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Post SRT-dosing concerns

Discussion in 'Acromegaly / IAA / Cushings Cats' started by Keskat&Rocket, Oct 6, 2019.

  1. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    Hello! I posted over in Rocket's SRT thread yesterday about his progress. He's doing well... maybe too well, as I think I'm starting to have a hard time keeping ahead of his (what looks like) rapidly declining need for insulin.

    Tagging @Wendy&Neko again - sorry :cat:
    But would love to hear from anyone with advice of course.

    I thought about posting this in the L/L forums, but this really is a question dealing with post-SRT concerns only, so I figured this would be the best place.

    Here's what's going on. I've taken what amounts to back-to-back reductions this week, because Rocket has been having some great time in low blues, some low (for SRT) greens, and some looooooong cycles where he keeps dropping all the way to shot time and beyond. This morning (and last night) I shot 8U; I was prepared to shoot 8.5 or 9 today because he was a little higher overnight, and I thought his reduction failed. But he kept dropping 'til shot time, so I shot 8U with his BS at 118. My last test at AM+4 was 79, which means we might be on hypo-watch again today.

    What this means is another tense day today. I'm so happy that his insulin needs are dropping, but the stress is getting to me. So much testing, no real time to do anything, but the hardest part is always wondering if I'm making the right choices, and the protocols don't apply here. Wendy, and/or anyone experienced with this, would you mind taking a good look at his spreadsheet for maybe the last two weeks and see if I'm missing anything? I'm looking particularly at some of the really long cycles, and how to make dose decisions when this stuff happens. I'm also curious what you guys make of his progress so far. Is this normal for post-SRT? I guess there really isn't a "normal."

    Ok to sum it up:

    What do you make of his long cycles, and his recent numbers in general?

    Am I making good choices so far?

    Should I reduce by half units, or whole at this point, and as often as needed?

    At what meter reading do I try to start steering his blood sugar back up? 50 like a "normal" diabetic, or sooner, like 70?

    Thanks, I just feel like this is new territory and I'm a little uneasy here. :blackeye:
     
    Last edited: Oct 6, 2019
  2. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    Going back to front: you don’t need to add high carbs unless he goes below 50, unless he’s he’s dropping fast early in the cycle and you want to slow him down, or you don’t like the trend of numbers and cannot monitor. I used to occasionally give a couple tsp of HC as my “get out of jail free” card, to leave the house if needed. 70 is still safe, you just want nadirs higher than that, at this point in Rocket’s journey.

    At this point I did 0.5 unit reductions. I did 0.5 unit reductions until we got to 3 units total dose, then went smaller because it stopped working and was too large a reduction for Neko. But every cat is different, and post SRT, each is unique. The rate of tumour cell death is highly variable. I also did back to back reductions, but kept in mind the effect of the depot,which can influence 4-6 cycles, more like 6 at the size of dose you are at. Today is cycle 4 after 10 units was last given, it is still influencing the numbers, as is the 9 unit doses.

    To reduce the impact of the depot, especially if you cannot monitor, after a reduction is earned you can shoot a one time half or two thirds dose. That will reduce the impact of the depot. Note, I only did that a couple times, cause I knew Neko would bounce and be safe. Experiment with this reduced dose or BCS (big chicken shot), to see what works for you.

    Rocket’s long flattish cycles are classic nice Levemir cycles, he’s looking really good on Lev. Those lower preshots are to be expected, but we dose based on nadirs. Flatter cycles are good, make it easier to predict what they will look like.

    FWIW, I followed the TR protocol, with the only modifications being reductions at 70, and allowing back to back reductions. I also didn’t test as much as you did. Once he is on his way back up, you don’t need to test hourly. I really tried to learn Neko’s cycles. There were patterns over multiple cycles that made it easier for me to predict when she would ask for a reduction. It was on Lantus then, but there was a particular three cycle pattern that told me to be ready for action next. I stared at the spreadsheet a lot.
     
