Okay, I will follow MPM then. But unlike SLGS, the MPM guide is incredibly poorly written.
Before I explain all of this for you so it makes it easy for you and other new members to understand, the MPM was written with input by several experienced members who also proofread it for accuracy, clarity, etc. Consider that because you are new to all this, you don’t quite understand it
which is normal. There’s a huge learning curve and we use alot of vernacular not found in everyday life. We all have the same issue when first looking at a method of dosing. So let’s break it down so you do understand the intent and how to use it.
My answers to your questions are based on the
Prozinc Dosing Methods Sticky just so we are on the same page and looking at the same document.
What exactly is the difference between it and SLGS.
SLGS is the initial method of dosing that was developed here long, long ago and all insulin users, regardless of the type of insulin they were using, used it. It’s all we had at first. It was formulated by the moderators and members back in the day based on anecdotal information and data that members were collecting data.
MPM is also anecdotal but is modeled after Tight Regulation (TR) used by Lantus/Levemir/Biosimilar insulins. The TR protocol was developed by Dr. Kirsten Roomp and Dr. Jackie Rand and published in veterinary journals. MPM, like TR, is more aggressive, allowing for more frequent dose changes in response to the BG. As an example, SLGS would have you hold a dose for a full week even if the BG was in the 300s or above where as the MPM allows for the dose to be changed when it’s evident it’s not working.
It says "if you started with SLGS and switch to the modified method, please skip to “Changing the Dose” below", does that mean everything that you skip is to be ignored and instead you follow everything in SLGS plus what is mentioned in "Changing the Dose" under MPM?
The reason it states this is the “starting dose” of insulin is only applicable under either method for the
very first time you use the insulin in a newly diagnosed cat. If you started the initial insulin dose under SLGS at either 1u if the kitty is on dry food or 0.5u if on wet, you wouldn’t go back and start over again if you switch to MPM. As an example, let’s say you feed canned food and start with SLGS. The starting dose is 0.5u. Assume your cat is on insulin for a month and, under guidelines for SLGS increasing the dose, after a month, the kitty’s dose has had to be increased 0.25u every week. After four weeks, the kitty’s dose would be 1.25u (0.5 for week one, add 0.25 for week two, add another 0.25 for week three, add another 0.25u for week four).
The starting dose under MPM (that is if you went straight to MPM without doing SLGS) is 1u. So if you switched from SLGS and the kitty was on 1.25u, why would you drop the dose back to 1u if the kitty had not earned a reduction? You wouldn’t. So you don’t need to consider the information on “Starting Dose” under MPM; that would be the only information you would skip. You wouldn’t skip everything before that.
I was about to create a flowchart of MPM, but I just noticed MPM cannot actually be flowcharted because it contains logical inconsistencies. For example, observe these four bullet points
- In general, dose changes are made in increments of 0.25u. In sensitive cats, it may be necessary to make even smaller changes.
- If a cat is having nadirs above 200, then dose changes of 0.5u are recommended.
- Occasionally we see cats who need the dose held longer than the recommended 3-6 cycles because they are very prone to diving BG numbers or bouncing. Collecting data and learning your cat’s patterns are essential to determining if your cat might be in this category.
- Conversely, holding the dose for too long can lead to glucose toxicity - when the blood glucose gets “stuck” and even increasing seems to do nothing. If this happens, seek advice on next steps.
It is impossible to satisfy all of those. Bullet point #1 recommends considering 0.25 or even smaller changes. Then bullet point #2 says 0.5u changes are recommended for cats with nadirs above 200. Which is it? How do I know that the high nadirs aren't caused by 0.25u changes being too excessive? It's not clear if 0.15u or 0.5u is more appropriate for a cat with high nadirs. Likewise, the last two bullet points are completely contradictory as well. Regarding the third bullet point, how do I tell if my "cat might be in this category"? By opting for bullet point #3, it will likely cause bullet #4 to happen. And vice versa regarding bouncing.
