? Yum AMPS 618 +5 504 +9 563 & the 3 day rule

Discussion in 'Lantus / Basaglar (glargine) and Levemir (detemir)' started by MJW, Dec 6, 2017.

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  1. MJW

    MJW Well-Known Member

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    I understand the importance of the protocol as a framework, but I don't really understand the 3 day (6 shot) rule for a cat with numbers as high as Yum's.
    Yum is clearly not going to go hypo if I increase her to 3u after 3 shots at 2.5u.
    Even if she did go hypo that might be good, since I would catch it and she would finally be out of the danger zone on the high end.
    Last spring she had to go to 4.5 before she started earning reductions. Her numbers are much higher now than they were then.

    Why can't I go higher a bit more quickly than 6 shots at each dose when I am clearly so far away from the correct dose? What are the arguments against being more aggressive? (1) The depot has to fill.

    I also don't understand why too high a dose can make a cat's numbers too high. Is that just because of the bounce? Is the nadir also too high? I don't think I've seen examples of that. I don't understand why too high a dose would cause high nadirs.

    I believe I read that for glucose toxicity, one has to race ahead in the dose. The damage occurs at high number and the dose requirement increases. The dose increase has to get ahead of the damage increase.
     
  2. Toro & Ovi

    Toro & Ovi Member

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    I would do the same as you intend to - increase (based on the current very high BG numbers, not as a rule). But I'm not sure what ORBAX does for these BG numbers.
    What happened on November 13th? On that day Yum's lost it just like that...what was the trigger for that ?
     
    Last edited: Dec 6, 2017
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  3. Barbara & Uncle

    Barbara & Uncle Well-Known Member

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    Just popping in to give my 2 cents (that's about all it's worth too).
    The 3 day/ 6 cycle hold rule as described to in the TR Protocol has it's function for a few things that I can think of. Here they are;
    Letting the depot fill
    Excluding the possibility of overshooting the best dose
    Usually that time period is enough to compensate for any bounce (or breaking bounces) that may occur
    Hope I'm being accurate and if not someone with more knowledge will correct me.

    I don't have enough experience with dosing advice, so I really hope someone will come along to weigh in as well.

    :bighug::bighug::bighug:
     
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  4. MJW

    MJW Well-Known Member

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    Her numbers were increasing slowly before they changed color on the 13th. I coincidentally took her in for bloodwork to check her phosphorus on the 13th. I started her on SEB because the vets thought her high BUN might be partly due to stomach bleeding. SEB is not known to increase BG. The next day the 14th I took her in for an x-ray, to see if she was going high due to constipation. She was not constipated. Then I noticed her bloodwork showed high monocytes and I emailed the vet. On Friday the 17th I took her in for a urinalysis at the vet's suggestion and she had a UTI. Her numbers were high and then seemed to recover on Monday the 20th. On the morning of Tuesday the 21st she shot to 513 and I left town for 7 days with her boarding for the first time at the vet. First time away since her diagnosis. Just a total disaster. Bad mom.
     
  5. Wendy&Neko

    Wendy&Neko Well-Known Member

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    TR is an aggressive but safe protocol. The cycle wait times allow the depot to build so you can see how low a dose is taking a cat. Even for cats that are stuck in red and blacks (and have been since they started insulin - not Yum's case), we hold for at least 4 cycles.

    Too much insulin can look like too little. It's the cat's bodies response to too much insulin. But they can't keep it up forever and will eventually crash. If you look at posts where people accidentally overdose their cat - often it's just high numbers. But not always. If you go up too fast and bypass a good dose, we don't know whether you are dealing with the too much or too little scenario. If you go up systematically, then we know. If it's the too high a dose scenario and she crashes, the depot can mean that you are dealing for a hypo scenario for a very long time - more than a cycle's worth. She does seem to be getting worse the higher you go in dose.
     
  6. Toro & Ovi

    Toro & Ovi Member

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    Wendy, I've heard before the myth about "too much looks like too little" but I couldn't google proof it - and I've tried hard. Every single web page says too much insulin can kill thru hypo, I'd be interested to find some proof of "too much looks like too little", that will make our miserable diabetic_pet sitter lives even more so........can you detail ?
     
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  7. Wendy&Neko

    Wendy&Neko Well-Known Member

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    Yes, too much insulin can kill through hypo. But we have some examples here of cats may initially showing higher numbers. Search here for people who have overdosed their cats. That's just one cycle of overdose though, and not an experiment I'd want to try, in case my cat was the one that didn't show high numbers and tanked instead. We've also got examples of cats that have hypoed over several cycles. We've also had a couple cases of cats that started here on too much insulin - one cat started by a vet on 10 units. :eek::mad: Thankfully caregiver started home testing and found us and cat only had a couple shots at that dose. Summary, we just don't know if the cat is overdose or underdosed - if you haven't been following the safety guidelines build into the TR protocol.
     
