PMPS = 504; Some advice please?

[Melissa and Celle]

Things were looking so good last weekend, then not so much. I was getting to the end of the vial though, so could that have been why things went south? As I switched to the new vial I did it in increments over three shots, thinking that if the new vial was terribly different in potency I'd see that right away. It didn't look like that was the case, but could the dose now be too high causing the bouncing? Or does it look like something else is going on (e.g., infection)? She has a history of UTI's, but they have never had a discernible effect on her BG, and she usually has obvious symptoms.

Advice on what to dose now? Stick with what I'm doing for a little longer to see if it settles in? Or go up? Or down?

 

[Dyana]

It looks to me like she could have gone into the 100s last night, and tonight's PMPS may be a bounce from those numbers.
If she's bouncing, you don't want to do the increase until the bounce is done. Let's see what others have to say.
Can you possibly get some more mid cycle tests during the night time?

 

[Sienne and Gabby (GA)]

I'm going to cut to the chase. IMHO, you're holding on to your doses for too long. Celle's been on the 4.0 dose for 23 days. There's a good chance she's building up glucose toxicity. Celle is getting used to spending time in high numbers and it makes it harder to get the numbers down and it may also cause your cat to bounce in response to lower numbers. If you are planning on using the Tight Regulation Protocol, you evaluate the dose after 6 cycles/3 days (unless your cat's nadir is routinely below 200) or if you are using the Start Low Go Slow approach, the dose is evaluated in a week. I would wait for this bounce to clear and raise the dose.

 

[Melissa and Celle]

I'm going to cut to the chase. IMHO, you're holding on to your doses for too long. Celle's been on the 4.0 dose for 23 days. There's a good chance she's building up glucose toxicity. Celle is getting used to spending time in high numbers and it makes it harder to get the numbers down and it may also cause your cat to bounce in response to lower numbers. If you are planning on using the Tight Regulation Protocol, you evaluate the dose after 6 cycles/3 days (unless your cat's nadir is routinely below 200) or if you are using the Start Low Go Slow approach, the dose is evaluated in a week. I would wait for this bounce to clear and raise the dose.

I don't really understand though why she would suddenly not tolerate the numbers that she had earlier on 4 units. If she was doing pretty well last weekend, why would those same numbers suddenly cause her to bounce?

We hold her doses for long (especially when we get such relatively good numbers) because of our experience on Levemir where we followed the protocol, increasing after three days, and the bounces got worse and worse with each increase. Slow increases seem to give her more time to get used to each dose.

 

[Cini Mini's Mom]

I agree with Sienne, you are holding at this one dose for too long. I would give it 6 cycles, maybe 12 at the most and then move up to the next .25 increase if nadirs are not consistently below 200.

I also don't understand the gradual switch to the new vial. If the old vial wasn't potent enough then mixing a little of it with the injection out of the new vial is not going to help. In essence you are giving her just the new dose which is most likely half of what she needs. (i.e. Giving 3 units of the new stuff and 1 unit of the old stuff is just like giving 3 units of the new stuff and 1 unit of water. Therefore you reduced her insulin to 3 units when she really needs 4 units.)

I also don't understand the reason for the reductions taken previously. I see a 50 BG here and there and can see why for those reductions, but then there are other times where you reduced her insulin but there wasn't a 50 BG to warrant it? Example would be 12/26/2011 where you went down from 3.5 units to 3.25 units. Was it because of the 59 BG? Close but not a 50 BG. Gotta wait for the magic number before reducing. Same thing on 1/22/2012. New vial yes, but not reason for a reduction.

So, in short, get rid of the old vial and try 4 units of only new insulin for a day and see if that changes anything. Or, if you're going to mix then up the dose to 4.25 units.

 

[Libby and Lucy]

it sure looks like there is something going on, but I doubt it's a bounce. How old was the insulin, and was it really at the very bottom of the vial? It could be bad insulin, or you're right that infection would be something else that could show up in her numbers suddenly like that.

My thought when it comes to high numbers is to get rid of them. :lol: I would increase the dose to 4.25, provided that you can monitor in case whatever is going on decides to fix itself. Hopefully a little more insulin will jump start things again. Sometimes dosing needs fluctuate, for no apparent reason. I wish it was just a steady progression upward in dose, then a breakthrough, then a progression down in dose. In reality, it usually seems more like "let's go up, then down, then up, then up some more, then down..." If the dose keeps going up, then a vet visit might not be a bad idea to rule out infection.

 

[Melissa and Celle]

I also don't understand the gradual switch to the new vial. If the old vial wasn't potent enough then mixing a little of it with the injection out of the new vial is not going to help. In essence you are giving her just the new dose which is most likely half of what she needs. (i.e. Giving 3 units of the new stuff and 1 unit of the old stuff is just like giving 3 units of the new stuff and 1 unit of water. Therefore you reduced her insulin to 3 units when she really needs 4 units.)

So, in short, get rid of the old vial and try 4 units of only new insulin for a day and see if that changes anything. Or, if you're going to mix then up the dose to 4.25 units.

