? Help with Merry's dosing please

Hi guys,

I really need some assistance with Merry's dosing. I posted about him still not being regulated in the main forum on Oct 25 & Larry kindly offered assistance. This is my post & our discussion & why you'll see on Merry's SS that his dose changed from 2.5 to 1.5:
http://www.felinediabetes.com/FDMB/threads/merry-is-still-not-regulated.185912/

So as of yesterday I've increased Merry from 1.5 to 1.75 (as close as I can to that) and his spreadsheet is up to date (he doesn't get his next shot for another hour, I do 8 am/pm).

Since Merry belongs to the rescue group I've been trying to follow the vets advice re dosage but it's obviously not working. I was considering following the Tight Regulation protocol from this point on but I'm not home to test at +3 & +6 during the day. I'm usually gone from 8am to 4:30pm Mon - Fri but I don't work weekends so can test more on weekends & will test more when I can during weekdays. I think I can still do the TR & do his increases on Fridays when I'll be home more during the weekends.

Any advice is greatly appreciated!!

 

Welcome...
to do TR - tight regulation, all that is required is the pre-test and at least one other test per cycle and that you are feeding caned food.
I added the guidelines below.

It's good that you recently increased.
Your next increase will be by the same amount , by 0.25u.

Try to test when you can, it's great if you can get an out the door test, and an in the door test.
Are you alone or is there someone else around who can help you .

You can also do the go slow protocol
where your reduction number is a bit higher to give more of a safety margin.

 

Thanks! I had the TR protocol printed out already so I can follow it. My out the door test is his AMPS # as I do that & give insulin & food just before I leave. Hubby is sometimes home during the day, sometimes not, depends on his shifts but he's often sleeping in late as well due to his shifts but he does check on Merry to make sure he's ok.

What do you think the reason is for Merry's flat curves even after increasing his doses? I just don't understand why they're so flat.

I'm hopeful now that we're starting back at a lower dose again that maybe things will improve & especially since I'll be following a protocol rather than letting him sit with a flat curve for too long on the same dose as the vet was doing.

 

Hi there, and welcome to L& LL

With being away at work 8.5 hours during the day it should be possible to do TR. It doesn't matter that you can't always get a +3 or +6

You may need to consider changing shot times. If you were able to shoot on a 6am 6pm schedule that would allow you to get a +1+2 +11 in the am cycle.
Remember that there are two cycles in every 24 hours and it is really crucial that you get some tests on the pm cycle, at the very least get a before bed test, I can't emphasize enough how important those pm cycle tests are, at the moment merry could be dipping into lower numbers at night and then 'bouncing' by day leading to the pinks you've been catching in the am cycle, or merry may simply be experiencing high flat numbers am and pm, we just don't know. Since dosing is based on how low the dose is taking kitty you can see how important it is not to ignore the pm cycle. Many cats have their lowest numbers at night, George was one of those in the beginning.




I would suggest you read the sticky on doing TR on a full-time job, it has some great tips and will give you some insight on how to manage.

Here's the link http://www.felinediabetes.com/FDMB/threads/is-tight-regulation-possible-with-a-full-time-job-yes.129378/

 

Thanks Gill & George. I've been trying to get readings before bed for a couple weeks now so there's some of those. Merry never seems to drop by +3 though, he seems to take a bit longer. The last couple nights I've set the alarm to get up at 2 or 3 am so I have a couple of those too. Based on Merry's spreadsheet now, should I increase? He's been on 1.75u for 10 cycles now & hasn't gone lower than 300 too often. The guidelines say to increase by 0.5u if nadirs are greater than 300. So do you guys think I should increase 0.5u or just 0.25u? I'm off work now until Tuesday so I can monitor him more closely if needed.

 

Yes I would take him up to 2u, unless he sees some green, that would be in line with TR, as long as you are getting enough tests in(which you have been doing) you reassess the dose every 6 cycles. Since he hasn't seen anything below 200, TR protocol calls for more juice.

At the moment on this dose his numbers are pretty high and flat, eventually when you hit a dose that works for Merry you'll start to see some patterns.
If you look at George's until he hit a good dose he was pretty flat, it wasn't until later when we got tons good dose that we started seeing drops earlier in the cycle, with George a +1 that was lower than ps more often than not signalled an active cycle.

When he has an active cycle that is the point where you will see a drop in numbers earlier in the cycle.

