12/17 Pumbaa - surfed green all day...and I was steering

No thread yesterday...nothing exciting to write about but a bounce, and too busy catching up on life and sleep.

Today's numbers might be the shed kicking in from the two doses of 3.25U he received? In any case, using higher carbed food, I really struggled all day to keep him above 50. Why did I do this? A) to try and prevent a bounce; and, B) because I didn't want him to earn another reduction since he just had one 4 cycles ago.

Here's what I did to steer his numbers:

AMPS = 72 Gave him his normal 5% carbs food. (Yes, I should have stalled, but I didn't, because if the shed really is what controls things, what difference would stalling have done?)
+1 = 77 Fed some 9% carbs food.
+2 = 67 Fed some more 9% food.
+3 = 64 Fed more 9% food.
+4 = 53 Still going down and a long way until nadir so I have him 19% carbs food (about half a teaspoon).
+5 = 75 He came up a bit, but I knew he could go down just as easily so I gave him more 19%.
+6 = 51 Good thing I gave him more 19% at +5, and also gave him more now at +6.
+7 = 60 Gave more 19% since there was still time for him to drop.
+8 = 87 Whew! Glad to see this number. Pumbaa didn't eat after this test. I'm sure his belly was pretty full at this point.
+9 = 83 Down very little. He didn't eat after this test, either, even though his 5% food was still out and available, as it was all day.
+10 = 82 I didn't see him eat after this test, either.

Some people will wonder, if these wonderful numbers were from the shed of the 3.25U dose, why I didn't keep him on that dose. Well, I can't work this hard every single day and night to steer Pumbaa up from numbers that would have gone too low, had it not been for giving him the higher carbed food when he needed it, which was nearly every hour. I would be absolutely elated if these numbers would have come naturally, without having to use a variety of levels of carbs to get these results. All of this testing/figuring out what to feed/enticing Pumbaa to eat really took a huge bite out of my concentration on work, and if I don't work, I don't pay the bills, as we all know.

Time for his PMPS test/feeding/shooting. Hope the PMPS is still around 80, if not a little higher!

Suze

The notes on his SS show you had to feed him 19% carbs for 4 feedings? Yeah, I'd say you had to work to keep him from dropping more!

If it takes this much "work" to keep him level, then why wouldn't a reduction make sense? When he dropped below 50 twice on 3.0, I kept wondering why the reduction wasn't taken, and why instead the discussion was about whether or not to increase.

I'm confused.

Carl

I have to add some comments about the food I gave Pumbaa today.

All I had in the house today to try to "steer" Pumbaa with was either 4%, 5%, 7%, 9% or 19% carbs. That was kind of fortunate, because I don't think anything less than the 19% would have kept Pumbaa from dropping below 50 between +4 and +8.

Tonight, I went to PetsMart (since they still have Friskies on sale for $.45 per can), and got a wider variety of % carbs food. I used Dr. Lisa's updated food value list, and made myself a cheat sheet that I taped to a 3 x 5 card, which will remain in my purse at all times. Anyway, I picked up some 13% and 14% carbed foods, in addition to what I already had on hand, for when 9% won't be enough, and 19% might be overkill. Here's the cheat sheet:



Once again, I will admit that, even two weeks ago, I was skeptical that I could use food to steer Pumbaa's numbers. But I'm a believer now! (Anyone else hearing that song by The Monkees after reading that? Hahahaha!)

What I like about this is that Pumbaa can eat less food overall, but get the extra boost of carbs, without being so full later that he can't eat even if he needs to food to feed the insulin. And the higher carbed food also seems to have more protein and less fat, and I think protein is important to fighting low blood sugar.

I think there should be much more discussion on these pages about steering the lows. Maybe there is, and I've missed it. But I really didn't get thinking about this until I heard it posed several times, because I swore that Pumbaa was just not carb sensitive, and he wasn't that I saw from the regular 4/5/7% carbed food he was being fed.

Suze

Impressive! :mrgreen:

Believe me it gets a lot easier once you find out what your carbs will do. And not every cycle requires that much steering.

Embrace the green! The ultimate goal of *tight* TR is green every hour of every day. Getting close! :thumbup

Notice I said *ultimate* the primary goal is to keep them between 50 and 200. But mostly flat green may actually be easier.

Carl,

Trust me, I'm confused, too! It just seems on TR that increases are called for more often than reductions are, for some reason. :roll:

I'm thinking Pumbaa's numbers today were from the shed of the 2 cycles he was at 3.25U, not from the 3.0U dose he's currently on. Which is why I didn't want him to earn a reduction, because I think he needs more time at 3.0U to level out, and because he just had a reduction 4 cycles ago. I am thinking that the 3.25U dose needs to work its way out of the shed, so we can see what Pumbaa can REALLY do at 3.0U.

Yes, in hindsight, as I've admitted, increasing him above the 3.0U dose was crazy. And I've been paying for that with having to fight the low numbers.

At the same time, I've seen nothing in the protocols discussing what to do when an FD cat drops below 50 on the first cycle of a dose increase. Maybe someone can enlighten me/us about this. It just seems insane to give a dose reduction that soon after an increase, when you have to consider shed-filling time, NDW, etc. (Even though I did a dose reduction 2 cycles into the 3.25U dose increase. And I'm glad I did!)

I could have decreased Pumbaa on 12/10 when he dropped to 49, but he still hadn't flattened out, and that is what I was waiting for. As well as the fact that 49 could have been a 58 with the +/- 20% meter factor. (Yes, it also could have been 39, but that is doubtful due his his next reading.)