  3. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    Thank you Wendy; I appreciate your help. I need to do more spreadsheet-staring too, especially over the last two weeks or so. Changes seem to be happening quickly (a good thing, I know!) so it's just a little nerve-wracking. Lately, Rocket seems very unhappy in higher numbers, and tends to get runny poo after even being in yellows for a bit (like last night). I'm not sure yet if it's directly related, or if it's just coincidence at this point.

    One last question for now: I need to schedule a checkup with just his regular vet for now. He's due for vaccines, and I want a couple of tests done. You recommended thyroid (T4 in particular), and kidney values I believe. Anything else I should ask for? And are there any vaccines we should avoid?
     
  4. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    I was told thyroid every three months for a year, so maybe a bit early for that. One test to discuss with your vet is ProBNP, which test the heart. I suggest it partly because Rocket had Maine Coon in him, like Neko did, and also cause heart issues are an acro thing. The vet may say to wait if there is no heart murmur. Neko had a heart murmur show up not too long after SRT. I did baseline geri or senior panel every six months, and that includes kidneys.

    I avoided all vaccines. Neko only went out under supervision. Vets tend to vaccinate more than needed. You can always get titers done.
     
  5. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    Ok, I may wait a bit then for the sake of the thyroid test. I do take Rocket out daily, but he's always on a harness, and I'll have to ask for an exemption from the rabies shot, as LA County requires proof of vaccination. Unfortunately the Dr. who did his SRT said he had a grade-2 heart murmur, and this was before SRT. So that's one thing we'll definitely keep tabs on. Thanks, it's nice to have this info handy in his threads. :)
     
  6. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    We did an echo on Neko after her heart murmur showed up. It showed the murmur was just age related/not a concern and heart heart was a bit big, but just one point up from normal size. Cardiologist was not concerned, and it gave us a baseline. He said only to worry if it changed, so after that I got the general practice vet to check the murmur each visit. Worth a discussion with the vet.

    We don’t have requirement on rabies here, so your mileage may vary.
     
    Keskat&Rocket likes this.
  7. JeffJ

    JeffJ Well-Known Member

    Joined:
    Jul 7, 2016
    We have rabies requirement in Texas too. Since Leo was sick and an inside kitteh, my vet wrote up the exemption. It's ridiculous, but we have to get Chinus vaccinated too. The only way she could catch rabies is by watching a rabid animal on TV, since she never goes outside.

    Rocket is doing great. It is great to finally see such obvious response to the SRT. I agree with Wendy's advice on dosing. With Leo, he was so bouncy that I adjusted frequently. But as I've stated before, I was working long hours so the doses kept him in a bit higher BG because I didn't have time to check (mid-day, or even every 2 hours).
     
    Keskat&Rocket likes this.
  8. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    Lol! :cat:

    Thank you Jeff. Rocket is being a bit bouncy himself today. Great nadir, high at preshot time. Maybe another adjustment tomorrow. Hopefully he’ll still hit something resembling a nadir tonight.
     
    Last edited: Oct 7, 2019
    JeffJ likes this.
  9. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    Karen, I recommend picking a dose, and sticking to it for six cycles, unless he earns a reduction. The depot needs time to settle, and having a consistent dose makes it so much easier to decide how to make dose changes. It may be 9 units is the right dose, for the moment.

    The nice thing about bouncing is you can get out of the house,
    .
     
    Keskat&Rocket likes this.
  10. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    Thanks, I see where you're talking about. I've increased back to 9 this morning, it could be he needs 9.5; I'll see how this goes, but I think we're close.
     
  11. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    Mkay, sorry if this is a little disjointed, we had another long night. So I went back up to 9U the cycle before last, since I thought 8U was a failed reduction. And Rocket hit 65 at PM+6 overnight, at which point since he was under 70, I decided to mix a bit of gravy in with his LC so I could get some sleep. Where should we go from here? I’m assuming the depot from when he was on 10U isn’t a factor anymore. Should we try 8 again (post-SRT under-70 reduction)? Or a depot drain first, then reduction? Something else?

    Sorry, I’m tired and a little frustrated. Happy that he’s hitting good numbers but I want him safe. Depot aside, isn’t some of this just SRT wonkiness too?

