Reduction time (forced by low nadirs). Experienced advice needed, please....

[Toro & Ovi]

Hello, Toro has earned a forced reduction (because of the repeated low nadirs)....our question to the experienced members of this forum is: had anybody used dose reductions smaller than 0.25u? Looking at the numbers from 2 weeks ago (when he was on 2.5u), we tend to go with 2.6u ( or 2.5u fat I guess if that's what means) instead of 2.5u...we don't want a failed reduction and start everything all over, we feel like 2 weeks spent at 2.75u was too short for the beta cells to recover. We use Feline Meter. Thank you.

 

[tiffmaxee]

I did resort to smaller decreases for Max because he was bouncing a lot. Looking at your ss you are getting great results. I would follow the protocol at this point if he were my cat.

 

[Toro & Ovi]

I did resort to smaller decreases for Max because he was bouncing a lot. Looking at your ss you are getting great results. I would follow the protocol at this point if he were my cat.

Thank you. Can you please what do you call F, S, VS, etc. on Max's SS? I'm not familiar with these letters, I can only guess...but better to know for sure what they mean.

 

[tiffmaxee]

Thank you. Can you please what do you call F, S, VS, etc. on Max's SS? I'm not familiar with these letters, I can only guess...but better to know for sure what they mean.

F was a fat dose and S skinny. I took reductions and increases in 1/8 unit instead of 1/4 because he bounced and wasn’t holding reductions. I also fed the curve so he wouldn’t earn a reduction at times for the same reason. That was done after several months though. Toro has lots of green so I would stick to the .25 unless things change. He’s looking really good.

 

[Gill & George]

This is the 5th time he has dropped below 68 (The reduction point for TR), using the 3 drops under 5o (human meter) or single drop under 40 (human meter) is usually recommended for cats that don't hold reductions or long term diabetics. Toro hasn't been on insulin long enough for you to say that he is not holding reductions, using the 3 drops below 68 is more aggressive than standard TR, additionally, since we don't have a way of converting that 40 into AT numbers I to wonder if that drop into 52 on the 20th would have measured below 40 on a human meter???
I would take him down to 2.50u, at the next shot, do not, mess around with less than full reductions at this point, I really think you would be playing with fire, I wouldn't be surprised if his depot is overfull at the moment so you may still see some pretty low numbers.

I can see that you might be worried that he didn't do to well on 2.50 before, but insulin needs do change, he's been spending a lot of time in green and it's time to see if he will hold the 2.5u. I think there's enough evidence there of him telling you that he is done with the dose.

 

[Toro & Ovi]

Thank you. He's doing great at low numbers, that's why we pushed him a bit.....some kitties are hard to regulate unless they see some constant low numbers and that's what we tried to do.

 

[tiffmaxee]

Thank you. He's doing great at low numbers, that's why we pushed him a bit.....some kitties are hard to regulate unless they see some constant low numbers and that's what we tried to do.

True but you can’t rush the process either. I think you need to take the reduction. What he did the last time means nothing now. JMHO.

 

[Toro & Ovi]

We tried, had a 2.5u for a second night in a row, went yellow right away. We'll watch him close and adjust as required. Maybe work the very low numbers with food. Thank you, we'll keep in mind our discussion.

 

[Sienne and Gabby (GA)]

As one of those experienced members you asked to comment, I have a few thoughts.

We do not typically recommend micro dose adjustments until you have a good deal of data. Think in terms of a year or more versus a couple of months of BG data. If you are still reducing doses if you get a lower pre-shot number, then you are not at a point to micro dose when a dose reduction is called for. Elise was not making micro-dose adjustments until she had a lot of data -- Max was diagnosed in 2013. Likewise, I didn't make micro adjustments with Gabby until I had years of data and copious amounts of experience at managing her low numbers.

Looking at Toronto's numbers, if you do not take a full 0.25u reduction, you are risking numbers getting away from you. Since there are no notations on your spreadsheet, I can't tell if you've been giving Toronto HC food when you're seeing numbers lower than 68. Three hrs of numbers in the 50s on 10/16 and more numbers in the same range on 10/19 warrants intervention with HC food on both occasions. It's helpful to make a notation on your SS if you are intervening with HC so anyone looking at Toronto's SS knows what you're doing. I sincerely hope you are not using the TR recommendations from other websites. If you are trying to incorporate Elizabeth Hodgkin's approach to TR, please be aware that her method was developed for use with ProZinc, not Lantus or Levemir. Frankly, cats prescribed Lantus have died from hypoglycemia using her approach to managing low numbers.

Numbers below 68 on an AT meter indicate that you need to reduce the dose. TR is an aggressive approach to dosing. Not reducing when numbers are low is risking your cat's safety. I also hate to point this out but I have no clue what approach to dosing you're using. It certainly isn't TR. TR is not safe if don't follow the guidelines and not reducing the dose when a dose reduction is indicated is not following the guidelines. At this point, based on Toronto's SS and without any other context, the dose should have been reduced on 9/28, 10/2, 10/11, 10/13, 10/16, 10/20, and 10/22. You are holding doses when reductions are warranted. Also, reductions are indicated, not "forced." Nadirs under 68 are a dramatic indication that your cat is getting too much insulin.

