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Info Tight Regulation & SLGS: Myths Debunked

Discussion in 'Lantus / Basaglar (glargine) and Levemir (detemir)' started by Libby and Lucy, Jan 1, 2014.

  1. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    A discussion in a condo today made me realize that there are many misunderstandings about the Tight Regulation Protocol, its history, and what the modifications mean. So we can keep our history alive, I wanted to start a thread where we can address some of the questions that often arise.

    Here are some examples from today (names removed).

    To clarify, there is ONE Tight Regulation Protocol for Lantus and Levemir. In LL, we have made some modifications over time, as have others, but it is all the same protocol. To further clarify for those who don't know, Kirsten (Tilly's caregiver) is the Roomp in Roomp/Rand.

    • Actually the order is:
    • 1) German Protocol - started in the early 2000's, and slight revisions have been made over the years by the German laypersons who created the protocol. We have made some of our own modifications too. Here is the spreadsheet of what was probably the first FDMB cat to use the German TR protocol in 2006: George.
    • 2) Rand protocol(s) - Dr. Rand has published a couple of protocols over the years, mid 2000's. Now Rand's previous protocols are gone and replaced by
    • 3) Roomp/Rand Protocol - a collaboration between members of the German Diabetes-Katzen forum and Dr. Rand, recently published in 2009 but was already in use before then.

    Slightly OT, but a pet peeve of mine that I see ALL the time on FDMB - there is no "Tilly Protocol." Tilly was a cat, not a protocol.:lol: Kirsten's page is not called the Tilly Protocol, it is called Protocol: Tight Regulation with Lantus or Levemir for Diabetic Cats.

    In LL, some tweaks have been made over the past 6-7 years, mostly by Jill & Alex and jojo and bunny(GA) and Y but it is an ongoing effort. These tweaks are based on what we have found to work best for the majority of cats on this board - hundreds of them! For the most part, we are more aggressive than what is written down in the original protocol. We can be more aggressive because we are testing more than the published protocol (which is published for vets).

    Not quite true. The other versions DO account for bouncing, they just don't say it that way.

    For example:

    What this says is:

    Nadirs under 200: hold doses for 5-7 days. Why? Day 1 & 2 - may see higher numbers due to "New Dose Wonkiness," Day 3 - this would probably be the day to see a lower nadir, if there is going to be one, Day 4-6 could be bouncing. If good numbers don't return, increase the dose. Use your own data to determine how long to wait before deciding the good numbers won't be returning.

    Nadirs over 200: who cares if there is bouncing, cat needs more insulin, increase after 2-3 days.

    Actually what Kirsten says is this:

    Basically this says "you can try these things, they might work, but in most cats they don't work as well as consistent dosing." Our Dealing With Low Numbers sticky is basically saying the same thing - the idea is that you need to learn to shoot consistently, but if you are not ready to do that, then you can stall based on our guidelines. You will probably find that stalling doesn't work, but most people need to see for themselves that shooting on time works better than the alternatives.

    This isn't really a difference either. Kirsten notes: "(N.B. there are some cats that do well with BGs >=40 mg/dl and are difficult to regulate unless the dose is held at BGs in this range, but a cautious approach should be used until you are sure your cat reacts this way)." We have observed and made note of what cats usually fall into the category of cats who might do better when allowed to go below 50: long term diabetics.

    One of the main things that *is* different in LL practice versus the written protocols is the concept of shaving doses instead of reducing by 0.25-0.50u. We try to reserve that practice for cats who have shown that full reductions don't hold for them because it is very aggressive.
     
  2. Michelle and Mannie (GA)

    Michelle and Mannie (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    Excellent - thanks for posting this. I hope it will clarify things for folks.
     
  3. Caryl & Sebastian & Alex (GA)

    Caryl & Sebastian & Alex (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    Thanks, Libby :razz:
     
  4. Hillary & Maui (GA)

    Hillary & Maui (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    I'm bookmarking this post. Thanks for the information. Helps to clarify things even for an old timer like me!
     
  5. Angela & Blackie & 3 Others

    Angela & Blackie & 3 Others Well-Known Member

    Joined:
    Mar 15, 2010
    Re: Tight Regulation Protocols: Myths Debunked

    Thank you, Libby. :D
     
  6. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    Here’s another misconception I have seen floating around LL from time to time:

    “Don’t Shoot a Dropping Number”

    I LOVE when I have an opportunity to shoot a dropping number! It’s a great way to take advantage of the overlap provided by Lantus and Levemir. Low or dropping preshots are a GIFT that helps us move our cats closer to tight regulation. This is a Tight Regulation forum, so grab it!

    Remember, you are not shooting the number your cat is at now. You are shooting the number he will be at hours from now, when the insulin kicks in. You have probably noticed that once your cat starts to rise, he/she can rise very quickly. If you shoot, you will also be feeding, which can also contribute to the rise. If you wait for the rise to start before shooting, you might be behind before you even get started. When you have an opportunity to get the insulin in before the rise starts, rejoice and SHOOOOOOT!!! Feed as usual and monitor the beginning of the cycle. Feed strategically in the first couple of hours if you need to prop him up until the rise begins. He will still rise, but probably not as fast or as far because the insulin will be there before he needs it.

