In search of the right dose

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Likameow

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It's been a while since I posted here. I was so sure that I had it figured out that I didn't need dosing advice. If you look at Ben's spreadsheet, clearly you can see I was wrong about that. Still can't figure out what tune that silly sugar cat wants to dance to. Looking at my spreadsheet I can see I'm very reactionary. So I'm hoping that cooler heads prevail and you guys can give me some suggestions.

Physically, Ben is doing just fine. He looks good, he's maintaining his weight and all his lab values are spot on.

Thanks, Lisa and Ben.
 
Hey Lisa. You really have some good data here and I applaud your efforts in trying all sorts of tactics. If you can give me about an hour, I thought I would try to see what kind of sliding scale I would come up with. I am also thinking about dosing down just a little and then tweaking each time you get a result. I will go into that later.
 
Thanks, Cindi. I appreaciate you taking a look. No hurry. I just gave him his evening dose. Went with 1.6 units for a PMPS Of 371. So whatever you come up with I'll start in the morning. Thank you again.
 
So a couple of observations.
1) The insulin seems to last a little longer during the day compared to the night cycle i.e. he has a little higher numbers in AM than at night.
2) He seems to bounce more at night when he goes low from his PMPS dose hence a higher number at AM than AM to PM.
3) Seven AM numbers that were in the 400's, you dosed 2.0 units and all seven got you a blue PMPS number (that's a good thing).
4) The majority of doses that you have administered is between 1.8u and 2.2u.

Your current sliding scale: 125-200=2U; 200-300=2.2U; 300-400=2.4U; 400+=2.6U
Your previous sliding scale: 150-250~1.8U; 250-350~2U; 350+~2.2U

How do I come up with a sliding scale? So, what I do is write down the numbers and dose that have gotten you to an acceptable nadir (or close to it) while also, writing down those that didn't but wrote down the dose that I thought that may have gotten to your safe, green nadir. This is what I collected.

2.2u - 457, 355, 432, 311, 335
2.0u - 432, 402, 281, 342, 392, 340, 262, 385, 334, 493
1.8u - 394, 336, 233, 230, 320, 290
1.6u - 323, 341, 232, 190
1.4u - 286, 227, 195, 280
1.2u - 181
1.0u - 143, 274

Then, I eliminate the super high and super low number within each dose and then try to fit the majority of the remaining numbers within a dose. This suggested sliding scale is a little lower than yours but I usually start off pretty conservative. Also, since you typically shoot between 1.8u and 2.2u, this new sliding scale has that covered. So here is what I have come up with.

2.2u - 433 - 457
2.0u - 395 - 432
1.8u - 342 - 394
1.6u - 281 - 341
1.4u - 227-280
1.2u - 181-226

So, how do you adjust or maintain a sliding scale? This is what I do however I am sure there are other ways to do this. With each number, I dose according to my sliding scale while also reviewing my spreadsheet for a previous, same number. Then I try to catch a nadir or at least a +4. If the dose gives me a safe green or even low blue number, I do not change anything. If the number is too high, I may adjust my sliding scale or may even wait to get a similar number one more time. If I get the same results, two times (this is why I look at previous numbers and doses), then I change my sliding scale. I also may put something in my comment section indicating that I have a "pending" change as a reminder to change next time (just like you did on 10/12). If I get a low, an unsafe number, I may change my sliding scale immediately or wait till I get another low number twice. It all just depends on whether I change the sliding scale the first time or the second time that I get the same result. Regardless, I am always, comparing my doses with previous numbers and my sliding scale and tweaking it constantly. Did I explain that correctly?

So back to my observations. One of them is pretty obvious that Ben goes higher in the AM and throws you lower numbers at night. I am assuming that you are shooting every 12 hours. I would like to see your AMPS numbers lower, so I am suggesting that you shoot 12.5 hours during the day and 11.5 hours at night. So if you are shooting at 6am and 6pm, then you would shoot at 6am and 6:30pm instead. That way, hopefully, we can get to the AM number before it gets to the 400's. Your evening shots will be a little higher but it shouldn't be too bad. This may also minimize any bouncing from lower numbers or not enough insulin throughout the night. If your AM number continues to be high and PM numbers lower, then I would change to a 13/11 schedule or 6am/7pm shot times.

One more note I thought I might add. Occasionally, you might see us shooting a "fat" dose or "skinny" dose. I typically only shoot "fat" doses just because it is easier to see on the U100 syringes. I may do this when I am at the top of my sliding scale and I want to add just a drop or two more but not quite a full 0.2u increase (Merlin is really sensitive). So say, I get a 340 and my sliding scale is telling me to shoot a 1.6u but since it is at the top of the sliding scale, I might go fat 1.6u (but not quite a 1.8u) just to drop me an extra 10-20 points. So that may be a consideration down the road.

