1/29 Dakota AMPS 256 Questions/Review

[Squeaky and KT (GA)]

Good Morning World! Welcome to our Home! Crash Condo

AMPS 256

Mr. Dakota has been feeling WONDERFUL the last few days. His numbers have been MUCH MUCH better, he's out and about more, back to climbing around us when we're sitting, watching squirrel TV, much more alert while he's awake. All P's in place, play is more than slapping irratating Bebo - played with paper wad for about 10 minutes last night.

I need help figuring out something to help with Doc's numbers which is why I tried what I did when he crashed a few days ago. Raising the dose is not the answer. I cannot keep up all that overnight testing but knew I had to do it over this period. I have a looong review of the crash and would like to understand where my thinking was wrong. I've studied it for many hours. If you see something striking, please point it out. If you have any other suggestions, please also share them! Here is my long review with comments/thoughts:

1/23 AM cycle - I shot regular f2u dose at regular time
He ran in green and blue numbers all day - prior to this, his history says he'll start bouncing by the end of the cycle.
AMPS 233
+2 - 143
+4 - 98
+6 - 84
+8 - 95
+9 - 78

1/23 - I shot 1 unit at +10 (131) - half the pm dose anticipating the bounce when he headed back up here
+10 - 131
+11a - 152

1/23 PM cycle - shot 1 unit at +12 (180) - the remaining half the pm dose to complete the cycle in a PMPS of 180. He normally continues up and up and up
PMPS 180
+1-+4 stayed in low 100's
+6 - dropped to 33
+6.5 - 50
+7 - 66
+7.5 - 71
+8 - 82
+10 - 92
+11 - 106

1/24 AM cycle - Shot 1 unit (Half regular dose) at AMPS of 139 due to hypo number in PM cycle - still rising off pm cycle.
+1 - 119 dropped back a bit off AMPS but still within meter variance
+2 - 71
+3 - 67
+4 - 90
+6 - 120
+7 - 151 rising again - only shot half dose (1u) at AMPS - following protocol says this is a REDUCTION of that extra 1 unit. NOTE - the 33 is PRIOR to this, not caused by this change.

1/24 PM cycle - +7 - shot REMAINING 1u from morning dose at +7 anticipating bounce beginning plus having short morning dose. Did NOT shoot again at what would be regular PMPS
+2 - 149
+3 - 174
+5 - 183
+6.5 - 154
+7.5 - 174
+9 - 189

1/25 AM cycle - 2.0u
AMPS 178
+2 - 276
+4 - 328
+6.5 - 207
+8 - 134 Gave SMALL drop of Karo to stop drop - still too close to that low time period
+9 - 215
+10 - 276
+11.75 - 223 stalled as this number dropped

1/25 PM cycle - f1.5u
PMPS (+12.75) - 339
+1 - 391
+4 - 373
+6 - 244
+8 - 126 no intervention other than fed bit of lc - just watch
+9 - 111 no intervention - just watch
+10 - 149
+11 - 187

1/26 AM cycle - 1.5u
AMPS 198
+1 - 198
+3 - 64 fed half 3oz can of LC
+4 - 89
+5 - 110
+6 - 96 ate rest of 3oz can of LC
+7 - 164
+9 - 177
+11 - 270

1/26 PM cycle - 1.25u due to too fast drop between +1 and +3 in last cycle
PMPS (+11) 270
+1 - 347
+2 - 412 suspect everything is back to 'normal' and pm dose isn't going to be enough
+8 - 177 Feel this is OK drop
+11 - 276

1/27 AM cycle - 1.25u want to be sure things don't drop so will not go back up
AMPS 323
+3 - 186
+5 - 179
+7 - 221
+10 - 251

1/27 PM cycle - 1.25u as didn't want to change dose with pm cycle
PMPS 368
+2 - 479
+8 - 319
+11.5 - 393

1/28 AM cycle - 1.5u raised dose back up to 1.5 Decent blue run...

@Libby and Lucy @Jill & Alex (GA) @Sienne and Gabby @Marje and Gracie

 

[Tina & Sammy]

@Squeaky and KT , WOW! that is all I can say. I have no advice on this, but he sure does like to be all over the place. After looking at the spreadsheet I can see why you would be tempted to try other measures. It sort of looks like even though this is not typical protocol, it might have helped lower Dakotas numbers a bit after a VERY long run of higher numbers. I hope those lower numbers hold. Maybe that was the boost that he needed.

I hope the Experts can help you figure this all out.

 

[carfurby (GA)]

I have no advice on the dosing. I'm glad to hear Dakota is feeling so good.

