Frustrated - Thinking about lowering dose

[Ele & Blackie (GA)]

After yesterday's good numbers, Blackie zoomed right back to the 300's. Talk about zooming:
pmps 179 2.2 units
+2 307
+9 290
amps 305 2.2 units
+3 361

I looked back at the spreadsheet and the numbers were similar (300's & even 400's) at 2.4 and 2.0. When you take out the infection times on the spreadsheet, his numbers were more consistently better at 1.6 - 1.8 and at .8 last Fall.

I'm thinking that if we're going to have high numbers, I might as well lower the dose and see what happens. It really can't be much worse than what I'm seeing now. On the other hand, I could switch him to Lantus and have more weeks of bad numbers before you can see progress. Sorry, I am very frustrated. :sad: I don't like Blackie being in the 300's with his kidney issues. So, I'm thinking about lowering to 1.8. That would be a 20% decrease in dose. What do you think - is that too much or ca I decrease to 1.6?

Thanks for sticking with me all this time. I thought by now we would have a good dose and good numbers.

 

[Joanna & Bix (GA)]

Gosh Ele, I don't envy you, it is overwhelming when the #s all over the place. On the one hand yesterday you got a 75% drop on 2.2u, which to me is a signal to reduce the dose a hair. On the other hand, you then got a pretty sharp rise back to +2 (80ish to 180ish in just a couple hours) rather than the nice long hang he sometimes gets, which suggests that you won't get the same response the next cycle (and yep, you didn't). Which suggests a dose increase for that cycle.

Here are the choices I see:

1) Try lowering the dose like you said and take a really systematic approach. Go back to the lowest dose that you feel 100% sure is not too much, and then raise in small increments every 3rd day or so. This is the approach that finally worked for Bix - probably mostly because it worked for *me* and took a lot of the decision making out of it. It was hard for me to stick out the higher #s for a few days, but it paid off big-time in our case.

2) Take an alternate PZI approach, and decide on guidelines that work for you, and commit to that approach for x amount of time and see if it will work. For instance maybe try to work out a definitive sliding scale, try shooting early, try shooting based on the rate of rise, etc., whatever makes sense to you, but write down your plan and really dedicate yourself (not like you aren't already!!!) to making it work if possible. So for instance decide that anytime you see a 150 past +8 you will check for a rising # and then shoot if you can. Frankly, I probably wouldn't even bother with this approach - I think it's too stressful, he's too variable, and you've put enough effort already into making sense of it and this would probably have you beating your head against the wall (I'm guessing your walls may already be dented a bit! :lol: ), but just mentioning it for thoroughness.

3) Lantus (or Levemir? I've heard that's better for kitties who have been on insulin over a year, but I have no idea why - also I don't know if Lev takes as long to build up the shed as Lantus seems to?).

4) Decide to lower your standards and not worry about it much - his quality of life seems good even with the higher #s, right? And you already know he has other health problems, which could be contributing to his BG wonkiness. So just focus on him feeling good, test a lot less, pick a dose and run with it for a while, testing PSs & occasional nadirs/mid-cycle #s to be sure he isn't too low, and then reevaluate the dose maybe once a week or two (afterall, this is what most vets recommend, right?), and take the pressure off yourself. Although the laid-back approach isn't generally advocated here, I'm a firm believer that there is nothing wrong with that. I'd do it myself if I could just chill out a little, lol.

If it were me, I would probably try option #1 if I weren't totally burned out by now with all you've already been trying for weeks now. If I were burned out, I'd probably switch to Levemir (or Lantus, if someone were able to convince me that it is just as good for long-timers, and has no longer shed building time than Lev). And if I switched, I would consider using R (?) in the beginning if the #s were running high.

And I can't honestly say I wouldn't take approach #4. Quality of life for both of you (and the rest of the household) are really what is important. Seems like you've been tearing your hair over his #s for ages now, and with all your other stresses.... and then it isn't working anyhow. Gosh I'm a downer. :lol:

My only hesitations in saying just switch to L or L are that 1) he was nicely regulated on PZI for a while, so in theory it seems like you could get back to that point someday, and 2) the possibility of high #s for weeks til the shed is full. If it weren't for those 2 things (and I'm not sure either of them is a compelling argument at this point), I would say "switch insulins, & don't look back!".

