9/20 Jake PMPS 162

Cloe & Jake

Cloe & Jake

Member
Hello, I hope I’ve formatted this correctly! I would very much appreciate your help with dosing my sugar cat Jake.

He has been doing much better on 4.5 units glargine. Today he has been mostly in the blues, which is a new milestone. 🥳

Is it safe for me to give him his full dose tonight with his lower PMPS? I think it usually weans off by about +3 so I’m thinking it would be good to continue this dose but I am worried about hypos. He has done ok in the past few days with full doses on 200-250 levels.

Thanks
 
I'm not qualified to give advice, but hopefully someone more experienced will come along soon. I'd recommend updating your thread to add a prefix (click "edit thread" and then choose the "Dose?" prefix) to catch attention. :)
 
Hi Cloe! I'm also not qualified to give dosing advice, but I notice he's seeing some greens tonight. If you are awake, I would give a little MC food (1/2 tbsp or so) to bump up that 59 a bit and flatten out the curve.

I'm not seeing which dosing method you are following noted on your spreadsheet. If you are following SLGS, reductions are taken below 90; if you are following TR, reductions are taken below 50. If you need information about the dosing methods, you can read this sticky: Sticky - Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR) Once you decide, please note it in the G1 column of your SS.
 
Mary & Jude said:
Hi Cloe! I'm also not qualified to give dosing advice, but I notice he's seeing some greens tonight. If you are awake, I would give a little MC food (1/2 tbsp or so) to bump up that 59 a bit and flatten out the curve.

I'm not seeing which dosing method you are following noted on your spreadsheet. If you are following SLGS, reductions are taken below 90; if you are following TR, reductions are taken below 50. If you need information about the dosing methods, you can read this sticky: Sticky - Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR) Once you decide, please note it in the G1 column of your SS.
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Thanks Mary. I am awake with him and he is not budging with food and I gave him quite a few table spoons. I have just given him some glucose as there is still a lot of the cycle to go and I’m worried it will drop further if we go back to sleep (it’s 3:30am here) as it’s only just holding with food. I am doing tight regulation but a bit more cautiously and usually treating around 60. I might give him a dose decrease after this and try 4 units. I find 1/4 unit dosing very difficult but with such a large dose I’m hoping it might be ok to decrease by 0.5 units.
 
I suggest that you check with @Sienne and Gabby (GA) or @Marje and Gracie regarding the dose adjustment. We typically don't take reductions (when earned) in .50 unit increments; rather, we typically take them in .25 unit increments. But your thought about the larger dose makes sense; I would just wait until one of the more experienced folks weighs in with you.

What carb percentage are you feeding Jake tonight? I see that you are giving him glucose. Is that by mouth? 59 is not too low (you're keeping him in safe numbers), but you're correct to give it some attention and stay on top of where he is right now so that he doesn't drop any lower.

Hang in there! I've had some late nights like this too, and they aren't fun.
 
@Mary & Jude - From Cloe's signature it looks like she's following TR.

Mary's point is well taken. You've been making dose reductions in larger amounts than TR indicates. The protocol specifies that dose changes are made in 0.25u increments. You also should be holding the dose for 3 days/6 cycles with TR. We don't really encourage modifying TR. The protocol is based on research and the only time we encourage personalizing the approach is if you have a lot of experience with it (in other words, quite a few months), there's some other medical condition that warrants modification, or it's not working for your cat. At this point, it looks like Jake is responding.

You have one more cycle at your current dose. I suspect you are going to see a bounce in Jake's numbers.

One question -- are you still feeding Jake any dry food? If so, you can't use TR. The protocol is based on a low carb, canned food diet. If you have transitioned him to a canned food diet, please change the information in your signature.
 
I am confused.
The instructions on the TR page say that minimum dose holds don’t apply to earned dose decreases. The instructions regarding lower pre shot values than normal also recommend decreasing doses?

“Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction.”
“Q4.4. My cat's pre-shot level was way below the usual value. Should I give the injection?
A4.4. There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.
  • Below 150 mg/di (8.3 mmol/L), don't give insulin.
  • Between 150 and 200 (8.3-11.1 mmol/L), you have three options:
  • a.) give nothing
  • b.) give a token dose (10-25% of the usual dose)
  • c.) feed as usual, test in a couple of hours, and make a decision based on that value
  • Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.
  • In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.
  • Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.”
All of that I have copied and pasted from this FDMB and are the instructions I have been using. Is that incorrect? Going by this, he earned a 10-25% dose (0.5-1u) last night, which I didn’t give and is probably the reason he had such low numbers afterwards. It would also mean he should have insulin withheld this morning. He is due in one hour and BGL is currently at 64.

