? 10/23 Lilly AMPS = 419 on a bounce. Need help with dose!!

I'm getting so so so frustrated. There has to be something I'm missing or doing wrong. I have been hivering between 1.25 and 1.75 since JULY and I still can't get Lilly regulated. (Of note, I was using SLGS. Now I'm being more aggressive with increases since we are in a temporary position to be able to test more at home.) Where do I go from here? Am I not taking reductions correctly? Should she go back to Prozinc? we only tried it for a short while, and I knew far far less about diabetes at that point. I'm just at a loss. I want her to feel better

 

Since you are able to test, why not try TR? It's more aggressive since you can increase the dose after 3 days and the threshold for a dose reduction is lower. (You reduce if numbers are below 50.)

What I think is happening is that Lily is bouncing. It's frustrating but not at all uncommon. What I would suggest is to not "fatten" or "skinny"your doses. The only time we usually recommend a micro adjustment to a dose is if you are zeroing in on what would be a good dose for your cat. Lily's not there yet. You may also want to use food to steer the curve. What I'm suggesting is that it looks like whenever Lily's numbers start dropping, she ends up getting a dose reduction. You can use food to prop the numbers up so she doesn't get the reduction. This may allow her to spend more time in good numbers and help to reduce the bouncing.

What oral meds was Lily getting? (You may want to mention what it was on your spreadsheet.)

 

I am (kind of) trying TR. but I was also told I couldnt fully follow the protocol with a pet meter. What are the reduction thresholds for TR on a pet meter? I searched but couldnt find them. I would think since it's below 50 on a pet meter that it would be below 68 on a pet meter? I've only reduced when we've hit that low. I'm nervous allowing her to go much lower. I know 59 doesnt "sound" low when everyone is used to human meters around here. But 59 is hypo range on a pet meter.

I actually thought I was trying to zero in on a dose? because 1.75 has earned her reductions each time we've gone there. But 1.25 and 1.5 has not been enough.

the oral.meds have stopped, that only was a short term for her stomach bug.

 

Actually both the dosing methods used here on this site were developed using human meters, and it is recommended that you use a human meter to follow either of them. You might want to read through some of these threads where one of our most experienced members explains why, I was just looking through these earlier this morning researching another matter, but thought you might find the discussion interesting.
http://www.felinediabetes.com/FDMB/threads/pardon-our-dust.210108/#post-2328166 post #10
http://www.felinediabetes.com/FDMB/threads/at-meter-huge-differences.201183/#post-2237347 post #14 17 19

But to answer your question, on TR the reduction point if you do decided to use a pet meter is 68 for safety.
So if you're able to monitor enough for TR and kitty is on a wet LC diet, I would just stick to the TR protocol as it's written, taking your reductions if she drops below 68 (unless you decide to swap to a Human meter, which personally would be my advice, seeing as the protocols were developed using a human not pet meter)

So given last nights numbers yes you need to reduce to 1.5u. If you are able to follow TR for now, it may help you regulate her, but it also is not unusual for kitties to go up and down on a dose. With TR you would be able to take the dose up much sooner if the reduction doesn't hold, if you are getting enough tests in. This will probably help you get a handle on her BG.

Post and ask for advice if you're unsure as how to proceed with TR protocol. Remember on TR if kitty doesn't earn a reduction, you will be re-assessing the dose at least every 6cycles, and asking yourself 'Is my cat's nadir in the normal range?', this more frequent re-assessing of the dose will most likely also help with getting your kitty better regulated.

 

I am comfortable with my human meter and would rather not switch if it's not necessary.

With TR, how do I know the difference between a "failed reduction" and just time for a dose increase? Lilly has also typically taken more than 6 cycles to adjust to a new dose / depot. Which is why I've held the doses a bit longer than TR suggests. But I suppose I could up the aggressiveness. I've read and re read the stickies, but it doesn't "click" for me. Like it says after a failed reduction go back to the last good dose, but if all those doses have earned her reductions, how do I know what dose to go back to?
And, as a more immediate matter, what do I shoot tonight?!

 

With a failed reduction you will see the nadirs trending up. Post if you are unsure and ask someone experienced to take a look. Today she has bounced quite hard from dropping fast into that 59 last night, before deciding if she's failed the reduction you would want to see what she does once she clears this bounce. (it can take upto 6cycles for her to do this)
Dropping 150pts from Pmps, that was a hard fast drop at the early part of the cycle.
Did that low BG reading catch you by surprise???
If back at that pmps of 207 and at the previous reading you got in the am cycle at +7 of 290, that should have been your first clue as to what she might be planning, she signalled loud and clear she was intending on clearing a bounce. When you shoot as a bounce is clearing they can gather quite a bit of momentum, as you discovered last night. This doesn't necessarily mean that you shouldn't shoot, but rather that you should take note and take some positive action. It would have been helpful to you to get a +1, it would have likely shown that she was heading down fast, but she would have still been in good numbers, the difference is that you could have steered by giving some extra food, getting some extra food into her before she onset would have helped to flatten the curve, this can minimise bounces and also help with getting those doses to stick.

