TIGHT REGULATION PROTOCOL (TR)

This document was replaced on 01/30/2019. The new document can be found here:
http://www.felinediabetes.com/FDMB/...-low-go-slow-slgs-tight-regulation-tr.210110/


TIGHT REGULATION WITH LANTUS OR LEVEMIR
FOR DIABETIC CATS
Note:
Lantus, Basaglar and Semglee are brands for insulin glargine.
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*** IMPORTANT DOCUMENTS ***
Print these out and keep them handy:
SHOOTING & HANDLING LOW NUMBERS
SYMPTOMS OF & HOW TO TREAT HYPOGLYCEMIA - what to do if your kitty experiences a hypoglycemic event
Jojo's HYPO TOOLBOX - what to have on hand in case of an emergency

THE USE OF PET-SPECIFIC METERS IS DISCOURAGED BECAUSE REFERENCE NUMBERS ARE FFOM BLOOD GLUCOSE METERS CALIBRATED FOR HUMANS ​

Every protocol or method has safeguards built into it's guidelines. It can become problematic or even dangerous to combine guidelines or suggestions from different protocols/methods.

The Tight Regulation Protocol with Lantus or Levemir for Diabetic Cats was developed by laypersons from the German Diabetes-Katzen Forum. The protocol was eventually published in the Journal of Feline Medicine and Surgery. Lantus, Basaglar, and Semglee are brand names of insulin glargine. Basaglar and Semglee are newer brands (biosimilars) of insulin glargine developed and made available since the TR protocol was written.

As of this writing, the Tight Regulation Protocol with Lantus or Levemir for Diabetic Cats is the only published protocol we know of for use with glargine or detemir. However, the guidelines are not intended to portray the ONLY way you can use Lantus and Levemir insulins or their biosimilars. The guidelines listed are how to best use Lantus or Levemir or the biosimilars when following this protocol. Please be aware there are other feline diabetes message boards on the web using different dosing methods/protocols successfully.

The tight regulation protocol was tested in 55 diabetic cats for Lantus/glargine and in 18 diabetic cats for Levemir/detemir from the German Diabetes-Katzen Forum. Owners measured blood glucose an average of 5 times daily and adjusted insulin dose based on the protocol. An overall remission rate of 64% was achieved in the cohort. Significantly higher remission rates were observed if good glycaemic control was achieved soon after diagnosis: 84% for cats started on the protocol within 6 months of diagnosis went into remission, and only 35% for cats that began more than 6 months after diagnosis.

Protocol Guidelines (same protocol, different formatting):

• Tight Regulation with Lantus or Levemir for Diabetic Cats
• Management of Diabetic Cats with Long-acting Insulin - summary published in 2013

FYI: IS TIGHT REGULATION POSSIBLE WITH A FULL TIME JOB? YES!

If the Tight Regulation Protocol isn't the right fit for you, the FDMB's Start Low, Go Slow Method offers an alternative method for regulating your cat.

The Tight Regulation Protocol is a great place to start, but once you gain experience and knowledge of YOUR cat's response to insulin you may find yourself in need of tweaking and refining your approach to treating your cat's diabetes. "Every cat is different" is not just a slogan. Following suggested guidelines is a great place to start, but some kitties will force us to think outside the box. Bring up any concerns you may have. Chances are someone else has been there, done that and may be able to help.

In most cases, Lantus, Levemir and their biosimilars are best given on a 12/12 schedule when following this protocol. However, sometimes life doesn't afford the luxury of adhering to a strict 12/12 schedule every day of the week... every week of the year. Don't let fluctuations in your schedule deter you from using these wonderful insulins. Shooting every 12 hours is best with this protocol, but many caregivers have worked around their limitations successfully.


Requisites when following a Tight Regulation Protocol with Lantus or Levemir:

• Kitty should be monitored closely the first three days when starting Lantus or Levemir.
  Blood glucose levels should at least be checked at pre-shot, +3, +6, and +9.
  More monitoring may be needed.
• It will be necessary to test kitty's blood glucose levels multiple times per day.
• Learn the signs of and how to treat HYPOGLYCEMIA and prepare a HYPO TOOLBOX.
• Test regularly for ketones and know about DIABETIC KETOACIDOSIS (DKA).
• Use U-100 3/10cc syringes with half units marked on the barrel for fine dosing.
• Feed a high quality low carb canned or raw food diet.
• Feed small meals throughout the day. Although, some kitties will adapt well to free feeding.

Many glargine and detemir users in this forum have been successful following a slightly 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.


