Comparing Roomp and Rand to more aggressive FDMB

[joanngold]

I do what I can to follow the R&R Protocol. The LL Group has introduced a much more indepth approach to the complex and contradictory numbers: Breaking the Bounce and NDW. But now there is picture that makes it harder to figure out where I am. Contributing to my uncertainty is R/R's approach the nadir and the peak. They mention in each step both the lowest acceptable limit of the numbers the nadir AND the highest acceptable number the peak before you must adjust the dose.

I'll be specific. One of the first comments someone made was that her "good" nadir numbers came during the night measures. I looked at the sequence of numbers and thought well the nadir suggested one action but so many of the peaks were dangerously high suggesting that one increase the dose. Saying it another way I'm confused and hoping for answers.

I am trying to sort this out as best I can but operating with a blurry data picture. I carefully read and reread the stickiesand the other comments that are made. I think/hope that what seems confusing to me, is very clear to you.

On a separate matter. I am unfortunately on a somewhat different schedule than most folks here. I administer the insulin at 12am and at 12pm. It is a schedule that I don't dare change because it could easily make me unreliable in giving the dose at the right times. I do see that its important to get at least one +2 BG that means 2am. I'm am thinking that it would be especially important to go for the 2am measure when the PM BG is very low and might possibly drop into hypo range. It is necessary but very funny really. I wake up at 2 am, poke my innocent sleeping little guy again. And, just in case I don't like the results I can grab the open can of fancy feast so that my poor confused creature makes it through to another day. On the other hand I say, I can do that.

 

[Marje and Gracie]

Hi Joann

The R/R TR protocol typically refers to either "nadir" or "peak" glucose concentration and those terms are used interchangeably to mean the lowest number in the cycle. So the "peak" is not the highest number; the "peak" is the peak of the insulin activity which would give you the lowest number or the nadir.

If someone's cat is "bouncing", which is what you described when you said the nadirs suggested one action and the "peak" another, then the CG should typically hold the dose until the bounce clears to see if the nadir (or peak)),when there are no counterregulatory hormones driving the BG, are normal.

The R/R does address NDW. Tilly was Kirsten Roomp's diabetic cat and Tilly's webpage discusses the TR Protocol in a narrative form more than the chart form in the R/R study. From Tilly's Webpage:

Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations.

Bouncing is also addressed with this comment:

Fluctuations are very common in this phase before BGs start to stabilize under consistent dosing:

I think this post on TR Protocols: Myths Debunked will also answer your questions in more detail and it explains the "history" of the TR and the LL modified protocols. I do not see the LL modified TR protocol as being alot more aggressive than the TR Protocol.

I've seen members with shot times all around the clock. If your 12/12 schedule works for you, I think that's great. While many cats do go low at night, not all do. Some go lower during the day; some flip it around so sometimes they go low at night and sometimes during the day alternatively.

I'm not sure if I've answered your questions....have I?

 

[Marje and Gracie]

I didn't get a chance to look at Big Shot's SS last night but on review of it this morning, and I mean this very respectfully, you aren't following the TR protocol as written or the modified TR protocol.

I am very concerned that you shot a 65 on an AT on 11/23. We generally do not shoot below 50 on a human glucometer which is roughly 68 on an AT. It would have been better to stall without feeding to see if his PMPS came up before you shot. A dose reduction should have been taken then so I'm glad to see you did reduce shortly thereafter.

If you need assistance with following the TR protocol, we will be more than happy to help. . But I have to reiterate what Julie, Wendy, and Amy told you before: you are missing half your data with no tests at night and if you have someone who is with him all the time, as stated before, then it would be good to get at least a +2 test at night and whatever other test they can get later in the cycle since someone is up.

 

[joanngold]

Marge,

I really thank you. I did not understand that "peak" and "nadir" are basically synonyms. I seem to have been looking at things from the wrong end of the telescope. My concern about how I fit “Bounce” and “NDW” into the scheme of things really evaporates with your clarification. Many, many thanks.

