Tigger 3/1 AMPS 450

All is well this morning, Tigger is feeling good. I dropped his dose just a tad to see if we can even out the high PS numbers. I didn't get a lot of checks in this weekend, but I should be able to today. If anyone has any input, that would be great!

 

MD, you and Tigger, and me and Puttz started ProZinc within a couple of days of each other, and I am yo-yoing at the two week mark, also...I am just starting to see some progress, I am sure you will be right behind us in the next few days...Hang in there, your numbers are not all that bad considering we made an insulin switch and are trying to figure out the workings of it...Stay patient, it has been a haul for me, too...

 

This is a new insulin and we are doing our best. It will take time and lots of testing. But we will get it.

 

Hmmm, I was hoping you'd see better #s on this dose, darn it! I hate it when my advice doesn't produce results!!! :evil:

Will you have a chance to get any spot tests in today? With PSs like that, it's so hard to know if you are seeing good action but it's just pooping out by +12, or if you are shooting water. Sometimes insulin can be so frustrating!!!!

[ETA: just noticed you already said you are getting spot checks in today... perfect! I will try to check back later to see how the mystery unfolds! }

 

I'm not usually big on giving a dose and holing it for many cycles but your guys's case it seems like you have high cycles followed by cycles with some bigger drops. It would be interesting to see if .9u has any effect over four cycles. And the .8u I just don't know about since it was only 1 [not so wonderful] cycle.

Sorry if I asked this one before but is Tigger in indoor only cat?

 

Yes Gator he is indoor only. So far I have gotten spot checks at +3- 171, and +6- 310, he's had wet food out all day that he has grazed on. We'll see how the rest of the day goes.

 

439 at +9?? This crazy cat is driving momma crazy! Lol

 

You took the words right out of my mouth. A few days ago we went from 173 to 517 in 2 hours. My eyes crossed and I retook with the other monitor (which just showed "HIGH".) A few days later we're seeing better numbers. Very frustrating! Hang in there Momma!

 

Well... you have a drop from 450 to 171 in something less than 3 hours, possibly could have been all within one hour (has anyone pinpointed any onset data for ProZ?). So that could trigger rebound, which might explain the jump back up. Although it's a steep drop, I don't think it's too much in terms of % drop. So in my eyes this could be a good dose in terms of getting insulin action, but either it is triggering rebound, or you aren't getting good enough duration, or some combo of the two.

To some extent you may just have to try some things and keep collecting data to see what works. That +3 test that you got is invaluable, because without that one would just think high #s all cycle long, so seeing that really changes the picture (yay! I always love a blue #!). But it's still hard for me to know for sure what you should do. :? It could be that Tigger nadirs on the early side and you aren't getting good duration (I don't think so, because when you look at the data from when you started on PZIR he looks to have decent duration). Or it could be the dose is too high and that is what is causing the steep early drop and then it's triggering rebound. Or it could be that at some point you will have to raise the dose back up and shoot through the rebound and force the #s to stay low. Not much help am I? ohmygod_smile Hopefully others will see it with more clarity than I do.

 

Joanna, I have not pinpointed anything as far as onset - mainly out of laziness and that things started to shape up well for us. And if you read that study about PZI Vet to ProZinc it kind of talks about nadir moving from day 0 to day 45 and I think that onset can move around too. And it depends if the dose was too much or too little. But I know you are speaking more of an average of perfect curves and I certainly don't have the data on that. But, with the little data I have, we've seemed to have anything from +2 to +5 as onset.

For Tigger,
One approach to rebound is the back off on the dose by 50%. So assuming you were having rebound at 1u then that would be back down to 0.5u. However, I'm just giving this as an example to maybe encourage you to try different lower doses. Right now you are kind of working at it backwards from high doses to low doses which is 100% fine. So you know you get action on 0.9u. This action might be too much action or not enough duration action on 0.9u. So you can hold the 0.9u and keep gathering data at that dose or you could head down to 0.8u and gather data at that level. However, it seems that you are needing to keep a dose for a number of cycles before you are getting much of a picture on how Tigger gets along with it. You're doing well getting data so just keep this up. And as Joanna alluded to capturing that +3 area is important the +6 is important too. I think definitively ruling out lower doses is the only way you are going to know what is too low of a dose. At 1.0 and 0.9u you have been shown to have some good if maybe even too good action so....

The confusing part is that on 2/23 1.5u you had a good looking curve then on 2/24 you have a really big drop with seemingly no rebound. Maybe the liver just had no more defenses left on 2/24 and just submitted? But it those big type drops that are a little scary too.

As we were discussing I think in the Meatball instance the rising the dose and trying to shoot though the rebound is the more aggressive approach and the exploring lower doses is the safer approach. You guys are not shooting as much as Meatball is getting though so perhaps less "danger" in moving up.

Anyway, I'd be inclined to try the lower end of the spectrum first. Looking at 2/27 and 3/1 it looks like you are getting early fast drops and that can be a sign of too much insulin.

 

I'm inclined to agree with Gator on experimenting a bit with slightly lower doses. I didn't really want to say that since I have been overly cautious at times with Bix on reducing the dose, so I didn't want to put my bias (play it safe, and rule out rebound, and then raise the dose more confidently if it's ruled out) on you in case I was being overly conservative. But I'm happy to second the idea.

