12/31 Quintus +11=270 after lime greens earlier (0.2ui). shoot or not? advice welcome for tonight

condo: http://www.felinediabetes.com/FDMB/...hed-lime-pmps-164-0-25ui-2-175-10-117.188797/

First, let me start by saying I have a heavy heart these days. A year ago today, I was heading back to the animal hospital in Bern an hour away to see my beloved Tounsi, Quintus's companion for five years. I had dropped him off in the middle of the night and got a diagnosis of Feline Aortic Thromboembolism (FATE), which concluded two very busy months running from vet to vet trying to figure out why he was doing weird things with his paws. We thought epilepsy, it was thrombi, and he had undiagnosed HCM. I knew he had little chance of making it, but we would still try. I would put him to sleep just under 48 hours of bringing him there, another thrombus having sent him into acute kidney failure. I still have his ashes. I haven't yet been able to bring myself to put them in the garden he loved. I have decided that I would do it on the anniversary of his death, Jan 1st, tomorrow. I have been having a really hard time grieving his loss, and that has made dealing with has been going on with Quintus since his pancreatitis was diagnosed all the more difficult.

So, it's an understatement to say I'm (cautiously) overjoyed at Quintus's progress. When Tounsi died, Quintus was already old, and I was preparing myself for his possible death. You know, old cats. Here today, gone next month. It can be fast. I could have accepted something happening to Quintus. It wouldn't have been easy, but it would have felt less unfair. When Tounsi died, I did not imagine that I would get through 2017 without losing Quintus. Again, cautiously, it seems that the old man will see 2018.

So, where are we today? I shot 0.25 last night because I wanted to come to a dose where I don't have to worry about getting food into Quintus or hovering around falling neon greens. He probably likes food being brought to him where he's napping, but I needed a break. And I'm low on strips.

I was preparing myself for higher numbers this morning, and maybe heading right up to 0.5 again. But no. His +10 is 117. I know there are still some big numbers in the depot, so I'm ready to up the dose again, but it looks like we're headed for 0.25 this morning again.

Now for the truly incredible news: Quintus asked to go out and walked on his own all the way up to the rubbish containers! He has not done this in months!! He's been asking to go out much more lately, and had ventured a bit further than just in front of the building (sniffing some bushes), but this is really a step further.

Backstory: when Quintus started going blind (and before I knew it) he stopped roaming the garden on his own. I noticed that he would only walk around with me. So I would walk him (and Tounsi) around the building. Once or twice a day. It was our little ritual. As his arthritis increased (and his blindness), and with the loss of Tounsi, who (I realised later) played a huge role in helping Quintus find his way (another white can in addition to me), we stopped managing that tour. So we would walk up to the rubbish bins, and a bit further, between our building and the one above. And then only up to the rubbish bins. And then, we wouldn't manage to get up there every day. Since Quintus has been sick and I started my new job, he hadn't been going out much. To go out, I have to carry him down the stairs and I put him down either in the building entrance, or outside the building. These last weeks, when we did go out, at the beginning he would just stay there, sniffing interesting things in the air, but not moving much. He slowly became more active, and I was already super happy to see him go to the bushes (there are videos: https://photos.app.goo.gl/7vCSM7NcMALUEYom2 )

And when we got back inside, a few minutes later, Quintus called me to the living-room to play! This is something we taught ourselves: Quintus is a very quiet cat. But every now and again he will go "meow!" from another room. It is a call for me. To play. Another thing he hasn't been doing in quite some time. And he wanted to go out again!

He then went to eat some of his food, without me intervening.

I am very happy with how things are going this morning.

 

It took me over 20 years to bury the ashes of my soul cat Simon, and then with great reluctance (the containers of ashes of many cats and guinea pigs were taking over the dining room side board). I didn't want to let him go. Some folks here have had pieces of jewelry made containing a small amount of the ashes. I'm sorry for your loss. And I'm glad Quintus is perking up.

 

I'm stumped: his AMPS is 72
Really wondering if I should shoot or not. I keep lowering the insulin and his numbers keep dropping. (ETA: and yes I know there is depot in there with some bigger numbers still)
AND he's eaten an hour ago.

 

Tagging @Marje and Gracie for you.

