7/10 Pumbaa - I need stronger patience pants!

[Pumbaa]

I can't even bring myself to type his numbers today.

Started the morning low red, went to mid-yellow at the AM +6, up to mid-black at the PMPS.

While it makes total sense to me that, if they are giving black and red numbers they are getting too much insulin, it breaks my heart to see Pumbaa with such high numbers. Especially since before he got started on the insulin, his numbers ranged from a high of 327 to a low of 277.

I'll do his PM +3 in a couple of minutes, and maybe that will bring me some encouragement.

Stay tuned....

Well, at least his PM +3 is back down to 353. Still a lot higher than I want, but much better than the PMPS of 549. If Pumbaa dives tonight, I won't even curse about the lack of sleep just to see him drop down into lower numbers.


Suze

 

[carolynandlatte]

Hi Suze-
I've been a bit of a lurker lately. I noticed your post asking for help the other day and that you decided to take the suggestions given. Even though I want to try and convince you to go back to the last good dose, I am not going to do that. This is your cat. You have gathered information from all sides and made the best decision you can to treat Pumba. HOWEVER, I cannot rest my head easily if I do not literally beg you to take multiple ketone tests/day. This is REALLY important to do. Anytime you do a drastic or continuous reductions; or have a cat steadily above renal threshold, you will want to test multiple times/day. And, if at any point you feel this is idea is not working for you, it is ok to go right back to the last 'good' dose. You do not have to do .25 increments every 6 cycles.

My situation with Latte was quite a bit different than yours, but I did a 'redo' on insulin dose + switched to Lev shortly after.
For us, it did not go so well. I suspect it contributed to her infections by being above renal threshold so much. BUT, I think this post http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=15544 will help you realize that I DO understand how agonizing it is to see the bouncing around. I mention in the post that my vet and I agreed it would be better to see her in higher/flat numbers than bouncing around like she was. Please keep in mind, our reference for high numbers was no higher than mid pink. I knew if she was pretty much flat pink to black, her dose would have to go back up. You are welcome to look at her ss, especially around that time (5/27). Unfortunately, due to her multiple health conditions factoring into the BG's it may be hard to know what affected what. Latte's health drastically declined after my 'restart' and switch to Lev. She passed away less than 2 months later from various issues.

It is not an absolute that a cat seeing red or black is being overdosed. Is it possible? Of course! But with testing (like you do), it is easy to see the difference between a cat which is bouncing and a cat that is OD. If there are other health issues involved, then things can be a little more complicated.

 

[Pumbaa]

Carolyn:

Thank you so much for checking in and posting your comments. I truly appreciate it!

Yes, instead of a ketone test once a week, I will try to grab Pumbaa and make him pee on demand at least once a day, if not more frequently. I appreciate your concern and reminder. Very much so!

I am so sorry to hear about Latte, after all that you did to try and get her FD regulated. And I do know that you understand my quandry with Pumbaa and his numbers/bounces/dives and being willing to try anything to just regulate him and get him into better renal threshhold numbers daily. What a nightmare some of us go through. And then there are other diabetic cats who just calmly take the insulin and have nice steady BG numbers with no bounces or dives.

Part of me wants to raise Pumbaa back to 2.25U, and the other part of me understands the too-much-insulin and higher numbers thoughts as well.

I've checked, and Pumbaa didn't come with an owner's manual for FD. *LOL* I just want to do the best for my little guy, since he is relying on me to make all of these decisions.

But with testing (like you do), it is easy to see the difference between a cat which is bouncing and a cat that is OD.

Please tell me how to tell the difference! Has Pumbaa been bouncing or OD'ing? I have no clue at this point.

All I do know is that reducing his dose from 2.0U to 1.50U did break his pattern of one day of lows followed by six days of highs. That, to me, was a breakthrough. After that, I was torn between increasing his dose or decreasing his dose. How do we know what to do when the symptoms of both too much and too little insulin are so much alike?

Thank you again, Carolyn, for giving me more things to think about! (((HUGS)))

Suze

 

[Jill & Alex (GA)]

like carolyn, i'm not going to try to convince you to go back to the last good dose. pumbaa is your cat and you've chosen to follow advice given to you, but i hope you don't mind me jumping in here with some thoughts for your consideration...

But with testing (like you do), it is easy to see the difference between a cat which is bouncing and a cat that is OD.

Please tell me how to tell the difference! Has Pumbaa been bouncing or OD'ing? I have no clue at this point.

suze, one of the first things those who are trying to help do is look at "how" the kitty arrived at the current dose. vets are famous for suggesting increases in full units. those are usually the kitties who have the best chance of becoming over dose... that and the ones who were started at too high of a dose to begin with. that's what we look for. edited to add: missed/not taking appropriate reductions can also result in a kitty becoming over dose.

on a side note: this is where the weight based formula described in the TR protocol comes in handy even if it's simply used as a tool to check to see if the starting dose was set too high. one thing to remember with the weight based formula... ideal weight is used rather than actual weight EXCEPT in the case of an underweight kitty. when a kitty is underweight the actual weight is used to determine the starting dose. kitties with initial starting doses that were too high or who have been increased too quickly or in large increments... these are the kitties who remain at risk for being over dose. their caregivers will sometimes see improvement when dropping the dose when seeing reds or blacks on their spreadsheets.

you did NOT do that with pumba. you mostly traveled up the dosing scale in 0.25 unit increments... except the few "fats" added to the dose. heck, you even went back down to 0.5u and started over again.

pumbaa is a bouncer, that's all. lots of cats are bouncers. pumbaa is not over dose. at this point he's also lacking duration due to the recent dose reductions.

bouncing always gets a bad rap. here's a discussion from one of Jetta's daily threads on bouncing that puts a slightly different slant on the subject: http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=55306.

