? Creamsicle-pmps 138, +3- 32

[Caren and Creamsickle]

I need help. Creamsicle seems to be very hard to manage. In the last 1-2 weeks he had dropped into hypo range numerous times. We are prepared, treat him immediately and his numbers go up but it seems his pm dose may be too high but not always. Some days when we test and he is in the 100 range we give a partial dose which has helped some times and sometimes not. I don't know if we are doing the right thing. I guess tomorrow we should reduce his dose to 1.25. Don't know if we are doing the right thing. Any input would be appreciated. Thanks in advance.

 

[Red & Rover (GA)]

bump

 

[Wendy&Neko]

A number in the 30's calls for an immediate 9.25 unit reduction. Congrats!

Keep testing every 1/2 hour to make sure he is coming up over 50.

 

[Caren and Creamsickle]

Yes I will. He just hit 50. I will give it more time just to be sure. Thanks.

 

[Bobbie And Bubba]

Wow, that was a low! Glad he came up for you. How did he act when he was that low.

Some days when we test and he is in the 100 range we give a partial dose which has helped some times and sometimes not

It is best to shoot the same dose for each cycle or the depot gets confused but, clearly 1.5 u is too much . Congrats on the reducie! New dose 1.25 ( think Wendy had a typo above with the 9.25)

When you get a chance can you add in your signature that you switched to a human meter? I know that it does also say it on the SS but good to have it in both places.

Creamie is looking good!

 

[Sienne and Gabby (GA)]

Let me make a couple of observations about things past.

• 5/25: Creamsickle dropped to 44 during the PM cycle at a 1.75u dose. You held the dose for 8 cycles (with the exception for one cycle when you shot a reduced dose.
  • You should have reduced the dose to 1.5u based on a drop below 50.
• 5/29: Creamsickle dropped to 33 on a dose of 1.75u. Clearly, this dose was too high.
  • You dropped the dose to 1.0u. This was probably too large of a dose reduction. Typically, dose adjustments are made in 0.25u amounts. If you were concerned about the drops into such low numbers, maybe reducing to 1.25u would have made sense. At the very least, the dose should have been reduced to 1.50u.
  • Numbers were OK at 1.0u, not great but not bad.
• 6/1: I'm guessing because you weren't seeing green, you increased the dose. The increase made sense but not by 0.5u. Again, with TR, you make dose adjustments in 0.25u increments.

I realize I'm commenting based on 20/20 hindsight. That can make me seem very wise. I'm also not home with you and Creamsickle.

It may help to always keep in mind that TR is, by it's very nature, an aggressive approach to dosing. There are certainly times when we increase or decrease the dose by more than 0.25u but there's nothing I see that currently suggests that Creamsickle is an exception to the guidelines in TR. At this point, I'd be hesitant to conclude that your kitty is "hard to manage." What I would encourage you to do is to stick with the guidelines in TR. If you're not sure what the next step is, please put a note in your subject line asking for help. I stopped by when I saw the 32 -- low numbers will get people's attention.

 

[Kris & Teasel]

Great advice!

 

[Caren and Creamsickle]

Let me make a couple of observations about things past.

• 5/25: Creamsickle dropped to 44 during the PM cycle at a 1.75u dose. You held the dose for 8 cycles (with the exception for one cycle when you shot a reduced dose.
  • You should have reduced the dose to 1.5u based on a drop below 50.
• 5/29: Creamsickle dropped to 33 on a dose of 1.75u. Clearly, this dose was too high.
  • You dropped the dose to 1.0u. This was probably too large of a dose reduction. Typically, dose adjustments are made in 0.25u amounts. If you were concerned about the drops into such low numbers, maybe reducing to 1.25u would have made sense. At the very least, the dose should have been reduced to 1.50u.
  • Numbers were OK at 1.0u, not great but not bad.
• 6/1: I'm guessing because you weren't seeing green, you increased the dose. The increase made sense but not by 0.5u. Again, with TR, you make dose adjustments in 0.25u increments.

I realize I'm commenting based on 20/20 hindsight. That can make me seem very wise. I'm also not home with you and Creamsickle.

It may help to always keep in mind that TR is, by it's very nature, an aggressive approach to dosing. There are certainly times when we increase or decrease the dose by more than 0.25u but there's nothing I see that currently suggests that Creamsickle is an exception to the guidelines in TR. At this point, I'd be hesitant to conclude that your kitty is "hard to manage." What I would encourage you to do is to stick with the guidelines in TR. If you're not sure what the next step is, please put a note in your subject line asking for help. I stopped by when I saw the 32 -- low numbers will get people's attention.

I appreciate all your input and great advice.
I think the issue lately is that in the evening Creamsicles numbers seem to drop low so giving him the full dose will make him drop too low so at those times when we reduced the dose we did so to try to prevent him getting below
50. This is the main issue for us at this point. How do we handle this? I thought according to the guidelines I could give a reduced dose.

When Creamsicle drops below 50 we don't see any real observable signs. He usually is sleeping at that time so but when it's time to test, he gets right up and seems fine.

 

[Sienne and Gabby (GA)]

With TR, you typically do not reduce the dose. To do so, means you're basing the dose reduction on the pre-shot number and with Lantus, regardless of the approach, dosing is based on the nadir. That said, if you think the pre-shot number is lower than where you're comfortable shooting, there are alternatives. However, you need to give yourself some time to get comfortable with shooting progressively lower numbers. If you look at Gabby's SS (or Marje's Gracie's SS), you'll see we would shoot any number above 50. It takes a bit of time and some nerves of steel to get comfortable with shooting low numbers.

