6/6-Scratchie-AMPS-352

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Scratchie'smom

Morning all, been a while since I posted. Was very ill over the weekend and the first part of the week but better now.

Wondering if an increase to 3.25 is needed? Thoughts and comments are welcome. We've been on this dose since 5/31 PM shot when we reduced. Think we need a little push....

Wishing everyone a great day, great numbers, safe surfs and prayers to all who need them including Jack and Jane over the loss of dear Karre.

Jo
 
Morning,

If he were my cat, I would just leave him where he is. He has had so many dose changes, and he is trying to settle. Yesterday's numbers were some of the lowest you've seen.

Just my two cents.
 
Jo

If he were my cat, there is no way I would continue to leave him at these high numbers. He was just starting to see some nice, blue numbers at 3.5. I think you are going to have to go up more than 3.5 to see a breakthrough because he's been at these high numbers for so long. He's likely built up insulin resistance.

If you haven read this post on Glucose Toxicity, it's well worth reading. You are testing enough now to show you these numbers are too high for too long.

When you reduce a dose, if its going to work, you will start to see better numbers in 6-10 cycles and you aren't. I can show you SSs of cats that obviously had too much insulin and needed a reduction.

Please take him back up.

I am so sorry you've been ill. I hope you are on the mend.
 
Just so you know, I strongly disagree with increasing his Levemir dose. He is not on Lantus, he is on Levemir. It tends to take more time to settle than Lantus.

As to insulin resistance, in this case Scratchie has been on insulin for a long time. He is responding to Levemir, albeit slowly.

I currently have 5 diabetic cats, two are in remission. I take a very start low and go slow approach. Many of the diabetics who have come thru my home have gone into remission.

Please just let Scratchie settle in to this 3 unit dose.

Claudia
 
My cat is on levemir and has been for +1.5 years. Cats don't "settle into" dose reductions.

From the post that Jill wrote on New Dose Wonkiness and Failed Reductions:

The concept of "New Dose Wonkiness" is NOT applied to higher numbers which may be seen after a dose reduction.

There is no "NDW" following a dose reduction nor do we hold a reduced dose 6 cycles (as done with dose increases) to "fill the insulin depot".
"Settling time" does not apply to dose reductions. We don't wait for a reduction to "settle".
Click to expand...

The bold is mine. I understand no one is specifically stating there is NDW here, but I am more concerned with the thought that a cat settles into a dose after a reduction.
 
I'm sorry, but ECID (Every Cat is Different).

And cats are mammals and they have other hormones that are interacting with the insulin we are giving them.

Scratchie has shown that he does react to Levemir. The last dose of 3.25 was followed by blues and yellows. Those lower numbers were not the result of the increase to 3.5. His ideal dose may be lower than we all think.

I would leave him where he is. If he were my cat, he would probably stay there for a week or two. Since half of the cats I have treated have gone into remission, I think I read "cat" numbers quite well.

Claudia
 
Jo,

If you want to know what I am using as a guide, here it is:

Five Steps to Regulation:

Step 1. Start at a low dose of PZI, Lantus, or Levemir insulin, as recommended by your vet. (Note: Humulin and Novolin Lente and Ultralente, two insulins with good track records in cats, have been discontinued by the manufacturers.) A conservative starting dose is 1.0-2.0 units, twice per day. If your cat's blood glucose was less than 400 mg/dl (22.1 mmol/L) at diagnosis, or if your cat is on a low-carbohydrate diet, the starting dose should be only 0.5-1.0 units twice per day. Fast-acting insulins such as Humulin Regular, Humulin 70/30, and Humulin N (NPH) are not suitable starting insulins for cats.

Step 2.
Don't increase the dose until your cat has been on it for at least a week. If you have reason to be concerned about hypoglycemia, or if your cat won't eat, do decrease the dose and contact your vet. Do test your cat's urine frequently during the regulation process using Ketostix or Ketodiastix, and contact your vet immediately if the cat tests positive for ketones. Do be consistent in the timing and type of food. Do give the shots at about the same time every day.