    Ok, shot in a little less than 3 hrs. Going to try to catch a little more sleep.
     
  12. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    At this point in Rocket’s journey, forget about the concept of failed reductions. Unless you have held a dose at least six cycles, which is time enough to drain the larger depot and establish the current one. You only gave the 8 units three cycles. And honestly, when SRT starts kicking in, as it is with Rocket, the reductions don’t generally fail. I did many back to back reductions and had them hold. Use the time in higher numbers to recharge your batteries.

    Good to see you went with 8 units, hold that dose at least six units, unless he drops again. The 10 unit depot was gone, last night was 9 that was too much.

    Not sure what you mean about SRT Wonkiness, SRT just adds a random element of needing less insulin as the tumour cells die off. After a while, I got so I could feel when another reduction was coming,

    A month ago at 13 units, today at 8. Pretty cool, if not a little crazy making.
     
    Keskat&Rocket likes this.
  13. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    Ok this helps, especially about failed reductions not really being a thing at this point when SRT is involved. I didn't realize. Thank you. It is pretty cool, and believe me, I'm so happy we're making progress. It's too bad he still tends to bounce (380s this morning?!?), because I'm really hoping his neuropathy will lessen a bit. I give him Zobaline at least once a day, more when his numbers are better (for absorption sake). He's getting around just a little better lately, but not great.

    Anyway thanks again; fingers crossed for decent numbers and a happy Rocket today. :cat:
     
  14. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    I found that after SRT, there would be a series of reductions, then they would pause for a while, then start again. Of course, each cat responds differently. There may be times when the SRT effect slows down, and you find you have reduced by too much. Just make sure you give the dose lots of time before deciding to increase. I once took too small a reduction, and saw 20’s on the meter. :eek: Caution is key. Fortunately, Rocket was still in safe numbers last night.
     
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  15. Keskat&Rocket

    Keskat&Rocket Member

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    Feb 4, 2019
    Eeek! Last question for now - I’m assuming I should reduce by half-units at this point, right?
     
  16. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    Let your intuition be your guide. It may sound flippant, but you will get an idea of what Rocket needs. There are many factors to consider. If he’s just dropping below 70, but comes up easily, a 0.5 unit reduction will work. If he drops a lot lower and you have to really work to get him into safe numbers above 50, you may choose a larger reduction. Throw in your ability to monitor as a factor, and how long since your last reduction and whether there is still a larger depot in play.
     
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  17. Keskat&Rocket

    Keskat&Rocket Member

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    Feb 4, 2019
    No, not flippant at all. :) It makes sense. Much appreciated.
     
  18. Bronx's dad

    Bronx's dad Well-Known Member

    Joined:
    Nov 30, 2016
    Rocket is looking pretty darn good! So glad he is responding quickly to the SRT. That procedure will pay for itself overtime in lower Levemir costs, and less vet visits too :)
     
  19. Keskat&Rocket

    Keskat&Rocket Member

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    Feb 4, 2019
    Thank you so much! :bighug: Rocket is keeping me on my toes, but we're pretty happy with the results so far. How is beautiful Mr. Bronx doing?
     
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  20. Bronx's dad

    Bronx's dad Well-Known Member

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    Nov 30, 2016
    That's awesome Karen! Bronx is doing pretty good. I know his days are numbered so I am spoiling him with the bad creamy and gravy fancy feasts on top of some raw. His BG #s really don't change much and he loves the bad stuff. He seldom moves fast, but when I open a can of the FF, he moves quickly! My theory with him is that since he isn't a diabetic, and now that the tumor has subsided, he can have the high-carb food just like a normal kitty? It's also easier to sneak in all the supplements with food he scoffs down. Thanks for asking!
     
