1/22 Sami AMPS 368 - Important Question about Protocol

Yesterday's Condo

Looks like we are seeing a little bit of rebound this morning, from all the yellow and blue yesterday, I am hopeful that Sami will come back down into those yellows and blues again today. I am keeping a level head and not freaking out, which is a new thing for me.

Sami is a very happy kitty. For most of the day yesterday, she did her normal, sleep. Getting up occasionally to explore, and she found a new favorite spot at the office. She started to purr every time I went to give her kisses and check on her. She has always been a lover, just not as much these last few months. She continues to eat well and appeared to be drinking a little more water overnight and this morning. I will be keeping the 1.25 dose for now. I probably won't re-evaluate until Sunday night for Monday change, unless she stays in the pink, then I might look at it again tomorrow night for a change Sunday morning.

 

Re: 1/22 Sami AMPS 368

Good Morning!

I just wanted to stop on in and sat hello! I hope Sami finds those yellows and blues again today. My Mannie seems to like the rebounds too - with lots of heavy sighs from me. Come on down Sami!

 

Re: 1/22 Sami AMPS 368

Hi Tina! It seems like you and I are in the same boat. Mally had a great day in the blues yesterday and then came back up last night and this morning. I share your thoughts about being patient and waiting to see what happens. Mally started her new dose on Wednesday, so it's very early in the game.

Being new to all this, it takes some time to see how things work. I hope Sami gives you a very pleasant surprise over the weekend!!!

 

Can someone tell me why, it seems, with some cats they start to get decent numbers, in the blues and yellows, and then when the dose is increased the sugar continues to rise? Before I came to this board I was all over the place with Sami’s dose and it seemed like the more insulin I gave her the higher her sugar spiked. Once I backed off a little on the size of the dose and also was more consistent her BG started to stabilize.

I totally understand a rebound, but that doesn’t typically continue for more than a day or so, but for instance some of the spreadsheets I have looked at show dosing at 1 unit and getting blues and yellow, then when they increase to 1.25 or 1.5, fully within protocol, they go higher and continue to stay elevated as the dose continues to go up.

Could it be possible that for some cats they need to stay at the same dose longer? I know protocol states that if the cat is having nadir 200-300 to increase by .25-.5 units every 3 days, which is what I am seeing on many of these spreadsheets. But is it possible that this could be too quick, maybe not for all cats but for some.

In Sami’s case she had a spike two and a half days after her increase; she had been steady until then. I had every intention to increase after just one more dose, and I would have still been within protocol to do so, but decided to hold back another day or so, and I got some amazing numbers. She still rebounded with a slightly higher BG, probably because of being lower than she has been in the previous weeks.

So can someone please help me to understand this?

 

It sounds like NDW (New dose wonkiness) http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=2731

 

I'm hoping I understand your question(s) and will do my best to respond. It may be that someone with more experience can provide the information you want.

With regard to rebound, the hormones producing rebound can take up to 72 hours to clear -- this is considerably more than a day. It is also why we give doses time to settle and don't make a change in the middle of a rebound cycle. Rebound is different from what has been termed, "new dose wonkiness" (NDW). Rebound is a result of the liver dumping glucose and other hormones into the system in an effort to "rescue" your cat from what is is being signaled as a dangerously low BG level. NDW only occurs in relation to a dose increase. According to the protocol:

It is always up to you whether or not to increase a dose. There can be practical reasons to not go ahead with an increase (e.g., you won't be home to monitor) or reasons that fall in the EICD category such as you feel that your cat might benefit from spending more time at a particular dose before changing.

The jump into the reds 2-1/2 days after an increase was most likely NDW (or Sami being a cat which explains many, many things!). Generally, the prevailing wisdom here is to hold doses for 3 days so any of this sort of fluctuation isn't a factor in a dose change, and this is why several people cautioned you to be patient and not increase the dose just yet. The German Forum, which originated the Tight Regulation Protocol, is more aggressive than you will typically see here. In Sami's case, I honestly don't feel that you have enough data to be aggressive with your dosing. You are getting better numbers because the NDW phase has passed. This does not mean, though, that 1.25u is Sami's ideal dose. That dose may still need to be increased or decreased. Sami will take the lead in this dance.