  8. LizzieInTexas

    LizzieInTexas Well-Known Member

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    It does with Gizmo. I switched to marshmallow root.
     
  9. MJW

    MJW Well-Known Member

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    What does that suggest to you? Too high a dose? Or glucose toxicity? She went higher with each dose last spring until: I gave her the antibiotic zeniquin, I hit 4.5.

    She goes in tomorrow morning for bloodwork and/or a urinalysis. I had asked them to culture the previous urine samples but they didn't. My mother's passing was hastened by being prescribed the wrong antibiotic. I should have been more forceful this time.

    I've got to decide her next dose in 45 minutes.
     
  10. MJW

    MJW Well-Known Member

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    Do you think I am already overdosing her? She held 2u for 6 cycles at the vet. I dropped her way down in case it was too much. Then it looked like a failed reduction, so I increased it back up. I am so worried.
     
  11. LizzieInTexas

    LizzieInTexas Well-Known Member

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    Have her teeth been checked?
     
  12. MJW

    MJW Well-Known Member

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    I had seen your post. I did a few experiments starting and stopping it and I thought it was okay.
     
  13. LizzieInTexas

    LizzieInTexas Well-Known Member

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    I can send you a handful of MMR capsules you could switch and see. I have plenty.
     
  14. MJW

    MJW Well-Known Member

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    What should I do? 2.5 or 3?
     
  15. MJW

    MJW Well-Known Member

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    Well. Gratitude. She gave me a 348. I will shoot 2.5.
     
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  16. MJW

    MJW Well-Known Member

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    It could have barn a false number. The meter didn't beep for my first poke with a small bleed. I put it down, poked another hole, and used the same strip. Ive done that before, but never for such a high stress decision number.
     
  17. MJW

    MJW Well-Known Member

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    By how much did it raise his BG? You used it for a long time, didn't you? At what dates should I look in your chart for the effect? It was nothing like what is happening to Yum, was it? Her vet thinks her teeth are okay.
     
  18. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

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    I have a couple of thoughts.

    First, I think you're confusing glucose toxicity with insulin resistance (i.e., insulin auto-antibodies). There's a similarity but they are not the same. Glucose toxicity occurs because a cat's body begins to adjust to being in higher numbers and treats that range as the new "normal." In dealing with glucose toxicity you do not "race ahead of the dose." Insulin resistance is a condition whereby the cat's body is developing antibodies that "fight off" the effect of insulin. It is a time limited high dose condition and you do need to follow TR closely to stay ahead of the antibodies so they don't keep blocking the action of insulin.

    With regard to not following TR and repeatedly increasing the dose every 4 cycles, it's dangerous. The depot doesn't stabilize and you have no clue how effective a dose will be. Lantus dosing has a cumulative effect. In a sense, you begin to overlap what amounts to the dose strength until the depot catches up with the dose from several previous doses and your cat crashes. At that point, you still have several dose increases floating around because all of that insulin is now in microcrystals that have deposited in your cat's tissues. This can potentialiy make recovery from a symptomatic hypoglycemic episode, at best, challenging. Or, to put it in my typically blunt style, if you keep increasing every 4 cycles, you run the risk of killing your cat.

    Has your cat ever had her teeth cleaned? If not, I'd lean toward your cat needing a dental. To be honest, Yum's SS looks like the SS of a cat that has something medical going on or that you've got toasty insulin. Did you bring your insulin to the vet when Yum was boarded? If so, I'd try new insulin. Some vets don't realize that you don't shake Lantus.

     
  19. LizzieInTexas

    LizzieInTexas Well-Known Member

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    Another thought along the same "thinking" as @Sienne and Gabby (GA) - could the food you are feeding have had a formula change (higher carbs)? That happened with me when Wellness changed :mad: (still mad about that).
     
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  20. MJW

    MJW Well-Known Member

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    Zero carbs radcat raw chicken.
     
  21. MJW

    MJW Well-Known Member

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    Yes. I meant insulin resistance. What do you mean you need to follow TR closely to stay ahead of the antibodies? 3 days is fast enough to keep ahead of them??

    Yes. I am very scared of killing her by going too fast (or too slow) or everything else.