    We do have guidelines for “Shooting Low Numbers,” but those guidelines are primarily an educational tool to help caregivers learn to shoot low. Once you know your cat’s response to food and insulin, then usually you will have the best results from shooting at +12, whether the number is high, low, rising, falling, whatever. Of course, common sense applies. 30s are not shootable, and 40s are not shootable unless you have TONS of data to show that it is ok for your cat (if you are wondering if that is you, it is not. ;-) Almost nobody should be shooting 40s and if you are in that category then you already know it). You do not want to shoot if there is any reason to believe you will not be able to keep your cat safe.

    These insulins are not at their best when we ask them to pull down high numbers. They are GREAT at grabbing onto lower numbers and holding them flat. SHOOOOOOOOT!!!
     
  7. Doug N Libby

    Doug N Libby Well-Known Member

    Joined:
    Jan 2, 2012
    Re: Tight Regulation Protocols: Myths Debunked

    Thanks, Libby. I know that 'shooting a falling number' was a hard concept for me to grasp coming from ProZinc.

    Thanks for the refresher and for all you do for us -

    Libby (& Hershey, too!)
     
  8. Ella & Rusty & Stu(GA)

    Ella & Rusty & Stu(GA) Well-Known Member

    Joined:
    Jan 11, 2010
    Re: Tight Regulation Protocols: Myths Debunked

    THANK YOU, Libby!!

    Ella & Rusty
     
  9. Re: Tight Regulation Protocols: Myths Debunked

    Bump
     
  10. tortie58

    tortie58 Well-Known Member

    Joined:
    Jan 3, 2012
    Re: Tight Regulation Protocols: Myths Debunked

    Thanks Libby for the clarification!
     
  11. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    bumpity-bump!
     
  12. Linda and Scooter & Jack

    Linda and Scooter & Jack Well-Known Member

    Joined:
    Nov 9, 2012
    Re: Tight Regulation Protocols: Myths Debunked

    Thank you Libby!

    I needed to read this today!

    Linda
     
  13. Cleo & Jane (GA)

    Cleo & Jane (GA) Well-Known Member

    Joined:
    Apr 6, 2013
    Re: Tight Regulation Protocols: Myths Debunked

    What great info! Thanks Libby!
     
  14. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    Bump.
     
  15. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    bump

    RE: TR Protocol

    fwiw, i've always found the explanation and guidelines of the TR Protocol on Kirsten's website the easiest to follow/understand: http://www.tillydiabetes.net/en_6_protocol2.htm. I'm so glad Kirsten took the time to write out the TR Protocol in that format versus in the form of a chart used when Roomp and Rand had the protocol published.

    interestingly enough, the "modified" version many in LL have used successfully is based off of the TR protocol developed by Kirsten and members of the German-Katzen Forum.
     
  16. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    Bump.

    I prefer Kirsten's page over the published protocol too. I like the say she explains things, so you can see where the guidelines came from.
     
  17. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    Re: Tight Regulation Protocols: Myths Debunked

    Let's talk about bouncing.

    Myth: "Don't Increase the Dose During a Bounce"

    This doesn't mean don't ever increase during ANY bounce!

    People quote this part of the protocol all the time without understanding where these guidelines came from. Did you know that we have already allowed time for bouncing in these timelines?

    What this says is:

    Nadirs under 200: hold doses for 5-7 days. Why?
    • Day 3 - this would probably be the day to see a lower nadir, if there is going to be one.
    • Day 4-6 could be bouncing. If good numbers don't return, increase the dose. Use your own data to determine how long to wait before deciding the good numbers won't be returning.

    Nadirs over 200: who cares if there is bouncing, cat needs more insulin, increase after 2-3 days.

    The way we have spelled it out in our modified protocol is pretty clear:

    The reason we are holding doses for 8-10 cycles when a cat is new to blue, and again when they are new to green, is because we want to see if this current dose might be the one that causes a breakthrough.

    Let's say your cat hits a nadir of 80 then he bounces. 80 isn't bad, let's see if he can do it again. Hold the dose until that bounce clears, usually 2-3 days. If the bounce clears and he hits a nadir of 80 again, great! That's a good nadir for now, let's see if he can do it again. I would hold the dose again and see what happens. If that bounce clears and his nadir is, for example, 110, then 110 is ok but could be better. There's really no reason to wait around (we are looking for Tight Regulation, after all). If this dose isn't getting him back to good nadirs after a total of 8-10 cycles, it's time for the next dose. There are some cats who might need a couple of extra cycles, but for the most part if a dose isn't working then there is no reason to hold it longer than 8-10 cycles. If the dose IS working, then hold it as long as you can!

    One other note:

    Every high number is not a bounce! Numbers go down, numbers go up. Often I see people comment that their cat is bouncing, when really they are just seeing the natural rise at the end of the cycle or a food spike. Other times I see people whose cats are stuck (really stuck) in a high pattern who think it's a bounce. If your cat has been in pretty good numbers for a while, then suddenly loses regulation, don't hold the dose, get the regulation back! If they are used to good numbers, it is much, much easier to get the good numbers back if you do it quickly.
     
  18. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Bump for newbies and oldbies as well as those offering advice! :mrgreen:

    There's some really good information here for members whose goal is a tightly regulated kitty.
    Please read carefully.
     
    jayla-n-Drevon likes this.
  19. lovey11

    lovey11 Well-Known Member

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    Aug 6, 2013
    Thanks for the refresher course. Helpful. Have a good day Libby
     
  20. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Another myth floating around the FDMB...

    One can't follow a Tight Regulation Protocol if they hold a full time job.
    One must be home and chained to their cat's ear everyday in order to practice Tight Regulation.

