New Day after yesterday's HYPO

Discussion in 'Prozinc / PZI' started by owlgal, Dec 19, 2011.

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  1. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    His amps is 452. This is really high for him. I guess this is a normal bounce from the low and all those carbs and karo. I went ahead and gave his morning insulin shot of 1.5u with a shaking hand and a prayer. I don't want another day like yesterday. Lori (Lori and Tom) gave me a sliding scale to use for this morning and said i needed to have the dose reduced because he will be insulin sensitive now after the hypo. She suggested >400 give 1.5 for just this morning. Carl, I think you are right, i will have to get back to the 2.0u and start over with that soon!

    I will be gone the first couple of hours this morning and should be back by +4 to observe. It's going to be so hard to leave him this morning after yesterday, but i have to go on with my life and scheduled commitments. I think it will be even harder walking back into the house and hoping not to see a cat in hypo again.

    Keep me in your thoughts and prayers today!

    THanks again for helping me through yesterday. It felt good to have a team supporting me.

    lori
     
  2. Anonymous

    Anonymous Guest

    Yes, I offered up my version of a sliding scale yesterday during the hypo.
    If this...than that.
    Becuase I would not be here this early in the morning and not many folks are.
    As well Lori called me last night midnight with the 520 reading at her +12 and altho' the general concensus was no shot, including me, with all the nerves I said I WOULS go ahead and at leat offer the token dose (for this cat that is a token) of .5

    May I say altho I am new to this case it feeels like it is being run fear based on dissagreeing with the good dr. lisa. If someone sees something a tad askew please speak up. I did. The last three days were all saying the same thing. Lower dose.
    As well, Dr. Lisa is not purrfect, she can make a mistake as she is also a human including being a Dr.
    It is ok to dissagree with the good Dr.
    If I am wrong...oh well, let the lambasting begin. Been there, done that.
    Lori

    PS Lori was afraid, as was I of admitting she gave the .5 last night. Can we not let fear run this room as it does in some other rooms.
    We just do the best with what we got. Carl actually said he wanted to quit advising since he almost killed a cat! Every day on this board chances of a cat being over or underdosed is a reality.
    PLease lets not go there.
    And let's not be so worried about law suits and such...god, do we not pull a child out of a cars way becuase we may be sued for breaking his arm in the process?
    I may be wrong sometimes....I may be right. Please help.
    No anger No ego...that is what this room especially is made of yes?
    Lori
     
  3. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    I first want to say to all involved, THANK YOU! I really mean that from my heart. I think the main problem through it all is, ME! Dr. Lisa said it right when i first started insulin that "I" was afraid of it and whimpy to go up. YES, i admit it. I just didn't want to ever hypo or experience it. My schedule is so hectic and being totally new on all of this i wanted to do it right and help my boy heal fast. I like to be educated about things and not relie on others fully. My personality is too question everything, only because of a bad experience i've had in my life. Won't go into details. But i learned from that experience to always be knowledgeable in a subject as much as possible so i can also help in making an educated quess. All this said, with FD i've tried to read as much as i can, get consults with an excellent vet(Dr. Lisa) and listen to the wisdom of the board. "I" take full responsibility for his care and his dosing. THe problem; I did relie too much on others and not use my brain and good instincts that i have been blessed with. I still don't have a clue how to treat FD and feel like i'm blind when it comes to treating him. But i can see now that only me, and ONLY ME, is responsible for the decision. I will take in the opinions and ideas, if anyone will ever want to help again, and keep trying to do the best i can do. I love him so and want him to feel better and i'm very frustrated that i can't help him. Instead I just made him worst to the point of almost death. Maybe i'm not the best for him. But all i know is while he is in my care i will try to do my best educated best in ALL my responsibility.

    Lori
     
  4. Anonymous

    Anonymous Guest

    so....what number did you get this afternoon? can't wait to see. i'm gonna go check the ss.
    Lori
     
  5. Anonymous

    Anonymous Guest

    Looks pretty good. A curve may be forming....fingers and paws crossed.

    If he just keeps going down and gives you another slant rather than a curve you may dose reduce again. Small amount depending on the number you get ok?

    FWIW, you did great yesterday under a very stress situation.

    Hugs,
    Lori
     
  6. bookw0rm

    bookw0rm Well-Known Member

    Joined:
    Aug 11, 2011
    Of course we'll still give you advice! You need to remember to calm down & take care of yourself, too. Copper didn't develop diabetes overnight, so it will take time for him to get.better. Now you know what.to do, so you don't have to worry if he goes low again.
     