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  21. JeffJ

    JeffJ Well-Known Member

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    Jul 7, 2016
    Bronx has really been a great success story, and you have done a great job taking care of him. I hope you are wrong about his numbered days.:bighug:

    Leo had the bad front elbows too. It is tough to deal with. Just like Bronx, he used to perk up quite a bit if some "special" cat food made it down to his bowl.:)

    It is also great to see the spreadsheet progress on Rocket, including the last few days.:bighug:
     
  22. Keskat&Rocket

    Keskat&Rocket Member

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    Feb 4, 2019
    Aww Paul, like Jeff, I really hope Bronx will be around for a great long time. He is a beautiful kitty and I’m happy to hear you’re spoiling him rotten. :cat: Like I’ve always said, gray kitties are the bestest kitties, and deserve allllll the treats. Give him another huge (gentle) hug from me! :bighug::bighug::bighug:
     
    Last edited: Oct 11, 2019
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  23. Keskat&Rocket

    Keskat&Rocket Member

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    Feb 4, 2019
    Thanks Jeff :) Rocket is throwing us a couple of curves again in the last 24 hrs but I’m so happy he’s doing better overall!
     
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  24. Keskat&Rocket

    Keskat&Rocket Member

    Joined:
    Feb 4, 2019
    @Wendy&Neko
    Ok... I'm back with more questions unfortunately. :rolleyes: So I've admittedly not been very good at holding doses for a good length of time, but in my defense, Rocket is doing some crazy stuff. In retrospect I think what I should've done is hold at 8U when I started with that dose on the PM cycle of 10/5, because I'm thinking now that the next couple of days were bounces with it breaking on the PM cycle of 10/8. The 9th was a beautiful day in greens, but too low post-SRT, so I did a med-chicken shot that night.

    I don't think the bigger depot is still in play; his last dose of 10U was 14 cycles ago, and even his last dose of 9U was six cycles ago. So I'm baffled.

    Anyway... detours aside, here's where I'm at this morning. We're 2.5 hours pre-AM shot, and he's at 65 (only because I've been feeding mc, even with honey at one point). Any ideas what dose I should shoot this morning (I may have to stall, I know), and where I should go from here? Rocket seems determined to head downward (which is great!) but handling the day-by-day has been really challenging for me. Thanks! :)

    Edit: PM+10 just now was 85, so he seems to be rising on his own (though still could be food-influenced).

    EDIT: ok, back to 60 !!! at one hour preshot. :nailbiting:
     
    Last edited: Oct 11, 2019
    Reason for edit: adding pm+10 info
  25. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    The good news is he isn’t bouncing very long. :D The bad news, besides me being offline, is that Rocket isn’t making it easy for you. 8 unit depot is still impacting today. I would pick either 6 or 7 units and stick with it as long as you can. No higher doses for higher preshots! Pick 6 if you need to catch up on sleep, 7 if not. Be patient, at least 6 doses, even if numbers are high, for at least six cycles. Unless he goes down again of course. I would almost be tempted to go to six units. Drain the depot, reset it at six, catch up on sleep.
     
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  26. Keskat&Rocket

    Keskat&Rocket Member

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    Feb 4, 2019
    Thanks Wendy! I gave him 6U this morning, so might be best to just stick with it then? I'm fine with that. This has been a little crazy. But I'm so grateful that the treatment is working!

    Now... hopefully Rocket will still want to eat when I take away all his carby fun foods. :cat:
    Edit: forgot to add that his last test was 107 - I'm sure still influenced by carbs, etc. so I'll keep checking. But I feel a little better now. :)
    2nd Edit: I'm a little wary of dosing too high tonight... you think 6U is low enough considering how today is going? I've really had to steer with carbs.
     
    Last edited: Oct 11, 2019
  27. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Feb 28, 2012
    You have a couple options, but it really depends on PMPS. If he’s on his way up 6 should be good. But if you need to sleep, try a half dose, 3-4 units tonight to help get rid of the depot from the higher doses, then resume with 6 tomorrow.
     
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  28. Keskat&Rocket

    Keskat&Rocket Member

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    Feb 4, 2019
    I was surprised to see a 117 after our evening sit-about (AM+8). He was at 165 earlier and I thought he was done for the day. Lil guy is full of surprises! Depending on the PMPS then... I might do a depot drainer like you said. Might help him be a little more stable for the next few days. But, if he shoots up to 340 or something (he's done it before :rolleyes:); I might stick with 6. Thanks! :)
     

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