Lost as to where to go now.

[Marci and Buddy]

MY Buddy is not getting better with his #'s. He's hungry, thirsty, and tired, yet playful and purring .
i'm wondering if tonight i should go up to 1u . I'm at my wits end, just dont understand why this time
last year he was green /blue with .50u.and now can't regulate him no matter what i do. :cry:
I am thinkning i should switch to Lantus. If anyone has gone from Lev to lantus i wd. like to know what happened.
Thanks very much.

 

[Marcy & Klinger (GA)]

Hi Marci,
I was just looking at Buddy's ss. Is there any way you could get a few more spot checks in today? It will give us a better picture and help you decide which way to go.
I wonder if the adequane (sp?) shots are factoring into his change from last year to how much insulin he now needs?? I keep hearing on the board that kitties insulin needs can change it's great that you were able to gather the data of going back to .50u.
You're doing a great job, Marci. Give Buddy some scritches from us.

 

[Vicky & Gandalf (GA) & Murrlin]

I'm going to back track somewhat from what I said 2 weeks ago, which was basically that he is rebounding and needs a lower dose.

The reason is that I looked all the way back to the beginning of your SS in Feb '09 when you started Levemir, is that correct? He had similar wonky cycles which sure looked like rebound, but after a consistent period where the dose was maintained at 1.5U, he began to stay below 200 and you were able to drop his dose progressively over time.

What stands out to me is that the 1.5U dose was held for almost a month. Now, no matter what dose you're using, it's not held for more than a week. It could be that he's just not able to stabilize on a dose because any one particular dose is not given enough time.

No matter what you do with dose from this point, please keep that in mind. Levemir likes a stable dose. Even if the dose is wrong, not giving that dose enough time to work through the bounces and shed or no shed from the previous dose makes everything a huge and confusing mess because none of the numbers make sense for any one particular dose.

So if you're going to 1U, you've got to give it a week or more. No fatting it or anything. On such low doses, even a tenth of a unit difference is a change.

 

[Marci and Buddy]

thanks for highlighting the time factor...i have been following Tilly(6-8 cycles)
but i get it may not be long enough. Vicky , could you please clarify abit more specifically- i will now continue on this f.75 dose for at least a few more days, right?Tilly also says if high flat continues to not even give it the full time, just increase, are we not going by that now? You also said the dose is too much, so should I reduce the dose now? or still wait? I appreciate your help.

 

[Marci and Buddy]

Marcy-i'm getting in more tests-thanks.

 

[Vicky & Gandalf (GA) & Murrlin]

thanks for highlighting the time factor...i have been following Tilly(6-8 cycles)
but i get it may not be long enough. Vicky , could you please clarify abit more specifically- i will now continue on this f.75 dose for at least a few more days, right?Tilly also says if high flat continues to not even give it the full time, just increase, are we not going by that now? You also said the dose is too much, so should I reduce the dose now? or still wait? I appreciate your help.

He may be experiencing glycogenolysis, which is defined in the Pet Diabetes Wiki here: http://petdiabetes.wikia.com/wiki/Glycogenolysis

It's sometimes called panicky liver. Basically it's when he gets lower numbers, the liver reacts and breaks down glycogen into more glucose. That would result in rebound looking numbers.

It becomes a matter of getting the liver to feel safe at a certain dose. The trick would be finding a dose which doesn't take him to the point at which his liver panics. .75U might be worth continuing on, even if it doesn't lower his numbers very much, because that's a good thing. So far it has produced some blues, which would probably help his liver feel safer than the greens.

Does that make sense? You would probably need to raise the dose after several more days though if you continue to see numbers like the past couple days, where he's not out of the yellow. This is also why we suggest increasing in very small increments, to prevent this panicky liver. Going from .75U to 1U is a 1/3rd increase and may be too big of a jump for the liver.

But see how he does on .75U for a few more days.

 

[Sheila & Beau GA & Jeddie GA]

I know how frustrated you must be! Been there myself with this ride (at least a couple of times).

IMO, the Tilly protocol is a good guideline, especially for newly diagnosed cats, and maybe for newly switched to longer insulin cats. After that, though, I think the "rules" don't work as well. Possibly because if good regulation and/or remission didn't happen fairly soon, it means your furbaby has not read the TP and/or isn't good at following instructions. Time to ad lib.

I think Vicky's suggestion of holding the dose for much longer is a good one. Jeddie was doing some bouncing and I was chasing doses until about a month ago. Aside from a couple of really low PS's that scared me a little and when I was out of town one weekend, he has been on .7u for 4 weeks. It has just begun to give nice even numbers in the past week to 10 days.

He used to have a decent cycle about once every 9 days, then he'd drop low, bounce high and I would change the dose (either lowering because it looked like rebound, or raising because he was near/at 300s). This last time I decided to grit my teeth and stay with the dose (except a PS of 68 that I reduced on). He has a little bounce over night yesterday, but looks to have stayed in the low 100s since then.