Well these are just suggestions. No problem if you want to try something else or continue with the consistent doses. Sometimes consist dosing really helps the kitty to get used to the insulin and hopefully minimize bouncing. Also no problem if you want to tweak the sliding scale numbers as I said, I am a little more conservative.
 
So back to my observations. One of them is pretty obvious that Ben goes higher in the AM and throws you lower numbers at night. I am assuming that you are shooting every 12 hours. I would like to see your AMPS numbers lower, so I am suggesting that you shoot 12.5 hours during the day and 11.5 hours at night. So if you are shooting at 6am and 6pm, then you would shoot at 6am and 6:30pm instead. That way, hopefully, we can get to the AM number before it gets to the 400's. Your evening shots will be a little higher but it shouldn't be too bad. This may also minimize any bouncing from lower numbers or not enough insulin throughout the night. If your AM number continues to be high and PM numbers lower, then I would change to a 13/11 schedule or 6am/7pm shot times.

Thank you so much for your work on this. I definitely appreciate it. On my days off I will definitely try the 12.5/ 11.5 schedule. Unfortunately for poor Ben on the nights that I work he is forced to be on a 11/13 schedule. It works out to be about three days a week. I've been flagging those mornings that it's 13 hours after his last shot on my spreadsheet with the star next to the date. Would it make sense on those mornings to drop the sliding scale by 0.2 because it will only be 11 hours until his next dose and increasing it by 0.2 that evening because it will be 13 hours overnight till his next dose? If that makes any sense.

Looking forward to implementing my new sliding scale in the morning. Thank you again.
 
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Oh that makes total sense...then a 12/12 schedule would even him out. You are right, the higher numbers are when you went 13 hours. Ok that explains that so disregard the suggestion of the 12.5/11.5 schedule.

I am really not sure about that thought to increase/decrease the dose by 0.2u during those 13/11 days, because Prozinc only last 12 hours and that is what it is lasting on Ben so not sure if it would work. I believe that by increasing the dose, it doesn't mean that Prozinc is going to last any longer than 12 hours but an increase dose would get you a lower nadir.
 
I am really not sure about that thought to increase/decrease the dose by 0.2u during those 13/11 days, because Prozinc only last 12 hours and that is what it is lasting on Ben so not sure if it would work. I believe that by increasing the dose, it doesn't mean that Prozinc is going to last any longer than 12 hours but an increase dose would get you a lower nadir.

OK. That makes sense. I'll stick to a 12/12 schedule when I'm not working. And I'll follow your suggestion for the sliding scale.

Thank you again.
 
Yep, an increase wouldn't really make the insulin last longer...just make it bring him lower. Cindi's sliding scale is spot on and she certainly explained it better than I ever would have been able to! :) I'm excited to see what sort of numbers this gets you!
 
Hey Lisa - just checking in this am. Noticed that you gave 2u for a 205. That seems like a pretty high dose for that number. Also noticed that you put in a different sliding scale on your spreadsheet. If you were going to use the new sliding scale, then you would have shot a 1.2u. Could you check him at +2 to see what his numbers may look like for the cycle? I am going to be gone all day and will not have access to my laptop. I am alerting @Rachel, @Robin&BB and @Sue and Oliver (GA) in case you need any guidance.

2.2u - 433 - 457
2.0u - 395 - 432
1.8u - 342 - 394
1.6u - 281 - 341
1.4u - 227-280
1.2u - 181-226
 
If you were going to use the new sliding scale, then you would have shot a 1.2u. Could you check him at +2 to see what his numbers may look like for the cycle?
Hi there, Lisa. Took a look at your SS, and I see what Cindi is talking about - appears you accidentally plugged in/used a different sliding scale than the new one Cindi was suggesting. Can you monitor him at all today? As I do have some concerns about how much his BG may drop during this cycle, based on the increase in dose this morning of close to a half-unit - and last night's cycle after 1.6U @ PMPS. Will await your response. Thanks.:)
 
Hi!! Lisa, when you get a sec, let us know about your dose? Just want to make sure all is well.
 
*hand to face* I did totally misunderstand Cindi's post and used the wrong sliding scale. Seems like I read that post a dozen time. How could I have misread it? "Sheesh!" Now I see what she was talking about. No worries though. Ben was fine all day. He never dropped lower than 175 and is back to 295 for his PMPS. And that is the fun that is dosing Ben. Some days a dose will drop him a lot and some days it won't. Putting the right scale on my SS right now.
 
Hey Lisa - Any chance you can get some nadir tests? That is the only way that we can tell how we can adjust the sliding scale. I also hate to miss the opportunity of seeing how low he can go with these new doses. Also be sure to see if you can catch some ketone tests too as we figure out Ben. Thanks.
 
I need to go buy some more Keytone sticks. Mine are expired. I'm off the next couple days. I'll try to get a few more checks during a cycle.
 
Doesn't seem to be dropping much with the dose for the lower numbers. I'm home tomorrow so I'll do a curve.
 
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