8/5 Farine PMPS 74

[kimouette]

Hi everyone,

I'm writing this message for Alain (who will be following this thread).

His cat, Farine, started to be very stable ever since we increased her dosage to 0.85u.
She had couple of low numbers since we started Lantus, but all were handled with low carb food (Evo), except for one case when Alain had to leave the house and left her 6 kibbles!

Here's Farine's spreadsheet . https://docs.google.com/spreadsheet/ccc ... sp=sharing

What's happening tonight is a first time AT NIGHT.
Here's what's written in the comment box of Farine's spreadsheet for today :

"First time we have such a doubt about whether Farine should receive her injection or not. Decided to opt for the "wait until the numbers get high enough" option, but it's getting late, so I gave her a shot at +4... I wont be sleeping a lot tonight!"

Anyone can help us figure out what happened here (if it was predictable?)?
Would you guys have done the same thing in this specific situation? and why?

Thanks a lot for your help!
Kim, Alain and Farine

 

[Marje and Gracie]

Hello and welcome!

I don't know if I've ever seen you all here before.

Many of us shoot every number above 50; for example, my kitty is on less insulin than Farine but I shoot all low Preshots above 50 so, yes, this is a shoot able number. We usually ask that you post when you get a number lower than you've shot before so we can help you.

Stalling four hours is a very long time to stall. The only issue is it takes a while to Get Back On Schedule slowly. Or you could skip her shot in the morning and then tomorrow night, shoot at your regular time or a new time that works better for you.

What concerns me more is you've missed some dose reductions. Each time Farines BG goes below 50 on a separate day, she should get a dose reduction although we don't give reductions for back to back cycles where numbers go below 50.

Farines dose should have been taken down .25u on 7/22 when she got to 48 and then another .25u on 8/2 with those 30/40s numbers. If it were me, I'd reduce her dose .25u in the morning to .65u. It is not unusual for cats to go lower at night. You may see numbers a little wonky for a cycle or two since you shot so late tonight.

I also read on your SS about hypos. We usually don't call it a hypo unless there are clinical signs. Most of our kitties want to eat if their numbers are lower so I wouldn't consider that a symptom of actually having a hypoglycemic episode.

 

[kimouette]

Hi Marje and Gracie !

Many of us shoot every number above 50; for example, my kitty is on less insulin than Farine but I shoot all low Preshots above 50 so, yes, this is a shoot able number.

Are you saying that any AMPS or PMPS above 50 should not even make us think before shooting? Or is it only a rule that applies to your kitty?

We usually ask that you post when you get a number lower than you've shot before so we can help you.

Can i ask the question the other way arround? For Farine's specific case, what is the current lowest shootable number?

Stalling four hours is a very long time to stall. The only issue is it takes a while to Get Back On Schedule slowly. Or you could skip her shot in the morning and then tomorrow night, shoot at your regular time or a new time that works better for you.

Thanks a lot for the link. I had never read it. I guess skipping the next injection is the only solution since the last shot was done at +4... But if the numbers are high in the morning, I can already anticipate that it will be tempting to give the shot anyway...

What concerns me more is you've missed some dose reductions. Each time Farines BG goes below 50 on a separate day, she should get a dose reduction although we don't give reductions for back to back cycles where numbers go below 50.

That doesn't seem to match the original protocol :
http://www.tillydiabetes.net/en_6_protocol2.htm

if the nadir glucose concentration is 40 - <50 mg/dl at least three times on separate days, try lowering the dose.

... and this is not Farine's case
Also, since Farine's nadir are still not in the "perfect range", based on the following part of the protocol, we were thinking of increasing her dosage (not reducing it!):

When the cat first begins to have daily nadirs in the normal range of a healthy cat (50 to 80 mg/dl) and spends significant amounts of time in this range each day, stop increasing the dose and switch to Phase 3. It doesn't matter when you measure these lower BGs, it can be at pre-shot or sometime between shots. Getting to this point generally takes 1 month, sometimes a lot longer.

Farines dose should have been taken down .25u on 7/22 when she got to 48 and then another .25u on 8/2 with those 30/40s numbers. If it were me, I'd reduce her dose .25u in the morning to .65u.

Have you noticed how she "bounces back" with high numbers the next cycle EVERYTIME she gets under 50? And then after couple of cycles, it goes back to "normal". What do you think would have happened if we reduced the dosage? Wouldn't numbers have simply gotten higher? And then she probably would have required a dose increase about 3 cycles later!

I also read on your SS about hypos. We usually don't call it a hypo unless there are clinical signs. Most of our kitties want to eat if their numbers are lower so I wouldn't consider that a symptom of actually having a hypoglycemic episode.

Based on FDMB's sticky post about low values, hunger is sign of a mild hypo... I would not even mention it if Farine was just "a little hungrier than normal", but when hunger is that obvious and she eats like a pig, I can only call it a mild symptom! Nothing to worry about, she's normally fine after eating a huge portion of food, but still it reminds us that maybe shooting a cat with a PS close to those green numbers (and especially an unstable cat that often has VERY EARLY ONSETS), might not be as easy to do as for a well regulated cat.