  7. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    Number are in. He really never went low and his numbers are climbing again. I'm @ +9 now. I will wait to test until +12(pmps) which will be about 9pmEST.

    Got to run to a family dinner thing. Will be back in 2hrs to post my pmps and we shall see.

    lori
     
  8. kse

    kse Well-Known Member

    Joined:
    Feb 10, 2011
    Hi Lori....I have followed along some with Copper, but not enough to feel comfortable giving advice. I am curious....I see you are from NC, so am I. What part of NC are you from?

    You are doing great with Copper. FD is a very complex condition and especially early on it is hard to determine doses etc...but, it will get easier. You are in good hands on the board. Even in situations like last night the group will be here to support you and give advice.

    Kitty and I have been here for about a year and with the help of the group in PZI she is now fairly regulated. Early on, Kitty was consistently in the 400 and 500s at preshot and got very little duration. Kitty, 16, is now dosed tid and outside of the occassional 300 preshot, she pretty much stays in the 200s or below----all attributed to the great help of the PZI group!

    The high numbers are to be expected today. Hang in there .....it does get easier!

    Kim and Kitty
     
  9. Anonymous

    Anonymous Guest

    Lori I like your choice of 1.5u tonight.
     
  10. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    Copper did ok today and seemed somewhat active. He was starved today and i've noticed that he is peeing and drinking more and his neuropathy is worse.

    Going to stay on the 1.5u for a couple more cycles and see how he responds and then decide which direction to go in.

    Thanks again everyone!

    Will post more tomorrow.

    lori
     
  11. Lisa dvm

    Lisa dvm Member

    Joined:
    Dec 28, 2009
    As I have mentioned several times on this board, the last thing I would ever want to do is scare someone off and I regret breaking my hard and fast rule regarding posting dosing advice here. I have never taken the 'I am vet - hear me roar' stance. Well...except when it comes to dry food and blocked cats....then you will hear me roar very loudly.

    I have been absent for awhile but I checked Lori and Copper's last thread and see that 2.6 vs 2.8 was discussed - so a significantly lower dosage was not mentioned and I can't fathom that I intimidate 'Hope and Baby''s human who has been at this dance a very long time.

    viewtopic.php?f=24&t=58737

    One other issue, if I remember correctly, is that some folks were looking at Copper's numbers at the top of the chart that were obtained with a bad meter. I say "bad" because the values were at least 100 points lower than the Alpha Track and Relion and his numbers were not matching his clinical signs at all. If his clinical signs would not have been so severe, we may have just accepted those nice numbers as 'real' but there was a serious disconnect.

    Absolutely! I love batting things around with smart people (time-permitting) and am not so arrogant that that I think I know everything - even after 35 years of involvement in this profession.

    I also posted a comment about this being a two-way peer review board on another thread. This is also to reiterate what others have brought up in the past regarding keeping dosing advice on the board and not via PMs.

    Honestly...I don't bite and I have never felt that DVM equals God.

    Here is one exchange from a few weeks ago when I was more active with Copper's case:

    and

    Now this is not to say that even if we had a continuous BG reading that we will always agree on the exact way every case is managed because that is just not reality.

    Strongly agree with the above.

    Copper's mom and I spent a a very long time on the phone tonight and I must say that she is one of the nicest humans I have ever met. She must have been a cat in a former life because she sure has a lot of outstanding qualities. (I generally like cats better than humans....)

    We are also both very upset to hear that ANYBODY is backing off from offering advice here. What a shame that would be and I will close this post by copying and pasting something I said in another post:

    and

    So....Carl...get your butt back here and do your 'thing' because you do it very, very well. You should be extremely proud of yourself for all of the cats you have helped in your time here.
     
  12. Anonymous

    Anonymous Guest

    Thank you for posting this Dr. Lisa.
    My opinion of the last couple of days, while different than yours, does not diminish my respect and gratitude that you are here. And I am happy that you welcome a differing opinion to look at as that seems to be the biggest obstacle between mere humans and Dr.s. The lack of courage to say to a Dr. that you think something is off.
    I also hope Carl can take whatever rest period he needs and come back to where he is not only needed but LOVED.
    Agree also that Lori is like the nicest person in the world.
    Agree also that I generally like animals better than people.
    Lori
    Newbie Kits
     
  13. Hope + (((Baby)))GA

    Hope + (((Baby)))GA Well-Known Member

    Joined:
    Dec 28, 2009
    LOL, Dr. P.......Actually, I was trying to ignore the beginning of the SS and the change of meters. I left it up to Lori as to whether she wanted to stick with 2.6 or move to 2.8 but to keep an eye out once insulin is "settled" and body is adjusting and either using it too well and going down too low or.....an increase is shown to be needed.

