Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~231

[Sushi (GA 5/05-3/14)]

yesterday


We have run into low pre-shot #s several times in the past few weeks. Really bad timing!! For the most part, the "Dealing with low preshots" info doesn't apply to us. Here are questions I have every time I read it:
"...most kitties can be shot at +12, almost regardless of the number, once you are data ready to do so."
I have worked very hard to become "data ready," but it seems that my data is kind of pointless because Sushi isn't regulated yet. Right? If I am "data ready," what does my data tell me?

"If the cat is not a food spiker or tends to have an early onset/early nadir then they may not want to shoot as low. "
Is Sushi a food spiker? Does he have an early onset/early nadir? Do I have enough data to tell?

"...withhold food and test in 15-20 minutes to determine if kitty is on the rise or hasn’t reached nadir yet."
His #s will continue to drop if he hasn't reached nadir yet?

"Perhaps the most important guideline in shooting low is that any time you shoot your lowest ever number, you should get a +1 and +2 to give you an idea of how the cycle will go...Those tests will also help you become even more data ready for the next time you are presented with a low preshot reading."
I feel like I've done that; what can my data tell me?
See:
Thurs 8/11 PM: +2~97(this was my PMPS) | +4~152
Tue 8/16 PM: PMPS~65 | +2~49 | +3~60
Sat 8/20 AM & PM: AMPS~150 | +3~65 | +4~53 | +4.5~47 | +5~50 | +5.25~59 | +5.75~89 | +7~72 | +9.75~85 // PMPS~105 | +2~186 | +3~198
Wed 8/24 PM: PMPS~111 | +0~102 | +3~107 | +4~71
Fri 8/26 PM: PMPS~92 | +0~86 | +.5~94 | +1~82 | +4~121

Here are inferences I've made; tell me what you think and whether I'm on the right track:
- His PM #s are lower than his AM#s
- His AM cycle seems to last longer--his lowest #s are at his PMPS and beyond.

Last week the amount of food he eats/I'd like him to eat seemed to alarm you guys. I worry about how much he eats because the less he eats, the more impact the insulin will have. If he only eats 3oz per cycle, his #s will be too low because of the high dose of insulin he's getting. I worry about how little he's eating and push him to eat more because the amount of food he's eating needs to be somewhat proportional to his dose.
Sushi weighs 16+lbs. I haven't been able to get a concrete # for the amount of food he should be eating, but I'd like to see him eat between 11 and 12oz a day. And you all think that's too much?
Because I'm gone, he's not nearly as active as he usually is, so he's not been eating well. If I had to guess I'd say ~4oz per cycle? I think this is part of the reason we're running into low pre-shot #s so often.

Still, my main concern is finding a dose that won't cause any trouble. I'm going to be gone most of the week again and the cat sitter will be testing/feeding/shooting Sushi twice a day. I need to find a dose that won't cause any trouble, even if it keeps his #s a bit higher than we'd like, but I haven't seemed to be successful here.

 

[Sienne and Gabby (GA)]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

The easy answer first -- food. Dr. Lisa gives a formula for calories per day: 13.6 x optimal weight +70 = calories per day. So if 16 lbs is Sushi's optimal lean weight, then he should be getting approximately 287 calories per day. Gabby weighs about 15 lbs. She gets about 4.5 oz (1.5 of the small cans) per day. She does need to lose weight. 11 - 12 oz sounds like a lot but it may also be contingent on the calories in what you're feeding.

I'm finding it hard to interpret Sushi's SS. There are a fair number of skipped shots and when you skip, the next pre-shot is high. There are some skipped shots followed by an unearned dose reduction (e.g., 8/24) and times where doses were changed (increased, decreased, and skipped) in the space of 3 days.

While you have data, it's inconsistent. Every time you skip a dose, the cycle count starts over. The more times you skip, the greater the impact on the shed. Data ready is not the same as regulated. Data ready means that you have enough information to guide your decisions regarding shooting and dosing. Perhaps once your schedule stabilizes, you'll be able to get more consistent data.

 

[julie & punkin (ga)]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

hi ashley!

i don't have the experience to add much. the only things i can say are that you shot a 105, but then you skipped the 111 and the 92. meters legally can have a 20% variance in how they measure. so those are all basically the same numbers.

the thing with the food and the insulin - it's a dance. but you can't make sushi eat more than he wants, so that's almost the dominant piece of the dance. if he's going to eat less, and therefore he needs less insulin - it will show up in his numbers and you have to shoot less. perhaps you can supplement him with some zero carbs so that if you're home and he wants to eat more, you have some boiled chicken pieces, or some canned fish cat food with very little carbs that won't really have much of an impact. but what you're looking for is for the dose guidelines to come from his testing information - which comes from the nadir tests. as painful as it is, if i were you i'd set an alarm to get up and test him at +5/+6 nightly. think of it as a dry run for having a baby - they wake you up and you do whatever they need and you go back to bed.

i don't know - i would worry less about the food and more about the testing/shooting consistently - and i realize you're dealing with a bit of craziness in life right now, so all you can do is what you can do.

 

[Angela & Blackie & 3 Others]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

I don't have anything to add, except that the other 2 ladies are right. Hoping that your life smooths out soon for you! Good luck, and have a great day! :smile:

 

[Sienne and Gabby (GA)]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

One final thought. You might want to decrease the dose if you are not going to be around to monitor or if the cat sitter can't monitor. I am wondering how low Sushi went on 8/26 given that you had a green PMPS.

