8/27 Sibon AMPS 469 Please help with dosing

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Elinor & Sibon

Member Since 2017
After being explained in my previous post that I shouldn't give different doses based on the preshot numbers, I've decided to stick to the tight regulation protocol - 1.5 units since August 21st.
I can't make sense of the numbers:
August 21 PMPS 120
August 23 AMPS 159
and then the numbers seemed relatively flat for the next two days for the 24th and 25th. So when I did the curve yesterday, I didn't except a drop to 92. This morning he's back up to 469.
Is there something I'm doing wrong?
 
Here's your previous post....it's easier for us to quickly go back and see what's been going on if you put the link to the previous post into your current one

Did you skip the shot last night when you got the 92? There's nothing entered in the U column

That's enough to explain the high number this morning.....skipping drains the depot

Also, dropping to 92 is enough to have triggered a "bounce"....Bounces happen when 1. they drop too low, 2, they drop too quickly, and 3. they drop into numbers their body just isn't used to anymore (or any combination of all 3)

I think probably you're looking at #3.....his body has become used to living in higher numbers so even though 92 isn't "too low", it's lower than his body is used to now, so his liver released stored sugars and hormones to bring him back up to where it's used to being.

It can take up to 3 days (6 cycles) for those sugars and hormones to clear the bloodstream, so you don't react to the bouncing "highs" by increasing the dose.....You just hold the dose and hope that once the bounce clears, they return to those good numbers and their body re-learns that it's OK to be there!!
 
Thanks Chris.
I did skip last night's shot.
Are you referring to this morning number of 469 as the bounce?
Wouldn't this keep happening every time I skip a previous shot because of a low number?
 
I'm adding that I just spoke with the vet who looked at his spreadsheet and recommended that I reduce his dose to 1 unit for the week and then perform another curve on the weekend. She thinks a reduction will guarantee that I'm able to give 2 shots per day because his numbers will be high enough.
Is this a right way of thinking?
 
I'm adding that I just spoke with the vet who looked at his spreadsheet and recommended that I reduce his dose to 1 unit for the week and then perform another curve on the weekend. She thinks a reduction will guarantee that I'm able to give 2 shots per day because his numbers will be high enough.
Is this a right way of thinking?
She's correct that a reduction can give two pre shot BGs that are high enough to give insulin. The key is deciding what is high enough. Your signature says you're following TR protocol. The reduction BG on a human meter is 50 in those guidelines. So far you haven't had a BG that low. Also, it's possible to give insulin on those blue numbers you've had when you decided not to shoot. It takes a little bravery from you and maybe some hand holding from people here on the forum but it can be done if you're able to monitor.
 
Your signature says you're following TR protocol. The reduction BG on a human meter is 50 in those guidelines. So far you haven't had a BG that low.

Hi Kris, could you clarify that part for me, please?

The vet recommended not to shoot if it's below 180. During the day I don't think I'll dare to since I'm out of the house for 10 hours.
 
Hi Kris, could you clarify that part for me, please?

The vet recommended not to shoot if it's below 180. During the day I don't think I'll dare to since I'm out of the house for 10 hours.
I'm going by what you've said in your signature - that light grey text below your post. It says, "following TR protocol".
Here's the link to the TR protocol for Lantus:
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-tight-regulation-protocol-tr.1581/

Have a read through it and ask questions here. :)
 
OK I misunderstood you before!
Right, he hasn't dropped that low, this is why I don't know if I should keep giving the same dose or listen to her and try going lower :(
 
OK I misunderstood you before!
Right, he hasn't dropped that low, this is why I don't know if I should keep giving the same dose or listen to her and try going lower :(
Almost all of us have come to a point where we have to decide whether to follow our vet's instructions or try to do things differently. I know I did - and my vet is great. However, my cat refused to follow the usual rule book. o_O

Read through the info stickies on Lantus protocols, TR and SLGS. See which one might work best for you right now. Ask questions here. I'm sure we can get your kitty on track. :)
 
Hi, Elinor. I'm not sure I've stopped by before today.

A couple of thoughts for you to consider....