Well anyhow, hope some of that helps. I seem to be writing a lot of books lately, sorry about that.

[ETA: I left out choice 5) figure you are actually closer than you realize, don't get discouraged by a couple cycles that aren't great, and just fine tune the dose a little more. I'm not sure I could face this choice in your shoes, seems like you've struggled long enough, but then on the otherhand, sometimes just having faith and sticking it out a little longer on the plan you are on can work wonders. Maybe shooting 2.3u on the faster rise yesterday would have been perfect, and maybe just little adjustments like that are all that you need?

More questions than answers here I realize. :roll: ]

 

[Terri and Lucy]

[ETA: I left out choice 5), which is figure you are actually closer than you realize, don't get discouraged by a couple cycles that aren't great, and just fine tune the dose a little more. I don't think I could face this choice in your shoes, seems like you've struggled long enough, but then on the othertimes, sometimes just having faith and sticking it out a little longer on the plan you are on can work wonders. Maybe shooting 2.3u on the faster rise yesterday would have been perfect, and maybe just little adjustments like that would work?]

This is the only one of the options I would select. One bad day doesn't warrant a change in approach from one that has been generally successful. You have to train his liver to stop panicking which means that you can't react when you see a couple of bad days.

I would raise the dose to 2.3 and keep shooting that dose for 3-4 days, maybe longer, unless he went too low. Take charge--tell that liver that it can't be the boss of you!

 

[Ele & Blackie (GA)]

I think Blackie's liver is protesting too much insulin and that's why we can't get consistent good numbers. I went back to the spreadsheet and here is what I saw:
*About 6 months ago he had great numbers (100's preshots, 70-90 nadirs) for almost 2 months at doses from .3 to 1.0 units. UTI blew up the bg's for the first time since testing.
*About 3 1/2 months ago he had great numbers (100's preshots, 70-90 nadirs) for 3 weeks at doses from .4 to 1.0 units. Then he had a UTI & we had a petsittter for 10 days that blew things up.
*About 1 1/2 months ago he had slightly better numbers than now for about 2 weeks at doses of 1.4 to 1.6. Then he got another UTI that increased bg's.
*Except for a couple of days since then, the doses haven't been below 2 units and with a few exceptions his numbers are in the 200 - 400's.

I am ready to try a lower dose. But how low can I go? Can go right from 2.2 to .8 or 1? Or should I go to 1.8 and work our way down?

 

[Sarah and Buzz]

Ele, I am so sorry you are going through this. I know it's really hard to watch high numbers, especially when you are doing all you can to prevent them. Blackie is such a mystery, and I really admire your perseverance and your ability to handle things without losing your mind (unless you've lost it already and are just really good at hiding it :lol: ). (((Ele))) (((Blackie))) (((Robert)))

I have to agree with Terri on the "don't give in to the panicky liver" thing. Believe me, I know it's hard not to give in and shoot based on the numbers, especially when they are really high. I have been scared to death for Buzz and her organs these last few weeks, and really really close to just throwing in the towel on Lantus. Although switching insulins may indeed be in your future, I would hate to see you give up on PZI on this note too. Maybe set a time limit for how long you will give it to see some improvement (set the limit and then tack on another week; sometimes these things take longer than you think possible) with a very set strategy. Sometimes just knowing there is an end in sight can be enough to give you the strength to stay the course.

Whatever you decide to do, we all support you and know that you are doing your absolute best for Blackie. Don't forget to love and cuddle him and enjoy your time with him; I know you know that, but again, sometimes it's easy to forget and get caught up in all the numbers drama and lose sight of the reason you're doing all this: to have more precious years with the boy you love. Let him know how wonderful he is and how much you appreciate him being so patient and loving.

 

[Terri and Lucy]

I am ready to try a lower dose. But how low can I go? Can go right from 2.2 to .8 or 1? Or should I go to 1.8 and work our way down?

You can go as low as you want. Yes, you can drop from 2.2 to .8 or 1.0.