    Lori, you've only been at this a little over a month and you seem to want too much too fast. You also are very worried about DKA. I ignore numbers where ketones are concerned because Mishka has proved to me time and again high numbers DO NOT ALWAYS mean ketones and LOW NUMBERS DO NOT RULE OUT ketones.

    I am one that is usually for trying less insulin or starting over and monitor and have always said for years, "sometimes less is more". I am also one for giving a dose a fair chance before increasing unless the cat is going too low and that dose is proven to be dangerous and needs to be lowered.

    There are those times it becomes a crap shoot as to which way you go so you monitor and test urine and go one day at a time. I have to worry about ketones because Mishka came to me in DKA and is prone to them and her numbers are usually in the mid 100 range. If she refuses to eat, she goes to ER ASAP. She is the only one of the 5 I've had/have that has ever thrown ketones.

    It will all come together but sometimes it is a slow process and sometimes it is a quick remission. Some cats are lucky and become diet controlled, some go into remission with a few shots of insulin and diet change, and some will never go off needing insulin no matter what their bean does. It just is not going to happen.

    Changing doses too quickly within just 2 or 3 shots is not the way to go unless the cat needs a decrease.

    You also wrote today that he is not eating. Can you take a temp on him? What else is Copper doing that is off?
     
  14. I suppose I should say something...

    I have "left the board". I won't be around much. It has become to big of a part of my life, causing other things to go undone.
    That it coincides with the "other night"..... that was just the straw that broke the camel's back. I'm not leaving because of that specifically.

    In simple terms, I'm drowning, and in order to keep my head above water, I need to get away from the daily participation. Too much time and too much responsibility. You will see me occasionally post, mostly on health. With my "other job", as a DCIN case manager, it is important that once a kitty becomes a "DCIN" kitty, that the beans join here or DCC and seek help and advice. The "obligation" on my part doesn't end when I send somebody some strips and a meter. They have to join a board, they have to home test, they have to manage diabetes correctly. I can't just throw them out here and expect them to just "do it". So I'll be helping them get settled. And trusting that they will continue to get the same great help and advice that everyone gets on FDMB.

    So yeah, sorry to disappoint anyone, but I'm done. I just don't have it in me right now.
    God bless everyone of of you. You are special people to do what you are doing for your cats and everyone else's.
    Carl
     
  15. Lisa dvm

    Lisa dvm Member

    Joined:
    Dec 28, 2009
    Believe me...I know where you are at. I use the word "drowning" on a daily basis since my website has become so popular (>100,000 visits (unique people) per month) .....with many thousands of emails coming to me every year begging for my help. It is INCREDIBLY stressful and has taken over my life. I am supposed to be retired but I spend - no exaggeration - at least 16 hours each day....pretty much every waking minute of my life.....helping cats.

    There are many days where it is just TOO DARN MUCH!! And I have to remind myself that I am only one person and can't save every cat in Russia...and China...and Taiwan...and in the 'middle of nowhere' where there is no vet care....but internet access to reach out to me. It gets overwhelming and highly depressing.
     
  16. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    First, I want to say again, THANK YOU for all your support and encouagement. Carl, i understand where you are coming from and sounds like you have a ton of responsibility on DCIN. My blessings to you. Thank you again for all your suport and encouragement. You were my nightowl at times with me. Thanks!

