9/8 Tableau - DOSE REDUCTION - ADVICE Requested

Status
Not open for further replies.
ehsuan

ehsuan

Member Since 2011
Previous Condo http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=51700

I didn't post yesterday, so here are the numbers:

09/07/11

AMPS 542
PMPS 278
+ 2 63
+ 2.5 80
+ 3 54
+ 3.5 35
+ 4 45
+4.5 69
+5 74

Fed Karo and Fancy Feast with gravy at 3.5 to get him up.

TODAY
AMPS 473 (dose reduction to 1.25)


So, he earned another dose reduction (2nd in 3 days), so he's now down to 1.25. However, given his steep drops, I do feel some custom dosing is in order when he gets a lower Preshot (like under 300). I know that's not the protocol per se, but as you can see by the spreadsheet, he does have a tendency to drop like a stone. I worry that this will happen when I am not around to watch him closely, which is most days.

What do you all think? Should I maybe try dropping him by .25 if he has a low for him preshot and I'm not going to be around?

Would love some advice.

Thank you so much.
 
Hmmm....not so much for custom dosing on lantus....

More for custom feeding plans. And there are a number of folks around that can discuss those options depending on the circumstances.

Atlas in one cat that has a custom feeding plan. We feed at +2, +3, and +4. Depending on his +6 and +9 we may offer low carb at those times as well.

It is the same amount of food he would normally get, just split up into more meals and feeding times.


PS edit: We use a timed feeder from Pet Safe for days I'm not around. If you look at our SS from 11/28 forward you see the installation of the custom feeding plan. While he still varies the range is reduced and after a few weeks indicates the need for an increased dose.
 
I agree with Blue. As a matter of fact, most of us feed mini meals within the first four hours of each cycle. I feed Champ 1 oz at PS and then 0.5 oz at +1, +2, and +3....or +2, +3, +4, depending on whether he's napping at +1 or I get tied up with something. I also feed a snack of nuked chicken breast around +9 or +10. I've found this actually helps Champ not shoot up too much before his shot. I don't know why, but a snack seems to keep his numbers down in the late part of his cycle.
 
I appreciate the suggestion of mini-meals, but the problem with that for us is that I can't be home during the day, most week days. A feeder won't work because I have two cats - the other one is a little piggy and will get the food first. Tableau has never been a cat that was interested in food. So often I have to literally put him in front of the food and sit with him and keep pointing at it in order to get him to eat. So, I really need to find another solution. nailbite_smile
 
Let's see what others suggest, but lantus is unfortunately not an insulin that cozies up with 'custom' dosing really. It does have its fair share of drawbacks in some situations.


I've got to run right now...but I'll check back in later to see what others may suggest!
 
Emily:

I'm wondering if you can shoot earlier so you can get some feeding in. That really is the solution here. Gracie used to be a HUGE diving queen like this but feeding the curve helped alot. She still does it occasionially, but not like before. Here is what Jill told me:

Manage the curve with food---->flatten the curve------->adjust the dose

I think alot of folks feed the PS, +1,+2, +3 or as Beth suggested. I front load Gracie so the majority of her food is at PS and +1.

Consistency in dosing is what you need to stay with; same dose, shoot the 12s as much as you can.
 
Unfortunately, adding 3 hours to my morning before going to work, is not going to work for me. I work AT LEAST 11- hour days, plus commute time, so if I adjusted the time to be up earlier by 3 hours, I wouldn't be home in time to give the eve. dose. In other words, I currently dose at 9:30 and 9:30. If I got up and dosed at say 7 am, I would need to be home by 7Pm to give the second dose. It's just not going to happen with my work schedule.