I understand your frustration that he needs more insulin now than he did shortly after his diagnosis. But from what I've read, with Type II diabetes in humans they are still producing their own insulin. The problem is that their bodies have stopped being able to use what they produce. If that is true (and I think it is) for cats like Blackie, then the insulin shots initially serve as "boosters" rather than replacement for a non-functioning pancreas. It makes sense to me that over time, if regulation and/or remission is not achieved, those cats will need incrementally more insulin. That is why I have always recommended a more aggressive approach with newbies.

You aren't the first to be in this position. This was basically the source of frustration that initiated the wholesale migration from PZI to Lantus a year or two ago. Most of them went through the same 'starting over' approach that you are contemplating. Only one of them pushed the PZI to an incrementally and systematically higher dose like they do on Lantus. From what I have seen, she's still shooting more Lantus than she did PZI and still getting about the same response.

 

[Joanna & Bix (GA)]

I am ready to try a lower dose. But how low can I go? Can go right from 2.2 to .8 or 1? Or should I go to 1.8 and work our way down?

I'm not sure there are any real rules on it. I mean if you wanted to, you could stop insulin for 3 days and see where you land. I would not recommend that personally, but I don't think there's any "risk" in how you lower the dose, beyond high #s, ketones, etc. As far as I know, the rules like that are more for dose increases, so you don't accidentally hypo them.

Here is what the Vetsulin (different insulin, but similar rebound issues) website says:

Somogyi Rebound....

Solution

Decrease dose by 50% or return to starting dose of 1 IU BID, whichever is lower.

source: http://www.vetsulin.com/vet/Cats_Monito ... mogyi.aspx

Personally if I wanted to test rebound, I would return to the last known dose that seemed to work well, and work my way back up if needed. I don't know whether that is the ideal approach or not, it's just what makes sense to me. You can always raise it back up, but if you don't lower it far enough, you're still left wondering whether or not you're triggering rebound.

And I'm not pushing at all that I think you *should* do this, just offering what I know since it sounds like you are ready to go this route. Even if the #s don't improve, you will learn from it. I did things like that with Bix that others at times disagreed with, but ultimately I had to prove it to myself - sometimes I was right in what I suspected, and often I was wrong, but I always (I hope!) learned from it!

And hopefully if you do try it, it will go well!

One question I have I guess is that there are different rebounds: rebounds from the dose being too high, and rebounds from the liver not being used to lower #s. So I guess for me the question rests on that (and I'm not sure if my distinction in approaches is valid or not). If it's liver training, then I don't know there's any choice other than shooting through the rebound, the #s just *aren't* going to come down on their own and you have to force them to stay down until the liver chills out. But if it's from the dose being too high, then in theory lowering the dose should result in better #s, because the liver will chill out once it realizes there is less exogenous insulin to fight against.

I think you are suspecting his dose is too high, right, rather than it's liver training you are facing? I'm not sure if that distinction makes any difference in the theory of shooting through the rebound? And I'm not sure there's evidence of the dose being too high, other than perhaps a steep drop here and there (but not regularly, and in theory rebound of that kind leads to more pronounced rebound, i.e. wider swings, which it doesn't look like you are seeing really).

Ok, well I've just totally confused myself, LOL, so time to sign off. Personally I think whatever you try (or don't try) is fine, just take some deep breaths and cut yourself some slack. Blackie is lucky to have you watching out for him so well, even if it doesn't feel that way to you right now.

 

[Ele & Blackie (GA)]

Thanks for the info, Terri.

I understand your frustration that he needs more insulin now than he did shortly after his diagnosis. But from what I've read, with Type II diabetes in humans they are still producing their own insulin. The problem is that their bodies have stopped being able to use what they produce. If that is true (and I think it is) for cats like Blackie, then the insulin shots initially serve as "boosters" rather than replacement for a non-functioning pancreas. It makes sense to me that over time, if regulation and/or remission is not achieved, those cats will need incrementally more insulin.

Blackie was diagnosed almost 5 years ago, so I'm not sure this applies. We didn't switch to lc canned food until last March when we started home testing. And that's when we were able to drop his dose from 3 units to under 1 unit.

He's got a late nadir again today, so maybe this is the time to lower the dose if I'm going to do it. Thanks for all the input. I may not get rid of my frustration, but at least I'll know that I've tried everything.

