Resistance or Rebound?

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Alison & Sarge

Alison & Sarge

Member Since 2014
I need a little help interpreting what Sarge is doing and I would really appreciate someone looking over his SS. I am desperately (but patiently) trying to get him regulated but no luck yet. I did a curve yesterday and he was high and flat again but then at night he responded to the Lantus. I can't seem to get him to have good day and night numbers at the same time. I don't know if he has just "forgotten" what normal is and I have to ride out some bounces or if I am seeing insulin resistance. I am also a little suspicious of his Cosequin but he really does need that or he limps around. So confused.
 
Hi there...

Just a couple quick things off the top of my head:

Lantus likes consistent dosing. Shooting different doses in the morning and evening is definitely going to contribute to Sarge's issue with not getting regulated. You should also be grabbing a few more early/mid cycle and/or spot checks, just to get a better feel for what Sarge is doing.

Also, I see a lot of dose reductions when the reductions weren't actually "earned". With the TR protocol, we reduce the dose by .25U when a kitty's BG drops below 50.

At the same time, I also think you are holding doses for too long. We generally increase doses every 6-10 cycles until we hit a breakthrough.

Here's an excerpt from the protocol:
Many Lantus and Levemir users in this forum have been successful following a somewhat modified version of this Tight Regulation Protocol for the last few years. These "general" guidelines are based on anecdotal evidence and personal experiences of laypersons frequenting the forum.
(Revised 10/28/2013)

"General" Guidelines:
Hold the initial starting dose for 5 - 7 days (10 - 14 consecutive cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 consecutive cycles).
Each subsequent dose is held for a minimum of 3 days (6 consecutive cycles) unless kitty earns a reduction (See: Reducing the dose...).
Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.

Increasing the dose:
Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

Reducing the dose:
If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. See additional notes in the next paragraph about drops into the 20s and 30s. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further.

Please do not let yourself become complacent or blasé about drops into the 20s or 30s.
If kitty drops into the 20s, a full reduction of 0.25u (or 0.5u if kitty is on a higher dose) is strongly recommended.
If your cat drops into the 30s, a full reduction of 0.25u is recommended. There are very few exceptions given for caregivers who have collected years of data and KNOW their cat's response to the combination of insulin and food backwards, forwards, and inside out.
Caregivers whose kitties have "High Dose" conditions may find the need to reduce in whole units or more.
Please ask for advice.

If anyone suggests otherwise, they are putting your cat at risk! Our kitties are not just numbers. They are living beings who trust us to look out for them. The TR Protocol is an aggressive method in itself. The modified version of the protocol is slightly more aggressive.

Keeping YOUR cat safe is the #1 priority of the FDMB.
Let's keep all our kitties in the Lantus Tight Regulation ISG safe by suggesting and taking appropriate reductions.
Click to expand...

And here's a link to the sticky - there is additional info in there so I do recommend checking it out:
TR Protocol Sticky

I'm sure others will be along with more ideas. Please ask as many questions as you need...we are all happy to help!
 
I am really happy to hear that resistance maybe off the table and I just need to keep working on mastering the TR protocol. Lantus being better with consistent dosage may explain is why his best numbers to date have been on 1.0 units AM, 1.0 units PM. I agree, I would really like to shorten the trials. A couple of them are that long per his vet's request. I do like that she wants start low and go slow but I think we now know enough about Sarge I can go with 6 to 10 cycles instead.

Just to get re-calibrated I gave 1.0 units this morning since 1 AM and 1 PM has worked the best so far. I wish I could get more mid-cycles and spot checks but I work six days a week. I am running home whenever I can and I will get back to spot checking him when I get home. I guess I let this slip because his +10 spot check was so close to his PMPS I didn't know if it helped me or not. Right now I am trying to catch a 6 and 8 hour in the wee hours of the morning because I am home.

So his latest curve tells me he should be at 1.5 units AM (from 1.25) but since his evening dose is only 1.0 units would I apply the .25 addition to evening and go to 1.25 AM and 1.25 PM to give consistent dosing?

Thanks so much for your help Amy :)
 
I am fairly new at this myself so no specific dosing advice from me, but I do agree with Amy that consistent dosing with Lantus is key.

It looks like you decided to go back to the beginning and start with 1u, I know that there is a formula based on weight to determine what the starting dose of Lantus should be. I am sure one of the more experienced members will be along and can provide that to you.

It sounds like you have been working with your vet on dosing, unfortunately not all vets are as well versed on FD and while well intentioned, do not always give the best advice. Fortunately for you, you found a place where the people ARE well versed on FD as they eat it, sleep it, drink it, live it. I have an amazing vet who sent me to this site and at this point she is cool with me following the lead of the amazing people here.

Skooter also has the added "fun" if IBD and the vet and I weren't sure we could take him off the food he was on (dry of course). However this TR group has helped me go from 5u BID on dry food to .5U BID on wet food. If your vet is not supportive of you following the directions of the awesome people here, the advice I would give is nod and smile when they tell you things and still follow this protocol.

I don't even really call the vet or send numbers anymore. I sent them a link to Skooter's spreadsheet, so they can look at it if they like, but that is about it. When I call to say I need new syringes etc, they are happy to call in a prescription wherever I like. From what I have read on here, I know I am one of the lucky ones to have a vet who is as supportive as she is.

