8/21 Sebastian +11 287 AMPS 266 +2 322 +4 302 +6 262 +8 238 +9 270 PMPS 240 +2 311

Yesterday. Little bit of an on going discussion in yesterday's thread.

287@+11, AMPS 266, 11lbs 11oz, b-ohb 0.5.

 

322@+2.

 

I posted after your last, on your condo yesterday.

 

302@+4. Also got his labs back which I entered on the sheet. High WBC, abs neutrophils, and abs eosinophils, so maybe a bit of an infection. We've got a follow up on Friday. I'm a bit loathe to give him antibiotics, don't want to mess up the gains from the FMT, but we'll see what the doc says.

 

I can't answer about use of R insulin, frankly I was way to chicken to try it.

I wonder why you didn't raise the lantus dose, clearly needs more. the lantus depot didn't have time to adjust before giving R. Also wondering why the 200 ml of subq fluids, that's an awful lot at once. Are you sure there is no heart issues?

My vet wanted me to give Ollie 300 but I refused to give that much, but she does have HCM. I spoke with her cardio about it. He said vet was wrong, just because it's absorbed doesn't mean it safe. If it's absorbed to fast it can still put them into heart failure. He put a limit on Ollies, no more than 200 per week. I can split it up however I want but don't give it all at once.

Just saw you post about infection. That could be why glucoses are higher. Infection + not enough insulin = DKA. I wouldn't worry about messing anything up, if AB is needed once infection is gone, glucoses should come down. You can start probiotic now in anticipation of needing AB. Could also be p'titis kicking in. I don't know if I would wait. There are a lot of flags popping up.

 

I did? Been increasing it by .5u every 6 cycles. If anything I've been surprised no one has yelled at me yet saying I've increased too much, too fast and "blown past the right dosage".

Always done 200ml, that's what the vet told us. Doesn't seem like too much based on his numbers, in fact on one of the days we had to give him 400ml over the course of the day to get the B-0HB down. No heart issues as far as I know.

 

Once you hit 6 units increases are done at .5. I can't comment about the speed you have increased. Ollie was done faster ONLY because of the acro and advice of the experts here.

Fluids over the course of a day isn't to bad. Just not that much at once.

 

262@+6

 

Adding on to yesterday’s conversation.... If you have a question, or need help, you will get more eyes on you if you use the ? prefix on the subject line and post the question as part of the subject. I never have time to read everyone’s posts in detail, and last week I had like 10 minutes in some evenings to skim the board. I saw you had a question about ketone meters, which someone answered, but nothing about using R in the subject line. If you had “need help with R to combat ketones” in the subject line, I or someone else might have responded.

As for using 3 units of R, I am still shaking my head. Neko was on a higher L dose than Sebastian, and never needed more than 0.5 units of R. Biscuits, on 40 units of Lantus, sees movement with 0.5 units of R. That is a little unusual, most cats on that high a L dose would be using more R. As for what happened between PMPS and +5 the other night, who knows. Besides a huge fast bounce causing drop, it’s possible he went green and went back up to +5. R typically onsets early and nadirs a lot earlier that Lantus or Lev and would have done all that before +5 in most cats.

One other thing to be wary of, especially in a cat with IAA, is that the antibodies can bind to the insulin, and release it later at a random time. Many people with IAA kitties notice a lot of action on the cycle after the one R was used.

While I am at it, what you really want to prevent when you use R is a bounce caused by using R, such as too fast a drop, having the L and R nadirs coincide, using R on the first cycle of an increase or a bounce breaking cycle. The worst thing is when people cause bounces with R, then use R to shoot down that bounce, causing yet another bounce, shooting R again, etc. That is a nasty cycle.

It is really important to test hourly when you first use R, to learn it’s onset and nadir. Typically that is +2 and +4, Neko was not typical. It influenced when I gave R so that I avoided sudden drops from both L and R action happening at the same time.

 

I'm lost then because I don't know what "I wonder why you didn't raise the lantus dose, clearly needs more" is supposed to mean other than as a comment on me not increasing quickly enough.

 

Sebastian is beautiful, Justin.
I have started following your journey, and hope you can eventually get everything worked out.
I see your Lantus increases look like you are following protocol. At first glance it looks like Sebastian is quite insulin resistant, since the R isn't doing more.

 

238@+8

 

Yeah, we got him tested back in March and he's got an Insulin Auto-Antibody of 85%, so quite high resistance. He likes to keep me on my toes though, if you look back you'll see periods where we got down to like 3.5u and he was still going <50, versus now where we're at 6u and he's still around 300. So obviously a lot going on under the hood with him. It's why I try to follow the guidelines when I can but a lot of times I have to throw the handbook out the window and go with my gut.

But all in all I'm feeling really positive about where we're at, despite the recent high numbers. Overall he's doing amazing, weight is up, coat is great, lots of energy, and a lot less vomit. And I've learned enough from the forums that I feel pretty comfortable getting us through the bumps in the road.

