? 10/26 Lilly AMPS 387 -- Questions about TR

The last couple of times I've posted, people have encouraged me to switch to TR. I have a ton of questions, and I've read (and re-read) the stickies. It makes sense, as the protocol is written, but applying it to my cat Lilly has proven more difficult for me to grasp. So, here are some questions generated from my last condo: (http://www.felinediabetes.com/FDMB/...unce-need-help-with-dose.220768/#post-2464687) Special thank you to Gill & George for all your help, support, and explanations. And another apology that I haven't had time to be on the board in the past couple days to reply!

I know how to theoretically find a nadir, but I honestly am unsure when Lilly's is, because her numbers have seemed all over the place for so long..... How do I find this??

How do I tell the difference between a "failed reduction" and when it's just time for a dose increase? Or are those the same thing?

The stickies say 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?

How do I begin to tell when "bounces" are wearing off? Do I wait for a bounce to clear, and THEN go for 6 cycles before I increase? Or would I increase the dose based on the numbers during bounce? Because that doesn't make sense to me?

How do I STOP the bouncing!? Lilly is especially prone to them, it seems. Almost any time she sees blue she's back to pink shortly thereafter. I was initially told/understood that SLGS was best for this, but that has obviously not worked for her. So I'm trying to be a bit more aggressive now that we can test more at home.

I do know that there are going to be limitations and times we aren't going to follow TR to the letter. (This week and next, for example, I'm out of town a good bit). There are also days/nights we just are NOT going to be able to get mid-cycle tests. There are also times we are NOT going to be able to "steer the drop" with food. She gets her food at shot time and sometimes eats a lot right away, and then others where she just takes a few licks and then walks away until a couple hours later, and we're not home to encourage her. Is that ok? Or should I not even try because of those reasons? I've read the thread about using TR with a full time job. But I also work in a prison and it's literally unsafe for me to go to work with 3 hours of sleep and caffeine lol (Insert amazing fiance here, but I also can't expect so much from him.)

A few caveats/explanations that I know are likely to come up:
1) SS isn't updated because work has been crazy. We've been testing her but I haven't plugged them in. She's been largely in the 300s with a yellow here or there.
2) I am out of town this weekend and the fiance is caring for Lilly, so we won't be making any increases until I get back. He is wonderful at testing her and giving her shots, and knows how to treat a hypo of course, but that's about the extent of his FD knowledge and assistance (I mean, I had to create a "chore chart" for him to remember to scoop the pounds and pounds of litter )
3) I know the protocols were written for a human meter and I'm using an AT. I am comfortable with my meter, and I feel like I would be throwing away months and months of data if I were to switch now. I'm not switching to a human meter for TR, because our ability to TR is only a temporary one while my fiance is able to be home during the day. Come January, I'll be back to doing this dance alone, and I'm away from home for 12.5 hours per day, at least. So I don't think TR is going to be a long term thing, even if I decide to try it for a few months.

Sorry for the long post, and thanks in advance for your help!!

 

Please plug in those AMPS values as soon as you can. That will catch everyone's eye first - because we never give insulin without getting a test first.

 

Have a great day Kelsey and Lilly

 

Nadirs: Theoretically, the nadir "should" be consistent and with Lantus, somewhere in the vicinity of +6. However, many cat's don't read the rule book. Nadirs can and do move around which is why you're having trouble figuring this out. Gabby's nadir was early -- generally around +3 or +4 except when it wasn't. The best way to try to sort out when your kitty's nadir falls is to do a curve. You'll want to test every 2 hours for a cycle. However, I would not plan on getting a curve if your cat is bouncing off of low numbers.

Increases vs failed reduction: This isn't an easy question. It may be a bit easier to tease out with SLGS since doses are held longer. It would probably help if you had a specific instance you wanted feedback about. The issue is that there are a lot of variables that can come into play when trying to sort this out. The last "good" dose is typically your previous dose. Again there can be exceptions but it's a reasonable rule of thumb.

Bounces: In the beginning, bounces often last up to 3 days. Again, this isn't written in stone -- every cat id different (ECID) and some even from day one, will clear bounces more quickly. As a cat becomes more used to being in normal numbers, bouncing may be less frequent and the bounces may clear more quickly. You can increase a dose once the bounce clears. You can increase a dose when a kitty is bouncing. We just suggest trying to not time the increase at the same time a bounce is breaking. The rationale is that when a bounce is clearing the numbers are heading down, sometimes with a good deal of momentum. If you are increasing the dose at the same time, you may increase the momentum and could be working hard to keep your cat in safe numbers.

Stopping the bouncing: There is no sure way to prevent bouncing. (This is probably the most frequently asked question I run across.) Bouncing is normal, albeit very annoying for caregivers. Part of the issue is that we usually don't know just how long our cats have been diabetic. Their system gets used to being in higher numbers. As they respond to insulin, their body wants to go back to where it's "comfortable." Alternatively, bouncing is a protective mechanism. It's the internal safeguard against hypoglycemia and we don't want it to disappear entirely. The only way that bouncing slows down is for your cat to spend more time in normal numbers. I don't think one method for dosing is preferable when it come to bounces.

Practicalities: No one is perfect. No one expects that you will do anything but your best. If you need to make an exception, put a note in the comments of your spreadsheet. Many of us will open your SS every time we stop by. I look for comments if something seems 'different.' Depending on when your shot time is, a mid-cycle PM test may be impractical. (Who is going to routinely get up at 2 AM to get a test? Or, in your case, you may not still be awake at midnight.) Getting a "before bed" test every night will be helpful, though. There are also times if numbers are in dose reduction range and you need to get some sleep that you abort the cycle by feeding a ton of HC food. You know your cat. If you are comfortable that Lily will continue to graze or that if her numbers are low that she will go looking for food that's fine. I work full time and did so throughout Gabby's life. I had my shot times set for how Gabby it best suited Gabby. I shot at 5:00. It gave me a couple of hours in the AM to get tests so I knew if I needed to leave HC food out. (Gabby had an early nadir so I would know by +2 what she was likely to do.) The. more familiar you become with your cat's cycles, the easier this is likely to be.

I hope this answered your questions. I'm sure some of the others will be along to jump in.

 

Thank you so much for taking the time to answer! I appreciate it. I think I'm just going to try my best and go from there. Because what else can I do lol.
Thanks!

 

Hi Kelsey

that's all anyone can ever do.

As you've read in the TR on FT job, if there are times when you are not sure how low the dose is taking Lily then you may need to hold the dose a little longer or wait till your weekend/days off to time when to take the dose up, or gather some more data to help you make a decision.

It's great that your Fiance is able to help know, even if you have to go back to SLGS because you are unable to test enough in January, perhaps if with TR you can get her spending more time in lower numbers she will flatten out some, paws crossed.

@Sienne and Gabby (GA) seems to have answered most of your queries is there anything you are still unsure about?

 

Just to be sure, should I take her right back up to 1.75 based on the numbers we've seen over the past 6 cycles? (I've updated my SS now.)

 

Hi it does appear as though the reduction is not holding.
She looked to clear the bounce last night, but didn't make it back to green.
I'd be tempted to take her back up to 1.75u/
Were you thinking of doing it in the morning or tonight? what works better for you with your schedule?

 

We are actually gonna have to hold until tomorrow night. No one will be able to be home with her tomorrow all day. Does that make sense?

 

Yep, makes sense to me.

 

Make a note in the comments, why you waited. It will help you keep track of your thought process.