 

[Terri and Lucy]

I think you are suspecting his dose is too high, right, rather than it's liver training you are facing? I'm not sure if that distinction makes any difference in the theory of shooting through the rebound?

I think it makes a difference. If the dose is too high and the cat is dropping low or having steep drops, you lower the dose. If the liver is in control, you shoot it into submission.

 

[Sarah and Buzz]

I think it makes a difference. If the dose is too high and the cat is dropping low or having steep drops, you lower the dose. If the liver is in control, you shoot it into submission.

If only there were other things in life we could as easily shoot into submission, huh?

 

[Ele & Blackie (GA)]

+10 175
pmps 185 1 unit
I'm really hoping this works. I told Blackie what I was doing and not to be scared by the lower dose. I hope he was listening.

Thank you all for the input and great discussion. I don't really get "liver training". Is there a link or thread I can read more about it?

Now, I'm putting on my cloak of "patience/don't freak out" for the next few days. :mrgreen: And some green numbers are welcome.

 

[Sarah and Buzz]

As I understand it, liver training is this: when the body gets used to high BG#s, the liver panics when it sees a lower number. The definition of "lower" depends on what kind of numbers you have been getting. For Buzz recently, her liver was freaked out by yellows because she has spent 2 weeks in pinks and reds.

When the liver panics, it sends out attack troops to fight the low numbers. These troops take the form of glucagon, which is the hormone (?) that creates glucose. The liver thinks the body is experiencing hypo, so it freaks out.

The liver has to (and will) get used to the lower numbers; hence the rationale of shooting through rather than reducing the dose. Reducing the dose is like giving a tantruming 2 year old what they want: it will produce the same undesirable result (panicking) every time, and it will allow the liver to think it is in charge.

Hope that helps (and Terri, please correct me if I'm wrong).

 

[Joanna & Bix (GA)]

I think it makes a difference. If the dose is too high and the cat is dropping low or having steep drops, you lower the dose. If the liver is in control, you shoot it into submission.

Perfect - that's what I thought, nice to have the confirmation! \M/

Sarah - :lol: - I can think of several things (people?) where shooting into submission would be s-w-e-e-e-e-e-e-e-t!

Bix had the liver training issue I think. It took me a LONG time to realize that was what I was seeing (didn't really get it actually til it was gone I think), and ultimately shooting through it worked great. I wish there were a term for it other than rebound (liver-training just isn't catchy enough!), I think it's gets so confusing when you see rebound-like #s. I know with Bix people would periodically tell me they saw rebound, but I didn't see lows or steep drops to explain rebound. But then he would get these crazy highs, like a day of pretty blues, and then a 500 PS at the end of it. I really didn't know what to make of it - I'm sure people explained it, but it just didn't click for me.

I think there's something about it on the Wiki - I'll go look for it and paste in a link if I can find it. [Hmmm, well I was thinking of something else, but here's what I found on the Wiki: http://petdiabetes.wikia.com/wiki/Panicky_liver. Doesn't really go into it much, but there are some vague references. I think it's the part they are calling "panicky liver", saying that sometimes the liver is confused about what it's supposed to panic over, just like Sarah said. Might be something good in the links at the bottom, I haven't checked most of them out...]

Hope things go well Ele!

 

[Linda and Tasha]

I have 18 years of dealing with a diabetic child and less then a week with a diabetic cat, so I am coming from a slightly different place. But, as I am quickly finding out, not really all that different at all. The only difference is the metabolic rate in which the cat uses the insulin, which is twice as fast. I really don't think you were having somogi effects (rebound). I think you cannot react to one or 2 bg numbers that quickly. You were doing much better with the 2.4 units and the morning highs might be what is called dawn phenomenon. Where the bg has a quick jolt in the morning. With people on an insulin pump it is easy to cover but on a long acting insulin you cannot be that selective. You will never get a perfectly flat line of bg unless your cat is in remission. When you decreased the insulin your numbers went up all over. That should show you it is not rebound. You may have to live with the morning highs or consider a drop of a short acting insulin to cover that morning high which I think really isn't worth it. Instead of worrying about a single number, maybe you should be looking at the overall numbers you have been getting. High bg can be caused by too much insulin in the way of rebound, to little insulin , dawn effect, or stress. Low bg can be do to a variety of things as well. Too much insulin, too little food, to much activity or sometimes....occasional highs or lows seem to happen for no reason at all.
Although I am no expert on cats, I know diabetes well having lived with it with my daughter since she was 3 years old. Seriously think about going back to the 2.4 or increasing her insulin. I think it may be possible you reacted to fast by lowering it assuming it was from rebound. The numbers you have had since doing so tell a different story to me.
Again...I am new to feline diabetes, so take this for what it is worth.

