2/10 Yoyo AMPS 294,+3 210,+4 180,+5 176,+8.5 230, +10.5 322,PMPS 383,+2 238,+4 112,+5 137,+6.5 204

Yesterday 2/9 http://www.felinediabetes.com/FDMB/...-315-pmps-265-2-303-4-220-5-243-8-280.210534/

Day 8 @.50Unit Lantus

 

I wonder if that 220 yesterday was Yoyo trying to clear the bounce, but then he ran out of juice.
I hope he clears it today. I like that he is spending more time in blues on this dose.

Sometimes I wonder if getting a burst of high numbers due to an outside stressor does something to the pancreas and get it to kick in sometimes. I've seen this happen to Bailey sometimes, most notably when we traveled from PA to FL. Her numbers bounced very high, but then she dropped lower than usual when the high numbers cleared. It doesn't usually happen, though, so I clearly won't go around jumping out at Bailey trying to scare her. I would do it every day if I thought it would work.

 

I hope Yoyo slides down for you today.

 

Hope you are enjoying your day.
I know that you have been helping me with dosing and recently Marje @Marje and Gracie has been helping me with dosing. I'm not sure where Yoyo should be at this time. He has seen some improvement at .50unit but I'm not sure how to read his SS. Any suggestions that you or Marje can give me are appreciated. I'm not sure if Marje @Marje and Gracie has been on the site lately.

 

Since you just saw that green two days ago, I'd hold the dose. Yesterday was a bounce day. He may keep sliding down today.

 

Hi Debra,
I think Marje has been away from the board the last few days. She may stop by later.
As long as you are still doing SLGS I think that you should still be holding on to the dose. (on TR I would take her up)

Looking at the SS on 2/8 she had a nice long run in blues dipping into the 90's, you steered her cycle with MC to keep her up. Then she then bounced on 2/9, her little body is not used to the blues and greens even though this is a good place for her to be, and this morning she is clearing the bounce.

So unless she drops below 90 today I would stick to the 0.50u. (SLGS)

Of course Marje has been helping you more regularly so she may have a different view.
Just thought I'd give you some input and an explanation as to why I would hold. Hope that helps.

 

No, you aren’t bothering me. DH is on vacation so we’ve been out hiking and traveling around. I had it on my list today to post some dosing advice for you.

I’ve got just a few things to take care of right now and then I’ll be back on. Sorry for the delay! I hadn’t forgotten about you all.

Are you sticking with SLGS? Just need to know when I look at his SS.

 

Thank you for getting back to me. I didn't want to bother you as I know everyone has their own busy lives. Please, only get back to me at your convenience.
Regarding SLGS or TR.......................
If possible I would like to modify the SLGS or modify the TR. I am fine with only holding a dose for 3 days instead of 7 days if an increase is needed and I am fine not taking a reduction at 90 but I will not be comfortable waiting for a reduction at 50. So can the reduction number be modify for Yoyo and me? Low numbers still scare me!
With SLGS I know you hold the dose if the range is between 90-150. With TR is there a range where one holds the dose? I really don't understand TR totally.

 

Thank you, I appreciate your help.
Marje has contacted me and said that she will advise me later today.
I asked Marje about holding a dose with TR. Does one hold doses with TR like with SLGS? I read that you hold a dose for 3 days if nadirs are less than 200. Then what? Does that mean that you are always increasing a dose until the kitty gets to 50 and then you reduce? I am confused?

 

Does anyone know if insulin effects thyroid medicine? Yoyo's T4 went up very high since 11/2018 when he had his last blood wk. In 11/2018 Yoyo's T4 level was 4.9 and now his T4 level is 11.2
Yoyo started insulin in November and this is the first time his T4 level has been checked since being on insulin. Yoyo is taking Felimazole for his hyperthryroid. Any info is appreciated (I'll post this under the Health section forum too).

