Yoyo -- Couldn't shoot 1.5u at 135 BG

Yoyo had a 135 for an AMPS this morning. I know the 135 would be within the guidelines to shoot the current dose, but I just could not bring myself to do it. I KNOW we shoot based on the nadirs! I STILL could not do it.

When you see a strikingly, downward trend over time but you are still seeing drops of 150 -200 point over a twelve hour cycle, what are your thoughts as to what is going on? It seems that once his body achieves a new low, it is initially shocked and rebounds but if he achieves the same low a couple of days later, then his body judges it to be the new "normal.'

Yoyo is still scratching and I am still finding tufts of hair around the house. I am inclined to think that his itching is not caused by a food allergy, however, Yoyo has always had a weird body odor and that is considerably improved.

Thanks,
Lana

 

Well, he was 240 at 3 hours ---- I should have shot the 1.5.

So, I guess I will see how well he can do on the 1.25 and keep it at that dosage for awhile if he can hold his own . . .

Lana

 

Yeah you experienced the conundrum for most users, even us old timers, what to do with a low preshot value.

My advice is to get some early cycle spot checks so you witness the early cycle rise which typically happens on Levemir, since the previous dose is on the downward slide and the new dose hasn't gotten up to speed yet. That gives you the knowledge and confidence that it's OK to shoot a lower preshot because you've seen the BGs rise for the first couple hours after the shot.

As for dropping the dose from 1.5U to 1.25U, you're not going to see another 135 anytime soon. Why not go back to 1.5U?

 

Yeah, that is a stressful - until you have the data to show it is safe to shoot those lows. It really IS how this insulin is supposed to work though. You actually WANT his PS's to be in the 100s so the dose is constantly keeping him below renal threshold, but not dropping too low at nadir.

You just have to reduce the dose if you are unsure and won't be there to test/monitor. That is never a wrong decision, but if you will be home you can shoot the full dose and test to see what happens.

With Beau, it proved that I could NOT shoot a full dose on lower PS's, but with Jeddie it proved that I CAN shoot the lower PS's with the full dose.

Changing the dose overall - meaning deciding to lower the dose and keep it lower, should be based on the nadir. Is he dropping below 40-50 or not? That is the target for a dose decrease.

Feed reg food if he goes below 60-70 early on in the cycle, or below 60 anytime in the cycle. Higher carb food can be used for below 40-50. Again the use of food and what type will depend on data and experience of how Yoyo responds to lows and feeding when low.

 

For what it's worth, I think you did right. I don't think you should have shot the 1.5u -- in hindsight it seems like you could or should have, but there is evidence that when a cat is poised on a low number, which might magnify the relative strength of any dose, that the insulin does not necessarily take 3+ hours for major effects to manifest. So if you shot 1.5, there was some chance, however small, that you would have had a crisis. Like others have pointed out, you don't have the data yet.

I know it's not supposed to happen, but once in the early days, when I massively overdosed Tom with Levemir (in error), from a PS of ~300+ he was showing something like ~60 at +2 if not sooner. That's a huge drop inside the window where the dose is just supposed to be thinking about taking effect. It answered one of the questions I still see debated, and that is: does the speed with which Levemir takes effect, get accelerated in overdose situations? - and the answer is Yes it does. Now an "overdose" can be one of two things: the physical quantity in units; or the relative quantity of insulin by comparison to the PS value, if the latter is low by reference to the regular level. ~135 is not a low PS, but it sure looks low when you scan up the AMPS column of Yoyo's ss. It also shows we have a lot to learn about how insulin, once injected, is detected in the system, and how the rate of absorption toward metabolism can vary based on the amount.

The good news is, Yoyo is tasting lower PS numbers. Nice.

Ilkka

 

Yoyo was back up to 335 at PMPS, not bad at all. I went back to 1.5 units. The last 10 days, as Yoyo's BGs have trended down, he has been a happy cat again. Well, not too happy. He has really rebelled against all the blood tests ... he never minded when it was 3 to 4 per day and I was rewarding him with a vast variety of tasty treats but now that I have been testing him day and night he has ceased to be so cooperative. He had always come when I called him but he stopped. So, I started controlling use of the kitty door: cats could come in but I had to let each one out. I simply kept Yoyo in until his six hour test was done. Neither of my cats was happy about that, especially Rusty who can be very vocal and obnoxious. So... they again have free access to the kitty door, but I am now dividing Yoyo's meals up, 1/3 after his AMPS, 1/3 at 3 hours, & 1/3 at 6 hours. For his pm, I give him 1/2 at PMPS and 1/2 at 6 hours ( I set the alarm to wake up to test & feed). He shows up on the dot now! The only problem now is that my own schedule has no flexibility any more.

Oh well, I am so pleased to see his BGs have headed downward, and I hold out that eternal hope that he will go into remission.... so, whatever it takes is worth it.

Lana

 

In the protocol that Pamela posted (thank you so much, Pamela!), on Reducing the Dose, it says "When the cat has its lowest BGs in the normal range of a healthy cat and stays under 100 OVERALL for at least one week . . ."