Step 3.
After 1-2 weeks at a given dose, you or your vet should perform a serial blood glucose curve (blood glucose tests every 2 hours, starting at shot time and continuing until the next shot). Follow the cat's normal feeding schedule during the curve. The curve should be evaluated by someone experienced at interpreting feline blood glucose curves, in order to check for signs of rebound and other possible problems. If no rebound is present, follow these guidelines for dose adjustment (smaller adjustments may be appropriate for cats on PZI or Lantus):
• If the lowest point of the curve is above 150 mg/dl (8.3 mmol/L), increase the dose by 0.5 unit.

• If the lowest point of the curve is between 90 and 149 mg/dl (5.0 and 8.2 mmol/L), keep the dose the same.

• If the lowest point of the curve is below 90 mg/dl (5.0 mmol/L), decrease the dose by 0.5 unit.


Step 4.
Repeat the cycle of curving and waiting 1-2 weeks. As your cat's blood glucose begins to fall mostly in the desired range [lowest point of the curve approaching 100 mg/dl (5.5 mmol/L) and pre-shot value around or below 300 mg/dl (16.6 mmol/L)], do lengthen the waiting time between dose increases. If you decide to change another factor (e.g., diet or other medications), don't increase the insulin dose until the other change is complete (but do decrease the dose if your cat's glucose numbers consistently fall below 90 mg/dl (5.0 mmol/L) as a result of the change). Don't be tempted to rush the process along by increasing the dose more quickly or in larger increments-- no matter how high your cat's blood glucose is! Rushing towards regulation will cost you time in the long run, because you may shoot past the right dose.

Step 5.
Once you can no longer increase the dose without the cat dropping below 90 mg/dl (5.0 mmol/L) at the lowest point, evaluate the duration of the insulin's action. If your cat's preshot blood glucose values are still consistently above 350 mg/dl (19.3 mmol/L), or if your cat's blood glucose usually returns to preshot values more than an hour before the next shot is due, ask your vet about longer-duration insulins or possible adjustments to your cat's food or feeding schedule.

That's it - 5 steps! These steps are general guidelines that work for the majority of cats. Because every cat is different and exceptional situations may arise, your cat's progress should be closely monitored by someone with experience regulating feline diabetics

This is posted by Rebecca above the Lantus Relaxed board and is credit to Susan (jan 2012). Rebecca posted it for people who cannot tested every hour or so.

Claudia
 
As someone with an M.S. in biology and having taught A&P at the college level, I understand the interactions of hormones.

Absolutely, ECID. It's great that your cats have gone into remission. But I think it is not the CG that controls that. One can do the best possible and the cat still not go into remission. Conversely, I've also seen cats where CGs have skipped shots, dose hopped, etc and the cat still went into remission. Because they are mammals with a variety of physiological functions interacting, we are not in control.

Jo...I hope you just see this as lively discussion. It is up to you and I know we will all be supportive of your decision.
 
Well, I'm confused.

It's my understanding that Lantus and Lev function pretty much the same way. There are some differences between the two types of insulin at the molecular level but their method of action is almost identical. Both are long-acting, depot medications. While I realize that Jo is following SLGS (the approach that Claudia posted), the Tight Regulation Protocol is used for BOTH Lantus and Lev because they are pharmacologically similar. Regardless of whether you're using TR or SLGS, you would treat Lantus and Lev dosing the same. I would also point out that SLGS is a generic approach that can be used with any and every insulin.It is not specific to either Lantus or Lev. In fact, it was an approach that was being used before either Lantus or Lev gained popularity and as such, it may need to be tweeked to maximize the utility of SLGS for cats that are on either of these long-acting insulins. It stands to reason that you want to take advantage of the most current information available in order to treat your cat's diabetes in the most effective way possible.

At this point, Scratchie has been at the 3.0u dose for 6 days. If following SLGS, an increase occurs after a week. With numbers consistently above 300, I would not encourage Jo to wait more than a week to increase the dose. With SLGS, it's not mandatory to wait a week to increase -- it's up to the caregiver. There are certainly people who bridge both the TR Protocol and SLGS in order to get their cat into BG numbers that are below renal threshold. Personally, my concern would be that you don't want to hold on to a dose that risks end organ damage for an extended period of time. Nor would I want to encourage hanging on to a dose that allows glucose toxicity to occur. At this point, Scratchie has not seen a consistent run of numbers that are below 300 since late April. IMHO, it can't hurt to raise the dose.

