12/31 Silver AMPS 295; +2=324; +6=229; + 8=243; PMPS 301

http://www.felinediabetes.com/FDMB/...227-8-290-pmps-346-4-351.188803/#post-2099593

It was suggested in yesterday's condo that Silver MAY be on too high of a dose and when he was on 0.25 and I had got a green the day after my return from UK, the pinks and reds following were bouncing and the dose should have been held. Thoughts anyone? Could he be on too high a dose? Need the old timers to weigh in here. @Jill & Alex (GA) you were right - he has given me a lower preshot as per 12/29. Perfect day for a curve. I will get a +2 but then I am out until +7 though.

Thanks

@Jill & Alex (GA)
@Marje and Gracie
@Sienne and Gabby (GA)
@Wendy&Neko

 

Being the person who made the suggestion, I really want to insist: don't give it too much weight, it's really just an idea maybe worth looking at. It could be completely bonkers, given my lack of experience.

 

Wish I was home to test today.....

 

Damn :-(

 

Don't take this the wrong way - but you have only been on the board less than a month and don't yet have the experience to be making those sorts of statements - and all it does is add even more confusion to the mix. If the experienced ones on here have encouraged me to increase based on his numbers, then that is what I listen to. Experience.

 

I know it's frustrating you have to go out today, but any extra data you get today can help us figure out what is going on with Silver's numbers. I just do what I can when I'm home with Furball. That's all we can do.

 

Let's just backtrack here. I presented this idea as a wild hypothesis. Not exactly a statement of how things are. I think I added enough caveats regarding my lack of experience on the board. It was an idea I was presenting you. And you do exactly what you want with it. Toss it out with the trash if you think it's BS, look at it if you think it's worth entertaining. That's your call, as you say. I am not trying to make you do anything different than you are doing. Just offering something to think about, if you so wanted. I don't take it badly if you don't.

You seemed to be in a frustration situation and, like everybody around here, even when it doesn't come across well, I was trying to be helpful. In my limited experience on the board, I have heard "too much insulin can look like too little" enough that I wondered if looking at Silver's SS with those glasses on could bring something interesting to the discussion. Clearly I have been mistaken.

Now, I remember reading in this post guidelines on how to deal with advice offered on the boards (even if I wasn't even giving advice in this situation): people on the board have varying levels of expertise. All that is being offered is advice and opinions, and that it is up to each person to be critical in accepting advice and information from others as true or valid, to figure out who is speaking and on what background, and to decide who they trust and don't.

Nowhere did I read (at least not in "suggestions for advice givers") that people with less experience were not allowed to make suggestions (but maybe I missed that elsewhere). And I'll repeat again: I think I made quite clear that my "wild hypothesis" was maybe an idea to consider, and that it could be completely wrong. I personally think it's worth looking at. No hard feelings if you don't.

 

Looks like a normal curve so far. Food bump at +2. Wonder what that +7 will look like!

 

FWIW, and I also have not been here that long, the increases are the way to go and he just hasn’t arrived yet at a good dose, but getting close!

Sorry you can’t be around for a curve today, cats are reliable at pretty much doing the opposite of what we want them to do, it seems!

Excited to see the +7

 

The below provided for information only. I’m not meaning to step into the discussion on either side. And while I don’t like copying and pasting, it’s a quote from Tilly’s webpage:

In all the years I’ve been on the board, I’ve seen a very, very low percentage of cats that were overdosed. One example is
Teronto (https://docs.google.com/spreadsheets/d/1TlFS6Sc_9xob0gbL7Dzv-wj7bzGrNvvmPj6WR4kHcpM/pub?output=html) whose vet started him at 10u bid. In that case, reducing the dose (i.e. a rebound check) was recommended and “paid off”. (sorry.....ever since I downloaded the last IOS update, my hyperlink does not work consistently on my tablet).

It’s important to note this cat’s dose was not systematically and slowly raised as we do in this ISG.

 

I want to give @Stephanie & Quintus some slack for making a suggestion that she did back up with a caveat. This is a peer-based discussion. I've been around a long time and I make mistakes or miss something (e.g., that someone is using an AT meter -- I did this yesterday). It's the value of having anyone and everyone weigh in The down side is that it can be confusing for the caregiver if s/he does't know how to sift through a myriad of conflicting suggestions. There are also people who have been around a long time and don't offer wise words.

Here's what I see. While too much insulin can look much the same as too little insulin, it's unusual for a cat whose dose has been systematically increased based on one of our dosing methods to be getting too much insulin. Doses can be increased by 0.5u if following TR and nadirs are over 300. Another consideration is that Silver is a long term diabetic having been originally diagnosed in 2014. The rules sometimes need to be modified slightly for a cat that's come out of remission. All of that said, there are some things to mull over. Since Juliet is following SLGS, while there is room for modifying the strategy with a larger increase, the increase from 0.25u to 0.66u was a bit aggressive. The dose was held for 7 cycles which again, is a bit aggressive for SLGS. With TR, the time frame is fine -- the increase from 0.25 to 0.66u is more than what we'd look for especially since nadirs look like they were not consistently above 300.