    Well, Yum had high monocytes in blood work the week before I boarded her. A urinalysis showed she had a UTI. We gave her Convenia. It didn't look like it was curing the infection. When her numbers went bad while I was away, they did an inconclusive urinalysis and put her on Orbax. She developed severe diarrhea. I assume that was due to the Orbax. She has lost almost a pound, about 10% of her weight. Most of that happened while she was boarded: they said she was eating but maybe not all of her food. Now I have her on metrodinazole for the diarrhea. She was diagnosed with CKD in August (~6 months post diabetes), which had me focused on toxicity. Her vet thinks her teeth are okay. Yum will have blood work and another urinalysis done in the morning.

    When Yum became a serious diabetic last spring, her numbers did keep on increasing with her dose. She had signs of infection. Maybe she had insulin resistance.

    I will ask the vet tech if she shook the Lantus. I don't see any crystals. It looks clear. I will phone in a refill tonight.

    Thanks!
     
  22. MJW

    MJW Well-Known Member

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    While she was boarded the vets thought she might be going high from stress. They thought she had better numbers on the weekend when it was quiet than during the week when it was busy.
     
  23. LizzieInTexas

    LizzieInTexas Well-Known Member

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    I would hold the dose for the 6 cycles before increasing. Then increase by 0.25U. Earlier this year she was on 4.25U before she leveled out and started to come back down the dosing ladder.

    I am hoping the more experienced beans are discussing and will follow up with you but I know how stressful it can be to not know what to do regarding the dose.

    I looked at Gizmo's SS and I have noted that I started MMR in July but don't have a good answer for you about the SEB (bad documentation on my part).
     
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  24. Marje and Gracie

    Marje and Gracie Well-Known Member

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    I’m glad you held the dose tonight. Raising every three cycles is just too fast. It doesn’t help her to chase the numbers.

    You asked how too much insulin can make a cat’s numbers high (although I do not believe Yum’s dose is too high), and Wendy referenced a cat on 10u and what his numbers looked like. Here is Teronto’s SS. The vet started him on 10u. Even after we had her drop the dose back to 1u, you can see it took a while for his body to adjust and deplete the depot. He then quickly went OTJ.

    Remember that insulin is a hormone and not a medication and so it doesn’t behave as a medication. Each cat’s body will deal with it individually.
     
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  25. Marje and Gracie

    Marje and Gracie Well-Known Member

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    Wendy and I were discussing Yum. Tilly’s states, on increasing the dose, that if nadirs are consistently over 300, increase the dose by 0.5u every 2-3 days.

    If she drops lower tonight, I would hold the dose a total of six cycles and reassess. If she stays in the high 300s or goes higher, I would suggest increasing the dose by 0.5u to 3u in the morning. But only if she does not come lower tonight.
    Wendy also felt this was a reasonable approach.

    Paws crossed.
     
  26. MJW

    MJW Well-Known Member

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    She is 592 at PMPS+4. Darn. I think the PMPS of 348 must have been a bad measurement. I did double dip the strip. She tends to have smooth curves and the 348 was an unusual outlier. I will probably do 3u in the morning. I thank you and Wendy for advising and for caring.
     
  27. Marje and Gracie

    Marje and Gracie Well-Known Member

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    I’d just wait the cycle out and see where she is in the morning before you decide.

    Here is my suggestion for you to consider: If she doesn’t come back down tonight and is still in the clouds in the morning, it’s fine to increase by 0.5u to 3u. I would then hold that dose a minimum of four cycles and reassess. If she’s getting consistently down into pinks, I’d back off and increase every six cycles by 0.5u until nadirs are consistently under 300 and then go back to 0.25u every six cycles.

    Of course, if she earns a reduction, that changes my suggestion above.

    How does that sound?
     
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  28. MJW

    MJW Well-Known Member

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    Sounds good. PMPS +6 625. My Poor Yum.
     
  29. Marje and Gracie

    Marje and Gracie Well-Known Member

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    Has the vet checked her out really, really well? These numbers just don’t jive with where she was and what has happened in the interim. They are pretty high and just make me think there’s could be some other issue.

    How does she feel? Eating, peeing, pooing, purring, playing, bathing, etc?
     
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  30. Stacy & Asia

    Stacy & Asia Well-Known Member

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    Just food for thought, if the vet thinks her teeth are fine, is that from visual examination or dental X-ray? Teeth issues can do horrible things to cats (have experience in that, unfortunately) and sometimes the issues aren't clearly seen with the eyes, but X-rays tell another story, and at her age, it's a good thing to rule out.
     
  31. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

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    @Stacy & Asia is correct -- it is very hard to get a good visual inspection of a cat's teeth when the kitty is awake and squirming.