 

[Sienne and Gabby (GA)]

Kim:

Actually there are points on Farine's SS where the reduction was overlooked that are consistent with the most recent version of the German (i.e., "Tilly") version of the protocol.

When the cat regularly has its lowest BGs in the normal range of a healthy cat and stays under 100 mg/dl overall for at least one week, attempt to reduce the dose. Alternatively, if the nadir glucose concentration is 40 - <50 mg/dl at least three times on separate days, try lowering the dose. If the cat drops below 40 mg/dl once, reduce the dose immediately!

On August 2, Farine dropped below 40 and no reduction was taken. The German version of Tight Regulation is aggressive. If you are going to hold the dose for three drops in the 40 to under 50 range, then it's important to follow the protocol exactly. After those 3 drops into lower numbers, the dose needs to be reduced by 0.25u. If you are going to shave the dose, then you the reduction needs to be made after one drop below 50. This modifications we use here also recommend a 0.25u reduction if numbers drop below 40.

Like Marje, I shoot low numbers. It's fine if Alain wants to shoot low but he must be available to monitor and to intervene with high carb food if necessary. None of us shoot low and leave the house. You might want to review (or have Alain review) the sticky note on Shooting & Handling Low Numbers.

If I had to guess, Farine was in lower numbers during the AM cycle but there's no way to know for sure without the test data. What happened at shot time is that Farine had a flat Lantus cycle. There's no way to predict when this will happen. I had the same thing happen this morning. My cat was at 70 when I went to sleep and was at 59 this morning. (I shot.)

 

[kimouette]

Marje and Sienne, thanks a lot for the replies and all the precious infos.

Alain and I both agreed that the only thing to do for now was to skip the morning injection (cuz 4 hours would be impossible to "recover" by 30 minutes periods).
The next injection will be the usual 0.85u and next time Farine gets a PS of 50 or more, he will give the shot and monitor closely by following everything in the "Shooting and handling low numbers" document.
Also, next time Farine has a value of 40 or under, he will shave the dose.

One question though... what should he do if he gets a value around 50, but needs to leave the house right away? I know that reducing dosage is not normally recommended, but do you guys agree that if he cant stall for 2 hours cuz he has to leave, he should still give the injection and leave low and/or high carb food to the cat? It sounds a little risky to me, but I'm not sure what other alternative he has....

 

[Sienne and Gabby (GA)]

Let me clarify. You have several options with numbers in the 40 - 49 range.

• You can reduce the dose by 0.25u which is the modification we use here or
• You can shave the dose -- another modification that we use here or
• You can wait for the 3rd time that Farine's numbers drop in the 40 - 49 range and then reduce by 0.25u which is the modification used on the German board.

You ALWAYS reduce by 0.25u if the numbers are below 40.

What you do NOT want to do is wait for the 3rd drop into the 40 - 49 range and shave the dose. That is far too aggressive and will likely result in very low numbers.

Most people will skip the shot if they have stalled and it's more than 2 hours. It's just too hard to recover the time. If numbers are anywhere, not just close to 50, and Alain has to leave the house, then you do what is safe. That may mean delaying the shot, giving a very small amount of insulin, or skipping. It all depends on the circumstances that are occurring that day.

 

[Marje and Gracie]

I also have some other thoughts to add and one of them was going to be about shaving vs a .25u reduction but Sienne addressed that. Unfortunately, I am on my way out to help a new member learn to hometest. I'll drop back by later and answer some questions more specifically that you asked me in an earlier post.

 

[Marje and Gracie]

Are you saying that any AMPS or PMPS above 50 should not even make us think before shooting? Or is it only a rule that applies to your kitty?

No, I'm not saying that. Sometimes, if you are sick or tired, if you don't have supplies, if you have to go out, it's best to not shoot a low number above 50. We help members learn to shoot lower and lower safely until they can shoot those numbers just above 50. But Farines number last night was a very safe number to shoot on time if you all were going to be there to test and had supplies.

Can i ask the question the other way arround? For Farine's specific case, what is the current lowest shootable number

It depends on the situation. You have to consider if you are prepared and can be there to test. Is the number dropping or rising? Do you know how to bring the numbers up with food? Do you know if she gets a food spike at +1? Do you know when she onsets, nadirs, and what her duration is?

From the modified TR protocol we use in Lantus Land:

If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit

. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further.

The bold is mine but Farine is newly dx so you should reduce her dose when her BG falls below 50.

Have you noticed how she "bounces back" with high numbers the next cycle EVERYTIME she gets under 50? And then after couple of cycles, it goes back to "normal". What do you think would have happened if we reduced the dosage? Wouldn't numbers have simply gotten higher? And then she probably would have required a dose increase about 3 cycles later!