 

I believe ashes are made to be scattered (that's what works for me). It was hard with Bagha, but it only took me a few months. There is something about Tounsi's death that is "stuck", because he was young, because we missed what was going on, because he was a special cat (well, aren't they all, specially once they're gone). So I will do it, even if I don't feel ready. Sometimes doing things makes you move on.

 

Thanks. For the moment I'm stalling. Actually tempted to feed him and see what happens to his numbers before shooting.

 

Oh! Wondering if the fall to 72 from 117 can be explained by the long (for him) walk he took outside at +11.

 

83 at +12.5

 

Here's where I'm at. I have two conflicting hypotheses running in my head.

1. he still needs insulin but depot is draining, hence why I'm decreasing doses. the dip we see is due to exercise, or his 117 earlier was due to him having eaten food not long before
2. his pancreas is kicking in and he's starting to not need insulin, or on the verge of it

If it's 1 and I don't shoot, he's going to go up, which is a shame. If it's 2 and I shoot, he's going to go lime green, which is annoying (I am still low on strips and want to do other stuff with my day). But on the other hand, even if it's 2, he might still need insulin for the last bit, and it would be a shame to put pressure on the pancreas by allowing his numbers to soar because I didn't shoot.

I'm going to wait another 15 minutes (we'll be at +13) and shoot 0.25. If he's come back down to around 72, however, either I stall yet again, or I shoot 0.1? The depot is a mess anyway.

My hope with 0.25 was to be able to shoot at 12 hour intervalls and not have to control his food (other than giving food at shot times). This is still what I'm looking for.

 

I'd assumed he would either go up or down but... well, no. He stayed flat. Decided to shoot a timid 0.25 all the same. If I spend my whole morning using up strips and battling lime greens, it means I probably won't be needing many strips these next days, right? Fingers crossed, either way (win-win). Either I don't need to use strips and was right to shoot, or I do and it means he's getting better faster.

 

Looking at the spreadsheet, he did dip down into lime greens at +2, let's hope that got it out of his system!

Dark greens are good, Quintus! Give your momma a break on using all those test strips!

 

He's been in and out of lime green. Given how little insulin I gave him (and how close I came to not giving him anything), I'm pretty sure we're headed for no insulin very soon. Like, tonight, to see what happens. Or 0.1. Though I'm not sure 0.1 really does something. If you give 0.1 to a healthy cat that is eating, will that cat go hypoglycemic? if not, it's probably not doing much... I also suspect that Quintus's organism is quite quite happy in the upper lime greens. Behaviour-wise, he's at his best when he's between 3 and 4, I'd say.

 

And you know what? that low dark green 72, well it was actually a comfy blue 110. But I thought "hmmm, that high? better be sure", specially as I had trouble getting the reading. So I took another one: 95. Hrm... better get a third one? 74. Eeeps! Got a last one: 70. Four strips gone

 

So tricky!

 

My condolences on your loss of Tounsi. My thoughts are with you today. Encouraging report on Quintus!

 

Now I'm wondering if I can trust the 115 I just got

Thanks @Alicia & Maggie -- it really doesn't feel like a year...

 

Maybe a little bounce?

 

or a little honey, rather, I'd say.

 

Sorry about your Tounsi, maybe Quintus is working so hard with his numbers to lift your spirits a little bit.

Looks like he kept you busy and went over his daily strip allowance! Did you shoot .2 like the SS says or .25 like your condo says?

I’m glad he’s being more adventurous and I hope it continues as he stays in better numbers!

 

sorry, 0.2! I'm seriously thinking about not shooting tonight (even though he's gone up, but I'm thinking bounce/honey, we'll see where he is around shot time). Particularly as, well, NYE party with the neighbours in my coworking space, I can't be hovering around lime greens.

 

So, somewhere (can't remember/find it) I was wondering about "asymptomatic hypos", ie, is it doing anything bad to Quintus to be staying in the lime greens for hours like he did on the day before yesterday. Haven't dug out the definitive answer, but found https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568263/ through http://www.felinediabetes.com/FDMB/threads/how-low-is-too-low.142105/ (which references a thread lost on the old board that I would have loved to read).

 

I don't think there's a really definitive answer to your question, unfortunately, because of everyone's favorite reason, ECID. There's just no real way to know how those lime greens affect Quintus-- even the cutoff for lime green vs. dark green is a bit of a compromise. There are some cats who will show mild hypo effects at "safe" numbers-- how many times has someone here noted that their cat will seek out food when they start to go low, well before they hit the lime greens?-- and some that will hang out in the 30's while on no insulin at all with no negative effects.

