Need help interpreting data

[Melissa and Celle]

We had just a couple of shots of the dose reduced to 0.7 before going out of town. It seemed to be leveling things off as far as I could tell.

Then we went out of town. I had pre-filled the syringes and had them in a glass with needle up. My sitter called before the fourth dose and said there was nothing in the syringe -- and that the prior three doses weren't what she would have considered 0.7 units (more like 0.35 units) but she assumed they were correct because they had been pre-measured. I'm not sure what happened, and now I don't know what dose she got while we were gone. The first three were likely less than 0.7, and the final one was (hopefully) 0.7. But she was in the 500s again the day we got back. What is the best explanation for that? Too little insulin the night before? Too much that morning? Too much after getting too little? Maybe it doesn't matter now, but I'd like to understand it.

So then things again seemed to be going in the right direction again until we got a 202 at +3.5 last night, which I suspected was too low. Sure enough, she had bounced up to 477 by pre-shot. So I reduced again to 0.5 units this morning. I don't understand where this is all going though. We can't seem to get her to level off. I don't think we ever had such a problem with rebounding when we were on Lantus. As soon as I have some time I'll put that data online. I keep thinking we should switch back. Is there still hope that Levemir is going to work eventually?

 

[Lana & Yoyo]

Melissa wrote, " I don't think we ever had such a problem with rebounding when we were on Lantus. As soon as I have some time I'll put that data online."

That would be very helpful. Lantus and Levemir do not have a 1:1 dose relationship.

Mellissa wrote, "So then things again seemed to be going in the right direction again until we got a 202 at +3.5 last night, which I suspected was too low"

Why were you thinking that was too low? Were you assuming Celle would continue a dramatic fall in BG? Not sure why you thought that was too low... Hopefully Pamela will post this morning and share with you some of the Tilly Protocols. I think it will take a lot of stress off of you to know there are general guidelines on raising, lowering, and holding dosages and at what BGs you should do it.

Does Celle have any other health issues?

Lana

 

[Melissa and Celle]

Why were you thinking that was too low? Were you assuming Celle would continue a dramatic fall in BG? Not sure why you thought that was too low...

Just because we've been having such a problem with rebounding, even when we aren't catching her falling below 100. She hadn't been that low at +3.5 since she was on 2.5 units, and in that case she did dip down below 100 with a pretty strong rebound. I wasn't worried about a hypo episode, just the rebound, which we saw.

Does Celle have any other health issues?

No, other than being on Paxil for excessive grooming (which it cured).

 

[Vicky & Gandalf (GA) & Murrlin]

Is there still hope that Levemir is going to work eventually?

It IS working! You wouldn't see the 100s or even 200s if it wasn't. This takes time, although Lantus is an excellent insulin too, I see no reason anyone should go back and forth between Lev and Lantus. (Sorry, Lana) Unless you stay with one insulin for an extended period of time, you'll continue to play the "Is it working?" game.

Since you did the smart thing and lowered dose to .5U, it would be worthwhile to stay with .5U for several days, at least 4. if not 5.

Lana, I understand the Lantus board uses Tilly successfully in many cases. Primarily they have Lantus users. I still don't know if there are enough Lev users out there to know if it really works as well with Levemir. That's my 50 cents on that. I don't mean to discount it - I refer users to it as it's a good baseline especially for cats who need more insulin - but many on Lev don't and that's where I begin to differ with Tilly.

My main issue with Tilly is that it does not address the phenomenon of swinging, which is caused by too much insulin. Tilly advises basing dose increases on nadir - which in a cat getting too much insulin can be in double digits! So that would mean no increase (thank goodness) but because of rebound, the next cycle could very well be in the 400s. Which calls for as much as a .5U increase.

So back and forth you go and no wonder new users are confused! The best advice in Tilly for Levemir is to hold a dose for 5 to 7 days, IMO, because it's only after that period of time a dose can reveal what it is doing. We have seen time and again people with whom we've stressed holding the dose raise it based on one preshot number or skip a shot because of a low number at preshot and that throws the whole process off track.

With cats who come to the board on too high of dose based on the swing from 300s to 93 by +5 like Celle had on 2U then 500s on 3U, it becomes very difficult to get back to square one, which would have been a low starting dose such as .5U.

Melissa, on interpreting what happened while you are gone - it's water under the bridge. Without the data for those few days it is impossible to tell if she was getting not enough insulin or what happened.