Starting dose for glargine or detemir when following the Tight Regulation Protocol:

• the formula is 0.25 unit per kg of the cat's ideal weight
• if kitty is underweight, the formula frequently used is 0.25 unit per kg of kitty's actual weight
• if the cat was previously on another insulin, the starting dose should be increased or decreased by taking prior data into consideration

Online Calculator for Converting Pounds to Kilograms


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:

The TR Protocol is an aggressive method in itself. The modified version of the protocol is slightly more aggressive. Let's keep all our kitties in the Lantus, Levemir, Biosimilars ISG safe by suggesting and taking appropriate reductions.

• 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. Please ask for advice immediately.
• 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.
• If an attempted reduction fails, go right back up to the last good dose as soon as you see kitty's numbers trending upwards. You don't have to hold the reduced dose for a certain number of cycles before taking the dose right back up. The guidelines listed under the topic "Increasing the dose" do not apply to a failed reduction. Please use common sense in this situation. The "last good dose" is not the dose that just dropped kitty into the 20s or 30s. You want to resume momentum by finding a dose in-between the dose that dropped kitty too low and the reduced dose.
• Since 2006 we've encouraged those practicing Tight Regulation to attempt reducing the dose from 0.25u to 0.1u before stopping insulin completely. During a two week OTJ trial, you want to see mostly green numbers (under 100) with only a few random blue numbers between 100 - 120 to help ensure a strong remission. Most kitties will be in the range of a healthy cat (50 - 80 mg/dL).

Remission: From Tilly's Diabetes Homepage, Phase 5: Remission

"14 days without insulin and normal blood glucose values. Most remission cats are able to stay in the normal range all of the time (50 to 80 mg/dl), although there are a few cases of sporadic higher and lower BGs. Don't stop feeding low-carb and try to avoid cortisone if possible.

Test the cat's BGs once per month.Approximately 25% cats that achieved remission using this protocol relapsed and required insulin again (frequent causes are hyperthyroidism or bouts of pancreatitis). Therefore, it is important to keep your diabetes kit up-to-date. Then you can react immediately by giving insulin and home testing. Importantly, the sooner you react to a relapse (i.e. preventing hyperglycemia and initiating other necessary veterinary treatment), the more likely a second remission will become.

The longer a cat has had diabetes, the less likely it will go into remission. Many long-term diabetics get stuck in Phase 3 or 4. Yet there is a benefit of using this method for such a cat as well: keeping the cat's BG levels as normal as possible is much healthier for it long term. Insulin requirements will often decrease to very low levels too."


Glycemic Status and Predictors of Relapse for Diabetic Cats in Remission



Random Notes:

• TR is the correct abbreviation used globally for the method known as Tight Regulation. Other abbreviations are incorrect and may not be recognized by the veterinary community.
• KNOW THY CAT. Shooting early or late is a practice best reserved for those who have a full understanding of the insulin used and it's effects on their kitty.
  • Because of the cumulative nature of glargine and detemir, please be aware: Shooting an hour or two early *could* act like a slight dose increase. Shooting an hour or two late *could* act like a slight dose reduction. How your cat will react has a lot to do with what kitty is doing that day. For instance, if a bounce is breaking shooting early probably isn't the best idea because you'll have a little extra action on the dose from both the early shot and the bounce breaking simultaneously. The next shot is due 12 hours after the time of the early or late shot if you're shooting twice a day. Oftentimes the effects of an early or late shot will not be seen until the next cycle. Please monitor carefully when shooting early. Ask for guidance if you're unsure.
• A "cycle" refers to the period of time between shots. There are 2 cycles in one day when shooting twice a day.
• Sometimes a dose will need to be "fine tuned" by adding some "fat" or "skinny-ing up" the dose. However, we strongly suggest caregivers do not skinny kitty's dose after a drop into the 20s or 30s. Instead, take the full reduction.
• The "best" insulin is the insulin that works for YOUR cat. Switch to another insulin if you're not seeing favorable results within 6 months to a year. A different insulin could be better suited to your kitty.

Sometimes there are circumstances such as ketones present, an unusually low preshot number, a caregiver leaving the cat with a sitter, relatively high flat curves, loss of appetite, infection, a schedule change, ability to monitor, etc. which may call for adjustments to these guidelines. Please ask for guidance if any of these or other circumstances present themselves or are of concern.

These are "general" guidelines which have worked for many cats. However, "Every Cat Is Different". Learn how YOUR cat responds to the combination of food and insulin.

Please be aware: There are no "dose advisers" on the FDMB. The FDMB is an open board subject to peer review where laypersons with varied amounts of knowledge and experience are free to share their own thoughts and opinions through explanation and by making suggestions.

We are not veterinarians. It is not our intention to take the place of your veterinarian. Please discuss dosing, methods, medications, and care for your cat with your veterinarian.​

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This document was written by FDMB members
Jill & Alex (GA) and jojo and bunny.
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