I can’t see how I can possibly give him a full 4.5 units this morning when his BGL has hovered around 50-90 all night despite being given glucose and moderate to high carb foods. It is still not increasing.

We are still waiting for his IGF results, so I’m not sure yet if he has a high dose condition. He has dry food available but he rarely eats it. Per my vets advice, it is there incase he does hypo while I’m not home and he has a ravenous appetite symptom and can self manage it up.

I have been a bit more cautious with low numbers than the usual TR as his vet said to treat all BGLs under 90 with 1ml 50% glucose. I have been giving that for levels under 60 instead. The big problem I have with holding doses that push numbers so low is that most days I am at work so I cannot treat a hypo if it drops even further to 40 or 50. I don’t want him on a dose that risks that while I am not there to watch him. For example, last night he has been most of the night around 70 despite being given glucose. If I was not there and didn’t treat it at 59, how much lower would it have dropped? I work full time.
 
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Is it better to
a) reduce his dose, or
b) maintain his current dose but titrate dose based on his pre shot BGLs like the above copy and pasted advice suggested

Eg. I could keep 4.5 units but he earns nothing this morning and would’ve earned 0.5-1.0 units last night OR I could decrease down to 4 or 4.25 units regardless of pre shot values so that his doses are consistent. I was under the impression that sliding scales weren’t great and that a consistent dose was better. Either way I am withholding his dose this morning as he is still so low.

Thanks
 
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Lantus dosing is not based on the pre-shot numbers. It's based on the nadir -- the lowest number in the cycle. It's what reductions are based on. Of course, there can be instances when it's not safe to shoot but if you're following TR, you have a set of options. Ideally, with Lantus you are able to shoot low numbers. With SLGS, that means shooting if numbers are at 90 or more. With TR, once you have garnered experience, you can shoot if numbers are above 50. (We don't suggest shooting that low when. you're still new at managing your cat's diabetes.) With Lantus, you do not want to make frequent dose changes because it doesn't allow the depot to stabilize. This is why you don't adjust the dose based on pre-shot numbers.

What you posted is correct information. However, it's for when you are still new at managing your cat's diabetes. If you note, the instructions state, "There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines." I encourage members to gradually get comfortable with shooting progressively lower numbers. If you skipped the shot for today's AMPS, your cycle count starts over. Any skip or temporary change in dose means that you are back to that dose re-starting the cycle count.

If you are feeding Jake any dry food, you cannot use Tight Regulation. You need to switch over to SLGS. You may be more comfortable with SLGS since the dose reduction point is 90.
 
Sienne and Gabby (GA) said:
Lantus dosing is not based on the pre-shot numbers. It's based on the nadir -- the lowest number in the cycle. It's what reductions are based on. Of course, there can be instances when it's not safe to shoot but if you're following TR, you have a set of options. Ideally, with Lantus you are able to shoot low numbers. With SLGS, that means shooting if numbers are at 90 or more. With TR, once you have garnered experience, you can shoot if numbers are above 50. (We don't suggest shooting that low when. you're still new at managing your cat's diabetes.) With Lantus, you do not want to make frequent dose changes because it doesn't allow the depot to stabilize. This is why you don't adjust the dose based on pre-shot numbers.

What you posted is correct information. However, it's for when you are still new at managing your cat's diabetes. If you note, the instructions state, "There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines." I encourage members to gradually get comfortable with shooting progressively lower numbers. If you skipped the shot for today's AMPS, your cycle count starts over. Any skip or temporary change in dose means that you are back to that dose re-starting the cycle count.

If you are feeding Jake any dry food, you cannot use Tight Regulation. You need to switch over to SLGS. You may be more comfortable with SLGS since the dose reduction point is 90.
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Thank you for your advice but respectfully, I think I will just do my own thing. A hybrid TR approach seems to be working for Jake. SLGS almost killed him with levels 500-700+ and hospital admissions with act rapid infusions. Sliding scale dosing also did not work. The only thing that has helped is TR. I am not sure why dry food excludes him, as he is on a low carb dry food and eats maybe a couple mouthfuls every few days. I work full time out of the house. I do not feel comfortable dosing him to levels of 50 without any food for him to bring himself up, or frankly, at all when I cannot treat promptly. I try to dose on nadir but historically Jake has dropped low when dosed below 230. I shot a full dose anyway last night as I was hopeful it would be ok and there is only one way to learn what he can cope with. He couldn’t maintain 60 without glucose. I will not be shooting on a AMPS of 117 when he couldn’t hold his levels at PMPS of 185. Also keeping in mind I am at work today and cannot treat with glucose like I did overnight. I work in human medicine, we would not shoot 1u/kg on a BGL of 50. It would probably kill the patient. I am happy not to risk that with Jake and continue as I am doing as it seems to be working. I understand it is a flexible and hybrid approach that you can’t recommend but I certainly won’t be doing SLGS. I am happy to dose on my data and considering the AAHA, ISFM, Roomp and Rand protocols myself. A balance of all of these, plus my vets advice, makes me feel more comfortable going to a low of 60-70 before considering dose reductions. I also suspect (as do his vets) that there is an element of glucose toxicity at play here. I am hopeful that now we have pushed doses and got the numbers down, that lower doses can maintain these numbers now they are not required to push them down from 600. I appreciate all the data and information here and it has helped me a lot to get Jake to this point. I will continue to utilise the great info if I will be respected for this approach. After all we are all here to try to do what we think is best for our cats.
 
