Questions about "bouces" under the Lantus TR protocol

Jo&Misso

Jo&Misso

Member Since 2022
Hello, Merry Christmas every one,

Our Miso is been under Lantus TR for about a month, starting from 3uts. (Her previous insulin was Prozinc)
We've reduced the dose to 2.75 and then to 2.5 actually due to her nadirs under 50.

Here's her spreadsheet.
https://docs.google.com/spreadsheets/d/11_3u2_lr3zpHJW47ntkGxNdwQru-2Yap7EtwCa7Zx1s/edit#gid=0

Her curve seemed going better and better just before the 13th December 2022, whereas she began to have skyrocketing numbers particularly before her 2nd shot at night. And this happens usually after having a quite low nadir (50~80) in the afternoon.

Under the dose of 2.5, we haven't seen any nadir under 50, so we keep this dose.

Our first question is should we maintain 2.5 ? And how should we do to resolve this 'bounce' phenomenon before the 2nd shot ?

The 2nd question, about her meals, I give Wild Free wet cat food multiple times a day (from 20g to 45g each time, around 320g in total daily). Would it be an ideal way to give food many times daily like this for a cat under Lantus TR ?

Thank you in advance,
Best regards,

Wei
 
Hi Wei,
Yes I would continue to feed Misso multiple times during the 2 cycles except for the two hours preshot.
Areyou also feeding during the Pm cycle?

looking at the SS I would suggest trying to get some tests in during the PM cycles. If you want to do TR you must get at least 1 test in every cycle as well as the 2 preshot BGs. I can see you are not always testing preshot which is a concern.
At the moment we really don’t have any data to speak of for the PM cycle and cats often drop lower at night. I would suggest getting at least a before bed test in every night and if that test is lower than the preshot BG that can indicate an active cycle and it would be worth while getting another test a couple of hours later. it is possible the abG is dropping under50 at night and unlesss you are testing you won’t know.
Here is information about bouncing from the yellow stickies, The Basics
  • Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).
 
Hi Bron,

Thank you so much for your instructions with valuable information.

I didn't know that we shouldn't feed the cat 2 hours before preshot, I'll follow it.
During the Pm cycle, I only feed her after waking up in the morning, around 7h-8h AM. No feeding from midnight to 7h AM.

Indeed, sometimes I skip testing preshot when the BGs happens to be relatively high after waking up (around 7h-8h AM). So do you mean that even if the BGs is very high at 8h AM, it is still recommended to test the preshot at 10h AM ?

About the Pm Cycle at night, in fact, we have tested a few times around 4h AM (6 hours after the 2nd shot at night) while her preshot at night being low. But Miso's nadir turned out always quite high at night (we don't understand why...). According to your suggestion, I tested last night at 4h AM, and her BGs was 250. Anyway, I'll test her BGs more frequently at 4h AM.

The extract about bouncing is very informative. We'll wait for the bouncing to calm down a little bit.

Thank you again for the help !
Kind regards:)
 
Yes I would always test before giving the dose of insulin.
At night can you get any tests in around +4 ( that is 4 hours after the shot)?

Are you giving snacks during the day routinely as well as the Preshot meals?
Would you consider getting an automatic timed feeder so that you could give Misso some snacks during the first half of the cycles during the night?
A snack is one or two teaspoons of low carb food. I wouldn’t feed at +10. I would feed the snacks during the first half of the cycles. Does that make sense.?
 
ˋWell, +4 would be 2AM, it would be a little bit complicated. Could I ask what the purpose is of testing 4 hours later instead of +6 at night ?

Yes, I give snacks (Wild Freedom dried chicken heart) but randomly, especially after each BGs test as a reward. And I give wet food many times during the day except 2 hours before injection.

An automatic timed feeder, yes, it's possible. Giving her some snacks during the first half of the cycles during the night, is it for avoiding a possible hypoglycemia ?

Thank you.
 