    The past five wks has been a whirlwind and a huge learning curve. It couldn't of come at the worst timing in my life, but when is a good timing for disease. Can't say i know anymore than when i started, just more confusion, frustration and questions with each day and cycle. There is so much that i would like to explain about the last 5wks, but don't want to go into details. The ultimate goal of this jouney is to get my Copper healthy again. I have used the advice and wisdom of a brilliant, competent, wise, humble and the most dedicated Vet around, Dr. Lisa to help in deciding which direction to go with copper. Also, i have used board members advice, full of experience and wisdom, to also help in the direction of copper. The combination of these resources with my natural "moma bean" instincts have led me in my dosing direction for copper. It was not done flippantly or with hast, but with great thought and consideration of the resources available and knowledge gained. I do not base my life on fear, but i am cautious and question everything just so i can undertand and help make an education guess. Can i say i go the wrong or right way? I don't know. No one is perfect and we all learn from our experience. I'm still learning. But, i do know Copper is very loved and great care and thought is going into his daily dance. But i can't do it without a team and more minds, especially those experience in FD More minds are definetly better than one. Ultimately, i am the final decision maker and i have to live with what way to shoot, and "I" hold the syringe. I can't, nor will i ever admit, i can do this on my own, especially when i don't understand this disease one bit. But it is all my responsibility. This weighs heavy on me, especially when i have a ton more weighing on me outside of this disease that copper has. VERY stressful and nerve racking. It has changed my whole life and my family. Anyway, i am sure you all have been there at times.

    Please hang in there with me and continue to post any comments or thoughts of direction to go. If you happen to see something that jumps out at you on my SS, please let me know. I have NO PRIDE in this at all! Like i said, it is teamwork.

    THANKS again!

    lori
     
  17. Lisa dvm

    Lisa dvm Member

    Joined:
    Dec 28, 2009
    Debate/disagreeing is how we all learn. Otherwise, we can get into a situation like lemmings headed for a cliff.

    My elderly parents are this way. They assume that anybody wearing a white coat with "Dr." in front of their name must know everything and are never wrong. They are so resistant to seeking second...or third...or fourth opinions....and are getting tired of me dragging them around to different doctors when I don't agree with the way their case is being managed.

    I looked at Copper's SS a few hours ago and saw two blues!! Excellent. :D Maybe he will give us a Christmas present of some safe greens.

    I must say, however, that he is on my 'bad list'. I could honestly say that before him....I had never...ever....had a cat drop that low.

    Lori and I did chat last night about the issue of too much karo. I am just not the type to panic in these situations and since Lori described a cat that was simply walking around meowing for food...not what I consider a hypo with overt/serious clinical signs.....I would not have been quite so aggressive.

    I think that we often pay too much attention to the meter number and not the patient and given just how INaccurate these darn meters are (and they ARE inaccurate....) I stress looking a lot more closely at the patient.

    In any case, I am thrilled that he is doing better since that is all that matters!

    Lori - I understand that you are taking him to a new clinic tomorrow. Make sure that they check his back (thorough palpation) and do a decent orthopedic exam on him.
     
  18. Hope + (((Baby)))GA

    Hope + (((Baby)))GA Well-Known Member

    Joined:
    Dec 28, 2009
    I'm one,when I see a kitty at 29,that doesn't want to wait for hypo symptoms to start showing and the reason I mentioned rubbing more Karo on the gums is because too many think one time will stop the drop and they quit with the karo. Food just doesn't kick in as quickly so Karo helps stop till food can. I also do not think he spiked so high from food and karo, I think the liver panicked and kicked in with some help also. Bottom line......Copper is fine and that is what matters and today is looking good. I would stick with this dose unless he goes down to where you are not comfortable for right now. I wouldn't increase just yet.......too soon.
     
  19. Lisa dvm

    Lisa dvm Member

    Joined:
    Dec 28, 2009
    Just to clarify - I am ok with that - putting a bit on the gums - but there was a lot of karo put into the food. (Lori knows that I am not picking on her at all...just trying to post informational stuff for future issues in case others are reading this thread.)

    Definitely agree.
     
  20. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    Yes, i will not increase at all for now. Does this day indicate he is on his way to healing? What do i do if he is still in the blue's @+12? Just give a token dose?

    lori
     
  21. Anonymous

    Anonymous Guest

    ok, so why was the curve not a curve and just a downward slant for 2 or 3 days dr. lisa? i will stand back and watch but for the life of me i cannot read that chart and not see a series of cycles that were indicative of too much insulin.
    i can tell by lori's pm that my future input is not really needed and all that is good and well....but am curious about what i am missing when i read that chart and see too much insulin.

    i would lower dose on a lower blue number. but thats me. cut in half in necessary.

    still, would love to know.

    lori
    newbie kits
     
  22. Hope + (((Baby)))GA

    Hope + (((Baby)))GA Well-Known Member

    Joined:
    Dec 28, 2009
    What time is the pmps? I would also lower the dose if Copper stays in the blues and continues down. Need to see what pmps is and go from there.
     