    Not true. It can work with a little careful planning.

    We've had many caregivers practice tight regulation while holding full time jobs... jobs that take them out of the home for 10 - 12 hours a day.

    Libby started a thread with some helpful hints here: STICKY: CAN I DO TR WITH A FULL TIME JOB? YES!.

    Please add your own experiences to the conversation. Your experience could help someone else.
    Thanks!
     
  21. Amy&TrixieCat

    Amy&TrixieCat Well-Known Member

    Joined:
    Feb 14, 2011
  22. tiffmaxee

    tiffmaxee Well-Known Member

    Joined:
    Nov 15, 2013
    So how do you keep a cat safe and not have to rest and feed for 12 hours out of 24? I must be missing something.
     
  23. Amy&TrixieCat

    Amy&TrixieCat Well-Known Member

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    Feb 14, 2011
    Elise - check out Libby's new sticky at the top of the forum....people are starting to share their tips and tricks about how to manage a full time job while caring for an FD kitty. It's a brand new thread, so there are only a few posts so far, but hopefully others will chime in.
     
  24. tiffmaxee

    tiffmaxee Well-Known Member

    Joined:
    Nov 15, 2013
    Thanks, Amy. Will do because I can't continue like I'm doing when family events happen and it would be nice for me to be able to be gone for more than a few hours. I know I can shoot reduced or skip but I don't want to risk losing momentum either after working so hard to get Max more tightly controlled. :roll:
     
  25. Amy&TrixieCat

    Amy&TrixieCat Well-Known Member

    Joined:
    Feb 14, 2011
    Skipping every once in a while for a special event isn't the end of the world, even though it's hard for us beans to think about it. I've skipped Trix's shot a few times so I could go see Bruce Springsteen, and I know Marje has skipped Gracie's a few times for special events, too. The kitties DO get back on track, and we beans do need to take of ourselves, too. We're no good to them if we're miserable and stressed out!
     
    Gussie's mom (GA) likes this.
  26. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    Definitely read the thread, and add any suggestions that have helped you. Even if it seems like a small thing, it might be exactly the thing somebody needs to read.

    I can relate to your feelings about losing momentum. I felt the same way when I was working with Lucy. With the 2nd diabetic cat and later the 3rd, I started to realize that they were going to be just fine if I took a night off every now and then. The good news is that the better regulated they are, usually the faster they get back on track.
     
  27. tonimarmalade

    tonimarmalade Member

    Joined:
    Jan 20, 2015
    I wish I had read "don't shoot a dropping number" before Marmy's dropping PMPS this evening. I should have shot and on time. darn! :banghead:
    Another question- What does "LL" mean? Lantus/Levemir?
     
  28. Amy&TrixieCat

    Amy&TrixieCat Well-Known Member

    Joined:
    Feb 14, 2011
    If your looking at my signature, "LL" means "Lantus Land". Until last Christmas, the format of the forums was different and the one we belonged to was specific to Lantus. Now that the forums have merged, I always call it L&LL...Lantus and Levemire Land.

    You did great tonight, Toni - no head-banging allowed!
     
  29. tonimarmalade

    tonimarmalade Member

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    Jan 20, 2015
    Marmy just told me she still loves me and so all is well. You people in L &L land are amazing!:bighug:
     
    Amy&TrixieCat likes this.
  30. Libby and Lucy

    Libby and Lucy Senior Member Moderator

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    Dec 28, 2009
    I think it's time for another bump!
     
  31. marniepaul & miles

    marniepaul & miles Member

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    Feb 28, 2011
    Thanks for bumping this...very helpful!
     
  32. Lydia--(Rosie & Basil) GA

    Lydia--(Rosie & Basil) GA Well-Known Member

    Joined:
    Dec 28, 2009
    Thanks! This is great information.
     
  33. tonimarmalade

    tonimarmalade Member

    Joined:
    Jan 20, 2015
    I have been doing this tr all incorrectly! Marmy hasn't ever been consistently in blues or greens for any extended amount of time. I just haven't understood that I must increase far more quickly. Now I have her at2.2. Seems so high. She just seems to be going higher with no success in the numbers. Could there be other issues here besides my stupidity? :(
     
  34. Chris & China (GA)

    Chris & China (GA) Well-Known Member

    Joined:
    May 10, 2013
    Not stupid at all Toni!!....but yes, if you're doing TR, you're holding the dose way too long and that can let glucose toxicity set in (which means you end up having to go even higher to bring him back down)

    I don't know how you're measuring a dose like 1.95 .....Best I can do is dosing in .25 unit increments (maybe a little bit of "fat" and "skinny" doses but they're tougher....a few people can do smaller increments using calipers but I don't use them

    If you'll try to post in the Lantus Forum at least every few days, we'll help you get Marmy under better control!
     
  35. tonimarmalade

    tonimarmalade Member

    Joined:
    Jan 20, 2015
    I do use calipers ( ala Marj and Gracie's recommendation)and a chart that gives the exact measurements for my syringe. I will certainly post every few days, Chris. Thanks for your help.
     
  36. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    "I think I'll take a bit from this method and a bit from the other method"

    In the Sticky - Lantus & Levemir Tight Regulation Protocol, there is simple but very important quote:

    That's right, the guidelines in the Tight Regulation Protocol and the Start Low, Go Slow method were not plucked out of thin air. Almost everything you see written in those methods is there for a reason, mostly to provide a check & balance for some other portion of the method. Rather than going into a lot of detail, I'll open an invitation here to ask about specific guidelines that you want to understand better.