"bounces" from numbers a cat who is not used to being in lower numbers is a very different thing from a cat with very high numbers due to being over dose.

by using the very logical and methodical dosing approach with lantus OR levemir as suggested in the TR protocol... we do not do rebound checks. we shoot right through the bounce... training the liver to eventually accept these lower numbers as "normal". why? because the body has been in high numbers for so long... it forgot what "normal" really feels like. by giving kitty the insulin required to pull the numbers down, we're helping his body "remember" how it feels to be in the normal range. consistency is the key in overcoming the bounces... and it takes time. more time for some kitties than others.

generally speaking, when it's been determined the cat is not over dose (see above), all we see when so called "rebound checks" are done (checking for the possibility of too much insulin) with lantus or levemir kitties is the caregiver finding it necessary to go right back up to the dose they were at weeks or even months later. seems to me it's just a whole lot of wasted time, money, and effort... not to mention the possibility of complications developing along the way from kitty spending more time in hypERglycemia unnecessarily.

ok, so you've previously indicated you're not following the TR protocol, but the premise remains the same.


just some thoughts. i really hate to see you struggling so...

:YMHUG: :YMHUG: :YMHUG:

 

[Dale 'n' Chip]

Or maybe you just need a better dose? :mrgreen:

You can hold this one longer as long as you get a ketone test in the next few days.

Or why not go back to 1.5? He was doing pretty good there (both times) might even fatten your 1.5 to see what that looks like?

 

[Jill & Alex (GA)]

You can hold this one longer as long as you get a ketone test in the next few days.

i'm sorry. i strongly disagree with this statement.

given the right conditions, ketones can and do develop too rapidly (sometimes within hours) to rely on getting a ketone test "in the next few days".
we've seen it happen over and over again. one minute kitty seems fine... the next thing you know, they're not.

efforts should be made to test urine for ketones frequently... daily when a dose has been reduced like pumbaa's has been.
please remain vigilant with testing urine for ketones.


alex was in DKA within 12 hours of diagnosis and trust me, you don't want to go there... for his sake and yours.

 

[Dale 'n' Chip]

I think that was the wise move to go back to 1.5.

Don't feel too bad Chip was even worse this AMPS. :-|

I would still test for ketones as soon as you can.

 

[Pumbaa]

I did take Pumbaa back up to 1.50U this morning, and spent 20 minutes trying to get him to pee for me, but only got treated to a very stinky poop instead. :roll:

 

[Carl & Polly & Bob (GA)]

Apparently he misunderstood the request. ;-)
It's hard for me to look at a spreadsheet and not think "PZI", but recent cycles (if he were on a P insulin) look like he isn't getting enough duration out of a dose, and that would indicate shoot more often (not an option of course with an L) or more juice.

I guess my question, for L users is "what does not enough duration look like on a Lantus/Lev spreadsheet?" Or is that even a consideration since it has a long duration?

Carl

 

[Pumbaa]

Jill:

Thank you for the input as well! I don't mind a struggle, if what I get in return is a better Pumbaa!

I understand what you're saying about the difference between OD and just regular bounces (I bookmarked that Jetta thread, btw), but I do know that dropping him from 2.0U to 1.5U on 6/29 did break his pattern of one day of low numbers followed by six days of high numbers. Would the pattern have been broken had I raised him back to 2.25U instead of lowering him to 1.5U? We'll never know because that isn't the route I took.

I truly appreciate those who think outside the box and pose questions and make suggestions which may seem unorthodox to some, but have worked for their cats, since ECID. And, since Pumbaa seems to defy all logic, at least from what I see, sometimes unorthodox approaches are called for. I mean, where is the logic in Pumbaa taking a dive every Friday night? :roll:

I spend so much time looking over Pumbaa's SS, because the only way to figure out the future is by studying the past, in Pumbaa's case, anyway. I may have to take him back up the dosing ladder, and may do so more quickly, i.e. more like TR protocol than "start low go slow", but it depends on how he reacts since he is the one leading this dance. Do I regret any steps I've taken in his care in the last 3 months since his diagnosis? Nope. You only learn by trying and by experience and by listening to others and trying to digest it all and make some sense of it all, taking into account your very own cat and that's particular cat's idiosyncrasies. In looking at his SS, would I now do anything differently than I did in the past? Certainly. But you can't change the past...you can only learn from the past and change the future.

Oh, and good news...Pumbaa just tested negative for ketones.

Suze

 

[Pumbaa]

Carl: *LOL* Pumbaa saw me with the "peespoon" in my hand and probably spent the next couple of hours with his legs crossed just to make my life more interesting!

 

[carolynandlatte]

Hi Suze-
Glad to hear the message came through loud and clear to check ketones as often as possible each day. Sorry for the lack of cooperation on Pumbaa's part. Isn't that the way it always goes! :roll:

I hope Jill's answer to your question made sense in your mind.

I was wondering if you have ever used the drop method when dosing? I see your increases/decreases have often been by full .25u. Some cats will have drastic reactions to just a drop of insulin (one way or another). Something to consider would be measuring the drops between 1.5 and 1.75, 1.75 and 2, 2 and 2.25, 2.25 and 2.5u. Then you could have something like a f1.5, sk1.75, f1.75, sk2, f2, etc...

I just wonder if increasing/decreasing in this manner may help you feel better about whether or not you are giving too much/too little insulin. You are doing it one drop at a time. At one point (6/15?), when Pummba earned the reduction you could have reduced to a sk2 instead of the full .25u to a F1.75 (which is a reduction he did not hold and prompted you to increase again). This is all in retrospect. We learn every day from our kitties, and unless I knew my cat had a hard time holding reductions OR was ultra sensitive to changes, I would have reduced the full .25u as well. It's just something to think about in the future.

