? 4/5 Millie Post DKA, AMPS 363, INSULIN INCREASE 1.25, +8 532. What to do?

[Sylvia & Millie]

My Millie is post DKA. She's had numbers in the 400s & 3oos. Due to a house emergency I forgot her AM insulin on 4/4. Last night I continued her 1u of Lantus and waited until this morning to increase it to 1.25. Just tested her and her +8 is 532. It seems like every time we increase her insulin she bounces. Since her numbers have been high and she is post DKA, I've been trying to get her dosing right. The bouncing throws me off and then I'm not sure what to do. Should I continue with the current increase of 1.25 or return to the 1u?


http://www.felinediabetes.com/FDMB/...ncrease-but-missed-am-shot-what-to-do.175867/

 

[Kris & Teasel]

On the face of it she looks like she needs a bump up in dose. As far as Lantus dosing goes, you've indicated in your signature that you're doing SLGS which means holding the dose for at least a week and then doing a full curve weekly. Your SS shows days where the AM dose is different from the PM dose, doses held for only 2 days and no full curves. I think you might have better luck following the SLGS protocol very closely and posting here for advice. You're doing enough testing to try TR if you want to raise doses more frequently.
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-start-low-go-slow-method-slgs.129446/
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-tight-regulation-protocol-tr.1581/

 

[Sylvia & Millie]

On the face of it she looks like she needs a bump up in dose. As far as Lantus dosing goes, you've indicated in your signature that you're doing SLGS which means holding the dose for at least a week and then doing a full curve weekly. Your SS shows days where the AM dose is different from the PM dose, doses held for only 2 days and no full curves. I think you might have better luck following the SLGS protocol very closely and posting here for advice. You're doing enough testing to try TR if you want to raise doses more frequently.
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-start-low-go-slow-method-slgs.129446/
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-tight-regulation-protocol-tr.1581/

I guess I felt like we were doing the 'start low' initially but she bounces easily and every time we up her dose so I get nervous, especially given her two bouts of DKA when she was first diagnosed and we were doing urine testing. I thought the TR was were you had to do lots of testing which is hard because it takes two of us to test her.

 

[Kris & Teasel]

I guess I felt like we were doing the 'start low' initially but she bounces easily and every time we up her dose so I get nervous, especially given her two bouts of DKA when she was first diagnosed and we were doing urine testing. I thought the TR was were you had to do lots of testing which is hard because it takes two of us to test her.

My guy bounces a lot too. I'm modifying the protocols to suit him. I hold a dose longer than TR calls for but I wait until he drops below 68 on the AT meter before lowering the dose. I do keep the doses consistent AM and PM and don't change a dose until he's been on it at least 3 days. Maybe a similar modification would help you with Millie.

 

[Sylvia & Millie]

My guy bounces a lot too. I'm modifying the protocols to suit him. I hold a dose longer than TR calls for but I wait until he drops below 68 on the AT meter before lowering the dose. I do keep the doses consistent AM and PM and don't change a dose until he's been on it at least 3 days. Maybe a similar modification would help you with Millie.

I was just reading the TR approach. I know it says you shouldn't combine approaches, which we're not, but I'll look into it. During another thread TR was mentioned. I tend to take the names of the approaches quite literally, lol, so the 'tight' thing made me feel perhaps we won't be able to stick to it. I'm going to continue with the 1.25 and do additional testing to make sure she doesn't go too low.

 

[Gill & George]

On the face of it she looks like she needs a bump up in dose. As far as Lantus dosing goes, you've indicated in your signature that you're doing SLGS which means holding the dose for at least a week and then doing a full curve weekly. Your SS shows days where the AM dose is different from the PM dose, doses held for only 2 days and no full curves. I think you might have better luck following the SLGS protocol very closely and posting here for advice. You're doing enough testing to try TR if you want to raise doses more frequently.
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-start-low-go-slow-method-slgs.129446/
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-tight-regulation-protocol-tr.1581/

With DKA history in the picture the protocols kind of go out the window, it's important to get enough insulin into the cat to prevent a repeat, this is especially true if the cat is off his food or if you suspect there is another issue, like an infection.
Ketones can build pretty quickly good job on getting those tests in daily.

A couple of things I would suggest looking at the ss is that anytime you shoot a lower than normal PS, you follow up with a test somewhere between +1 and +3, I'm looking at 4/3 amps and wondering whether he dropped that cycle and that triggered a bounce which resulted in the high numbers you were seeing. With no data midcycle it's impossible to tell.
Also, try to always get a test midcycle in the pm cycle, even if pmps is high, with the way Millie drops and with many cats having there lowest cycles at night a high pmps does not guarantee that she is not seeing lower numbers at night, getting those pm tests and follow up tests I suggested will make the picture of Millies patterns clearer and less confusing. In fact try to get at least one test in pm and am cycles.
One other thing try not shoot blind, shooting without getting an amps or pmps can prove disastrous.

As for her going up in numbers when you take the dose up at first, is a phenomenon we term New Dose Wonkiness (NDW).

from the new to the group sticky

• Also worth noting: "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." http://www.tillydiabetes.net/en_6_protocol2.htm. Here in the Lantus and Levemir Insulin Support Group (ISG), we've affectionately dubbed this unexplained phenomenon "New Dose Wonkiness" (NDW).

Additionally with the skipped dose the other night and the depot will have emptied some so that may lead to higher than usual numbers until that settles.
Another thing to note is with the skipped shot and then the dose change on the back of that, may lead to wonky numbers overall, we find it easier to see what a dose is doing for a kitty by keeping the shooting consistent, this is not a criticism of the choices you have made, just wanted to give you a heads up in case you see some weird numbers.

 

[Sylvia & Millie]

With DKA history in the picture the protocols kind of go out the window, it's important to get enough insulin into the cat to prevent a repeat, this is especially true if the cat is off his food or if you suspect there is another issue, like an infection.
Ketones can build pretty quickly good job on getting those tests in daily.

A couple of things I would suggest looking at the ss is that anytime you shoot a lower than normal PS, you follow up with a test somewhere between +1 and +3, I'm looking at 4/3 amps and wondering whether he dropped that cycle and that triggered a bounce which resulted in the high numbers you were seeing. With no data midcycle it's impossible to tell.
Also, try to always get a test midcycle in the pm cycle, even if pmps is high, with the way Millie drops and with many cats having there lowest cycles at night a high pmps does not guarantee that she is not seeing lower numbers at night, getting those pm tests and follow up tests I suggested will make the picture of Millies patterns clearer and less confusing. In fact try to get at least one test in pm and am cycles.
One other thing try not shoot blind, shooting without getting an amps or pmps can prove disastrous.

As for her going up in numbers when you take the dose up at first, is a phenomenon we term New Dose Wonkiness (NDW).

from the new to the group sticky

• Also worth noting: "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." http://www.tillydiabetes.net/en_6_protocol2.htm. Here in the Lantus and Levemir Insulin Support Group (ISG), we've affectionately dubbed this unexplained phenomenon "New Dose Wonkiness" (NDW).

Additionally with the skipped dose the other night and the depot will have emptied some so that may lead to higher than usual numbers until that settles.
Another thing to note is with the skipped shot and then the dose change on the back of that, may lead to wonky numbers overall, we find it easier to see what a dose is doing for a kitty by keeping the shooting consistent, this is not a criticism of the choices you have made, just wanted to give you a heads up in case you see some weird numbers.

Yes, we did test last night at +3 (midnight our time). Great information and very helpful to know about NDW because we definitely react to the high numbers and feel confused. Thanks!