Looking forward to seeing how the more consistent dosing goes!
 
I agree that the dosing needs to be the same day and night. When Max started lantus my vet saw from the ss that he would be lower at night and suggested I give less at night. I think he felt I would get to sleep that way. Since lantus is a depot drug that just doesn't make sense. If your are worried that a hypo event might happen, then you need to find a dose that works that you can give and keep it the same to get the full benefit of lantus. Does that make sense?

After looking at your ss I definitely think your dosing makes no sense. I too let the experts help me with that and send a copy of the ss to my vet usually weekly. One question I have is why did you make the last dosing change? I don't see anything to show that it needed to be lowered. I see why you made changes are several points although according to the protocol it would not have been warranted to this last one really confuses me.

You've come to the right place for help. The advisors here are really skilled in how to guide this crazy dance. :-D
 
Welcome to Lantus Land!!

Amy's summary reflects my read of Sarge's spreadsheet (SS), as well. I wonder if your vet is familiar with the Tight Regulation Protocol that we use here. Lots of vets aren't and they work with Lantus the same way they work with other types of insulin and Lantus is very different. That may have been the rationale for adjusting the dose based on the pre-shot numbers. Lantus dosing is based on the lowest numbers in the cycle (i.e., the nadir).

If your vet hasn't seen the journal article describing the TR Protocol, you may want to share the article:

The tables in the article encourage increasing the dose every 3 days if the numbers aren't in the normal range (50 - 120). Also, don't be surprised if your vet is apprehensive if Sarge is in numbers below 100. Most caregivers do not home test. As a result, vets are understandably more comfortable with having kitties stay in higher numbers.

If you're not at home for several hours during the day, you might want to consider getting a timed feeder. This is s good way to insure that there's food available when you're not around.
 

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I noticed you said he limps around....
I didn't get any help from cosequin... but what has made a big difference for my girl is Adequan.
There are a few of us giving adequan shots ( mine are every 3 weeks) and my girl actually started playing again after we started using it.
 
I would like to follow the TR protocol. I have been keeping it mind as I do curves but until now I admit it really wasn't guiding the dosage. It was more of a weekly consult with his vet. Initially, I was a little scared of rebound too because the dosage (Novolin) from his first vet was way too high and thanks to this group I caught it. Saved my kitty!

The TR protocol really makes sense and is my plan going forward. I think my vet will like the systematic approach too. Based on his last curve I know that he needs to go up .25 units. I dosed 1 unit this morning because until now, 1 unit AM and 1 unit PM gave his best result to date. I thought if I was going to start dosing consistent AM and PM doses it was a good place to start. I am not staying there but at least for today if I dosed 1 unit again tonight he would have a consistent dosage if I didn't have a new plan by tonight's shot.

So, knowing his nadir on Saturday's curve earned an increase, am I at 1.25 units AM and PM now and the next raise if that doesn't work in 6 cycle (3 days) would be 1.50 units twice a day? I should be able to get away from work tomorrow to check near nadir and I have two timed feeders so I know food availability won't be an issue. Timed feeders are awesome :) So, to get me started on the TR protocol path do I shoot 1.25 units tonight or start with the higher dose tomorrow?
 
When you start a new dose depends on your situation. Some people like to start at night because they are home to test to see how it goes, and away at work during the day. It's great you can get home for lunch to see how Sarge is doing. Any chance of getting an out the door, perhaps a +2 test before going to work? That is often a good indicator of how the cycle will go and let you know if you should leave out some food for safety during the day.
 
It is much easier to make changes in the PM dose because I can be around all night. 1.25 units is what he was getting in the morning so it's not that big of a change tonight but nighttime is when he tends to go lower. That would also put me at home when he gets his third 1.25 units in a row tomorrow night.

That is a great idea on the AM tests too Wendy, I think I can grab and out the door number since I shoot at 7 am so I can probably get a quick test in before I leave at 9am. I think 1.25 units tonight it is.
 
Hi there and Welcome :cool:

In looking at Sarges ss I think once you get a month or so of TR under your belt you will likely see improvement.

My Black Kitty suffered extreme insulin resistance. Looking back at our journey, I see how I stumbled along in the beginning and sometimes wonder if that contributed in some way to his extreme resistance. He was the last cat anyone, including myself, thought would go 'off the juice'. Still. after 21 months on insulin he went into remission. :mrgreen:

Although the TR protocol was pretty new on the scene back in our day, if I were starting on the path today that's the one thing I would do differently is to get on board with the TR protocol without delay. Does that make a difference in a kitty developing resistance? Maybe....maybe not. But why tempt fate ;-)

Being newly diagnosed (<1yr since diagnosis) is an advantage.
You are in good hands here.
Make the most of both :cool:
 
Wow!! Great work and congrats to Black Kitty! That is awesome :) I am trying to educate myself as quick as I can to give Sarge every chance to be an OTJ success story. I sometimes struggle with what I don't know yet or didn't do sooner but looking back at where Sarge and I started back in May (ground zero) gives me perspective. There have been wins and there will be more. I can honestly say this board did help to save Sarge from some really close calls when he was first diagnosed. I am very grateful.
 
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