Discussion: Pogo Stick Cat - How to Dose/Stop Bounce

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Not sure why you are asking the question based on Max's SS. He looks very good since 7-26 or so. As you have been reducing the dose by .25u for every time he is under 50 he has responded well.

As for the general question on how to handle "bounces", I found that since they are caused by either too much insulin or by a low number the cat was not used to, looking over the SS is key. You can usually see a pattern - like a first green in a while to show it was the lower than usual number (but not a "too low" number), or swings from 100s to 300s repeated to indicate it is probably too much insulin. The first thing I look at in any SS is patterns that emerge over several days or weeks.

For the former (lowish number) I would hold the dose and let the BGs settle out. For the later (swings) I would reduce the dose a bit (about 10-20%) and wait for the swings to stop then reassess if an increase is needed. If I thought an increase was needed, I would do it in smaller increments and/or hold for longer before increasing again.

We have many cats here on lev, Jeddie being one of them, that need/needed much longer settle periods - up to 14 days. Also, several cats that have switched from lantus to lev in the past year or so have stopped bouncing even on equivalent doses. There seems to be a greater possibility of bouncing with lantus for some reason.

Also, the TR protocol, IMO, raises the chance for 'bouncing' because of the aggressive dosing. Again, IMO, it seems to force the BGs down by increasing beyond the cat's ability to respond to too much insulin with their built in defense mechanism of releasing the hormones glucagon, epinephrine and cortisol and stored glucose from the liver, which is there as a safety net. After all, that is what "bouncing" really is - rebound from actual or perceived hypoglycemia. To me, the really negative effect of creating a stage for chronic rebound is that those hormones cause insulin resistance while they are circulating. That is one of the reasons, maybe the main one, for the length of time needed to "clear a bounce".
 
Great explanation, Sheila. I also found that I could not stabilize Gandalf on the TR dosing structure of .25U increases and decreases, he need much more fine tuning to keep those bounces from happening. So that also is a way to stop the bounces, lower the amount of increase in insulin, especially if dose is less than 1.5U.
 
These are awesome answers! I'm asking because I was very frustrated, as you all know, and worried, and fearful, etc. when Max was bouncing. I'd like to see everyone chime in with their opinions on this issue in case it will help the people who are going through this problem right now with their cats.

Sheila in the Lev forum says:
. . . swings from 100s to 300s repeated[ly] . . . indicate it is probably too much insulin
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. That was a major question for me, and I've seen others ask it repeatedly. How do you know whether you are overdosing or you need to raise the dose? Is there any way to guesstimate?

If you are afraid you are overdosing then you are afraid to leave your cat alone, and you are worried that the high spikes are causing a lot damage. Shelia says:
. . . the really negative effect of creating a stage for chronic rebound is that those hormones cause insulin resistance while they are circulating. That is one of the reasons, maybe the main one, for the length of time needed to "clear a bounce".
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Additionally, I read that it may be that high spikes are more damaging to the organs that a high BG that is more consistently high. I have no way to evaluate that statement, but it made me rather upset, and then, when I saw Max bounce over and over, I got more and more upset.

If you are afraid you are not giving enough insulin, you are trying to figure out when to increase, and it's very difficult because you don't want to increase based on a liver panic response number. I felt, most of the time, that my cat was "always bouncing," and might never stop. You might do what I did -- decrease and decrease in an attempt to find out in the safest way possible. If your cat actually needed more insulin as mine did, you waste time with your cat in high numbers. Better than doing nothing, but still unfortunate.

(Of course, with my cat, he had an infection. ((I'm wondering if that is another reason he bounced or THE reason.)) We are all trying to treat this expensive disease without spending too much money on the vet, who may not be very supportive of our interest in being intimately involved in the treatment. So, we may try to find the dose before we get crazy with vet bills, and if that doesn't seem to be possible, then we go in desperation to the vet. My vet didn't want to clean my cat's teeth, and didn't think about doing it with only a sedative until I pushed him to be creative. He didn't want to risk giving anesthesia to a 16 year old with CRF and uncontrolled diabetes, and I can't blame him. The fact that he was really afraid to clean the cat's teeth made me afraid to let him do it. Finally, he said, "Let's try a sedative and see how it goes." Excellent result, too.)

