Lucy Wednesday 11/7/12

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123joan

123joan

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AMPS 445 (+24)
Maybe this would have been a good day to begin an increased dose. Since she had such a bad day yesterday (GRAND vomit episode and low PMPS) I didn't think it would be a good day to change dose. I cannot be here to check mid-cycle today, so wouldn't know what results would be anyway.
Tomorrow (Thursday) I can be here to check mid-cycle. Would an increase to 1.4 from 1.0 be too big an increase to try tomorrow? Or should I try 1.2? 1.4 equals almost one and a half units, so I'd be increasing her dose by almost 50%. Too drastic?
 
I think going to 1.4 is fine if you can test mid-cycle.
Carl
 
Hmmmm. Well, you know I am always more conservative than Carl. So another idea to ponder. One unit has given you two pmps numbers that you skipped and then a few wonky cycles after that. The high number this am is because you skipped last night - it's not a "true" number.

I would continue with the 1 unit and get a little more daring at those 140 - 160 numbers. Postpone dinner (she really won't starve even though she will think so) and be sure it is rising and shoot a little less than the one, but not much - maybe .8? You could reduce your no shoot number to that 150 range (as long as you sure it is going up). It has been happening at night so it might be easier to plan to wake up at the nadir and check?

I would be nervous that she would throw you a low number at 1.4
 
I have to agree with Sue.

If you lower your no shoot # and reduce the dose on a lower but rising # you might be able to keep her in lower numbers overall.
 
I would be nervous that she would throw you a low number at 1.4
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Joan,
This is why we are "peer-review" based and opposing opinions are encouraged! The more people input, the more options you have at your disposal.

The "nervous" factor is understandable. But that's why I conditionally said that 1.4u would be okay. If you were to increase at all, the critical thing is that you are there to monitor. If you're there with a lancet in one hand, and a meter in the other, that's how you can remove the majority of the nervousness. You also have to feel confident in your ability to "deal with" the low numbers when you see them, especially if you have to do it with no help at home or from the members of this place.

I've seen a lot of cats, here, in Lantus, on Health, that have dropped to low numbers....."hypo numbers" under 50.

There have been cats that have had clinical hypoglycemic incidents that I've "watched", or rather, I've seen the aftermath.
In just about every case, it has been a cat who had been on a given dose for a while, or a cat who was not being tested regularly, and the bean came home and the hypo was already happening. Never saw it coming.

But I haven't seen a cat who was being closely monitored suffer a true "hypo". There have been a couple of times where a cat went low, and did have minor hypo symptoms like looking drunk or walking funny, or ran off to hide. But in every one of those instances, the caregiver was there, and saw it happening, and was able to intervene quickly. The key to increasing is that you need to be there, and you need to be able to watch for low numbers and react accordingly.

Carl
 
The high number this am is because you skipped last night - it's not a "true" number.
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I respectfully (you know I love you Sue!) disagree. It is a true number. It was caused by the skip last night, but that is exactly why it's "true". If it contained numbers that were due to a bounce from low numbers, then it wouldn't be a "true" number. If it included a boost from food, it isn't a true number. But her BG was over 400 because she hadn't had insulin for 24 hours. It was her real BG, and shooting "more" insulin into it would not have been a bad thing.

You don't want to shoot more if food or a bounce is the cause. But when a number is high because of a skipped shot, it's high for a warranted reason. And if the next PS reading returns her to more "normal" readings (number's that you expect to see or had been seeing), then you would lower the dose back to the normal dose you'd been giving.

Carl
 
I was in a hurry when I posted so I wanted to add that I think the first skipped shot on the 1st was because you shot the regular dose into a lower PS.

Just something to think about.
 
Robin,
Do you think going back to a sliding scale would maybe help?

Carl
 
I'm confused, Carl. I have consistently said that you should not react to a higher number with a higher amount of insulin after skipping because you run the risk of giving too much. If one unit gave Lucy an unshootable pmps, why would you shoot a higher dose after 12 hours without insulin? Yes, it's a higher number but not because the one unit wasn't working and isn't a good dose. It's a higher number because the cat hasn't had insulin for the past 12 hours.
 