 

[Toro & Ovi]

As one of those experienced members you asked to comment, I have a few thoughts.

We do not typically recommend micro dose adjustments until you have a good deal of data. Think in terms of a year or more versus a couple of months of BG data. If you are still reducing doses if you get a lower pre-shot number, then you are not at a point to micro dose when a dose reduction is called for. Elise was not making micro-dose adjustments until she had a lot of data -- Max was diagnosed in 2013. Likewise, I didn't make micro adjustments with Gabby until I had years of data and copious amounts of experience at managing her low numbers.

Looking at Toronto's numbers, if you do not take a full 0.25u reduction, you are risking numbers getting away from you. Since there are no notations on your spreadsheet, I can't tell if you've been giving Toronto HC food when you're seeing numbers lower than 68. Three hrs of numbers in the 50s on 10/16 and more numbers in the same range on 10/19 warrants intervention with HC food on both occasions. It's helpful to make a notation on your SS if you are intervening with HC so anyone looking at Toronto's SS knows what you're doing. I sincerely hope you are not using the TR recommendations from other websites. If you are trying to incorporate Elizabeth Hodgkin's approach to TR, please be aware that her method was developed for use with ProZinc, not Lantus or Levemir. Frankly, cats prescribed Lantus have died from hypoglycemia using her approach to managing low numbers.

Numbers below 68 on an AT meter indicate that you need to reduce the dose. TR is an aggressive approach to dosing. Not reducing when numbers are low is risking your cat's safety. I also hate to point this out but I have no clue what approach to dosing you're using. It certainly isn't TR. TR is not safe if don't follow the guidelines and not reducing the dose when a dose reduction is indicated is not following the guidelines. At this point, based on Toronto's SS and without any other context, the dose should have been reduced on 9/28, 10/2, 10/11, 10/13, 10/16, 10/20, and 10/22. You are holding doses when reductions are warranted. Also, reductions are indicated, not "forced." Nadirs under 68 are a dramatic indication that your cat is getting too much insulin.

Thank you. All the low numbers from the past were resolved with LC food (FF, 1-4% carbs) - few teaspoons of LC and after that the numbers were flat or going up - the liver was doing his job. No HC without hypo signs - and there were none, Toro was pretty active and happy with the low numbers.
In the past 48 hours we had two reduced doses to 2.5u - and the result was yellow this morning (after more than a week of greens and blues). So 2.75u seems to be a bit too much, 2.5u seems too low. We'll try to put him on Frieskies instead of FF ( 5% carbs vs. 1-4% carbs) and see if the middle cycle will stay on the safe zone. Trying different ways to keep him in between the yellow and light green.
We are using Tilly's TR ("Alternatively, if the nadir glucose concentration is 40 - <50 mg/dl at least three times on separate days, try lowering the dose. If the cat will not stay in the normal range after a reduction, immediately increase the dose again to the last good dose." That's 58 - <68 mg/dl on Feline Meter, Toro's been there 5 times, tried reduction, BG numbers went up - so we are back back to the previous good dose and watching).

 

[tiffmaxee]

We do three times under 50 here BUT not with newly diagnosed. I am just concerned that there will be an active hypo. With the AT meter that number is 68.

 

[Amy&TrixieCat]

I agree with both Sienne and Elise - and am also one with much experience. As Elise said, the "three drops below 50" is for long-term diabetics who do not hold reductions well, not for newly diagnosed kitties (even if said newly diagnosed kitty doesn't appear to hold reductions well - at this point, there isn't enough data on Toronto to say he is one of those kitties).

The lack of hypo signs, while a good thing, is not a reason to not take earned reductions. Even though he came up easily with food (also a good thing), those numbers are his body saying he is getting too much insulin. Not taking the reductions is playing with fire.

Sometimes it does take a while for a kitty to settle into a dose. Toronto did hit 50s - which is potentially dangerous on an AT - on the 2.50 dose. Increasing only pushes things in a possibly more dangerous zone for Toronto. IMO, I see far too many AT 50s on 2.75U.

As Sienne mentioned, it would be very helpful to document in your SS what foods you feed and when. That will give us more information to work on with regards to how Toronto is responding.

 

[Toro & Ovi]

We understand, thank you for your concern, we watch him closely and we'll keep him in the range of safe numbers.
We feed him FF pate 1-4% carbs (salmon, chicken, turkey) and Frieskies pate 5% (sometimes when he has very low numbers) - we try different approaches in order to learn his reactions in different situations - he's usually eating almost everything +1 to +6 (fasting after that till the next PS). The logic behind that is to feed his liver during the drop (+2 to +6) and help him stay longer in greens and blues thru fasting after that.

 

[Marje and Gracie]

As another very experienced member, I’d also like to comment.

After I had a couple years of data, I tried to be more aggressive with Gracie’s dosing. I knew her patterns really, really well and what she would respond to. However, insulin is a hormone and not a medication and by being aggressive, I unintentionally let her depot get ahead of me....which may very well happen to you and Toronto if you continue down this path of not reducing when you should.