 

[Pumbaa]

Carolyn:

I tried getting urine from Pumbaa for the last couple of days, but he kept outsmarting me. This time, I woke him up from his post-breakfast nap around +4, figuring that all the water I add to his canned food would have worked its way to his bladder, and sure enough, he nearly flooded the litterbox for me. *LOL*

I was doing the "fats" just to try and calm down Pumbaa's bounces, not that it seemed to help. Now that I have better syringes (love, love, love the accuracy of the Monojects from ADW), drop dosing is an option to consider. And, in hindsight, on 6/16, I could have just dropped him down to a regular 2.0U, instead of going down the entire .25U. Then again, that was when he was in the rut of having low numbers on Friday night, followed by six days of high numbers, so it might not have made any difference.

Question for Jill and Carolyn (and anyone else who wants to chime in):

From what you see in Pumbaa's SS, do you think he would/could/might do better on Levemir instead of on Lantus? I know it's a loaded question, but I'm willing to try anything to smooth out his bounces and dives, other than dancing naked in the street while Google's Satellite takes photos. Hahahaha!

Suze

 

[Jill & Alex (GA)]

I truly appreciate those who think outside the box and pose questions and make suggestions which may seem unorthodox to some, but have worked for their cats, since ECID. And, since Pumbaa seems to defy all logic, at least from what I see, sometimes unorthodox approaches are called for. I mean, where is the logic in Pumbaa taking a dive every Friday night? :roll:

suze, i agree with you 100%. following ANY protocol is simply a place to start. a place to enable the caregiver to begin to collect the necessary data required to make educated decisions. most caregivers end up tailoring their approach to their kitty because ECID is absolutely true. oh how i used to hate every time someone muttered "ECID" to me when i was new! i wanted to know what steps to take and in what order to them... to make my cat well yesterday! kwim?

as far as unorthodox approaches go...
always ask to see the spreadsheets of those offering advice because sometimes the advice giver has not correctly interpreted their own data. this is the internet and you'll get all sorts of advice from people who have the very best intentions, but that doesn't mean they know how to interpret a spreadsheet. although i have to say, simply by virtue of being new most newbies have not accumulated enough knowledge yet to correctly interpret their own data let alone someone else's. i've seen that happen much too often.

in my experience, unorthodox approaches should be tried (there's a whole lot of trial and error involved) when all else fails... and not before then. if tried too early, unorthodox approaches only serve to cloud the picture and render previous data collected null and void. fwiw, imho, pumbaa has not yet reached the point where unorthodox approaches should take precedence over the norm.

i've been "doing this" for a lot more years than the majority of the members currently posting in the support groups. i've spent hours upon hours studying the spreadsheets of countless lantus and levemir kitties. imho, pumbaa's response to lantus has been pretty typical of kitties who are not making a beeline straight for the Falls. however, that does not mean he won't get there. when i look at pumbaa's spreadsheet, i see a kitty who not yet reached his optimal dose. that's all. am i always right? nope. nobody calls it right every single time... i don't care how much experience they have under their belts.

there's a funny thing about using lantus or levemir with our kitties...
every time we increase the dose, we naturally expect to see better numbers. it *usually* doesn't work that way... which can be a HUGE source of frustration for us. more often than not, we'll increase and increase and increase and increase... while not seeing much of an improvement. and then a day comes along and BAM! kitty's green! woo-hoo! time to celebrate, right?

yes, and no.

yes because gosh darn it... we're finally seeing our precious kitty in "normal" numbers, but no because what happens most of the time? our celebration grinds to an abrupt halt because they lose it and return to those yucky higher numbers. as caregivers, this is where we feel like we're repeatedly and senselessly banging our heads against a brick wall, but if you look at enough spreadsheets you begin to understand this is pretty normal. the solution? keep on keepin' on. it's just going to take more insulin before you see most kitties flatten out into normal numbers and stay there!

"this is a marathon, not a sprint"... another one of those phrases you hear so often around here. i wanted to spit every time someone said that to me when i was new to feline diabetes but it's soooooooooooooooooooooo true!


no ketones = AWESOME news!!! :mrgreen:

if you have difficulty collecting urine for ketone testing you might want to consider using a blood and ketone meter occasionally.
Nova Max Plus has a free blood/ketone meter offer here: http://www.novacares.com/cwd.php. i received the blood/ketone meter within a week. unfortunately, i already donated it to the LLEF or i'd send it to you. i answered the questions as follows: parent of a child with diabetes, 18+, take insulin via injection, 14 (i think), and no coverage. using a blood/ketone meter is often the ticket when a caregiver has a hard time collecting urine.

hope this helps a little...

 

[Jill & Alex (GA)]

I guess my question, for L users is "what does not enough duration look like on a Lantus/Lev spreadsheet?" Or is that even a consideration since it has a long duration?

not enough duration looks the same on a spreadsheet... no matter what insulin is used. a pattern will emerge in most every cycle.
it's when the action of the insulin appears to "poop out". we call it BIPO. big insulin poop out.

 

[Jill & Alex (GA)]

I was wondering if you have ever used the drop method when dosing? I see your increases/decreases have often been by full .25u. Some cats will have drastic reactions to just a drop of insulin (one way or another). Something to consider would be measuring the drops between 1.5 and 1.75, 1.75 and 2, 2 and 2.25, 2.25 and 2.5u. Then you could have something like a f1.5, sk1.75, f1.75, sk2, f2, etc...

I just wonder if increasing/decreasing in this manner may help you feel better about whether or not you are giving too much/too little insulin. You are doing it one drop at a time. At one point (6/15?), when Pummba earned the reduction you could have reduced to a sk2 instead of the full .25u to a F1.75 (which is a reduction he did not hold and prompted you to increase again). This is all in retrospect. We learn every day from our kitties, and unless I knew my cat had a hard time holding reductions OR was ultra sensitive to changes, I would have reduced the full .25u as well. It's just something to think about in the future.

thank you, carolyn! this is definitely another option worth suze's consideration.