I've been using the new vial since 6/2 PM. I did the gradual switch because if the old vial was less potent, then I don't really know what the equivalent dose in the new vial would be. I thought that maybe I had been really giving her less than 4 units all along due to reduced potency, so 4 units out of the new vial could be too much. I still wonder if that's the case and the reason for the bounces.

How old was the insulin, and was it really at the very bottom of the vial?

It was 4 months old, and yes, it was really getting to the bottom of the vial. Any advice in that regard? At what point should I be switching? The good numbers at Christmas were with a 4-month-old vial (but not yet the bottom), so the age didn't worry me too much.

I also don't understand the reason for the reductions taken previously. I see a 50 BG here and there and can see why for those reductions, but then there are other times where you reduced her insulin but there wasn't a 50 BG to warrant it? Example would be 12/26/2011 where you went down from 3.5 units to 3.25 units. Was it because of the 59 BG? Close but not a 50 BG. Gotta wait for the magic number before reducing. Same thing on 1/22/2012. New vial yes, but not reason for a reduction.

The reduction on 12/26 was because I was afraid to shoot such a low preshot number (88). The reduction on 1/22 was the same worry that the vial had lost potency and her true dose was less than I had been giving. The other reductions are when she seems to be bouncing. I reduce with the hope that she'll level out and I can try more slowly increasing. But OK, I can see going up. I'll try tonight when I can monitor her.

 

[Sienne and Gabby (GA)]

FWIW, I don't worry when switching out a pen. (I find the pens to be more economical than the vials.) I am concerned that if you think your insulin is losing potency that you're still using is. On the odd occasions where I think I've gotten bad insulin or that something is effecting the dose, I open new insulin. Your insulin should be equally potent throughout the lifetime of it's use.

I don't think the strategy of reducing due to a bounce is effective. I'm aware that there are other forums here where that strategy is endorsed. If you look at people's spreadsheets who utilize that approach, I think you are going to see unnecessarily high numbers. Bounces are normal. It's the liver's method of preventing what could be a potentially dangerous situation of hypoglycemia. However, until your cat once again is accustomed to spending time in normal numbers, the liver is going to go into emergency mode because lower numbers are responded to incorrectly as "dangerous." If you lower the dose, the liver never gets re-trained to stop responding in this manner to normal numbers. The strategy that most of us use is to wait until the bounce clears and then make a decision about the dose. In many, if not most cases, that may mean a dose increase. Likewise, we would not permanently reduce the dose because of a pre-shot in the 80s. If using the TR Protocol, a pre-shot would need to be in the 40s to warrant the dose being reduced. Otherwise, a dose may be reduced for that one shot and raised back up thereafter.

 

[Melissa and Celle]

FWIW, I don't worry when switching out a pen. (I find the pens to be more economical than the vials.) I am concerned that if you think your insulin is losing potency that you're still using is. On the odd occasions where I think I've gotten bad insulin or that something is effecting the dose, I open new insulin. Your insulin should be equally potent throughout the lifetime of it's use.

I've tried just switching vials every time something seems off, but at $150 a vial, that's pretty hard to keep doing, especially when it has never worked. Nevertheless, I do always worry about reduced potency when switching, in part because of not being diligent about never reinjecting insulin back into the vial as I am pulling up the shot.

Likewise, we would not permanently reduce the dose because of a pre-shot in the 80s. If using the TR Protocol, a pre-shot would need to be in the 40s to warrant the dose being reduced. Otherwise, a dose may be reduced for that one shot and raised back up thereafter.

Wow, good to know. I don't think I have the stomach for shooting so low, but raising it back again at the next dose is something I hadn't really thought to do.

Thanks for the advice!!

 

[Sienne and Gabby (GA)]

No one would expect you to immediately shoot low. You need the data to know your cat. Most of us worked our way down to shooting lower numbers. I will pretty much shoot anything above 50 -- I monitor like crazy but I'm not afraid of shooting low because I know Gabby and I know I can manage her numbers with food. How about deciding on a number that's a little lower than what you're used to and shooting when you get that number? Please consider posting when that happens. People who are here will help you to build your confidence. (Take a look at Fluffy's condo from today. It's a good example of how people provide support when your on new ground.)

I'd also suggest you price out the Lantus Solostar pens. A box of 5 pens runs around $200 -- or $40 per pen. You also get more insulin than you what's in a vial. While it is always a pinch in the pocket book if you have to toss out insulin, it's a much smaller hit if it's $40 vs. $150. Most of us who's cats are on relatively small doses use the pens for these reasons. There are also some places where you can purchase individual pens. Obviously, that makes the out of pocket expense more bearable. (Often a hospita, outpatient pharmacy will sell a single pen but some of the big box pharmacies do, as well.)

 

[Cini Mini's Mom]

Another source for single pens would be a Veterinary compounding pharmacy. That's where I get mine, the cost is $60 for a single pen in Arizona.