Smiffy's numbers - need opinion

http://www.felinediabetes.com/FDMB/threads/smiffy-autumn-progress.165580/#post-1811777

@MrWorfMen's Mom @manxcat419


The link above is to Smiffy's main thread where I update her progress every now and then.

However, she is showing a change in her numbers and the dose that she needs eg in the evening I used to hesitate to dose her at all on a number much lower than 10 (180) but now I can be confident to dose her at least one unit and her number will not come down much.

She does seem to have got herself into a pattern of coming down nicely in the day time but heading higher from her PM shot time even on the same dose. The question is whether she's dropping low very early in the PM cycle (have tested her a few times at +2 in the evening) and bouncing or whether she does just run higher at night and might need a slightly bigger dose then. It's a bit odd because when I give her one unit in the mornings, she pretty consistently drops a good number of points, but the same dose at night seems to send her higher - I wonder if someone on the here might have the answer to this for me?

Just from looking at the numbers, it almost looks as though I could be giving her 1.5 units even on a fairly low number at PMPS, but my concern with that is that if it is some sort of bounce or Somogyi, it wouldn't be safe....

My instinct is not to give her 1.5 units on a number around (just less or above) 10 (180).

 

1,5 might be a little bit too much. Why not try to sneak up on the ideal dose by tiny increases, like a fat 1unit for a few cycles, then you could go up to 1,25 and so on. I hope that could help.

 

I can only dose in 0.5 units with the Vetpen but thank you for the suggestion

 

Lucille, when one looks at Smiffy's spreadsheet, it may seem that she is getting pretty good staying power with the AM doses of insulin and that is giving you a lower PMPS. But that perception can be totally wrong because too much insulin can sometime look like too little. The problem is that those lower PMPS readings may be a combination of Smiffy coming down off a night cycle bounce as well as the higher dose of insulin she's been getting during the day cycle.

When you shoot 1u of insulin at those lower PMPS readings, given the quick onset of Caninsulin, Smiffy's body may be panicking and putting out glucagon to ensure her numbers do not sink too low. If you could give her 0.75u for example instead of 1u with readings below 10, she might level out more, and not pump out glucagon so she's end up with a lower AMPS. That in turn would result in lower doses on the day cycle too. Many cats tend to go lower overnight so while it looks like Smiffy is not reacting to the Caninsulin with +2 and +3 readings higher than PMPS, that looks to me like it's a result of the dosing causing her to bounce. Then of course her higher AMPS makes you give her a larger dose the next day to counteract the bounce creating a perpetual circle that needs to be remedied.

The only way to prove that theory would be to get more PM tests to see exactly what she is doing on the night cycles along with working on being able to make dose changes of a quarter unit rather than halves as that can make a substantial difference.

I know this isn't what you want to hear Lucille, but if you keep doing the same thing over and over and it isn't working, then you have to change something to get the change you desire and in this case, it looks to me like being able to increase and decrease by less than half units is the key to getting Smiffy to level out.

 

I will cut and paste all that you have said and send it to Roberta so thank you.

I need a while for that information to sink in.

Thank you

PS I do understand and I am surprised that quarter units could make that much difference to break a cycle of bouncing so I will, as I say, have to relay all this to Roberta.

I've started a message to Roberta

 

In any cat on relatively small doses the difference of a quarter unit can have a significant effect (and not only with regard to bouncing).
This is why some very kind people have been encouraging you, tirelessly, to learn to use syringes.
The bottom line is, using syringes will give you far greater flexibility with regard to varying your doses by smaller amounts. And that could enable you to help your cat to achieve better control of her BG numbers.
If you want better control over your cat's numbers I strongly suggest that you learn to use syringes.
If you elect to not use syringes then, obviously, that may affect what you're able to achieve.
.

 

Will try lower doses for the next few days and see what happens.

Thank you Linda

 

I have some vision problems in my old age, and I have found that extra strong reading glasses that I buy at the $ store really help me get more exact doses. I sure hope you can try syringes. Try to get ones that have one half markings. With one half markings, you can get quarter unit doses by going between the lines.

 

It's so funny you should say that! I bought some +4 reading glasses from Amazon to help me see what I am doing too

 

"syinbe"?
.

 

@MrWorfMen's Mom @manxcat419

So in the absence of syringes at the moment, I am going to try the lower dosing strategy as of tonight to see if Smiffy is bouncing from me dosing her too high.