I would really recommend that you adjust your shot time so you can at least get a +1 in the morning before you head off to work. Perhaps you can test feed shoot as soon as you get up, and then do a quick test before you head out the door? I know it may seem pointless right now, but when you start to see some movement in numbers it can be a real useful indicator of how the cycle will pan out.

Good job with those pm tests!!

 

This is how we proceed with Toro:
The majority of kitties have lower BG's during the night (night predators, eh? ).
Being able to test @PMPS+4 to+6 will give you an idea where Merry's BG numbers are during the night and you can extrapolate for the day.
It's not 100% bulletproof (what is it with diabetes?)but if you are not at home, you are not at home....nothing you can do about it.
Cheers.

 

Hi Luanne,

No matter the technique you choose the objective is to seek the lower point of the curve. Intensive testing
do not seem to be required for Merry before +6-7. Past this time in the cycle you test every 2h or so until
you get rising numbers. Stick on this for 3 days or so to make sure your lowest point is not one out of a bounce.
If a kitty get in a zone where is pancreas is not comfortable, sugar will be injected into the blood stream.

No matter high or low, you just need a low number to adjust your dosing (follow the chart then). The .25 increment
is not to miss this magic low number. The only time I would skip an increment is if I've done testing every 3h and
I'm sure no low numbers have escaped my attention. In doubt, consider it could have gone down and your increase
will make it worse.

Follow what the protocol says in matter of lowering and increasing insulin, this works. For the rest, as far as
you're sure no low number have escaped your net. Tendency seem to be like that

[shot time] + + + + + + - - - + + + [shot time]

where the ''+'' and ''-'' are high and low numbers receptively.

Chase the ''-'' as often as possible (no need to test every hour). If you wake up at night to go to the
bathroom put your meter and strip somewhere for a quick test. At the morning put the number on your spread sheet.
Most meter will have memory, you don't need to write anything down or turn on the computer.

Also, always make a one day curve per week with 3h increment tests and cross fingers that it's a day out of
a bounce.

See what the other members have to say, there is lot's of good people here dedicated in helping others.

Sébastien

 

Thanks guys! I increased Oreo to 2u on Nov 10. I'm seeing more yellow numbers than I have in a while now (since he was on 2u late September) so that makes me happy to see again Altho some blues would be nicer.

I think last night somewhere between +4 and +9 he probably had a bit lower reading but I missed it. I meant to check it at +7 but didn't wake up until +9 (I set my alarm buy in my drowsiness must have turned it off or something). And today he seems to be bouncing with some red numbers. I don't know how long a bounce lasts, if that's what it is, but maybe tonight that will settle down.

I do appreciate everyone's feedback!! This disease is so confusing but I feel a bit better now that I'm starting to see a bit of progress again. For a foster kitty, Merry is costing me a fortune. I've been paying for all his diabetic supplies myself. The rescue doesn't want me to test very often because they don't understand the need so I'm paying for his strips myself & also his needles & food. And I have a houseful of my own furbabies too. But Merry is a sweetie & he was in remission once so it should be possible to do again, paws crossed!

 

Hi Luanne,

Good job getting those tests, nice that he's seen some yellow, on TR you would take him up to 2.25u.



From the protocol
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.

 

Yes, I increased Merry to 2.25u this morning He has very high day time numbers. Does that mean he's bouncing during the days? And if so, will that settle down soon?

 

Continue following the TR protocol and the numbers will settle down like magic...but only after you hit the magic number (dose).
Lots of people here use ReliOn human meters which have cheap strips (1/4 of the price of AlphaTrack strips or so) - in U.S.A, Walmart has them, I believe.
In Canada, there are a lot of choices of human meters with strips at half price of AT2 strips.
Be patient......
Good Luck.

 

I think that it is more related we haven't found the right dose yet. Yesterday daytime maybe a bit of a bounce from the lower number the day before. Bouncing is normal and some cats bounce all the time, others bounce less once they get used to getting lower than normal numbers. It take a while for them to get used to lower numbers, and since the goal is to get them in normal range the bouncing cycle can last a while, as they are slowly going down in BG, which mean they have to get used to almost every lower than what their body deems normal for them. Cats that clear bounces quickly is good, bouncing is good too means you are doing something good.

 

Good luck with the dosecrease.

It just looks like he likes to run a little lower at night, we find a lot of kitties do that. Is there anything different in what/how you feed at night?

Not all high numbers are bounces, I just think that he hasn't got to a good dose yet. Hang in there, it will happen

 

I switched to the FreeStyle Lite test strips with the AT2 meter. I can buy 200 of those strips for about $75 at Walmart where as 100 AT2 strips costs at least $80 or more. I used them side by side for a few days until I felt comfortable with just the FreeStyle Lite & once in a while I'll double check a reading with the AT2 strips just to be safe.