 

[Jill & Alex (GA)]

Question for Jill and Carolyn (and anyone else who wants to chime in):

From what you see in Pumbaa's SS, do you think he would/could/might do better on Levemir instead of on Lantus? I know it's a loaded question, but I'm willing to try anything to smooth out his bounces and dives, other than dancing naked in the street while Google's Satellite takes photos. Hahahaha!

no, it's not a loaded question. unfortunately, my crystal ball is still out for repair. :mrgreen:

here's what i can honestly tell you... i don't know.

some kitties have done better on lev than lantus, BUT some haven't. do i think lev is the magic cure for bouncy kitties? absolutely not. we've seen lev kitties who bounce just as much as they did while on lantus.

fwiw... with as much as you test, if i were in your position i would do two things before considering a switch to levemir:
1). follow the TR protocol and post in that forum for help.
2). use up the lantus remaining in my possession (i don't waste insulin --- it's too darn expensive!).
if at the end of that time if lantus isn't cutting it for pumbaa, i'd make the switch.



just my thoughts...

 

[Carl & Polly & Bob (GA)]

I guess my question, for L users is "what does not enough duration look like on a Lantus/Lev spreadsheet?" Or is that even a consideration since it has a long duration?

not enough duration looks the same on a spreadsheet... no matter what insulin is used. a pattern will emerge in most every cycle.
it's when the action of the insulin appears to "poop out". we call it BIPO. big insulin poop out.

OK, I first heard "BIPO" from Dr. Lisa, so I understand exactly what you mean. Thank you Jill!

Given that then, if I look at Pumbaa's recent AM and PM cycles on 7/9 and 7/10, BIPO is what I see. It looks like the insulin just doesn't carry the weight for 12 hours. I don't see any number that would warrant a bounce into the blacks, like if it were too much insulin.

Suze, it looks like you went back up to 1.5? IMO, and I'm not an L user of course, I think that was the right direction. When I look back at Pumbaa's SS, the last really pretty numbers I see came from 2.0u. Yes, it looks like the greens caused the expected bounces, but those go away, right?
Carl

 

[Pumbaa]

Wow...you all were busy typing while I was busy working and then doing chores at my mom's! Thank you. Time to read and digest...

1) Big Insulin Poop Out = BIPO. That's a new one. *LMAO* I see where Carl is saying that the PMPS numbers on 7/9 and 7/10 were BIPO's instead of bounces. How about the +10 and PMPS on 7/3? I figured that was a bounce after the 152 on 7/2. I see high numbers and I think "bounce". Now I'm going to have to pay attention to BIPOs as well 'cause that really makes a difference. I'm now looking at Pumbaa's SS from the very beginning, and rethinking what I considered to be bounces to figure if maybe they were BIPOs instead. To help me understand the difference, if anyone has the time/energy/inclination to point out some early BIPOs for me, I am going to mark them as such. What a learning curve this is!!!!

2) Protocols: Jill, I'm glad that you agree that protocols are a place to start. And this is in response to your suggestion that I start Pumbaa back on the TR protocol. We tried that, and Pumbaa just didn't react well to it, which caused me to stress. This was very early in his treatment, and he wasn't feeling as good as he does now 3 months later, so that might have played a big part in his reaction, so I will think about trying TRP again, now that Pumbaa and I are both 3 months older/wiser/more used to this whole routine. I will say, though, that I did feel pressured to increase his dose when I didn't think he had cleared a bounce yet, and that is why I'm glad that you agree that protocols are simply a place to start. So, if I decide to follow TRP, it will still most likely be in the Relaxed Lantus forum, so that I don't feel pressured to follow a sheet of paper instead of doing what's best for how my little guy is reacting.

3) Crystal Balls (not to be confused with Balls of Steel, needed to shoot during low PS numbers *LOL*): If anyone has one in working order, please PM me!

4) Urine Tests: Jill, thank you for the heads-up on that meter. Pumbaa is a wily and devious little juvenile delinquent, and once he's peeing I have no problem sliding the "peespoon" under him and collecting urine. The problem is me outsmarting him now and catching him with a full bladder. (Damn, I hate admitting that it taxes my brain to outsmart my pets!) This was so much easier in the beginning because he was peeing so much! All I had to do back then was put him in the litter box and he'd pee on command.

5) Unorthodox approaches: My entire life has been based on unorthodox approaches to problems. I always look for a more efficient way to reach a goal. Not shortcuts, not sacrificing quality, but improving efficiency. I was born without the patience gene, but was also a born problem-solver. Pumbaa's FD is probably the first problem I have faced in my entire 55 years, where I can't analyze the problem, look at the data, and fix it. If Pumbaa belonged to someone other than me, he'd probably be doing better just due to my MO. Realizing and typing this just made me cry, because I only want the best thing for my little guy. So, Jill, while some of those oft-repeated phrases make you grind your teeth, I appreciate them because they need to be drilled into my head. (Marathon not sprint, ECID, they bounce until they don't, the cats are the ones leading the dance, etc.)

6) Spreadsheets: I've studied so many spreadsheets in the last 3 months that I dream insulin spreadsheets at night! Jill, yes, I totally agree about looking at the SS of anyone giving advice and then deciding if the advice was good or not. I also read a lot of the problems others posts on the boards, and read the responses and look at the spreadsheets. Every day I learn something new. That's good, 'cause I feel that a day without learning something is a wasted day!

Lightning out...need to log off quickly and unplug all computer equipment...

7) Lantus vs. Levemir: My plan was to wait until Pumbaa is done with his last 2-1/2 Lantus pens before switching. Until then, I am studying the SSs of those who have already switched, and asking lots of questions, and just trying to deal with Pumbaa, today and tomorrow.

(((HUGS))) to you all for your for your input and support! I'll be back later when the lightning has stopped.