 

Yes you hold doses with TR but instead of holding for 7 days, you would hold for 3days/6cycles and reassess the dose.
After 6 cycles you look at the nadirs and see if they are in the range you want them to be.
If they are below 200, you might hold the dose a little longer, especially if Kitty is new to seeing numbers below 200. You are basically waiting for them to clear the bounce and see if when they do they can get lower. You are always asking yourself how low is this dose taking my kitty?? and the answer to that is what governs your decision to hold or raise the dose.

No you might hold a dose a little longer if nadirs are in the normal range. So if kitty was getting down into the low 60's for example you would continue to hold the dose. If you see the nadirs creep up then that might be the sign to take the dose up.
In an ideal world kitty would spend a week in normal numbers most of the time time, and then you would reduce, but often kitty will have their own ideas and they will earn reductions by dropping below 50. George did both. He got up to 3u, I raised his dose per TR, he was in a sea of red and ping for 6 weeks or so, then he started earning reductions by dropping below 50, slowly he bounced less and became regulated, from 0.75u to OTJ he earned his reductions by spending a week in normal numbers.

I'm sorry I don't know

 

So if I am correct in saying this....... in TR Yoyo can gradually end up with a much larger dose of insulin as one keeps increasing to get nadirs lower?

 

Forgot to ask you.....you wrote that you hold a dose in the normal range....What is the Normal Range in TR?

 

Forgot to ask you.....you wrote that you hold a dose in the normal range....What is the Normal Range in TR?

 

50-80 with a Human meter is the range defined as normal in TR (The protocol was developed with Human Meters), when using a pet meter the reductions are taken if kitty drops below 68, I can't give you an equivalent range for the AT2, it's been impossible to develop an acurate conversion, the difference is not linear, this is one of the reasons that it's encouraged to use a human meter.

From the TR Protocol sticky

Reducing the dose:

The TR Protocol is an aggressive method in itself. The modified version of the protocol is slightly more aggressive. Let's keep all our kitties in the Lantus, Basaglar, & Levemir ISG safe by taking reductions when appropriate.

• If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit.
• Alternatively, try to make sure kitty maintains numbers in the normal range of a non-diabetic cat (50 - 80mg/dL) for seven days overall before reducing the dose any fur
• Please do not let yourself become complacent or blasé about drops into the 20s or 30s. Please ask for advice immediately.
• If your cat drops into the 30s, a full reduction of 0.25u is recommended. There are few exceptions given to caregivers who have collected years of data and KNOW their cat's response to the combination of insulin and food backwards, forwards, and inside out.
• Caregivers whose kitties have "High Dose" conditions may find the need to reduce in whole units or more.
• If an attempted reduction fails, go right back up to the last good dose as soon as you see kitty's numbers trending upwards. You don't have to hold the reduced dose for a certain number of cycles before taking the dose right back up. The guidelines listed under the topic "Increasing the dose" do not apply to a failed reduction. Please use common sense in this situation. The "last good dose" is not the dose that just dropped kitty into the 20s or 30s. You want to resume momentum by finding an in-between the dose.
• We've found many kitties benefit from reducing the dose from 0.25u to 0.1u before stopping insulin completely. During a two week OTJ trial, you want to see mostly green numbers (under 100) with only a few random blue numbers between 100 - 120 to help ensure a strong remission. Most kitties will be in the range of a healthy cat (50 - 80 mg/dL) overall.

 

When I started checking Yoyo's BG the Vet told me that I needed a Pet Glucose Meter. Should I switch now to a human meter? The numbers will be so different.

 

I forgot to say "Thank you"...thank you for taking the time to write to me and for trying to get me to understand everything.

 

It's up to you. I have two meters, I keep one as a backup, just in case one conks out. George threw his meter in his fountain once, I had no back up! Ended up having to speed to the pharmacy before it shut and race back home, of course it happened on a day he decided his BG was going to drop after that image sure I kept two.

If it were me I'd get a human meter, the strips are easier to get hold of and much much cheaper. The protocol/dosing methods were developed using Hunan meters so to me it just makes sense.

Keep the AT2 as a backup, or use it when the vet asks you to run a curve as he/she will probably prefer it as the readings with the pet meter are more comparable to his in house equipment.