Generally, if you get a low number toward the end of the cycle, it's still helpful to test at your usual pre-shot time. There's a phenomenon called a "double dip" -- numbers drop again after nadir and close to pre-shot time. I'm not sure anyone really knows why, but it does happen. (It's probably our cats doing their jobs and confusing us!)

With TR, you want to get used to the idea of shooting low numbers. Most of us, as we gain experience, will shoot anything above 50. I wouldn't recommend you do this now. Rather, give some thought to what number you would feel comfortable shooting and gradually get used to shooting progressively lower numbers. You want to have a feel for how Sibon responds to lower numbers and whether his cycle begins to flatten out. While it's counterintuitive, with Lantus, shooting low often produces a low, flat cycle versus causing numbers to plummet.

The advice your vet provided is pretty consistent with what many people hear from their vets. Most vets don't have very many people who will home test or who become knowledgeable about how to steer low numbers with food in order to keep their kitty safe. As a result, they tend to keep cats in higher BG ranges and discourage shooting low. This makes sense if someone doesn't home test. With Tight Regulation, the goal is to keep your cat in normal BG numbers (or get into remission) and it's very hard to do that based on letting your cat sit in higher numbers or not shoot below 180.

I believe what Kris was suggesting is that you're dealing with 2 factors that are influencing Sibon's numbers this morning. When you skip a shot, most of the time, the numbers will be high by the next shot time. (Sometimes, this doesn't happen due to the depot kicking in and keeping numbers level.) In addition, with the drop into the "green" zone, it's very likely you're seeing a bounce. With a bounce, a cat's body reacts to low numbers, a fast drop in numbers, or a drop into numbers the cat's body isn't used to by causing the liver and pancreas to release a stored form of glucose along with counterregulatory hormones. These cause numbers to spike upward as a naturally occurring safety measure. It's annoying but normal.

If you are following TR, you want to evaluate Sibon's dose every 3 days/6 cycles. If his nadir is largely above 200, you increase the dose by 0.25u after 3 days. If nadirs are mostly under 200, you hold the dose for 5 days and then evaluate if the dose is bringing your cat into normal numbers. That said, because you skipped and there is likely a bounce in play, you can wait to see what Sibon's numbers look like once the bounce has cleared. My best guess (and it's a guess) is that Sibon's nadirs are likely in the high blues/low yellows.

If this were my cat, I'd probably increase the dose but I've had years of experience at dealing with low numbers so what works for me may not work for you. Generally, with TR, we tell members who are new to FD to post and ask for help if you get a pre-shot that is under 150. If you are nervous about numbers in that range occurring during the week, I don't know if reducing the dose to 1.0u is the greatest idea. If you feel the need to reduce the dose so you are reliably shooting twice a day, I'd give some thought to reducing the dose to 1.25u (a 0.25u reduction).

 
Hi Sienne, thank you so much for the detailed response. Some of the things you wrote are new to me. It's strange to consider that if I shoot the same amount of units when his BG is low this would result in a flat cycle.
It's impossible for me to check his BG during the daytime or attend to it if he goes too low, I think I am willing to try 1.25u for the next week. My vet doesn't believe in 0.25 units since it's not possible so properly measure it with a syringe, it was exhausting discussing this possibility with her, but I do not feel comfortable dropping to 1 unit just like that.

If his nadir is largely above 200, you increase the dose by 0.25u after 3 days. If nadirs are mostly under 200, you hold the dose for 5 days and then evaluate if the dose is bringing your cat into normal numbers. That said, because you skipped and there is likely a bounce in play, you can wait to see what Sibon's numbers look like once the bounce has cleared. My best guess (and it's a guess) is that Sibon's nadirs are likely in the high blues/low yellows.

Do you suggest I keep shooting 1.5u in the meantime? What would it look like when the bounce clears?
 
Theoretically, when a bounce clears, numbers look like what you're seeing pre-bounce. However, it's not uncommon for a lower nadir, a bounce, a return to the lower nadir, then a bounce, etc. It's annoying. Depending on how low that lower number is, you can increase the dose. However, it's best to try to increase the dose prior to the bounce breaking so there's not too much momentum with the dose increase plus breaking bounce. (I hope that makes sense.)

