8/29 Tableau getting lots of black - what's going on?

Tableau is getting more and more black. Not sure what's going on. He'll have a decent run, and then he'll end up over 500 at his preshot or a couple hours after. I wasn't even getting 500s when he was diagnosed. Does anyone know what's going on here? Is his dose too high...thing is, he's not getting into the greens. He also seems to actually be higher, a couple hours after a shot, and then he goes down (so I'm pretty sure they aren't fur shots)

I would really appreciate any feedback or ideas as to what's happening here, and whether or not I should reduce his dose.

Here are yesterday's numbers:

08/28/11
AMPS 519
+ 2 272
+ 4 161
+5 162
+6 130
+ 8 225
+10 311
PMPS 417
+ 2.5 521

Please see his spreadsheet for more data.

Thank you.

Tableau's condo: http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=50850

Just to make sure the obvious are addressed, you noted that Tableau was on antibiotics for e. coli. Has this been checked to see if the infection is still present or is Tableau still on antibiotics? Is everything in the litter box area resolved (no more constipation)?

What this looks like to me is bouncing. Tableau sees some blues, usually due to a big drop (e.g., 500s to 100s) and then bounces back into higher numbers. Bounces occur either due to drops into low numbers (e.g., lower greens) or fast drops. In either case, the liver reacts by dumping a stored form of glucose and counterregulatory hormnes are produced. These cause BG levels to rise back into higher ranges. These bounces can take up to 72 hours to clear.

Don't reduce the dose. Once the bounce clears, it's likely that the dose will need to be increased. Don't do anything until the bounce clears.

Sienne and Gabby said:

Just to make sure the obvious are addressed, you noted that Tableau was on antibiotics for e. coli. Has this been checked to see if the infection is still present or is Tableau still on antibiotics? Is everything in the litter box area resolved (no more constipation)?

Click to expand...

obviously, the answers to the questions sienne asked could definitely affect numbers. however, i have to ask why was the dose increased to 1.75u only three cycles after tableau hit mid-greens?

it can take as much as 72 hours to clear a bounce from numbers a kitty's body is not used to. when you increase the dose prematurely, you run the risk of kitty becoming over dose. too much insulin can cause high numbers just as too little can. increasing the dose too soon can cause a vicious circle of high numbers, sometimes with an occasional steep drop to low number. sometimes all you'll see is high numbers. being impatient and increasing the dose prematurely ultimately causes more problems in the long run. you'll end up having to increase the dose to get right back to the point you were at when kitty was throwing green numbers.

i think marjorie/gracie is in charge of handing out "patience pants". :lol:



edited to add: please check for ketones frequently.

hi emily! haha on marjorie and the patience pants - we all need them. i know it's taken me months to be able to see a bounce. you'll get it down and it will get easier. Tableau will settle down in his numbers as well - lantus flattens out the cycle over time. hang in there!

Looking at the SS, I wonder if Tableau has had some very low numbers overnight, and the days are bounces back from hypos some nights. You may want to set the alarm and get a +6 reading a couple nights to see what is really happening. Just a thought

Here you go Emily....one set of very sexy patience pants coming your way from the Sisterhood of the Travelling Patience Pants:



So check out Gracie's SS. I reduced her to .75u and she got into green and then started bouncing....lots of pinks and yellow which, for her, is high....she doesn't typically get into other ugly colors. But I held the dose and now she's coming back down into blue and I'm hoping she'll come into green. I can speak first hand about what Jill referenced. I kept increasing Gracie's dose and had to take her way up (for her...from .5u to f1u) to finally get a breakthrough. Good luck!!

Hi, everyone. Thanks so much for your replies. I re-read the protocol and it does look like a bounce that is to be expected.

Regarding "prematurely increasing the dose" I I didn't think I did, per the protocol. It states in several places:

- "Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose." (Lantus sticky on tight regulation and Tilly's page)

- "If nadir blood glucose concentration < 200mg/dL but peak is > 200mg/dL (11 mmol/L) Increase every 5-7 days by 0.25-0.5 IU depending on if cat on low or high dose of insulin Tableau's nadir's have consistently been under 200. " (University of Queensland - I think this is "Rand")

Am I misunderstanding this? Now I'm really confused, as I thought I was following it correctly. I see in Tilly's page where it says

"Phase 3: Holding the dose

Try to keep the cat at a dose where the BGs are in the 50 to 200 mg/dl range for as much of the day as possible. The majority of cats are actually able to achieve consistent BGs in the 50 to <100 mg/dl range with consistent dosing."

But I haven't seen Tableau in this range for most of the day - at best it looks like he's achieving numbers on SOME days for maybe 3-4 hours (in blue or green), but that's about it, which is why I've been increasing the dose after 5 day.

To answer Sienna, yes Tableau is still on the antibiotic for ecoli and probably will be for another week at least, and while the constipation is "better" it sure isn't resolved...

P.S. The patience pants are STUNNING! Can't wait to get a pair... :lol:
Sam - good idea, I will set the dreaded alarm and get up and check him at +6, ugh

Here's where I think your confusion is. You did wait the number of days/cycles. However, you need to wait for the bounce to clear before you start counting the number of cycles at a given dose.

I realize that the protocol isn't particularly clear on this point. If you think about it though, it will make sense. If your cat bounces off of a low number (and, BTW, low numbers are not the same as a "hypo" since your cat is not experiencing symptoms of hypoglycemia) and his numbers are now high, even though it may be the 3rd day on a dose, and you then increase, once numbers come back down, you could be in trouble. You've increased the dose prematurely. As the bounce clears, you may find that you're now giving too much insulin. This is why we encourage you to hold the dose and evaluate it's effectiveness after the bounce has cleared. There are a lot of cats who will go into green numbers, bounce, then come back to green numbers and earn a decrease. The instructions are more the general guidelines and don't take every situation -- like a bounce -- into account.