We recommend getting at least 4 tests per day -- your AMPS and PMPS along with at least one test during both the AM and PM cycles. Generally, getting a test before you go to sleep (i.e., a "before bed" test) is helpful so you know if Misso's numbers are dropping.

One other bit of information, unlike with Caninsulin, with Lantus you can test, feed, and give the insulin dose all within minutes. You do not need to wait between your pre-shot test and giving insulin. Lantus onset is roughly 2 hours after you give an injection.

When you test depends on your cat. If you know that Misso's nadir (lowest point in the cycle) is typically at +6, then getting a test at or around nadir can be helpful. The concern is that not all cats have their nadir at +6. My cat's nadir was at +3 or +4. It does look like it's important for you to get some tests in earlier during the PM cycle. There are times, like on Dec. 9, when Misso's bounce broke last in the PM cycle.

I suspect what Bron meant was that you can give Misso several small meals spread out through the time prior to nadir rather than "snacks."

Also, bounces are a normal part of a cat getting regulated. As your cat spends more time in normal numbers, the bouncing will decrease. There is very little that anyone can do to avoid bouncing. Just keep doing what you're doing.
 
It looks like your schedule is 10am: 10pm…is that correct?
Is there a reason why you have those later times?
Most of us have schedules around 6:6, 7:7, 8:8 as that lets us get some valuable tests in during the pm cycles before bed.
Is that an option?
 
Sienne and Gabby (GA) said:
We recommend getting at least 4 tests per day -- your AMPS and PMPS along with at least one test during both the AM and PM cycles. Generally, getting a test before you go to sleep (i.e., a "before bed" test) is helpful so you know if Misso's numbers are dropping.

One other bit of information, unlike with Caninsulin, with Lantus you can test, feed, and give the insulin dose all within minutes. You do not need to wait between your pre-shot test and giving insulin. Lantus onset is roughly 2 hours after you give an injection.

When you test depends on your cat. If you know that Misso's nadir (lowest point in the cycle) is typically at +6, then getting a test at or around nadir can be helpful. The concern is that not all cats have their nadir at +6. My cat's nadir was at +3 or +4. It does look like it's important for you to get some tests in earlier during the PM cycle. There are times, like on Dec. 9, when Misso's bounce broke last in the PM cycle.

I suspect what Bron meant was that you can give Misso several small meals spread out through the time prior to nadir rather than "snacks."

Also, bounces are a normal part of a cat getting regulated. As your cat spends more time in normal numbers, the bouncing will decrease. There is very little that anyone can do to avoid bouncing. Just keep doing what you're doing.
Click to expand...

Hi Sienne,

Thank you for your information. Indeed, just like what Bron suggested, since our PM shot is at 22h, it becomes tricky to get an effective test before going to bed and thus the PM cycle is not well observed. We'll consider changing our schedule.

You indicated that with Lantus we can test, feed and shoot within minutes. But one thing I wonder is that what would be the threshold with which we have to wait for the injection or simply skip it ? For example, if her BGs being 55 or 62 at Preshot, could we still make the injection ? I've skiped once the 21th December with the preshot BGs 60, but withing few hours her BGs jumped up to more than 400.

About bouncing, it's assuring for us hearing that. We will keep going.

I have another question : I've noticed that during these past 3 days Misso's BGs never dropped under 100, furthermore, her BGs today were always 200-300. Is this a sign to increase the dose by 0.25 ? (We've reduced the dose to 2.5 from 2.75 since the 19th December)

Best regards
 
Bron and Sheba (GA) said:
It looks like your schedule is 10am: 10pm…is that correct?
Is there a reason why you have those later times?
Most of us have schedules around 6:6, 7:7, 8:8 as that lets us get some valuable tests in during the pm cycles before bed.
Is that an option?
Click to expand...

Hi Bron,

Exactly, we are doing 10h/22h since we switched to Lantus... In fact we had been following the schedule of 8h/20h with previous Prozinc and Canisulin, but we found that performing the injection just after waking up was tricky for us (we weren't fully awakened...)