Tonight she is 9.4 (170) so instead of giving her one unit as I would do recently on that number I am going to give her just half a unit and test her at +2 and +3 if I can to see what happens.

I have recorded on her spreadsheet in the notes that this is what I am doing.

Let's see what happens tonight and over the next few days with this strategy.

Oooh she is a little tinker ..... I fed her and then she went under the big chair downstairs and I had to drag her out to give her her shot .... she doesn't make things easy for me!

Now she is upstairs in one of our two tiny bedrooms (my room) where there is no central light and I have to take a torch up to test her ..... she keeps me on my toes!

 

Funny story for you Looby. When Rosa was first on insulin, I bought the 1 unit marked syringes (on my way home from the vet with a new diagnosis and no idea that there were even options with syringes). At the time, with a little practice, I was able to see even tiny doses. I bought some half unit marked syringes, but when I ran out of those not so long before Rosa went OTJ, I went back to the 1 unit marked ones I still had left over. And I could even measure a 0.1u dose with them although it sometimes took a little squinting first thing in the morning when I'd only just woken up. Well, something's changed in the last year and a half and now I struggle to even measure 0.25u increments for Roxi using half unit marked syringes! Apparently these cats are ageing me!! I'd probably not have noticed that I might need reading glasses for another couple of years yet if it wasn't for measuring insulin doses.

 

It will be interesting to see if that makes any difference over the next few days. Is there any way for you to get another night cycle reading later in the night cycle like around +8/+9. All readings add a bit to the puzzle.

 

Well I tested Smiffy at +2 tonight (after her reading of 9.4 (170) preshot and giving her a reduced dose of half a unit) and she has already gone up to 12.7 (229) and she hardly ate anything so not a food spike.

But I will see what happens tomorrow morning.

 

+8/+9 would be 6am and 7am so no is unfortunately the answer to that I'm afraid! Just done a +2 as you can see but she is rested up for the night under the big chair in the middle of our little house from where I had to drag her out for her shot hissing and lashing out! Managed to entice her out with a treat (freeze-dried chicken 100% protein treat) but can't do that every hour .... will try to get her out for a +4.

You know it feels like I can't win .... a few weeks ago I was told to dose more aggressively so I did and now I am being told to reduce the dose ..... but I will see what happens over the next few days ... I am not complaining just bewildered! I hope this strategy will get some good results

 

Unfortunately, that is just the nature of the dance Looby - cats like to keep us beans guessing by going up and down the dosing scale. And sometimes there's a little guesswork involved in deciding whether they really want to go up or down that scale too! But you will get there - the next day or so should tell you if reducing the dose is the right thing to do for Smiffy. And if in doubt, it's safer to try the smaller dose first before assuming you need to increase - less chance of seeing a hypo that way even if it does turn out that you have to increase later on.

 

Lucille, just to illustrate what April said, I had to increase my girl's insulin dose a couple of times in the last two weeks after it being pretty stable for a few months. Then last night she earned a reduction and tonight I am holding a PJ party for a few hours because she dropped into hypo warning numbers from a mid teen reading at +6.5 post shot. Our kitties are ever changing biologic beings. That's why we test.... to ensure it's safe to give insulin and to see how kitty is reacting to it everyday. If we could expect exactly the same readings/result everyday on the same dose of insulin, testing wouldn't be so important if needed at all. Insulin is a hormone not a medicine. It is the key to a chain of other biological activities in the body so while it's effects may be very similar from day to day, it's never exactly the same. Sometimes the differences are subtle and other times they can be dramatic.

I agree it can be confusing when you get told to be more aggressive and then to back off on the dose but the steps to this sugar dance are different for each kitty and change from time to time for each and every one of them. As caregivers, we are always challenged to learn the new steps our unique kitties decide to do from day to day.

 

Caregivers aren't "told" what to do here with regard to insulin dosage. There is nobody here who has the authority to do that.

Members here may make suggestions based on what they think might help the situation. And those suggestions may vary. It is for the caregiver to weigh up any suggestions and then take whatever course of action they think best. Ultimately, "the caregiver holds the syringe". (Or in your case, the vetpen... ).
(Note: The only time people may be told emphatically that their dose needs to change is when it is clear that it is dangerously high.)

If managing feline diabetes was a really easy thing to do there would probably be no need for a forum like this one. And some of us would have a lot more time to have fun, or adventures, or to sit on a beach sipping 'pina coladas'. But learning to manage feline diabetes isn't like learning to mix a cocktail. You're not going to find that 'perfect recipe', the one that always comes out exactly as you want it to, every time....

