Info Tight Regulation & SLGS: Myths Debunked

[Squeaky and KT (GA)]

....The phenomenon we refer to as a bounce is what Roomp & Rand are calling asymptomatic or biochemical hypoglycemia....

@Sienne and Gabby - unconfuse me please. Isn't a 'bounce' as we use the term a biochemical HYPERglycemia caused by the liver releasing counter-regulatory hormones to combat a perceived threat of either low glucose or too fast of a drop in glucose? If it's 'hypoglycemia', most of us are using the term incorrectly.

 

[Andy & Pimp]

a bounce refers to LOW

high

values that we see during

after

a BG drop/asympotmatic hypoglycemia.

 

[Chris & China (GA)]

HIGH BG after a dose reduction due to low BG.

If I'm understanding it right the "High" BG that indicates it's a bounce is due to the "numbers dropping low, dropping fast, or dropping by a large amount"...so when we talk about bounces here, it's because we see a higher number soon after any one (or more) of those things

A "high BG after a dose reduction due to low BG" isn't necessarily a bounce (although there can be a bounce involved ALSO due to the low BG)

When they drop too low and "earn" a reduction, if they don't return to "typical" numbers for that cat, it's not a bounce....it's a failed reduction

example....cat drops to 40 and earns a reduction ......the next cycle they're in the high 200's....THAT part is a bounce and has nothing to do with the fact you just reduced the dose.....if the cat doesn't return to what would be "normal" numbers for them, then the reduction failed

 

[Sienne and Gabby (GA)]

@Squeaky and KT :
Numbers drop and then there's a bounce into higher numbers. What the Roomp and Rand article points out is that the cat may bounce back into what may be that kitty's typical range. The low number cause for the bounce, though, isn't symptomatic hypoglycemia.

 

[Andy & Pimp]

I think some important topics got buried in post #42-43

 

[Sienne and Gabby (GA)]

1) if someone is doing SLGS but testing like they're doing TR where is the harm in increasing sooner than the prescribed week?

I'd ask a different question. If you're using SLGS and testing sufficiently (which means at minimum, at shot time and at least once per cycle) to do TR, why not use TR?

My understanding is that TR is more aggressive. You follow the protocol or you don't because the protocol has certain safety factors built in based on the research. You don't pick and choose. SLGS was developed based on practical knowledge. It means you "go slow."

As for food, I don't have an answer to that. One consideration, though, is that some of the lower carb dry foods that are available here may not be available overseas which is where the research is being done.

 

[Mocha aka Cold Play]

bump and will read and absorb

 

[Thabbo]

As for food, I don't have an answer to that. One consideration, though, is that some of the lower carb dry foods that are available here may not be available overseas which is where the research is being done.

That is true, the low/zero carb dry food is not available in the vast majority of European stores.

 

[Andy & Pimp]

If you're using SLGS and testing sufficiently (which means at minimum, at shot time and at least once per cycle) to do TR, why not use TR?

Good question, simple answer. Dry food.

Recommending to get rid of the dry food just isn't an option for some. It may be possible, but mabye beans don't have the patience threshold to deal with the process.

We all understand that TR says you can't use dry food.
This isn't a question about the protocol anymore. I'll start something up in think tank later.

 

[Vyktors Mum]

I'd ask a different question. If you're using SLGS and testing sufficiently (which means at minimum, at shot time and at least once per cycle) to do TR, why not use TR?

My understanding is that TR is more aggressive. You follow the protocol or you don't because the protocol has certain safety factors built in based on the research. You don't pick and choose. SLGS was developed based on practical knowledge. It means you "go slow."

As Andy said dry food is one reason but I also see some others that aren't using dry food and are testing frequently but are just a little nervous or something about letting their kitties get as low as we do following TR. Ideally they ditch the dry and/or get more comfortable with low numbers so that they can follow TR instead. But failing that, or until that happens, my thinking is that the safety factor built in to the TR protocol for increasing more rapidly is the frequency of testing so if that part is covered I don't see why a SLGS kitty couldn't be increased faster than every week, particularly if they're running high.