You also suggested that I should have withheld an injection when PMBG measured 65. But I didn’t.
I would have taken action if the PMBG report <50 or 55. At PMBG 65, I hesitated to do that. Why? Because AlphaTrak results vary from measure to measure. For example take two consecutive tests with AlphaTrak test strips to the same BG drop, and there is a good chance that you will get different BG reports. AlphaTrak discusses these measurement variances on the test strip insert. I would never give up the AlphaTrak. But I use it knowing that in certain situations I must include my judgment. With PMBG I saw a possible boarder line report. And it led me to take other things into consideration: 1) Consistent dosing in time and amount work best of all. 2) And, know thy cat.

I didn’t ignore the PMBG measure. I was concerned and gave very clear instructions to the person who keeps an eye on most of the night. He knew that he should wake me if he saw anything out of the ordinary.

I agree that night testing would provide a much more accurate profile. I can only say that I do what is realistically possible. If there is a dangerous PMBG, I will set the alarm for 2am.

Again I thank you for explanation of peak and nadir and all of your comments. I feel like I am watching things through very shaky binoculars that with guidance become more stable.

Jo Ann

 

[julie & punkin (ga)]

It's true that with any meter if you retest again you are likely to get a different BG measurement. That's not just alphatraks. In most cases, we just accept the # if it seems correct in context. If it doesn't make sense entirely, then we encourage people to retest. For example, recently there was someone with hourly tests that were all over 300 and in the middle of that popped up a very low number, maybe a 40 or so. Then the cat's BG tests returned to 300+ with the next hourly test. That test was likely a bad strip.

However in your case, if you get a test below 68, the protocol would have you decrease the dose by 0.25u. The <50 is for those using human glucometer. <68 is for those using ATs or other pet glucometers.

One more thing I would add is that with the long-lasting insulins like Lantus & Levemir, by the time a person is seeing hypoglycemic symptoms the cat will likely be dangerously low. A hypo on these insulins can last as long as 16 hours and often requires the vet's help to get through. We encourage people to rely on testing data instead of just watching for symptoms because of this.

Here is the original published protocol that has the dosing guidelines for AT users: http://www.felinediabetes.com/Roomp_Rand_2008 dosing_testing protocol.pdf You'll note that on this page, the recommendation for a reduction is at 80 or less. There have been mixed directions for AT glucometers - here it is 80, in another publication by Rand it is 68. However, both of those would support reducing at anything less than 68.

 

[Marje and Gracie]

Jo Ann

I'm glad to see you back! I'm also glad my post helped clarify a few things.

You also suggested that I should have withheld an injection when PMBG measured 65. But I didn’t.

No, I didn't suggest you withhold the injection. :smile: I suggested you stall without feeding for a bit until the number came up and then shoot. There is a difference. The latter is safer especially if you aren't testing at night. To shoot that low of a number and go to bed and not test again is....candidly, unsafe.

Because AlphaTrak results vary from measure to measure.

Every single meter, AT or human glucometer, can (and usually does) vary from measure to measure even a few seconds apart. Glucometers can have a 20% variance from reading to reading. We do not base our decisions on shooting a low number on what the variance "might" be. For instance, I am a very experienced member and I have years of data on my kitty. I also use levemir which has an onset of around +4 as opposed to +2 of lantus. If I get a 49 on my meter at pre shot, I do not shoot it. I let her rise a bit. I don't think "well, if I retest, I might get a 52 and then it's ok to shoot". Her safety is number one for me and I know Big Shot's is for you as well.

I would never give up the AlphaTrak.

And we would never ask you to do so. Each member should use the meter they feel most comfortable with.

1) Consistent dosing in time and amount work best of all.

I agree but stalling 30 mins to see if he is coming up or going down does not affect consistency. And consistent dosing matters not if your cat hypos from shooting a number that is too low to shoot and then not testing.

2) And, know thy cat.