Help me stay sane, Carl! :?

Suze

Congrats on the green day! Great work Pumbba & Suze!

Dale 'n' Chip said:

Impressive! :mrgreen:

Believe me it gets a lot easier once you find out what your carbs will do. And not every cycle requires that much steering.

Embrace the green! The ultimate goal of *tight* TR is green every hour of every day. Getting close! :thumbup

Notice I said *ultimate* the primary goal is to keep them between 50 and 200. But mostly flat green may actually be easier.

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Chippendale's:

While I loved learning that I can, indeed, steer Pumbaa's numbers via different percentages of carbed foods fed, I would think the goal of TR would also be to find a dose where you didn't have to steer like this, every hour on the hour. If I have to keep doing this, I will be living on the streets with Pumbaa and Larry and Beck, and there will be no money for insulin or test strips. :cry:

As I said above, I do embrace the greens! But not when it's a constant battle to keep the numbers in the healthy level of above 50 (or 40, or whatever). That is why I wish Chip's SS was more detailed and had more info about what you had to do to keep him at those great, above 50 numbers. It seems effortless to me when I view Chip's SS, yet I know you are steering him. That's misleading to the rest of us, since we are praying that our FD cats also had those great, constant not-too-low greens, with no effort. 'Ya know what I mean?

Suze

tortie58 said:

Congrats on the green day! Great work Pumbba & Suze!

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Thank you, Helen! (((HUGS)))

Pumbaa said:

...As I said above, I do embrace the greens! But not when it's a constant battle to keep the numbers in the healthy level of above 50 (or 40, or whatever). That is why I wish Chip's SS was more detailed and had more info about what you had to do to keep him at those great, above 50 numbers. It seems effortless to me when I view Chip's SS, yet I know you are steering him. That's misleading to the rest of us, since we are praying that our FD cats also had those great, constant not-too-low greens, with no effort. 'Ya know what I mean?

Suze

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It wasn't easy. But like I said it gets a LOT easier.

And it's certainly easier than the alternative for Chip which seems to bouncing to flat pink (or worse) and staying there.

I tried that for oh... about 4 months. It took a huge toll on Chip and an even bigger toll on me than this *tighter* TR.

Nope I won't be going back to that.

Me help keep you sane? That may fall into the "blind leading the blind" category, Suze :lol:

I'm thinking Pumbaa's numbers today were from the shed of the 2 cycles he was at 3.25U, not from the 3.0U dose he's currently on. Which is why I didn't want him to earn a reduction, because I think he needs more time at 3.0U to level out, and because he just had a reduction 4 cycles ago. I am thinking that the 3.25U dose needs to work its way out of the shed, so we can see what Pumbaa can REALLY do at 3.0U

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.

Well, you could very well be right. BUT, if it takes a few cycles to drain, then shouldn't it also take some time to fill? So then you wouldn't expect to see an immediate first-cycle reaction, like what happened when you increased to 3.0u. I do think you've already seen what he can really do on 3.0u. He dropped under 50 twice on that dose.

It could be that his "right dose" is somewhere between 3.0 and 3.25? Something to maybe consider if it happens that he needs an increase?

I'll keep watching and learning Suze. And I'll give sanity saving a good try too ;-)

Carl

Dale 'n' Chip said:

It wasn't easy. But like I said it gets a LOT easier.

And it's certainly easier than the alternative for Chip which seems to bouncing to flat pink (or worse) and staying there.

I tried that for oh... about 4 months. It took a huge toll on Chip and an even bigger toll on me than this *tighter* TR.

Nope I won't be going back to that.

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I'm confused...you tried what for about 4 months? Putting in your SS how you were steering Chip to get him to those numbers? I never saw that, and seeing that would help so many of us! Or do you mean going "relaxed" instead of following a specific protocol? If you meant going relaxed instead of tight, I'm still not sold. Not since Carl is the only one who called the dose decreases at 3.0U instead of calling for increases since he was following the protocols to a "T".

I share Pumbaa's SS as I do, instead of posting it to the web, so that everyone can see the detailed information/notes that I added to many of the cells, just by mousing over them, instead of having to scroll way down to see numeric citations. If anything I do with Pumbaa is going to help someone else, even if it was a warning to "not do this", I want to make sure that that information is shared, easily. And Chippendale's, my whole point on the previous post is that you have eluded to "steering", but haven't supplied us with the information about what you were doing to steer, in Chip's SS, to educate us about how you were achieving these amazing numbers. Numbers which seemed so effortless to the rest of us, when they aren't "effortless" at all.

That's my point. If people are steering numbers with various levels of carbed foods fed, I think that should be very evident on the spreadsheets. I finally, recently, figured out Marje's Gracie SS, and saw how she was documenting the % of carbs fed at what time. Those notations never made sense to me before, but they do now!

Suze

Chip was unregulated for the first 4 months on Lantus/Levemir.

Now he is regulated and it makes a big difference in his health and well being.

You say Pumbaa is *surviving* now, if you can manage to keep him regulated he might thrive.

Once you get there I'll bet you won't go consider going back. :smile:

Suze,
I appreciate that you flipped your SS back over, since it does make it easier for me to read. And on the share vs. publish thing.... well I found the share way very helpful tonight when looking at the notes you had every hour of today's cycle. Yeah, it takes a little longer to load, but mousing over the triangles beats the heck out of scrolling down to read footnotes on my computer. It doesn't help with my phone or tablet (since mousing isn't possible), but it sure makes it nicer on the PC.