I am most interested to know if others see any potential problems with that. @Libby and Lucy we're still waiting on your thoughts when you have the time too - sorry to nag

 

[Libby and Lucy]

sorry guys, very busy at work and busy at home these days too. I'm going to have to break these responses down into manageable chunks.

SLGS

An important thing to remember about SLGS is that it is NOT a protocol. It is a set of guidelines. Where is it flexible? The whole thing! As you learn your cat's responses, you will probably adjust some of the guidelines. And yes, that says you will probably adjust some of the guidelines. Not that someone else will adjust the guidelines for you. SLGS is about learning your cat and learning what will work for your situation, then applying that knowledge to make the insulin work better for your cat. It is not about following a set of dance steps (neither is Tight Regulation, but that is another discussion for another day).

You'll notice that there are no instructions for how to go OTJ in the SLGS sticky. That was left vague intentionally. There are many ways to approach remission using SLGS. Andy asks whether you would just stop giving insulin after the cat goes low on a low dose. Actually YES, that is one way to do it. Sometimes cats (especially newly diagnosed) will settle down after a few days and no longer need insulin. Other ways would be to try reducing the dose further, or lowering the threshhold of what you consider low, or trying shooting once a day or as needed, or adjusting the food carb % (lower isn't always better) or timing to keep the numbers from going low, or any number of other ideas.

Quoting Jill & Alex in another thread because she said it better than I could:

The SLGS Method was written with a whole lot of flexibility in it which seems to have been lost over the past year. SLGS is a thinking man's protocol... not steps to be followed. As written, it's a method designed to allow what you learn and eventually know about your cat to guide you when making decisions. For example, notice phrases like, "In the beginning we suggest following the guidelines..." and "Keep in mind that these are general guidelines, and they should be personalized to your own cat's reactions to insulin. If your experience is that your cat does not became hypoglycemic with a dose which is close to her usual, then your experience should be your guide." and "With experience, you may find that lowering these thresholds may work well for your cat." and "Look at your data to see what numbers you have shot in the past and decide what would be a safe, shootable number for your cat." and "We usually...". Get my drift? These are guidelines, not rules. In the beginning, following guidelines is great, but eventually your data and observations are worth their weight in gold.

DRY FOOD AND TIGHT REGULATION PROTOCOL

The bottom line here, in my estimation, is that we just don't know how dry food will affect regulation. The Tight Regulation Protocol is very aggressive and we cannot afford to have unknowns when we are letting cats run below 50 on insulin. I personally am not willing to take that risk with someone else's cat.

From a personal perspective, my cat Kris Kringle ate dry food due to other health issues. I didn't necessarily find his numbers to be higher with dry food, but they were definitely unpredictable (and after all these years I'm usually pretty good at understanding numbers). I tried to keep him over 60 so I would have time to intervene if he threw me a curve ball. Are chances of remission as good if you do not let them run lower? Probably not, but I'd rather have my cat alive and on insulin than dead because of an error in judgment.


PLEASE REMEMBER

The Tight Regulation protocol is aggressive, and our modified version is slightly more aggressive than the original. We feel safe allowing our cats on Tight Regulation to run as low as 40s because we know the dose is a safe one for that cat at that time. We know that because of the way we work up to a dose, and the way we work down from a dose. It is not about the number of tests or how many cycles a dose is held, it's about gathering the RIGHT data rather than just a lot of it.

Cats following SLGS will probably not have all of the safety nets in place, therefore you will probably not be able to approach 50 with the same confidence that the cat is safe. If you are sure that low numbers are ok for your cat, that is fine, but please do not ask anyone else to tell you it is safe. In my mind, if you are asking, that means you are not confident so I will probably steer you back toward the guidelines.

 

[Mocha aka Cold Play]

sorry guys, very busy at work and busy at home these days too. I'm going to have to break these responses down into manageable chunks.

