Info Tight Regulation & SLGS: Myths Debunked

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Libby and Lucy

Libby and Lucy

Member Since 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).

The protocol (name removed) is referring to is the Tilly Protocol. Take a look at the tab with the TR Protocol and you'll see 2 different links in the text. One goes to the Rand/Roomp, which is based on the Tilly, but with slight modifications. Our own is slightly different as well. So there are actually 3 versions of a very similar protocol.
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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.

Here's the full link to the protocol used by the German board. The Roomp & Rand (U of Queensland) is the original TR Protocol. Both the German board, that Kirsten Roomp is involved with, and this board have made modifications to the original 2009 TR Protocol.
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  • 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).

One difference is that we give weight to bounces and hold doses through them.
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Not quite true. The other versions DO account for bouncing, they just don't say it that way.

For example:

Phase 2: Increasing the dose

Most cats need to have their dose increased. Do it in 0.25 IU or 0.5 IU steps (0.25 IU if the cat is getting a low dose and/or relatively low BGs, 0.5 IU if the cat is getting a higher dose and/or relatively high BGs). Hold each dose for 5-7 days. However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU. Alternatively, if the cat is continuously producing moderately elevated BGs (nadir always >=200 mg/dl), increase the dose every 2-3 days by 0.25 IU ( if the cat is getting a low dose) or 0.5 IU (if the cat is getting a higher dose). From this point onward test for ketones once per week, or more often if the nadirs are still >=200 mg/dl. (emphasis mine).
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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.

A second is that the Rand/Roomp and Tilly both have you feeding when faced with a low-preshot number on Lantus. (That would be different with Lev, because of the later nadir that many cats have.)
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Lastly, the R/R offers the possibility of split dosing when faced with a lot preshot. we discourage that.
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Actually what Kirsten says is this:

Try reducing the dose the first few times to see what happens - in all likelihood the cat will have higher BGs as a result. A second alternative is to feed the cat, wait 1 to 2 hours, test again, and when the BGs start rising, give the normal dose. A third alternative is to split the dose: feed the cat, give most of the dose immediately and give the remainder 1 to 2 hours later when the BGs start rising. However, in most cats none of these alternatives have shown themselves to work as well as consistent dosing. You will have to learn how your cat reacts to Lantus/Levemir before you determine the best way to deal with this problem.
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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.

A third difference is when you take reductions.
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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.
 
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!
 
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!!!
 
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!)
 
Re: Tight Regulation Protocols: Myths Debunked

Bump
 
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.
 
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.
 
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!

Phase 2: Increasing the dose

Most cats need to have their dose increased. Do it in 0.25 IU or 0.5 IU steps (0.25 IU if the cat is getting a low dose and/or relatively low BGs, 0.5 IU if the cat is getting a higher dose and/or relatively high BGs). Hold each dose for 5-7 days. However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU. Alternatively, if the cat is continuously producing moderately elevated BGs (nadir always >=200 mg/dl), increase the dose every 2-3 days by 0.25 IU ( if the cat is getting a low dose) or 0.5 IU (if the cat is getting a higher dose). From this point onward test for ketones once per week, or more often if the nadirs are still >=200 mg/dl. (emphasis mine).
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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:

Increasing the dose:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
    • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
    • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
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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.
 
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.
 
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!
 
So how do you keep a cat safe and not have to test and feed for 12 hours out of 24? I must be missing something.
 
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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.
 
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:
 
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!
 
tiffmaxee said:
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:
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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.
 
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?
 
tonimarmalade said:
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?
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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!
 
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? :(
 
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!
 
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.
 
"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:

Jill & Alex (GA) said:
WARNING: Every protocol or method has safeguards built into it's guidelines. It can become problematic or even dangerous to combine guidelines or suggestions from different protocols/methods.
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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.

Kirsten said:
I personally have to fight overly cautious dosing much more than rebound checking, but it is also very, very tedious. In the vast majority of cats Lantus/Levemir won't allow you to achieve regulation without having daily nadirs <80 or <100. If you try to avoid nadirs <80 or <100, the cat generally ends up with long periods above the renal threshold each day. I've also come across a few people who believe that they can pick an upper and lower threshold that fit their personal comfort zone and easily maintain the BGs of their cat within that range. Aside from the fact that this is only rarely doable, in cases where it works there is still a slight level of hyperglycaemia present which IMO has a negative effect on the pancreas. You really have to work *with* these insulins and accept that euglycemia is part and parcel of how they work.

The time-window in the weeks and months after diagnosis is a precious, once in a lifetime opportunity for a diabetic cat to have a really good chance at remission. We've tried to minimize the risks as much as possible in the TR protocol, while still maximizing the chances at remission. Of course there are hard to regulate cats for which the protocol will not work, but these cats tend to be hard to regulate period.
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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...
 
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.
 
Libby and Lucy said:
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.
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this is so very helpful …. thank you---it is scary for us who will be new shooting low--appreciate this so much-
 
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?
 
Libby and Lucy said:
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.
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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:
Steve & Jock said:
It's a matter of overcoming fear of the 'normal' blood sugar ranges, because those are the stable ones. ..... it's way harder for most diabetic cats to get regulated between 150-250 than it is between 75-150, but you won't know this until you try.
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Kirsten said:
I personally have to fight overly cautious dosing much more than rebound checking, but it is also very, very tedious. In the vast majority of cats Lantus/Levemir won't allow you to achieve regulation without having daily nadirs <80 or <100. If you try to avoid nadirs <80 or <100, the cat generally ends up with long periods above the renal threshold each day.
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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.

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

Vyktors Mum said:
2) TR was developed before the advent of the very low carb dry food that some beans now have access to. However from a TR point of view I wonder why not?
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.
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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?
 
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Libby and Lucy said:
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!!!
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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.
 
@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?
 
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.

 
Sienne and Gabby said:
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.
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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.
 
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