But you are right, thanks for the reminder by the way, we lost the opportunity to observe her Pm cycles if we follow 10h/22h.
We consider to make it earlier gradually.
 
Jo&Misso said:
Hi Bron,

Exactly, we are doing 10h/22h since we switched to Lantus... In fact we had been following the schedule of 8h/20h with previous Prozinc and Canisulin, but we found that performing the injection just after waking up was tricky for us (we weren't fully awakened...)

But you are right, thanks for the reminder by the way, we lost the opportunity to observe her Pm cycles if we follow 10h/22h.
We consider to make it earlier gradually.
Click to expand...
You can change the time by 15 mn each shot, or 30 mn a day, without problem. Or, if you miss a shot (if she is too low, for example), you can then change the next one to be where you want it.
If you follow TR, the threshold is 50, but for a newly diagnosed cat, you can choose a higher one for now. You can read about that here: https://www.felinediabetes.com/FDMB...y-to-shoot-handle-lower-pre-shot-numbers.147/
As for increases, yes, you increase by .25 unit after a few cycles if the nadirs are too high: https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/ I cannot tell you if that's a good time now but you can start by reading those :-)
 
With TR, the goal is to shoot low numbers. I was able to shoot any number above 50. However, when I started to shoot low, I had a LOT of data. We do not suggest you shoot low numbers when you are first learning about how to manage your cat's diabetes. With TR, if you get a pre-shot number that's lower than 150, please post and ask for help. Typically, someone would suggest that you stall. We don't recommend stalling more than 2 hours. Frankly, I don't think I ever stalled that long as it would have made a mess of my schedule. It would have been more reasonable for me to skip the shot. (I was working. My shot time was at 5:00 and it would have played havoc with keeping Gabby on a viable schedule.)

As you noted, there's a downside to skipping a shot. Usually numbers jump high due to two issues. First, you haven't given insulin. Second, with a low pre-shot, there's a good chance there will be a bounce. The combination can cause numbers to skyrocket.

If you're following TR, you want to evaluate the dose providing you haven't skipped or reduced the dose for any reason after 3 days/6 cycles. (Any time there's a change in dose, your cycle count starts over.) You skipped a dose on the 21st. Misso's nadirs were in good numbers for several days after. I would likely have encouraged you to hold the dose. It looks like since the 25th, the nadirs have been higher. Depending on what the numbers look like tonight, I'd consider a 0.25u increase at AMPS.

Also, just a word of caution. Looking at Misso's numbers on the 25th, your PM +10 was 203. Your AMPS on the 26th was lower -- 168. The AMPS was a dropping number. If you shoot a dropping number, I would suggest that you get a few tests early in the cycle. Typically, numbers are not dropping early in the cycle since the insulin from the previous PMPS is wearing off, it takes approximately 2 hours for Lantus onset, and you've fed your cat. The early (e.g., +2) test, will tell you if numbers are still dropping.
 
cecile & bella said:
You can change the time by 15 mn each shot, or 30 mn a day, without problem. Or, if you miss a shot (if she is too low, for example), you can then change the next one to be where you want it.
If you follow TR, the threshold is 50, but for a newly diagnosed cat, you can choose a higher one for now. You can read about that here: https://www.felinediabetes.com/FDMB...y-to-shoot-handle-lower-pre-shot-numbers.147/
As for increases, yes, you increase by .25 unit after a few cycles if the nadirs are too high: https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/ I cannot tell you if that's a good time now but you can start by reading those :)
Click to expand...
Hi Cecile, thank you for the method for adjusting the schedule and also for the links. I'll read them.
I've been delayed twice 15 minutes for the shots by far in order to attend 6h30/18h30.
 