Another problem I had was being afraid to test Max too much, and I'm sure that is very common. It's really hard to do something to your cat over and over that he doesn't understand, doesn't like, and that you feel guilty about unless you understand that it is absolutely necessary for his overall well being. Without those numbers, I didn't have the data for anyone to help me, but I didn't realize that without them, I would have very long road indeed.

Vicky (also in the Lev forum) and Shelia agree that maybe an increase of 0.25 is too much at once for a cat that bounces a lot -- a really important point, I think, and I would not have thought of that on my own.

Libby (and Lucy) in Lantus TR wrote:
You don't really want to look at your spreadsheet one cycle at a time. Look at a 3-4 day period. What was the lowest number during that period? In general, that is the number you want to base your decisions on . . . If you are getting nadirs in a good green range and you're happy with them, then wait. If you are getting nadirs in green and you wait a while and the bouncing isn't getting better, then you can consider increasing the dose and feeding the curve to keep the nadirs from getting too low.
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Thanks for the input you three!

Anyone want to expand on what "feeding the curve" means for those who aren't familiar with that concept? Is it the same as "chasing the number?"
 
"Feeding the curve" to me is a concept of giving food to offset a low that is developing. A good plan for that occasional early low or a 50 you catch, but not something you want to rely on as a way to always counteract a number below, say 60-65, when reducing the dose a hair might prevent a further drop as well. I do not, as a rule, like doses that daily drop the cat into the 40s. Sure, the 40s are number we sometimes see in non-FD cats, but with a cat on insulin it leaves too little wiggle room . I never aimed for lower than 80. I saw a post by an old timer that said she would not aim for lower than 100 given that there can be a chance of +/- 20 point in even a tightly regulated cat.

Why dose so high that you have to test a million times to catch the falling number as it dips below 50 and feed to keep from going into the 30s? Why not dial back the dose a bit until the nadir is comfortable at or above 80? To me that also reduces the chance of rebound.

"Chasing the number"s I always thought was increasing and decreasing dose based on PS's, which can have a tendency to keep the numbers swinging and even intensify the swings. I haven't heard that term in the past couple of years with the longer acting insulins that work best with steady doses, but maybe it is used more on other forums.
 
Here is a great critique from Jill (and Alex in Lantus TR) of the spreadsheet for my cat, Max. I posted below in the next post about Max's weight, and how I went about dealing with the possibility he was over dose from the beginning of the treatment.

Re: Discussion: Pogo Stick Cat - How to Dose/Stop Bounce

Postby Jill & Alex » Wed Aug 08, 2012 11:39 am
good questions! however, after studying max's spreadsheet at great length, i don't think we can come to general conclusions for the masses based on the data presented because of certain circumstances:

the TR protocol bases an initial starting dose for a newly diagnosed kitty based on ideal weight. that would mean max's ideal weight is 17 pounds. 17 pounds cat is pretty big for a cat at their ideal weight! "if" 17 pounds is more than max's ideal weight, the initial starting dose of 2u bid was set too high.

there's no data for the first month at 2u bid. we have absolutely no idea how low 2u bid was taking max.

the next 3 weeks show the probability of chronic bouncing due to the strong possibility of being over dose.

then roughly the next couple of months show dose adjustments being made (both increases and decreases) without sufficient data.

the next month again shows the strong possibility of chronic bouncing due to the strong possibility of being over dose.

imo, it took a dose of 2.75u to break through the glucose toxicity which had set in.
edited to add: it's probable glucose toxicity had set in early on... possibly as early as the first month max was on insulin.

