Hi Lori (of Lori and Tom),
I am going to write this post as if more people are reading it than just you so don't think I am 'dumbing it down' or talking down to you. I am simply going to try to spell out my general thoughts as thoroughly as I can. I take every case very seriously no matter my level of involvement so bear with this War and Peace-length post. I will make some general comments then get to your specific questions.
As we all know, there is more than one way to manage a diabetic cat…..different roads leading to the same goal. I understand that there has been a rift between the YDC and the FDMB management styles but I will say that I am a bit of a hybrid between the two concepts because I will always struggle with the fact that giving two injections of exogenous insulin - at set amounts - exactly 12 hours apart - is miles away from how the body works physiologically. The pancreas, in real life, spits out different amounts of insulin…. many times a day….. depending on the current BG level. Cats vary in the speed in which the metabolize both endogenous and exogenous insulin…etc…etc. Lots of variables. This is why Dr. Hodgkins' management style has always intrigued me - even while recognizing its cons.
Keep in mind that when Lori first contacted me many weeks ago, she was a YDC member and was also intrigued with their management style; much of their protocol made sense to her, as it does to me. Also note that I have not been involved for the entire duration of Copper's management.
For anybody reading this who is not familiar with YDC, they shoot based on a sliding scale (SS) depending on the BG value at that point in time. The higher the BG, the more they shoot - just as the pancreas would do in a natural setting. They will shoot up to 4x/day in varying amounts but usually shoot 3x/day (every 8 hours)….again, closer to what the pancreas would do in real life. Their goal is to
NOT have a definite curve but to keep the cat euglycemic (normal BG) for as many hours each day….mitigating the devastating effects of
glucose toxicity on the body.
It is not the FDMB way but it does work for many cats. That cannot be argued. Remember…. more than one road…..
We are all products of our experience and that is going to be reflected in how we approach any task. My style has worked for me resulting in a lot of cats going into remission without a single clinical hypo. Of course, the same can be said for other management styles. Is that to say that I am not upset over Copper's 29? Absolutely not! I do not take that lightly because even though he was not showing clinical signs of a serious hypo, it goes without saying that we do not want to see 29 on a meter. Plain and simple. As stated above, this was a first for me but given the fact that exogenous insulin is all that we can control (other than diet) and the fact that there are so many factors influencing a cat's BG, it will probably not be the last.
Copper had been on that dosage for 6 days before he dropped low and there was no obvious reason to suspect that kind of a drop. (I see 2.6 as not statistically different than 2.8 and even IF you could measure a 0.2 dosage with great accuracy, we are only talking about a 7% difference. I see this as close-to-negligible which I know others will disagree with.)
Given that there are MANY things going on in the body that influence the BG level, it is my opinion that we all get too caught up in thinking that the dosage we give is so critical down to the 0.1 or 0.2 unit….and that the *only* reason a hypo occurs is because of an overdose. Exogenous insulin is only one piece of the puzzle. This is why there is always going to be a risk of hypo because what if the pancreas just decides to wake up that day and join the party…adding to the exogenous insulin? What if some infection/inflammation subsided….or stress was reduced….or the patient lost some body fat…..any of which would render the patient more insulin sensitive? (Again, I know I am preaching to the choir here but am just 'talking out loud'.)
We have all seen those cats that just suddenly decide to go into remission (which is why we always test before shooting….which my colleagues think is
pure craziness….ie…."stressful micromanaging"….you guys should read the comments I get on VIN when I so much as mention testing before every shot….they think I am nuts and I have caught a lot of flack for it…..but I digress….).
Most cats *gradually* go into remission but I am working with a patient now that suddenly decided he did not want to be diabetic anymore. Fortunately, he made a nice soft landing down to 0 insulin from 3 units BID being supported on the way down with small amounts of insulin. (That's another thing that drives me crazy about my colleagues…they just pull the rug out from under the cat by stopping insulin….zero support on the way down.)
So after the *general* comments above….I will address your question here - keeping in mind that *generally* speaking *some* cats experience longer durations with a higher dosage….shorter durations with lower dosages:
ok, so why was the curve not a curve and just a downward slant for 2 or 3 days dr. lisa?
Here is where our management styles are going to diverge.
