Different TR protocol - what is your opinion or experience?

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Michele&Errol

Michele&Errol

Member Since 2013
The following is from another TR protocol (Dr Hodgkin's), and I was wondering about opinions on it, from those who have experience in all 3 or know anything about them?

"....II. Proper insulin

Protamine zinc insulin (PZI) is, by far, the most effective form of insulin available for use in the diabetic cat today. Beef and pork insulin molecules (beef is closer than pork) more closely resemble natural feline insulin and give the greatest response for the lowest dosages in the vast majority of feline diabetics. It can be dosed at 6-12 hour intervals and, because many canned or pouched cat foods are supportive of low blood glucose from diet, PZI allows good control of the diabetic cat, far superior to that from Caninsulin/Vetsulin, NPH/ Humulin insulin or the newer human products called Lantus (Glargine) or Levemir.

Although one small study has shown that Lantus (Glargine) can be used to create remission in new diabetics on low carb (wet only) cat foods, this study does not really prove that Lantus is superior to PZI as the method of use of the PZI in the study was not optimal and considering that brand new diabetics will readily go into remission regardless of the insulin used as long as low-carbohydrate wet foods are fed to these cats. In my experience with this human insulin, the effects of Lantus in the cat are far more unpredictable than that of PZI, making regulation and remission more difficult to achieve. Further, Lantus is a human insulin product and at least theoretically more antigenic (allergy producing) in the cat than the bovine-origin PZI insulins. Bovine insulin has a much closer amino acid structure to the cat’s own insulin than does human insulin, a likely explanation for its superior results in managing feline diabetics. ..."
 
Re: Different TR protocol - what is your opinion or experien

I have not seen any studies that show the bovine PZI insulin is better than Lantus or Levemir. When Dr Hodgkin's started her protocol, Lantus and Levemir did not exist or not yet proven in cats.
 
Re: Different TR protocol - what is your opinion or experien

I read the same thing two and a half years ago when Bob was on bovine PZI. But I did not follow the Hodgkin's protocol with Bob.

And Larry is right. The PZI that existed when she wrote that isn't even available today, and her protocol predates the Roomp/Rand TR protocol for Lantus and Levemir.

The small study she mentioned did show that Lantus worked better, but it only involved 24 cats, and it wasn't a Tight Regulation protocol. Lantus, PZI and I think the third was Humulin N. Eight cats got each. None if the N cats achieved remission. Three if the PZI cats did. All eight of the Lantus cats did.

And it did have its flaws.

The fundamental flaw is that the three insulin's work differently from each other. One "protocol" isn't going to work on all three types, and the methods used in that study were better suited for Lantus.

In today's world, the same issue exists. The TR protocol used here with Lantus is not suited for Prozinc. And the Hodgkin's TR protocol would not work well if you were using Lantus or Levemir.

She's sort of comparing apples to oranges.
 
Re: Different TR protocol - what is your opinion or experien

I couldn't agree more with Larry. At present, the American Animal Hospital Assn recommends both ProZinc and Lantus for the treatment of diabetic cats.

My concern is when people are extending the Hodgkins approach for PZI and instead using Lantus or Lev. In fact, this is supported on the website/message board that was originally developed by Dr. Hodgkins. While others who have been here longer than I can attest, cats have died utilizing this adaptation. The crux of the problem, at least as I see it, is that ProZinc/PZI is not a depot-type insulin. It is not wise to try to translate what may work admirably with a non-depot type of insulin to one which relies on a depot for its longer action, overlap between doses, etc. Lantus and Lev dosing are based on nadir; the dose is not adjusted based on the pre-shot number the way it is with ProZinc. Further, Hodgkins' followers eschew the use of high carb food to intervene if numbers are running low. Because Lantus and Lev are long-acting and rely on overlap, there is always the potential of a prolonged hypoglycemic event or a cat running in lower than ideal numbers without symptoms. At a personal level, I would prefer to use high carb to allow my cat to stay in numbers (i.e., above 50) that leave me with a comfortable margin of safety.

