? ? On reduction 11/2 Methos amps 345 +3 238, +5 190, +8 192, +10 183; pmps 231; +2.25 309;

[SmallestSparrow]

Last post: https://felinediabetes.com/FDMB/thr...-202-4-195-5-209-6-166-9.295210/#post-3217438

not to be a broken record but I never got a feel for the answer and here I am again (with another twist)

when last seen @Wendy&Neko had wisely suggested I decrease to 2.75 BUT I wasn’t sure at what point I should do that AND several periods of high BG and ketones 0.8-1.0 intervened so instead he was increased to 3.5. His nadir merged with PS and his dose decreased to 3.25. He continued to (I assume) bounce or at least have totally erratic nadirs and the highest BG he’s had so far. Despair doesn’t come close to describing my level of depression.

I think here @Suzanne & Darcy @JL and Chip and @tiffmaxee all took turns bucking me up and wondering about 2.75. This past week he had a virtual IM appointment and among my many questions was did he need a different insulin or just how I was supposed to manage when he swung so widely and unpredictably and increasing helped one cycle then things were worse for two more.

I still don’t understand if the idea is if I keep giving 3U (current dose) with PS of say 150 if he will eventually not need me to poke and push MC food. If the answer is yes I will continue to do that I just want to know it won’t be forever.

or if I should decrease to 2.75 when do I do that? When his PS is on the low side? Or it doesn’t matter? And should I expect his BG to worsen for a while? If so should I wait until his ketones are normal?

I ask again because I may be facing a lower PS in 90-120 min (I may slip in honor of daylight savings)

to add the new info the IM said since he’s had BG in 70/80 on 3 he didn’t think increasing insulin was the answer (didn’t clearly state however if 3 was too much). He thought the answer was an increase in vetoryl which I plan to do Monday (to avoid ER if issues if possible). Increasing the vetoryl may (?suddenly) decrease his BG (depends on how much is cortisol driven). Unfortunately he wasn’t diabetic when I was increasing him up to his current dose so I have no past history.

Would you say give 3 tonight no matter the PS? If PS is low 200s or lower should I try 2.75 and if not, when would I try that? I asked my vet Friday and she wanted me to stay at 3 for at least 3 days (and I get the rationale for seeing where he’s going) but if this is a perfect time to switch I can beg forgiveness afterwards. I think she thinks 2.75!wont be enough (and when his ketones were 1.0 I was totally on board with that) but I don’t know that part of his swinging between 470 and 80 is because his dose was a bit too much.

to reiterate, it’s not the having to test and feed that’s the issue but I don’t think these 300+ BG swings are good for him. Otoh he looks like death when his BG is 400+ so I also want to avoid that.

so confused. So desperate.
Thanks for your help

I’ll try to post the IM report but it was blurred when my vet forwarded to me so not sure if it will be readable.

edit: to be clear he’s had some low nadirs (I know not low for here but low for me & vets) on 3 but often his nadir on 3 can be mid to high 200s which is how he got to 3 and beyond in the first place)

I know he’s not the usual cat but since some have said 2.75 may be a more even dose, if i change to that when would be the best time to try?

 

[Heike & BInie]

That is really a lot to handle with Methos various conditions and you are such an amazing advocate for him! I hope you get an answer on your question soon!

 

[JL and Chip]

I don’t have a direct answer to your dosing question, but I do have a couple of questions that might help guide the decision. Knowing that you’re using an AlphaTrak 3 meter:

1. What is your goal for nadir?

2. What is your “reduce dose” number?
This should be the number at which you take a dose reduction, no need to analyze in the moment.
For the garden-variety feline diabetic using a pet meter and SLGS dosing, I believe the number is typically 90. However, that can be adjusted for extenuating circumstances and Methos certainly qualifies.

You’ve wobbled around a bit on dosage and I sympathize with you, but you have a lot of variables to contend with and it seems to me that if you pick a reasonably “safe” dose and stick with it (even shooting what you consider uncomfortably “low” PS numbers) you’re at least removing the variable of dose jumping from the equation.

Also remember that what you shoot in the current cycle can affect future cycles, just as what you’ve done with previous doses can potentially affect the current cycle. It’s not a matter of “in and out in 12 hours”—Lantus can have some “hang time” in cats.

It’s also probably good to have a “no shoot” number. Obviously if he’s at 56 on a pet meter, for example, you clearly wouldn’t shoot and you would immediately intervene with food/karo. Anything much under 70 on a pet meter is considered too low. But you might need to get more comfortable shooting blues. And remind yourself that you’re not shooting where his BG is now, but where it’s going.