Carl

Dale 'n' Chip said:

Chip was unregulated for the first 4 months on Lantus/Levemir.

Now he is regulated and it makes a big difference in his health and well being.

You say Pumbaa is *surviving* now, if you can manage to keep him regulated he might thrive.

Once you get there I'll bet you won't go consider going back. :smile:

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Chippendale's:

You are ignoring my comments about your sharing what you did to steer Chip and get the numbers that appear on his SS. Why won't you share what you have done, instead of leading the rest of us to believe that those numbers were effortless?

The only reason that Pumbaa is surviving now is that I learned how to steer his numbers up with food, when peer pressure on the TR boards caused me to increase him too much. I stand by this statement!

Per Roomp/Rand protocol, I never should have increased Pumbaa up to 3.25U, and should have reduced him when he was at 3.0U. But I didn't feel like he was ready for a reduction when he was at 3.0U, and you, and others, here on TR, pushed for that dose increase. For whatever reason.

Once again, I think that TR is not the place for me and Pumbaa. *sigh* It has only caused us grief, and stress, once again.


Suze

PS: And Pumbaa isn't regulated yet. Not when he keeps bouncing, and then diving. Or, diving and bouncing. It just depends on how you read his numbers, I guess.

Carl & Bob said:

Suze,
I appreciate that you flipped your SS back over, since it does make it easier for me to read. And on the share vs. publish thing.... well I found the share way very helpful tonight when looking at the notes you had every hour of today's cycle. Yeah, it takes a little longer to load, but mousing over the triangles beats the heck out of scrolling down to read footnotes on my computer. It doesn't help with my phone or tablet (since mousing isn't possible), but it sure makes it nicer on the PC.

Carl

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I'm so glad that some of my documentation is easier to read, even it it takes more time to load.
And I'm still trying to get used to reading Pumbaa's data from the top down again. It was so much easier for me to read it from the bottom up!

Suze

Suze

I want to comment about your observations but I am pooped tonight to make sense. So I'll give it a go tomorrow. I want to be sure you understand thenTR protocol and what it is and isn't because I'm not sure you do so please hang tight and ill try to put some cohesive and coherent thoughts out there for you tomorrow.

Pumbaa said:

...Why won't you share what you have done, instead of leading the rest of us to believe that those numbers were effortless?

The only reason that Pumbaa is surviving now is that I learned how to steer his numbers up with food, when peer pressure on the TR boards caused me to increase him too much. I stand by this statement!

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I'm certainly not leading anyone to believe anything is effortless. If anything looking at the SS you'd have to believe I'm crazy.

And that's because for whatever reason I've had to do this pretty much all by myself, so I'm not taking any chances. I'm just more comfortable testing *more* presently. I guess I could take the SS down if it's really such a terribly disruptive influence. :lol:

I've mentioned several times about the steering and there is not that much to it, besides knowing exactly how Chips reacts. I feed the steep drops preemptively when I see them coming and I dose the carbs required to keep him surfing 55-75 but not much higher, when it's possible for me to do that. Many people here seem to do the same thing. I generally don't free feed, unless I need to leave him locked in a room with food if I must leave him and I'm unsure of what his numbers are doing. That also means I usually don't offer food when he is surfing with numbers that aren't dropping.

One thing I thing I think would help you feel like you have more control of things is to work on your karo strategies, such as known drops of karo on Stella and Chewy's (or some other treat) and see what you can get from those doses. So you will always feel like you control his low numbers instead of the other way around.

That's the thing, why I'm able to do this with Chip. Because with ample testing, and experience/knowledge of carbs/spikes, I'm always in control of the lows. In spite of the fact that Chip is a cat, as long as I can test and know what the numbers are, I feel there is always something specific I can do about it. I even have carb dosing plans to address the possibility of a sputtering pancreas, which I already went through with Chip when he was on NPH.

The ususal caveats apply, these strategies are only applicable to Chip. And only because I make every unreasonable effort to be able to test him any time of the day or night that I might feel the need. :smile:

Chippendale's: You are crazy. ;-) I don't know how you manage on such little sleep!

The SS isn't disruptive...it's beautiful to look at. But...my whole point was that, other than your occasional mention of "steering the numbers" in your infrequent posts, it just looks like Chip surfs those safe greens effortlessly, without intervention from you.

Because with ample testing, and experience/knowledge of carbs/spikes, I'm always in control of the lows. In spite of the fact that Chip is a cat, as long as I can test and know what the numbers are, I feel there is always something specific I can do about it.

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Yesterday taught me a lot about controlling the lows, with Pumbaa. Without waiting for the big drop and then having to resort to honey/Karo Syrup. But I can't go without sleep like you can, and still have productive work days. *sigh* Last night, I was exhausted...and I tried staying up to get a +7, but put out 9% carbs food after Pumbaa's +5 just in case. (It was barely touched this morning, so it appears that Pumbaa didn't need to feed a low last night.)

I know you now totally embrace TR/Roomp-Rand/Tilly's (whatever you want to call it), and Chip has done well with it. But it doesn't address everything, including what to do if a cat earns a reduction within one or two cycles of a dose increase. And when it's not prudent to increase a dose. Since I control the syringe, what occurred yesterday is totally my fault for going against my gut and increasing Pumbaa to 3.25U in the first place. But I still don't understand why "increase" is the common battle cry instead of "hold" or "take the earned decrease".