Suze

 

[Jill & Alex (GA)]

suze, suze, suze.........................................

i wish we could hear tone of voice thru the message board, but we can't so please hear what i have to say as gentle, caring, and with utmost respect for you because that's how i'm typing this. i'm not a "flowery" type person. i'm usually pretty direct and to the point. :roll:

imho, you're over-thinking this without a solid and diverse knowledge base... just by virtue of this experience being relatively new. you mentioned feeling pressure to increase a dose before a bounce had cleared. it's not always necessary to hold a dose while a kitty clears a bounce. sometimes it's a desirable/strategic move to make... just like shooting an hour or two early or shooting a dropping number can be. i can appreciate studying spreadsheets, but you do realize there are caregivers who have been around for years who speak with confidence and authority in each and every forum and still don't know how to analyze/interpret a spreadsheet? it takes a long time to really "get it"... and most never do. in some cases, they're giving advice and it's being followed by an unsuspecting caregiver... one who through no fault of their own... doesn't know any better. :?

when i said protocols are a great place to start i meant eventually (not in the first few months) most caregivers find themselves fine-tuning things like portions fed, feeding schedule, increasing doses or taking reductions in increments other than 0.25 units, length of time to hold doses, shooting SID or TID or as needed, etc. these things come about because some kitties need individualized plans. mine's one of them. i doubt there's another cat on this board that follows the same exact plan as i do with alex. however, it took months and months to know what i now know with her.

if you should decide to practice TR, you're certainly welcome to post anywhere you want, but i have to tell ya... you'll receive the most timely attention, expertise, and support needed for a kitty who hasn't read the manual in the TR forum... with people who live it day in and day out.

the beauty of the TR protocol is it takes so much of the guess work out of dosing. it's not necessary to re-invent the wheel... a tendency many people have long before it's necessary. maybe it's time to break from the MO you described??? :mrgreen:




having said all that, you're pumbaa's person. you hold the syringe. i respect decisions made in pumbaa's care as yours to make. i'm also a firm believer in these wise words from the "Suggestions for Advice Givers":

"Don't act as if you're entitled to tell people what to do. You can offer help and advice, but it's up to the other person to decide what advice to take for their cat. They won't always agree with you -- that's life. If it makes you crazy, move on to someone who is interested in what you have to say."

not that you're making me crazy because you're truly not... i tend to simply ignore "crazy". :lol: :lol: :lol:

 

[Pumbaa]

Jill, you and I are both very direct and to-the-point people, and I wish that did come through in typing at each other. I really am smiling! That is I pepper my posts with emoticons, so people can see my mood while I typed!

I do know that everything that you (and everyone else) have shared/suggested has been with the best interests for Pumbaa in mind. And I so appreciate that!

I AM an over-thinker, as you said. That is my best, and worst, trait. My clients love me for overthinking and saving their asses, regularly. Some members of my family hate my overthinking and call me a control freak instead of realizing that thinking ahead can cause you to NOT have to deal with emergencies down the road. My overthinking has most likely been detrimental for my Pumbaa. I admit this! And I wish this wasn't the case.

And, it's also my MO to question everything (like the very old nutritional values on Binky's site), simply because I don't trust anyone but me to make decisions that will affect myself or those that I love and care for. That is my responsibility, and mine alone. Simply because I have learned in the past to trust no one but myself, when it comes to decision-making data.

While it may not always be necessary to hold off increasing a dose before a bounce has cleared (TRP), I do know how my Pumbaa was reacting, and that is what I had to take into consideration. That is why I left TRP. How Pumbaa reacts is the deciding factor. My loyalty and love is for my Pumbaa, and I try to do the best for him.

Yes, I agree that many still can't, or won't, analyze SS data, and cat data, and put the two together. And I admit that Pumbaa's 3 months of data still perplex me. But people offering advice need to think both about how the cat is reacting as well as the protocol being followed. That is what I saw as being lacking in the TRP. I felt that some of the TRP people only viewed the TRP guidelines and didn't look at the overall cat being discussed. But it works for some cats, and that is what counts. It may even work for Pumbaa, now that he has more history with the Lantus and is feeling better, overall!

Suze

 

[Dale 'n' Chip]

I did take Pumbaa back up to 1.50U this morning...

Looks better already! :smile:

Do you plan to hold this for a few days to see what happens?

 

[Pumbaa]

Do you plan to hold this for a few days to see what happens?

Yes, will hold at 1.50U for a few days to see what happens. He already hit a blue at +3 this morning, and didn't bounce after his blue last night. How amazing is that????

It is just such a relief for me to see some blue numbers again. Whew!

 

[Pumbaa]

Jill, I've been wondering something ever since you typed:

it's not always necessary to hold a dose while a kitty clears a bounce.

TRP is based on 3-5 days/6-10 cycles. Also, it can take up to 3 days for the shed to fill to the new level. Correct so far?

If a bounce occurs around day 3, and you don't wait for it to clear, aren't you basing the decision to increase on numbers that are higher than they would be had you waited for the bounce to clear?

When would it not be necessary to wait for a bounce to clear? I'm confused.

Suze

 

[Dale 'n' Chip]

...He already hit a blue at +3 this morning, and didn't bounce after his blue last night. How amazing is that????

Almost as amazing as Pumbaa's first green on 1.5?

You know compared to some of those who seem to think they are the only ones who get it, Sheila sure has a knack.

 

[Jill & Alex (GA)]

Jill, I've been wondering something ever since you typed:

it's not always necessary to hold a dose while a kitty clears a bounce.

TRP is based on 3-5 days/6-10 cycles. Also, it can take up to 3 days for the shed to fill to the new level. Correct so far?

correct.