 

Hey I resemble that comment! ohmygod_smile Yup it's true take a look at my SS, but keep in mind my cat was also on dry food with 28% carbs most of that time until he was at the lower doses. Took a year to convince the dummy that he is a cat and should eat meat!!! :roll:

 

If NDW sometimes last or can occur up to 3 days after the dose increase, can you explain why the protocol pushes to increase the dose in three days if the nadir is >200. This really doesn't make too much sense to me. I understand that it is important to get those numbers down as quickly as possible, but if the NDW can last for three days wouldn't it be better to wait at least 5 days after a dose increase regardless of what the nadir number is. That way the NDW can be out of the system before a new dose is introduced.

I am just trying to figure this all out, not trying to relegate the protocol.

 

I think I can help with that, basically, the key words are can and may, and every cat is different.

Sami will figure it out Tina, just takes a little patience and a little time, you'll see!

 

Well, I am not just talking about Sami. I am also thinking of all the other people that might be increasing too quickly and wondering if that is causing the rise in some of the BG levels. I know there must be more information behind the protocol, I just wish I knew what it was.

 

It can be frustrating and confusing when you just first start. I think I'm dealing with some wonkiness myself.

You're doing great with the spot checks. It seems like you have a good routine down, good job!

 

what we've dubbed NDW (new dose wonkiness) is explained better here:

"Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations."
Tight Regulation Protocol

*usually* NDW lasts for less than 24 hours. :smile:

increasing the dose every 3 days is part of a modified version of the tight regulation protocol most of us follow here. bringing down the numbers as quickly as safely as possible is beneficial for several reasons including a better chance for some newly diagnosed kitties to go otj.

however, there are some kitties who do take longer to respond to a dose. we affectionately call them "slow responders".
if you suspect sami is a "slow responder"... there's nothing wrong with holding the dose for 5 - 7 days. feel free to experiment.

when alex was on insulin the first time in 2006, i did notice it often took her 6 days to respond to a dose. 3 years later, with a lot more knowledge under my belt... i made a conscious decision to use the insulin as effectively as possible. this included raising the dose before i saw the response that i had seen after holding the dose for a longer period of time in 2006. see her 2009 levemir ss to see what i'm talking about (link in my signature).

incidentally, several years ago the german tight regulation protocol suggested holding each dose for a week before increasing the dose. this is illustrated in the spreadsheet of Tracey and George. since then the tight regulation protocol has morphed into what it is today largely do to first-hand experience, collective wisdom, and finally... the collaborative study done by rand and roomp using data collected from members of the german katzen forum which was published last year.

hope this helps...

 

Yes, this does help a little. I guess my line of thinking right now, and it might change in an hour, tonight, tomorrow, or next week, is to maintain a specific dose until there Sami levels out, and then determine if a dose increase is necessary. I don't know how this will work as I still have limited data, but that is my thinking at this moment. I know it is important to get Sami into the 80-100 range if I ever hope to get her OTJ, but I would really like to try to avoid the spikes and all the wonkiness, if that is at all possible.

My vet was encouraging me to increase Sami's dose to 1.5 earlier this week and I went against her recommendation, but at this point I think I made the right decision. More than likely Sami will be increased to 1.5 at some point in the near future, but for now I am very happy seeing her with yellows and blues. Sure I would be much happier with blues and greens, but like everyone has been telling me, Be Patient.

Thanks for all the help, every bit of information helps. With all the information I have been reading about on FD, as well as another medical problem with another one of my cats, I am surprised my brain hasn't exploded yet. I am the type of person that likes to know the facts and in the case of FD the numbers don't lie. I just have to figure out how best to interpret them to make the best decision possible.

 

to ease your mind, hold the dose for 7 - 10 days for purposes of data collection. i really wouldn't recommend any longer than that because we have found the longer kitty remains stagnant in higher numbers... the longer it takes to pull those numbers down.
actually, that's a huge factor in raising the dose every 3 days...

 

I am not saying that I want to hold the dose longer than the protocol says, I just want to make sure she is consistent rather than bouncing from one extreme to the other. Depending on what happens over night might determine what I do tomorrow. for 3 cycles Sami has gone down into the high 100's and then rises back up. Yesterday her AM and PM pre-shot numbers were very similar. Today, although higher, her AM and PM numbers have been similar. That shows consistency to me.

If tomorrow she is higher still with the AMPS then I might consider increasing her dose to 1.5 tomorrow morning. If she is below 250 at her AMPS I will probably hold the dose for another day to see where she goes. Right now Sami has been at a dose of 1.25 for 4½ day, but I would really like to have her dose changes in the morning rather than at night.

So we will see where she is in the morning.