So I think my choices are

a) reduce the dose based on the preshot (custom dosing)
b) reduce the dose and keep it reduced to avoid hypos during the day (which means Tableau will possibly be not getting enough insulin).
c) keep the dose the same even with a lower preshot, leave food out on a timer, and keep my fingers crossed (sounds like a lousy option to me, given that Tableau apparently likes dipping into the 30s).
d) change insulin (not sure what would be a better choice)

So I guess, which is the best option?
 
hmmm, i'm looking at tableau's ss and see

the low on 9/2 of 79 followed by a bounce to 454 the next morning and 542 the second morning.

then the low on 9/7 of 35 followed by the zoom to 473 this morning. wonder if it will go higher still?

i'm so not an expert on this - i'm just learning and you should definitely wait for someone with more experience to speak - but i'm thinking out loud - with 2 dose reductions and still dropping low, could it be that you are seeing some response coming in from Tableau's body? his pancreas came alive before - did it act like this?

i guess what i'm wondering (again, not an expert) is if you can be patient and work life/work around him for a short time longer if that wouldn't give you the best chance of getting him OTJ again.

i would also wonder if you could separate your 2 cats on the days that you are gone to work and put the timed feeder in with tableau.

there is always the option of giving a lesser dose to keep numbers higher if it's necessary. it's not best for the cat, but that's what we do with petsitters.
 
ehsuan said:
So I think my choices are

a) reduce the dose based on the preshot (custom dosing)
b) reduce the dose and keep it reduced to avoid hypos during the day (which means Tableau will possibly be not getting enough insulin).
c) keep the dose the same even with a lower preshot, leave food out on a timer, and keep my fingers crossed (sounds like a lousy option to me, given that Tableau apparently likes dipping into the 30s).
d) change insulin (not sure what would be a better choice)

So I guess, which is the best option?
Click to expand...

Well, actually ...

a) Lantus is not adjusted based on preshot levels, it is adjusted based on nadir. I am known quite well around here to have "BOS," in that I have been known on more than one occassion, to shoot into a pre-shot of 50. :o What I have in order to shoot like that is routine and history. We don't quite have that with Tableau and is not a direction I would encourage at this time. There is a sticky dealing with low preshot numbers though and it provides a decision tree that you can think through. SHOOTING & HANDLING LOW NUMBERS This particular sticky brings up a very good point that with Lantus you are in fact wanting to shoot the overlap and create a flat curve, not the traditional curve. Again custom feeding may help with this.

b) If Tableau is getting down into green numbers but showing signs of "bouncing" he is getting a proper amount of insulin. The question I view in your case, is knowing if he is indeed getting down that low and what your are seeing is bounce or insufficient insulin? Generally speaking doses can be held and need to be held at least 6 cycles or more, so this would mean you would need to be able to get a curve on the weekends or an off day to generate dosing data.

c) Food and timer? Yes, in your case it does sound like it is not your best option. For Atlas I am fine with him as he will tend to 'hunt up food' if he is low...and the other kitties in the house tend to not like his raw rabbit.

d) Changing insulin is always an option and one that could be discussed with your vet.


I would wait a bit longer and see who else chimes in on your thread before reaching any decisions. And yes there have been times I've needed to walk out and go to work and pray....and that has happened on both Lantus and Humilin N.
 
Just a quick addition of info...

Please note the two Hypos in 3 days...with dose decrease. That's why I'm thinking of preshot numbers. I know that's not a usual case, but from what I can tell, he has these massive (200 points in 2 hours) and then he has hypo numbers (the 30s). That's why I'm mentioning preshot numbers. If he's in the 300s or 400s preshot, I have no problem with giving him his usual dose, but I don't want to come home and find him dead.

I also understand about holding doses, but it also says in the protocol that an immediate .25 reduction is warranted if he dips below 40, which he has.

Anyway, I just wanted to clarify my thought process, so you all don't think I'm just randomly trying to adjust his dose based on preshot. It's because he does seem to have a history of massive 200 point drops in 2 hours. Yes, and I appreciate I don't have alot of data yet, but I'm reacting to the recent 30s he's gotten - it's really freaked me out. :o

Blue you sure do have "BOS"!!! Gutsy to shoot at 50!
 
one of the things i've learned is that just because a cat will drop from 300 to 100, doesn't mean they'll drop from 200-zero. i'm not ignoring what you're thinking, because i thought the same thing - just that as the cat gets regulated, most cats will stop their giant ups and downs.

that's one of the benefits to lantus - it flattens out the curve.
 
Atlas sometimes gives me back to back low numbers 30 or 40's and it is a feeding issue. He generally will have missed a meal vs. needing a real dose reduction.