 

[Sushi (GA 5/05-3/14)]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

Hi!
Thank you all for your input. I like where you are going with this; we're on the same page!

From the protocol:
"If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further."
>>Okay, so the only way to properly "earn" a reduction is to have a "close brush with a hypo" incident? How stressful!!!

One final thought. You might want to decrease the dose if you are not going to be around to monitor or if the cat sitter can't monitor. I am wondering how low Sushi went on 8/26 given that you had a green PMPS.

>>Exactly!! I would like to decrease the dose even though Sushi hasn't "earned" a reduction. And that is why "There are some skipped shots followed by an unearned dose reduction (e.g., 8/24) and times where doses were changed (increased, decreased, and skipped) in the space of 3 days."

...you shot a 105, but then you skipped the 111 and the 92. meters legally can have a 20% variance in how they measure. so those are all basically the same numbers.

>>I felt okay shooting at 105 because it was in conjunction with a dose decrease. I skipped at the 111 and 92 because I was not planning to decrease.

Basically, here's where I'm stuck:
I would like to reduce Sushi's dose to make sure we're in a safe range, even if that means #s are higher than ideal, because neither I nor the cat sitter will be around to monitor him. It could be up to a month before I'm in a position to be able to be around and able to monitor closely/handle a "close brush with hypo" incident.
However, according to the protocol, Sushi has to have one of these "close brushes with hypo" to properly earn the needed reduction.
So, what I've been doing is skipping any time I feel we might have a close brush with hypo, because I'm not there and/or able to monitor.
So I either:
(a) continue to give unearned reductions
(b) continue to skip doses whenever I feel Sushi's #s put us in a situation that will require a lot of monitoring (basically 150 or below). In other words: his #s start to gradually fall >> when his pre-shot gets to 150 or below, I skip >> his #s go back up >> resume dosing >> and the process starts all over again. This doesn't feel safe, and it surely doesn't keep things consistent. There's got to be a better way!



A few more questions:
"Every time you skip a dose, the cycle count starts over."
I've started counting the # of cycles at a certain dose. Let me make sure I have this right:
>>On Thur 8/25 I reduced the dose to 4u. Sushi had 3 doses of 4u before we ran into low preshot #s and I skipped. Would the next dose following the skip be #1 (because the cycle count starts over) or #4 (continuing from the first dose @ 4u)? (it may help to look at my spredsheet)

"The more times you skip, the greater the impact on the shed."
>>Does this apply to consecutive skipping or skipping in general? I have a lot of questions on this.

 

[Sushi (GA 5/05-3/14)]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

Obviously, the main question here is: Can I go ahead and give another unearned reduction? If I do, what do I drop to?

Sienne, I know you mentioned you decrease when you go out of town and a sitter takes care of Gabby. What is Gabby's usual dose and what do you drop to in these situations?

 

[Sandy and Black Kitty]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

Hi Ashley,

Basically, here's where I'm stuck:
I would like to reduce Sushi's dose to make sure we're in a safe range, even if that means #s are higher than ideal, because neither I nor the cat sitter will be around to monitor him. It could be up to a month before I'm in a position to be able to be around and able to monitor closely/handle a "close brush with hypo" incident.

IMHO, until the dust settles, you absolutely need to reduce to a dose that will keep him safe, as if he were to be in the care of a pet sitter that was shooting blind.
Put tight regulation and strict adherence to the protocol to the back of your mind for now - your life situation simply doesn't allow it right now.
An exception to that advice would be that if even at the reduced dose you decide on, you happen to catch a 40, then you reduce according to protocol because that's the safe thing to do.
Likewise, if when you are able to test you encounter consistently high numbers, then get some input on whether or not to increase a bit.
It's still very important to shoot 12/12 and not skip. given the right dose, there likely will not be skipping due to low numbers


You will need to be vigilant about ketone testing if you go this route.

Take a look at BKs ss, starting at 07/28/2008. that week and the one that follows gives you an idea of the effort that was required to treat his FD with the presence of IAA and with him being ketone prone at the time. We had to use a strong fast acting insulin called "R" in conjunction with lantus and for quite a while during his journey had to give an R shot every six hours, around the clock. Being that R is so strong and we were giving large frequent doses, we had to closely monitor. DBF (aka the night watchman) went out of town 08/10 - 08/21. I could properly manage the AM cycle, but there was no way I could properly manage both AM and PM. You can see on the ss I just held steady, in spite of all the pink, did plenty of ketone testing, and when DBF returned, we got back to the task at hand.

If you decide to go this route, you will have to steel yourself emotionally to the fact that his numbers won't be ideal.

That's my $0.02 :smile:

 

[Sienne and Gabby (GA)]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

Gabby's dose has varied at the times that I've had my cat sitter here. I've reduced her dose by anywhere from 1/3 to 1/2. I'd suggest you shoot 3.0u vs. the 4.0 you're currently shooting. Any time you can collect data -- evenings, weekends, holidays -- I'd suggest you do so. And, like Sandy recommended, test for ketones anytime you can stalk Sushi to the litter box.

 

[Sam and S'mores]

Re: Low PreShot ?s/Sushi 8/27: AMPS~536(?)|+7.75~258|PMPS~23

Hey Ashley,

Food-wise, S'mores is 14lb and currently eating ~10-11oz per day. That said, he's gained ~1lb in the last month. He's probably still 1lb underweight, so I'm not changing anything, but at some point, I'll probably have to thin it back a little.