joanna

[Anonymous]

just looking at bix's ss. those are some beautiful #'s. i was wondering if you could put + however many hours since last meal for all the #'s that don't involve a shot. i could'nt tell how long you've been at this but i think you are THERE! get out the raincoat your heading to the falls. is this bix's first time around or is this remission.
seriously those are beauties....some might suggest you let it ride and see if those low 100's would come down on there own given time.
that's how did it last time. i stopped shooting anything under 170 becuase of his frequent self come downs and started seeing him do it himself.

 

[Joanna & Bix (GA)]

I've been wondering that too, if I ride out the #s if he will come down on his own - I guess I'm scared to try it and have him just hovering in higher #s for days. When you were at this before, how long did you wait to see if he would bring the #s down on his own? The one time I really tried it, tested for food spike, etc., he started at 180, went up over 200, and then came back down to 135 I think, and that was it. But maybe I should have waited longer, or see what happened after the next snack?

He freefeeds (and is a nibbler) so it's hard to correlate mealtimes. I try to test when it seems like he's been napping and hasn't eaten in a while, but it's hard to track for sure.

He was diagnosed about a year 1/2 ago, but I couldn't get him to canned food til last June, so progress was difficult before that. He was on Vetsulin for a long time, and got good nadirs, but didn't stay in good #s for more than a few hours a day. After he finally went LC, he was regulated pretty fast - last July - and then after a couple months he started getting amazing duration & clear pancreas action, but still seeming like his #s are often in the 100 - 150 range, rather than the 60 - 80 or so I'd like to see.

So I've been fumbling around with it since maybe October or so, not really sure what the best approach is. For a while it seemed to be improving, I even saw a couple #s below 80, but then the last few weeks he's seemed a little higher. Not sure if that's because maybe I'm overshooting and causing problems, or undershooting and he's losing ground because his pancreas has to work too hard. Come to think of it, he seemed best back when I had the flu and ended up only testing every 2 or 3 days, I was just too out of it to focus. And that's when I noticed he seemed to be doing just fine without me! So maybe I should go back to that strategy and just let things be w/o insulin for a few days, and see how he does.

Well, thanks for the suggestions!!!!

 

[Anonymous]

joanna i wanted to give you a quick reply before i go off to dr.s appt.
in 07 tom had a hypo after 29 days. i did'nt shoot for awhile with the following days high#'s yep a 367 followed by 247 then 219 then in +24 243, can you imagine i did not shoot those #'s.. then he started coming down. for the next 2 weeks or so he got maybe 3 or 4 super mini shot if he hit above 200. i mean like .2u. l let the 180's go and the next day he was 118. this went on for awhile and then poof, routine # between 80-maybe 110 but mostly under 100.
back then anything under 140 was cause for celebration! times have changed. with #'s like bix's i wonder if his pancreas would do the work if you were'nt doing it for him. plus like i said some of those #'s are normal after food #'s so indicate that if you can.
i think the notion is let the pancrease take over for awhile and see what she can do. she won't kick in for those low #'s if your doing it for her.
IMHO.....JUST MY THOUGHTS for anyone who has strong feelings otherwise, i humbly admit to my limited experience.

 

[Gator & H (GA)]

When Bix's numbers are as good as they are it is a difficult choice to let them potentially zoom off because it can take quite a while to get them back into that zone if it turns out their P can't do the job.

 

[Joanna & Bix (GA)]

i think the notion is let the pancrease take over for awhile and see what she can do. she won't kick in for those low #'s if your doing it for her. IMHO.....JUST MY THOUGHTS for anyone who has strong feelings otherwise, i humbly admit to my limited experience.

That's what I thought, but then I started thinking about how Lantus has a higher remission rate (at least some seem to think so), and there it's tighter regulation. So that made me think maybe lower #s would promote the last bit of healing that might be needed.

Well, who knows really. I think I'll try setting a higher no-shoot, and see what happens, and try only shooting if he's staying higher consistently. He hasn't zoomed high in ages, so I may be being overly proactive. And if I'm not, then at least I can know that for sure and stop guessing.

Thanks for the input everyone.

 

[Terri and Lucy]

If you were using Dr H's approach, you wouldn't shoot unless he went over 150. When my foster boy went into remission (NPH not PZI), he hung around in the low 100s for a couple of weeks, then gradually dropped down into double digits. He gobbled his food normally so I had to feed him in very small meals throughout the day.