 

You can check some numbers from Toro's SS and Toro's SS Human meters to make an idea of how the numbers compare - the last 3-4 days you'll have the BG numbers for both AT2 and Freestyle Lite.
Now is more simple, just follow the protocol written for human meters and you'll be fine.
Merry is such a cute kitty.

 

Merry eats at 8am when he gets his shot & he usually cleans his plate. He doesn't eat again until I get home at 4:30 or 5:00 but I'll often check his BG first (4:30-5:00pm) & then feed him. I pick whatever is left up around 6pm so food doesn't influence his PMPS value. At 8pm he eats when he gets his shot & if he doesn't clean his plate I pick it up by 9pm so I can get a good reading before bed. My hubby stays up later than me so after his bedtime BG check I give him another snack & hubby picks it up 15 minutes later so that when I get up in the middle of the night to check Merry's BG it isn't influenced by food. I think all that is ok & hopefully shouldn't be causing him issues. He definitely needs to eat more than every 12 hrs & would be howling if he only got fed twice per day. When he came to me he was actually being very under fed. He's a big boy but his previous person was only feeding him 1 can of DM per day so he was starving & scrawny. Now he's put on weight & looks really good

 

Just a clarification, you don't need to worry about food influenced readings except no food 2 hours before test at shot time. You want to know what his BG reading is before insulin injection, in case it is affected by food. None of the other BG tests you choose to do have that constraint. Multiple feedings are a great idea.

I'm glad Merry is putting on some weight, that means he's metabolizing more of the calories now!

 

It's not recommended to use the freestyle lite strips with the AT2 meter. FWIW the freestyle lite strips and AT2 meter are not made by the same company anymore, I doubt that the calibration of the device will work properly with the freestyle strips.
If it were me I would get a freestyle lite meter, sorry I know it's more expense

As Christie says don't withhold food because of when you want to test, its only the amps and pmps that you need to worry about the 2 hour window.

Just a thought for the future, something that made life a little easier with feeding George. I used (and still do use) and auto feeder, it supplies George with regular snacks through the night (or when we are out), he would just guzzle everything in one sitting otherwise. Anyways with an auto feeder you can have it turn so that it hides the food 2 hours before his amps, but you can still leave food out for him for the rest of the evening.
In Georges case, when he was on insulin, I would normally not feed after +7, so I would have the autofeeder set so that he had no food from +7 onwards.

 

The Freestyle meter comes free with the purchase of 100 strips....one just has to ask for it. No extra expense involved.

 

I got mine free over here, but the strips were expensive here in spain, $60 for 50!! So I ended up using a different meter kept the freestyle as a back up. Just in case George decided to sabotage the testing by flicking his meter into his water fountain

 

Ugh! Others on FDMB said it was ok to use the FreeStyle Lite strips with the AT2. I've been using them for approx a month and when I double check the readings against the AT2 strips they are pretty much the same. I bought the AT2 meter for Merry because I didn't like the human meters he came with (I forget which ones they were) and I had only used the AT2 in the past & liked it a lot better & was comfortable using that one but I really cannot afford to pay $80 or more for 100 strips especially with all the testing I'm doing. I've gone through over 300 FreeStyle Lite strips already & am working on the 4th container of 100 strips.

At first I wasn't worried about food influenced readings except the preshot times but then my vet suggested that maybe his curves are flat because his snacks are influencing his BG levels so then I started to be more diligent about picking up his food so I can try to find his true nadirs. In another thread on the health forum someone mentioned recently as well about not feeding when it's close to nadir so that the level is not affected by the food. I feel better with his meal times right now in case it does help to get him regulated.

Merry gained weight right away as soon as he came to live with me, he's never had a issue metabolizing calories since he's been here & getting plenty of food. He's a big boy & 1 can of food was not nearly enough especially for a hungry diabetic. He does love his food

 

@Toro & Ovi I see you're in Toronto, I live in Belleville Where do you get the free meter with the purchase of the FreeStyle Lite strips? I buy the strips from Walmart & they've never mentioned a free meter.

 

I increased Merry's dose 0.25 this morning as he had 3 days on 2.25u so it was time to increase according to TR. I'm hoping 2.5u will give us better numbers. I was not able to get night time readings the last couple nights because I couldn't wake up even with the alarm. I was so tired from getting up in the middle of the night the few nights before that but I will try hard to get a reading around 3am tonight since I increased his dose.