Does "overall" mean every BG test? Pre-shot, nadir, etc?

Lana

 

Yes, all day long. You're getting close to remission at that point.

 

Well, it looks like worrying about reducing the dose is premature. Yoyo had a 303 nadir today and a 309 PMPS. I don't know what happened. Maybe a shot into the dermis (wasn't a fur shot, for sure. I always feel for wet fur after I shoot).

A lot of my worry stems from my experience with Yoyo when he was diabetic in 2008. The vet told me not to give insulin if Yoyo's BG was less than 120 so I didn't have any angst over "should I or should I not shoot." And I only occasionally tested for nadirs. Ignorance is bliss. Yoyo's remission was sudden:

9/05/08 9:30 PM +12.00 277 2.0 Vetsulin
9/06/08 9:30 AM +12.00 346 2.0 Vetsulin
9/06/08 9:30 PM +12.00 164 2.0 Vetsulin
90/7/08 9:30 AM +12.00 369 2.0 Vetsulin
9/07/08 9:30 PM +12.00 280 2.0 Vetsulin
9/08/08 9:30 AM +12.00 362 2.0 Vetsulin
9/08/08 9:30 PM +12.00 361 2.0 Vetsulin
9/09/08 9:30 AM +12.00 55
9/09/08 9:30 PM +24.00 66
9/10/08 9:30 AM +36.00 92
9/10/08 9:30 PM +48.00 66
9/11/08 9:30 AM +60.00 86
9/11/08 9:30 PM +72.00 106
9/12/08 9:30 AM +84.00 131 2.0 Vetsulin
9/12/08 9:30 PM +12.00 186 2.0 Vetsulin
9/13/08 9:30 AM +12.00 47
9/13/08 9:30 PM +24.00 101
9/14/08 9:30 AM +36.00 191 2.0 Vetsulin
9/14/08 9:30 PM +12.00 99
9/15/08 9:30 AM +24.00 62
9/15/08 9:30 PM +36.00 77
9/16/08 9:30 AM +48.00 55
9/16/08 9:30 PM +60.00 65
9/17/08 9:30 AM +72.00 45
9/17/08 9:30 PM +84.00 62
9/18/08 9:30 AM +96.00 116
9/18/08 9:30 PM +108.00 99
9/19/08 9:30 AM +120.00 73
9/19/08 9:30 PM +132.00 48
9/20/08 9:30 AM +144.00 37
9/20/08 9:30 PM +156.00 32
9/21/08 9:30 AM +168.00 41
9/22/08 9:30 AM +192.00 81
9/23/08 9:30 AM +216.00 91
9/24/08 9:30 AM +240.00 132 2.0 Vetsulin
9/24/08 9:30 PM +12.00 114
9/25/08 9:30 AM +24.00 92
9/26/08 9:30 AM +48.00 61
9/27/08 9:30 AM +72.00 47
9/27/08 9:30 PM +84.00 70
9/30/08 9:30 AM +144.00 76
10/8/08 9:30 AM +336.00 82
11/2/08 9:30 AM +936.00 85
12/1/08 9:30 AM +1,632.00 78

But..... I will follow the protocol this time around. I'll reduce the dose when:

Case 1 --- all BGs are under 100 for a week
Case 2 --- Nadir is 40 - 50 on three separate days
Case 3 ---- Any time nadir is less than 40

Thanks,
Lana

 

Let me be the first to say that I love those numbers -- I mean the story that it tells. Not the least because it spells ECID in bold type, but also because it supports a theory of diabetes which recognizes that the disease and remission are not ultimately about the amount of insulin, but about something else totally. The injected insulin is just a disruption mechanism. I realized sometime back that everything I thought I knew about diabetes mellitus was wrong. I mean look at it... Yoyo wasn't weaned off with smaller doses, but "snapped" from the 300s+ to the 50s in one day on 2 units -- and then, when the higher numbers reasserted themselves, the same dose was used, of what was in my view an inferior insulin (Vetsulin). Thank you for sharing.

Ilkka

 

Definitely ECID - seeing 2u of vetsulin shot on mid-100s gives me heart palpitations! Most cats would have rebounding with drops from mid-300s to 50s and on 2u....

He looks like he is getting near the right dose. He may need a much longer time to settle on the 1.5u, but the next increase should probably be .25u or less. I guess Yoyo, is earning his name though, right?

 

It's my understanding that Vetsulin was recalled because it might have "varying amounts of crystalline zinc insulin in the formulation." From this side of the recall, I have to say that I must have been quite lucky.

As to dosage, Yoyo had a nadir of 232 last night and a AMPS of 386 this morning. He seems to have lost his downward momentum. It is very frustrating. I don't know if I should go to 1.625 or 1.75.

Lana

 

I would get some spot checks today on the 1.5u. He took 5 days to get to that 87 before and this is day 3. I know you only dropped the dose for one shot, but emptied the shed a bit (that is why yesterday's am shot was "screwed up").