 

You're welcome.

 

Good to see those blues

 

Can you recommend which human meter I should buy. I do need one that only needs .3 microlitre of blood for accurate results. And for the test strips to be less expensive than the ones I use now. They are a dollar each.

 

I’m glad Gill provided you with some information.

One thing I’d like to be sure you understand is that as long as you are using a pet meter, if you are doing TR, dose reductions for newly diagnosed cats (cats who are diabetic less than one year) are below 68, not 50. If the cat has been diabetic more than one year, the TR dose reduction for a human meter is below 40; there is no equivalent for pet meters.

A little history might help. The TR Protocol was developed using human meters and the number provided within it are for human meters with one exception. The authors provided a reduction number (newly dx cats) for pet meters of 68. This does not mean that 50 on a human meter is 68 on a pet meter. It’s just the number they determined gave the CG a safety net on pet meters.

Other than that, the thresholds are the same for pet or human meters under the TR Protocol.

For SLGS, it was developed solely with human meters in mind. Therefore, if you are using a pet meter, you still use the same numbers as you would for human meters. Under SLGS, the reduction number for a newly diagnosed cat is 90.

If nadirs are less than 200 under the TR protocol, you hold the dose for at least 8-10 cycles unless the kitty earns a reduction by going below 68 for a pet meter or 50 for a human meter. If nadirs are below 100, hold the dose ten cycles, unless kitty earns a reduction, before deciding if a dose increase is warranted.

Let’s take an example. Let’s say YoYo is mostly getting nadirs in the 90s and you are doing TR. Perhaps he’s also bouncing up to yellow. Then you, as the CG, need to decide if 90s with bouncing are fine for YoYo or whether you want to see the nadirs a little lower. If you are fine with the 90s and bouncing, you can hold the dose for as long as you want as long as he’s not earning a reduction or his nadirs don't start creeping up. If you want his nadirs lower, then you can fine tune the dose by increasing it a bit.

The normal range of 50-80 is using a human meter; that’s the range we look at when determining if a cat’s dose should be reduced after a week with the majority of BGs within that range.

Does all of that make sense? I know it’s a challenge when moving from one method to another. One thing to keep in mind: you can make your goal of the nadirs you’d like to see (e.g. 90) but that doesn’t mean he earns a reduction under TR if he drops below 90. To earn a reduction under TR, you’ll need to wait until he gets to 68 on the pet meter or 50 on the human meter. However, there are times that a CG might be really working hard to keep kitty’s BG above 68 (pet meter) or 50 (human meter) and when that happens, we might suggest you lower the dose. By working hard, I mean you are having to test and feed a lot of HC to keep the numbers up.

The meter I used to use is no longer made but the equivalent is on American Diabetes Wholesale and is the Arkray Glucocard01.

I also agree with Gill that if you stick with SLGS, I’d continue to hold the dose another 7 days. He’s getting into a nice range under SLGS. If you decide to go to TR, I would also suggest a 0.25u increase.

And your other question.....if you go to TR does it mean his dose might go up? Yes, but I can’t tell you how much. In other words, if you give him a 0.25u dose increase now (or tomorrow), it might be just what he needs to get him into more green but you might also find he’ll need a bit more insulin. Some of the best advice I ever got was “don’t get attached to a dose”. If he needs more insulin, he does.

And it’s possible if you stay at SLGS, he might peter out at this dose and need an increase. Or he might stay here a long time and earn a reduction.

Only YoYo knows!!

In terms of the thyroid levels, it can be harder to control the BG when the thyroid is not in check but ECID.

Please let me know if you have questions.

 

Thank you for all the information......I'm trying to understand TR. To me it is similar to SLGS except there is no reduction if he goes below 90 and TR seems to be more flexible with dose increases. If I am comfortable with him in the 90's, I don't have to increase his dose to get lower? Now for my next question....as his nadirs get lower I am assuming his PS's will get lower too! That is where I have my issues giving him insulin. I don't know how low I will be able to shoot. If I do TR and I am more stressed, can I go back to SLGS?
Knowing now that his thyroid levels, T4, are HIGH - I read that if the T4 is high it can make him insulin resistant. In your opinion knowing his thyroid is high, would you make any changes from SLGS to TR at this time? Make any difference?