 

[Marje and Gracie]

I think the split dosing brought him down because he was getting so much overlap between the extra shots. Since you stopped the split dosing (and glad you did), the doses have been really inconsistent which could possibly account for the wonky numbers.

I also note that he was consistently getting into green over a year ago when his dose was around 4u. When I scroll through his SSs, he looks like a cat that isn't getting enough insulin. I know you say that increasing his dose doesn't work but if his dose doesn't get to the right dose, it won't work. And he hasn't been on the higher dose in over a year. Being in high numbers all this time might also mean he's built up some glucose toxicity.

If he were mine, I'd start taking his dose up according to protocol and keep going up (every six cycles) by 0.25u if nadirs are below 300 and by 0.5u if they are above 300 u til you hit blue. Then slow it down a bit.

It will be good to also get other thoughts but that's just what I see.

 

[Libby and Lucy]

I've been studying Dakota's spreadsheet. All 3 years, actually. What I'm noticing is a pattern of seeing 1-2 green numbers on a dose, then the green never comes back on that dose. That has happened on big doses and small doses. He hasn't ever hit a dose that gave him a breakthrough that stuck. It looks like he is building some kind of insulin resistance.

There are a couple of reasons that come to mind for that to happen. One is that you're reducing the dose almost any time he sees green. That doesn't seem to be working. He's not holding the reductions, then by the time you increase again he has built up some resistance (glucose toxicity probably) so even the dose that brought some green isn't enough anymore. So then he needs to go even higher in dose to find green again.

Another reason I have seen that sort of pattern happen is IAA (or sometimes acromegaly). It's also interesting that his numbers when you took him off insulin last May were similar to his numbers on insulin. It may be nothing, but it's something to think about.

If I were in your shoes, I would probably do the following:

• Continue shooting BID but work up the dosing scale more aggressively than you have been (I know you have some limitations about night testing). Try not to hold doses too long because that can let any resistance take a firmer hold.
• Let the green happen. I can't tell what you've been using as a reduction number, but I would try either lowering that threshhold a bit or (maybe even better in his case) waiting until he gets there more than once before reducing.
• Don't be afraid to shoot lower, if you get an opportunity. You know he's going to bounce, so if you get a good preshot go ahead and shoot it, within reason. You don't really need to wait to see if he's rising because you know he will. Worst case you might have to feed a little extra early in the cycle if the bounce doesn't start right away.
• I think you would be fine to shoot at +10 or +11 occasionally if you know he's starting a bounce and if you're available to monitor.
• Consider the use of R at the beginning of a bounce (instead of shooting Lev at +10 or +11), only if you are available to monitor. Given your PM limitations, this might be a safer option because you can decide when to use the R based on what your availability is to monitor. Because we know he can get green if he wants to, I would be careful to only use R at the very beginning of a bounce. You don't want to give it at a time when he might be thinking about dropping on his own.
• If he gets to a higher dose again, or if you're at the vet drawing blood anyway, maybe consider IAA and/or acro testing.

I'm not ignoring your thoughts above. The way I work on dosing issues is to first study the spreadsheet and work out my own theories based on what is there, without letting my thoughts be influenced by what someone else thinks. I did run my IAA thoughts past Jill because I didn't want to drop a bombshell without getting a second opinion on whether that was possible. Tomorrow I'll try to read through your notes and see if anything else comes to mind.

 

[Wendy&Neko]

I'm glad to hear that Dakota is feeling good.

I was in the middle of a post when I saw Marje and Libby had posted, so I erased most of it. As someone with an IAA and acro kitty, all I can say is that they can act like they are almost allergic to green. The only way to get them to stop bouncing and accept the green is to force the issue and do as Libby says "let the green happen". With Neko, she will still be really bouncy if she's at a dose where the nadirs are in the blue. Her best dose is the one with nadirs in the 70's.

 

[Jill & Alex (GA)]

I'm glad you stopped what was basically shooting early rather than split dosing. It was labor intensive and wasn't really getting you anywhere long term. I think it's also safer to take a different approach... incorporating the use of R if and when you're able to monitor.

All I'd like to add to Libby's comments is this...
Take a look at 5/8/14 (PM cycle) through 5/14/14 (AM cycle). You withheld insulin. I find it interesting that Dakota's number were basically the same as when he was on insulin.
Looks to me like you're battling some sort of insulin resistance.

Dakota was definitely doing better on higher doses of insulin. IMO, we're looking at a kitty who is under dose. I believe it's because generally the dose is backed down prematurely after hitting green. I agree with both Marje and Libby about raising the dose according to the suggestions in the protocol... taking an aggressive approach. If you get back up to 4u - 5u BID with the same results it'll be time to discuss testing for a High Dose condition.