2.75u appears to be the break through dose which then caused a series of rapid reductions.... well that combined with the positive effects of having a dental done.

imho, unless max is lean and fit at 17 pounds, max was over dose from the get go... setting the stage for the "bouncy kitty". insufficient data and dose adjustments based on preshot numbers or lack of knowing how low certain doses were taking max compounded the problem.

when following the tight regulation protocol, the initial starting dose is based on kitty's ideal weight (the exception being when kitty is underweight). doses are systematically and methodically adjusted in small increments of 0.25 unit and dose adjustments are made based on nadir with only some consideration given to preshot numbers. unfortunately, this does not prevent kitties from bouncing. however, we ignore the bounces and forge onward and upward in an effort to get kitty into normal numbers overall as quickly as safely possible... before glucose toxicity has a chance to set in.

when kitties arrive in the TR forum without having gone up and down the dosing scale as described in the TR protocol and there's a strong possibility of kitty being over dose, we *usually* find it necessary to increase the dose (when a caregiver is testing faithfully) in order to cause a break through... which is exactly what was suggested with max. increasing did indeed cause the desired outcome and the expected rapid reductions which followed. we do this rather than suggesting reductions because we've found more often than not... given the same circumstances, suggesting reductions only leads to kitty spending unnecessary and prolonged time in hypERglycemia... setting the stage for other complications to set in. furthermore, anecdotal evidence has shown us that the caregiver almost always ends taking the dose back up.... often surpassing the dose kitty was at weeks or even months ago.

having said that, i do believe there is room for smaller dose adjustments than 0.25u when trying to achieve regulation. the knowledge comes from "knowing thy cat"... a method of "fine tuning" dose adjustments based on the individual cat. it's a method i've used and continue to use successfully with alex.

just my thoughts...

Jill & Alex
DX: 07/05/2006 with DKA
PROFILE ~ 2006 LANTUS and 2009, 2010, 2011, & 2012 LEVEMIR DATA
LANTUS & LEVEMIR: WHAT'S THE DIFFERENCE? ~ LANTUS & LEVEMIR: MORE INFO
FDMB member since 2006
 
Post by max&emmasmommie » Wed Aug 08, 2012 1:27 pm in Lantus TR:

Jill, Thank you for looking at the spreadsheet, and giving it a critique. That is VERY helpful. Maybe someone reading this will not have to go through the frustration and anxiety I did.

Of course, I have no idea how the vet determined the dose. Obviously not based on Max's weight or ideal weight. Max was usually around 11 pounds most of his life. I remember buying flea medication and not wanting to use the type for cats over 10 lbs. (I didn't, and it worked just as well.)

He got up to 14 pounds in 2010. Then, he started losing weight for no apparent reason. I did nothing to facilitate the weight loss, and I guess we noticed he ate more, but we thought he was bored. When he got back to around 10 or 11 pounds, we were pleased, but he kept losing. This was all before his diagnosis of CRF in Sept of 2011.

At the time Max was diagnosed with CRF he had lost a significant amount lost weight. He was less than 10 pounds at that point, and at one point, I think it was after he was diagnosed with FD, he was down to less than 9 pounds. The vet prescribed 2u bid. I gave that for about 24 days or so, and then the vet raised it to 3u bid. I gave that dose one time and went back to 2u after reading this board. Then, we had the near hypo incident on 3/19. I started dropping the dose slowly in the hopes that if it was too high, I would see good results. I suppose the glucose toxicity was firmly rooted by then. So, I raised it slowly.

I'm glad he's doing so much better, but, of course, I wish the vet had been responsible at the beginning.
 
Interesting for sure. I'm really glad I changed that headline and got more responses!

Here's a newbie's (perhaps naive) idea of what "chasing the numbers" might mean: When a pre-shot is too low, the bean would wait until the cat had not eaten for 2 hours and then find two 2 (or 3) consecutive tests that showed a rising number. Whenever that process was complete -- +0.5, +1, +2 . . . then the bean would give a reduced dose and change the shot time to 12 hours in the future. (Maybe there would be a limit to the wait time, and the bean would skip the shot altogether and stay on the previous schedule). Sound crazy? Maybe, but what if it worked? I'm not suggesting anyone do this, but I'm hoping that if that is what anyone means by this phrase "chasing the numbers," we will hear from him/her.

I have found that more often than not, no two people mean exactly the same thing when they use a conceptual phrase such as this. Most people don't have time to ask for explanations, etc., but (can you tell) I'm an intensely curious person.
 