It's not 'necessary' but it certainly makes it so that you can't take full advantage of the protocols as they are written. It's important to remember that the 68 is an arbitrary number that has been chosen when folk started using pet meters in an attempt to keep cats safe, but it does not equate to 50 in a human meter.
I'll use last nights drop into lime green as an example.

If you are using a human meter and you drop below 50, in a newly diagnosed cat you would take a full 0.25u reduction. In kitties who repeatedly fail reductions some CG may adopt a strategy of fattening/ shaving dose for drops below 50 but above 40, I think this is what you have decided to do. A drop into the 30's would warrant a full 0.25u reduction.

So what is that 59 in human meter terms? The answer is.... We do not know, there is no conversion that is available or works. So you are left with having to flip a coin when deciding if she should have the full 0.25u reduction or sticking with shaving the dose.
What does that mean, well if you shave the dose and she did in fact drop into the 30's you are already making an aggressive protocol more aggressive, and the added risk inherent in that.
Conversely if you took a full reduction and she didn't drop much below 50 or even didn't drop below 50 at all, you would be likely taking a reduction that wouldn't hold.

Can you see how that might lead to some of the issues you have been having with failed reductions?? And how you are not able to follow the protocol and make full use of it's nuances?

What is it about the meter that you are comfortable with? Honestly for me there was never any question about whether I should use a pet or human meter, given that all the work/studies had been done with a human meter it just made sense to use the same instrument that the researchers had used.

All that said

I'd probably err on the side of caution and take the full reduction to 1.5u.

 

I would take the reduction she earned last night by dropping below 68 and drop down to 1.5 tonight.

We don't usually start trying the "fat" and "skinny" doses until we're really close to dialing in a good dose, so for now, I'd stick with the .25 increment changes.

You mean you're comfortable with your pet meter? (since you're using the AlphaTrak2)? You don't need to change meters to do TR if you don't want to.

This is a harder one....the best answer is that it takes a lot of time, experience and looking at others spreadsheets until you really start to understand the difference. For the first couple of years, I always had to ask for help from people with a lot more experience than me until I finally started to really pour the time needed into analyzing my own and lots of other people's spreadsheets and asking lots of questions.

 

If you are trying TR, could you put that in your signature? For kitties that don’t hold reductions well, one option is to go to three times under 50 on the human meter (68 for you) on separate days. On a human meter, if she goes below 40, it would be an immediate reduction. Not sure what 40 on a human meter means s for the AT, there is no conversion. Holding for multiple times under the reduction point gives her more time in greens, allowing her to become more used to them.

 

All of this is so confusing!!!!!!!

This brings up a couple of issues, in addition to the pet vs. human meter debate (which, I'm far less worried about at this point TBH). For one, it always feels like it takes forever for my posts to get answered, and if/when they do, I even get conflicting advice or digressions about me using a pet meter or not following the protocol to the letter. A related, but still separate issue, is that Lilly has often needed more than 3 days on a dose for me to really gauge how she's doing on it. (Or, frankly, maybe *I* have needed more than 3 days on a dose to understand things.) She typically doesn't hold reductions well, either. Anytime I take one it quickly becomes apparent that she's just running high. I don't fully even know her nadir times because they're all over the place, and I have no idea when she's bouncing or when she's just running high or not on a high enough dose.

This is also confusing to me. I did not think she was bouncing or clearing a bounce that day. Is it possible I missed a low number the night before last? Sure. But based on other data I've got, it's also possible (maybe even likely) that she was just running in the pinks, as her normal. Besides, she doesn't typically clear bounces that quickly. So, I'm not seeing the low numbers prior to last night that would have led to a bounce, and then her clearing that bounce yesterday?

I think this is another reason I'm not fully adhering to TR just yet. I just don't *get* it. And, I'm away from home 12.5 hours per day. My fiance has to make decisions on PM doses, and, he barely understands the basics, much less TR, if I don't even get it!

It just seems like all she's doing is "bouncing" every. single. time. she gets to green. Every time. She'll earn a reduction. I'll reduce. She'll go back to pinks for almost a week. I'll increase. Once the depot grows, she goes to green, and bounces. Never ending cycle and I don't know how to get out of it.

I'm sorry, I'm just so exhausted with this illness and trying to understand it and everything and I feel pretty alone.