It is hard to say that is the same case with Tableau as he isn't getting fed throughout the cycle. I understand your concerns with the big swings and low numbers, but many of us have seen cats do the same thing from numbers in the 400's to then in the 30's. Just like a human diabetic needs to feed their BG, so do cats on lantus. The big ups and downs can in themselves trigger the rebound/bounce highs too. Not just the low numbers.

Is there any chance you can feed and shoot upon awakening and then get a plus one test and feed again?

Unfortunately lantus just doesn't have the dosing flexibility. In order for it to be effective it needs consistent amounts and times. As Julie pointed out falling back to a lower dose and holding it for a week until a full data curve can be done is not the worst thing to happen. Many handle their situation(s) just that way too.

What was the insulin you were on before?
 
ehsuan said:
Please note the two Hypos in 3 days...with dose decrease. That's why I'm thinking of preshot numbers. I know that's not a usual case, but from what I can tell, he has these massive (200 points in 2 hours) and then he has hypo numbers (the 30s). That's why I'm mentioning preshot numbers. If he's in the 300s or 400s preshot, I have no problem with giving him his usual dose, but I don't want to come home and find him dead.
Click to expand...
The thing is, because of the Lantus "shed," reducing a dose doesn't have much effect in that cycle. That cycle is running partly off of shed action from the previous dose. A reduced shot is more likely to affect the numbers in the NEXT cycle. You would have to reduce the dose by a whole lot to have much chance of it keeping the numbers up in that cycle. My Jazzy is an acro cat and I usually skip shots when she is too low to shoot and I have to work. I've learned that reducing her dose, even by half, doesn't change her cycle. (I don't usually suggest skipping shots for most cats, but acro cats can respond to food differently so I treat her with more caution. With Lucy I shot almost any preshot number). Get some tests on a weekend or evening and see how Tableau responds to reduced doses. You'll probably find out that it doesn't change things much.

I also understand about holding doses, but it also says in the protocol that an immediate .25 reduction is warranted if he dips below 40, which he has.
Click to expand...
Yep, he has earned his reductions. :smile:

Anyway, I just wanted to clarify my thought process, so you all don't think I'm just randomly trying to adjust his dose based on preshot. It's because he does seem to have a history of massive 200 point drops in 2 hours. Yes, and I appreciate I don't have alot of data yet, but I'm reacting to the recent 30s he's gotten - it's really freaked me out. :o
Click to expand...
This probably won't make you feel any better, but when Lucy was on insulin, I was a lot more worried about shooting full dose when she was in the 300s than when she was in the 100s. If you spend some time studying her spreadsheet, you'll see that often when she was 300+, she would drop like a rock and end up low. If I shot 100s, usually she would just keep surfing (unless she was ready for a reduction anyway, in which case she sometimes cruised downward). That is the pattern we see more often than not - if they are 300-400 and a bounce clears, they can go green easily, but when shot at lower numbers Lantus tends to give flatter cycles. That's why so many of us can shoot low numbers very easily, once we have learned our cat's response to insulin and food. Your job is to learn your cat's response to insulin and food, by testing as much as you can when you are home and keeping good notes.

Are you able to move your shot time just one hour earlier, or maybe an hour and a half? If you look at Tableau's spreadsheet, the times he dropped low he dropped very early in the cycle. Try getting some +1 tests. If he is dropping fast at +1, then you can go ahead and feed high carb to put on the brakes. It looks like that is a fairly common pattern for him and I think if you learn to recognize it, you'll learn when to intervene and that will help you feel in control.
 
Thanks Blue, Libby, Julie, Patty, Marjorie...

Thanks for your patience with me and all the good info. You've given me a lot to think about. Yes, I could manage getting up an hour earlier and getting a plus one. So I will shift down in 15 min. increments to do so.

I also forgot about the shed - Thanks for reminding me. Last nights low numbers were probably because he was still draining additional insulin from the shed, right?

Interestingly enough I was able to leave work early today and got a + 8 ish, and got a 10!!! So I checked with my other meter and got a 64. So maybe my meter is giving me lower numbers than it should be. I swear these meters are unreliable. I switched to my back up meter a few weeks ago, as I was getting weird readings with the regular one, and now it's the opposite.

I will go ahead also and do the timed feeder thing, it can't hurt. Maybe he'll eat it.

I've been warned to be patient by others...guess the lesson hasn't stuck yet.
 
Status
Not open for further replies.
Back
Top