From both the perspective of TR and SLGS, it looks to me like Scratchie would benefit from a 0.5u increase.

ETA: If I'm remembering correctly, didn't Scratchie have an issue with ketones? Even though that may not be an issue now, some kitties are prone to developing ketones. While high numbers isn't a guarantee that ketones will develop, it is a risk factor. If for no other reason, getting Scratchie's numbers down will help to lower that risk.
 
Actually, Scratchie did have ketones. His ketones surfaced for the first time when his numbers dropped below the renal threshold for the first time in over a year.

As I said before ECID (Every Cat is Different), and Scratchie is certainly on his own path.

Claudia
 
Jo, I'm sorry to hear you've been so sick. I've been keeping an eye out for a Scratchie condo and was glad to see one today. I'm glad you're feeling better.

It's good to see that Scratchie has been feeling so playful. If it was me, I would try and increase and see if I could get rid of the pinks. Good luck with whatever you decide to do.
 
Scratchie'smom said:
Morning all, been a while since I posted. Was very ill over the weekend and the first part of the week but better now.

Wondering if an increase to 3.25 is needed? Thoughts and comments are welcome. We've been on this dose since 5/31 PM shot when we reduced. Think we need a little push....
Click to expand...

hello everyone! i have a bunch of house guests and haven't been around and won't be for several more days, but i was asked to look at this thread.

interesting discussion as well as some good points have been made. however, fwiw after looking at scratchie's spreadsheet i concur an increase is called for.

imho, the dose should never have been decreased per mel and claudia on 5/31: "Hmm, neg on ketones, member of CPC - didn't eat much during the night though. Demeanor is awesome - happy and playful. Per Mel and Claudia reduce to 3u and see where he is in 5 days" (https://docs.google.com/spreadsheet/pub?key=0AuRGwuNiGAh8dGpkTVFSZVpDNVRFREZfZGdDRThSTmc&gid=4). scratchie was finally getting somewhere on 3u since re-starting levemir, was experiencing a typical bounce, and the bounce was due to clear at any time... and the dose was reduced.

regarding the above, this is exactly why it's helpful to the caregiver & the cat for dosing advice/suggestions to be kept on the board by FDMB members rather than offered in PMs, emails, or in phone calls. if FDMB members offer suggestions/advice publicly... on the board, the suggestion to drop the dose would have been open to peer review. this would have allowed the kind of discussion which is taking place today. if this was done, please disregard my comment. i didn't see any posts to that effect, but i might have missed them.

cjleo said:
This is posted by Rebecca above the Lantus Relaxed board and is credit to Susan (jan 2012). Rebecca posted it for people who cannot tested every hour or so.
Click to expand...
yes, rebecca did re-post susan/shadow's "5 Steps to Regulation" in january 2012 for those who did not want to or couldn't follow the Tight regulation Protocol. I'm not sure when susan actually wrote this piece. when i arrived in 2006, i had no idea who susan & shadow was and still don't. :? the version i have says "Version 1.08, July 31, 2006": http://binkyspage.tripod.com/SLGS.html. like sienne mentioned, the SLGS method came about before lantus and levemir were widely used on the FDMB. what was the line from that old cigarette commercial... something like... "We've come a long way, baby!" :lol:

yes, we've come a long way in learning about how to best use lantus/levemir since 2006. i'll bet we'll even learn more in the years to come. there's no doubt in my mind claudia as well as many others have regulated or guided their kitties into remission using the SLGS approach. heck, i was one of them to a certain extent. when alex was on insulin the first time i didn't try tight regulation for quite some time and even then my methods were a watered down version of the information we have available to us today.

i guess what i'm trying to say is there is no right or wrong path to take. jo, you've been presented with opposing views. it's up to you to decide if the latest and most up-to-date methods are a good fit for you or not. i'm just pleased that you've been afforded the opportunity to hear as marje put it... a lively discussion. :mrgreen:


ETA: i forgot to mention anything about ketones. since scratchie has a pretty recent history of throwing high ketones resulting in hospitalization, if i were in your shoes and could make it work... i'd be looking to pull his numbers down sooner than later. again, fwiw jmo.
 
I also agree, after looking at Scratchie's spreadsheet, that a dose increase is in order. Especially..because of the recent ketones.
 
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