However, dosing has been very consistent for the past month. If the dose were too high, I would have expected to see a drop into low greens by now. There hasn't been a precipitous drop so I'm going to assume the dose is fine.

One other consideration to keep in mind. There are people who adhere to the "chronic Somogyi rebound" camp and will suggest lowering the dose for a bouncing cat. I've never seen this work. In part it's because Somogyi rebound is what amounts to an urban myth. There's no research to support it and it was promulgated at a time (1938) when long acting, depot-type insulin didn't exist. All the "lower the dose" strategy seems to do is keep the kitty in high numbers overly long and you end up wasting a lot of time getting the dose up to a point where the kitty responds.

 

On 12/27 and 12/29, he had blue PMPS (and the one on 12/27 was 126) followed by a bounce. There is potential he got into green those a.m. cycles. IMHO, holding the dose is the correct thing to do.

Insofar as overdose, his SS does not look like a cat that is overdosed, at this point. He’s clearly bouncy and we know he’s getting nadirs below 200. We don’t know how low below 200 and hopefully we can find out.

 

Thx all. FYI the increase from 0.25 to 0.66 is bad recording on my part. It was only to 0.5. At the time I didn’t think I’d measured 0.5 correctly and so put 0.66 but I think it was 0.5 he got now I’m more experienced at measuring.

 

First, thanks to @Marje and Gracie and @Sienne and Gabby (GA) from me too for your instructive comments and analysis. But I'm now very confused regarding Somogyi/bouncing. I had understood them as one and the same, ie, cat gets into "low" numbers, BG goes up in reaction ("panicky liver"). I thought Somogyi was when there had been clinical hypoglycemia, and that bouncing was the same phenomenon when the numbers were "safe" but the cat's metabolism thinks they are dangerous.

Obviously I am missing something here as you both seem to reject Somogyi (if I read right) but accept bouncing.

What am I missing?

 

Maybe start a new condo to continue this discussion? In think tank maybe.

 

Rather than reinvent the wheel, there is a great discussion regarding Somogyi in this condo. It’s got a lot of good info in it and I know you like to read! Love your inquiring mind!

ETA: @Stephanie & Quintus if you do want to discuss further and have questions, let’s move it over to Quintus’s condo since he is also very bouncy and goes pretty low. If anyone else reads this condo, they have the response to your question.

 

I know we don’t like to do condo hijacks but I do think this discussion is pertinent to what’s been brought up about Silver regarding bouncing and overdose. It’s not really Think Tank material as Stephanie is just asking for information.

 

Ok so he’s not dropped much at all at +6. I will do a curve from now - +6 to +6 and then we can make a dosing decision at that point. Looks like he DOES need a dose increase as I have caught nadir today and will catch it again in this curve. Usually by +8 hrs on his way back up. His nadir is around +6/+7. I hope I don’t need to wait until Tuesday to increase as per SLGS as the curve should tell us what’s needed and I need to get him back on a weekend curve/increase schedule. Hoping you might be online around his +6 tonight @Tracey&Jones as you’re 2 hrs behind me in time zone.

 

I should be. Staying up to watch the New Year celebrations. Nice to see that drop though. It looks like a normal curve.

 

I wonder if he will be blue at PMPS??? Look at the previous 4 days....a possible pattern.

 

That’s what I’m hoping for but do you really think he’ll keep going doen? Would love him to but then I’ll be expecting a pink AMPS. wish I could break this cycle.

 

Point taken. And apologies if I’ve caused offense today. I’m very stressed out and sensitive regarding Silver and I’m already confused enough without adding more to it. Did not mean any offense @Stephanie & Quintus

 

Maybe Can you get a +10?

He is clearing the bounce...he has some momentum.

 

No apology necessary...you haven’t caused offense. We all understand how stressful the numbers are and that your schedule adds to it.

Hang in there, Juliet. I do believe it will get better...it might take time but just keep focusing on all you are doing to help him and how great he feels.

 

Try not to jump the gun. He’s very flat which means he might clear the bounce tonight. It’s great that you can do some testing but we need to see where he goes.

And don’t forget you’ve got two cycles on this dose where we already know he has nadired below 200.

 

Aren’t we aiming for nadirs below 90? Will ask for advice after today’s curve. I really do not think he is going anywhere close to 90. He is high and flat.

 

Yes. I’m home now so will be getting a +8, +10, PMPS, +2; +4 and +6 - a full 12 hour curve.

 

From yesterday's thread:

You're welcome. I cringe every time I see seasoned members reduce the differences between TR and SLGS as, "You can raise the dose every three days with TR, but have to hold the dose for a week when following SLGS" (I'm paraphrasing, but close enough to get the idea). It's so misleading in that no matter which dosing method is chosen, the caregiver must have data to support their decision before increasing the dose in order to keep kitty safe. That was the whole point I was trying to make. Everybody has to know how low a dose takes kitty prior to making dose adjustments.