    Also, there is this interesting post from Kirsten in an old Think Tank thread: The longer I do this, the more I feel like Dr. Hodgkins! . If you are not aware, Kirsten is the Roomp in Roomp & Rand. She has been working with the Tight Regulation Protocol for Lantus & Levemir on the German Diabetes-Katzen forum since 2004 - that's right, more than 10 years!

    There are a couple of points I would like to pull out of Kirsten's comments, though her entire post gives a lot of insight.

    Finally, if you are interested in reading through the discussion regarding adapting the Start Low, Go Slow method for use with Lantus & Levemir, please read this Think Tank thread: Proposed Adjustment to Start Low Go Slow.

    The Start Low, Go Slow method was designed to leave some flexibility for caregivers to adapt for their individual situations and for their cat's response. While remission is possible using Start Low, Go Slow, there is less emphasis on remission as a goal with this approach. The Tight Regulation Protocol, on the other hand, is a more aggressive approach. There are some caregivers who will adjust aspects of the protocol for their cat, but those adjustments should be undertaken only by experienced caregivers who thoroughly understand the insulin, well enough to understand the risks when they choose to throw out the checks and balances.

    Trying to mix and match the two methods usually does not work very well, and most importantly, can be dangerous.

    Discuss...
     
  37. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    let's not forget that 50 is a low number for cats receiving insulin! The reason 50 is seen as a safe nadir for cats following the Tight Regulation Protocol is because we know the dose is a safe one for that cat. We know that because of the way the dose is worked up to. SLGS does not have the same safeguards built in, so 50 may not be a safe number for cats using SLGS.
     
  38. jayla-n-Drevon

    jayla-n-Drevon Well-Known Member

    Joined:
    Oct 11, 2015
    this is so very helpful …. thank you---it is scary for us who will be new shooting low--appreciate this so much-
     
  39. Andy & Pimp

    Andy & Pimp Well-Known Member

    Joined:
    Oct 18, 2015
    Thanks Libby;)
     
  40. Gill & George

    Gill & George Well-Known Member

    Joined:
    Oct 27, 2015
    Thanks Libby.
    Will need to read through this several times to have it sink in.
    :bookworm::bookworm::bookworm:
     
    Stacy & Asia and jayla-n-Drevon like this.
  41. Vyktors Mum

    Vyktors Mum Well-Known Member

    Joined:
    Nov 15, 2011
    I'm glad you opened this discussion Libby because I have been wondering about a couple of things lately and would appreciate others thoughts and the opportunity to discuss (yes I know, I probably should have started a thread in the think tank but we are here now) - feel free to slap me down beans I can take it ;)

    1) if someone is doing SLGS but testing like they're doing TR where is the harm in increasing sooner than the prescribed week?

    My thinking is that the reason for waiting a week until a curve is done is because the way SLGS is designed the beans aren't testing much so there's generally not enough data to properly evaluate what the dose is doing for the kitty.

    Personally I find the thought of increasing based on one days data which could have been a bounce much more frightening than doing it the TR way :eek: but I guess you've then got another week to see if you get any low preshots to alert you that something might be going on within all the blank space on the spreadsheet.

    So if someone is getting all the midcycle tests and we can clearly see what the dose is doing, why wait for a week?

    2) TR was developed before the advent of the very low carb dry food that some beans now have access to. Dry food is still bad from a hydration point of view (with all the health problems that can bring) regardless of the carb level and although I have never seen the stuff it must still be highly processed so my thoughts are that it's still junk food just like any human highly processed foods so bad, bad, very bad for our kitties. However from a TR point of view I wonder why not?

    The only answers I have seen to that question is that the studies weren't done that way so we don't know that it's safe. I think this is a very valid point but I think the idea may deserve a little further exploration and by that I do not mean that anybody should try it on their kitty, just that some discussion would be good.

    In my mind a potential problem with it could be the time taken to process dry food v wet food. We know that high carb dry food takes a lot longer to get out of the system than high carb wet so I'm guessing that even with low carb dry the food effect would stay in the system longer and therefore you couldn't be sure that removing food two hours prior to shot time would give you a preshot number that wasn't food influenced and could therefore present a danger. Does that sound right?
     
  42. Andy & Pimp

    Andy & Pimp Well-Known Member

    Joined:
    Oct 18, 2015
    What is flexible about it? The preshot numbers? Anyone who's started learning the dance knows you have to shoot low to stay low. If you're not shooting low 100's kitty is not going to spend time in 100's at all and we may as well not even treat them. I get the fact that most beans are stressed about shooting lower numbers (I know I was) and we have to let them figure out for themselves that it is safe, and as they learn their cat they can slowly lower it. But that goes back to the The longer I do this, the more I feel like Dr. Hodgkins! thread where they talk about most beans being overly cautious of hypo and taking too much time to get kitty regulated, or not regulated at all. Some quotes from that thread:
    Sounds to me like Kirsten is (indirectly) saying you can't get a cat regulated using SLGS, at least not with reductions at 90. The method should provide guidelines for lowering that number over time as more data is collected, and make clear the possible risks in doing so without data. Another issue with reductions @ 90 - what do you do when you're only on .25u and kitty hits 80? Stop insulin therapy? I don't think so.

    I think it's also assumed that beans aren't around during the week to intervene if something went wrong. They're definitely not testing enough to prevent a crisis, either.
    Especially if kitty is spending most of their time in pink and red. I thought we wanted to at least stop the damage to their bodies as soon as possible.