Suze

Marje and Gracie said:

Suze

I want to comment about your observations but I am pooped tonight to make sense. So I'll give it a go tomorrow. I want to be sure you understand thenTR protocol and what it is and isn't because I'm not sure you do so please hang tight and ill try to put some cohesive and coherent thoughts out there for you tomorrow.

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Looking forward to it, Marje! I was too pooped to make sense last night, as well, so I don't even know if my questions/observations were clear. And all the in the world won't help me much this morning, either. *LOL*

Suze

Carl & Bob said:

It could be that his "right dose" is somewhere between 3.0 and 3.25? Something to maybe consider if it happens that he needs an increase?

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In total agreement here. Especially due to the fact that Pumbaa gets very good low numbers on the 3.0U, but it hasn't seemed to be enough to break him out of the dive/bounce syndrome.

Suze

Pumbaa said:

Carl,

Trust me, I'm confused, too! It just seems on TR that increases are called for more often than reductions are, for some reason. :roll:

I'm thinking Pumbaa's numbers today were from the shed of the 2 cycles he was at 3.25U, not from the 3.0U dose he's currently on. Which is why I didn't want him to earn a reduction, because I think he needs more time at 3.0U to level out, and because he just had a reduction 4 cycles ago. I am thinking that the 3.25U dose needs to work its way out of the shed, so we can see what Pumbaa can REALLY do at 3.0U.

Yes, in hindsight, as I've admitted, increasing him above the 3.0U dose was crazy. And I've been paying for that with having to fight the low numbers.

At the same time, I've seen nothing in the protocols discussing what to do when an FD cat drops below 50 on the first cycle of a dose increase. Maybe someone can enlighten me/us about this. It just seems insane to give a dose reduction that soon after an increase, when you have to consider shed-filling time, NDW, etc. (Even though I did a dose reduction 2 cycles into the 3.25U dose increase. And I'm glad I did!)

I could have decreased Pumbaa on 12/10 when he dropped to 49, but he still hadn't flattened out, and that is what I was waiting for. As well as the fact that 49 could have been a 58 with the +/- 20% meter factor. (Yes, it also could have been 39, but that is doubtful due his his next reading.)

Help me stay sane, Carl! :?

Suze

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I think you're getting it! Your thinking here is pretty solid. Disclosure: I am not looking at your spreadsheet right now (stupid work computer has google docs blocked!) so I'm not commenting on any specific numbers or actions, just on your observations and some thoughts about TR in general.

The numbers yesterday could have had influence from the 3.25, or maybe not so much, so if it happens again then you'll probably want to take the reduction.

I agree with you that for most cats, taking a reduction if they drop low on the first cycle or two of a reduction doesn't make sense. It's not written that way, largely for safety's sake. You've seen the cats who come in here, give insulin for a few weeks while kinda sorta following the protocol and then go OTJ. Many, many, many of them never even post here, they lurk, find the written protocol, sort of follow it on their own, and go OTJ without ever introducing themselves. The written guidelines are meant to teach people how to get data and "know thy cat." The written guidelines are what people should follow to start with. Then as you learn your cat, you will learn how to change things to fit your situation. I know I'm not here much anymore, but my approach when I'm working with a newbie is usually to let them take the reduction the first time and see how it works. If the cat is heading OTJ anyway, then it will probably work just fine. Otherwise the caregiver will usually say something like "sheesh, why didn't that reduction work?" Then it becomes a teaching opportunity to talk about what to do differently next time.

I will say that in my opinion, there is way too much "steering" going on in LL these days. I'm not saying it isn't the best option for some cats. Some of us have very challenging kitties, and I sure did my share of it with Lucy. I don't really know how it got started that almost everyone here is steering all the time. Back when Lucy was on the juice, we called Lantus the "Zen insulin" and people were told to wait and let the numbers come to you. Same protocol, just a different way of applying it... Sometimes trying to chase the numbers can mess things up even more. Sometimes, not all the time. ;-) IMHO newbies should keep it simple at first (because many of them will go OTJ anyway), then start tweaking as needed.

I did end up getting aggressive with Lucy and it worked for her, and it has worked for Chip & Dale and Gracie and others. But waiting has also worked for a lot of cats. Get the nadirs where you want them, keep the nadirs where you want them (increasing or decreasing as necessary) and just wait until the preshots come down. They almost always do come down, just that most of us aren't patient enough to wait that long. :mrgreen: And I don't mean waiting 8-10 cycles, I mean waiting as long as it takes. It can be many months. And yes, I include myself in that group of people who aren't patient enough to wait. :lol: Jazzy got increases any time I started seeing more yellow than I liked, but she was also a very easy to regulate cat so I could get away with that.

Regarding doing increases when there are low numbers, well, that is an individual thing. Sometimes if you have tried holding the dose and that doesn't give the results you want, or you're tired of waiting, increasing the dose a little and steering the middle of the cycle with food might help bring the high preshots down, or bring the bounces down. So, do you want to try to force the numbers down? And if so, are you willing and able to do whatever it takes to keep your cat safe? Or do you want to wait for the numbers to come down on their own? Either way is perfectly viable. I don't think I ever increased Lucy when she was getting low nadirs. Jill does it all the time with Alex, but Lucy and Alex are two VERY different cats. Alex gets a food spike from freeze dried chicken. Lucy sometimes doesn't even with high carb food.

So, know thy cat and do what works best for him, even if it goes against the grain. ;-) I like to see thinking going on.