Heh. Just because you don't see me posting doesn't mean that I'm not aware of the situation.

The thing is, I'm not going to bore you or waste your time, nor mine with re-visiting the topic when it's one others have covered with you. It's simply my responsibility to voice concerns by offering the advice you need to hear in order to keep Silver safe while following methods used on this board. How and/or if you choose to follow that advice is your business. You know your schedule, your limitations, where exceptions might be made, etc in order to obtain the data you need to keep Silver safe.

Spot on, Stephanie!

Juliet: Holding the dose until you can determine how low that particular dose is taking kitty will give you the information you need to make intelligent dosing adjustments. And that doesn't mean you have to hold the dose for another whole week. It means hold the dose until you're comfortable knowing how low it's dropping kitty. That could be another day... another couple of days... whatever it takes.

Juliet, while I don't agree with Stephanie's hypothesis, she was only trying to help. Being kind of hard on her, don't ya think?

The FDMB is a peer reviewed board for a very good reason. This incident illustrates how well peer review works. Stephanie proposed a hypothesis. Sienne and Marje posted info why they thought the hypothesis didn't hold up. Everything was handled well.

BTW, there are NO "experts" here... only members with varying amounts of experience and knowledge. With 11 and a half years under my belt, I can tell you with utmost certainty the amount of time one has been on the board can be subjective at best. For example, sometimes newer members surprise me with a quick understanding of basic principles while "older" members who post often and all over the place leave me shaking my head in disbelief... and vice versa. And yes, unfortunately that happens in this forum, too. It's up to each caregiver to learn as much as they can so they can weigh advice being offered and then make a decision. The yellow tagged posts marked as "Sticky" at the top of this forum contain tons of information. It's there for the taking. They contain the most recent info as we have.

As for today...

Try not to get ahead of yourself. So you caught a +6 today. Is it the low for this cycle? Based on the data you've accumulated, are you convinced this is as low as this dose is taking Silver? He's been in the blues a couple times already. You don't want to make dose adjustments until you know how low the dose is taking him.


I won't be around later, so I'll say Happy New Year now.
Wishing you the all the best in the coming year!

 

Thanks. I am more familiar with how low Silver goes than you might think. I’ve done several curves. He’s never been in danger and I wouldn’t put him in danger. That’s why I skipped a shot and reduced a dose. Both on morning AMPS that were too low in my opinion to shoot and leave for 12 hrs. I’m not irresponsible when it comes to silver. And I did apologize to Stephanie. No one is in this board because they want to be and it gets very stressful with conflicting advice. Happy New Year to you too and I do appreciate the advice. i Am glad I held the dose for now. Heck I want to keep reducing and get him OTJ.

 

@Tracey&Jones oops he’s on his way back up. Guess it’s not gonna be a blue preshot.

 

Under SLGS, a reduction is earned when he drops below 90 whether the BG that earns that reduction is the nadir or not. A kitty might earn the reduction on SLGS when he onsets from a low blue PS. The nadir could even be lower than that.

With any method of regulation, the goal is to get the numbers into safe green numbers. For Silver, what would be your goal for his nadir that would make you feel he is safe while you are working? Maybe it’s 100.....with your knowledge of him, you would need to make that determination.

The SLGS guidelines recommend holding doses when the nadirs are between 90 and 149. Knowing what you know about Silver and your schedule, is that an acceptable goal?

 

Well I’m only going to know his nadir one day of the week. So I’m going to have to only make dose decisions on that one day after his curve. Only trouble is most times the curves have been done on bouncing days.

Sooo I will do a curve every Saturday. Dose increase and/or decrease based on nadir. However. If I see a low blue preshot at AMPS one weekday I will have no choice but to shoot a reduced dose. If I see a green on a working day AMPS I will not shoot. If it’s at PMPS then I can make a different decision if I am home. That’s the best I can work with.

 

And I’m quite happy for his nadirs to be in green. I’d prefer nadirs not to be blue. My goal will always be to get him OTJ as I am going bankrupt caring for him.

 

You do a great job of testing at night so don’t discount that you might see a nadir there.

I like the way you are thinking it through and setting goals. Just be sure you stay flexible as we never know what they’d will throw at us

 

I don't know that +8 seems a little flat. Guess we will find out at PMPS. He might surprise you.

Just looking to see if he has decided on a pattern. That said, that is just when they change things up..

I will be around later. Going to go make an apple pie.

 

Holding dose two more days unless Silver shows otherwise. Think he MAY have got a fur shot tonight - typical....these things are sent to try us for sure.

Sooo tired tonight so I may go to bed now even tho its only 6 pm here but am falling asleep. Will try and set an alarm later as no work tomorrow. Still have to wake for 6 am for his shot tho. When is best to set alarm for - +5? +6? +7?

 

Any time mid-cycle is good.