 

You’re welcome. It takes some time.

Not really. To me, they are very different approaches in how long you hold the doses, the trigger points for changing doses, whether you skip or shoot, etc.

No you don’t but he also will likely not improve as fast. It’s the long times in greens and not just green nadirs that allow the pancreas to heal.

Typically, yes. We all had to learn to gradually shoot lower preshots and once you do it, you’ll be surprised at how easy it becomes. If there is a PS you just aren’t comfortable shooting.....say a 60, you can stall or skip but it’s really just for your benefit, in most cases, and not his.

Certainly but we just don’t mix and match them.

I’m not seeing a lot of insulin resistance in his SS. I see a lot of bouncing. It’s not a question I can really answer for you because I’ve always been a proponent of TR over SLGS. It gives the kitty a much better chance at remission and keeping those higher numbers down because you can change the dose every six cycles if the numbers are too high.

 

Again, thank you for answering all of my concerns.

If I change meters, pet to human meter, will Yoyo's BG numbers look lower on the SS? Isn't this going to look like Yoyo is doing so much better but it is just because the human meter will register lower numbers? Will this be confusing in comparing how Yoyo is doing? I know to me it is going to look different.

Well I have a lot to think about, just what I needed.

I need to decide if I stay with SLGS or switch to TR and I need to decide which meter to use. My brain is on overload

Enjoy the rest of your night and thank you again for your time.

 

You’re welcome.

Yes it’s likely his numbers will look better. Generally, human meters read lower. It might look to you like he’s doing better in that his bounces might not look as high and his nadirs might look lower. Those of us used to reading SSs don’t think that way when we see a change from pet to human meter.

BTW, if you do change, pls send me a PM and I can reformat his SS so you can leave it all on the same one.

There’s no hurry on deciding. Read more, ask more questions, and do what makes you feel most comfortable.

Has your vet ever mentioned doing I131 for the hyperT?

 

My Vet mentioned the radioactive iodine therapy but did not think it was the way to go. If Yoyo was healthier and younger I think I would have done the radioactive iodine. Where the procedure is done they have them stay at the facility for several nights and at this time that would be too much for Yoyo. Plus I don't know if he could handle what the radioactive iodine could do to the rest of his body. I don't like giving him the medicine as it has deadly side affects. And now the vet wants me to increase his medicine dosage because for some reason his count has just about tripled from 3 months ago. Also, about 3 months ago I started to wipe off the pink coating from the tablet to reduce the amount of sugar he would intake and I may have messed things up with the potency of the drug. So starting yesterday I am leaving the pill alone and giving it to him with the coating. It's hard to believe that I could have altered the pill by wiping off the coating, but who am I to say. I sure don't know enough and I should have just left the pills as they were. He was diagnosed back in 2016 and he was pretty stable until now.

Are you familiar with felimazole (for cats only), which is equivalent to the human drug known as methimazole?

When you say that you will reformat his SS if I use a human meter, what will change? The lower numbers will make me nuts, I know I'll compare it to the pet meter to see where he is at. It will take time to get used to seeing different numbers and relating them to the pet meter.
Does PM mean a private message? Sorry, I don't know all abbreviations.

Feel free to get back to me tomorrow as I know it is late in the night.
I appreciate your kindness

 

I am familiar with felimazole and methimazole. I had a hyperT kitty and we did I131. Before we did it, I had the med compounded into a flavored liquid with no sugar or sweeteners so it was easy to give. You might want to check into that.

All that changes on the SS is the color coding. Right now, anything below 68 is lime green but with a human meter, it doesn’t turn a cell lime green until numbers are below 50.

Yes, PM is private message. Just click on “ Marje and Gracie” on the left and “start a conversation”.

You’re welcome!