 

Walmart. They don't mention it, you have to ask them. Not fair, I know.........
If I were you I would get a Freesyle Lite meter for free with your next purchase of 100 strips....it works and uses the same small amount of blood as the AT2 - and it will be more simple for you to follow the protocol.

 

Thanks so much! I will definitely get the free meter when I go in again

 

With Merrys numbers, he look pretty pink and flat, getting that test just before bed was good enough, there's no sign of him dropping, so I'm glad you got some rest.

He certainly looks like he needs more juice, good luck with the dosecrease.

On TR though with his numbers the way they are you could take him up by 0.5u. I've highlighted below the part of the guidelines that apply, given where his numbers are at.

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.

 

Thanks @Gill & George I wasn't quite sure so I did 0.25 to be safe. His numbers are still pink at 2.5u so far. Should I jump up another.25u now or wait the entire 3 days? It's only been 2 days on 2.5u. Or maybe after 3 days on 2.5u I will increase the 0.5u so he'll be getting 3u.

I got a hold of Merry's previous vet records & I changed my signature to reflect what his vet records show, as opposed to what we were told when he was surrendered to rescue. He was dx'd Oct 2014 & then was in remission from June 2016 - May 2017, almost a whole year. He's also going to be 11 yrs old in December but we were told he was 9 years old. Not that any of that matters, it's just interesting & nice to know the actual story. He was rehomed shortly after he went into remission in 2016 so the lady who he lived with before coming into rescue didn't quite have the full story. I'm not sure why he was rehomed in 2016 but when he was surrendered to rescue this year it was because the lady was moving & just didn't want to have the continued responsibility of insulin every 12 hrs, testing etc. So I know so far he's had 3 homes during his life. I'm assuming the person who had him when he was originally dx'd was his original person but I'm not sure. So that's Merry's story.

 

Poor merry, so much disruption in his life, he's lucky to have found you.

Rather than mess with the dose, I'd give him 6 cycles on the 2.5, before making a dosing change.

On cycle 6 post up for dosing advice, just to confirm your next move.

 

Thanks @Gill & George Cycle 6 is coming up & he's been in the pinks so in the morning should I increase by 0.5u? I thought it was promising when he was at 2u & getting the yellows but now he's all pinks again. This disease is so confusing.

 

Yes, I think you could go up to 3U tomorrow morning

Good luck with the dosecrease!!!

 

Yes go up to 3u, as long as you don't see yellow tonight.

 

I don't know if this helps but I got a free Freestyle Lite meter from Shoppers Drug Mart when I bought 100 strips. I know Shoppers is generally more expensive than Walmart but I wait until seniors' day to buy strips. If you're not in that demographic you could ask an older friend or relative to buy them. They're 20% off then plus I accumulate points on my Shoppers Optimum card and can use those to buy strips. I've been able to get 100 strips almost free occasionally by using points and the seniors discount.

 

How is merry doing on the new dose?

 

This is day 2 on 3 units and Merry's numbers are 18-20 whenever I test him
His readings were at least in the yellows on 1.75 - 2 units.

 

I suspect he has built up some glucose toxicity and needs regular small dose increases as per the guidelines you're following (TR? SLGS?). You WILL eventually reach a dose that starts getting his numbers down.

 

I wonder if I should try different canned food? He was on DM canned & I switched him to FF Chicken Pate & Holistic Select GF Turkey & now he just gets the Holistic Select GF Turkey. The Holistic Select does not have as much protein as the DM so maybe I should try to find something a bit higher in protein than the Holistic Select. Or should I leave his food alone for now? What brand(s) are you feeding @Kris & Teasel ? I see you're in Ottawa so we have access to the same foods. I'm actually going to be in Ottawa on Thursday to take one of my other cats to AVAH to see the Opthamologist & Cardiologist.

 

You're in Belleville, right? We're almost neighbours! Alta Vista Hospital has a big range of vet specialists.

I think that food is less of an issue than him needing a larger dose of insulin. I feed Teasel a mixture of DM pate and Friskies low carb pate and he's doing fine on that. He's not an extremely carb sensitive cat though. If Merry is very carb sensitive food might have a significant effect on BG level, especially if the food is above 10% carbs. Often, though, it's a case of needing more insulin.

Kudos to you for taking care of this sweet boy. I hope someone gives him a good home - permanently.

 

I agree with @Kris & Teasel I don't think the food is a problem, I checked on Dr Lisa chart and the holistic select turkey is low carb.