The take action number is meant to provide a safe buffer for most cats, but any time a cat is on insulin, my inclination is to err on the side of caution and spend as little time as possible in the very low numbers. There's no way (that I know of) to tell if a cat is experiencing low numbers as a hypo if there aren't any outward symptoms, so better safe than sorry.

 

Sorry I missed the tag last night....it must have come up just about the time I called it a night.

Stephanie...I’m so very sorry for your loss. Yes, all our kitties are special but there’s always that one that is truly connected to our heart and soul like no other. Thinking of you and wishing you peace

 

No worries, we all have a life (and nights!)

Thanks for your kind words.

 

You’re welcome.

 

I wanted to respond to your Somogyi inquiry on Silver’s condo. I also find it to be very confusing and I will explain why. I’ve yet to convince a vet that it doesn’t exist, it is drilled into their heads in vet school and they see something that looks like Somogyi and that reinforces what they’ve been taught and they cling to the term like a child’s favorite blanket! I think the problem is that “bouncing” and Somogyi can look like the same thing, I wish I knew what the literature calls what we refer to as bouncing, but unfortunately, I think they just call it Somogyi and that’s not a correct term.

Here’s what Somogyi observed: patients with a high fasting glucose in the morning, he purposed was from a silent hypoglycemic event while sleeping and the release of hormones to counter regulate. And the answer to this is: suspected hypo = too much insulin = lower the insulin dose.

With the innovation of continuous glucose monitors (like the freestyle libre you mentioned the other day), it is clear to see if Somogyi happens or if it doesn’t. If one goes hypo overnight, you may indeed see a higher number in the morning, or the numbers may stay lower, I think research with CGM suggests the numbers often stay lower in the morning following a hypo. The insulin dose part is the problem, the high number in the morning may not be from any hypo event, it could be from several things, including, but not limited to, lack of duration (insulin has worn off before next shot). In that case, if you lowered the dose, you’re doing nothing other than assuring more high numbers. Seems like a closed case to me, but somehow that is not enough evidence to remove the drilled in Somogyi from people’s brains.

I think the confusion lies in that there is some metabolic response (for some) to hypo numbers or big drops/perceived lower numbers and whatever that is, we call it bouncing, is often called Somogyi (I would say incorrectly). The problem lies in that it is only one possible explanation (for a problem with several explanations), with one solution (less insulin) and it can and often is just plain wrong. Yes, if there is a hypo and then a bounce, you would likely lower the dose and that makes perfect sense, but no, if you have a high number in the morning it does not mean there was a hypo at night and what to do about that high number depends on why it is high in the first place: bouncing from a low (non hypo) number, bouncing from a steep drop, bouncing from a hypo number, lack of duration, too many carbs/food influence, dawn phenomenon etc.

But it seems to be one of those terms that had an original meaning and has since morphed to mean something else, like regardless and irregardless, except Somogyi has worse implications than bad grammar. The term may have changed in meaning, but the solution is still tied to the original (less insulin).
I hope that made sense and I got the finer points right, the changing meaning of Somogyi is just my personal observation as I have seen it used to describe something like bouncing, but always the answer is “less insulin”.

This is just one study, one article (from 2005) finding no support of Somogyi rebound, there have been more, yet near 2 decades later, Somogyi is still being used and probably taught:

https://link.springer.com/article/10.1007/s00125-005-1946-5

 

I'm very hesitant over what to do this PM. With the lime greens this morning I had pretty much decided not to shoot tonight, particularly as it's NYE and I have a party going on downstairs with the neighbours. And I'm running low on strips.

His +11 is 270. Higher a number than I'd anticipated. Granted, it's not red, or even purple, but still. Is he bouncing from the lime green this morning? High on honey? (Seems a bit late for that.)

Given the strips and what my evening looks like, I'm still leaning towards not shooting, even if he could probably do with some insulin. I'd hate to find him sky high tomorrow morning.

I see these options:
- shoot 0.25 and run the risk of having to run upstairs from the party every thirty minutes and use up my strips
- not shoot and run the risk of him going into "bad numbers" again
- shoot later
- shoot 0.1 or something

Does one of these options seem better than the others? Opinions welcome.