The section from the Tilly Protocol that you quoted is more applicable once a cat is better regulated.

Hi guys .. sorry to see tableau is spending so much time in the blacks lately but I see lots of people have offered up advice for you guys .. It's hard to see our kitties so high .. but that's where those stunning patience pants come into play!

Ok. Thanks so much for clarifying. That makes sense. So as a general rule of thumb, it seems if I'm getting high numbers after a dose increase - wait 72 hours (or three days) and then start counting cycles.

Will do. I greatly appreciate your spelling it out for me.

hi emily. trust me, you're not alone in your confusion. to successfully follow a tight regulation program, it's necessary to not only understand the action of the insulin used, but also how your cat responds to the action of the insulin. imho, this is the hardest part to understand of this thing we call the "sugar dance".

when a cat dips to numbers lower than it's body is used to kitty will bounce. it's a given. in most cases, these bounces can last for as long as 72 hours (some may clear their bounces in more or less time). eventually, kitty becomes used to lower numbers and ceases to bounce.

part 1:

in tableau's case...
you wanted to know what was happening. 1.25u brought him down to mid-greens (normal bg range). what we saw afterwards was the expected bounce. you want to give the cat time to clear that expected bounce (usually up to 72 hours, some cats *may* need more time) before increasing the dose again. you want to remain consistent with dosing because you know that particular dose has the ability to bring tableau exactly where you want him to be... in the normal range. in other words, why increase the dose when the current dose is bringing him down to where you want him?

now that doesn't mean the dose would never have to be increased. chances are, the dose would have to be increased for various reasons (eg. fine tuning, some kitties "get stuck" and need a nudge, you want to bring down the entire range, etc).

however, combine what we know about the action of the insulin along with kitty's response (dumping counterregulatory hormones into the bloodstream after a drop to numbers lower than the body is used to). we don't want to increase the dose before that bounce has cleared. this is why protocol suggests holding each dose for 5 - 7 days except in cases where nadirs are over 200.

"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)."
http://www.tillydiabetes.net/en_6_protocol2.htm

"If nadir blood glucose concentration < 200mg/dL but peak is >200mg/dL (11 mmol/L) - Increase every 5-7 days by 0.25-0.5 IU depending on if cat on low or high dose of insulin"
http://www.uq.edu.au/ccah/docs/diabetesinfo/link4.pdf

these guidelines for increasing the dose are based upon nadirs greater than 200. tableau had dropped into greens. therefore, no increase according to protocol guidelines. the bounce cycles do not count. ignore them. base all increases on how low the dose can drop your cat.

we know cat's will experience a temporary bounce lasting for as much as 72 hours. holding the dose as suggested for 5 - 7 days (or at least 3 days) will allow those counterregulatory hormones to clear the body. once you know how long it takes YOUR cat to clear bounces, you will be able to assess where he's at and shorten that time period accordingly.


part 2:

when the dose is increased prematurely (kitty becomes over dose), one of two things will happen. either kitty's numbers will remain high and relatively flat OR kitty will experience steep drops followed by dramatic bounces into high numbers. vicious circle. no matter which happens, in most cases, the dose just gets higher and higher before it forces a break through.

re: sam's comments
it's certainly possibly there have been some missed lows on the current dose. remember, lows which set up a bounce are not always green numbers. actually, missed lows and then seeing those blacks and reds illustrate a steep drop followed by dramatic bounces as mentioned earlier.

so, what to do?
there are three options: test like a crazy woman to determine how low tableau is dropping, reduce the dose in an effort to get off the rollercoaster, or plunge onward and upward in dose while sticking to protocol guidelines. all three options will require more monitoring than usual in order to get a clear picture of what's going on. the reduction earning cycle will come 'round again.



hopes this helps. i know it can be very confusing...

Emily:

So as a general rule of thumb, it seems if I'm getting high numbers after a dose increase - wait 72 hours (or three days) and then start counting cycles

Click to expand...

No..I don't think that is what Sienne is saying. If you get high numbers after a string of lower numbers (could even be blue numbers but often green), THEN you wait 72 hours or six cycles and see what he does. Some kitties clear bounces in less than 72 hours; you'll have to figure out if he has a "norm". Consider two different scenarios below:

1. he gets into green, and then numbers shoot up into 300/400. This is the bounce. Wait at least six cycles (72 hours) for him to clear because, as Sienne said, after he clears, he could come back down. He might clear in three cycles and come back down....then you decide what to do. If he does not clear in less than six cycles, then wait the full six cycles, see what he does, then decide whether you need to take him up.

2. once you increase his dose, he may have higher numbers for a bit due to "new dose wonkiness". See the post below. New dose wonkiness tends to clear out after a day and then you can see where he's headed. He might not get NDW. On an increase, you follow the protocol:

Increasing the dose:
•Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose.
•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.

Click to expand...

Here is a post Jill did on "New Dose Wonkiness".

NDW

I've also attached Jill's recent post about counting cycles:
Counting Cycles

And I'm glad you like the patience pants. Don't worry about getting your own...we share ;-)

Ok, clearly I need to re-study the documents as if I were in graduate school again.

Thanks for setting me straight and thanks Julie, Sienna, and Marjorie for the detailed explanations.

My plan at this point is to wait and see how he does on this dosage...and go from there, maybe it will require a dose drop, maybe an increase. Will have to wait and see. Unfortunately, my life really doesn't allow for testing much more than I am - it's been quite an effort to get home and test him in the middle of the day, as my work schedule doesn't really allow for that. I will try to get a couple of middle of the night tests, this week, but that's probably going to be about all I can do.

I miss PZI. The protocol was so much clearer.