 

[Joanna & Bix (GA)]

I'm confused about Dr. H's 150 no-shoot (to let pancreas work, vs. for safety reasons) and the (?) success rate of L & L where as far as I know, there's no aspect to the guidelines like that. Presumably with L & L because there is less of a hypo risk based on where the PS is, it's a non-issue, but then for me it puts into question whether or not Dr. H's premise is true - that if #s are too tightly regulated, the pancreas won't bother kicking in. Does that make sense? i.e. I'm thinking maybe I should go for tigher regulation like L & L do, since Bix doesn't seem to be getting big scary drops anyhow. But then I remember Dr. H's thing to wait for 150, and get lost in which approach is better (or maybe with L & L they still hit 150s, it's just not at the PS time?).

The thing with Bix is that after he hovers in the low/mid 100s for a while he starts walking more on his hocks, and climbing up on things instead of jumping. So then I end up shooting even it he's in the 120s or something, rather than waiting it out to see if his pancreas will kick in better in a few more days. Maybe I should try B-12 or something, but most of the time when I start seeing that with his hindlegs and shoot, then he runs around and starts playing after a few hours, and by the next day, his legs seem back to normal.

So I keep coming back to that (when I see that in his legs) and shooting. But it's bugging me that he's clearly had pancreas action since at least October, and I'm still putzing around with periodic shooting. So I don't know if that's just him - maybe partially healed pancreas is all we get for now, maybe the Budesonide is making it harder, who knows. Or if it's my strategy (or lack of!) that's holding him back from going fully OTJ.

Ultimately he is doing well and it may not really matter - close enough #s, and he seems happy. But being an obsessive perfectionist ;-) I'd like to see him in DDs most of the time.

Any thoughts, insights?

Thanks everyone for your input.

 

[Sarah and Buzz]

I'm confused about Dr. H's 150 no-shoot (to let pancreas work, vs. for safety reasons) and the (?) success rate of L & L where as far as I know, there's no aspect to the guidelines like that. Presumably with L & L because there is less of a hypo risk based on where the PS is, it's a non-issue, but then for me it puts into question whether or not Dr. H's premise is true - that if #s are too tightly regulated, the pancreas won't bother kicking in. Does that make sense? i.e. I'm thinking maybe I should go for tigher regulation like L & L do, since Bix doesn't seem to be getting big scary drops anyhow. But then I remember Dr. H's thing to wait for 150, and get lost in which approach is better (or maybe with L & L they still hit 150s, it's just not at the PS time?).

As far as I understand it, which albeit is very limited, the approaches can't really be compared because PZI and L/L work very differently. Cassandra had this to say on my condo in LL the other day, regarding LTS (liver training school) and Buzz's bouncing: Lantus/Lev are worked differently than other insulins like Vetsulin and PZI because we hold through the bounces rather than decreasing the dose to let them even out. There is no rebound check used here - just waiting for her liver to train and adjusting the dose as called for based on nadir. Not sure if that really helps or not, but I thought it was interesting.

The thing with Bix is that after he hovers in the low/mid 100s for a while he starts walking more on his hocks, and climbing up on things instead of jumping. So then I end up shooting even it he's in the 120s or something, rather than waiting it out to see if his pancreas will kick in better in a few more days. Maybe I should try B-12 or something, but most of the time when I start seeing that with his hindlegs and shoot, then he runs around and starts playing after a few hours, and by the next day, his legs seem back to normal.

If you want to see if his pancreas can/will do more work, but you are concerned about his walking (which I totally understand; I would be too), what if you did give him some B-12 and then didn't shoot those low 100s (waited for him to get above 150)? If it doesn't work, or you get really worried about his hocks, then you could always shoot, which you know will get him back to normal quickly. I think at this point you have nothing left to lose, and since walking on his hocks isn't a health/safety issue (not in the short term of 4 or 5 days, at least), then I think it's okay to experiment like that. You never know until you try, right?

So I keep coming back to that (when I see that in his legs) and shooting. But it's bugging me that he's clearly had pancreas action since at least October, and I'm still putzing around with periodic shooting. So I don't know if that's just him - maybe partially healed pancreas is all we get for now, maybe the Budesonide is making it harder, who knows. Or if it's my strategy (or lack of!) that's holding him back from going fully OTJ.

Ultimately he is doing well and it may not really matter - close enough #s, and he seems happy. But being an obsessive perfectionist ;-) I'd like to see him in DDs most of the time.

FWIW, I don't think there's anything wrong with having a goal (DD's). Some goals can't be reached, through no fault of your own, but that doesn't mean we still shouldn't try. This may draw some fire, but I have never understood why people say that remission shouldn't be the goal. Why not? If you are realistic, and know that some cats will NEVER go OTJ, and yours might be one of them, then what's wrong with pursuing the goal of remission? Why not strive for the thing that you want? If you take it to such extremes that it ruins your kitty's life (or yours), then that is obviously a problem. You do have to know when to say when. Again, you don't know unless you try.