Also agreed but I don't think you have enough data to justify this statement. You have no night time data and cats very often go low at night.

I was concerned and gave very clear instructions to the person who keeps an eye on most of the night. He knew that he should wake me if he saw anything out of the ordinary.

By the time the night person sees "something", it could be too late. My kitty has dropped into the 20s at night without one single sign. As an example, one night, I tested her at +5 before I went to bed and she had come up to 119. Because she drops later in the cycle due to levemir, I got up and tested her at +8 and she was at 66. I fed her HC food because I do know my cat; I retested her at +8.5 (30 mins after she ate) and she was at 24.

If there is a dangerous PMBG, I will set the alarm for 2am.

Please let me give you an example of why this statement causes me great concern for safety. Look at Big Shot's AMPS on 11/23. It was 194 on your AT which is roughly 145 on a human glucometer. At +6, he was at 78 on the AT which is approximately 58 on a human glucometer and at +12, he was at a number which would "require" a reduction under the R/R TR protocol. You were able to catch all those numbers because you are doing well at daytime tests. Shooting a 65 at PMPS and going to bed is dangerous.

I can only say that I do what is realistically possible.

I can appreciate this very much. But I have to ask if you have a person there watching him at night, why can't he grab a test or two for you? It should be easy to teach him to test. Then you know he is safe.

I realize I am perhaps being more candid with you than you might like. But I am all about safety with our cats. Cats can and have died of hypoglycemia on lantus. They can also have irreparable brain damage including blindness. Sometimes they are going to go low no matter how we try to avoid it and by testing, we catch those lows and hopefully bring them quickly up before they can show any symptoms. But realize that we don't have our cats hooked up to any monitoring equipment so even when they are below 40 on a human meter (51 on an AT), we do not know what effects it has on their brain or at what point deprivation of blood glucose is affecting brain cells.

If you aren't going to be able to test at night or have the watch person do it, I would suggest that to keep Big Shot safe, you lower the dose. I do think you are currently endangering him especially if you are shooting blind (not getting a pre shot test every single cycle) and then going to bed.

My comments are not meant to disparage you; they are provided from the standpoint of being a very experienced member who has seen hundreds of SSs and knows what insulin can do even used safely. It is a hormone, not a medication, and you can't control it but you can use it more safely than you are. Again, we are here to help you. It's our number one goal to see Big Shot do well on insulin, stay safe, and teach you how to work with the insulin and FD.

Side note: PMBG means "pm blood glucose" which indicates no shot (AMBG is am blood glucose = no shot). AMPS (am pre shot) and PMPS (pm pre shot) are used for when you shoot

 

[joanngold]

FDMB,

Thank you very much for your comments. There is a lot for me to consider.

Jo Ann

 

[Marycatmom]

It's a ton for us newbies to absorb! I've found that the experienced members here like Marje and Julie, are super helpful in guiding me. I hope you'll feel free to make daily posts and get their help. It really is a sanity saver.

 

[Amy&TrixieCat]

Please continue to ask as many questions as you need...we are happy to help and clarify anything and everything. As Marje said, we are all about safety,in addition to healthiness, here. Insulin is a powerful tool in the fight against diabetes, but because it is so powerful, it also commands a lot of respect - and, unfortunately, it also does come with a steep learning curve. Lean on the folks who have been working with it for years...everyone here is very generous with both their knowledge and moral support.

 

[Sandy and Black Kitty]

Hi there

It took me a very long time to wrap my mind first around all the basics and then all the nuances. Knowing that the foundation of the guidance I received here was 'safety first' allowed me to proceed with confidence, particularly as we navigated to and through the condition of IAA (extreme insulin resistance) which was uncharted territory back then.

It is indeed a steep learning curve, at the same time requiring a certain 'leap of faith'.
Like most of us here in Lantus Land, I took that leap of faith.
With no regrets

Hang in there - and hang in here!
It's the very best place a sugar kitty can be.