As for holding the dose a few cycles, I see merit in it for dose increases, but not as much for dose decreases. If you decrease and can see in the 1st cycle it is too little, no point in holding there for longer (unless you are waiting for rebound to clear or something like that). If it appears to be too much, for safety I think you have to decrease, although it is possible that in a few cycles when overlap wears off if would be the right dose, but I couldn't in good conscience advise someone to hold a dose that is clearly too high on that basis.

With dose increases I found the overlap can build up nicely and give you a dramatic improvement around cycle 3 or 4. With Bix it was fairly predictable once I had enough data. With him, I learned to basically ignore the results I got in cycles 1 & 2 on a higher dose, and look to cycles 3 & 4 for good data. But ECID, and Bix got good duration on PZI, so overlap was always a key factor for him in how he would respond. If a cat isn't getting good overlap, it's probably academic as I doubt you'd see much improvement at cycle 3 or 4 without that.

As for onset, I was curious in terms of calculating how fast that drop by +3 happened. If PZIR onsets at +1 then it's not so steep, but if it doesn't kick in til +2.5 say.... well then, yowza! I never could figure it out for Bix, as he would get an earlier drop with good overlap vs. not, so it was hard for me to sift through the different factors and identify it. I hadn't read the study, that's interesting about the data points moving around in the first 45 days. Weird.

Thanks Gator for clarifying things - I agree there is a more aggressive approach one could take, or the more cautious one. I tend to err on the side of caution as long as you don't have anything like ketones in the picture. With Bix, I ended up going back to the highest dose that I felt 99% sure was not causing rebound, and then working back up from there. It probably wasn't the quickest way to get him regulated, but it worked, and stopped me from going around in circles on what to do with the dose.

[ETA: On 2/23 & 2/24 with the 1.5 my guess would be that was shooting through rebound. I'm thinking the reason it stayed a U-curve towards the end of the cycle is because the dose was high enough to cancel out the rebound going on. That could be why the next cycle was all reds on the 0.8 - just not enough insulin to even touch the rebound left over from the last cycle. Not 100% sure, but that's what looks like a possible explanation to me.]

 

Joanna, I completely understand what you are saying about not waiting on decreases but in this case since things are a little strange and Tigger might have had going on what you explained with the last dose of 0.8u, that's why I was suggesting to wait it out on the dose lowering. If Tigger is having rebound it is my assumption that it *might* take up to a cycle or two for things to stabilize enough to get any kind of feel as to what is going on with the lowered dose. So by the time one has the dose change cycle and maybe a rebound cycle and a couple cycles at night when the data is sparse then you are at about four cycles.

Anyway, that just my thinking [as we've seen here today, depending on your perspective I might be a little crazy - so user beware of my thinking :smile: ]

 

Well, we ended the day with a PMPS of 425. My .9 I was giving was an eyeballed dose with a U40 syringe. I used a U100 and shot an actual .8 tonight, so we will see how he does. I'll get a couple of early checks to see when he starts going down. Thanks for all the help, I don't know what I would do without these boards!

 

Not at all Gator, I totally agree with you. I tried to edit my post b/c I realized I contradicted myself and made no sense ohmygod_smile but my internet is molasses at the moment and I got sick of trying. I figured I could sneak by & no one could catch me, lol! I was actually commenting on the dose holding b/c you wrote somewhere that you aren't always a fan of holding doses, so I wanted to explain where I've found it useful. What I meant was if you have a nice pretty U-curve on a lower dose and no suspicion of rebound in the picture, but still higher #s, then there's no need to hold it and let it settle for a few days IMO. Academic, since that's not the picture here anyhow.

Not to say that you AREN'T a little crazy, lol!!! :lol:

 

Yes we are dealing with some very fine gradients, this makes me suspicious of the 0.9u. Also, just switching back and forth between the syringes can cause substantially "larger" changes in dose. Sooooooo. We'll just kind of look to the 0.8u on the U-100s and see how that goes for a little. Who knows, you may even want to try to 0.9u again on the U-100s at some point.

Is this like trying on shoes or what?

 

LOL, I like shoes a lot more than this!

 

Already dropped to 282 at +1, 200 +2

 

Wow - I've never seen a drop at +1, but then I guess I haven't seen all that many +1 spot checks along the way. Either you've got some crazy-early onset, or........ the 0.9u was too high and you are seeing the late-drop effect, or rebound clearing, or something along those lines. Either way, I'm really glad you dropped the dose! Nice to have what looks like confirmation that was the right move.

This could be a sign that even the 0.8u is too high, assuming the reading is correct. When Bix was at the right dose (Idexx though, not PZIR, though I would figure it should be similar), he would run flattish for the first couple hours of the cycle. Zooming a lot higher = dose not enough, dropping earlier = dose too high. But ECID, so we'll see.

[Almost 150 pts in 1 hour may trigger rebound. Hopefully not, but if you see high #s again in the +6-+9 range, I'd guess that's why. Thinking you might want to try 0.6u in the morning...?]

 

ohmygod_smile Wow, I'm an idiot lol! I just caught Tigger munching out of the dog food sack! I don't know why I didn't think he would get into it. Maybe that has been the problem with his numbers. Going to have to get a plastic tub with a lid to put that in from now on.

 

LOL!!! Whooo! An indoor only... dog food kibble eater! We'll lets hope that brings some fixes!! This could be a good turn of events.

 

LOL! Sneaky little bugger, eh?