Thanks for letting me go on and on and on in your condo. :mrgreen:

I also want to add that I also don't really think the "old" way of just waiting forever is always the way to go. Absolutely there are cats that are helped by carb manipulation. Usually the goal should be to feed their normal food and their normal quantity of food, but learn at which times during the cycle are best to feed that food. The goal should NOT be to use different carb % to steer the cycle every single day. If you need to feed 15% in the middle of every day to keep the cat safe, then your dose is too high. That's when you end up chained to the cat and not ever able to leave the house. Yes, it will probably bring the numbers down, but you have to be aware of the cost.

With Lucy, and what I have suggested to others since then, if she dropped low, I liked to first try a bit of her regular food to see if that would help her surf. I also watched to see if she would head for the food dish on her own when she was low. I saw that she would feed her own lows (whew!). If low carb food would bump her into a surf, then I could feel safe leaving her knowing that she would head to her food dish and she would be ok. When the dose got ahead of me and the low carb didn't put on the brakes, then she needed a reduction. Safety comes first, always. If you are someone who can be home 24/7 and is ok with that, then do what you want to do, but for most of us that isn't something we can do for any length of time.

There have been a few times since I started helping here when Jill and I did suggest carb manipulation. We used to agonize over the very idea, because we knew it meant that we were suggesting someone be chained to their cat. The ones I'm thinking of were cats who were down to 0.1u of insulin or less, appeared for all the world like they wanted to go OTJ, but were still bouncing. Couldn't stop insulin but couldn't safely continue it either, without doing some kind of manipulation. So we might suggest increasing the carbs by a couple of percent. The cats eventually went OTJ but needed some additional time on insulin to get there.

Ok, now I'm getting back to work. :mrgreen:

Libby and Lucy said:

...I did end up getting aggressive with Lucy and it worked for her, and it has worked for Chip & Dale and Gracie and others. But waiting has also worked for a lot of cats. Get the nadirs where you want them, keep the nadirs where you want them (increasing or decreasing as necessary) and just wait until the preshots come down. They almost always do come down, just that most of us aren't patient enough to wait that long. :mrgreen: And I don't mean waiting 8-10 cycles, I mean waiting as long as it takes. It can be many months. And yes, I include myself in that group of people who aren't patient enough to wait. :lol: Jazzy got increases any time I started seeing more yellow than I liked, but she was also a very easy to regulate cat so I could get away with that.

Regarding doing increases when there are low numbers, well, that is an individual thing. Sometimes if you have tried holding the dose and that doesn't give the results you want, or you're tired of waiting, increasing the dose a little and steering the middle of the cycle with food might help bring the high preshots down, or bring the bounces down. So, do you want to try to force the numbers down? And if so, are you willing and able to do whatever it takes to keep your cat safe? Or do you want to wait for the numbers to come down on their own? Either way is perfectly viable. I don't think I ever increased Lucy when she was getting low nadirs. Jill does it all the time with Alex, but Lucy and Alex are two VERY different cats. Alex gets a food spike from freeze dried chicken. Lucy sometimes doesn't even with high carb food...

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Thanks for jumping in here Libby. I've really appreciated your essays all over the forum. It was your entries in the Pogo Stick Cat thread (which Suze linked to in one of these recent condos) which were an important turning point (back then) in my thinking about how to approach Chip.

But there was something else you mentioned recently (and it's all right on topic for this condo) that I've been mulling and meaning to ask:

Libby and Lucy said:

For Gracie, I can think of three approaches that might be worth a try.

One is to leave things alone, nadirs are good and just wait to see if the bounces disappear on their own. Adjust the dose only if the nadirs require you to.

Another would be to say that maybe she doesn't hold reductions from 40s, and just wait until she gets 30s to reduce. Risky, wouldn't work for most people but you guys monitor around the clock so you could try it (I did that with Lucy, and it drove Jojo and Jill crazy! I didn't fully understand the risks I was taking and I don't think I would do it that way again).

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If I might ask, exactly what drove Jill and Jojo crazy? And why? And what were the unacceptable risks? At this point Chip clearly didn't hold his last mandatory reduction in the 30's (only a nudge at that) and I had to take him right back up. I feel like the choices are dealing with those unwanted reductions, or having him unregulated. Perhaps again for months or longer? Which seems *more* unacceptable after all he has been through. I can accept "being chained to the cat" for the time being, although not forever.

BTW I certainly don't steer all that much, not every cycle or every day. The majority of Chip's lazy green surfing probably is as easy as it looks. As long as I track with plenty of testing. It's just not enough carb manipulation that I felt the need to alter the SS to log it.

Dale 'n' Chip said:

If I might ask, exactly what drove Jill and Jojo crazy? And why? And what were the unacceptable risks? At this point Chip clearly didn't hold his last mandatory reduction in the 30's (only a nudge at that) and I had to take him right back up. I feel like the choices are dealing with those unwanted reductions, or having him unregulated. Perhaps again for months or longer? Which seems *more* unacceptable after all he has been through. I can accept "being chained to the cat" for the time being, although not forever.

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30s really aren't a place where most cats should be encouraged to go. If they are surfing merrily along in the 40s and 50s and happen to dip a toe into the high 30s, that's one thing. If they are dive-bombing to the 30s, that can be really hard to control. You don't have much time to react and correct the course, and once they are in the 30s and dropping you have no margin for error. It might only take a few minutes for 30s to become 20s and we don't want 20s ever.