It sounds like you see a downward slant as a sign that the previous dosage was too high and you would want to lower the dose to get the curve that you are comfortable with. Lowering the dose may shorten the duration which would allow you to shoot your set BID dosage. This decrease in dose may - or may not - result in a decent nadir. If not, then the patient will continue to suffer with glucose toxicity for more hours than he may have if a downward slant had been accepted. Keep in mind that as that curve rises back up again, the hyperglycemia will harm the body.
I don't focus on whether the numbers form a curve or slant -
I focus on how many hours the body has to deal with hyperglycemia. When I see a slant, I am actually happy because I see that the patient is not drowning in sugar.
If you are using more of a hybrid style of management, a downward slant is just fine. I don't need to see a curve but then that is where the sliding scale comes in which drives the 'anti-dose hopping' folks to drink. :smile: That said….UNwarranted dose hoping makes me crazy just like it does to you guys. I would much rather stay consistent because this journey is hard enough as it is without adding more inconsistency to the mix so we are on the same page there.
That may seem like I am contradicting the YDC style but the bottom line is that I just have to take it case-by-case, cycle-by-cycle and am loathe to follow a set, rigid protocol that demands a curve and not a slant. (I was kicked out of Girl Scouts for not wanting to conform….)
I digress, yet again…...In my youth I was more stubborn in thinking that "there is a right way and a wrong way, by golly!!" and would accuse others of doing it "wrong" or state that they were "making a mistake" if they were not doing it *my way* Now I just see that there is more than one way to get to the same place and I am less judgmental when others are doing things differently. Also, it gives me more flexibility with each patient.
Don't get me wrong - the vast majority of my patients are handled the FDMB way with a set amount of insulin twice a day but, with some patients, I step outside of the rigid 'box' and try a hybrid management protocol and it has worked very well for my patients. (Honestly, I really do hate rigid protocols because one size never fits all. I think back on how much I have altered/expanded on what I learned in vet school 30 years ago.)
i will stand back and watch but for the life of me i cannot read that chart and not see a series of cycles that were indicative of too much insulin.
And, as I have already acknowledged on other threads, Copper may very well need a lower dose but I disagree with you that this is a clear-cut, "no brainer" case.
By your statement and question above, I am assuming that you are focusing on the downward slants because there are no *clear* cycles that are scream rebound. (It goes without saying that any *clear* indication of *warranted* rebound (versus UNwarranted) signals a need to lower the dose.) Therefore, I am going to assume that you are talking about slanted lines because this is what you were heavily stressing on the phone with Lori.
Again, downward slants just get less insulin for that low PS - after checking for a rising BG….or I may even shoot just a very small dose on a plateau. I don't see slants as a "no brainer" indication that the dose needs to be lowered in every case.
Another digression….but an important point is that Copper is not the same cat today as he was a month ago…or the same cat that he will be in 2 months from now given the dynamic changes in the body with time. That is why it is impossible to state with complete certainty that any cat will react the same way to any dose at any given point in time as he may have previously - considering all of the physiological variations in the body. He may very well be more insulin sensitive today (and need a lower dose) than he was a month ago given the effect that glucose toxicity (which we are trying to rescue him from) has on insulin sensitivity….ie…it decreases insulin sensitivity/promotes insulin resistance......necessitating a higher dose.
That is what all of our management is all about - rescue the cat from glucose toxicity and, hopefully, watch his insulin needs drop right into remission.
Back to your question:
The FDMB way, which is the management style that you practice, says to lower the dose if:
1) there is a downward slant or
2) there is an indication of rebound
#2: Of course we all agree with #2 - IF we think the rebound is
warranted but not necessarily for
UNwarranted rebound. (Unwarranted = the body overreacting to a lower - but still very safe - number that it is simply not 'used to'…..a number that is still higher than we want.) I digress again…and this was covered in another thread…but sometimes the distinction between the two (warranted vs unwarranted) is not made. Or, the distinction is made but the dose is lowered on an UNwarranted rebound which I do not necessarily agree with. Dr. Hodgkins' protocol pushes through the unwarranted rebounds. However, I am careful to take a more moderate approach and am not as aggressive as Dr. H.
#1: I don't necessarily agree with #1 in every case for reasons stated above.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Getting away from the slanted line issue and moving to rebound which is my most significant concern with *any* case that hints at it…..
My concern with Copper was always the possibility of unrecognized rebound - not slanted lines. This is where that 24/7 BG monitor would come in very handy. (Again, the issue of unrecognized rebound was previously discussed on another thread - the one that said "you guys may be right and that a lower dosage is needed"…and talked about with Copper's mom at great length.)