If a bounce occurs around day 3, and you don't wait for it to clear, aren't you basing the decision to increase on numbers that are higher than they would be had you waited for the bounce to clear?

i don't think i've ever seen a bounce from a fast drop or a drop into low numbers occur on day 3. most kitties start a bounce that same cycle as the drop or in the following cycle. sometimes, we'll see kitties begin to bounce in the 2nd cycle following the drop cycle... it all depends what the "drop cycle" looks like.

When would it not be necessary to wait for a bounce to clear? I'm confused.

in the TR forum, it's common practice to suggest newbies wait for a bounce to clear before increasing the dose for a practical reason. it's good data collection. we want the caregiver to become familiar with their cat's response... including how long it's taking kitty to clear a bounce.

once a caregiver becomes more familiar with their cat's responses, we revert to the guidelines as outlined in the modified version of the TR protocol: hold the dose for 6 cycles. if nadirs are greater than 200, increase by 0.25 unit. if nadirs are greater than 300, increase the dose by 0.5 unit. if nadirs are less than 200, increase the dose after 6 - 10 cycles.

the goal of the TR protocol is to get kitty into the normal range as soon as safely possible. it's the reason behind the rapid adjustments to dose. if kitty's nadirs remain high, there's not a reason to forge ahead as outlined in the protocol in order to reach that goal.



hope this helps...


ps --- i'll try to check back when i can in case you have more questions. i'm not only having intermittent connection issues, but we also have a fun-filled weekend ahead of us. i doubt i'll be online much.

 

[Jill & Alex (GA)]

You know compared to some of those who seem to think they are the only ones who get it, Sheila sure has a knack.

these kinds of comments/innuendos from you have been going on long enough. most would have copped a clue after reading mel's candid and eloquently written post to you last month.

have you noticed suze hasn't been getting a whole of input from the general membership? have you wondered why?

think about it. this is a volunteer board. most prefer not getting involved when they have to put up a constant barrage of negativity coming from an individual poster. they have better things to do than to put up with this kind of nonense.

whatever pleasure you're getting out of bashing, innuendo, and snide comments is costing your friend, suze and ultimately pumbaa. i, for one, have felt sorry for suze because she's obviously trying so hard to understand and figure things out for pumbaa and getting little input... or i wouldn't have bothered. i'd be willing to bet carolyn feels the same.

for their sake, knock it off... once and for all.

 

[Pumbaa]

Jill, thank you for explaining that comment about bounces and raising the dose.

Yes, I still do have questions, but the response can wait, we're not going anywhere! Hope you have a great weekend and your weather is more tolerable.

The questions are...

Pumbaa is now on day 3 of his 1.50U dose. He dropped to 96 in the 3rd cycle of this dose and is now bouncing since the end of the 3rd cycle. So, per TR, I wait until the end of the 10th cycle for the bounce to clear, as well as due to the fact that he had one nadir less than 200? (That doesn't take into account that it's Friday, and he could take another dive tonight, as he has done for the last 4 consecutive Friday's, then bounce again from that dive. If he does dive tonight and then bounce again, I would start counting over from the latest bounce, correct?)

I think I finally figured out some of my confusion: in the TR protocol, under "increasing the dose", it states "nadirs" as in plural. But in "start low, go slow" you look at the nadir during a curve run after 1 - 2 weeks. Pumbaa never has consistent nadirs (plural) after 3 days, and seldom after 5 days. *LOL* So, in TR, are you really basing a dose increase on the lowest nadir during the 3 - 5 days?

Maybe I'm just being obtuse, or maybe my obtuseness is due to Pumbaa's fluctuations. I don't know.

Suze

 

[Libby and Lucy]

I'm not Jill, obviously, but I'll chime in. :mrgreen:

Pumbaa is now on day 3 of his 1.50U dose. He dropped to 96 in the 3rd cycle of this dose and is now bouncing since the end of the 3rd cycle. So, per TR, I wait until the end of the 10th cycle for the bounce to clear, as well as due to the fact that he had one nadir less than 200? (That doesn't take into account that it's Friday, and he could take another dive tonight, as he has done for the last 4 consecutive Friday's, then bounce again from that dive. If he does dive tonight and then bounce again, I would start counting over from the latest bounce, correct?)

Yep! I would wait at least 6 cycles after the green, which will be the 10th cycle total on the dose (eh, I guess that is actually the 9th cycle, but waiting for 10 cycles on the dose is a good idea). The point is to wait until the bounce has had time to clear, see where the numbers go, then base your decision on what you see then. He hit 90s yesterday. When the bounce clears, does he go back to 90s again, or go lower than 90s, or not go quite so low? Only Pumbaa knows. ;-) Once he shows you the answer, then you'll decide what to do about the dose.

From there, the main idea on any protocol is to work the dose to get the nadirs where you want them. He hit 90s yesterday. Good. See where he ends up when the bounce clears. If he's around 90s again, then you can make a decision. If 90s are where you want him to be, then slow down (or even stop) increasing and see if he flattens out there. Give it enough time to see if it works. If he doesn't flatten out, then increase the dose and wait again. Most of the time a cat ends up needing one or more additional increases once he first starts hitting green before he can flatten out in those numbers. Some cats don't end up needing more increases, and some will even start needing decreases pretty soon after the first green.

In TR, our goal is to get them more or less green overall. We will usually keep adjusting the dose until the nadirs are lower than 90s so the preshots will eventually come down to the 90s. In TR, I wouldn't normally suggest stopping increases for a nadir of 96 (slowing down, maybe, but not stopping) because while he is almost there, he is not quite there. If your goal is higher, then you can follow the same basic techniques but set your own guidelines for what you want his numbers to be. With a bouncy cat, the progress is not always fast, but he'll get there.

I think I finally figured out some of my confusion: in the TR protocol, under "increasing the dose", it states "nadirs" as in plural. But in "start low, go slow" you look at the nadir during a curve run after 1 - 2 weeks. Pumbaa never has consistent nadirs (plural) after 3 days, and seldom after 5 days. *LOL* So, in TR, are you really basing a dose increase on the lowest nadir during the 3 - 5 days?