That's just my .02, take it or leave it, I won't be offended.

 

[Gator & H (GA)]

Any thoughts, insights?

Every day is a blessing.

 

[Terri and Lucy]

The difference between PZI and Levemir is the time spent at peak values, so the treatment approach is different. In the old days on FDMB (before Lantus became the majority insulin), there was a standard practice of doing rebound checks. Then Dr H came along and said stop it--don't give in to a panicky liver. Her approach, called shooting into rebound, works. In fact, it works so well the Lantus folks adopted it even though they renamed it. That's why you hear me constantly telling people not to reduce the dose because someone thinks they are rebounding. So what if the cat is rebounding? Giving in to the panicky liver doesn't solve the problem, it just changes the nature of the problem.

But Bix isn't rebounding. His liver doesn't get the chance to work without exogenous insulin. So there's the primary difference between Dr H's approach and Lantus. Dr H said encourage the liver to work on its own as soon as possible. The Lantus folks use an incremental dose decrease based on dropping down into hypo numbers (below 40).

You know Bix has a functional pancreas, but you're straddling the fence on what to do next. I think you're just going to have to make an executive decision to either maintain tight control or give him a chance to fly on his own. There isn't one single right way, just you deciding what you're most comfortable with.

 

[Joanna & Bix (GA)]

If you want to see if his pancreas can/will do more work, but you are concerned about his walking (which I totally understand; I would be too), what if you did give him some B-12 and then didn't shoot those low 100s (waited for him to get above 150)? If it doesn't work, or you get really worried about his hocks, then you could always shoot, which you know will get him back to normal quickly. I think at this point you have nothing left to lose, and since walking on his hocks isn't a health/safety issue (not in the short term of 4 or 5 days, at least), then I think it's okay to experiment like that. You never know until you try, right?

I think I'm more worried that it's a sign there might be other damage (unseen) going on. Like the leg thing is just the tip of the iceberg, and meanwhile his kidneys are probably being destroyed, etc. Maybe I'm overreacting? (It's been known to happen, lol!!!!)

Every day is a blessing.

The difference between PZI and Levemir is the time spent at peak values.

I guess where I'm getting confused is that if L & L work well for remission because there is more extended time at peak values, then doesn't that mean that Dr. H is wrong about the 150 NS to let the pancreas work? Doesn't it suggest that the best chance for remission is as long as possible in non-diabetic #s, and that the pancreas kicks in just fine on it's own with the L/L strategy?

But Bix isn't rebounding. His liver doesn't get the chance to work without exogenous insulin. So there's the primary difference between Dr H's approach and Lantus. Dr H said encourage the liver to work on its own as soon as possible. The Lantus folks use an incremental dose decrease based on dropping down into hypo numbers (below 40).

I'm not sure I understood this - you're saying that the exogenous insulin is triggering his liver (even though not to an extreme where we see high #s), so if I stopped shooting at all that would let his liver rest, and that in turn would lead to lower #s? So to compare apples & oranges :mrgreen: if Bix were on one of the Ls I would be now keeping him pretty TR regardless of anything else (like pancreas action), and only lowering the dose if he goes low. Vs. on PZI I let go of such tight TR and in theory his liver will stop reacting and his pancreas will do the job (in theory) if I wait it out a few days?

Not to open a whole can of worms here TT style just trying to understand, since I feel like the two approaches are in conflict over this one point (letting higher #s exist up to the 150 point, as part of pancreas training). It seems like there *ought* to be one right answer, LOL, but I guess we know that cats go into remission kind of all over the map and they certainly aren't reading the protocols/guidelines to decide whether or not they should alert their pancreases it's time to go to work.

Well anyhow, thanks everyone for the ideas, I am still digesting them all, but it's lots of good food for thought. I've also concluded I need to get some more data, since a lot of the time I really don't know if he's spiking high after food and how much his pancreas is bringing him down, etc. So I'm going to work on that angle too.

 

[Terri and Lucy]

I guess where I'm getting confused is that if L & L work well for remission because there is more extended time at peak values, then doesn't that mean that Dr. H is wrong about the 150 NS to let the pancreas work? Doesn't it suggest that the best chance for remission is as long as possible in non-diabetic #s, and that the pancreas kicks in just fine on it's own with the L/L strategy?