As April says regarding changing numbers/dosage, "that is just the nature of the dance".
BG numbers and patterns can change a lot over time. And when the situation changes we may need to change our dosing strategy too. Managing FD is not referred to as a 'dance' for nothing: The music changes, and the steps have to change accordingly. That's just how it is.

Most caregivers do learn how to adapt to the changes. I wouldn't want any newcomers reading this to feel that they will have to depend on this forum for advice for the duration of their cat's life (although they certainly can if they want to).
There is quite a bit to learn at the beginning. But as the caregiver gains in experience and confidence they naturally also feel more able to make their own decisions. And for many that sense of self-reliance and independence is a good feeling.

.

 

Well Smiffy is only 12.1 (218) this morning so I think Linda (@MrWorfMen's Mom and @manxcat419 ) the lower dose worked

I will only give her one unit this morning once I have made sure she has eaten her breakfast and see if she can hold a good number all day today

 

Dear Linda (@MrWorfMen's Mom ) and dear friend April (@manxcat419 ),

I am sure that neither of you took my use of the word "told" in the context that I only ever do what you and other members tell me to do. I was talking to you in colloquial language and as if to say "oh my goodness this sugar dance can change from one moment to the next". I was also extremely tired last night when I posted

I have, as you both know, been dosing Smiffy based on my own experience and data for some time now and completely independently from advice here on the Board. I posted this thread because I was concerned that Smiffy's numbers/dosing were increasing and am very grateful to you Linda for pointing out that I could in fact gain control and lower numbers back again by reducing her dose.

I appologize to anybody (especially new members) here who might have taken the word "told" in the wrong context and as meaning that we have to seek 'for ever advice' on dosing.

I didn't intend to use the word "told" in any way negatively. I hope that clarifies any misunderstanding

The most important thing is that I think you are probably right with your advice Linda and Smiffy is going to benefit from it

 

Lucille, I'm glad to see the slightly lower AMPS this morning and yes that might be from the dose decrease but it will take a few days for Smiffy to settle into the new dosing before you see the full results of giving the lower dose. Then you'll need to re-evaluate whether that change has met your expectations or more dose finessing is needed to reach your goal. And I think that too is something you need to be clear on. What exactly are you aiming for? Do you want Smiffy regulated and getting decent though not perfect numbers or do you want to see if you can get her into remission? Obviously the latter is not a guarantee for anyone and it takes a lot of commitment and some intense monitoring. Either goal is perfectly fine but knowing what you are aiming for makes it easier for you to make decisions and for your helpers to make suggestions when asked.

 

Thank you Linda,

She crept up to 13.7 by +4 so early days yet I think as you say.

For the moment, I would be happy to see Smiffy as she was a few weeks ago with numbers consistently below her renal threshold (which seems to be about 13 (235)) and where she 'surfs' around the 10 (180) mark (mostly below) it ie regulated with mostly 'blue' numbers.

Each time I do her urine test, she is negative for ketones and glucose and all her clinical signs are good as well as her personality and behaviour as she was before she was ill.

I just wanted to say that I was aware of her bouncing at night and through to the morning but it didn't occur to me to reduce her dose in order to get her good numbers back.

I had been dosing her more aggressively as suggested by members here which gave me good results for a while but then her numbers started to increase again.

This is where my learning curve is here. Even after 6 months one can learn new things about ones own cat and how to adjust doses for them.

I posted because I was concerned that her numbers were getting too high again and it puzzled me how we had got to that.

I tested her at +2 some evenings to try to find out if she was going very low and then bouncing back up but that didn't seem to be the case. Perhaps she went very low before +2.

I didn't realise that bouncing could push up her numbers to the extent that we would get into a viscious cycle of dosing higher to get numbers down but it having the opposite effect.

I am optimistic that this strategy will over the next few days get Smiffy's numbers down.

So, I would like to see Smiffy regulated as she was a few weeks ago and where she was even showing possible signs of pancreas activity and so when, for her, she was spending some of her time at healing numbers. Then as I get better in myself, I would like to aim for remission.

I am going through a very difficult stage of my own rehabilitation which I know must be very difficult for you all to imagine but it is very hard and it has its limitations which I don't really want to go into here.

But I have managed to get Smiffy well so I am proud of that and I always want and need to surround myself with positivity and kindness as I believe that I show to others.