 

Gabby was pretty bouncy during the earlier phase of her diabetes. In addition, her numbers could drop like a rock early in the cycle. The strategy that ultimately helped was to keep an eye on her numbers and use food to intervene and to prevent her from getting a dose reduction. The more time a cat spends in better numbers, the more her body will get used to normal range numbers. The more your cat's body gets adjusted to normal range, less less she will bounce. My goal was to keep her in green numbers mid-cycle and blues at shot times. It can take a while to get the numbers to cooperate but the bottom line is that the more time a cat spends in lower numbers, the greater the chance she will acclimate and stop bouncing.

The great meter debate -- bottom line, you can use whatever meter you like. The reduction point on an AT is 68. Personally, I used a human meter. I was a testaholic and I would have gone broke if I used a pet meter. None of the vets I used got into a twist over my using a human meter. (and frankly, I wouldn't have cared if they did).

This is a huge forum. A couple of things will help get attention to your thread (we also call each cat's thread a "condo"). If you are posting at a busy time or feel that your post got buried, add a post to the condo. It will bump your post up to the top. If you have a question, do what you did today and ask for help in. your subject line. Many of us scan the board looking for those members who are asking for help especially on days when our time is limited. One thing to keep in mind is that everyone here is a volunteer. There are some of us who have been hanging around for quite some time. There are others who are far newer. Looking at the date of diagnosis in someone's signature will give you a clue as to who has experience. Even among experienced members, we have differing opinions. In some cases, there is no one "right" answer. What may work with my cat, may not be effective with Lily so sometimes, it can be trial and error to figure out what works. In Lily's case, I don't know that I'm seeing what you are in her spreadsheet. There are certainly cats where their caregiver has to hold a dose longer. One of our most popular bits of slang is ECID -- every cat is different.

One other thing that will generate more eyes on your condo is visiting other kitties condos. This is a social board. People get to know each other and each other's cats by "visiting" their condos. The other advantage of doing this is you can look at other spreadsheets. The more you study someone else's SS or ask a question or leave a comment in the condo, the more people will get to know you and Lilly and post in your condo.

If you're confused with TR, can you let us know what you're struggling with? I'm happy to decipher what may be confusing.

 

Hi there, sorry it's taken a while to get back to you, I was asleep, I'm in Spain so it was 2.45am for me.

Looking at your SS this morning it says you shot 1.75u last night oct 23??? I so hope this is a typo, she earned a reduction down to 1.5u, holding onto that 1.75u dose based on the data you have is an extremely risky decision to take.
My advise would be to bring her back to 1.5u at the very next cycle, additionally, please monitor her tonight, though this is probably to late and you have gone to bed.

It's great that he is willing to help you, would he be willing to post on the board if he was unsure? It's not unusual for couples to be joint CG, my DH also helped out, he never posted, but he had access to the forum just in case he needed help. My petsitter also had access to the forum should she have needed help.
perhaps he saw the high PS and decided on the 1.75? I'm wondering if the fact that you've come from using Prozinc might be influencing your/his decisions.
I haven't used Prozinc, but from what I understand with that the dosing decisions are somewhat based on PS numbers, that is not the case with lantus, with lantus, it is the nadir (that AT59 on the night of the 22 that governs your dosing decision) If it was just a typo, just ignore the above. Last night his only choice on what to shoot would have been shoot, 1.5u , unless she is too low (you may have to decide on a no shoot number for him or a number where he would ask for help), taking the dose up, was never an option.

I really just came on to reply to your [post, the response to that follows regarding patterns and what I see in the last couple of weeks, which I hope helps you get things a little clearer in your mind.

OK I'm going to start from first principles as I'm not sure what you do or do not understand with regards to bouncing.

What is a bounce?
Is when we see numbers stay high and flattish for a period of up to 6 cycles. The numbers can bobble about a bit in some kitties.
Why/when do kitties bounce?
When kitties get into BG levels that they are not used to, this can trigger a physiological reaction that essentially results in stored Glucose being dumped into the bloodstream by the liver. Note it doesn't have to be low numbers, for example I remember when George saw his first blue, he didn't hang there for long, he just bounced straight back up.
Another trigger for a bounce can be a sharp fall in numbers, so a kitty might be at say 455 and drop 200pts in 3 hrs to 255, and that could also trigger a bounce back up into the reds.
I like to think of bouncing being a result of a messed up fail safe in the kitties physiology, their bodies have gotten used to being in high numbers and they have come to accept those as being normal, when we take them out of that range, their fail safe, 'thinks' kitty is in danger from a perceived, imminent dangerous low (not an actual low), and that triggers the glucose dump.