And there is also the matter that I was working full time, so couldn't be chained to the cat. I'm very, very lucky that Lucy decided to do her big race down the dosing scale at Christmas, when I had time off and could manage it. If you look at Christmas 08, you'll see that I had quite a time keeping her from bottoming out while I tried to get ahead of her depot. Not fun! And I know it was not fun for Jill & Jojo either. I remember poor Jill cooking Christmas dinner with her laptop on the counter keeping an eye out for my next test. Now that I've been on that side of the laptop with other people, I understand that there are 30s, and then there are "OMG 30s!!!". Jill and Jojo acted calm because that's what we do, but later once we became friends they both let me have it privately. LOL! It did work for Lucy, but I didn't understand how close to the edge I was riding.

Libby and Lucy said:

Dale 'n' Chip said:

If I might ask, exactly what drove Jill and Jojo crazy? And why? And what were the unacceptable risks? At this point Chip clearly didn't hold his last mandatory reduction in the 30's (only a nudge at that) and I had to take him right back up. I feel like the choices are dealing with those unwanted reductions, or having him unregulated. Perhaps again for months or longer? Which seems *more* unacceptable after all he has been through. I can accept "being chained to the cat" for the time being, although not forever.

Click to expand...

30s really aren't a place where most cats should be encouraged to go. If they are surfing merrily along in the 40s and 50s and happen to dip a toe into the high 30s, that's one thing. If they are dive-bombing to the 30s, that can be really hard to control. You don't have much time to react and correct the course, and once they are in the 30s and dropping you have no margin for error. It might only take a few minutes for 30s to become 20s and we don't want 20s ever.

And there is also the matter that I was working full time, so couldn't be chained to the cat. I'm very, very lucky that Lucy decided to do her big race down the dosing scale at Christmas, when I had time off and could manage it. If you look at Christmas 08, you'll see that I had quite a time keeping her from bottoming out while I tried to get ahead of her depot. Not fun! And I know it was not fun for Jill & Jojo either. I remember poor Jill cooking Christmas dinner with her laptop on the counter keeping an eye out for my next test. Now that I've been on that side of the laptop with other people, I understand that there are 30s, and then there are "OMG 30s!!!". Jill and Jojo acted calm because that's what we do, but later once we became friends they both let me have it privately. LOL! It did work for Lucy, but I didn't understand how close to the edge I was riding.

Click to expand...

dale, thanks for asking some thought provoking questions.

libby, thank you for replying with explanations that are right on target.


some food for thought...
several years ago a highly respected member, Jess & Earl (who also happens to be a vet tech who works in a reputable ER), posted the following comments in a thread and they've stuck with me:

"Unless someone has evaluated her blood pressure, EKG, temperature, and checked electrolytes, you can't know if she is really having a hypo or not. Seizure and coma are the end stages of hypo--there are lots of potentially brain-damaging steps before that. Never hesitate to treat a worrisome number."

my intention is not to scare, but to emphasize libby's comments about the potential dangers of aiming for 30s or allowing cats to run in the 30s. seizures and coma are the end stages of a hypo. unless the cat is being properly monitored for all the things jess mentioned, we just don't know if in fact the cat is having a hypo when for all practical purposes, they appear to be asymptomatic.

Thanks Libby and even the *actual* Jill! :smile:

I don't let Chip surf 40's without intervention let alone 30's. So perhaps I'm not crazy for testing so much, and will remain "chained to the Chip" until such time as I can succeed with these reductions, if even still then.

Take a look at this cat when you get the chance and look at 11/3/12, Levemir. It looks like she was surfing in the 20's for as long as 6 hours, that certainly freaks me out. And that was with a Bayer Contour meter (I asked) which does not in my experience read low on the low end, unlike some of the Arkray Relion meters which may? So the cat really was/is surfing 20's on a regular basis.

BTW I just want to take this chance to publicly apologize to Jill. Not for any standard mischief or even questioning things, but for the far more dire offense of ever implying or suggesting there might be any better alternative to variations of Tilly TR for dosing felines with human depot insulin. I now firmly believe it's downright foolish if not dangerous to start any place else, I almost feel the need to dig through my posts and edit any that might have suggested anything to the contrary. Those really were the dark old days when people just had to guess and were routinely doing self defeating things like deliberately underdosing to avoid so called rebound, as opposed to orderly Tilly based dosing.

Then as now I was worried about Pumbaa, as is everyone in this thread. And I hope that Suze can get this all figured out, and do everything safely and by the book with least amount of stress and strife possible. The one thing I am now very sure of, she has the best help in the world right here all working together with a single goal of helping to get Pumbaa regulated, and without *unregulating* Suze in the process. :smile:

Libby:

First of all, thank YOU for commenting on this thread. Much appreciated that you took the time to do so. You make a lot of sense!

Thank you for thinking that I'm "getting it." That means a lot to me.

And thank you for the, "So, know thy cat and do what works best for him, even if it goes against the grain." That is the hard part, especially when exploring uncharted territory, which, in Pumbaa's case, was any dose above his previous high of 2.75U. After 8 months on insulin (Lantus for the first 5 months and now Levemir for almost 3 months), Pumbaa is still not regulated. He still bounces and dives, regularly. I figured that this was because I was too chicken to raise his dose higher, because he could easily dive below 50 on lower doses. But on 12/6, I bit the bullet, and raised Pumbaa to 3.0U. That very first cycle, he went down to 46. Which should have been a dose reduction per TR, but, like I said, it seemed stupid to do a reduction one cycle after raising the dose. This got me questioning the shed, and if Pumbaa actually reacts to the current dose, and doesn't wait for the shed to fill. I'm still not sure, but it does seem to me like he does react to the current dose increase immediately, based on recent dose increases.