It does look to me like glucose toxicity may be in play. You are doing a good job of testing, so we can be sure he's not going low anywhere. Eventually you will hit a dose when you will see him move into good numbers again. Hang in there don't become complacent, he will eventually move for you.

No amps today? Or did you forget to fill it in?


How come you only feed one flavour? my George gets bored so I rotate various flavours textures, to keep his menu varied,

 

I was thinking maybe it didn't have enough protein since it's lower in protein than the DM even though it's low carb. I was mixing FF Classics Chicken Pate with it but haven't been adding it lately. He always gets fresh cooked meat on top, he's spoiled now & won't eat his food without the real meat on top

It's just frustrating when I keep seeing the pinks & occasional red & not even any yellows now.

I actually didn't check his AMPS because when I checked at +7 in the middle of the night it was 20.8 so I didn't feel the need to check preshot since I knew it would be safe (assumed it wouldn't do a crazy drop at that point).

I was trying to find a reasonably priced food, that was a bit better quality than the DM and so far the Holistic Select GF Turkey is the one I found. He doesn't like the lamb flavor at all. My other kitties get a ton of variety, I believe that's so important for them. But for Merry I thought while I'm messing with his dosages that if I stick to one food than the question of it being a problem with food can be ruled out (or in) easier.

I lived in Ottawa for 13 yrs & moved back to Belleville 5 yrs ago. I still go back to AVAH to see the specialists & if any of my dogs or cats needs surgery. It's worth the drive

I would keep him if he can fit in with the other kitties. I've never had an issue integrating cats before, they new kitty gets their own room for a couple weeks & then it's very slow & safe introductions over a period of time. But it's different with Merry, maybe because he's deaf, but he's not getting along very well with the others. I'm still trying & hoping it will work out. Merry has the whole rec room & foyer to himself & I let him come up to the main floor once a day when I can closely monitor them & will usually send a couple of mine down to the foyer/rec room so there's less for Merry to worry about. He's an extremely assertive, dominant boy & he's a BIG boy too, very loud because he's deaf which I think my kitties tend to read wrong. I'm not giving up yet though and Merry is quite happy & relaxed.

 

FF Pate(main food)and Friskies Pate (for low numbers nights and days only) will work just fine......White Fish FF has zero carbs, Chicken has 3% .....the rest come in between them. Friskies Pate (Chicken and Turkey) have around 5% carbs. FF have little more protein % than Friskies. i'm almost sure that Friskies will do the job and are pretty cheap - Toro has been on them for his whole life, no complaints......
The colours on the SS are just....colours. If you'd use a human meter you would already have been in solid flat yellows..... and the old yellows had been blues.
Be patient.....

 

It’s really important that you get in the habit of always checking the preshot. I know he’s high and flat now but sometimes things change quickly. The BG can drop fast and you can’t always be certain that, just because it was ok past midcycle, that it won’t drop.

I’ve seen many members go to bed when the BG was in the 300s and wake up to a 40.

A few of us were talking about the best route for you to go now and all agreed with the suggestion of taking him up 0.5u every six cycles until you start seeing nadirs below 300 regularly.

He’s very lucky you have such a big heart and are caring for him. I hope he settles in with the other kitties. He’s been through a lot.

 

Hi there

I’m adding my voice to the “Always test before you shoot” choir. I will add that not only is it the safe thing to do, the PS numbers help you identify onset and duration, both very important landmarks.

I also agree on .05u inceases everyz 6 cycles until yellow becomes a regular part of the picture.

Hang in there and hang in here

 

Morning Luanne, last night I asked some other long time experienced members to take a look at Merry's SS, just wanted to make sure I wasn't missing anything.

Everyone is in agreement about sticking to the 0.5u every six cycles until we see some movement from Merry.


This thread is getting quite long so could you start a new one, please.

The usual format on the Lantus forum, because it's so busy, is to start one thread each day, and we link the previous thread, in the new thread for the day.

The thread title is usually in the following format.

Kitty's Name / Date / AMPS/relevant readings/Question

For example:
Merry 11/21 amps323 350@+6 pmps 345 Dose advice please?

If questions or a situation (like a sudden drop in numbers) arise during the course of the day, you can edit title to reflect the new question/situation and use the prefixes in
the drop down list to catch attention if you need help quickly don't be afraid to shout for it.

I will look for your new post.

Hope you and Merry had a good night.

 

Thanks guys I appreciate it & will increase 0.5u every 6 cycles unless we see improvement & I'll start a new thread