Jill (and Alex) in Lantus TR wrote:

sheila's understanding of "chasing the numbers" is the same as mine. :mrgreen:

your interpretation of "chasing the numbers" is similar, but not quite the same as what was commonly done back when alex was on insulin the first time. the only exception was we would go ahead and feed while stalling (gasp!) and wait for a "shoot-able" number... usually closer to 180 or 200. see her 2006 (pre-TR) tab on her ss. in some cases, we ended up with shot times that would travel 'round the clock. did it work with newly diagnosed kitties? yep. in many cases it did. although, i have to say... it wasn't until i started lowering my no shoot number that i began to see much better results. it's when i began to see the merit in the TR protocol . . ..
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Thank you, Jill. That must have been a wild ride trying to change the shot time forward over and over again.
 
Libby (and Lucky in TR) wrote:
There is a pretty definitive answer to how to dose to prevent bounces. You can simply reduce the dose enough that the cat doesn’t go low enough to bounce! There are down sides, though. The main down side is that usually that means they will stay flat in yellow or pink. Notice that most cats who either aren’t getting insulin, or aren’t yet up to their good dose, don’t bounce. ;-) They are high and flat because they are hanging out in numbers to which they have become accustomed. Your cat was probably diabetic for a while before you noticed, and his/her body probably became used to hanging out in yellow and pink before you started insulin. However, renal threshold in most cats is thought to be in the 230 range. The more time spent above that, the more potential for organ damage to occur over time.

To be clear, those who suggest lowering the dose to prevent bouncing are usually not suggesting that you leave them in high numbers forever. The idea is that once the cat flattens out and gets used to yellow, you may eventually be able to increase the dose to bring them into flat blue. Some cats will even go OTJ that way. On the other hand, some cats will need increasing amounts of insulin just to maintain the same numbers, if glucose toxicity takes hold.

Those of us following the Tight Regulation protocol tend to think “but I don’t WANT my cat to get used to yellow. I want her to get used to healthier blue or green!” The goal of Tight Regulation is to get the cat into a “healing” range as quickly as is safely possible. That means pushing their numbers down to below renal threshold, and then into “normal” numbers (under about 120). Doing that means bouncing is part of the process. It’s a GOOD thing if it means you are facilitating healing! If you look at the spreadsheets of cats that went OTJ, you’ll notice that in almost every case, once they got to a point where they were spending almost 100% of their time under 120, they started healing (and earning dose reductions) very quickly. They all spent some time bouncing, whether it was 2 days or 2 years. I know it's frustrating when it seems like the bounces never stop. Lucy bounced until right before she went OTJ. It was fine, though, because I understood why it was happening and that it was normal. Back in the day, we called it "Liver Training School" and we would joke about when our cat would finally graduate, or whether they would have to repeat a grade in Liver Training School.

It is important to point out that if we follow the protocol carefully, we are not pushing the cat into unsafe territory. That includes adhering to the prerequisites mentioned in the protocol sticky, and it means increasing the doses methodically while relying on good data, feeding an appropriate diet, and taking reductions when they are called for. Some people will choose to push the envelope by either being more aggressive than protocol, or by making decisions without enough data. Those are individual decisions and should only be made by experienced caregivers who are fully aware of the pros and cons of their approach. There are plenty of good reasons why folks will choose to stray from the protocol once they know their cat, I did with both of my cats, but those need to be informed decisions based on data.

There are pros and cons to any approach, and each caregiver needs to decide what his/her goals are. Then evaluate those goals against your specific situation, your cat’s needs, your own scheduling limitations, your ability and willingness to monitor, etc. Then communicate your goals so those who are helping you will understand what you are trying to accomplish.

My first vet said that while avoiding kidney damage was important in people, it didn’t matter for cats because they don’t live long enough for that damage to become significant, and besides, old cats have kidney issues anyway. Maybe she really believed that, and maybe it’s even true, but to me that wasn’t what I wanted to aim for! And she is no longer my vet.
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Libby (and Lucy in TR) wrote:
There is a pretty definitive answer to how to dose to prevent bounces. You can simply reduce the dose enough that the cat doesn’t go low enough to bounce! There are down sides, though. The main down side is that usually that means they will stay flat in yellow or pink.
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Thank you, Libby.

If you drop the dose down, you have to check religiously for ketones, right?

