4/14 Oliver pmps 445 +2~457 +4~425 +5~401 +6~349

Yesterday’s Condo for Oliver

Nothing different this morning; Oliver eats, Oliver poops, Oliver sleeps.
Apparently his internal alarm clock goes off an hour before mine; too bad for him.

 

Re: 4/14 Oliver +11~337 amps 346

Sounds like Oliver is pretty predictable. cat_pet_icon

 

Re: 4/14 Oliver +11~337 amps 346

He sounds so happy...hope you guys have a good day today! Maybe some lower numbers Oliver?

 

Re: 4/14 Oliver +11~337 amps 346

I'd like to see more aggressive increases here Gayle, I think his resistance is getting ahead of the insulin. I understand some people might have a different opinion about this, but I think it's more likely that he is still far behind where he needs to be, than overdosed. An overdosed cat would have broken by now, and R should have promoted that. My observation of resistance is compounded by the lack of response to R. A "normal" diabetic cat would have dropped like a stone on .5u and he didn't even flinch at 1u R. People are very quick to jump to the overdose conclusion when the numbers very clearly spell that the cat is not getting enough insulin. Bottom line is that it's far easier to control a dropping number than it is to control ketones and the more time he spends stuck in this range, the more likely it is that he will develop them. I would consider 1/2u increases every 6 doses at this point and review in short time.

 

Re: 4/14 Oliver +11~337 amps 346

i totally ,wholeheartedly agree with yu carolynn.i dont feel that oliver is being overdosed,in fact i feel the opposite is the case.i feel oliver is in need of increase and is not getting enough on the basal dose. gayle....its very easy to get overwhelmed by different voices of opinions,some who (i feel) dont have any experience to advise yu so.as one who has been there and still is.....u are not overdosing your cat.(((((hugs))))

 

Re: 4/14 Oliver +11~337 amps 346 +11~394 pmps 445

Alrighty, we went with an increase of .5u Lev up to 4.5u.
That pmps is not good at all, but seems to be how Oliver is. It's almost as if he runs outta gas before the finish line, and even the fumes are gone, so UP he goes!

I am checking for ketones daily and all negative so far. Just tested now and again negative. He is eating like a horse and drinking his water nicely. He does like to have some water mixed with his food just like Shadoe.

He has been actually playing with some of the catnip toys that litter this place, so despite his high numbers, he continues to settle in and try out what stuff is around here.

Now we wait to see if he recognizes the increase or chooses to ignore it.

 

Re: 4/14 Oliver +11~337 amps 346 +11~394 pmps 445

Great job today Gayle
Hopefully he will end up like Max.
Going up and up and then, bang.
Down we came crashing and last day of trial tomorrow.
Good luck with Oliver on this dose.
We both know that climbing tree.

 

Re: 4/14 Oliver +11~337 amps 346 +11~394 pmps 445

Randi,
That's what I am doing; hoping we are getting close and will finally break through.
I am hoping, but not feeling too hopeful.

Be sure to give Max his very favorite brand of gum tomorrow!

 

Re: 4/14 Oliver +11~337 amps 346 +11~394 pmps 445

that will quit when you get him closer to where he needs to be

and if he does choose to ignore it, you may remind him of Jill's timeless advice: "there's more insulin where that came from" hehe

 

Re: 4/14 Oliver +11~337 amps 346 +11~394 pmps 445

ooooooooo!!! i so know your state of mind right now Gayle. yu will find the dose..it may be a bit and a few more units before u do but yu will find it.i like WCR is good... ketones neg ...etc. oliver is gonna find his dose,and he does have his dose.

 

Re: 4/14 Oliver +11~337 amps 346 +11~394 pmps 445 +2~457

It looks like he has decided to ignore or NDW or something. Whatever the reason, he's going in the wrong direction.

I took a ton of pictures, and here are some.

 

Re: 4/14 Oliver amps 346 +11~394 pmps 445 +2~457 +4~425

I sure hope he doesn't stay red all nite :sad:

 

Re: 4/14 Oliver amps 346 +11~394 pmps 445 +2~457 +4~425

Me too. :sad:

 

Re: 4/14 Oliver +11~337 amps 346

What seems to be overlooked is that Oliver was not started on low dose, was not tested or curved during those first few days of treatment and was not tested much thereafter. He was fed dry food. His dose increases were based on occasional spotchecks. He has never been given the opportunity to see what would have happened at lower doses with any consistency. Every time the dose is raised, the numbers stay flat or go up. This is what rebound looks like and the only way to treat it is less insulin and giving the system time to clear out which can take up to a week.

My point is, and always has been, that the important first steps in treating Oliver were not followed per Tilly or any protocol. That is how chronic rebound begins. Raising the dose every few days compounds it. When the protocol says that the dose can be increased every 2 or 3 days, it is presuming that one is starting from the beginning, not after the cat has possibly been in rebound for a month. The concept of "shooting through rebound" does not apply to a cat who's been experiencing it chronically for a long time.