 

What does the protocol you are following say to do?

 

Off the top of my head if I’m going SLGS (which I was approximately aiming for but never reached before Quintus started running down the dosing ladder) this should be his third (?) back to back réduction. To... zero?

 

Given I was giving him 2ui a week ago and now it seems 0.25ui is sending him in the lime greens, I'm not sure he's playing by the rules.

 

He went up pretty fast. While the honey is out of his system, it’s possible he’s not getting enough insulin duration to overcome that. I’m not saying, yet, that the dose is too low.

I found with Gracie that the lower her dose went, the less carbs she needed to control the drops. If I gave her the same % of carbs on a low dose that I did on a higher dose, it clipped her duration.

Time and data will tell if that is the same effect on Quintus.

But, for tonight, if it is a duration issue because of the honey halting the action of the insulin but the dose is a good one, he will likely come back down after PMPS.

Or...he could be starting a bounce.

It’s also possible the reductions are now causing the depot to be emptied and the dose is too little.

Big help, aren’t I? You are a thinker so I’d like you to think about all the options for his BG right now.

We won’t know the answer until we see what he does the next cycle. Goal one is to keep him safe. You don’t have many strips, and you want to go out (which is absolutely fine....we must have a life). If you decide to skip, think of it as a fur shot, test before you go to see he’s safe, have fun, test when you get home. If he goes high, you’ll have some info and he will come back down.

The decision is yours.

 

yeah, I thought about that one too. which is what is making me hesitant to skip. I also agree that it's too early to say for sure the dose is too high.

I think tonight I am going to take a "fur shot" decision (funny, I never did a real fur shot) to preserve my evening while being sure I don't endanger him.

Tomorrow is another day (what am I saying: another year!) and we will pick up again with an adjusted dose if necessary.

 

Have fun!!!! New Year’s Eve in Europe was always one of my favorite nights.

But please remember to grab a couple tests....just to be sure he doesn’t have his own plan even without insulin.

 

When Silver was close to OJT he was getting just one drop. Or a fat zero. If I remember rightly one drop was obtained by squeezing hard on the syringe. Placing it in vial and releasing. A perfect drop each time. Fat zero I can’t remember. I may have made a note in Silver’s ss as to how I got it.

 

Gah, I'm second-guessing my decision now.

 

281 is virtually the same as 270. But I take it you were hoping for a higher number to make it clearer?

 

So, the visual chart I made is helping me see that in fact he’s been pretty flat since +7. Gentle slope.

I was actually hoping for a lower number

 

We still have Hollycat's ashes. When the last of us goes we, that is myself , husband, Hollycat and Tylerpuss will all be scattered together back home from whence we all came. It is already arranged.
Me and him have no children so these matters need organising.

 

+16 212 -- he seems to be slowly coming down. Curious to see where he'll be at when I wake up!

 

Happy Healthy New Year to you and Quintus Sorry about your loss

 

Hi Stephanie, and Happy New Year! I am, though, so sorry for your loss on this anniversary. That's very, very hard.

Re: the 0.1: yup, they can go into shark territory (and potentially hypo, I would assume, on 0.1, but let someone else with more experience speak to that). I keep Girlie up out of shark territory on 0.1 by use of higher carbs. And take a look at @Alicia & Maggie 's SS on just a drop of insulin: it's a fascinating study.

I hope all goes well for you and Quintus in 2018! My Burmese, Girlie, will be 19 this year. It's hard to believe it, isn't it, when they achieve these mighty ages. @Stacy & Asia is the oldest, I think, at 21, but there could be some older kitties here as well.

Lovely numbers (though way too much shark diving!) for Quintus. Fingers crossed for good things for you both!

 

Rex went under 50 on a "drop" dose so it can happen.

 

@Girlie's mom, @Mandy & Rex, thanks!
I'm going to try the 0.1 drop today, I think: http://www.felinediabetes.com/FDMB/...how-to-stay-away-from-the-sharks-dose.188907/

 

These two posts might interest you as well, Stephanie in relation to reductions and OTJ trials:

Reductions: http://www.felinediabetes.com/FDMB/threads/reductions.81242/#post-2020916

Earning reductions and starting OTJ trials: http://www.felinediabetes.com/FDMB/...ng-reductions-and-starting-otj-trials.150160/