Please read my post on Reductions as it discusses what happened when I failed to reduce when I should have. If you are allowing him to drop below 68 more than three times on different dates without giving a 0.25u reduction, you are putting him at risk.

While we can tell you many stories of hypoglycemic episodes that ended in the loss of the kitty, I think the one that will, hopefully, allow you to understand the risk you are taking involves a long time and very experiecned member who joined a little after Gracie and I did. She was able to get her kitty pretty stable on insulin and he remained that way for almost six years. A few months ago, after him having been on the same dose for a very long time and having not dropped too low, she came home to find him non responsive lying in a pool of his own urine. She rushed him to the ER and they did manage to revive him and he got to go home after a couple of days. But the effects remained and she had to help him cross.

Perhaps that will illustrate how unpredictable insulin can be even in a stable and tightly regulated cat with a very experienced caregiver who knew his patterns extremely well.

I know you say you watch him closely but what worries me is that you do not understand how the insulin depot works and without that understanding, you are throwing safety out the window by disregarding the TR protocol guidelines.

 

[Toro & Ovi]

We've been ready for a full 0.25u reduction (after yesterday's discussions) - and we started it last night.
Now we try to explain the AMPS@263 from this morning, following the first ever multiple reduced doses in a 48 hours span- and we can only think at a failed reduction, as this is the first yellow(a high yellow) in more than a week....
True that with 2.5u he once hit a light green....but that looks like an exception for me, the majority of the numbers were yellows and pinks - after 33 cycles.......

 

[tiffmaxee]

Bouncing. Let him settle into the dose. It can take a couple cycles. That's where patience pants come to play.

 

[Toro & Ovi]

Ladies, you convinced us...we'll start a trial on a reduced dose tonight. Keep you posted. Thank you so much, your help is much appreciated.

 

[tiffmaxee]

Safety first. The saying here better a day or two to high than too low. They regroup from the highs but too low can have dire consequences. You are seeing a. Great response. It’s a marathon rather than a race. I truly believe you will get there.

 

[Marje and Gracie]

Yes, he’s bouncing today.....and you shot 2.75u so you can see that bouncing can occur even on a dose that you believe might be a good one (because he’s spent a lot of time in lower numbers than usual).

Keep in mind that it’s not uncommon to go up and down around a dose before it really seems to work and the reduction holds. There were many doses for Gracie that she would fail a reduction, I’d take her back up, several cycles, she would earn a reduction, I’d drop her back down and let the bouncing clear then have to take her back up. Then she would hold the next reduction.

Don’t get worried if he does that. It’s not unusual. I always tell members that while we don’t want to dose hop, we also don’t want to get “married” to a dose that is too much or too little. Following the protocol will ensure you don’t dose hop or put him at risk.

 

[Sienne and Gabby (GA)]

Ummm....

What your referring to from the Tilly's website is correct. However, the BG numbers refer to numbers on a human meter -- not on an AlphaTrack. The numbers on human vs animal meters are calibrated differently. On a human meter, a drop below 50 indicates that a reduction is needed. On an AT meter, 68 is the point where the reduction is needed. I would not hold the dose for a 3 time drop below 68 since your cat is not particularly bouncy, which is when we generally suggest the alternative approach. What you noted is an alternative. I would encourage you to use the basic approach first.

That's 58 - <68 mg/dl on Feline Meter,

That is an extrapolation and not correct. We can't directly translate from an AT to human meter except for the number at which you reduce the dose. It is not a one-to-one correlation between the 2 meters. At the minimum, Toronto has been skating very close to numbers in the 30s on a human meter. A drop below 40 on a human meter, even with the "alternative" method, indicates that you reduce immediately.

 

[Toro & Ovi]

Ummm....

What your referring to from the Tilly's website is correct. However, the BG numbers refer to numbers on a human meter -- not on an AlphaTrack. The numbers on human vs animal meters are calibrated differently. On a human meter, a drop below 50 indicates that a reduction is needed. On an AT meter, 68 is the point where the reduction is needed. I would not hold the dose for a 3 time drop below 68 since your cat is not particularly bouncy, which is when we generally suggest the alternative approach. What you noted is an alternative. I would encourage you to use the basic approach first.


That is an extrapolation and not correct. We can't directly translate from an AT to human meter except for the number at which you reduce the dose. It is not a one-to-one correlation between the 2 meters. At the minimum, Toronto has been skating very close to numbers in the 30s on a human meter. A drop below 40 on a human meter, even with the "alternative" method, indicates that you reduce immediately.

We didn't assume these numbers, we got them from a a newer (2013) Roomp & Rand Prototcol :" ... if AT is used, increase the target blood glucose concentration by about 1 mmol/L or 18 mg/dL (eg, change 2.8 to 3.8 mmol/L; change 50 to 68 mg.dL)".
The R&R protocol is pretty similar to Tilly's protocol.

 

[Sienne and Gabby (GA)]

It's identical. Kirsten Roomp is the Roomp in Roomp and Rand. The data are based off of the German Lantus forum that she is involved with and Tilly was her cat.