For what it's worth, I would research carefully. Dr. Hodgkins' patented her approach and she was a Technical Advisor to Hill's Pet Nutrition. From what I can tell, she is primarily a clinician in a private practice and does not do research -- or my search engines aren't picking up any studies she's authored regarding her protocol. She is a strong advocate for appropriate feline nutrition. In comparison, Jacqui Rand, DVM, one of the co-authors of the Lantus/Lev TR Protocol, published the fundamentals of this protocol in a peer-reviewed veterinary journal and continues to do research at a major university veterinary medical center.
 
Re: Different TR protocol - what is your opinion or experien

Oh, I forgot to mention why I didn't choose to try the Hodgkin's protocol even though I used PZI on Bob.

I thought it was too intensive, much more than the one used here with Lantus. I wasn't ready to chase my cat around the house with sharp objects and give insulin every time his BG rose above some line in the sand regardless of how many hours had gone by since his last shot. Some cats on the H protocol get three and even four shots in a 24 hour period. That would have been fine if I worked and slept in a lab, but didn't really work with my schedule.:-)
And also the reasons Sienne mentioned like withholding carbs on low numbers. Way too risky and dangerous for my taste. I've read claims that a cat can't hypo following that protocol. Frankly, I don't buy it.

I was lucky. Bob went OTJ with compounded bovine PZI in ten weeks without any sort of TR protocol.
 
Re: Different TR protocol - what is your opinion or experien

There was a Think Tank thread about this a while ago that is worth a read-through when you have some time.

I agree with pretty much everything everyone has already said. I joined the Diabetic Cat Care (and the YDC) forum around the same time as I joined here. I got way more responses to my questions here with actual documented references to their answers, so I stuck around here instead. Also, the awesome spreadsheet is more along my lines of data collecting. ;-)

Then, back when Mikey hit around a year since diagnosis, I rejoined the Cat Care forum to see if there was anything else I might be doing to help him along since it looks like he might be a "lifer." He is peculiar since he was diagnosed at 6 months old and has never gone into remission nor does he have any co-morbid issues and I know that many things that work for other cats just don't work for him (and vis versa). They tried to help me on the forum, however no one was ever able to properly explain their sliding dosage scale that they use with Lantus to me. Basically, they're using Lantus as an in-and-out insulin, which it's NOT, and they don't really take into account the Lantus depot or the overlap of doses (because Lantus lasts longer than 12 hours).

After the initial comments of restating their protocol and what I needed to change, I never got any follow-up comments on my post over there to answer my questions as to how it's supposed to work on a sliding scale and/or how I'm supposed to dose Mikey when he spends a majority of time under 150 already.

For me, I'm a research junkie and I don't blindly follow anything. If there is no documentation to back something up, then I'll either be a pioneer and create the documentation or I wait for substantial proof and let someone else be the guinea pig. And that's what I basically took away from the experience. They didn't have any external references or links to support what they were doing so I wasn't going to jeopardize Mikey's life when he's doing as well as can be expected on a thoroughly documented protocol that is a lot safer and less time-intensive.
 
Re: Different TR protocol - what is your opinion or experien

One thing I should mention that I did take away from them is that I'll sometimes give a shot early if his numbers warrant it. Of course, his next shot will also have to be given early otherwise he'll run higher numbers the next cycle and this should not be attempted if you don't yet know how your cat might react (because an early dose is like a dose increase with Lantus). It works for us, especially if I'm needing to move his shot time around with minimal disruption to my schedule and minimal disruption to his BGs.
 
Re: Different TR protocol - what is your opinion or experien

Thank you for explaining, everyone. It can be very confusing when you know very little about a subject to see varying protocols. When Errol was diagnosed a month ago, this was the first lifeline I found, and I am thankful every single day for it. I remember being totally overwhelmed, panic stricken and terrified that I would make a mistake. I've found everyone here extremely helpful, knowledgeable and able to back up their information with proof which is very important. The other thing is, it's a teaching forum, so not only are you guided every step of the way, you also get to learn from other's experiences. Honestly do not know what I would have done if I hadn't found this board.
 
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