You Linda, April and Alexi and all of Smiffy's regular followers on the FDMB are helping me a great deal in this way.

I may not always be able to express myself as well as I would like as my recovery is very tiring.

So, back to Smiffy and she is well and that is what I am hoping for her. I am so pleased to see her playing and purring and being cheeky and difficult and affectionate and chasing off cats again She and Pasha mean the world to me

Let's see what happens over the nest few days and see if the lower dosing will get her down into the below or just over 10s (180s)

 

Looby, I'm so glad to see you got a better number from Smiffy this morning. Hopefully this will be the start of a run of better numbers for her on both the AM and PM cycles though, as Linda says, any dose adjustment takes time to show what it can really do as Smiffy has to adjust to the changing dose before you can see the full effect. I know it's confusing - you see higher numbers, but then people suggest that you might need a lower dose to control them, not a higher one - sometimes the help that's offered feels counter-intuitive. But the thing to remember with dosing is that, as long as you don't give a dangerously high dose, any of the changes you make can be reversed if they don't seem to be working after a few days. It is very difficult when you're not well yourself - I'm sure a lot of people in your position would have found it too difficult to persevere with Smiffy's diabetes treatment as well as your own recovery and yet you are managing both and that is something to be proud of. And never forget - things will get easier as you feel better in yourself and as you gain more experience of the nuances of FD. And you will get Smiffy's better numbers back, even if it takes a little trial and error with the dose to get there.

 

Thank you April

I know that you understand and it is warming and positive to have your support and encouragement

My priority as always is to keep Smiffy well and safe and sometimes I still need a bit of help in doing that.

I have a feeling she is going to settle down to some better numbers soon now that I am understanding a bit better how to deal with this bouncing and I am really appreciative of you and the others being there for me with your advice

 

Same day Sunday 30th and Smiffy is now 16.6 (299) at +7 which is the highest she has ever been at this time of the day since she was diagnosed.

@MrWorfMen's Mom @manxcat419 if she is still this high or higher at PMPS I am not sure what dose I will give her. I didn't leave any food out for her today either to try to keep her number down .... she has only had a third of a sachet of wet since her breakfast.

 

Not quite the result you were hoping for Looby. Unfortunately, I don't know enough about Caninsulin to offer anything for tonight's dosing. The only thing I do wonder about is that, as her numbers seem to have reversed today...she gave you a lower AMPS this morning, but has gone up quite dramatically since then...whether maybe reducing this morning's shot to a half might have helped? I'm not suggesting you should try that without input from others as I just don't know - it just seems a little odd that the bigger dose this morning has sent her higher again later in the cycle.

 

I would try to hold the dose for the next few cycles, although the number is higher than you are used to her body may be rebelling at the lack of grazing she is used to, she may well be hungrier at PMPS time which might help with the challenge she gives you about her food. We all get wonky numbers from time to time, I think trying to get her adjusted to not having food there through the day will help with your dilemmas about how much to give at shot time.

 

Sunday 30th still and Smiffy's PMPS is down to 10.4 (187) so I am very pleased with that and will go ahead happily with the plan to give her just half a unit

 

I understand everything you are saying. The only things is that if she has not eaten much for her breakfast, I just leave a small amount for to eat if she goes too low as, as you know, I am not around for her daytime Nadir or should I say until +4. Also I have Pasha to think of who is also used to grazing. I took the food away from them last night after they had eaten and poor Pasha was crying out for food this morning she was so hungry.

However, I think they can both get used to a new regime and realize sooner or later that there they need to have a proper breakfast and tea and not expect to be able to eat again in between times.

Pasha is tiny but eats more than Smiffy as she is much more active so at +4 during the day, when I put out wet food, Pasha will eat a full sachet and Smiffy will eat about a third.

Just so that you all understand both their eating habits.

Thanks Alexi, I will persist with the lower dosing and try to get the two of them used to not grazing between meal time and +4 which is when I usually take away what is left of their two main meals

Now to get Smiffy out from under the chair by means of a treat to give her her shot!

 

Had to move all the furniture to get Smiffy from under the chair to give her her shot - wouldn't go for the treat and now she is upset and hissed at me. I want to test her again at +2 but I have a feeling she will just come down and sit under the chair again. Really the only way I can get her out is to prod her and thus upset her. This is her latest tactic to get out of having a shot or being tested ..... told you she was a tinker!