SLGS

An important thing to remember about SLGS is that it is NOT a protocol. It is a set of guidelines. Where is it flexible? The whole thing! As you learn your cat's responses, you will probably adjust some of the guidelines. And yes, that says you will probably adjust some of the guidelines. Not that someone else will adjust the guidelines for you. SLGS is about learning your cat and learning what will work for your situation, then applying that knowledge to make the insulin work better for your cat. It is not about following a set of dance steps (neither is Tight Regulation, but that is another discussion for another day).

You'll notice that there are no instructions for how to go OTJ in the SLGS sticky. That was left vague intentionally. There are many ways to approach remission using SLGS. Andy asks whether you would just stop giving insulin after the cat goes low on a low dose. Actually YES, that is one way to do it. Sometimes cats (especially newly diagnosed) will settle down after a few days and no longer need insulin. Other ways would be to try reducing the dose further, or lowering the threshhold of what you consider low, or trying shooting once a day or as needed, or adjusting the food carb % (lower isn't always better) or timing to keep the numbers from going low, or any number of other ideas.

Quoting Jill & Alex in another thread because she said it better than I could:




DRY FOOD AND TIGHT REGULATION PROTOCOL

The bottom line here, in my estimation, is that we just don't know how dry food will affect regulation. The Tight Regulation Protocol is very aggressive and we cannot afford to have unknowns when we are letting cats run below 50 on insulin. I personally am not willing to take that risk with someone else's cat.

From a personal perspective, my cat Kris Kringle ate dry food due to other health issues. I didn't necessarily find his numbers to be higher with dry food, but they were definitely unpredictable (and after all these years I'm usually pretty good at understanding numbers). I tried to keep him over 60 so I would have time to intervene if he threw me a curve ball. Are chances of remission as good if you do not let them run lower? Probably not, but I'd rather have my cat alive and on insulin than dead because of an error in judgment.


PLEASE REMEMBER

The Tight Regulation protocol is aggressive, and our modified version is slightly more aggressive than the original. We feel safe allowing our cats on Tight Regulation to run as low as 40s because we know the dose is a safe one for that cat at that time. We know that because of the way we work up to a dose, and the way we work down from a dose. It is not about the number of tests or how many cycles a dose is held, it's about gathering the RIGHT data rather than just a lot of it.

Cats following SLGS will probably not have all of the safety nets in place, therefore you will probably not be able to approach 50 with the same confidence that the cat is safe. If you are sure that low numbers are ok for your cat, that is fine, but please do not ask anyone else to tell you it is safe. In my mind, if you are asking, that means you are not confident so I will probably steer you back toward the guidelines.

I follow this.

I am not familiar with the differences, and I am seeking expertise to grasp them. I will delve into the stickies that I printed. I have already seen others trying to find their own decisions because of conflicting directives to stay or decrease, etc. I get what you are saying.

It is not that I am "not confident" because I ask for input. I believe this is intended to be a place of knowledge sharing and looking at my cat's response and sharing. Whatever I do, I will be confident with. But, I have only been in this forum maybe 2 months. My knowledge base is almost nil. And, my vet is of no help to me. He is overly concerned that she had one number below 90. Not grasping that the majority of her trend was far higher and he questions insulin dosing and is holding out on my refills for even syringes!

It takes a community right? If we can't ask, we can't learn as we should.

 

[Libby and Lucy]

I don't mean not to ask, I just mean that if you are planning to deviate from written guidelines, those are decisions that YOU need to make. We're more than happy to help with interpretation of guidelines and of your cat's patterns. I just can't really say "oh yeah, for your cat it's fine to go below 60 on SLGS" because I really have no way of knowing that. I can point out what I see that might affect your decision.

The 90 in SLGS is the safety net - throwing out a safety net has to be your call. There are lots of safety nets so you don't necessarily need all of them with SLGS, but it's your call to decide how many you need and which ones you can let go.

 

[Andy & Pimp]

Beautifully stated, Libby. I hope everyone finds this as helpful as I do.