  23. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    Getting ready to test about 10:30EST. Will be back with post.

    LORI and TOM:

    YOU ARE MUCH NEEDED ALWAYS!!!

    lori
     
  24. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    PMPS

    Here it is: 304

    Actually what it was @ amps. So i assume i would give the same of 1.5. I really can't watch him tonight. Got to get to bed. early day tomorrow.

    thoughts!

    lori
     
  25. owlgal

    owlgal Well-Known Member

    Joined:
    Nov 15, 2011
    Dosed him @ 1.5u again. Going to bed. YEA!

    Thanks everyone!

    lori
     
  26. Lisa dvm

    Lisa dvm Member

    Joined:
    Dec 28, 2009
    Hi Lori (of Lori and Tom),

    I am going to write this post as if more people are reading it than just you so don't think I am 'dumbing it down' or talking down to you. I am simply going to try to spell out my general thoughts as thoroughly as I can. I take every case very seriously no matter my level of involvement so bear with this War and Peace-length post. I will make some general comments then get to your specific questions.

    As we all know, there is more than one way to manage a diabetic cat…..different roads leading to the same goal. I understand that there has been a rift between the YDC and the FDMB management styles but I will say that I am a bit of a hybrid between the two concepts because I will always struggle with the fact that giving two injections of exogenous insulin - at set amounts - exactly 12 hours apart - is miles away from how the body works physiologically. The pancreas, in real life, spits out different amounts of insulin…. many times a day….. depending on the current BG level. Cats vary in the speed in which the metabolize both endogenous and exogenous insulin…etc…etc. Lots of variables. This is why Dr. Hodgkins' management style has always intrigued me - even while recognizing its cons.

    Keep in mind that when Lori first contacted me many weeks ago, she was a YDC member and was also intrigued with their management style; much of their protocol made sense to her, as it does to me. Also note that I have not been involved for the entire duration of Copper's management.

    For anybody reading this who is not familiar with YDC, they shoot based on a sliding scale (SS) depending on the BG value at that point in time. The higher the BG, the more they shoot - just as the pancreas would do in a natural setting. They will shoot up to 4x/day in varying amounts but usually shoot 3x/day (every 8 hours)….again, closer to what the pancreas would do in real life. Their goal is to NOT have a definite curve but to keep the cat euglycemic (normal BG) for as many hours each day….mitigating the devastating effects of glucose toxicity on the body.

    It is not the FDMB way but it does work for many cats. That cannot be argued. Remember…. more than one road…..

    We are all products of our experience and that is going to be reflected in how we approach any task. My style has worked for me resulting in a lot of cats going into remission without a single clinical hypo. Of course, the same can be said for other management styles. Is that to say that I am not upset over Copper's 29? Absolutely not! I do not take that lightly because even though he was not showing clinical signs of a serious hypo, it goes without saying that we do not want to see 29 on a meter. Plain and simple. As stated above, this was a first for me but given the fact that exogenous insulin is all that we can control (other than diet) and the fact that there are so many factors influencing a cat's BG, it will probably not be the last.

    Copper had been on that dosage for 6 days before he dropped low and there was no obvious reason to suspect that kind of a drop. (I see 2.6 as not statistically different than 2.8 and even IF you could measure a 0.2 dosage with great accuracy, we are only talking about a 7% difference. I see this as close-to-negligible which I know others will disagree with.)

    Given that there are MANY things going on in the body that influence the BG level, it is my opinion that we all get too caught up in thinking that the dosage we give is so critical down to the 0.1 or 0.2 unit….and that the *only* reason a hypo occurs is because of an overdose. Exogenous insulin is only one piece of the puzzle. This is why there is always going to be a risk of hypo because what if the pancreas just decides to wake up that day and join the party…adding to the exogenous insulin? What if some infection/inflammation subsided….or stress was reduced….or the patient lost some body fat…..any of which would render the patient more insulin sensitive? (Again, I know I am preaching to the choir here but am just 'talking out loud'.)

    We have all seen those cats that just suddenly decide to go into remission (which is why we always test before shooting….which my colleagues think is pure craziness….ie…."stressful micromanaging"….you guys should read the comments I get on VIN when I so much as mention testing before every shot….they think I am nuts and I have caught a lot of flack for it…..but I digress….).