I think of PZI as a "if this, then that" insulin.
Theoretically, if you shoot let's say 1u into X, you are going to get a certain amount of drop in BG, right? Just to put numbers on it...
AMPS 250 1u
+6 150
PMPS 125 skipped shot.
The 125 might be the lowest number in the cycle, might not be. Maybe it was 100 at +10?
In any event, you skip because you don't wanna shoot a 125, right?
So, 24 hours later, you get....
AMPS 400
The prior cycle, let's say the low point was 100, just in case it was lower that that 125. So you got 150 points drop from the 1u dose, right?
If the next day you see a 400, and shoot 1u, why would you assume you would get more than 150 points drop from the same dose? So now you get a low point in the cycle of 250. And you're likely to see a PMPS of 300 or higher, or some number over 250 anyway.
Now you have a higher overall cycle. Things aren't getting any better. Yes, you can now shoot at PMPS, but the numbers are all higher.
If instead, you shoot a higher dose into the 400, you get more drop, and likely get a yellow PMPS that you can shoot the 1u into.

This is the whole logic that sliding scales are based on. If the PS number is higher (or lower), and the number is NOT due to bouncing or boosted by food, you adjust based on the number, up or down.
When you skip a shot, you almost guarantee a high number 24 hours later, right?

If what you are after is to be able to shoot every 12 hours, and you can't because the PMPS is too low to shoot, then the corrective action would be to lower the dose. And you would hope that would work and keep the numbers in the same range at shot time, not cause low nadirs, and for this continue to improve going forward on that lower dose.
Skipping sets that process back, because now you have higher preshots, and a dose that isn't likely to be effective on those higher numbers. And I see the way to fix that as being shooting a higher dose into the post-skip PS in order to get all the numbers back down to the levels you had before the cycle that resulted in the low PMPS (the first AMPS in my example), and adjust the dose down to maybe .75 and see if that gives you a shootable number every 12 hours.

In your example, yes the 1u looks like it was too much on the AMPS Lucy had. I guess my argument is that after skipping, and getting the higher number 24 hours later, the 1u would probably be not enough, and the end result will be having to raise the dose to get back to where you were. I think my way gets you back there faster?

Carl
 
I see your logic, Carl. I guess my thinking is that she had several long cycles with unshootable pmps numbers. So I am thinking one unit is a smidgen too much for Lucy. If she shoots a dose into 400 (as though it was a usual number in a usual cycle), she can't be sure how Lucy will react to the higher dose. (since we are thinking she may need a lower one overall) Yes, if she is there with food and the meter and can intervene, it probably won't hurt anything. I just like the idea of letting things settle back down after a skipped dose, see where you are numberswise and then decide how to proceed.

I guess the answer is that Joan needs to be sure she can monitor if she shoots more into a higher number after a skipped dose. I know Lantus TR users are all about reacting to numbers agressively and feeding the low numbers, but that is only safe for people who are around all the time during those cycles. And it is not something I can comfortably advocate.

So, bottom line, Joan. Carl is more agressive with dosing than I am and if you can be there to monitor and feed the lower numbers (if you get them) it can certainly pay off with generally lower numbers.
 
I guess the answer is that Joan needs to be sure she can monitor if she shoots more into a higher number after a skipped dose. I know Lantus TR users are all about reacting to numbers agressively and feeding the low numbers, but that is only safe for people who are around all the time during those cycles. And it is not something I can comfortably advocate.
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I agree completely. I you can't be there to watch, then always side with caution.

And yes Sue, I agree, that Lucy's "normal" dose going forward should be less than 1u so that Joan gets a shootable number AM and PM. Joan can try a reduction to see if that works, and if the numbers climb higher, then she can increase back to 1u if needed.

I think my point was to point of the difference between a high number caused by bouncing/food vs. a number caused by not enough insulin or skipping a dose. And that the caregiver needs to be able to know the difference because (IMHO) the "corrective action" to the cause of the high numbers should be different.

And yeah, I'm the aggressive doser, and Sue is the conservative doser. Which is (again IMHO) a good thing, because if we all agree all the time, there's not much point in asking for advice or giving any for that matter.

Carl
 
Carl, yes I am a fan of the sliding scale but I heard that she already tried it and it didn't work.

I would also agree about lowering the dose a little bit to get shootable PS's but just by a drop, like skinny or fatten it up. I think she's close to the right dose.
 
Carl, yes I am a fan of the sliding scale but I heard that she already tried it and it didn't work.
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Hi Robin,
You know my mantra:

1 - Don't assume that what works today will work tomorrow.
2 - Don't assume that what failed yesterday will fail tomorrow.

I didn't think a scale was working too well for Bob at first. But he was on one the whole time. I'm thinking a "simple" scale might work if/when it makes sense to adjust the dose? It's up to Lucy though, just like it is up to every kitty. :smile:

Carl
 
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