 

[Mocha aka Cold Play]

I don't mean not to ask, I just mean that if you are planning to deviate from written guidelines, those are decisions that YOU need to make. We're more than happy to help with interpretation of guidelines and of your cat's patterns. I just can't really say "oh yeah, for your cat it's fine to go below 60 on SLGS" because I really have no way of knowing that. I can point out what I see that might affect your decision.

The 90 in SLGS is the safety net - throwing out a safety net has to be your call. There are lots of safety nets so you don't necessarily need all of them with SLGS, but it's your call to decide how may you need and which ones you can let go.

Thanks. Understand what you mean. Appreciate your weighing in. And, everyone else.

 

[Libby and Lucy]

I have already seen others trying to find their own decisions because of conflicting directives to stay or decrease, etc. I get what you are saying.

Thank you for bringing up a point that needs to be made. This is an open forum. There are no "experts" and no "advisors." Everyone, new and old, experienced and not, is welcome to give advice. Hopefully people will give responsible advice based on their knowledge and experience, but that is not always the case. Unfortunately you can't always tell who to trust based just on who has a lot of posts, who seems liked, who acts like they know what they're talking about.

Each caregiver is ultimately responsible for vetting the advice they are given and deciding what to do for their cat. Click on the spreadsheets of the people who are helping you. Does their spreadsheet look like what you are hoping to achieve? If they don't have a spreadsheet in their signature, ask for it. If someone is telling you something that doesn't jive with what you think you know, ask questions. Lots of times conflicting advice is just a difference of opinion with several viable options (this *is* a disease, after all, not a puzzle that has a right answer). On the other hand, conflicting advice can also mean that one person isn't necessarily on target. We also have some people who do a lot of copy/pasting their advice and it doesn't always apply to the exact situation at hand. Make sure they are looking at YOUR spreadsheet too!

And just to be sure I'm clear, of course if someone is giving you moral support or feeding advice or something other than specific insulin dosing advice, then it doesn't matter if their spreadsheet is beautiful yet. Even if someone just started yesterday, I would hope they feel welcome to go around and say hello and encourage others. If someone is giving me insulin dosing advice, though, I'm going to look at their spreadsheet to see if it looks like they understand how to use the insulin.

 

[Jill & Alex (GA)]

Andy asks whether you would just stop giving insulin after the cat goes low on a low dose. Actually YES, that is one way to do it. Sometimes cats (especially newly diagnosed) will settle down after a few days and no longer need insulin. Other ways would be to try reducing the dose further, or lowering the threshhold of what you consider low, or trying shooting once a day or as needed, or adjusting the food carb % (lower isn't always better) or timing to keep the numbers from going low, or any number of other ideas.

Some examples:

I've always found Linda & Sruffy's spreadsheet to be one of the most interesting albeit extreme examples of a kitty going OTJ using what many would consider an unorthodox approach: https://docs.google.com/spreadsheets/d/1oilhgpiRKWN-LC2ju6XyfBamC6lcNHMBKhGUXyCIJEI/pub#. Click on the "Numbers" tab at the top and then scroll all the way down to March and then April 2008. Note the color coding is a little different. Less than 100 is blue. 100 - 200 is yellow. Notice the shooting as needed. Scruffy bobbled around for quite awhile before settling into double digits. Interesting, huh?

If you look at Alex's spreadsheet, click on the 2006 tab at the top of the page: https://docs.google.com/spreadsheets/d/1ooNFj_Fd7be3QQJ41bl8fXka3QkSo_H1UIONkEh_2I8/pub?output=html#. This was before TR with Lantus was accepted on the FDMB. I did try to take her down from 0.5u to 0.1u for a few cycles before going OTJ only because I had been in touch with Kirstin (the Roomp in Roomp & Rand), but she started throwing inverted curves so I withheld insulin. For all practical purposes, Alex went from receiving 0.5u Lantus to going OTJ for almost 3 years. Worth noting, she was still throwing 2-300s a couple weeks before going OTJ!