    Most cats *gradually* go into remission but I am working with a patient now that suddenly decided he did not want to be diabetic anymore. Fortunately, he made a nice soft landing down to 0 insulin from 3 units BID being supported on the way down with small amounts of insulin. (That's another thing that drives me crazy about my colleagues…they just pull the rug out from under the cat by stopping insulin….zero support on the way down.)

    So after the *general* comments above….I will address your question here - keeping in mind that *generally* speaking *some* cats experience longer durations with a higher dosage….shorter durations with lower dosages:

    Here is where our management styles are going to diverge.

    It sounds like you see a downward slant as a sign that the previous dosage was too high and you would want to lower the dose to get the curve that you are comfortable with. Lowering the dose may shorten the duration which would allow you to shoot your set BID dosage. This decrease in dose may - or may not - result in a decent nadir. If not, then the patient will continue to suffer with glucose toxicity for more hours than he may have if a downward slant had been accepted. Keep in mind that as that curve rises back up again, the hyperglycemia will harm the body.

    I don't focus on whether the numbers form a curve or slant - I focus on how many hours the body has to deal with hyperglycemia. When I see a slant, I am actually happy because I see that the patient is not drowning in sugar.

    If you are using more of a hybrid style of management, a downward slant is just fine. I don't need to see a curve but then that is where the sliding scale comes in which drives the 'anti-dose hopping' folks to drink. :smile: That said….UNwarranted dose hoping makes me crazy just like it does to you guys. I would much rather stay consistent because this journey is hard enough as it is without adding more inconsistency to the mix so we are on the same page there.

    That may seem like I am contradicting the YDC style but the bottom line is that I just have to take it case-by-case, cycle-by-cycle and am loathe to follow a set, rigid protocol that demands a curve and not a slant. (I was kicked out of Girl Scouts for not wanting to conform….)

    I digress, yet again…...In my youth I was more stubborn in thinking that "there is a right way and a wrong way, by golly!!" and would accuse others of doing it "wrong" or state that they were "making a mistake" if they were not doing it *my way* Now I just see that there is more than one way to get to the same place and I am less judgmental when others are doing things differently. Also, it gives me more flexibility with each patient.

    Don't get me wrong - the vast majority of my patients are handled the FDMB way with a set amount of insulin twice a day but, with some patients, I step outside of the rigid 'box' and try a hybrid management protocol and it has worked very well for my patients. (Honestly, I really do hate rigid protocols because one size never fits all. I think back on how much I have altered/expanded on what I learned in vet school 30 years ago.)

    And, as I have already acknowledged on other threads, Copper may very well need a lower dose but I disagree with you that this is a clear-cut, "no brainer" case.

    By your statement and question above, I am assuming that you are focusing on the downward slants because there are no *clear* cycles that are scream rebound. (It goes without saying that any *clear* indication of *warranted* rebound (versus UNwarranted) signals a need to lower the dose.) Therefore, I am going to assume that you are talking about slanted lines because this is what you were heavily stressing on the phone with Lori.

    Again, downward slants just get less insulin for that low PS - after checking for a rising BG….or I may even shoot just a very small dose on a plateau. I don't see slants as a "no brainer" indication that the dose needs to be lowered in every case.

    Another digression….but an important point is that Copper is not the same cat today as he was a month ago…or the same cat that he will be in 2 months from now given the dynamic changes in the body with time. That is why it is impossible to state with complete certainty that any cat will react the same way to any dose at any given point in time as he may have previously - considering all of the physiological variations in the body. He may very well be more insulin sensitive today (and need a lower dose) than he was a month ago given the effect that glucose toxicity (which we are trying to rescue him from) has on insulin sensitivity….ie…it decreases insulin sensitivity/promotes insulin resistance......necessitating a higher dose.

    That is what all of our management is all about - rescue the cat from glucose toxicity and, hopefully, watch his insulin needs drop right into remission.

    Back to your question:

    The FDMB way, which is the management style that you practice, says to lower the dose if:

    1) there is a downward slant or

    2) there is an indication of rebound

    #2: Of course we all agree with #2 - IF we think the rebound is warranted but not necessarily for UNwarranted rebound. (Unwarranted = the body overreacting to a lower - but still very safe - number that it is simply not 'used to'…..a number that is still higher than we want.) I digress again…and this was covered in another thread…but sometimes the distinction between the two (warranted vs unwarranted) is not made. Or, the distinction is made but the dose is lowered on an UNwarranted rebound which I do not necessarily agree with. Dr. Hodgkins' protocol pushes through the unwarranted rebounds. However, I am careful to take a more moderate approach and am not as aggressive as Dr. H.