In any case, my point is that when you are exploring new territory that you have no experience in, you either have to wing it, or rely on research (the protocols) and/or the experience of others for input. That's why on 12/14 I caved, and increased Pumbaa's dose to 3.25U, against my "know thy cat" better judgement. While others were encouraging me to follow the protocol and raise Pumbaa, Carl pointed out that Pumbaa had had two readings that called for dose reductions during the 16 cycles at 3.0U. Color me :?. Since taking Pumbaa down in dose in the past did nothing to even out his numbers, and because I have seen so many spreadsheets where increasing can cause the "magic" dose to be found, where the cat finally stops bouncing, I succumbed and forged ahead.

I like what you had to say about the "steering". Especially, "The goal should NOT be to use different carb % to steer the cycle every single day. If you need to feed 15% in the middle of every day to keep the cat safe, then your dose is too high. That's when you end up chained to the cat and not ever able to leave the house. Yes, it will probably bring the numbers down, but you have to be aware of the cost." I totally agree about the dose being too high if you have to "steer" like that. Yesterday took a lot out of me, and Pumbaa, and was not a very productive bill-paying-income work day. My goal for steering is simply to prevent the lows that cause the bounces and try to even Pumbaa out. IF I can and WHEN I can. Without being chained to my meter 24/7.

Libby, you also said, "The ones I'm thinking of were cats who were down to 0.1u of insulin or less, appeared for all the world like they wanted to go OTJ, but were still bouncing." OMG! Down to .1U of insulin and still bouncing? All this time I've thought that until Pumbaa stopped the bouncing, he wasn't at his ideal dose. Which is why I have ignored some earned dose decreases. People have told me to "ignore the bounces", but until I read what you said above, it never once occurred to me that cats could still go down the dosing ladder and go OTJ if they were still bouncing! This is such an epiphany, you have no clue! :YMHUG: I am now going to go and study Pumbaa's SS with this in mind. Have I been grabbing for the wrong ring on the Merry-Go-Round this entire time?

Libby, thank you, so much, once again for your input today!

Suze

Dale 'n' Chip said:

BTW I certainly don't steer all that much, not every cycle or every day. The majority of Chip's lazy green surfing probably is as easy as it looks. As long as I track with plenty of testing. It's just not enough carb manipulation that I felt the need to alter the SS to log it.

Click to expand...

I accept this. After what I went through steering Pumbaa yesterday, I simply wondered how much "steering" you were doing every cycle to cause Chip to have those great numbers, since you didn't notate it on the SS. And you are so lucky that Chip's green surfing is usually as easy as it looks on his SS!

Suze

Jill & Alex said:

some food for thought...
several years ago a highly respected member, Jess & Earl (who also happens to be a vet tech who works in a reputable ER), posted the following comments in a thread and they've stuck with me:

"Unless someone has evaluated her blood pressure, EKG, temperature, and checked electrolytes, you can't know if she is really having a hypo or not. Seizure and coma are the end stages of hypo--there are lots of potentially brain-damaging steps before that. Never hesitate to treat a worrisome number."

my intention is not to scare, but to emphasize libby's comments about the potential dangers of aiming for 30s or allowing cats to run in the 30s. seizures and coma are the end stages of a hypo. unless the cat is being properly monitored for all the things jess mentioned, we just don't know if in fact the cat is having a hypo when for all practical purposes, they appear to be asymptomatic.

Click to expand...

Thank you, Jill! Excellent information as Pumbaa has been in the high 30's with no signs of going hypo, but that doesn't mean that no signs mean he's okay.

Suze

Hi Suze,

I'm sure people who have been here long will be able to come up with other examples, but check out this SS, particularly around 11/18, 11/26, and 12/1. All green days, with bounces to follow. All on doses of .25u or less. It's just my sense that this is the exception rather than the rule, but yeah, drops of insulin will cause a bounce with some kitties.

https://docs.google.com/spreadsheet...JidERiWHIzZmNnV0F1QVVFZS12d3NodUE&output=html

Whew, Doug and Libby must be pulling their hair out, and I sure wish Libby would post more often. If not for help, then at least for support.

Carl

Dale 'n' Chip said:

Then as now I was worried about Pumbaa, as is everyone in this thread. And I hope that Suze can get this all figured out, and do everything safely and by the book with least amount of stress and strife possible. The one thing I am now very sure of, she has the best help in the world right here all working together with a single goal of helping to get Pumbaa regulated, and without *unregulating* Suze in the process. :smile:

Click to expand...

I'm also worried about Pumbaa, as I have been 24/7 since April.

And I appreciate all of the Pumbaa/Suze concerns and input in this thread, and previous threads. Truly!

But, the "by the book" is the problem. Especially when the input I'm getting tells me simultaneously to reduce and increase. And "the book" doesn't cover things like bouncing and diving, and earned dose reductions during the first cycle of an increased dose. And doesn't cover that a 49, which should be a dose reduction, could also be a 58 or a 39, with the +/- 20% meter accuracy ratio.

As I said (way, way above), my biggest concern is that people on the Lantus TR board are too willing to suggest dose increases after a certain number of cycles, because that is what protocol says, but protocol doesn't take a lot of pertinent information into consideration. Like, has the cat dropped below 50 on the current dose? And, at what cycle of the current dose did the <50 reading occur? And is the cat in question still clearing a bounce.

I hope I can get it figured out, too. Libby's comments really helped me get my confidence back, a lot!