Sienne and Gabby (GA) said:
With TR, the goal is to shoot low numbers. I was able to shoot any number above 50. However, when I started to shoot low, I had a LOT of data. We do not suggest you shoot low numbers when you are first learning about how to manage your cat's diabetes. With TR, if you get a pre-shot number that's lower than 150, please post and ask for help. Typically, someone would suggest that you stall. We don't recommend stalling more than 2 hours. Frankly, I don't think I ever stalled that long as it would have made a mess of my schedule. It would have been more reasonable for me to skip the shot. (I was working. My shot time was at 5:00 and it would have played havoc with keeping Gabby on a viable schedule.)

As you noted, there's a downside to skipping a shot. Usually numbers jump high due to two issues. First, you haven't given insulin. Second, with a low pre-shot, there's a good chance there will be a bounce. The combination can cause numbers to skyrocket.

If you're following TR, you want to evaluate the dose providing you haven't skipped or reduced the dose for any reason after 3 days/6 cycles. (Any time there's a change in dose, your cycle count starts over.) You skipped a dose on the 21st. Misso's nadirs were in good numbers for several days after. I would likely have encouraged you to hold the dose. It looks like since the 25th, the nadirs have been higher. Depending on what the numbers look like tonight, I'd consider a 0.25u increase at AMPS.

Also, just a word of caution. Looking at Misso's numbers on the 25th, your PM +10 was 203. Your AMPS on the 26th was lower -- 168. The AMPS was a dropping number. If you shoot a dropping number, I would suggest that you get a few tests early in the cycle. Typically, numbers are not dropping early in the cycle since the insulin from the previous PMPS is wearing off, it takes approximately 2 hours for Lantus onset, and you've fed your cat. The early (e.g., +2) test, will tell you if numbers are still dropping.
Click to expand...
Hi Sienne,

Thank you for your explanations.

Could I still shoot when I get a pre-shot number above 100 ? According to our experiences with Misso so far, I feel that 100 is some what a "middle land' where we can shoot without worrying too much for a possible hypo.

About stalling, we will not wait for more than 1.5 hours after our scheduled time. If the BGs is always low (below 100) we will skip it. Is it okay doing like this ?

Following your suggestion, I've increased 0.25 for the dose this morning (2.75 uts) since her preshot number was always high (251). We'll see.

Have a nice day~
 
You can shoot at whatever number you're comfortable. If you want to use numbers above 100 for the time being, that's fine. Most new members are nervous about shooting lower numbers so we use 150 as a convenience. Ideally, you want to be able to give a Lantus injection at progressively lower numbers.

What I would suggest with a low pre-shot is to monitor -- check if numbers are heading upward every 15 - 30 min. When numbers are clearly rising, shoot. The exception would be your schedule. Remember, if you stall for 1.5 hours and then shoot, your next shot is 12 hours later. You then have to adjust the time in the way Cecile & Bella outlined. You do not go back to your usual shot time. (With Lantus, an early shot acts like a dose increase and a late shot acts like a dose reduction so you have to slowly move the time so you don't throw the depot off.) If you've not had a chance to read this post on becoming data ready/low pre-shots, it may help as a good reference.
 
Sienne and Gabby (GA) said:
You can shoot at whatever number you're comfortable. If you want to use numbers above 100 for the time being, that's fine. Most new members are nervous about shooting lower numbers so we use 150 as a convenience. Ideally, you want to be able to give a Lantus injection at progressively lower numbers.

What I would suggest with a low pre-shot is to monitor -- check if numbers are heading upward every 15 - 30 min. When numbers are clearly rising, shoot. The exception would be your schedule. Remember, if you stall for 1.5 hours and then shoot, your next shot is 12 hours later. You then have to adjust the time in the way Cecile & Bella outlined. You do not go back to your usual shot time. (With Lantus, an early shot acts like a dose increase and a late shot acts like a dose reduction so you have to slowly move the time so you don't throw the depot off.) If you've not had a chance to read this post on becoming data ready/low pre-shots, it may help as a good reference.
Click to expand...
Thank you Sienne for these further clarifications. Lantus is definitely very different from Canisulin and Prozinc... We have lots of things to learn.
We'll keep going.
 
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