I have found over the years that things change and what works for a while may not always work. You have to be fluid with how you deal with diabetes.

 

[Ele & Blackie (GA)]

Thanks for the input, Linda. I appreciate you giving your opinion. I do think you're right that my drop to 1.4 is too low. But I'm still not convinced that 2.4 is the right number. From 1.4 we can go up gradually and find the right dose. Maybe it is 2.2 or 2.4, but I won't be sure until I try a couple of other doses. It's always good to get a point of view from different experience (child diabetes). Thanks again.

 

[Linda and Tasha]

Well, as I said it is all pretty fluid. What works for awhile might not continue to work. I only suggested that number because you had good results on it and that wasn't very long ago. It certainly may be too much for your kitty. My gut tells me there has to be an increase of insulin and this is not a rebound. Although not with a cat, I have been doing this for so many years, you do build up an instinct when you see a series of numbers before you. Maybe up her to 2 units and see what happens?

 

[Terry and Puttz]

Linda...Thank you for your great posts! I also have been on ups and downs recently with my SugarKitty, and it was just comforting to read your post and know that it is okay to be calm and take what you get, work through it...thank you from Puttz, too....

 

[Gator & H (GA)]

I think it makes a difference. If the dose is too high and the cat is dropping low or having steep drops, you lower the dose. If the liver is in control, you shoot it into submission.

When Ele first came on board it seems this was kind of what was going on. Blackie was getting a lot of insulin at low numbers. Then Ele backed off the dose and things were ducky until the blow-ups. One might say Blackie almost got shot into submission. :mrgreen:

All I can say is that for whatever reason H is needing more insulin now. And I've found it VERY difficult for me to come to terms with this - to get me back into the comfort zone.

This UTI thing seems awfully chronic, like maybe it has never really been gotten rid of?

As for the rebound issue, my general [perhaps stupid] approach is to identify when the rebound is happening then test the heck out of that time [every hour for about 4 hours] and watch for it.

 

[Ele & Blackie (GA)]

Gator, I'm sorry to hear that H's insulin needs are increasing. I can feel your frustration and pain. I have finally resigned myself to Blackie's higher dose needs, but I'll probably always wonder why. Re the UTI: Is H having recurring UTI's? Or were you talking about Blackie? Because the next time Blackie gets a UTI, I'm going to have to seriously look for something to prevent them. I know it's aggravated by high glucose and by his CRF, but there must be something we can do.

 

[Gator & H (GA)]

Gator, I'm sorry to hear that H's insulin needs are increasing. I can feel your frustration and pain. Re the UTI: Is H having recurring UTI's? Or were you talking about Blackie? Because the next time Blackie gets a UTI, I'm going to have to seriously look for something to prevent them.

Thanks Ele, there's really no sorry about it though - and it's not like I've ever had any hope that we would do remission. It's not like his needs are really that high [seemingly 66%-100% more than in the past - still under 1u]. But I was just voicing the fact that I've found the change to be a little hard to get used to.

H is not having UTIs [thank almighty!] - or at least that I'm aware of. I was talking about Blackie. Maybe you should have a conversation with Blackie about laying off the crazy sex - maybe that will help? LOL. Yea, I don't know what one does about the chronic UTI thing in cats. I guess it were me I'd be reading about UTIs in humans to figure out the latest. As I said my impression is that the thing never really went away. It would be interesting to know how a human infectious disease person would approach it? I don't know if there are any more advanced type testing to find out what antibiotics the specific bug Blackie has is susceptible to. If the old school way of testing antibiotic receptiveness is up to the latest [perhaps genetic methods?] I know a couple approaches to chronic bacterial infections in humans are probiotics and the other is a constant low dose of antibiotics. Maybe there's a way to change the PH of the urine so that it is less hospitable to bugs? - just thinking crazy.