Just thought I'd share that so you can mull it over.

 

[Marci and Buddy]

Thank you both for your help and support.Vicky-he is on fat .75, not .75
(i don't think u mean I should lower to .75,right?) So we'll ride this out and see where he goes.Hopefully my boy will follow in Jeddies bouncesteps.

 

[Vicky & Gandalf (GA) & Murrlin]

Thank you both for your help and support.Vicky-he is on fat .75, not .75
(i don't think u mean I should lower to .75,right?) So we'll ride this out and see where he goes.Hopefully my boy will follow in Jeddies bouncesteps.

You're right, stay where you're at with the fat .75U.

 

[Pam & Alley]

Hang in there, Marcy, even the experts have a roller coaster ride from time to time, but their advice is the best available anywhere. It is so hard to keep at a consistent dose for a week or more, but it really does get better. Alley was once on 8 units of Humulin N, talk about a roller coaster!!! Now we just experience flashes of those days from time to time.
Good luck, you are doing a great job.

 

[Marci and Buddy]

thanks so much fo this note of encouragement;means alot to me -esp. today when my boys amps was RED!
I agree with you about the expert advice... i have faith i am trusting the right people here-i know by following this boards advice i am doing all i can to help my Buddy.

 

[Vicky & Gandalf (GA) & Murrlin]

Marci and Pam,
You both are too kind. Thanks for the vote of confidence, although I want to express a word of caution about using the word "expert." None of us here are and even medical professionals are sometimes at a loss to explain the ups and downs of a medical condition.

Any experience we have had teaches us things, which is knowledge we can impart to others, and although it may not always be exactly correct, it at least gives others some guidelines. That's all we're doing, helping you to help yourselves and your cats.

 

[Vicky & Gandalf (GA) & Murrlin]

Hey marci,
I have a question about your spreadsheet. When you list a BG value in the +11 box, but the +12 hour box is blank and there is a dose amount listed, does that mean you shot at +11 or just that you didn't think it necessary to test again at +12 when you gave the shot?

If you do shoot early or late, it's helpful to put an arrow --> or <-- pointing to the dose amount to show that you shot that number. Or make a notation in the notes box, "shot +11."

Thanks. I am wondering because if you are shooting early and late sometimes, it will make a difference in their cycles, sometimes a tremendous difference. Sorry about that 430 this morning. Ugh.

 

[Ilkka and Tom]

MY Buddy is not getting better with his #'s. He's hungry, thirsty, and tired, yet playful and purring .
i'm wondering if tonight i should go up to 1u . I'm at my wits end, just dont understand why this time
last year he was green /blue with .50u.and now can't regulate him no matter what i do. :cry:
I am thinkning i should switch to Lantus. If anyone has gone from Lev to lantus i wd. like to know what happened.
Thanks very much.

Hi Marci,

I guess I already answered this question (your pre-dose-lowering posting), but will just add a quick note. I realize my original comment was too long and not clear. But now you are on the other side of having bought the argument for halving the dose, and Buddy is where I thought he would be -- not saying this with an "I told you so" attitude at all.. just saying that all the data supports the interpretation I already gave. He has been compromised by underdosing at key moments, call it optimism, and it is still continuing. That said, he shows great resiliency and is not insulin resistant, which is the danger you run with chronic over- and underdoses, both -- especially the latter over a long term.

Holding the dose longer, which is generally a good idea with Levemir (and with Lantus), won't work either. Holding the dose is the way to go -- if it is the right dose. It generally rewards you when there is a pattern of sharp ups and downs (where PS is more than 2.5x nadir) that get settled over time to some average, which happens because the hormone system as a whole stops reacting to insulin the cat's own beta cells did not make. That is not the case with Buddy...

I don't know of anyone who has gone to Lantus from Lev, thought I am sure there are some people. I almost put Tom on Lantus this time, when he came out of remission, just because it is easier to extract the prescription out of the average vet; then I decided on what for me was the proven course. But I fully believe Lantus would do as well for him. They are extremely similar products.

Good luck. A paw wave from Tom.

 

[Marci and Buddy]

I do appreciate your input-i guess where i am alittle confused is how to know where the ideal dose is, if not from starting at a low dose(50u).i dont think that the higher dose produced better results, i was getting reds when shooting 1.25+...are you saying that wasn't enough and should have gone higher, rather than starting out at 50u and working our way up?
Vicky-to clarify...the +11 # doesn't indicate an early shot, just did not retest an hour later.Thanks guys.

