good ones and then back up. It took me a very long time to learn the value of holding doses when she bounced even when we were seeing green nadirs. I still occasionally get an itchy trigger finger but I've been doing much better at holding doses when it's indicated and it's paid off.

I must admit, I was a bit disappointed when you first told me to wait a little longer on this dose. Mostly, I get the itchy trigger finger because I feel if I wait too long I might loose the window to get her OTJ... and frankly... I'm getting tired of seeing nice YELLOW curves

 

[missMeows]

... and today was supposed to be her low number day

 

[Marje and Gracie]

I must admit, I was a bit disappointed when you first told me to wait a little longer on this dose. Mostly, I get the itchy trigger finger because I feel if I wait too long I might loose the window to get her OTJ... and frankly... I'm getting tired of seeing nice YELLOW curves

I understand. But your goal should be tight regulation. All of us want remission. But I can't help but think that I pushed Gracie so hard that I caused a lot of the bouncing when I could have, perhaps (who knows), gotten her better regulated earlier. I'm not sure remission was ever in the cards for her because she was not a dry food kitty ever and she had not been on oral steroids for over six months and then it had just been a short course.

We've seen cats go into remission up to the three year point. It isn't as common but it's happened. I think a reasonable and more common window is 6 months to a year. Focus on regulation and then tight regulation. Once there, if it's meant to be, she will go into remission.

And remember....if you don't see some green in the next few cycles, the protocols are just guidelines. I'd increase the dose.

 

[missMeows]

Focus on regulation and then tight regulation. Myron there, if it's meant to be, she will go into remission.

This is good to remember. Sometimes when I read what others are doing or trying to do, I often get caught up in the frenzy to get her OTJ. I definitely don't want to push her little body too hard. Me thinks I'll be rereading your words of advice for a while to help me keep my patience pants on

 

[Marje and Gracie]

One thing I would be remiss in not adding is when I say the TR is a "guideline", I don't mean "follow it when you want and forget about it when you don't". It is the only approach based on scientific research published in a veterinary journal. By "guideline", I mean that sometimes life requires we shoot late or we shoot an 18 hour schedule to do something we really want to do. It's not so rigid as to not allow that flexibility for life. But, for the most part, you want to try and stick as closely to it as possible especially in that timeframe where it is possible for remission.

I'm probably one of the more aggressive in L/L as I believe you should shoot on time, full current dose when it's safe to do so and you are Data Ready, to the greatest extent possible.

 

[missMeows]

One thing I would be remiss in not adding is when I say the TR is a "guideline", I don't mean "follow it when you want and forget about it when you don't".

No worries! I gotcha. I'm definitely a stickler for all that - being on time and no fur shots etc etc. But it is always nice to know that when life happens, there is a little flexibility.