Right! I'll be honest, I know SLGS is supposed to be the more conservative option, but the way it is written I don't see it that way. If you pick one cycle and do a curve, what if that one cycle you picked just happens to be a cycle when they are bouncing, or when for whatever reason they decide not to drop that day? If you had randomly decided to do a curve last night, you would have thought "oh, he stayed in 300s, time to increase the dose." I would much rather see spot checks in several different cycles, even if it is just one spot check a day, than a curve in one cycle and no other mid-cycle tests for the whole week. Maybe it's just me, but I have a hard time trusting one curve a week and am more comfortable with a bit more testing than that.

 

[Pumbaa]

Thank you for chiming in, Libby!

What you said about increases and waiting for the bounces to clear makes total sense to me. Pumbaa's 468 this morning appears to be a bounce from last night (aggravated by the fact that I was 45 minutes late this morning *sigh), or, possibly just his bounce of 7/12 not having cleared yet. So I am just going to wait out the 10 cycles from the dose change ('cause I like to make increases in the morning so I can watch for changes easier) and go from there.

I find the semantics in both the SLGS and TR to be confusing, and maybe needing rewording, IMHO. Because I test regularly, in SLGS I wasn't waiting to do a curve after 1 - 2 weeks, I was looking over my data for that timeframe and finding the lowest nadir during that timeframe to base the increase on. Maybe SLGS was initially written for people who take their cats to the vet for testing every 1 - 2 weeks and don't home test and/or people who, due to work, can't random test during the day except on weekends? But I totally agree that picking a random day to do a curve doesn't tell you the whole story, especially since step 3 states "If the lowest point of the curve is below 90 mg/dl (5.0 mmol/L), decrease the dose by 0.5 unit". A random 89 reading in a sea of yellow/pink/red numbers, to me, does not warrant a dose decrease.

And with TR, since Pumbaa seldom, if ever, has similar numbers for his nadirs (plural) in a 3 - 5 day period, the same thing was true for my interpretation of TR...I would look for the lowest number during the timeframe, and base the increase/decrease on that.

And I am in total agreement with:

In TR, our goal is to get them more or less green overall. We will usually keep adjusting the dose until the nadirs are lower than 90s so the preshots will eventually come down to the 90s. In TR, I wouldn't normally suggest stopping increases for a nadir of 96 (slowing down, maybe, but not stopping) because while he is almost there, he is not quite there. If your goal is higher, then you can follow the same basic techniques but set your own guidelines for what you want his numbers to be. With a bouncy cat, the progress is not always fast, but he'll get there.

The above is my goal, too!

Suze

 

[Marje and Gracie]

((Suze))

I have admired your dedication to Pumbaa and really being in touch with him and his needs. You ask a lot of excellent questions. I am like you....an overthinker. I like answers. FD has taught me that sometimes there are none. Sometimes it's just not clear whether to go up or down in dose. Sometimes we have to accept those weird cycles where we get a high number out of nowhere. Sometimes we just have to wear those patience pants (and I am the queen of impatience). Mike teases me that I have OCD but because I'm such an organized, meticulous kind of person, I think of it as CDO because the numbers should be in alphabetical order :lol: :lol: :lol: :lol:

I felt that some of the TRP people only viewed the TRP guidelines and didn't look at the overall cat being discussed. Suze

I am very sorry if you felt this way. I do not think it was anyone's intent to make you feel that way. When a new member comes into TR, we have to start somewhere and the TR protocol provides us with excellent, science based guidelines. When you were in TR, you were building data. It takes time for patterns to develop... longer for some cats than others. And so, we follow the TR protocol because it's proven to work for many, many cats and it's safe. It allows you to build data so you can not only know how Pumbaa is doing by observing him but also how his numbers might account for how he might feel at different times during the day.

While there is a dichotomy in what I'm about to say, I'll say it anyway Yes....absolutely, every cat is different. They respond to insulin differently, to carbs differently, to dose adjustments differently but I also believe there are alot of similarities that we often do not want to recognize in our own cats. It's common (done it myself ) to believe that our own kitty is really different, really an anomaly, needs something special because it's a good way to try and explain crazy numbers.

But quite often, the kitty is not as different as we'd like to think and the approach of the TR protocol works great for them as they start their FD dance if we give it a chance. And it gives us time to get to know our kitty's true nuances. How long does it really take for him/her to settle into a dose after an increase? How long does it normally take to clear a bounce? Lots of things we can learn about our kitties.....often only to have to relearn them because, at any given time, they can and do change. We might think their cycle is really inconsistent but if we look closely, we can pick up consistencies in the inconsistency.

One of the things we like for members in the TR forum to do each day is to post some kind of Whole Cat Report. That's because we do recognize that the kitty is not just the numbers. I also think that in the early days, lots of cats feel off.....their little bodies are going through alot of adjustments. Maybe you see Pumbaa feeling better now because he's three months into it; I think you said that is something you've considered.

This is one of the other really important adages here: Know Thy Cat. I love it when a caregiver asks for help and is able to tell us some specific info that we might not be able to pick up off the SS but that might be important in determining a dose. I think we do really try to take into consideration the cat and the caregiver as well as the numbers. I do know I give different advice for the same type of patterns based on what I know of the cat and the caregiver's situation. And it's the caregiver's job to help us fill in the blanks when it comes to the kitty. But this takes time...it takes time to learn your kitty's FD dance....lots of time.

I like to think of us as a team when it comes to helping each individual caregiver and kitty. You're the captain of Pumbaa's team....you gather the information from us and other sources and make the decisions. The rest of us are here to give you information, experience, support, compassion, opinions, suggestions, whatever you need so Pumbaa's team is the best it can be to make his journey a successful one. Does successful always mean OTJ? We'd all like to think so but I think most of us also realize the importance of a healthy, happy cat who is tightly regulated.

