Dosing Question

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Smokey

Smokey

Member Since 2010
Hello LL!

I have read the Tight Regulation Protocol and understand what it says. However, it also seems to be for a kitty that clearly shows it's nadir's. I am having a difficult time determining if Smokey should have a dose increase according to his SS. Due to the fact that his highest readings are +6 and his lowest seem to be right before he eats (+12). His evening readings are always nice and his daytime readings scare me due to being so high. His clinical signs are: excessive water drinking, excessive hunger, no weight gain. I'm so scared that his readings are actually harming him.

This Thursday is going to be my, "Talk" with my vet to try to get him on board with this protocol however, I don't want to go in there sounding like a big dummy either! :shock:

I would like to propose an increase due to Smokey's clinical signs and I would like to bring my SS with me to explain why however, since Smokey seems to be all over the place...I actually just don't know what to say to support this new dose.

If I had clear nadirs at 5-6 hours post injection that were above 300, I could say, "Look, according to this protocol, Smokey is due an increase" but my nadir just doesn't seem to be clear. My pre-shot is always lower.

I would appreciate any feedback that you all may have!
I hope everyone had a safe weekend!
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I think what you're reacting to are bounces. When Smokey has had a lower number (e.g., 80 on 4/7, blues on 4/9 and 4/14), what you then see are numbers heading back up. Sometimes the numbers go way up, like the red pre-shot on 4/8 or they go up much more slowly like on 4/16. This response to lower numbers is normal. It's the way the liver reacts when your cat's system is acclimated to having spent time in higher ranges. It's a protective mechanism whereby the liver dumps a stored form of glucose, along with counterregulatory hormones into the bloodstream. It can take up to 72 hours for that bounce to clear. You saw the bounce clearing fairly quickly on 4/8, although it looked like Smokey may have bounced again from the blues.

What I would arm you for is your vet telling you that this is chronic Somogyi rebound. It's not. Somogyi is a controversial phenomenon at best. It was first documented in 1938 in a small sample of humans. Subsequent studies have failed to replicate the original study. Further, there has been no research documenting chronic Somogyi rebound in cats that are being given a long-acting insulin like Lantus.

Depending on what today's cycle looks like, you may be able to increase this evening.
 
adding a little bit to what sienne has said...

mid-cycle nadirs are *typical*, but not every kitty received that memo! some have early nadirs, some have late nadirs. kitties with late nadirs are fine. no problem! you can still follow the TR protocol with success. the data you're collecting will support shooting full doses on low preshot numbers.

we don't know why, but many of our lantus and levemir kitties show more "action" at night than in the AM cycle. smokey is very typical in that regard. :-D we also know that AM preshot numbers are *usually* the last numbers to come down. some attribute this to Dawn phenomenon.

at this point in smokey's treatment you won't necessarily see a true nadir every single cycle. when a specific dose shows us what it can do by lowering kitty's blood glucose level into a range that the kitty's body is not used to most kitties will bounce for up to 6 cycles (3 days). most kitty's bounces (eventually and over time) will clear faster and fade away resulting in the flat green cycles lantus and levemir are known for.

smokey has been on the 2u dose for 14 consecutive cycles with nadirs in the 100s. 14 consecutive cycles is more than enough time for us to see that 2u is not enough because ideally, we'd like him to reside in the 50 - 100 range overall. according to the TR protocol, increasing the dose to 2.25u is the next step... unless he surprises you today with some low numbers.

something to keep in mind when talking to your vet...
typically, vets do not see kitties in the 50 - 100 range in their office. even a non-diabetic kitty may have elevated glucose levels simply due to stress while visiting the vet. my own vet (who i consider a fantastic partner in managing alex's diabetes) raises his eyebrows when he looks at her spreadsheet. just thought it was worth mentioning because you may meet some resistance when talking about bringing smokey down into the normal blood glucose range.

in addition to the materials and information offered in the stickies, you could even bring along some of the spreadsheets to our OTJ kitties who have followed the TR protocol for examples. here's the link to the master list: http://spreadsheets.google.com/pub?key=0Atw2USzqQY6PcFoxc29OcE9XUkNCNVdLenVreF9kSFE&gid=1. and don't forget the protocol itself: http://felinediabetes.com/Roomp_Rand_2008 dosing_testing protocol.pdf!

hope this helps...
 
Thank you Sienne and Jill, that was very well explained and exactly the kind of information that I needed! I realy appreciate you taking time away on a Sunday to go into such detail!

When you say that Smokey's Nadir's have been in the 100's, your not referring to a specific time frame, your referring to the lowest he has been on any given day or time (regardless of how many hours have passed since his shot). Is this correct? Is this how I should determine his nadir going forward?
 
I have nothing to add but would like to say that I have a cat with a late nadir, Oliver and his lowest BG is usually just before his ps. My other cat has the usual mid cycle nadir.

As you gather and record more info from your testing, you will start to see patterns and know what to expect, and what seems 'off' for YOUR cat.

I take an updated ss for my vet on every visit; she loves to see how they have been doing since last visits.
 
I would love to see your kitties SS if you could post it! Thanks for the information!

Was Oliver's highest BG of the day at +6?
 
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