There's merit to your vet's comment. The markings on the syringes are not always consistent and you have to eyeball a dose that's not on a line. There are two ways to deal with this. You can measure out a dose using colored water and compare your insulin dose with the sample syringe. Or, you can buy digital calipers and use that as a means to measure your dose. The calipers are probably the more accurate solution. I ordered mine (4" digital calipers) from Harbor Freight but I bet Amazon carries them. There are instructions on the Board for how to use them. Either way, the goal is to be consistent with regard to the the amount that's in the syringe. Lantus likes consistency.

If it were me and given your concern about low numbers during the week, I'd lower the dose to 1.25u at PMPS. It helps to remember that there can be a lag in Sibon's responding to any change in dose due to the influence of the depot. It can sometimes take a few cycles for the depot to catch up with any change in dose.

My situation with Gabby wasn't that different from yours -- I work full time. Gabby did give me a bit of a reprieve in that her nadir was rather early in the cycle. As a result, I shot at 5:00 so I could be home to get tests early in the cycle so I could intervene with high carb food if it looked like her numbers were dropping. If you look at her SS, you'll get a feel for how she could nose dive by +3. If you don't have one, a timed feeder may help to insure that there's food available if you can't be home.



 
@Sienne and Gabby (GA) This is really reassuring, thank you so much. I usually leave him frozen bits of fancy feast and there are always leftovers by the time I come home. My concern was that he would feel so ill that he won't be able to go and eat, but according to what you're saying he should be able to because his body would force him that way.. (?)
 
Exactly! Most cats (unless they are sleeping) will look for food when their numbers are dropping.If you think about what happens if your blood sugar drops, you look for something to eat. Our kitties are the same. Gabby used to come over and stare at me if her numbers were low and there wasn't food in her bowl. Every cat is different (ECID) but Sibon will develop his own way of communicating with you. The trick is that we need to be smart enough to listen!
 
Are you referring to this morning number of 469 as the bounce?
Wouldn't this keep happening every time I skip a previous shot because of a low number

I'm glad to see Sienne chimed in to help explain.....A skipped shot will usually (but not always) cause them to go higher (but not that high since there's usually some insulin in the depot that will continue to work) and he also dropped into a lower number that his body isn't used to being at anymore. Between those two things, it wasn't a surprise that he was so high. Most of that is probably due to the "bounce", not the skipped shot, but that has to be taken into consideration too

If you get a Preshot that you're not sure you want to shoot, the best thing to do is stall, don't feed and post for help. Test again in 20-30 minutes to see if the number is rising without the influence of food. The key to using Lantus the best way possible is to learn to shoot those lower numbers. The first few times you do it, we'll want someone with experience to watch over you to make sure he stays safe.
 
This morning I stalled for an hour and a half and his BG was still 104 and I didn't shoot. Would you have given the shot if you were in my stead?
I take into consideration that I'm in a completely different time zone and will not get a prompt response to my morning 911s...
 
This morning I stalled for an hour and a half and his BG was still 104 and I didn't shoot. Would you have given the shot if you were in my stead?
I take into consideration that I'm in a completely different time zone and will not get a prompt response to my morning 911s...
Yes, I would have shot it, but I have LOTS of experience.;) If I were totally in your shoes, probably not. You have a fair amount of data, but you shouldn't shoot a number if you are uncomfortable doing so. The trick is to gradually decrease your "no shot" number - push your comfort zone a little. So your "no shot" number has been 180. How about you lower it to 150, assuming you have all the supplies you need and can test. Then, once you are comfortable with that, you can lower it to 120, etc. Data is your friend. The more you have, the better idea you have of what the insulin is doing.

If you haven't already, I'd print on the sticky on shooting low numbers, so you have it handy in case you can't get help here. Time zone differences can offer real challenges, unfortunately.

Besides looking at the PS number when deciding whether or not to shoot, look at the previous cycle. Is the PS higher than the other numbers? That means that the BG is rising, which makes it safer to shoot than if the BG is dropping This is where the SS comes in soooo handy!
 
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