I'll just put it this way - since you are now at .5U the best thing to do is stay there for the period of time Tilly recommends and then make it a priority to get a curve on the 5th day. And test for ketones, especially if there are any eating issues or cat-not-acting-right.

I'm sorry that does not answer your question, Melissa. I am glad that you are trying to understand and rest assured you will eventually be able to help Celle. It just takes time and that's hard for us humans. Remember that animals don't have a sense of time. Celle only knows you're doing what's best for her. cat_pet_icon

 

[Lana & Yoyo]

Vicky wrote, " I see no reason anyone should go back and forth between Lev and Lantus. (Sorry, Lana) Unless you stay with one insulin for an extended period of time, you'll continue to play the "Is it working?" game."

I am absolutely clueless where you are coming up with this remark. If you are referring to my comment about Lev & Lantus not being 1:1, I was telling her that if Celle was on 2 units of Lantus before she switched to Levemir, she should not expect 2 units of Levemir to be the same effective dosage.

Vicky wrote, "Lana, I understand the Lantus board uses Tilly successfully in many cases. Primarily they have Lantus users. "

OK. I get the message. Loud and Clear. However, any knowledge I have of the Tilly Protocol comes from Pamela on this board and I have found it to be invaluable. If you have problems with it, you need to work it out with Pamela, not use me to take a swipe Pamela's advice.

Lana

 

[Vicky & Gandalf (GA) & Murrlin]

Vicky wrote, " I see no reason anyone should go back and forth between Lev and Lantus. (Sorry, Lana) Unless you stay with one insulin for an extended period of time, you'll continue to play the "Is it working?" game."

I am absolutely clueless where you are coming up with this remark. If you are referring to my comment about Lev & Lantus not being 1:1, I was telling her that if Celle was on 2 units of Lantus before she switched to Levemir, she should not expect 2 units of Levemir to be the same effective dosage.

Just because Melissa asked if it's working.

Vicky wrote, "Lana, I understand the Lantus board uses Tilly successfully in many cases. Primarily they have Lantus users. "

OK. I get the message. Loud and Clear. However, any knowledge I have of the Tilly Protocol comes from Pamela on this board and I have found it to be invaluable. If you have problems with it, you need to work it out with Pamela, not use me to take a swipe Pamela's advice.

Lana

It's nothing personal, I know Pamela fairly well and I agree that Tilly can be very useful for a lot of cats on Lantus. If I have an issue, it's that Tilly is not the end all/be all which it sometimes is promoted as on the board as a whole. And I am afraid that it might confuse things even further for Melissa because Celle is not following the Tilly rules since her dose was so high.

Sorry if I came across as confrontational. I directed the comment to you because it's easy to just throw Tilly out there (I am afraid I have done the same thing occasionally) as the solution, but there is sometimes more to finding a good dose than Tilly offers.

 

[Sheila & Beau GA & Jeddie GA]

It's water under the bridge, but I find it hard to believe that predrawn syringes "lost" insulin. I have left predrawn syringes for sitters on several occasions without trouble and I leave them needle up in a glass in the fridge too. The first time was when Beau was heading OTJ and my sitter was testing and didn't use them at all so I used them myself after I got home. The dose was tiny, but it was still there - and still worked even 3 weeks after I drew it.

Melissa, right now I would second the idea of letting .5u settle. There have been so many changes in the past month (insulin, doses, food, etc.) it is hard to tell what is causing the high numbers. And, in general, .5u is the dose "we" recommend as a starting dose on lev. If you can get any additional tests in every bit of data will help figure things out.

I also have to confess to thinking that the Tilly protocol doesn't answer all the questions and situations that come up when trying to regulate a cat on the longer acting insulins. It is/was a very good guideline to start out on, but at least for lev it is too "coarse". We have found with cat after cat that lev 'likes' smaller does changes then are called for in Tilly. I am not even sure you can look at the numbers the way it suggests to determine dose changes. I have a big problem with the dismissal of the rebound phenomenon. And many cats simply don't follow the rules :mrgreen: so you are left with having to do what is needed for your cat anyway. I do think the basics of starting low and making stepped dose increases and allowing them to settle is good. Frankly, since the TP is many years old by now, the collective experience on this board goes way beyond it anyway.

 

[Melissa and Celle]

Thank you everyone for the advice. I'll stick with 0.5 units and do a curve on Saturday, which is my only chance this weekend to test during the day.