If you click on the 2009 tab on Alex's spreadsheet, you'll see an illustration of practicing TR and shooting low to stay low as well as my attempts to feed the curve with a cat who could throw a food spike of 50 points from a piece of freeze-dried chicken! Don't worry. No one has to test as much as I did. All I wanted to do was to create a teaching tool for shooting low that would show others how to get and maintain those flat curves the Ls are known for when kitty doesn't have a bunch of medical problems to complicate the issue. Thankfully, Alex didn't seem to mind.

These are just a few of many, many examples of treating feline diabetes successfully.
Every cat is different. Every caregiver is different.

If one spends the time to learn the basics...
Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose,
Peak/Nadir - the lowest point in the cycle,
Duration - the length of time insulin continues to lower blood glucose,
observes kitty's response to food,
and understands the reasoning behind the choices... rather than immediately stressing over a choice between TR or SLGS and having someone tell you every move to make... things tends to fall into place.


Perhaps some food for thought...

 

[Mocha aka Cold Play]

Some examples:

I've always found Linda & Sruffy's spreadsheet to be one of the most interesting albeit extreme examples of a kitty going OTJ using what many would consider an unorthodox approach: https://docs.google.com/spreadsheets/d/1oilhgpiRKWN-LC2ju6XyfBamC6lcNHMBKhGUXyCIJEI/pub#. Click on the "Numbers" tab at the top and then scroll all the way down to March and then April 2008. Note the color coding is a little different. Less than 100 is blue. 100 - 200 is yellow. Notice the shooting as needed. Scruffy bobbled around for quite awhile before settling into double digits. Interesting, huh?

If you look at Alex's spreadsheet, click on the 2006 tab at the top of the page: https://docs.google.com/spreadsheets/d/1ooNFj_Fd7be3QQJ41bl8fXka3QkSo_H1UIONkEh_2I8/pub?output=html#. This was before TR with Lantus was accepted on the FDMB. I did try to take her down from 0.5u to 0.1u for a few cycles before going OTJ only because I had been in touch with Kirstin (the Roomp in Roomp & Rand), but she started throwing inverted curves so I withheld insulin. For all practical purposes, Alex went from receiving 0.5u Lantus to going OTJ for almost 3 years. Worth noting, she was still throwing 2-300s a couple weeks before going OTJ!

If you click on the 2009 tab on Alex's spreadsheet, you'll see an illustration of practicing TR and shooting low to stay low as well as my attempts to feed the curve with a cat who could throw a food spike of 50 points from a piece of freeze-dried chicken! Don't worry. No one has to test as much as I did. All I wanted to do was to create a teaching tool for shooting low that would show others how to get and maintain those flat curves the Ls are known for when kitty doesn't have a bunch of medical problems to complicate the issue. Thankfully, Alex didn't seem to mind.

These are just a few of many, many examples of treating feline diabetes successfully.
Every cat is different. Every caregiver is different.

If one spends the time to learn the basics...
Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose,
Peak/Nadir - the lowest point in the cycle,
Duration - the length of time insulin continues to lower blood glucose,
observes kitty's response to food,
and understands the reasoning behind the choices... rather than immediately stressing over a choice between TR or SLGS and having someone tell you every move to make... things tends to fall into place.


Perhaps some food for thought...

On 4/1 of Sruffy's....the glucose of "48" was not used to give a reduction. I assume that is because the pmps though delayed was 114 and insulin was still given for same amount. On the following amps it was 143.....so this is where the knowledge base of the caretaker said do not reduce, stay? Using the guidelines but weighing the knowledge of Scruffy more?

I appreciate the sheets and pointing something out. Sometimes, it just seems like there is so much to take it. I am sure it will get easier for me to comprehend in time.

 

[Andy & Pimp]

....and understands the reasoning behind the choices... rather than immediately stressing over a choice between TR or SLGS and having someone tell you every move to make... things tends to fall into place.

Perhaps some food for thought...