Finally, cat’s insulin needs can and do change, so how Methos reacted to a dose a month ago might have no bearing on what he will do on that dose today. That doesn’t mean it’s hopeless, it just means don’t get too hung up on the past when evaluating the “now.”

Hopefully the others will be along soon with more specific advice. But I will say that nailing down a target nadir and “reduce dose” BG can take some of the guessing out of everything. You will have a “recipe” to guide you. You can always tweak and perfect the recipe as you proceed on this journey.

 

[tiffmaxee]

I would not have increased to 3.5 on 10/31. The stall and not shoot with the AT is 68 and not 50. With the ketones I would do everything in my power not to skip unless under 100. I’d stall and hope the bg goes up and you could at least give a token dose. There’s so much for you to have to consider your head must be spinning. Mine is and I so wish I had the answers. See what the pm bg is.

 

[SmallestSparrow]

Huge thanks to @tiffmaxee and @JL and Chip. So pmps 231 (I knew if I asked he would so that) so he got 3. He’s been getting something ever since his ketones problems began. The wavering between 3.25 and 3.5 was me not clearly understanding how much of an increase my vet wanted (when we discussed an increase I was using syringes that wouldn’t allow a 0.25 estimate. Finally I said screw it and changed to ones that did but wasn’t going to text her at 3 am to ask if 3.25 would be better.

my no shoot number was 100. Now with ketones it’s more “let’s try to avoid having a PS of 100”. My first month there were a couple of NS in low 100s bc i hadn’t clarified what NS would be since until those he’d had PS of high 200s to mid 400s.

the problem is his nadir. Between 1 and 3U his nadir tended to fall at +4.5-5.5 IIRC but would be in the high 200s to high 300s. BUT at 3.5U he began to have an occasional nadir in the 100s (still most in the mid 200s or higher) which in theory says “needs more”. Just before I gathered my courage for an increase he decided to push his nadir to the following PS. This resulted in a delay and four cycles later a NS (which I admit by rules should have been 1U). We tried going back down to 3.25 in search of a number that would move the nadir earlier or at least not approach a 100 PS. He responded by giving me an unexpected 75 at +5 for an AMPS of 342. Scarring me for life so I now almost always get a +2 no matter the PS. Dropping to 3 he continued to sprinkle cycles of nadirs in the mid 300s with PS under 80. So back down to 2.5. So I guess you could say we reduce if his BG goes below 80 and definitely if that’s his PS. I’ve been texting my vet if he’s been on a dose at least a week and Nadirs are still above goal (her goal 100-150, I’m fine w/below 200) —to ask about an increase,
Sometimes she has me go another week or two—or I text anytime I’ve had to shoot a decrease dose or if he’s gone below 100 or only stayed above 100 with tons of food.

I was hopeful at 2.5 (which earlier had done nothing) because his numbers were much better BUT it meant I often had to test and feed him non stop all day long and he’d have good numbers one cycle then bad ones the next until his nadirs again moved to PS. Coinciding at this point I stopped his vetoryl and spiranolactone for 2 days for hyperkalemia, then gradually resumed vetoryl and half strength spiranolactone. His ketones went up just prior to stopping his vetoryl and spiranolactone, actually during a cycle of lower BG (so who knows) and have been pretty bad since then no matter what his BG is but definitely worse with higher BG. He got back to 3U and then 3.5 for nadirs that were at best (rarely) in the 190s and more often 250-350, losing weight he can’t afford to lose and not eating.

TLDR: I guess for now I’ll be holding at 3U and see what 15 bid of Vetoryl does besides stress my heart. But he may need to drop to 2.75 (my vet doubts this and she’s usually right) and if he does is there a better time? Don’t do it if “bouncing” or do it if bouncing or doesn’t matter? Don’t do it if ketones up or ignore ketones and just do it?

 

[tiffmaxee]

I think 2.75 is not enough. Better to give 3.0 and extra carbs if getting too low and needing too many ear pricks. What do you think?

 

[SmallestSparrow]

I think 2.75 is not enough. Better to give 3.0 and extra carbs if getting too low and needing too many ear pricks. What do you think?

I think if my vet says it and you say it then it must be right. He’s going be be getting an extra half pill pocket twice a day with the Vetoryl increase. I need to find a med carb food that isn’t the one I have now. He adores it but I’m not a fan of the ingredients. But how would I avoid the ear pricks, just assume he will be low and feed more carbs with breakfast and dinner? Or check +2 and then put more carbs in his subsequent snacks and meals (4 meals and 4 snacks daily)? Today I tried giving him a bigger breakfast (since he cooperated with that but it makes me anxious about his pancreas to stuff him) to wait for a +3 test trying to get over my anxiety of getting a +4 below 80

 

[tiffmaxee]

You need to update the ss.

