11/2 Jack amps 342 +3 368 +6 306 +10 310 pmps 345 +5 310 +9 250

yesterday's condo

Jack seems to be stuck on his halloween sugar rush. I can either increase the R or the Lev, but he definitely seems to need a little more insulin. I thought it would be clearing his system by now, but he is still stuck in the land of pink.

I'm hesitant to do too much more with the R until I get a little guidance. I am still new and probably being a little too cautious with it.

Vines for all our kitties and civvies in L&L and for the beans that need it

 

I'm just not able to give any R advise for Capt. Jack. Let me tag @Jill & Alex (GA) and see if she's available to help.

 

Hi Wes - sorry Jack is suffering from a sugar high. One time Neko got her face into some bread starter (including yeast ) that DH left on the counter. It took a good couple of cycles for that to clear out. Given naughty Captain Jack got pure sugar, it may take a cycle or two yet to clear out. Good thing you had R around to help.

I asked a couple of other people with experience with high dose cats and R to pop in, but you may not get more replies until later today. But here are my thoughts.

First off, you've held onto this Lev dose too long. If you don't see green, I would never hold an IAA cat longer than 8 cycles at a dose. I know you didn't want to combine R experiments with a Lev increase and I wouldn't initially do both on the same cycle, until you have more R experience. I like your idea the other day of a 2 unit Lev increase. You might even to be able to go as high as a 3 unit increase (15% of the dose size), to try to bring it to the antibodies.

Back later with more thoughts on R.

 

Oops, a question first. Are you giving R at +1 or at preshot as per previous discussion?

 

At least this bump in the road is all his doing... little sugar bandit.

Sandy thought it was better to give R closer to normal shot time. In the evenings he gets both shots at the same time. In the AM I don't do TFS, so I have been giving R at +1.

Initially I was hoping to hold at 20u and use R to get him down, but the cautious ramp up of R is not seeming to have much effect yet. The R increases were what had kept me from increasing lev at the same time, but with pink and some red(yuck), I agree time to change plans. On the 31st he hit 119 which was getting close to green, then he went and ate some candy throwing that one out the window.

Unless something else changes with the discussion later, I will plan on doing the 2u increase tonight and holding the R steady and monitoring for a few cycles to see what effect it has.

Thanks for the input. It has been too long since the spreadsheet had consistent good colors in it.

 

Hi there! I like Wendy's idea to increase the Lev dose first. I also agree with her that you could increase by 3 units Lev, but if that makes you uncomfortable, stick with increasing the Lev dose by 2 units bid.

The R dose...
I did not have a high dose cat, but when Alex's BGs were running high and flat and I knew a bounce was not breaking, I did give R more frequently than just at the preshot or +1 times knowing R wore off after about 4 hours with Alex. That may be something to consider for those high, flat cycles in-between the lows if someone is available to work with you closely the first few times.

Just a few thoughts...

 

Thanks Jill. Interesting on the R during the normal L cycle. I could see where when it is a flat day this could help get some downward movement.

I don't think 3u is out of the question, in my limited experience the iaa seems to respond better to bigger increases. He is acro so will eat anything as evidenced by the recent twix episode, this makes getting him to come up much easier. At worst it is just a long night of testing. I don't have any visits tomorrow so can be around to monitor as well. This makes it a pretty good time for a larger increase test. Sometimes he responds quick to increases, sometimes it takes him a cycle or two.

310 @ +10 and guessing he will be rising by shot time. New plan would be 3u lev increase, would you still give the same amount of R(2.5u over 300)to be consistent or withhold it due to the increase?

 

As you know, the important thing with R is to not have its nadir coinciding with the nadir of the Lev. I used R a lot right after Punkin's Lantus nadir. If I saw the nadir and the beginning of a rise, I knew that the Lantus wasn't going to make him go lower at that point. Shooting the R then allowed me to either keep the rise flat, or bring it down a little bit, which then allowed the next shot Lantus to start from a lower point. I was very comfortable with that strategy and it was probably my favorite way to use R.