    I know I've seen beans here that give their kitty a dry crunchy treat after every test. Most don't, and use freeze dried or something similar like I do, but I know it happens. I'm sure those 6 or 7 crunchies through the day take a long time to wear off, too. But if crunchy takes so long to wear off, what's the worry? Kitty will have more crunchy before this one's worn off, so it should be pretty consistent, I would think. Otherwise the cats that eat only carby dry food would have serious issues on any method of insulin therapy, even with reductions at 90. If carby crunchy affects BG's by 100-150 points, and it could actually "dip out" like that...SLGS wouldn't be safe.
    Some cats won't show a spike from Evo dry or YA, some will. If you know that your kitty won't, what's the danger?
     
    Last edited: Dec 11, 2015
  43. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    great questions! I'm going to have to read these tomorrow because my brain has shut down for the evening, but I like seeing a discussion starting.
     
  44. Nancy and Scotty

    Nancy and Scotty Member

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    Jul 13, 2014
     
  45. Nancy and Scotty

    Nancy and Scotty Member

    Joined:
    Jul 13, 2014
    I have a cat that has not been tested but my vet feels is an IAA cat, he was diagnosed in 1/2014 and went up to 13 units ProZinc twice a day before I switched to Levemir in July of 2014, he was doing really well but about 3 months in went low and bounced and then his blood sugar did not come down, I took him to my vet who could not give me a good answer on what was going on, I came home and started researching on this site and found what you had written about increasing during a bounce and then I increased, I finally had to go up to 6.5 units twice daily but then his needs started decreasing and in February went into remission. You cannot imagine how much what you had posted helped me, unfortunately he came out of remission the first of November, I had tested him him a week earlier and had gotten a 76 and a week later he was drinking too much water and I tested and he was 385, I took him to the vet to check for infections and then put him back on Levemir, I had to get up to 7 units twice a day but I have had him regulated back in low blues and greens now for over a week, I feel like all the information you have posted helped me save his life, on the ProZinc he never went under 350 and when I started him on Levemir I knew I had to get him regulated quickly, all your tight regulations posts helped so much, I have learned so much from this board that the vet clinic I use suggested that if I wanted to make some extra money they would even give me names of some of their clients with diabetic cats and see if I could help them, since I work about 15 hours a day at my regular job I turned that down but I did tell them they just needed to tell everyone about this board, to quit rambling though I just want to say that you are the expert on TR.
     
  46. Thabbo

    Thabbo Member

    Joined:
    Oct 8, 2015
    @Jill & Alex (GA) I would like to discuss 'bouncing" a little further.
    If I understand it right, what is referred to as 'bouncing' here is a phase where we could expect increased BG values for a few days after a hypoglycemic event.

    However, a new study from Roomp/Rand showed that only 0.42% of >10.000 blood glucose curves did actually show a pattern that could be consistent with that effect. They found:
    The important finding in our study was that blood glucose curves consistent with rebound hyperglycaemia were very rare in cats treated with glargine, despite blood glucose being measured a median of five times daily for 10,767 days. Only 1/240 (0.42%) blood glucose curves were consistent with rebound hyperglycaemia, and could be found only in a subset (25%) of cats. Furthermore, blood glucose curves that were consistent with rebound hyperglycaemia with insulin resistance were even rarer; four individual events were identified in four cats, representing 1/2692 (0.037%) curves.

    The authors also state:
    The authors know of no published studies which demonstrate that diabetic cats with insulin-induced hypoglycaemia have persistently increased concentrations of counter-regulatory hormones (growth hormone, cortisol or most particularly glucagon or epinephrine), or have insulin resist- ance for up to 72h. In fact, there are no studies in cats demonstrating an increase of counter-regulatory hormones in response to hypoglycaemia.

    So, according to these findings, we should be way more careful when thinking about a 'bounce'. An increase in BG after a hypo event that lasts more than just a few hours would most likely (>99%) represent just a lack of insulin, right?
     
    Stacy & Asia likes this.
  47. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    There is a distinction between what we refer to as a "bounce" vs what Roomp & Rand are calling rebound hyperglycemia (i.e., Somogyi). The issue of Somogyi in cats is peppered throughout the literature and message boards despite there being very little research to support its presence. The term came about in 1938 based on a study involving a very small number of human subjects. The findings were never replicated in humans and there has been a lack of convincing evidence in cats, let alone with cats using a long-acting insulin such as Lantus or Levemir.

    When we refer to a bounce, it is not after a symptomatic hypoglycemic event. It is typically when numbers drop low, drop fast, or drop by a large amount. The phenomenon we refer to as a bounce is what Roomp & Rand are calling asymptomatic or biochemical hypoglycemia and at least based on my quick read of the paper, the "bounce" was back into ranges that were typical for those cats.

     
  48. ctmorris

    ctmorris Member

    Joined:
    Aug 25, 2015
    Wow - Thanks guys - this thread was a great read!
     
  49. Thabbo

    Thabbo Member

    Joined:
    Oct 8, 2015
    Thanks for your feedback Sienne!
    So, a bounce refers to LOW values that we see during a BG drop/asympotmatic hypoglycemia. I got confused on this, because I have seen a lot of people talking about bounces when they see HIGH BG after a dose reduction due to low BG.
     