Furthermore, the protocol states: "Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations." Therefore it is not logical to raise the dose yet again if the cat is still reacting to the previous increase. Being too focused on the numbers usually ends up making things more complicated than they need be. Hammering the cat down to celebrate all the pretty colors is just as hard on his system as underdosing and since it's not producing much response it should be apparent that it's not working.

Yes, he's a big cat. So what? I took an even bigger cat last weekend, >18 lbs. and not obese. He was on 6 units bid of Lantus at the shelter - per vet - and has not needed a drop of insulin since he arrived here. According to his records, he was tested fairly regularly in his previous home and ran high and flat so the vet just kept raising the dose. Oliver had much less testing.

We who are concerned for Oliver have been at this for years and with multiple diabetic cats. Every cat is different, every situation unique, and we've had to learn to deal with them. For me it always paid off to just start over, which is what should have been done with Oliver. I have cared for eight rescue diabetics - four have gone into remission and one is getting close - so do tell me, what is your definition of experience?

 

Re: 4/14 Oliver amps 346 +11~394 pmps 445 +2~457 +4~425

Oliver's ss shows that we did go back to 1u 'to start over' and we did follow the protocol for increases.
Before tonite's increase, Oliver was on the same dose for 8 cycles with absolutely no change, good or bad, just solid high numbers.

 

Re: 4/14 Oliver amps 346 +11~394 pmps 445 +2~457 +4~425

Unless I'm completely misreading Oliver's SS and not recollecting what Gayle did, I believe that she re-started Oliver at 1.0u. It's pretty clear on the SS (see the PM entry for 3/23). Further, the Tilly Protocol stipulates that doses can, in fact, be increased every 2 - 3 days by up to 0.5u in a cat who has nadirs over 300. Per the protocol:

I believe that Gayle has been adhering to the protocol and has been getting input from quite a few very experienced Lantus users, such as Jojo, Jill, Libby, and several others.

 

Re: 4/14 Oliver amps 346 +11~394 pmps 445 +2~457 +4~425

Gayle did start over.
Gosh, when Oliver's dose was started over and dropped to 1 unit, he went into the black (above 500) and very high reds.

 

Re: 4/14 Oliver +11~337 amps 346

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Re: 4/14 Oliver amps 346 +11~394 pmps 445 +2~457 +4~425

http://www.tillydiabetes.net/en_6_protocol2.htm

Phase 1: Starting dose
In many cases, the starting dose of Lantus or Levemir has been 0.25 IU per kg of the cat's ideal weight and is always dosed BID (two times a day, 12 hours apart). If the cat received another kind of insulin previously, the starting dose should be raised or lowered by taking this information into account. When selecting a starting dose, it is important to know that while Lantus and Levemir have a longer duration than other insulins, they also have a lower potency in most cats.

Done – at an ideal weight of 12 lbs., starting dose would be 1.36. Oliver was started conservatively at 1 unit.

The cat should be monitored closely on the first 3 days on Lantus/Levemir: do curves between the AM and PM-doses, e.g. AM pre-shot, +3 hours, +6 hours, +9 hours, PM pre-shot. Generally the starting dose is kept for 3 days. Test for ketones daily. Cats that have a tendency to get ketones and/or who are getting relatively high flat curves after the switch should have their dose raised earlier (after 24-48 hours). It is extremely rare that a cat will need to have its dose reduced in the first 3 days, but if the cat falls below 50 mg/dl, reduce the dose.

Done – high flat curve, so held dose for 48 hours and increased.

Phase 2: Increasing the dose
Most cats need to have their dose increased. Do it in 0.25 IU or 0.5 IU steps (0.25 IU if the cat is getting a low dose and/or relatively low BGs, 0.5 IU if the cat is getting a higher dose and/or relatively high BGs). Hold each dose for 5-7 days. However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU. Alternatively, if the cat is continuously producing moderately elevated BGs (nadir always >=200 mg/dl), increase the dose every 2-3 days by 0.25 IU ( if the cat is getting a low dose) or 0.5 IU (if the cat is getting a higher dose). From this point onward test for ketones once per week, or more often if the nadirs are still >=200 mg/dl.

Done – doses have been held 2-4 days before increasing according to what the numbers show.

If you don't agree with the protocol that is fine, there is more than one way to do the FD thing, But I don't think it's fair or accurate to say that the protocol has not been followed.

 

Re: 4/14 Oliver amps 346 +11~394 pmps 445 +2~457 +4~425

You're doing an awesome job Gayle with Oliver!
:thumbup

 

And we finally made it into pink by +6.
Time for us all to go to sleep now.