    Trying a new vial/pen of Lantus may be a good idea. I've gotten a one bad pen in a box of 5. It's unusual but it can happen. Stress is also a likely factor when Yum was boarded.

    FWIW, Convenia is NOT an appropriate antibiotic for a UTI. It's only indication is for skin infections. Vet's like using it because the caregiver doesn't have to pill their cat. It's also a problem if your cat has a reaction/allergy to it. Once it's administered, it lasts over 2 weeks. Frankly, the only way to know what antibiotic to give with a UTI is to get a cystocentesis (use a needle to withdraw urine from the bladder so the sample is sterile) and have a culture and sensitivity run. The latter lets you know what antibiotic is appropriate for the bacteria. It is possible that the Orbax isn't addressing the problem and that's the reason Yum's numbers are high.

     
  32. MJW

    MJW Well-Known Member

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    Her appetite decreased overnight and she had foam vomit at 4:30 AM, something that hasn't happened for a long time. She wouldn't eat breakfast this morning until I brought out the Fancy Feast Classic phosphorus bomb. And she only nibbled at that---UNTIL we came home from the vet just now. The vet says Yum's urinalysis looks clean but we are sending it out for culture. She gave her some fluids in case mild dehydration is interfering with the insulin absorption. She wants me to stop the slippery elm bark until the diarrhea has cleared. She agrees too high an insulin dose can cause a sudden crash.
     
  33. MJW

    MJW Well-Known Member

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    Didn't see this until after our appointment. Visual examination only. I will bring up dental x-rays. Thanks.
     
  34. MJW

    MJW Well-Known Member

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    They don't know if the Lantus was shaken. I will have a new vial for her PM shot.
    She had Convenia in the spring---not sure it worked then either. They gave me a choice. I was going out of town and hoping to leave her at home so I chose Convenia and regretted it soon afterwards. One of my more difficult civvies did clear a UTI with a Convenia shot last spring. We sent Yum's urine out for culture this morning, but it looks clear of bacteria.
     
  35. MJW

    MJW Well-Known Member

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    Thank you everyone for your advice and support.
     
  36. DebG

    DebG Well-Known Member

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    Could it be pancreatitis? With all the vomiting. It sure looks like something happened at or around the boarding time.
    As far as ORBX Fritz was on it earlier this year with no side effects at all having said that ECID.
     
  37. MJW

    MJW Well-Known Member

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    The early morning foam vomit on an empty stomach is a classic sign of her chronic kidney disease.
    Lucky you re ORBX. Yum also got diarrhea last spring from ZENIQUIN, a related antibiotic.
     
  38. Marje and Gracie

    Marje and Gracie Well-Known Member

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    I am also wondering if she could have a kidney infection which will not necessarily show up on a culture and sensitivity. Speaking of the C&S, did the vet obtain the urine through cystocentesis? That is the only sterile way of getting urine for a C&S.

    Back to kidney infections. CKD cats can be prone to them. My Gus had two over the course of his CKD (four years) and we were only able to detect it from ultrasounds. He had a tiny bit of blood in his urine but no bacteria. He did not run a fever. When we did an u/s, it was clear, both times, that he had a kidney infection also known as pyelonephritis.

    From Tanya’s:
    Here is the entire discussion on urinary tract infections from Tanya’s. A worthy read!

    I’m just trying to brainstorm some other ideas for why her numbers might be so high. You might start with the new insulin and then go from there. I would not lower the dose when you start a new pen; just be extra vigilant on the testing.
     
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  39. Toro & Ovi

    Toro & Ovi Member

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    I'm not a vet but I would look back at what happened/changed (food/drugs/B12 injection/anything) around November 10th, 2017 - going from the light side to the dark side in matter of days. There must be a trigger for that.........
    Just my 2 cents.
     
    Last edited: Dec 7, 2017
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  40. MJW

    MJW Well-Known Member

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    They always do cystocentesis. On November 17th, it was ultra-sound guided, so maybe they looked at the kidneys then. I didn't know kidney infections could be revealed by ultra-sound. The vet today didn't use the ultrasound or draw blood. She felt a kidney infection would probably not show up in the blood work. I do have 2 sequential reds today! AMPS 616. +5 491. +8 434. Maybe I will wait on opening the new insulin vial if she shows sustained progress---it's only been open 2 months. They always act a bit shocked at the pharmacy when I spend that much on my cat. They know her name.
     
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  41. MJW

    MJW Well-Known Member

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    I think it was the urinary tract infection. It showed as elevated monocytes in coincidental blood work on 11/13 and then in the urinalysis on 11/17.
     
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