 

Him looking so good, with a nice luscious looking coat, and being energetic is solid improvement. Great description about something going on under the hood! I have been trying to see some kind of key, in your SS, and I can't figure it out. You sure have been working hard to help Sebastian.
Didn't the pic you used to have of him, look like a tiny little black cat? I didn't know he was gray. I hope I'm not confusing you with someone else.

 

Deleted. Cat hit the post button before I was finished.

 

The old pic was from farther away and less light but he still looked pretty grey.

As far as the key in the SS, I'm not sure I've figured out all the factors I need to detail to paint the whole picture, I'm still kind of figuring it out myself. And a lot of times when I do figure something out it's not until after the fact. Like these past two days he's had a really big appetite during the day and eaten a whole lot, I'm talking like 200-300 calories in the first couple hours, which is possibly contributing to the large spikes, so I'm starting to try and note that.

The only big key I've come up with, and it still hasn't happened quite enough to draw a firm correlation, is that his dips in bg & dosage seem to coincide with vomiting, either right before or right after. We haven't had a green BG in a while but, other than a rogue hairball the other night, he hasn't vomited in a while either. So I'm pretty sure there's something there, not that I know exactly what it means, just that if he starts vomiting I need to be on the lookout for a big drop in BG also.

 

270@+9. Was hoping to see where the nadir would go but he ate a bit more shortly after the last reading and looks like we got a bump back up from it.

 

From yesterday:

I had to check this out because if a member is repeatedly asking for help and is lost in the shuffle... well, we might need to come up with a better system.

I read through two weeks of Sebastian's threads in the L,B,&L ISG prior to administering R for the first time. All I could find was an announcement of sorts, "I gave him a drop of Novolin-R and will watch his BG closely."

I found the dedicated thread you mentioned: "Novolin R dosing recommendations". There's some good information there.

If there are other posts, please let me know. I'd hate to think your questions went unanswered. If so, we need to fix that.

 

Adding on to this...
A sweet use of R (especially for those new to R) is to administer R at the very first signs of a bounce. It will prevent kitty from going as high as they would have without R. The bonus here is there's no mistake made in giving R when the bounce is breaking.

 

It had been months ago that I was looking for guidance on the R. I just looked over by credit card transactions and I think I might have bought the bottle back in February, so I was probably asking about it back then. I wasn't planning on using it but just trying to learn about it so it was in the toolbox. I got a few tips but never a "hey, I'll walk you through this". Then that dedicated thread is from when he jumped back up into some purples so I was considering starting to use it but I again didn't any dedicated guidance. And then a couple days after that is when vomiting and diarrhea started and with all that going on I didn't want to add that into the mix so I didn't really pursue it beyond that. And then when it came time to actually use it, I didn't bother to reach out again since the first two attempts were unsuccessful and it was an immediate need due to the 2.2 on the blood ketone meter. I had picked up a few tips from the responses I did get, namely start small and monitor a lot, that I didn't feel like I was going in completely blind.

 

Ok, that makes sense, but so does no one walking you through its use if you weren't planning on using it back then. I wouldn't have either. Things change.

Obviously, not the guidance you were looking for, but suggestions were made to have an experienced R user work with you at first and to post in the L,B,L ISG for guidance.

Sigh, and the rest is history.

I am sorry, but I also wish you would have posted for help in the group as was suggested. This has been a tried and true method which has kept cats safe and made life easier for the caregiver.

That said, your situation has been quite the eye-opener. Sebastian has been diabetic since 2013. We can't make any assumptions, and we must all strive to do better.

 

So looking at his numbers, the very first attempt AM 8/13, I just did a drop. He did have a curve but the nadir wasn't until later and as far as I could tell, the R didn't do anything. Plus with the high ketones I really wanted him in the blues. So I upped it to .1 that night, checked the +2 and +5 and still basically saw no movement.

Next morning ketones were low so I didn't give any, I really was trying to be as cautious as possible and only do what was necessary. That night BG and ketones looked like they were rising, so I upped it to .25, checked +2 and +5 and they were higher. That day it actually looks like he just bounced off the 188.

Morning of the 15th, ketones up and BG high, upped it a little more to .5u. Completely flat all day long. Pretty much the same thing the following day, upped it a bit more to .75 and again completely flat.

So at this point it's feeling like the small doses aren't getting the job done, however we increased lantus that morning and while I knew it wouldn't have kicked in the first cycle, I didn't want to mess with the second cycle when it might have, so I held off. Same thing for morning of the 17th, I wanted to give the increased lantus a chance.

Then night of the 17th we hit 2.4 on the blood ketone meter and I was done screwing around so 2u R. Checked him the first two hours and then the fourth and then the 5th, only 40 total points of movement, still in the yellow.

Morning of the 18th, numbers were actually looking okayish, we were deep enough into the lantus increase, so I wanted to try 2u R and confirm if it did anything or not. Bit of a dip, about 50 points, I was actually pretty pleased with that. So I stuck with 2u again for that night, however checked him at +5 and didn't see much movement. Yeah, I only checked the +5 but the subsquent numbers from the morning don't really indicate a bounce.