Thank you, Jill. I think this answers all the questions I had earlier.

It all goes back to "Know Thy Cat" and ECID

 

[Jill & Alex (GA)]

On 4/1 of Sruffy's....the glucose of "48" was not used to give a reduction. I assume that is because the pmps though delayed was 114 and insulin was still given for same amount. On the following amps it was 143.....so this is where the knowledge base of the caretaker said do not reduce, stay? Using the guidelines but weighing the knowledge of Scruffy more?

Linda didn't note a reason on her ss, but if I were to guess it was because Scruffy didn't always hold reductions. So yes, she was using her knowledge about Scruffy.

 

[Jill & Alex (GA)]

Bump!

 

[Jill & Alex (GA)]

 

[Jill & Alex (GA)]

bump

 

[Sweet Spot]

These are just a few of many, many examples of treating feline diabetes successfully.
Every cat is different. Every caregiver is different.

If one spends the time to learn the basics...
Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose,
Peak/Nadir - the lowest point in the cycle,
Duration - the length of time insulin continues to lower blood glucose,
observes kitty's response to food,
and understands the reasoning behind the choices... rather than immediately stressing over a choice between TR or SLGS and having someone tell you every move to make... things tends to fall into place.


Perhaps some food for thought...

I really, really liked what was said here as a newbie. Of course, there is so much good data info in this thread...but this quote stuck out emotionally because that is how I have felt. I want to get to know Spot first because every cat is different (and caregiver). I see it as Spot teaching me how to dance. HE knows the moves but it will take me time to catch up and be a good dance partner for him.

Of course, I know getting those high numbers down as fast/safely as possible is of utmost importance for his health - but the picking a method/protocol at the start has been a huge stressor. In my corny analogy, I am choosing the music (TR or SLGS) but don't know enough steps yet to determine if he is teaching me a waltz, polka or what?

Corny analogy over - but my husband and I are just taking it a day at a time - and reading/learning from other's posts, spreadsheets, etc.

Thanks for bumping this - very helpful!

 

[Jill & Alex (GA)]

Of course, I know getting those high numbers down as fast/safely as possible is of utmost importance for his health - but the picking a method/protocol at the start has been a huge stressor. In my corny analogy, I am choosing the music (TR or SLGS) but don't know enough steps yet to determine if he is teaching me a waltz, polka or what?

I understand more than you could imagine.
The basics are continually over-looked on every forum on the FDMB. I'm a firm believer in what I said previously:

"If one spends the time to learn the basics...
Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose,
Peak/Nadir - the lowest point in the cycle,
Duration - the length of time insulin continues to lower blood glucose,
observes kitty's response to food, and understands the reasoning behind the choices... rather than immediately stressing over a choice between TR or SLGS and having someone tell you every move to make... things tends to fall into place."

 

[Jill & Alex (GA)]

Bump for newer members!

 

[Jill & Alex (GA)]

Bump for newer members!

 

[Meridith and Zeke]

Very informative!

 

[Gill & George]

bump

 

[Girlie's mom]

And bump!

 

[Steph & Quintus & L & O]

Just read through this attentively, wow! I love these old "thinking" threads. Not sure why I hadn't come upon it before!

 

[Jill & Alex (GA)]

Overdue for another bump!

 

[Figaro's Liz]

THANK YOU

 

[Ti-Mousse (GA) Pepe (GA)]

Thanks !!

 

[Tomlin]

SO HELPFUL!!!! Thank you

 

[Sam & Oscar]

Thanks for bumping this up for us new members. This was a great read-through. Now to go back and read through all the links!

 

[Jill & Alex (GA)]

Bumperoni!

 

[Wendy&Neko]

Bump!

 

[Julia Rae]

I am going to have to read this several times to process and absorb the info Thank you Libby, Lucy as well as Chris and China Wendy and Neko Victor,s mum and they many other wonderful people here that help keep the rest of us sane and our fur children safe.

 

[Marje and Gracie]

Bump