We all know that this is the big question anytime we have high PS's and don't have a lot of data to give us a good idea of nadir….leaving us wishing that we had a minute-to-minute monitoring device on him to see if:
1) he dropped low enough to trigger a warranted rebound….or
2) he just dropped lower than his sick body was happy with….triggering an UNwarranted rebound…..or
3) he was just experiencing shorter duration that cycle….or, if no mid-cycle data….
4) he was simply high and flat suggesting possible insulin resistance
All we can do is guess - being careful not to make strict assumptions based only on the shape of his chart.
As discussed on another thread, I think that many people focus on rebound and do not ask the question "is it simply a lack of duration?" (Jojo called it "BIPO"…big insulin poop out.)
The choices, as we all know, are to:
1) lower the dose ('rebound check' - with ensuing
**exacerbation of glucose toxicity if not in rebound** or
2) to *slowly* (definition varies among us) raise the dosage and keep monitoring. As we all know, this is a decision-making situation that occurs here daily.
4-5 years ago when I was spending more time on this board, I saw many cases of 'rebound checks' that made me cringe as I watched these cats
*drowning in glucose* as the owner *slowly* crawled their way back up the dosing scale. Truth be told, it made me crazy and I had to stop looking at those cats' charts.
Back to our 2 choices:
Given that I focus heavily on *glucose toxicity* - which Copper was/is showing serious signs of (unless he has an ortho problem that we are not aware of) -
*and* the report from Copper's mom that he was *doing better as the dosage was being increased* -
*and* my past experience with other cases like Copper's -
the decision was made to slowly raise the dose - with sincere acknowledgement that "a lower dose may very well be needed" as already stated on a previous thread.
I know that I am preaching to the choir here but Lori had made several mentions of Copper doing better, clinically, at higher doses. This was factored into the decision as it should always be. We can't just look at the numbers - especially without that magical 24/7 monitor.
I am going to digress again here: Regarding the word "slowly" - Unfortunately, my colleagues rarely raise or lower a dosage by any amount less than a full unit. I am trying VERY hard on VIN to change this mindset and to remind them that there really are smaller doses. I am having luck with getting them to embrace 0.5 unit increments but forget anything lower. I get laughed at when I mention anything lower than 0.5 units….mainly because they feel that it is impossible to accurately measure. I also got laughed at when using "fat" and "skinny". On a good note, at least they are now discussing syringes with half unit marks.
i would lower dose on a lower blue number. but thats me. cut in half in necessary.
Are you talking about simply a blue PS? Or a mid cycle number? If you are referring to a PS, then yes, a lower dosage is warranted - for that shot - but you see a slant as a failure…an indication that a previous dose was automatically too high…whereas I don't. I just see it as a great PS/long duration….with the need to establish direction and shoot accordingly…..the need to be flexible (not rigid with the dosing) and closer to natural physiology as stated above.
Glucose toxicity:
Why am I sometimes more aggressive than most? It is because
I can't stand to watch cats drown in sugar. There is, understandably, a fear of hypo but, on the flip side, I rarely see glucose toxicity discussed. Yes, I know that patience is definitely a virtue with this disease but, as noted above,
I have also seen the 'start low go slow' mantra seriously overdone in some cases when I used to spend more time here. I have no idea how it is now since I am not here much. Compared to some of my colleagues, I move like a damn snail but others think I move too fast.
Lori - I know that you see this case as very clear and very straight forward when looking at the previous data but If Copper's case was so straight forward then what would that say about my other cases that have shown his pattern (including downward slants) that have been well-managed right into remission with gradually increasing dosages? That is certainly not meant to sound defensive but it is simply a valid question/comment/fact.
I may follow a 'road less traveled' but it sure has gotten a lot of cats into remission just as other 'roads' have accomplished.
I really do appreciate your questions which only results in more learning for all of us. I don't think that any of us come away from any case without learning from it. But that said, I have often asked: "why are we so wise once we are on our death bed"? That seems like such a waste of experience and knowledge! :smile: I always wish that we could have a dry run at life…gather all the wisdom we need….then start again. But since we can't, we just all have to do the best that we can and expect to be thrown curve balls on occasion since we can't predict or control everything.
Oh…and could we add on a crystal ball and a continuous glucose monitor to that wish list?
Maybe he will give us a Christmas present of some safe greens.