  50. Squeaky and KT (GA)

    Squeaky and KT (GA) Well-Known Member

    Joined:
    Jul 19, 2011
    @Sienne and Gabby - unconfuse me please. Isn't a 'bounce' as we use the term a biochemical HYPERglycemia caused by the liver releasing counter-regulatory hormones to combat a perceived threat of either low glucose or too fast of a drop in glucose? If it's 'hypoglycemia', most of us are using the term incorrectly.
     
  51. Andy & Pimp

    Andy & Pimp Well-Known Member

    Joined:
    Oct 18, 2015
    high
    after
    ;)
     
  52. Chris & China (GA)

    Chris & China (GA) Well-Known Member

    Joined:
    May 10, 2013
    If I'm understanding it right the "High" BG that indicates it's a bounce is due to the "numbers dropping low, dropping fast, or dropping by a large amount"...so when we talk about bounces here, it's because we see a higher number soon after any one (or more) of those things

    A "high BG after a dose reduction due to low BG" isn't necessarily a bounce (although there can be a bounce involved ALSO due to the low BG)

    When they drop too low and "earn" a reduction, if they don't return to "typical" numbers for that cat, it's not a bounce....it's a failed reduction

    example....cat drops to 40 and earns a reduction ......the next cycle they're in the high 200's....THAT part is a bounce and has nothing to do with the fact you just reduced the dose.....if the cat doesn't return to what would be "normal" numbers for them, then the reduction failed
     
  53. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    @Squeaky and KT :
    Numbers drop and then there's a bounce into higher numbers. What the Roomp and Rand article points out is that the cat may bounce back into what may be that kitty's typical range. The low number cause for the bounce, though, isn't symptomatic hypoglycemia.
     
  54. Andy & Pimp

    Andy & Pimp Well-Known Member

    Joined:
    Oct 18, 2015
    I think some important topics got buried in post #42-43
     
  55. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    I'd ask a different question. If you're using SLGS and testing sufficiently (which means at minimum, at shot time and at least once per cycle) to do TR, why not use TR?

    My understanding is that TR is more aggressive. You follow the protocol or you don't because the protocol has certain safety factors built in based on the research. You don't pick and choose. SLGS was developed based on practical knowledge. It means you "go slow."

    As for food, I don't have an answer to that. One consideration, though, is that some of the lower carb dry foods that are available here may not be available overseas which is where the research is being done.
     
  56. Mocha aka Cold Play

    Mocha aka Cold Play Well-Known Member

    Joined:
    Sep 23, 2015
    bump and will read and absorb
     
  57. Thabbo

    Thabbo Member

    Joined:
    Oct 8, 2015
    That is true, the low/zero carb dry food is not available in the vast majority of European stores.
     
  58. Andy & Pimp

    Andy & Pimp Well-Known Member

    Joined:
    Oct 18, 2015
    Good question, simple answer. Dry food.

    Recommending to get rid of the dry food just isn't an option for some. It may be possible, but mabye beans don't have the patience threshold to deal with the process.

    We all understand that TR says you can't use dry food.
    This isn't a question about the protocol anymore. I'll start something up in think tank later.
     
  59. Vyktors Mum

    Vyktors Mum Well-Known Member

    Joined:
    Nov 15, 2011
    As Andy said dry food is one reason but I also see some others that aren't using dry food and are testing frequently but are just a little nervous or something about letting their kitties get as low as we do following TR. Ideally they ditch the dry and/or get more comfortable with low numbers so that they can follow TR instead. But failing that, or until that happens, my thinking is that the safety factor built in to the TR protocol for increasing more rapidly is the frequency of testing so if that part is covered I don't see why a SLGS kitty couldn't be increased faster than every week, particularly if they're running high.

    I am most interested to know if others see any potential problems with that. @Libby and Lucy we're still waiting on your thoughts when you have the time too - sorry to nag :oops:
     
  60. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    sorry guys, very busy at work and busy at home these days too. I'm going to have to break these responses down into manageable chunks.

    SLGS

    An important thing to remember about SLGS is that it is NOT a protocol. It is a set of guidelines. Where is it flexible? The whole thing! As you learn your cat's responses, you will probably adjust some of the guidelines. And yes, that says you will probably adjust some of the guidelines. Not that someone else will adjust the guidelines for you. SLGS is about learning your cat and learning what will work for your situation, then applying that knowledge to make the insulin work better for your cat. It is not about following a set of dance steps (neither is Tight Regulation, but that is another discussion for another day).

    You'll notice that there are no instructions for how to go OTJ in the SLGS sticky. That was left vague intentionally. There are many ways to approach remission using SLGS. Andy asks whether you would just stop giving insulin after the cat goes low on a low dose. Actually YES, that is one way to do it. Sometimes cats (especially newly diagnosed) will settle down after a few days and no longer need insulin. Other ways would be to try reducing the dose further, or lowering the threshhold of what you consider low, or trying shooting once a day or as needed, or adjusting the food carb % (lower isn't always better) or timing to keep the numbers from going low, or any number of other ideas.

    Quoting Jill & Alex in another thread because she said it better than I could:


    DRY FOOD AND TIGHT REGULATION PROTOCOL


    The bottom line here, in my estimation, is that we just don't know how dry food will affect regulation. The Tight Regulation Protocol is very aggressive and we cannot afford to have unknowns when we are letting cats run below 50 on insulin. I personally am not willing to take that risk with someone else's cat.