Sorry if that reads a bit blunt - not my intention - but I am only trying to do what is best for Jake. He is a much loved family member. I am restricted by work but I am doing my best with continuous glucose monitoring (which is extremely expensive in Australia) to override these limitations. I do not want to do SLGS, this protocol lead to vets suggesting euthanasia. I do not want that. I like TR and think considering my circumstances, it is ok to just be a little more cautious with low numbers. It upsets me that this does not feel respected. I cannot do any more than I am currently doing for Jake and I am really trying my best. He is the biggest priority in my life but I still must work and that means leaving him for 10-11 hours some days. I could never live with myself if he had a hypo/seizure/died because I dosed him too low and wasn’t there to treat him.
 
I'm not put off with your being blunt. It's also OK to be cautious with lower numbers. We don't ask anyone to jump into shooting low. It takes a while to grapple with how your cat responds to insulin and know how to manage those numbers. It takes a bit to develop the confidence and the skill. We do our best to ensure that members understand the parameters of the dosing method they're using. I would, however, suggest that you indicate that you're using custom dosing in your signature vs stating that you're using TR. Since you're not strictly following TR, if your signature and/or spreadsheet says that's what you're doing, we will assume that that you are following the protocol and there will be people like me who will point out where you're deviating.

I'm not sure where Jake was in his journey but I do wonder if some of the high numbers were due to the Toujeo. There have been so few cats prescribed this insulin that we really don't have a good handle on how well/whether it's effective. In addition, the dose may not have been sufficient to bring Jake's numbers to a better level.

For those of us who work outside of the house, a timed feeder can be very helpful. I routinely used one with canned food for Gabby.
 
Sorry to be late for the discussion, but there are some good thoughts on the post on Protocol Myths, The one I've linked is about mixing the two methods, but there are a lot of other topics worth reading throughout the discussion.

An important factor to consider in your custom dosing is the effect of the depot. The larger depot influences the BG numbers for 4-6 cycles after you do a reduction. This means that if you were following TR, it would be a consideration on how long you hold a reduction after a dose reduction. You factor in both how long it takes for any bounce to resolve so that you can see the nadirs on the new dose, and whether the depot of the larger dose is still impacting the BG numbers in the first few cycles after that reduction.

In post #7, the part you were quoting about Q4.4 in your second paragraph there, was from the SLGS section of the Dosing Methods Sticky Note. The Sticky Note has two halves, the top part describes TR, the second SLGS. I hope that helps the confusion. You follow either the top half (TR) or the second half (SLGS) of that Dosing Methods Sticky, or do custom dosing. Which some people do when they follow guidelines from their vet.
 
Wendy&Neko said:
Sorry to be late for the discussion, but there are some good thoughts on the post on Protocol Myths, The one I've linked is about mixing the two methods, but there are a lot of other topics worth reading throughout the discussion.

An important factor to consider in your custom dosing is the effect of the depot. The larger depot influences the BG numbers for 4-6 cycles after you do a reduction. This means that if you were following TR, it would be a consideration on how long you hold a reduction after a dose reduction. You factor in both how long it takes for any bounce to resolve so that you can see the nadirs on the new dose, and whether the depot of the larger dose is still impacting the BG numbers in the first few cycles after that reduction.

In post #7, the part you were quoting about Q4.4 in your second paragraph there, was from the SLGS section of the Dosing Methods Sticky Note. The Sticky Note has two halves, the top part describes TR, the second SLGS. I hope that helps the confusion. You follow either the top half (TR) or the second half (SLGS) of that Dosing Methods Sticky, or do custom dosing. Which some people do when they follow guidelines from their vet.
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Wendy, I am reading the Protocol Myths link: what is "rebound checking"?
 
Mary & Jude said:
what is "rebound checking"?
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There a FB group out there that is notorious for it. It is resetting the dose waaaay back, in hopes that the bouncing is caused by too high a dose. Invariably it isn't, cat goes in high numbers. And worse case, a ketone prone cat gets high ketones or DKA - seen that happen. :(
 
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