So, morning of the 19th, ketones are looking good but BG is pretty high, 2u didn't quite get the movement I wanted, so I upped to 3u. Between being so high and the movement from 2u, I wasn't expecting a whole lot, also had an appt, so I didn't check again until +4 and saw about what I expected to, 50-60 points of movement. Keep in mind at this point I had never heard the "don't want more than 100 points drop" so I probably should have been content with that. And actually I did look back at the thread and I see where you did in fact mention that Wendy, so that's my bad for missing that. Anyways, so night of the 19th we hit purple, however I want some sleep so I stick with the 3u and check at +5 and get 199.

Morning of the 20th looks really good, 201 and ketones low. I did find it a bit odd that it seemed flat from the +5 but I let it ride. Then the 412 hits and I go right to the R. Knowing the 3u only gave me about 50-60 points of movement and I'm wanting like 200 to get him back to a "normal" level, I go with 5u. And it does pretty much exactly what I wanted to, brought him right back down to 200. Big drop, sure, but nowhere near hypo range. And since the PMPS was under 200 I let it ride that night. But I get a few more tests to see what's what.

And then this morning has been up and he probably could have done with some R but I wanted to get this all sorted first.

So, here's my thoughts on it. I don't think at any point he got even close to hypo range, probably never even below 150. The biggest gap in data that would have helped the most is from the night of the 19th, however, I still resist the "went too low" idea. If he went too low between the PMPS and the +5, why wasn't the AMPS higher? And given the cycle of the R, it just doesn't seem like there was enough time in the cycle for him to go much lower between the +5 and AMPS. I'll admit it's hard to draw any kind of curve that night so he was probably up and down a bit. But based on the couple urine readings I got from him it looks like his renal threshold is right around 200. So what it looks like to me is that he's spent so much time above it lately that even going as low as 180/190 was enough to trigger a bounce, which we can see a couple instances of over the span. Obviously we don't want bounces but I don't think he was ever at risk of hypo.

But I suppose there is one bit of info I never thought to ask about that now seems relevant, are the bounces triggered by where he drops to or by how much he drops by? If the simple act of dropping by too much, regardless of where it's to, is enough to trigger a bounce then yeah, I absolutely triggered a bounce with the 5u bringing him down 200 points in 4 hours.

And just to bring it back to my resistance to the "going to low" idea and the night of the 8/19, that's the part I don't understand the most. How people are drawing the conclusion he went too low based on that data. Like I said above, I just don't see the curve that allows that to happen, based on the PMPS, mid cycle, and AMPS data.

Honestly I thought that's what I was doing at the 412. Big jump, give the R, bring him back down.

 

Just so I'm clear, you're saying I should have posted it in the Lantus forums, not the general health? I'll keep that in mind if something like this ever comes up again.

Yeah, from what I understand that's a pretty long time to be a diabetic and still kicking, especially since I didn't seriously start treating it until this year. Guess he's just stubborn. I'm definitely not expecting to ever get OTJ, and even a stable consistent dose is probably a 50/50, but I do think I can wring a few more years out of him, especially with what I learn here. I haven't mentioned it in a while and I want to make sure it doesn't go unsaid, but I am eternally grateful to everyone and everything I've learned here. I'm absolutely positive he would not have made it through the first few months after the pancreatitis without you guys.

 

PMPS 240, 11lbs 10oz, b-ohb 0.6. Started adding in some s.boulardii in anticipation of possible antibiotics on friday when we see the vet. Still not really sure what's going on. He's acting perfectly fine and I think his poops are getting a little better. Maybe I'll get lucky and this 6u depot will kick in tonight and get him <200. I'm not really sure I want to increase dose in the morning as would normally be time for. 6u is already the highest we've been since the diet change so I feel like we're in "abnormal" territory here, so I kind of want to give it maybe a couple more cycles to build.

 

311@+2. No like.

 

Yes. I'm glad you're finally seeing the 412 was part of a bounce (which is why you gave the R). Where was the bounce which caused that 412? There's only logical place for it to have come from/happened = between the drop from 333 at PMPS and the 199 @ +5. It was only a 134 point drop but with 5u R packing a punch, Sebastian either dropped low or fast. And when I say low, I include time spent in numbers which are lower than he has become accustomed to.

To compound the problem, the 5u of R shot on that red 412 the next day created yet another bounce. 5u was too much R (caused an almost 200 point drop).

Yes, that was the advice given to you at the time. It's better to post where there are more eyes... experienced eyes who are well versed in the nuances of the insulins used as well the EXCEPTIONS. While R is a great tool to have, simple mistakes have the potential of becoming dangerous or fatal.

I don't like it either, but as long as he isn't close to 2.0 BK, if he were mine, combined with the events of the last few days, I would let it ride. He's had 2 R-free cycles in a row. I'd hold off with R again this cycle to eliminate any possible influence from the R. We all know R is in and out of the system quickly, but it can and will often interrupt the normal sequence of events in the following or subsequent cycles.

If I were in your position, I'd want to start with a clean slate, BUT it's your decision to make. You hold the syringe.


And on that note, I have to walk away for now. I have a hard time dealing with pot-stirrers (not you) and the pay for this (volunteer) job just isn't high enough to continue taking it, especially when it comes from one who has a perpetual ax to grind. Life's too darn short.