Now lets look at Lilys numbers
Starting Oct 19
am cycle she dropped from a pink amps of 322 to a blue 104 at +5 staying flat with a 111 at +6 and then by +7 she was shooting up to yellow (this is the start of a bounce) and was up at 394 at pmps.
pm cycle of 0ct 19 mid cycle test shows she is still high, so bounce ongoing (cycle one of bounce)

Oct 20
amps 405 +5 311, pmps 386 + 309 oct 21 amps 314 so showing a downward trend over 24 hrs but essentially still high and flat over these two cycles (cycle 2 and 3 of bounce)

Oct 21
amps 314 +6 293 yellow, but not much different to amps, (could she have gone lower early? and this is her on her way up? possibly... I'd be looking to what she does at the next test to get some indication if she got lower earlier in the cycle) pmps was 359, so looking at those numbers that you got overall the seem flattish, so it doesn't appear to me that she dropped into low numbers which you missed early in the cycle, possible but not probable, though we can't know for sure. No tests in the pm cycle on oct 21 ??? but she was red by morning. That might be another bounce, she may have dropped overnight and you missed it, no way of knowing.
So still bouncing in the morning (cycle 4 of bounce) and cycle 5 we don' t know if she is still bouncing or if she had an active cycle, we will have to look to the am cycle of Oct 22 to look for clues.

Oct 22
amps 434, back up in red??? hmmm that would start me wondering did she do something naughty last night?? Lets see how the morning pans out... +7 shes 290 (probably didn't go lower than usual last night), approx 150 pt drop from amps, that's a significant (large ) drop, this is cycle 6 so I would be looking for that bounce to finally clear, 207 at pmps, thats 227 pts lower than amps, definitely clearing the bounce, why do I say that, well we are at the end of the cycle, we are at the point of least insulin action, but BG is the lowest it's been all cycle. What could have caused that, could it be that the bounce cycle is over, the liver has stopped over reacting and has decided to stop dumping glucose into the blood stream? (probably)

So to me that 207 was a big sign that the bounce was clearing, not because it was yellow, but just because when you looked at the trend in that preceding cycle she was dropping consistently during the day, her numbers continuing to slide in spite of the insulin action waning.

In contrast to that if we look back to the pmps of oct 4 In the morning she was 398 and at pmps she was 208, why did we not see the same happen on this day, well if we look to the midcycle test we see she is at 182 at +8, so although the 208 is a lot lower than amps we can see that the numbers are trending up or flat at best, so possibly she nadired a bit earlier in that cycle and by pmps was on her way up, starting a bounce, which incidentally cleared 4 cycles later 4 cycles later on am cycle of october 6 where she earned a reduction, she then looked to clear two cycles later with that blue on oct 7th but didn't quite make it, eventually taking a further 4 cycles to clear into green earning another reduction.

One thing to bear in mind is that when you see a bounce clearing at the end of a cycle like that and you shoot they can often gather quite a bit of momentum, it doesn't mean that you shouldn't shoot, (in fact shooting in my opinion was the right choice) it's just important to be aware of what is happening, so you could take appropriate action.
What could you have done different?
When you shoot a PS number, that is falling or flat that can often be a sign of cycle that is going to be active, that is, that we are going to see the BG drop at onset (usually around +2) and continue to drop through to nadir (usually around +5+6) So that is a heads up to pay attention, particularly in a kitty that has shown she has a flare for the dramatic such as Lily.
So on that night if it had been me, I would have got a +1. That would have probably been lower than the PS number, absence of a food spike(flat) at +1, or even more important a drop instead of rise at +1. At that point it would have been possible to attempt to steer the cycle with food, to see if she would level out, this is what Sienne has talked about in her post above. You might have been able to hold on to the dose by simply feeding some LC food in the early part of the cycle, holding on to the dose a little longer may help minimise the yo-yoing with doses, though some kitties just take longer to do so than others.

At +1 food should be impacting BG but the Lantus shot will still not have onset, so we would normally expect numbers to spike a bit, how much depends on the cat, my guy never had much of a food spike, but if he had a significant drop at +1 I knew I was in for a bit of a ride, it took me time to learn this about my kitty, be patient with yourself.

I'm sorry you are feeling so low. I think all of us who have dealt with FD have felt like that at some point. For me being on the board really helped, I made new friends all of us sharing a love for our cats, I've rejoiced in their successes and mourned their losses alongside. It takes some time to build relationships on the board, when you do get some rest, if it's something you haven't tried do visit the other condos post a comment or two, it doesn't have to be advice, a hug, an expression of empathy, or a a little joke to make someone smile can be the start to you building a support network on the board.

My kitty is OTJ now, has been for a few years, so I'm not on every day, but I will look for you when you are. If you feel in desperate need of help, and not getting any response after trying Siennes suggestions of how to get more attention. Send me a PM I can't guarantee I will be there quickly, but I will make a special effort to log on and visit your condo as soon as I can.
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