 

[Vicky & Gandalf (GA) & Murrlin]

Holding the dose longer, which is generally a good idea with Levemir (and with Lantus), won't work either. Holding the dose is the way to go -- if it is the right dose. It generally rewards you when there is a pattern of sharp ups and downs (where PS is more than 2.5x nadir) that get settled over time to some average, which happens because the hormone system as a whole stops reacting to insulin the cat's own beta cells did not make. That is not the case with Buddy...

Ilkka, the part I put in bold is all kinds of confusing. How can you determine the right dose if you don't give each dose enough time to show you what it can do???

And you're also critiquing without offering any solutions. I know you're illustrating a point, but it's not helpful and leads me to ask, so what is the case with Buddy? Clue us in please.

It's obvious from Marci's reply that she is now really confused as well. Our goal here is to help caregiver's understand Levemir's action so they can make the right decisions.

Sorry to speak harshly, but Marci is very frustrated and I don't like seeing ideas thrown out that contradict one another and don't offer solutions or at least a course of action.

 

[Marci and Buddy]

Vicky i am actually not as confused now as i may have sounded before...
after reading Ilkka's reply, i went back to his old post and found he suggested that i increase till i hit the right dose,and explained why. i think you missed that post last month. I was not comfortable with increasing, but i do appreciate even the differing views here,they add to my knowledge base. As you say we learn from others experiences, what to do and what not to do.. it's all good. Thanks so much for all your help and concern.

 

[Sheila & Beau GA & Jeddie GA]

The frustrating thing about Buddy's numbers is that a single dose can give both a 93 PS and a 430. And on 1.2-1.25u he was getting to a great nadir, but still bouncing high from it. He goes from 63 to 363.

Ilkka, when you write about holding the dose as long as it is the right dose:

It generally rewards you when there is a pattern of sharp ups and downs (where PS is more than 2.5x nadir) that get settled over time to some average, which happens because the hormone system as a whole stops reacting to insulin the cat's own beta cells did not make. That is not the case with Buddy...

That is exactly what Buddy was doing on the higher dose, so if you suggested raising from there a while ago, this is now contradicting that, isn't it?

What my thoughts on suggesting a "start over" at .5u was to come in below his best dose and slowly raise up to it so he isn't experiencing bounces - so his body can get a "re-boot" from always reacting to a decent, but low number, as a threat and dumping sugar.

Anyway, if he is able to get to 93 at +11 pf .75u, I think he must be near his best dose.

 

[Marci and Buddy]

thank you Sheila , hope he gets it soon, my dear Buddy .

 

[Ilkka and Tom]

I do appreciate your input-i guess where i am alittle confused is how to know where the ideal dose is, if not from starting at a low dose(50u).i dont think that the higher dose produced better results, i was getting reds when shooting 1.25+...are you saying that wasn't enough and should have gone higher, rather than starting out at 50u and working our way up?

Hi Marci

This is the first time I've had a chance to check back in a few days, and I am sorry to have done the ol' "post and run" (I also want to respond to others who have commented on my first posting in this thread).

But yes, to answer your question, I believe that at 1.25 the dose was too low. Why? because the glucose was too high... not just rebound glucose, but week on week of agitation and too many 300s. Just really simply: look at Buddy's chart and see when was the last time that you had a run of a one week or longer, with no 300+ glucose at AMPS? It is Jan 1 - Jan 9, and the dose was 1.5u. Am I not looking at the same chart that everyone else can see? Those numbers are not a matter of opinion.

Now, I am not suggesting that 1.5u is now the right dose. It was then -- but it changes because the cat is not a machine, but a living biological system making adjustments, secreting its own insulin in varying amounts, influenced in part by what you are doing with the dose. Almost the moment the dose was lowered by a mere .1u, the 300+s returned. That is also on the chart ... which is why I questioned whether lowering the dose further was the solution now. Yes, you were getting reds on 1.25 recently, but so what? where have we gotten to the idea, on the Lev boards, that more often than not a high glucose number means too much insulin? Yes, it can, in temporary circumstances -- but isn't the first possibility most of the time the opposite? When we take our pre-dx cat to the vet and he repeatedly measures +400 glucose, is the textbook advice to figure out how to take insulin out?

In any case, Buddy's numbers speak for themselves. Look, I am not for high doses -- they freak me out, actually. I am for low blue and gentle green numbers. If you can get Buddy there by lowering, or holding, or by chanting Om Mani Padme Hum (Tibetan prayer about finding the ideal point), I am all for it. I just don't see how a lower dose has worked beneficially for Buddy and I don't see how the argument that it "kind of did," or that you have not given it a real chance, is convincing; nor do I see that .75 is working for Buddy now. You can't be happy with those numbers... From the chart it seems that whatever the ideal dose is now, it is at least 1u -- maybe more.

 

[Ilkka and Tom]

The frustrating thing about Buddy's numbers is that a single dose can give both a 93 PS and a 430. And on 1.2-1.25u he was getting to a great nadir, but still bouncing high from it. He goes from 63 to 363.