It's water under the bridge, but I find it hard to believe that predrawn syringes "lost" insulin. I have left predrawn syringes for sitters on several occasions without trouble and I leave them needle up in a glass in the fridge too. The first time was when Beau was heading OTJ and my sitter was testing and didn't use them at all so I used them myself after I got home. The dose was tiny, but it was still there - and still worked even 3 weeks after I drew it.

I also did a test to see if I could replicate the problem, and I couldn't. But if the sitter said there was no insulin in one of the syringes, then presumably there wasn't, so I don't know what happened. I'd like to know so that next time I leave I have some confidence that I know what dose Celle will get -- either by pre-measuring or having the sitter measure.

 

[pamela and tigger]

Regarding using Tilly, I like protocols and I like guidelines whenever possible. I do agree that increases of .25 and 0.5 can be too much for a lot of these lev kitties.

Usually when I post it I try to remind the person that it is a "General Guideline" just like it says in the sticky. That the increases may be much smaller than that.

Lana, I also found it invaluable when I started out using Levemir. I was so used to PZI after so many years that just constantly reading the modified version of the Tilly protocol would remind me that Levemir was not PZI and not to treat them the same way.

Also keep in mind that Tigger is not a low dose kitty either. Just recently he has gotten back down to 2 units but was back and forth between 3.0 and 4.5 units for a long time.

So I still will refer people to the protocol when warranted. I think even if someone doesn't want to follow the protocol exactly it does help to understand how the L's work.

Sorry to hijack your thread Melissa!

I wanted to ask you how old is Calle? I looked back in your posts and couldn't find it. I did see that there was a discussion on the importance of getting a dental. I agree with what those posters said. It is hard to get a cat regulated if there are dental issues possibly standing in the way.

I think vets use that phrase, "lets get him/her regulated first before we tackle the teeth" and the anesthesia thing, is only said because they don't want to dump too much on the caretaker right off the bat because just dealing with diabetes at first is such a challenge! Also, they want to see them get 'somewhat' stabilized on insulin and a routine established.

Also, how often do you give her the Paxil? I think you said she has been on it for years? I wonder if it would be possible to wean her to smaller and smaller doses to see if the hair pulling comes back? (Of course, you would have to check with your vet).

Hopefully this dose will do the trick. The curve on Saturday will be interesting to see.

 

[Darlene & Jack]

Thanks for the more in depth explanation and discussion on the Tilly protocol. I was so confused by that too. it was recommended to me to follow when I first switched to Levemir. So after sitting on doses for a week or more than changing by a drop increase, I was told I was "dose hopping" too much. So I was totally confused because Tilly says to change every 3 days or 6 cycles. Very confusing for us newbies!

 

[eeraby]

Keep up the good work! I, too, think the 0.50 is worth doing for 5-7 days

 

[Sheila & Beau GA & Jeddie GA]

I also did a test to see if I could replicate the problem, and I couldn't. But if the sitter said there was no insulin in one of the syringes, then presumably there wasn't, so I don't know what happened. I'd like to know so that next time I leave I have some confidence that I know what dose Celle will get -- either by pre-measuring or having the sitter measure.

Could you have put an empty syringe in there by mistake? You know, filling a bunch and missed one? Maybe putting them on their side instead of needle up in a flat dish? I have a glass dish that is rectangular and about 5"x7" - something like that. That way they would get picked up by the barrel instead of by the cap. I could see someone reaching into a glass to grab the syringe by the top (cap) and accidentally pushing down on it, or an adjacent one.

 

[Vicky & Gandalf (GA) & Murrlin]

Melissa, I just realized you have an avatar now! Celle is a very pretty girl! Such intense eyes. Hope things are going well.

 

[Melissa and Celle]

Could you have put an empty syringe in there by mistake? You know, filling a bunch and missed one? Maybe putting them on their side instead of needle up in a flat dish? I have a glass dish that is rectangular and about 5"x7" - something like that. That way they would get picked up by the barrel instead of by the cap. I could see someone reaching into a glass to grab the syringe by the top (cap) and accidentally pushing down on it, or an adjacent one.

I guess I have to consider it a possibility that I forgot to fill one, but I remember being super vigilant to check that all were exactly the right dose, so I doubt it.

Melissa, I just realized you have an avatar now! Celle is a very pretty girl! Such intense eyes.

Thank you!! She's my beauty.