I was afraid to drop the dose down to 1.0u because Max has CRF and is 16 years old. I was worried that with compromised kidneys any toxins that built up in the blood would be an even bigger problem for him than for a cat with normal kidneys. I was terrified of ketoacidosis, and could not in any way, shape, or form think of going through that or spending the $4k it would take to try to save him. I hoped that I could inch the dose down without as great a risk of ketones. I have no way of knowing if inching the dose down made a difference or not. However, he was in higher numbers longer thus risking ketones. And that whole time he had an infection in his teeth -- a compounding risk factor for ketones. I had to take the dose back up, but he didn't have ketones. That doesn't tell us anything for the greater good except -- try to get your cat checked for an infection before you decide whether to drop the dose down or take it up.
 
Pip (and Rupert in TR) wrote:
I do think his bounces are beginning to get smaller and smaller
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When the bounces start to get smaller and clear faster what does that mean?

Is a cat like Rupert getting closer to his dose? (Rupert just went down to 2.0u this morning. He got a dose reduction indicator on 6/8 during the daytime cycle, and Pip waited until the bounce cleared to take the reduction.)

I'm wondering if when you see a cat bouncing smaller bounces and clearing them faster you would think he's getting closer to his dose regardless of whether he is earning dose reductions or requiring dose increases? Does it matter or is it only dose increases that reduce bouncing? It would seem that the elimination of bouncing should start to occur even if the dose is going in the downward direction. This would seem to be likely considering the fact that a dose decrease would lower the risk of bouncing caused by very low lows triggering the liver to release an inordinate amount of glucose to (over)compensate.
 
Libby (and Lucy in TR) wrote:

max&emmasmommie wrote:If you drop the dose down, you have to check religiously for ketones, right?
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Right. So the question becomes, "is it more important to me to prevent bouncing, or to help my cat get healthier?"

My opinions, based on my 5 years here and studying hundreds of spreadsheets, follow. Your opinions might be different.

Lowering dose to prevent bouncing:
Pros - if you come in with a cat that has been diabetic for just a few weeks and is already on a high dose, and the dose was reached by increasing in 1 unit increments based on vet curves while the cat was eating dry food, then reducing the dose and starting over often makes sense.
Cons - in any other case, cat will probably stay in higher/possibly organ-damaging numbers longer. Cat may be prone to ketones. Cat may be more prone to urinary infections due to glucose in urine. Cat may develop glucose toxicity, resulting in the need for an even higher dose of insulin to maintain the same result. Takes more time to get to a good dose, maybe reducing the chance of remission. Usually the cat will end up needing dose increases anyway, usually up to at least the dose they were at before, if not higher.

Maintaining or increasing the dose according to protocol, ignoring the bounces:
Pros - cat will probably reach a good working dose sooner. Less frustration for caregiver because they know they are approaching dosing in a logical manner that works for a large majority of cats. Cat will probably reach healing numbers sooner, resulting in an increased chance of remission. If cat is one that does not respond well to the standard protocol, then in the process caregiver will have gathered valuable data that will help in determining an approach that will work. (note - I'm not referring to cats that have not responded after a month or two. Give it plenty of time before deciding your cat is different! We do see some cats that go OTJ in 1-2 months, but even with tight regulation that is the exception rather than the rule).
Cons - cat will most likely hit a breakthrough, requiring fast dose reductions. This is exhausting! But as one of our wise ones used to say, the path to OTJ is made up of a series of dose reductions. Eventually one of the reductions might be the reduction to a dose of 0.00 units.

If somebody asks me "should I lower the dose?" I will consider every bit of information I have access to (spreadsheet, profile, diet, history). Almost every single time, my answer will be "no, I do not think that is a good idea, but it is your decision." Almost every single time, the cat ends up going back up in dose to where they used to be or higher. The exception is if a cat is over dose to begin with, like in the example of a new diabetic on a high dose. In most other cases, even cases like yours in which Max probably has been over dose, we usually see that decreasing does not work because glucose toxicity has had a chance to set in. The cat usually still has to go up in dose until they hit a breakthrough, THEN go down the dosing scale as reductions are earned.

Libby and Lucy

Lucy: dx 9/27/07 with DKA, hepatic lipidosis, and renal failure
OTJ on 2/22/09 (17 months on insulin!)
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