Re: impatient mom-dose help please / ("rebound" reviewed)
Marci and Buddy said:
Atfer 7 cycles of 1.15, thought abit more to 1.20 will help bring Buddy to blue,which it did(even some green
)
but now he's either in rebound ,( again) or needing more insulin, not sure what 's going on.
Thinking enough time with 1.15u ah past and should go up tonight to 1.20, but don't want to shortchange
his attempt at 1.15u. trouble is I'm not able to withstand his lathergy and thirst at these #'s, so I
feel the need to increase. Am i risking losing his ideal dose, even now? how long should i wait,or not?
thanks very much for your help.
Marci, there is no ideal dose, unfortunately, because the best dose can be undermined by a thousand factors, including changing it in a way that is no longer the best. I'd say, follow the force, or whatever it is the Jedi do. I hugely respect and often follow the advise of the other people here.. but in this case, I don't read Buddy's ss at all like they have.
If you do go with the "LESS" that is being recommended, I don't think it is a disaster, but only because the data is already so muddled. You would think that if you reduce and it is wrong, you will see higher numbers, but often that is not the case.... you often see lower numbers because your cat will do its best to cover for you by producing more itself; then a few days later, you start going higher than where you started, because your cat is a diabetic and needs insulin. One thing's for sure -- Buddy can't draw his own dose to where he would like it, you have to do it.
I think you have done an unbelievable job of the many basics -- dose consistency, close monitoring, reasonable dose adjustments, caring in every way... The chart is quite a story in itself. But I think the same data that is being interpreted as calling for a lower dose, can be viewed in another way. This is not about anyone being right or wrong, either -- it is about Buddy. My view, for what it is worth, is that during 2009 you had week on week of great stability, with steady greens, relatively flat ranges, only scattered warm colors, all of which added to opportunity to bring true regulation if not remission. The weakness I see in the ss is that at each opportunity to give Buddy a steady taste of sub-60 numbers, which he probably needed to move his homeostatic glucose "set point" to pre-remission levels, his dose was reduced a little in response to a 50 or something like it, instead of being maintained to keep pushing the bg down until you
had to lower. A cat in remission, it need not be said, has an injection dose of zero, but a cat does not normally get regulated because you reduce the dose, but the other way around: you reduce the dose because it is safely in the normal ranges and then gets even lower. Are there exceptions? Yes. Should you assume your cat is an exception? no.
Buddy needs to get the "had to reduce" experience, where you draw back because you have to, not because you can. Fifties or even 40s are far less frightening when you have the kind of data you have for Buddy. That range -- 40 to 55 -- I admit is problematic because it is also the zone of vigilance, the "approaching the ledge of hypo" zone, more dangerous for some cats than others, and I don't want to make light of it. For many cats, moving toward remission or "pre-remission" is the scariest part. But in Buddy's case, I think he needed more surfing at 40-60, and his return to the high side simply says, to me, that his hormonal system memory is jangled, he is irritable, seeking adjustment -- because he has been unable to find stability in the lower ranges.
Another thing... "Rebound," which is a real phenomenon, also can be viewed in two ways: either as the hyperglycemic bane on regulation and to be avoided if at all possible; or as an inevitable and routine part of normalizing a cat -- information about the hormonal system seeking re-adjustment when Levemir is disrupting the disease. Rebound tells you that there is much more in the picture than insulin and glucose, pancreas and liver. There is an entire endocrine messaging network involved, with seven other hormones in addition to insulin, and that is a big republic of voices. Rebound is an exaggerated effect of a self-regulating endocrine system, there as protection of the cat's internal perceived interest, which is skewed because of the disease of diabetes. How to handle rebound involves a tradeoff, because by feathering the dose or backing off you can often minimize it, but if the bean overreacts to the overreaction that is rebound, it is often at the cost of prolonging the cat's experience of moderately high ranges of glucose, which is exactly what the problem is with diabetic cats to begin with. Rebound needs to be seen in context because it is more and more evident that in diabetes it is not just that the pancreas is not producing enough insulin, or that the insulin is not able to lock on .. it is that insulin is part of an endocrine
system which ALL gets renormalized to a higher range, and over-writing that system set, which is the disease making itself at home, is what therapy is about. So rebound is just a way of the cat telling you that this revision, how the rest of its hormonal system views the extra insulin you inject, is not totally easy and there is a shock. When you give more insulin the glucose and liver are ok with it, but it is the rest of the hormonal system that gets blindsided and insists on responding to this new "threat" of normal sugar levels -- hence the pancreas sends out a message to the liver to release stored glycogen (so much for "panicky liver"). Bottom line: often, lowering the dose is asking for rebound later, not now. It is also not recognizing that temporary low numbers are also a form of rebound -- the same adjustment, inverted.
With Buddy, there has been a lot of indecision but I don't think it is too late. Though I am skeptical of the advice to decrease, I will be happy to be wrong, and certainly the people who are counseling it are experienced, smart and sincere and I respect them greatly. They may be right -- and there are cases where that strategy is the right one, to be fair. If you do follow that and it works, I will be as pleased as anyone.
Ilkka