Ilkka, when you write about holding the dose as long as it is the right dose:

It generally rewards you when there is a pattern of sharp ups and downs (where PS is more than 2.5x nadir) that get settled over time to some average, which happens because the hormone system as a whole stops reacting to insulin the cat's own beta cells did not make. That is not the case with Buddy...

That is exactly what Buddy was doing on the higher dose, so if you suggested raising from there a while ago, this is now contradicting that, isn't it?

What my thoughts on suggesting a "start over" at .5u was to come in below his best dose and slowly raise up to it so he isn't experiencing bounces - so his body can get a "re-boot" from always reacting to a decent, but low number, as a threat and dumping sugar.

Anyway, if he is able to get to 93 at +11 pf .75u, I think he must be near his best dose.

Sheila, you're right - he was doing that on a higher dose, but the fact of the agitation just introduces alternative theories about the cause, so the same data serves different theories. I do support the approach of "re-boot" and finding the good dose from below, by raising up, and I would go for that with Buddy, were it not for the fact that we have so much data on him that, short of a real shock, we can't reboot. Even if we subtract the mist and smoke, there remains the fact that his last significant stretch with no pinks was at 1.5u. I think the current numbers also show that rebooting from a low point that causes more reds, is not the best way to go (but it is where we are now).

Re the viability of .75, that lonely 93 would have been encouraging were it not for the fact that it is exactly that -- all alone, the sole green cell, and it really does look like either a fluke or the artifact of hormonal phase synchrony, where various insulin agonists are all at maximum, coinciding with the antagonists being at nadir.

 

[Ilkka and Tom]

Vicky i am actually not as confused now as i may have sounded before...
after reading Ilkka's reply, i went back to his old post and found he suggested that i increase till i hit the right dose,and explained why. i think you missed that post last month. I was not comfortable with increasing, but i do appreciate even the differing views here,they add to my knowledge base. As you say we learn from others experiences, what to do and what not to do.. it's all good. Thanks so much for all your help and concern.

Thanks Marci -- had I been less swamped in the last few weeks I would have answered Vicky along those lines already .. Here's hoping you get to the right dose soon!

 

[Ilkka and Tom]

Holding the dose longer, which is generally a good idea with Levemir (and with Lantus), won't work either. Holding the dose is the way to go -- if it is the right dose. It generally rewards you when there is a pattern of sharp ups and downs (where PS is more than 2.5x nadir) that get settled over time to some average, which happens because the hormone system as a whole stops reacting to insulin the cat's own beta cells did not make. That is not the case with Buddy...

Ilkka, the part I put in bold is all kinds of confusing. How can you determine the right dose if you don't give each dose enough time to show you what it can do???

And you're also critiquing without offering any solutions. I know you're illustrating a point, but it's not helpful and leads me to ask, so what is the case with Buddy? Clue us in please.

It's obvious from Marci's reply that she is now really confused as well. Our goal here is to help caregiver's understand Levemir's action so they can make the right decisions.

Sorry to speak harshly, but Marci is very frustrated and I don't like seeing ideas thrown out that contradict one another and don't offer solutions or at least a course of action.

Hi Vicky,

Yes, sorry for the confusion -- & I don't mind the criticism ... you've always been straight forward and I actually appreciate that. Also I would have liked to reply in a more timely fashion..

With regard to your comment that my postings confuse Marci, I don't think that is right. I don't think it is valid to try to control diverging opinions based on the idea that they confuse the person who is receiving advice --you probably didn't mean it that way, but it goes against the whole idea of a forum offering advice and discussion of the basis for it, not to mention that it is a way of pre-judging the rightness of some advice in order to suppress others.

re Buddy.. you do make a valid point that we can't know if a dose is right unless we hold it long enough for the "noise" (reverb / bouncing) to settle. Dose-holding is critical -- but there are exceptions to the rule. Such as what? well, if there is data to indicate that the dose is wrong, and if at the same time, the cat is being harmed (high pinks, reds), we get to break a rule -- and both things are the case with Buddy. The sheer amount of data on him provides lots of guidance. He was at .75 when I posted, and that dose wasn't any smarter then, just because it was a reluctant retreat from an even lower dose that failed.

Frankly, what baffled me is how anyone could look at the chart and conclude that .5u was anything but a gamble -- maybe justified if the risk was not too high. I was equally curious to know what it is that people see in the chart to suggest that the last known good dose parameter (at least 1.3 - 1.5) is now null and void. Since Jan there is agitation -- doesn't look particularly restful or healing. That is why I think the good dose is in the 1.3 - 1.5 range --& my fear is that if the dose is raised by tiny increments, and slowly, instead of by .25 based on nadirs and not too many hold cycles, the good dose may retreat to even higher ground -- needlessly.