Let's discard the references to the other insulins. I'm not well enough to handle party crashers looking for a fight right now. nailbite_smile

It sounds like you're asking whether you have to keep a cat tightly regulated (60-130 mg/dL) in order for him/her to go into remission. That is the approach used by Tilly. But there were plenty of cats going into remission before Tilly. Maybe not as consistently, but there also weren't as many cats dropping down into hypo numbers (<40 mg/dL) in search of remission/tight regulation. FDMB blew up when YDC came along because cats that had been cruising along in the 200s suddenly started going into remission once their beans started aiming for tight regulation. That doesn't mean that they were tightly regulated, just that they were using a TR treatment strategy. In fact, given that Dr H doesn't believe in shooting below 150, those cats couldn't be tightly regulated even though they were going into remission at a pretty high rate.

you're saying that the exogenous insulin is triggering his liver (even though not to an extreme where we see high #s), so if I stopped shooting at all that would let his liver rest, and that in turn would lead to lower #s?

No, I'm saying that his pancreas doesn't have to produce insulin because you're providing it. Since he's getting all that he needs from a syringe, the theory is that his pancreas can sit around drinking martinis all day long. I'm also saying that since Bix isn't rebounding, his liver has nothing to do with this. (The pancreas produces insulin; the liver produces glucagon, the hormone that signals the body to release stored glucose in response to a real or perceived emergency--which is what we call rebound.)

Remember that food stimulates the pancreas to produce insulin. Have you done a food test (test, feed a tablespoon or so of food, retest 30-60 minutes after its been eaten) recently? With Honey Boy, anytime he got up to 150, I gave him a little bit of food. It meant we did a lot of testing, but using the food in place of insulin worked for us. It's worked for several others too.

 

[Joanna & Bix (GA)]

It sounds like you're asking whether you have to keep a cat tightly regulated (60-130 mg/dL) in order for him/her to go into remission.

Bingo! That's exactly where I've been confused, and I think your answer cleared that up, whew!

No, I'm saying that his pancreas doesn't have to produce insulin because you're providing it. Since he's getting all that he needs from a syringe, the theory is that his pancreas can sit around drinking martinis all day long. I'm also saying that since Bix isn't rebounding, his liver has nothing to do with this. (The pancreas produces insulin; the liver produces glucagon, the hormone that signals the body to release stored glucose in response to a real or perceived emergency--which is what we call rebound.)

Ok that makes more sense, I think I just read what you wrote wrong. Except that in theory on Tilly, insulin is being provided and yet cats do go OTJ, but I'm thinking I'll throw that whole issue out the window and just do more testing and let things ride and bit and see if I can really figure out whether or not his pancreas can go it 100%.

Remember that food stimulates the pancreas to produce insulin. Have you done a food test (test, feed a tablespoon or so of food, retest 30-60 minutes after its been eaten) recently? With Honey Boy, anytime he got up to 150, I gave him a little bit of food. It meant we did a lot of testing, but using the food in place of insulin worked for us. It's worked for several others too.

I just tested him a little bit ago on a food spike (last insulin shot was 24 hrs ago) and got 146. So I'm planning to test again in a couple hours and see where he is. I wonder if maybe I need to actually give Bix fewer, bigger meals. He is a grazer, and eats just a couple nibbles at a time, all day long. Maybe he's not getting enough food at one go to really trigger his pancreas, or alternately is keeping himself at a constant low-grade food spike? Guess I can play around with stuff like that & get some tests in and see what I find out.

Hope you are feeling better soon Terri.

 

[Joanna & Bix (GA)]

Update:

Last shot was 24 hours ago, just now fed him a fair amount.
45 minutes post-food he was at 146.
2 1/2 hrs post-food he was at 81.

Ooooh, I iz feelin a hol lot betteh now!!!!

Thanks again to all for the input. I really appreciate being able to bounce the ideas around. All in all, I think I'm going to try to focus more on data, and if he goes higher do some food experiments (and maybe B-12 sup!) as suggested, and try to sit on my hands for the shooting (I know I said that the other day, and caved already!!! :roll: ) unless he really seems to be in sustained higher #s and not coming down on his own with feeding. I'll try to start posting his #s more regularly too, so if I get the urge to shoot when it might not be needed, the PZI team can weigh in first.

 

[Terri and Lucy]

Patience is a virtue that is hard to achieve.

You may also want to test him before he eats now and then. You really do need to understand how his body processes the food, just like you understand how it processes the insulin. So test before he eats (not everytime), test him 30 minutes after he eats, test 1 hour after he eats, etc. until you understand the pattern.

 

[Anonymous]

could joanna's bix be an infection kitty too. i ask becuase those #'s are so freakin good it's almost like he's not really diabetic. obviously functioning pancrease. joanna, many think tom's come back to diabetes is tooth infection related.