Rather than feeding a bigger meal at shot time I would feed at onset.

 

[SmallestSparrow]

To be clear my vet didn’t ask him about Regular Insulin that had been a question of mine, asking since trying to lower his nadir pushed it sometimes into PS and threatened to push PS under 100, could we use a lower baseline of Glargine that suits the days he decides to be low, and on days he spikes use regular. The answer was no, increase vetoryl. But I don’t want anyone to think that was my vet’s question. I was just getting desperate to stop his BG swings from 70s to 500 and neither increasing nor decreasing his Glargine was doing it
Report

turned out as illegible as I feared. I’ll get a hard copy next week to scan

 

[SmallestSparrow]

Also to be clear the 2.75 was suggested to try to get a curve without lows requiring lots of sticks to his tattered ear, and a reliably PS no where near 100, and reduce his exaggerated bouncing if his nadir goes too far below 150. I liked that idea a lot but his ketones have seemed too high and his BG too high to figure out a good time to try it. Every time I’ve thought “ok this time” he says “not tonight old woman” and plays a red card.

 

[Wendy&Neko]

If you were following our SLGS dosing method (which I don't think you are), he is due an increase to 3.25 unit. You want his nadirs regularly in the 90-149 range if following SLGS. It's only be seeing more time in those lower numbers that he'll stop bouncing as much.

Don’t do it if “bouncing” or do it if bouncing or doesn’t matter? Don’t do it if ketones up or ignore ketones and just do it?

Bouncing doesn't impact when we change. If he needs and increase (or decrease), then he needs it based on nadirs. The only thing we try to do is increase on the same cycle as a bounce is clearing, because bounce clearing cycles by themselves often have lots of downward action. An increase on top of that clearing can make a more "interesting" cycle. Side effect, a reduction earned during a bounce clearing cycle often doesn't hold.

We have certain cases where we suggest R with basal insulin, such as cats with ketone conditions recently out of DKA, or higher dosed cats with either acromegaly or IAA. Methos is not a case where R would normally be suggested.

There is a tradeoff with Methos in getting him to a better insulin dose that will consistently see lower nadirs and longer stretches of lower, but safe, numbers to reduce the bouncing. Unfortunately that comes with having to test him more with his fragile skin and more anxiety for you. Keeping him at a lower dose will mean less poking, but has the unfortunate side effect of contributing to glucose toxicity. His ketones are not high enough that I'd use them as a factor just yet.

One thing at a time, let's see what increased vetoryl dose first.

 

[SmallestSparrow]

thanks so much @Wendy&Neko

The only thing we try to do is increase on the same cycle as a bounce is clearing, because bounce clearing cycles by themselves often have lots of downward action. An increase on top of that clearing can make a more "interesting" cycle. Side effect, a reduction earned during a bounce clearing cycle often doesn't hold.

Did you mean you try *not* to increase in a cycle where bounce is clearing? If so, and if he were to increase to 3.25 (this is academic as he won’t bc of vetoryl increase) would that mean *now* is OK if I assume his pink this past cycle is a “bounce”…and is this a bounce?

bouncing. Unfortunately that comes with having to test him more with his fragile skin and more anxiety for you.

again I will test his poor ears frequently if it means he’s going through this but will eventually stop “bouncing” and won’t need continual hourly testing. Testing isn’t anxiety for me. Shooting low numbers isn’t anxiety for me. Causing a bounce for no gain IS anxiety for me because this bouncing (if that’s what it is) is pushing his BG and ketones higher than they’ve ever been. I don’t want to “chase perfection” (which is unobtainable) and do it all the time indefinitely. This is the question —bc I look at other spreadsheets (ecid) and people are shooting low numbers then testing/feeding hourly a lot—like that is their normal. Which if they are seeking remission I get but Methos will never be in remission without surgery. I haven’t found an example where someone is shooting low numbers and then at some point doesn’t need to test/feed frequently afterwards (ie their cat “gets used to the lower numbers”) this could be I haven’t found the right SS to look at which is why I keep asking “will shooting low numbers now mean eventually I can stop the test/feed frenzy and his bouncing stops” bc if “yes” I will do it. If “no” then I am not sure he gains from it esp bc the bounce if anything is adding to his ketone problem and he can’t test hourly indefinitely. And I can’t glue something to his skin so libre is out