    #1: I don't necessarily agree with #1 in every case for reasons stated above.

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    Getting away from the slanted line issue and moving to rebound which is my most significant concern with *any* case that hints at it…..

    My concern with Copper was always the possibility of unrecognized rebound - not slanted lines. This is where that 24/7 BG monitor would come in very handy. (Again, the issue of unrecognized rebound was previously discussed on another thread - the one that said "you guys may be right and that a lower dosage is needed"…and talked about with Copper's mom at great length.)

    We all know that this is the big question anytime we have high PS's and don't have a lot of data to give us a good idea of nadir….leaving us wishing that we had a minute-to-minute monitoring device on him to see if:

    1) he dropped low enough to trigger a warranted rebound….or

    2) he just dropped lower than his sick body was happy with….triggering an UNwarranted rebound…..or

    3) he was just experiencing shorter duration that cycle….or, if no mid-cycle data….

    4) he was simply high and flat suggesting possible insulin resistance

    All we can do is guess - being careful not to make strict assumptions based only on the shape of his chart.

    As discussed on another thread, I think that many people focus on rebound and do not ask the question "is it simply a lack of duration?" (Jojo called it "BIPO"…big insulin poop out.)

    The choices, as we all know, are to:

    1) lower the dose ('rebound check' - with ensuing **exacerbation of glucose toxicity if not in rebound** or

    2) to *slowly* (definition varies among us) raise the dosage and keep monitoring. As we all know, this is a decision-making situation that occurs here daily.

    4-5 years ago when I was spending more time on this board, I saw many cases of 'rebound checks' that made me cringe as I watched these cats *drowning in glucose* as the owner *slowly* crawled their way back up the dosing scale. Truth be told, it made me crazy and I had to stop looking at those cats' charts.

    Back to our 2 choices:

    Given that I focus heavily on *glucose toxicity* - which Copper was/is showing serious signs of (unless he has an ortho problem that we are not aware of) -

    *and* the report from Copper's mom that he was *doing better as the dosage was being increased* -

    *and* my past experience with other cases like Copper's -

    the decision was made to slowly raise the dose - with sincere acknowledgement that "a lower dose may very well be needed" as already stated on a previous thread.

    I know that I am preaching to the choir here but Lori had made several mentions of Copper doing better, clinically, at higher doses. This was factored into the decision as it should always be. We can't just look at the numbers - especially without that magical 24/7 monitor.

    I am going to digress again here: Regarding the word "slowly" - Unfortunately, my colleagues rarely raise or lower a dosage by any amount less than a full unit. I am trying VERY hard on VIN to change this mindset and to remind them that there really are smaller doses. I am having luck with getting them to embrace 0.5 unit increments but forget anything lower. I get laughed at when I mention anything lower than 0.5 units….mainly because they feel that it is impossible to accurately measure. I also got laughed at when using "fat" and "skinny". On a good note, at least they are now discussing syringes with half unit marks.

    Are you talking about simply a blue PS? Or a mid cycle number? If you are referring to a PS, then yes, a lower dosage is warranted - for that shot - but you see a slant as a failure…an indication that a previous dose was automatically too high…whereas I don't. I just see it as a great PS/long duration….with the need to establish direction and shoot accordingly…..the need to be flexible (not rigid with the dosing) and closer to natural physiology as stated above.

    Glucose toxicity:

    Why am I sometimes more aggressive than most? It is because I can't stand to watch cats drown in sugar. There is, understandably, a fear of hypo but, on the flip side, I rarely see glucose toxicity discussed. Yes, I know that patience is definitely a virtue with this disease but, as noted above, I have also seen the 'start low go slow' mantra seriously overdone in some cases when I used to spend more time here. I have no idea how it is now since I am not here much. Compared to some of my colleagues, I move like a damn snail but others think I move too fast.

    Lori - I know that you see this case as very clear and very straight forward when looking at the previous data but If Copper's case was so straight forward then what would that say about my other cases that have shown his pattern (including downward slants) that have been well-managed right into remission with gradually increasing dosages? That is certainly not meant to sound defensive but it is simply a valid question/comment/fact.

    I may follow a 'road less traveled' but it sure has gotten a lot of cats into remission just as other 'roads' have accomplished.