    From a personal perspective, my cat Kris Kringle ate dry food due to other health issues. I didn't necessarily find his numbers to be higher with dry food, but they were definitely unpredictable (and after all these years I'm usually pretty good at understanding numbers). I tried to keep him over 60 so I would have time to intervene if he threw me a curve ball. Are chances of remission as good if you do not let them run lower? Probably not, but I'd rather have my cat alive and on insulin than dead because of an error in judgment.


    PLEASE REMEMBER

    The Tight Regulation protocol is aggressive, and our modified version is slightly more aggressive than the original. We feel safe allowing our cats on Tight Regulation to run as low as 40s because we know the dose is a safe one for that cat at that time. We know that because of the way we work up to a dose, and the way we work down from a dose. It is not about the number of tests or how many cycles a dose is held, it's about gathering the RIGHT data rather than just a lot of it.

    Cats following SLGS will probably not have all of the safety nets in place, therefore you will probably not be able to approach 50 with the same confidence that the cat is safe. If you are sure that low numbers are ok for your cat, that is fine, but please do not ask anyone else to tell you it is safe. In my mind, if you are asking, that means you are not confident so I will probably steer you back toward the guidelines.
     
  61. Mocha aka Cold Play

    Mocha aka Cold Play Well-Known Member

    Joined:
    Sep 23, 2015
    I follow this.

    I am not familiar with the differences, and I am seeking expertise to grasp them. I will delve into the stickies that I printed. I have already seen others trying to find their own decisions because of conflicting directives to stay or decrease, etc. I get what you are saying.

    It is not that I am "not confident" because I ask for input. I believe this is intended to be a place of knowledge sharing and looking at my cat's response and sharing. Whatever I do, I will be confident with. But, I have only been in this forum maybe 2 months. My knowledge base is almost nil. And, my vet is of no help to me. He is overly concerned that she had one number below 90. Not grasping that the majority of her trend was far higher and he questions insulin dosing and is holding out on my refills for even syringes!

    It takes a community right? If we can't ask, we can't learn as we should.
     
    Andy & Pimp likes this.
  62. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    I don't mean not to ask, I just mean that if you are planning to deviate from written guidelines, those are decisions that YOU need to make. We're more than happy to help with interpretation of guidelines and of your cat's patterns. I just can't really say "oh yeah, for your cat it's fine to go below 60 on SLGS" because I really have no way of knowing that. I can point out what I see that might affect your decision.

    The 90 in SLGS is the safety net - throwing out a safety net has to be your call. There are lots of safety nets so you don't necessarily need all of them with SLGS, but it's your call to decide how many you need and which ones you can let go.
     
    Last edited: Dec 16, 2015
    Reason for edit: spelling
  63. Andy & Pimp

    Andy & Pimp Well-Known Member

    Joined:
    Oct 18, 2015
    Beautifully stated, Libby. I hope everyone finds this as helpful as I do.
     
    Mocha aka Cold Play likes this.
  64. Mocha aka Cold Play

    Mocha aka Cold Play Well-Known Member

    Joined:
    Sep 23, 2015
    Thanks. Understand what you mean. Appreciate your weighing in. And, everyone else.:cat:
     
  65. Libby and Lucy

    Libby and Lucy Senior Member Moderator

    Joined:
    Dec 28, 2009
    Thank you for bringing up a point that needs to be made. This is an open forum. There are no "experts" and no "advisors." Everyone, new and old, experienced and not, is welcome to give advice. Hopefully people will give responsible advice based on their knowledge and experience, but that is not always the case. Unfortunately you can't always tell who to trust based just on who has a lot of posts, who seems liked, who acts like they know what they're talking about.

    Each caregiver is ultimately responsible for vetting the advice they are given and deciding what to do for their cat. Click on the spreadsheets of the people who are helping you. Does their spreadsheet look like what you are hoping to achieve? If they don't have a spreadsheet in their signature, ask for it. If someone is telling you something that doesn't jive with what you think you know, ask questions. Lots of times conflicting advice is just a difference of opinion with several viable options (this *is* a disease, after all, not a puzzle that has a right answer). On the other hand, conflicting advice can also mean that one person isn't necessarily on target. We also have some people who do a lot of copy/pasting their advice and it doesn't always apply to the exact situation at hand. Make sure they are looking at YOUR spreadsheet too!

    And just to be sure I'm clear, of course if someone is giving you moral support or feeding advice or something other than specific insulin dosing advice, then it doesn't matter if their spreadsheet is beautiful yet. Even if someone just started yesterday, I would hope they feel welcome to go around and say hello and encourage others. If someone is giving me insulin dosing advice, though, I'm going to look at their spreadsheet to see if it looks like they understand how to use the insulin. ;)
     
  66. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Some examples:

    I've always found Linda & Sruffy's spreadsheet to be one of the most interesting albeit extreme examples of a kitty going OTJ using what many would consider an unorthodox approach: https://docs.google.com/spreadsheets/d/1oilhgpiRKWN-LC2ju6XyfBamC6lcNHMBKhGUXyCIJEI/pub#. Click on the "Numbers" tab at the top and then scroll all the way down to March and then April 2008. Note the color coding is a little different. Less than 100 is blue. 100 - 200 is yellow. Notice the shooting as needed. Scruffy bobbled around for quite awhile before settling into double digits. Interesting, huh?