Just to add to what Wendy and Jill are saying about the Lev dose - consider that the "average" low dose cat getting an increase might go from 1.0u to 1.25u - an increase of 25%. At 20u, a 25% increment is 5u. I would probably not give that much of an increase with Jack getting blues regularly, but it is just a bit of perspective to add to the situation. I think 2-3u would be fine as well.

Just saw your last question. I wouldn't increase both the Lev and the R on the same cycle. I'd wait and see what the Lev increase does, at least a couple of cycles, and then address the R dose.

Sandy is going to pop by later tonight to comment. She has a lot of experience with larger R doses.

 

@Suzanne & Cobb(GA) also might have some suggestions to offer you.

 

It would be the same amount of R he has been getting the last few days when PS is in the pinks. I think it is okay, but experience trumps "I think"

ETA: Thanks for the input Julie. Yes I am thinking more in percentages at this point as well with how big the doses have gotten. Sad, but a bit funny that this increase will be more then many cats need for a whole day. That's my boy though, always the stubborn cuss.

 

Initially, we don't suggest giving R when increasing the basal dose. Unless he's extremely high, I think I'd hold off on R when you increase the dose for the reason you stated above:

I agree with Julie. I wouldn't increase the Lev and R doses on the same cycle. It's usually best to change one thing at a time. However, that may change as you become more experienced using R. See how it goes.

I think Levemir is more conducive to using R at the beginning of the cycle than Lantus because the onset of Lev is later than that of Lantus. Overall, IMHO, adding R into the dosing plan seems to be more flexible when the basal insulin is Levemir. That said, when numbers are high and flat (and there's not a concern about a bounce breaking), one can almost shoot R anytime in the cycle... whether the basal insulin is Lantus or Lev.

 

Hi!! Julie tagged me and asked me to check in. Cobb was a high doser and your spreadsheet looks so similar.

I'm going to work to familiarize myself with Jack and where you are in this dance. But here are my initial thoughts...

I'll echo the above. Don't change your R dose at the same time as your Lev dose. One thing at a time. It also helps, imho, you to determine if your R scale (i.e. 2.5 over 300) is on track. I would increase your Lev dose by 3u. You're at 20. 3 is a little more than 10%. And if you don't see a change in 4 cycles, increase again. You have to stay ahead of those antibodies.

Regarding R, I liked shooting R at +9 or +10, as long as you know that's after onset. I liked to pull down that preshot number to see if Cobb could hold the BG low enough for the next onset. I did find that Cobb had a floating nadir...sometimes it was +5, sometimes +9. That made shooting R tricky, but battling both IAA and acro, I felt I had a little leeway because there was so much keeping those numbers high.

I will start checking in more often!

~Suzanne

 

Whoops, already did TFS and I did give him the latest standard 2.5R and increased his Lev by 3u to 23u. The current R dose doesn't drop him much if any so it should be ok. Will get a few extra tests to make sure all is good.

I have a troubleshooter's mind and completely agree about changing one thing. Taking away the R is a change too which partly led me to give the same R dose.

Thanks Jill great info. Not too many experienced R users so I appreciate all the info. At least 80% of the time Jack rises from PS to +4 so finding a good R dose to prevent the rise could be good, it is that other 20% that gets me a little worried. At the same time, a large depot has a lot more momentum behind it then R's quick in and out.

It has been quite a ride, the Vet is going to be shocked at his current dose(she was a never more then 5u type of vet until she talked to the tech at MSU after his IAA/IGF-1 test).

Still at the beginning, but the music is playing fast with all the knowledge and help I've gotten here. The spreadsheet tells most of the story, right after the PZI switch and September were interesting spots. It seemed like we were getting ahead of the IAA then and I have since fallen behind again. He has had a few bouts of not wanting to eat, suspect minor acute p'titis. Since then I've gotten an autofeeder and give 3 oz PS meals and 1 oz midday snack. Late July/early August we were working with a little R, but later in August I had a few out of town work trips and we stopped R. His first reduction was pretty hard and fast but was pretty short lived. Since then we've been climbing the ladder again and here we are today.