And with TR, since Pumbaa seldom, if ever, has similar numbers for his nadirs (plural) in a 3 - 5 day period, the same thing was true for my interpretation of TR...I would look for the lowest number during the timeframe, and base the increase/decrease on that.

I think there is a bigger picture here. If I'm looking at a SS and in a five day period, the lowest number is 70 but it only happened one time six cycles before, I interpret it differently than if it just happened the night before or if there were several numbers around that 70 on different cycles. We can help you see those differences and make suggestions....then you can decide what you want to do with your knowledge of Pumbaa. Of course, for reductions, it's more cut and dried and needs to be for the safety of the cat.

We would welcome you back in the TR forum, Suze, but what's most important is that you are comfortable wherever you and Pumbaa are. If you prefer relaxed, that's fine and you can always pop over to TR if you have a question and it's slow in Relaxed. But it does help us if one of us has their eyes on your condo most days....so we can stay abreast of things that happen.

 

[Pumbaa]

Marje,

Thank you so much for chiming in as well. And thank you for the huge compliment on my dedication to Pumbaa...that means a lot to me. (((HUGS)))

Glad to hear someone else admit to being an overthinking, over-organized, meticulous, queen of impatience...but I'll challenge you for the impatience title. *LOL*

I'm glad that I explained my MO, so now maybe people know where I am coming from with all of my questions, including questioning whether Lantus is right for Pumbaa, and whether TR is right for Pumbaa, etc. I don't mean to offend anyone with my incessant questions, because whatever works for anyone's particular cat is the perfect regimen for them, but maybe not the perfect regimen for Pumbaa.

Like I said above, I've always been the problem-solver, and, in normal life, am able to absorb and process data quicker than many other people I know. But, to my chagrin, Pumbaa's FD and getting him regulated isn't like a normal, daily life or work problem. Every time I figure out that he's dancing a Tango, he's on to me and changes to a waltz. When I figure out that he's waltzing, he changes to a foxtrot. And before I ever figure out he's dancing a foxtrot, he changes to a polka! :roll: At the same time, I appreciate what you said about, although ECID, there may be more things in common then are different. And I truly do try to keep an open mind! I have to, for Pumbaa's sake.

When I said, "I felt that some of the TRP people only viewed the TRP guidelines and didn't look at the overall cat being discussed", it was in regards to being very new at giving Pumbaa insulin, and getting recommendations in TR to increase the dose based on the 3 days/6 cycles alone, when Pumbaa was in the middle of a bounce, and was reacting poorly overall, and was reacting even worse with the constant dose increases. I think that Libby and Jill both said that, for newbies, the 3-day/6-cycle doesn't apply as getting good data on the cat in question is very important. I agree. Not just about the getting good BG number data, but also in order to let the already stressed-out cat, and equally stressed-out human come to grips with everything, including all of the poking and shooting and diet changes, etc. The worse Pumbaa reacted, with his numbers and also with his demeanor, the worse I stressed out. "Yikes!" I said. And then I dropped him back to .50U and started over again with SLGS in the Relaxed forum.

Do I think that TR is a bad protocol? No. Not for some cats. And not for people who don't overthink as I do. And not for people who already know how their cats react to the insulin and dose adjustments. And now, maybe, because I know more and Pumbaa is more used to the Lantus (or as used to it as he will ever be, since he still does all that he can to try and avoid the injections), maybe TR could work, because I now have the knowledge (always had the Steel Balls *LOL*) necessary to reply to "I would advise that to increase the dose" after 6 cycles with, "Are you nuts? He's in the middle of a bounce!" *LOL*

I totally agree on the Whole Cat Report, and have been trying to do that for Pumbaa, not just in my daily posts but also on his SS, because any info I have on my SS is going to help me, and anyone else, analyze that data. It's too hard for anyone, including the cat owner, to figure out "Whole Cat" info if the that info is only in that particular day's FDMB thread, and not in the SS. I've even been documenting, for me, the %Kcals for protein/fat/carbs in Pumbaa's "foods" column so that I could watch for a reaction based on carb values. Yes, on top of everything else, I am anal-retentive about details. Are you surprised? ;-)

I like to think of us as a team when it comes to helping each individual caregiver and kitty. You're the captain of Pumbaa's team....you gather the information from us and other sources and make the decisions. The rest of us are here to give you information, experience, support, compassion, opinions, suggestions, whatever you need so Pumbaa's team is the best it can be to make his journey a successful one.

I agree. I truly like the team approach an have learned so much from "the team". I just think that some of the people who have been dealing with FD for a long time, and who have been indoctrinated into using the "3-days/6 cycles then increase" regimen for TR tend to forget that some of us are newbies, and don't have a good history of documentation with our FD cats, and maybe they don't even realize that they are giving "increase the dose" advice without looking at at the "total cat" and how new the cat is responding to receiving insulin in the first place. Everyone needs to be cognizant of the "whole cat" before saying that would give a dose increase or decrease. That's all that I'm saying, 'cause advice you would give to a seasoned DB cat owner is different than the advise you would give to a newby. Right?

I have been so happy to be able to give back, and help people newer than I am to deal with their stress or questions about how to test or where to purchase supplies, etc. Or even just to give mental support to people who have been at this longer than I have. And I have been so happy with those who think outside the box looking at Pumbaa's SS and seeing things that others haven't seen, and giving suggestions that are unorthodox and don't align with any protocol, but which shocked Pumbaa out of a bad pattern.ø

I'm so damn tired I can't even type cognizentally anymore. I still have to finish cooking chicken for Beck the drooler on a diet, and make sure that unpredictable Pumbaa doesn't go lower than 50 tonight.

Again ,thank you Marje, for checking in about Pumbaa, and offering your input/advice.

Suze