    If you look at Alex's spreadsheet, click on the 2006 tab at the top of the page: https://docs.google.com/spreadsheets/d/1ooNFj_Fd7be3QQJ41bl8fXka3QkSo_H1UIONkEh_2I8/pub?output=html#. This was before TR with Lantus was accepted on the FDMB. I did try to take her down from 0.5u to 0.1u for a few cycles before going OTJ only because I had been in touch with Kirstin (the Roomp in Roomp & Rand), but she started throwing inverted curves so I withheld insulin. For all practical purposes, Alex went from receiving 0.5u Lantus to going OTJ for almost 3 years. Worth noting, she was still throwing 2-300s a couple weeks before going OTJ! o_O

    If you click on the 2009 tab on Alex's spreadsheet, you'll see an illustration of practicing TR and shooting low to stay low as well as my attempts to feed the curve with a cat who could throw a food spike of 50 points from a piece of freeze-dried chicken! Don't worry. No one has to test as much as I did. All I wanted to do was to create a teaching tool for shooting low that would show others how to get and maintain those flat curves the Ls are known for when kitty doesn't have a bunch of medical problems to complicate the issue. Thankfully, Alex didn't seem to mind.

    These are just a few of many, many examples of treating feline diabetes successfully.
    Every cat is different. Every caregiver is different.

    If one spends the time to learn the basics...
    Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose,
    Peak/Nadir - the lowest point in the cycle,
    Duration - the length of time insulin continues to lower blood glucose,
    observes kitty's response to food,
    and understands the reasoning behind the choices... rather than immediately stressing over a choice between TR or SLGS and having someone tell you every move to make... things tends to fall into place.


    Perhaps some food for thought...
     
  67. Mocha aka Cold Play

    Mocha aka Cold Play Well-Known Member

    Joined:
    Sep 23, 2015
    On 4/1 of Sruffy's....the glucose of "48" was not used to give a reduction. I assume that is because the pmps though delayed was 114 and insulin was still given for same amount. On the following amps it was 143.....so this is where the knowledge base of the caretaker said do not reduce, stay? Using the guidelines but weighing the knowledge of Scruffy more?

    I appreciate the sheets and pointing something out. Sometimes, it just seems like there is so much to take it. I am sure it will get easier for me to comprehend in time. :cat:
     
  68. Andy & Pimp

    Andy & Pimp Well-Known Member

    Joined:
    Oct 18, 2015
    Thank you, Jill. I think this answers all the questions I had earlier.

    It all goes back to "Know Thy Cat" and ECID;)
     
    Mocha aka Cold Play likes this.
  69. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Linda didn't note a reason on her ss, but if I were to guess it was because Scruffy didn't always hold reductions. So yes, she was using her knowledge about Scruffy.
     
    Mocha aka Cold Play likes this.
  70. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
  71. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
  72. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
  73. Sweet Spot

    Sweet Spot Member

    Joined:
    May 12, 2016
    I really, really liked what was said here as a newbie. Of course, there is so much good data info in this thread...but this quote stuck out emotionally because that is how I have felt. I want to get to know Spot first because every cat is different (and caregiver). I see it as Spot teaching me how to dance. HE knows the moves but it will take me time to catch up and be a good dance partner for him.

    Of course, I know getting those high numbers down as fast/safely as possible is of utmost importance for his health - but the picking a method/protocol at the start has been a huge stressor. In my corny analogy, I am choosing the music (TR or SLGS) but don't know enough steps yet to determine if he is teaching me a waltz, polka or what?

    Corny analogy over - but my husband and I are just taking it a day at a time - and reading/learning from other's posts, spreadsheets, etc.

    Thanks for bumping this - very helpful!
     
    AEHawkeye and Jill & Alex (GA) like this.
  74. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    I understand more than you could imagine.
    The basics are continually over-looked on every forum on the FDMB. I'm a firm believer in what I said previously:

    "If one spends the time to learn the basics...
    Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose,
    Peak/Nadir - the lowest point in the cycle,
    Duration - the length of time insulin continues to lower blood glucose,
    observes kitty's response to food, and understands the reasoning behind the choices... rather than immediately stressing over a choice between TR or SLGS and having someone tell you every move to make... things tends to fall into place.
    "




     
  75. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Bump for newer members! :)
     
    PussCatPrince - GA likes this.
  76. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Bump for newer members! :)
     
  77. Meridith and Zeke

    Meridith and Zeke Well-Known Member

    Joined:
    May 22, 2017
    Very informative!
     
  78. Gill & George

    Gill & George Well-Known Member

    Joined:
    Oct 27, 2015
  79. Girlie's mom

    Girlie's mom Well-Known Member

    Joined:
    Jul 3, 2017
    And bump!
     
  80. Stephanie & Quintus/Luna

    Stephanie & Quintus/Luna Well-Known Member

    Joined:
    Dec 9, 2017
    Just read through this attentively, wow! I love these old "thinking" threads. Not sure why I hadn't come upon it before!
     
    Martine et Gomette likes this.
  81. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

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    Dec 28, 2009
    Overdue for another bump!
     
    Zorro's mom, Sam & Oscar, TSP and 2 others like this.
  82. Figaro's Liz

    Figaro's Liz Member

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    Jun 18, 2019
    THANK YOU :bookworm:
     
  83. Ti-Mousse

    Ti-Mousse Well-Known Member

    Joined:
    Dec 2, 2018
    Thanks !!
     
  84. TSP

    TSP Member

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    May 30, 2019
    SO HELPFUL!!!! Thank you :)
     
  85. Sam & Oscar

    Sam & Oscar Member

    Joined:
    Jul 8, 2019
    Thanks for bumping this up for us new members. This was a great read-through. Now to go back and read through all the links!
     
  86. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009

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