 

ni-ni Gayle and Oliver and Shadoe and Booboo. I-)

 

Re: 4/14 Oliver +11~337 amps 346

I have been an active poster on this board for several years, having 4 of my own diabetics, 2 of whom are remission cats, one acromegalic and one who was regulated on PZI and then Lantus. I have used PZI, Lantus, Levemir and R. I have had a high dose cat (Oscar), a low dose cat (Roxanne), a microdose cat (Spot) and an acro cat (Leo). Some cats need more, regardless of the reason, and fooling around leads to massive danger, as I am sure you know after YOUR vast experience. I believe my experience, as well as that of Lorna's far exceeds the majority of the high dosers on this board. Please do read Oliver's spreadsheet thoroughly before bandying about accusations about who is not following protocol. To Oliver's detriment, the protocol was actually carried a bit too far In MY Humble Opinion. She has tried low, she must increase this dose before she is dumping thousands of dollars into DKA treatment.

Not really clear on the harshness I am reading in your post, perhaps it is due to my extreme exhaustion at this hour, but I would highly recommend that you continue to review the advice you see being given with the knowledge that experienced users are talking to her and not a solitary one of us would put this cat in harm's way. We do know what we are looking at, we do this ALL the time, and the time has come for this poor cat to get his dose to where it needs to be before full on toxicity, or worse, settles in.. without either harm to the cat, or harsh judgmental words for the owner. She is mom to this cat now, please allow her to treat him.

//Most Respectfully,
..Carolyn

 

.

 

Looking at that spreadsheet

Hi guys, someone's asked me to check in and offer yet another conflicting opinion, so:

Okay, some clues I see:

1) March 22- 23, 3U Lantus was a GREAT dose, worked real nice. Previous dose of 1U obviously doing nothing.
Switching down to 1U that evening was obviously a disaster. Continued lower doses were not adequate, though 1.5 made a slight dent the evening of March 25. Looks like at this time, 3U was about right.

2) By March 28, 2 Units is making a pretty good attempt, getting to the 200s, but only for a few hours. It looks like by this time diet is down in carbs some, so not surprising perhaps that 2U is nearly enough.

3) By that evening, all bets are off, as 2U and even 2.25U are being overwhelmed by high blood sugar. It just gets worse from here on. I've seen this happen before and it's not rebound.

There are two reasons I'd suggest for the increasingly high numbers from Mar 28 to 31: Either some external cause (food carbs or infection), or the glucose toxicity of having numbers over 300 most of the day caught up with kitty and started insulin resistance increasing.

Possibly even both, though just the second one would suffice.


4) Switch to Lev in April -- This is where things get weird. At this point I'd say kitty's dose is no longer 2 or 3 units BID, it's probably well up into 4 or 5, of Lantus. No argument there. (A few days of reasonable numbers below 200 all day would probably lower that, but we're not seeing them.)

But so far as I can see, that Levemir is water. I haven't seen much effect from it the whole time from April 10 onward. Even the brief yellow number on April 17 is likely the effect of that big glob of R.

Again, this doesn't look like rebound to me. (Look how ineffective even a unit of R is.) Oliver currently needs a lot more insulin. BUT he won't for long. The moment you find a dose that holds him down below 250 for a few days, he'll suddenly roll over on his back and start loving smaller doses, and you better be watching carefully for that.

I note, however, that the Levemir has NEVER been useful in any reasonable dose, whereas the Lantus worked a few times. (even though the numbers don't come down MUCH, they obviously do come down each day.) I love Levemir, I use Levemir, but honestly I don't see it helping here so I'd be considering going back on Lantus for now until I see things under control. Don't know why, but the Levemir really seems overwhelmed here.

As for whether this is aggressive, yeah it is, but it looks to me like Oliver's glucose toxicity is out of control and forcing more and more insulin resistance. Aggressive dose increases are called for, and increasing dose at the maximum rate allowed for by Tilly's protocol seems like a good idea to me.

I'm even on board with the occasional R bolus doses, just to give an idea of the current level of insulin resistance and as a reality check on the effectiveness of the basal insulin. At the moment, they're convincing me that you're seeing serious insulin resistance due to glucose toxicity (and/or possibly also due to diet; I don't know what Oliver's eating)

But be aware that even if I'm right, once you find that "right" dose of Lantus or Levemir, it will come DOWN fast. And I'm seeing very few tests around Lev or Lantus peak time (9-11 hours), so you won't see when it's time to lower dose! BE CAREFUL. Test at +9, +10, or +11 every time you raise dose, and as often as possible, so you know when it's time to lower again!

That's my guess anyhow! Best to all of you!

Steve

 

i don't know who asked you, but thank you for taking the time to stop by, steve.
your thoughts are much the same as most of us here in LL. GMTA! :mrgreen:

interesting thought about going back to lantus. i don't think it's been discussed as of yet...

 

Thanks so much to Steve for stopping by with his interpretation.
The switch back to Lantus is definitely worth a consideration and discussion as I do have the 2nd pen still and could easily switch over tonite, if given the dose.

For the foods, I take a printout of Binky's list with me when getting stock, so the food is definitely not a factor. He does eat like a horse so there may be some rationing in the big boy's future, but carbs are all low with plenty of water and ZERO dry foods.

Ketones are checked daily and always negative, but numbers continuing in 300s has to be resolved as quickly as possible within the protocol guidelines.

Decision will be in Oliver's condo for today, 4/20/10.