I definitely need some help from "Team R" on figuring this out. So far it has just been give some R and see if it helps. So far it rarely drops the numbers but can help slow the rise. He typically rises about 100pts from PS to +4, but in catlike fashion, not always. I like the idea of shooting R around the same time as PS, it works good for me and is in a spot where the Lev is wearing off and he is rising.

Jack hopes you check in too.

 

Since you did give the Lev increase and the R both tonight, it's an opportunity to get some information. I see you've got a +2 already - I'd test hourly for at least 3 more hours if you can to see what that combo brings about.

 

I can do that, so far a pretty typical cycle. Looks like the dosecrease is waiting a cycle or two before it gets going. Jack is easy to test so more data never hurts.

 

Good luck with the Lev increase. Good to see R has kicked in and started it's thing, though it could just be keeping him flat. All good to know. Like Suzanne, I liked giving R late in the cycle, around +10 if I knew she was done dropping, but for a different reason. As is most things Neko, she's a little later getting going. R typically didn't kick in until +3-+4 and hence was active later. By giving R a couple hours before preshot, I was more likely to get most of the R action out of the way when her Lev onset. Sometimes she'll take a big dive at Lev onset and I didn't want to make that worse with a little R action still going on.

 

Sorry I'm just getting back here now. Had to stay up to watch the Chicago Cubs clinch the World Series!!!

I think the overwhelming message here is ECID.

This is basically what you'll need to determine when to effectively administer R in any given cycle (and keep Jack out of any trouble):

• learn/know the onset, peak/nadir, duration of both basal and bolus insulins
• understand the concepts of carryover, overlap, and the insulin depot
• learn/know kitty's typical response to both insulins, but always be prepared for surprises
• learn to recognize YOUR cat's patterns
• understand how the timing of meals or mini-meals affects YOUR cat

There are also some givens:

• You don't want the nadirs of the basal and bolus to coincide.
• You don't want to yank BG numbers down. In many cases all you want to do is prevent them from going higher. In other instances you'll only want R to pull down BG numbers around 100 points. Much more than that simply sets kitty up for another bounce.
• R can pretty much be given at any time during a cycle when numbers remain high and flat (often for 2 - 3 cycles after a bounce begins).
• Experienced R users will sometimes administer R more than once in a cycle when they have a full grasp of it's use.

It takes time and data collection to discover all the points I mentioned, but soon you'll develop a feel for it and your instincts will take over.

Please ask any questions you may have.
Good luck!

 

Hi there,

It looks like you already received a lot of good info on using R. It is indeed an ECID thing and as always 'Know thy cat'

If you have not seen an R scale, there are examples of BKs on one of the tabs of his ss. You can see I leaned on it quite heavily at times (note that BK was IAA only).

You develop your initial (and subsequent) R scale based on your kitty's responses to your R trials. Then as you learn Jacks responses you adjust and expand your scale accordingly.

A good place to start is with the PSs. Gather data on the effects different doses have on his BG and take it from there.

Question-You noted on the ss that on 10/28 you reduced the amount of food you give Jack- what was the reason?

 

It was quite the game, I'm in Tampa and we all were happy to see Joe Maddon get a big win, even if it got a little late watching the long game.

I've gotten a pretty good grasp on Lev's action, at least when the IAA/Acro is relatively consistent. Still learning on the R, and definitely still learning on the R&L combo. This has been very productive for me and will be adding it to my reference links when I need to refresh my memory.

Very helpful info for working on formulating an R scale for the pesky Capt. Jack. So far the doses primarily slow the rise, occasionally causing a small drop. I'll continue to fine-tune it as more data gets pulled out of his ears.

So far 2.5R seems to slow or keep the rise flat, will need to cautiously experiment with slightly larger doses to find the number that drops him a little but not too much.

That note should have been written different once I re-read it. No change in overall food allotment. About every 4-6 weeks he seems "off" not interested in food, lethargic. I suspect(no tests to back it), that it might be a minor acute p'tits flare. I got an autofeeder and split up the food allotment. A smaller PS meal, with a midday snack to equal the same amount he was getting before. I loosely monitor weight and use that as a guide for how much food he needs.

Thank you all again for all the great info. Nice to hear from some members with much more experience then myself. I learned a lot today and will put it to good use.