    I really do appreciate your questions which only results in more learning for all of us. I don't think that any of us come away from any case without learning from it. But that said, I have often asked: "why are we so wise once we are on our death bed"? That seems like such a waste of experience and knowledge! :smile: I always wish that we could have a dry run at life…gather all the wisdom we need….then start again. But since we can't, we just all have to do the best that we can and expect to be thrown curve balls on occasion since we can't predict or control everything.

    Oh…and could we add on a crystal ball and a continuous glucose monitor to that wish list?
     
  27. dmartini4

    dmartini4 Well-Known Member

    Joined:
    Nov 6, 2010
    Thank you Dr Lisa,
    I am going to have to read this thread a few times in order to try to absorb everything you said,
    but I can say that it has been so helpful having all your wisdom and advice here lately
    It is so very much appreciated.
    I thank FDMB every day for saving me and Shakepeares life.
     
  28. Lisa dvm

    Lisa dvm Member

    Joined:
    Dec 28, 2009
    I'm sorry that it was so long-winded! ;-)

    Thank you for your kind words - much appreciated.

    This board is fabulous - a true lifesaver. I learned much of what I know about diabetes from the very smart people who have given so generously of their time throughout the years on this board....much more than from any veterinary text book or continuing education meeting, by far.
     
  29. Barbara

    Barbara Well-Known Member

    Joined:
    Apr 10, 2011
    I just wanted to jump in to say don't ever apoligize for being long winded, we can all learn from anything you have to say. And I agree with Denise, as do many of us. If it were not for this board & all the many wonderful people giving so freely of their precious time I think my cat would not be here.

    I also just wanted to take this opportunity to say thank you for the litter box article, in addition to all your other great information on your website. I have owned cats for 39 years but learned SO much from you! I now have a huge plastic tote box with the side cut out as one of my litter boxes & it is wonderful! The only reason I haven't totally switched to tote boxes is that it will not fit in one of the designated spaces and I didn't want to remove that box altogether. Thank you so much!!

    Sorry to hijack your thread Lori! :smile:
     
  30. Anonymous

    Anonymous Guest

    Joining the choir to thank you for ANY time you take to share your thoughts, ideas, experience with us.

    My suggestion to reduce or cut in half dose was based on low blue ps number. I really should be more clear.

    As for the interesting 'slant' discussion...may I join?

    I understand your goal of getting out of glucose toxicity asap as a rule (and by the way I am by no means one of the real smarties on the board....I know that) but I thought that a gradual removal from the higher numbers was preferable for a few reasons:

    1. Getting away from them too quickly leads to confusion about the dose. If you go 'slant' was that the insulin....or was it a bit of pancreatic action? How does one know.
    2. Reduce the mere suggestion of rebound by getting the cat in a nice groove of lowing numbers. This eliminates the risk of those bouncy numbers I see an obscene amount of over in tight regulation Lantus.
    3. Short term removal of glucose toxicity is not as productive and gradual long term keeping it there.

    These were my thoughts anyway.

    Things change of course when you have a DKA prone kitty...or maybe even as in Lori's case a possible nueropathy.

    My other thought on the 'slant' was I believed I was seeing a rebound the evening before the hypo when she slanted all day and after her next dose did nothing but ride higher all night.
    Also, if we are going to be dosing a slant line....should we not automatically be prepared to custom dose each ps? We would not want to dose the amps 370 the same and the pmps 216 if it were on the downslide with no curve would we?

    Again Dr. Lisa, I do appreciate your caring about the board enuf to even be here with you busy schedule.
    It is a gift for us all when you take the time. At the same time if you post on a ISG please note that the conversation can still go on as I would think not many would want to think beyond anything you have said.

    Also Lori had mentioned to me that your primary experience was Lantus. I asked her if she was sure you were told this was a PZI kitty. I had a concern there becuase the dosing did look a bit more like a lantus dose thing.

    The reason I said I would watch from the sidelines was in Lori's pm she was so kind as always but I just felt that I may have offended her and knowing me I was afraid I had. I was emphasizing nobody could tell her for certain what would happen with her cat. Whether it be hypo, DKA or anything. That Lori holds the syringe and the ultimate responsibility for her baby. Only becuase she asks questions in that fashion...'will my cat goes DKA if I cut his dose'
    I told her she had excellent instincts which I believe it really true. But some questions can only be explained with details and not yes/no answers.

    Actually I will always do whatever anyone here asks me to do in the long run. I think most of us will.

    Hugs Everyone Involved,
    Lori
     
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