maybe Glargine is the wrong insulin bc units high enough to lower his nadir below 150 puts the nadir at about +3 of the following cycle which eventually gives him a number below 80 (at least once a PS below 80) and that would get him a reduction (aaha guideline, I understand the rules here are different) which in turn puts his nadir above 150. I just feel like he’s been up to 3.5 and back to 2.5 and up to 3.5 twice now and the result is the same. The IM felt his kidneys can’t clear the excess glucose (which made me again mourn quitting the SGLT-2 inhibitor esp if his spec fPL is tumor caused not drug related). Unfortunately a benefit from change in insulin wasn’t directly answered by the consultant—just that he thought between kidney problems and tumor production his sugar was going to spike and regular wouldn’t help the spikes. In humans regular can be used in conjunction with basilar insulin to provide a steady baseline and then extra as needed (eg with meals)so I wondered if I could take the place of a pump for him

hopefully the vetoryl increase helps ; I’d discussed it before with my vet (I think before his DM and possibly after) but he was already on a lot of off-label vetoryl.

Everyone please cross fingers and paws for him on Monday—supposedly adrenal infarct and addisonian crisis and hyperkalemia risks are not dose related but each increase puts my heart in my mouth twice a day for a month

 

[Wendy&Neko]

I haven’t found an example where someone is shooting low numbers and then at some point doesn’t need to test/feed frequently afterwards (ie their cat “gets used to the lower numbers”) this could be I haven’t found the right SS to look at

Define test frequently. How often is that for you? Have you seen Tansi's spreadsheet?

Did you mean you try *not* to increase in a cycle where bounce is clearing?

Bounces can last up to six cycles. The last cycle plus this cycle look like bounce cycles. You want to avoid increasing on the same cycle as he goes to down blues (or greens). PM of 10/16 is one example of a bounce clearing cycle. After that he bounced for 4 cycles, then cleared the bounce on 10/19AM cycle.

I am familiar with how R works with the basal insulin, I used it with Neko when her acro tumour flared up the second time after her first SRT. And have helped a few others with IAA or acro cats use it too.

maybe Glargine is the wrong insulin bc units high enough to lower his nadir below 150 puts the nadir at about +3 of the following cycle which eventually gives him a number below 80 (at least once a PS below 80) and that would get him a reduction

Or you need to start dosing in the 0.25 unit amounts to find the dose in between those two scenarios. My cat was sensitive to changes as small at 0.125 units at a time. Yes, I used calipers. Also, a cat's insulin needs change over time, you won't find a dose you can lock and forget. Especially with cats who have tumours that can pulse up and down. I don't know what insulin would be better. Maybe Levemir, but I think it's now unavailable in the US. Ideally an insulin with slightly longer duration that you could still use U-100 syringes would help.

 

[SmallestSparrow]

Define test frequently. How often is that for you? Have you seen Tansi's spreadsheet?

Bounces can last up to six cycles. The last cycle plus this cycle look like bounce cycles. You want to avoid increasing on the same cycle as he goes to down blues (or greens). PM of 10/16 is one example of a bounce clearing cycle. After that he bounced for 4 cycles, then cleared the bounce on 10/19AM cycle.

I am familiar with how R works with the basal insulin, I used it with Neko when her acro tumour flared up the second time after her first SRT. And have helped a few others with IAA or acro cats use it too.


Or you need to start dosing in the 0.25 unit amounts to find the dose in between those two scenarios. My cat was sensitive to changes as small at 0.125 units at a time. Yes, I used calipers. Also, a cat's insulin needs change over time, you won't find a dose you can lock and forget. Especially with cats who have tumours that can pulse up and down. I don't know what insulin would be better. Maybe Levemir, but I think it's now unavailable in the US. Ideally an insulin with slightly longer duration that you could still use U-100 syringes would help.

Thanks. I thought that’s what you meant to say about a bounce clearing. Of course it could decide to clear the cycle you’ve already made an increase but life means risk.
Idk if he needs a longer duration, the problem he has now is once a dose lowers his nadir enough it pushes it into the next cycle. I will just hope the vetoryl increase helps. I’ll look for tansi’s ss once I’ve had some sleep. Getting too old for 3 days of being awake.
I tried some quarter unit doses (that took a little negotiating) but with starting the increased Vetoryl dropped to 3U—if the Vetoryl lowers him enough the next dose down will be 2.75 but she doesn’t think the Vetoryl will make that much of a difference. I’ll be happy if it just evens him out a bit…a couple of cycles he went down, came back up, then dropped again so his curve was more like a flattened W. It feels like he’d do better if he could have a baseline amount and then a way to flexibly adjust …well hopefully the vetoryl will smooth him out a bit. I just wish they made 15mg capsules, he’s going to get an extra pill pocket every day because of this increase