I’m a scientist by education and experience and I disagree that MPM can’t be flowcharted but I also don’t believe it requires it. FD can be difficult enough as it is so keep it simple and don’t make it harder
First, note what it says at the beginning...”general guidelines”. That doesn’t mean every one of these will apply to every cat. So you don’t need to “satisfy” all of them. These list special circumstances you might see that need some flexibility to the standard way we do dose increases. It’s not a hard and fast rule.
Every cat is different.
The first bullet opens with “In general, dose changes are made in increments of 0.25u”. That’s where you start. You don’t make changes in smaller amounts unless you have the data to tell you the kitty needs that particular approach which typically takes quite some time to gather the data. In 12 years, I’ve seen a few cats that needed smaller dose adjustments and my Gracie was one of them (on Levemir) but almost all of these cats are long-term diabetics (as Gracie was).
The second bullet allows one to make larger dose increases if the nadirs warrant it. This guideline is separate from the one above it. And note...it also says “are recommended”. Perhaps that much of an increase is too aggressive for your kitty. So don’t do it. But there are definitely cats here in the +300 BGs on 5u bid who need that kind of increase as well as cats on a lower dose than that.
The third bullet is also separate from the other two. It’s all about
collecting data and knowing your cat. I learned with Gracie that if she responded well to a dose, I needed to hold it for at least 11 cycles to see if she would continue to do well on it.
And the fourth is a warning about what can happen if one holds the dose too long. Members, especially new ones, are often reticent to make changes in the dose especially if the vet is telling them that 300 is a good nadir to have. That builds glucose toxicity but many vets are overly cautious because they are not able to be there 24/7 to help a client with dropping BGs. But this doesn’t just apply to cats in higher BGs. If the nadirs are consistently 250-300, that’s too high and over renal threshold for many cats.
You asked “How do I know that the high nadirs aren’t caused by 0.25u changes being too excessive?” Well, you collect data but that is not what happens. If a 0.25u increase is too excessive, it’s going to cause the BG to drop, not rise. Again, as I said before, it’s unusual for newly diagnosed cats (i.e. cats diagnosed less than a year) to need really small adjustments in dose unless the kitty is just about to remission and we need to taper the last few doses down by drops. You will know if you get to that point because we know what it looks like and when it’s needed. Ask.
I’ve yet to see a high dose cat need a dose increase of 0.15u. But my bigger question is why are you worried about that
now? A high dose cat is one that is on greater than 5u bid. If Mister’s dose continues to climb and you continue to post, members will help you decide how much to increase his dose. For cats that have acromegaly or IAA, once they get over 6-7u, we are increasing by 10% the dose so if a cat is on 8u bid, we’d round up and the dose increases would be by 1u bid.
But you are putting the cart before the horse. Take a deep breath and follow the MPM basics: 0.25u increases for nadirs under 200 and 0.5u increases for nadirs over 200. As you build data, you might determine that 0.5u increases are too much for him if his nadirs are 200-300. So do 0.25u. Keep.It.Simple.
The last two bullets are not contradictory. Read what bullet 3 states: “Collecting data and learning your cat’s patterns are essential to determining if your cat might be in this category”. We also have many experienced members to help you look at data and make that decision. Sometimes it’s very hard to see the forest for the trees and an unbiased eye can spot if the cat needs more time at a dose. For example, consider a situation where Mister is seeing nadirs in the 100-150 range, especially when he first starts seeing those numbers, but then he pops up into the 400s because he’s bouncing. The first thing to do is flatten the curve so he’s not experiencing such fluctuations. That would require holding the dose a little longer.
But again, MPM does not explicitly state how often and when to test. Terms like "at least one" and "ideally" doesn't compute for me.
Not every cat needs to be tested at the same time or with the same frequency. Insulin is not a medication; it’s a hormone. Don’t expect to get the same results from it every cycle and especially not in every cat. Insofar as testing....
let your meter be your guide!!! Unless his BG is dropping quickly or into lower numbers, test at different parts of each cycle especially during the a.m. cycle. Figure out when his onset, nadir, and duration are. That will help you learn when you generally need to test. If he’s dropping by onset, you definitely need to test more. If he’s rising, you can test less.