You could raise him to 1.6 though to see if you can speed up the shed refill. Then hold that for at least 5 days. He looks like he takes longer to settle than the "6 cycles" referred to in the protocol. Jeddie takes a really long time too - like weeks.

 

This morning I raised Yoyo to 1.625 units (from up to the 1.5 line, to include the the 1.5 line).

Out of the past 12 days, I shot one 1.25 dose (April 7th) but I also think something went wrong on April 8th with the AM shot. So, I think his shed probably took a hit on two cycles.

As his number fell over the past 12 day period, I began to make some sense, finally, in a general way, out of Yoyo's numbers. When Yoyo hits a number that is a new low, he rebounds. If his BG is around that number again, close in time, his body now thinks it is normal and doesn't rebound. So, the question in my mind is, "How long is the window from one low to the next similar low for the body not to rebound?" Any thoughts on that???? His February greens and blues are of no help because I was changing his dose too often. Not having a clue to the length of the window is why I raised Yoyo to 1.625 units this morning. I want to regain the momentum of his downward movement without having to start over from scratch.... that is.... go through the many rebounds all over again as his numbers fall.

I think Sheila and Vicky are quite right that it takes Yoyo longer than 6 cycles to settle into a dose. I'm going to leave him at the 1.625 a good while before reassessing.

Lana

 

I think that window of time is going to be different in each cat. You just have to collect and analyze his data to see what his *window* is. Probably a couple of days at least, since the first 24-36 hrs after a low are the rebound and then settling from that.

Jeddie used to have a 9 day cycle (I think it was 9 - something like that) where he would have gently improving numbers, then a great day, followed by a pretty low PS, where I would reduce the dose (anticipating the rebound), then rebound and terrible numbers for about 3-4 days, then start to gently settle again - until the next time. I held the dose through the low PS's and he seemed to not bounce as much (until yesterday/today, at least :roll: )

 

On Apr 12th, Yoyo had a AM pre-shot of 157. The AMPS 157 was also his nadir for that 12 hr cycle. Five days previously, he had a 154. Was his window good for 6 days? Or did the fact that his BG did not fall at +6 constitute a rebound of sorts?

His the PMPS on Apr 12th was 268 and he dropped to 137 at +6. He had a pink 335 this morning (was this a rebound? or just normal fluctuation) and his nadir at +6 today was 121. Is this a new, threatening low? or a BG in close enough proximity to last night's 137 that his body is likely to ignore it? (I guess time will tell on that one but it would please me to acquire some ability to predict).

For most of March, Yoyo was getting red rebounds off low numbers so it was much easier to draw conclusions as to what was happening. Since his numbers have trended lower, it is more difficult.

I am sure I am on a fool's errand trying to make some kind of sense where none, really, can be made. . . . but I would still like to hear your comments, thoughts, intuitive judgments, or whatever.

Lana

 

Yeah, you're going to drive yourself nuts trying to predict his response at this point. He is still not at a "right" dose, so things will be unpredictable (although, in a way, that itself is predictable :roll: )

I think he could have been lower between the 198 and the 157 on the 12th, but I was looking back over his SS and seeing that he had some nice numbers on .5u back in the end of Feb. It's possible that you raised too soon - seeing those 300s that followed the 61 and 81 as needing more insulin and not a panicky response to those two low numbers.

I'm kinda thinking he needs less insulin - somewhere in the .5u to .75u range, but allowed to really settle over more time. Giving more insulin than us needed will give you occasional low/decent numbers, but they will be out of sync with doses, like a low PS followed by a high, then higher PSs over a few days or so, followed by a decent PS and a decent nadir, and then it all falls apart again (I'm looking at 3/31 to 4/5) and seeing that.

Those 500s in early march sure look like rebound to me and that was only on 1u. 500s, in a cat on a decent diet are not "normal" occurrences and always make me think rebound.

 

Sheila, my question got answered ---- Yoyo did not rebound off his numbers on Apr 12th & 13th so it looks like he might have a good 5 day window. He has a new low today. I was not able to test at +6, alas, but +4 was 113 and +8 was 100. He probably had a green nadir today. My fingers are crossed that he does not rebound off today's numbers, but I fear he probably will.

We have discussed the insulin dosage and I had dropped Yoyo to 0.75 on March 20, 21, & 22 without effect. So, I don't know. That said, I am concerned about the amount of insulin. I don't know what he currently weighs, but I know, without a doubt, that he has packed on considerable weight since I changed to Levemir. In humans, insulin is the hormone that stores fat. If Yoyo is awash in insulin, then that may be why he has gained weight just as humans who are insulin-resistant are awash in insulin and gain weight. I lowered him back to 1.5 units last night & this morning simply because I had raised him to 1.625 to replenish his shed after some shot problems. I am thinking about dropping him to 1.25 units tonight to see how he does. I would not be following the protocol if I did that...but I really am not ready for any low green numbers. I am just now feeling like I am getting a handle on the red and black numbers.

Lana