You're also correct in that some cats are prone to experiencing lower numbers during the PM cycle. The problem with reducing the dose is that because you're using a depot-type of insulin, there's no guarantee that you'll see the effect of the dose reduction during the current cycle. The depot can have make up the difference. Also, every time you change a dose, with TR you need to wait 3 days/6 cycles before you can change the dose (dose reductions excepted). Any change in dose has an effect on the depot.

Gabby would also drop early in the cycle. I routinely tested a lot early in the cycle. I also front loaded her food. By that I mean that she was fed at pre-shot, +1, and +2. By spreading her meals into 3 installments, it helped to keep her numbers a bit "bumped up." You could try experimenting with a similar approach. If you see that numbers are dropping, you can add a bit more carbs to the mix, if necessary.

 

[Caren and Creamsickle]

With TR, you typically do not reduce the dose. To do so, means you're basing the dose reduction on the pre-shot number and with Lantus, regardless of the approach, dosing is based on the nadir. That said, if you think the pre-shot number is lower than where you're comfortable shooting, there are alternatives. However, you need to give yourself some time to get comfortable with shooting progressively lower numbers. If you look at Gabby's SS (or Marje's Gracie's SS), you'll see we would shoot any number above 50. It takes a bit of time and some nerves of steel to get comfortable with shooting low numbers.

You're also correct in that some cats are prone to experiencing lower numbers during the PM cycle. The problem with reducing the dose is that because you're using a depot-type of insulin, there's no guarantee that you'll see the effect of the dose reduction during the current cycle. The depot can have make up the difference. Also, every time you change a dose, with TR you need to wait 3 days/6 cycles before you can change the dose (dose reductions excepted). Any change in dose has an effect on the depot.

Gabby would also drop early in the cycle. I routinely tested a lot early in the cycle. I also front loaded her food. By that I mean that she was fed at pre-shot, +1, and +2. By spreading her meals into 3 installments, it helped to keep her numbers a bit "bumped up." You could try experimenting with a similar approach. If you see that numbers are dropping, you can add a bit more carbs to the mix, if necessary.

I guess the main confusion is that since it seems that he will drop in the evening and his pmps is low 200s or lower, we may have an issue with him dropping too low. So giving the full dose will be an issue. We have given the full dose and sit and wait but it can't be good that he drops that low. Do we just do a dose reduction by .25 and deal with low numbers until we can do another reduction?

 

[Sienne and Gabby (GA)]

I know this is going to sound counterintuitive but the magnitude of the drop is not always related to the amount of the dose. If your kitty started in the pinks and dropped into the blues on 1.0u of insulin, it doesn't mean that if the pre-shot is in the blues, there will be the same big drop with a lower pre-shot. The curve may simply flatten out. The ideal Lantus curve is flat.

Let me use an example. On 5/27, you shot 1.75u with an AMPS of 193. Creamsickle surfed in blue numbers right up to his PMPS of 139. Rather than shoot your usual dose, you gave a drastic dose reduction and then didn't test until +5 (BG = 129). There is a very good chance that the dose reduction had no effect whatsoever given the amount of carryover from the depot. You had a yellow AMPS the following day. The PM cycle on 5/28 was an active cycle with a big drop into the 30s. ​

Part of what makes interpreting your kitty's numbers difficult is that you haven't been taking reductions when they were needed. The drop into the 30s that I noted in the above paragraph is one of those times. Creamsickls's dose should have been no more than 1.5u but you were still shooting the old 1.75u dose. It's no surprise that the numbers tanked. Also, it's possible that the AM cycle on 5/29 was flat yellow. Some cats telegraph an active cycle with the preceding cycle being flat yellow. Shooting inconsistent doses also disrupts the depot and tends to result in wonky numbers. So, is it a matter of the changes in the PM doses that is making your cat's numbers challenging or is the dose too high?

I would also suggest that if you do give the full dose when numbers are lower, you may want to test like crazy early in the cycle. Last night was a good example. I would have coached you to get at least a +2 -- if not a +1 and a +2. The extra tests give you greater control and you could have intervened earlier with food. If you had intervened, chances are you might not have seen the big bounce this morning. You may want to take a look at Gabby's SS. She was an early nadir kitty and I used food aggressively to steer her numbers. I would shoot anything above 50.

 

[Caren and Creamsickle]

Thank you Sienne. It makes a lot of sense what you say and I will stick to the dose and test him early in the cycle. The problem is what would you do on a day that you can't be home after you shoot on a low number. That's what happened on the day when we gave 1 unit. I'm nervous doing that. It doesn't happen often because we basically focus on Creamsicle and stay home if we have to, but just in case.
Thanks again! I don't know what I would do without you and all of the other members who help me make sense of this crazy diabetes!

Caren

 

[Kris & Teasel]

Thank you Sienne. It makes a lot of sense what you say and I will stick to the dose and test him early in the cycle. The problem is what would you do on a day that you can't be home after you shoot on a low number. That's what happened on the day when we gave 1 unit. I'm nervous doing that. It doesn't happen often because we basically focus on Creamsicle and stay home if we have to, but just in case.
Thanks again! I don't know what I would do without you and all of the other members who help me make sense of this crazy diabetes!

Caren

Once you have more data under this new plan you'll likely have a better idea about his responses. That can give you peace of mind if you have to leave after a lower PS. If he's a good eater an automated feeder that dispenses snacks at +2 etc. might be very helpful.