"How low has the current dose taken kitty over the last 72 - 96 hours" (3-4 days), which is impossible unless your cat fasts the entire curve and you do a full 24hr curve the entire time for those 4 days. Does that mean I have to wait the 1.5-3 days and then do curve testing for an additional 3-4 days in a row, or can these windows overlap? [/QUOTE]
We don’t test 24/7 and you use the data you have. You also don’t need curves for MPM as you would for SLGS.
You should test enough early on to determine his onset, nadir, and duration. If you know “about” when he nadirs (and yes, this can change), then you know when to test and based on that, you’ll see how low the dose is taking him over several days. So it’s not impossible. Members do it here every single day. You are missing the point. If you hold the dose for 3-6 cycles and only test at PS, you are never going to know how low the dose is taking him. So you shouldn’t increase. Conversely, if you have gathered some spot checks at different times of the cycles and it’s clear he’s onsetting at +2, you can start testing at that point consistently to see how far he drops. If you’ve figured out his nadir is in the +4 to +6 range most cycles and after four days, you see his nadir is not dropping below 100 at any cycle, then increase the dose by 0.25u. No curve needed.
Lastly, to increase the dose by 0.5u or less, MPM says I need to do (5 tests in a curve)*(4 days)*(2 curves in a day) = 40 tests before each 0.5u increase?!
No...it doesn’t say that anywhere. It states when you first start out, you’ll want to check at least at PS, +3, +6, +9 for a few days. That’s building data. That’s keeping you from surprises since a new member will not know how the kitty will react to the initial dose of insulin.
MPM should be rewritten to be more explicit. An unordered list is an unacceptable format for something like this. For starters, during that non-curve window of 1.5-3 days, exactly when should I test him and how often? I can test him anytime and any frequency. If I test him at +2 and +4 and see high numbers, then anyone could argue that I missed a nadir at +3 or +5 or +6 or +7. If I test him at +6 and see high numbers, then how do I know the nadir didn't happen at +2, +3, +4, or +5? With these mid-cycle tests, the takeaway seems to be that I'm never picking the correct window. If I pick +4, then I shoulda picked +7 in hindsight. Now that I'm doing +5 and +7 tests, now I need to go back to something before +5?
One thing you will learn is that managing FD is as much an art as it is a science. No two cats are exactly the same just as no two caregivers are. That’s why dosing methods are not written to be so explicit. If they were, many members couldn’t follow them as written because of a variety of factors including their work schedule, other family members’ needs, a cat that doesn’t like to be tested, etc etc. I could go on and on. There has to be built-in flexibility.
The information is right there for you to read. There is a very detailed discussion under “Increasing the Dose”. Again...MPM does not require any curve. No one can tell you when you should test him exactly and how often. It depends on what his cycle is looking like. If you test him at +2 and +4 and you get high BGs, it’s unlikely he’s going to drop so you might want to test at +10. It’s very unlikely he nadired between +2 and +4 if both those BGs were high. I hate to repeat myself but don’t make this harder than it is. It’s never a bad idea to check at PS and +2. If numbers are headed down at +2, how fast? If they’ve come down fast from PS, test again at +3. If it’s slow, test at +4. If the +2 is really high compared with the PS, test at +5 or +6. We can help you decide when to test if you post but this is a learning curve
for you; you will ultimately have to learn when you need to test based on his onset, nadir, duration that you see after you have data and based on what your meter says.
Please read all that, absorb it, and ask me questions. We are here to help and explain things but as you read everything over, keep in mind we have to have flexibility. We have to give general guidelines that members can use to apply to their cat. There is structure but there is also the ability to do what works for your cat. That’s the problem with the AAHA flow charts.....they assume every cat reacts in the same manner. They don’t. Your job is to learn your cat and we can help you learn how MPM works for your cat.