Farine is bouncing, yes. When she gets numbers that her liver is not used to (they don't even have to be really low) or she drops fast, the liver releases counterregulatory hormones and glucagon to bring the BG back up to what the body feels is normal. Look at Siennes Gabbys SS or my Gracies SS. They both still bounce but come right back down. Gracie nadirs in the 50s. I can't take her dose up based on the bounce number or she will be overdose. So will Farine if you raise her dose based on the bounce numbers. Ignore them. If her nadirs are 50-120, hold the dose and be patient.

maybe shooting a cat with a PS close to those green numbers (and especially an unstable cat that often has VERY EARLY ONSETS), might not be as easy to do as for a well regulated cat.

For cats that might nadir really late, the caregiver has a harder time but its also gives you the ability to take advantage of carryover and overlap to se those nice, long, flat curves Lantus if known for. Again, check out Gabbys SS; she onsets early. If you start feeding the curve early and front load her food, you might feel better shooting those green numbers above 50. I had the same challenge when Gracie was on Lantus and learned how to do it. But I had alot of data.

Please let me know if this generates more questions,

 

[kimouette]

Farine is bouncing, yes. When she gets numbers that her liver is not used to (they don't even have to be really low) or she drops fast, the liver releases counterregulatory hormones and glucagon to bring the BG back up to what the body feels is normal. Look at Siennes Gabbys SS or my Gracies SS. They both still bounce but come right back down. Gracie nadirs in the 50s. I can't take her dose up based on the bounce number or she will be overdose. So will Farine if you raise her dose based on the bounce numbers. Ignore them. If her nadirs are 50-120, hold the dose and be patient.

Oh my god I never planned on dosing Farine based on the bounce numbers! Of course that would be very dangerous. Maybe you got mixed up with 2 different things I said. It's true we were planning on increasing her dosage but that was based on her nadirs, not on a bounce!

:?: But I have to ask my question again :

Have you noticed how she "bounces back" with high numbers the next cycle EVERYTIME she gets under 50? And then after couple of cycles, it goes back to "normal". What do you think would have happened if we reduced the dosage? Wouldn't numbers have simply gotten higher? And then she probably would have required a dose increase about 3 cycles later!

Sorry to repeat myself, but I know this is going to happen! Farine's spreadsheet clearly shows that after a bounce, IF WE DONT CHANGE DE DOSAGE, the subsequent cycles go back in the blue values (not even with perfect nadirs; everything just plain blue). If we reduce the dosage wont the next cycles just be worse ?

:?: Oh and one last question....

What you do NOT want to do is wait for the 3rd drop into the 40 - 49 range and shave the dose.

3rd drop on what period? I mean if a cat has 3 drops in a year he might not need to have a dose reduction, as opposed to a cat that has 3 drops in a 2 week period? I cant believe these 2 cats would fall in the same category and both get a reduction.

But to be more specific, here's why I'm asking...

Farine's drop under 40-49 :

6/30/2013 : 45 (she got a dose reduction, but she was on Caninsulin!!)
7/11/2013 : 34 (her lowest value EVER! She got a dose reduction of .25u)
8/02/2013 : 39 (Unfortunately wasn't there to help Alain.... but if you look at all the numbers since august 3rd (4 days ago), they don't tend to show that Farine needs a reduction...)

So once again we're in a situation where we don't perfectly fit the profile described in the protocol. Farine's first value under 50, was on Caninsulin. The second one, she got a reduction of .25u right away (while we should have just shaved the dose), and the third one, we didn't do anything. So when do we start counting 3 drops? Since she got more reduction than she needed on 07/11, cant we just "reset" the counter?

 

[Sienne and Gabby (GA)]

6/30/2013 : 45 (she got a dose reduction, but she was on Caninsulin!!)
7/11/2013 : 34 (her lowest value EVER! She got a dose reduction of .25u)
8/02/2013 : 39 (Unfortunately wasn't there to help Alain.... but if you look at all the numbers since august 3rd (4 days ago), they don't tend to show that Farine needs a reduction...)

So once again we're in a situation where we don't perfectly fit the profile described in the protocol. Farine's first value under 50, was on Caninsulin. The second one, she got a reduction of .25u right away (while we should have just shaved the dose), and the third one, we didn't do anything. So when do we start counting 3 drops? Since she got more reduction than she needed on 07/11, cant we just "reset" the counter?

Kim:

That reduction after the second drop -- the one on 7/11/2013 -- was done correctly. You DO take a 0.25u reduction if numbers are below 40. You do NOT shave the dose.

I'm confused. Are you saying that after the bounce clears, you would increase the dose? That may be the right thing to do but it really depends on where the numbers are. It's not an automatic response to increase (or decrease) a dose after a bounce. Each situation needs to be evaluated on it's own merits.

3rd drop on what period? I mean if a cat has 3 drops in a year he might not need to have a dose reduction, as opposed to a cat that has 3 drops in a 2 week period? I cant believe these 2 cats would fall in the same category and both get a reduction.

That's a good question! There aren't any guidelines as far as how much time needs to elapse. I don't think any protocol can take every possible situation into account. Some of this is a judgement call. I think the point here is that if you are using an aggressive approach to dosing (the 3 drops into the 40 - 49 range) you don't want to be doubly aggressive by shaving the dose.