Suze

Dale 'n' Chip said:

Thanks Libby and even the *actual* Jill! :smile:

Click to expand...

ha! it's no secret i don't post much any more, but you'd probably be surprised at the amount of time spent reading, researching, and studying spreadsheets... not to mention keeping up via emails sent between a number of LL members. some habits are hard to break after so many years. :lol:

Dale 'n' Chip said:

I don't let Chip surf 40's without intervention let alone 30's. So perhaps I'm not crazy for testing so much, and will remain "chained to the Chip" until such time as I can succeed with these reductions, if even still then.

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i'm with you. "feed the 40s". there's good reason behind that statement. safety is the number one priority.

Dale 'n' Chip said:

Take a look at this cat when you get the chance and look at 11/3/12, Levemir. It looks like she was surfing in the 20's for as long as 6 hours, that certainly freaks me out. And that was with a Bayer Contour meter (I asked) which does not in my experience read low on the low end, unlike some of the Arkray Relion meters which may? So the cat really was/is surfing 20's on a regular basis.

Click to expand...

i can't speak to the accuracy of the Bayer Contour as i haven't used it. however, i've used both the arkray vital and a couple of the relion meters. i have to agree they do seem to read low on the low end.

i had already seen the spreadsheet as well as the cycle you've mentioned. it wouldn't be fair for me to comment since the caregiver is not participating in this discussion. if the caregiver had been posting in this isg the advice would have been to feed and retest for as long as it took to pull those numbers up and keep them up.

for some reason there are some people who seem to think kitty is *safer* in low numbers when using levemir. i don't understand that thinking. earlier this year there was a lev kitty who experienced a symptomatic hypo:

• first shot. there was not any residual action from the depot involved.

• dose = 0.1 unit.

• preshot number = 480.

• +4 = 29 - she was staggering, unable to walk, glassy eyed, and trembling.

hypos can and do happen no matter what insulin is used. we don't have to fear low numbers when we're prepared to deal with them, but we must have a healthy respect for them.

Dale 'n' Chip said:

BTW I just want to take this chance to publicly apologize to Jill. Not for any standard mischief or even questioning things, but for the far more dire offense of ever implying or suggesting there might be any better alternative to variations of Tilly TR for dosing felines with human depot insulin. I now firmly believe it's downright foolish if not dangerous to start any place else, I almost feel the need to dig through my posts and edit any that might have suggested anything to the contrary. Those really were the dark old days when people just had to guess and were routinely doing self defeating things like deliberately underdosing to avoid so called rebound, as opposed to orderly Tilly based dosing.

Then as now I was worried about Pumbaa, as is everyone in this thread. And I hope that Suze can get this all figured out, and do everything safely and by the book with least amount of stress and strife possible. The one thing I am now very sure of, she has the best help in the world right here all working together with a single goal of helping to get Pumbaa regulated, and without *unregulating* Suze in the process. :smile:

Click to expand...

dale, thank you, but an apology is not necessary. you had different ideas and thoughts, but that was about protocol. over the years, those of us who have hung around here to help when they could have been off doing other things all come to the same conclusion: "you can lead a horse to water, but you can't make them drink."

the horse always drinks when he gets thirsty enough.
now that's not to say i didn't bang my head on my desk a few times after reading some of your posts! :mrgreen: :mrgreen: :mrgreen:



it's good to see chip doing so well! :mrgreen:

Carl & Bob said:

Hi Suze,

I'm sure people who have been here long will be able to come up with other examples, but check out this SS, particularly around 11/18, 11/26, and 12/1. All green days, with bounces to follow. All on doses of .25u or less. It's just my sense that this is the exception rather than the rule, but yeah, drops of insulin will cause a bounce with some kitties.

https://docs.google.com/spreadsheet...JidERiWHIzZmNnV0F1QVVFZS12d3NodUE&output=html

Whew, Doug and Libby must be pulling their hair out, and I sure wish Libby would post more often. If not for help, then at least for support.

Carl

Click to expand...

Carl, I did check out that SS, and my question is, what high carbs is Hershey getting into to cause those high numbers? Does he still have access to dry food other cats (or the dog) are being fed? Answered my own question with a little research. This, posted on the 11/20/12 SS, tells me that Hershey's numbers are caused by dry food he's getting into: "AM KIBBLE! grrrrrrrrr Had it REALLY well hidden, but *oops* led to kitties not being fed on time. Apparently, Oreo thought he should take matters into his own paws and we awakened to a MESS where he had knocked the container from the top of the fridge to the floor!"

In my house, all three animals are off kibble. There is no kibble in my house that Pumbaa can get into. It was too hard for me to take away Beck's kibble if she didn't eat it all during feeding times, to make sure that Pumbaa didn't go at it. Beck (the drooler) is doing wonderful on her all natural, no dog food diet. And, I make sure if I eat any carbs, that there are no crumbs anywhere for Pumbaa to snarf up and cause a false high in his numbers.

Suze

Yeah, that day Hershey and Oreo decided to mess things up. But the other bounces weren't caused by dry food. Hershey's always been a bouncy boy. And definitely a deep sea diver. You know Pumbaa's Friday Night Adventures? Libby's had quite a few of those too, but not on a schedule like Pumbaa. Hershey's much more random :lol:

Carl

Jill & Alex said:

dale, thank you, but an apology is not necessary. you had different ideas and thoughts, but that was about protocol. over the years, those of us who have hung around here to help when they could have been off doing other things all come to the same conclusion: "you can lead a horse to water, but you can't make them drink."

the horse always drinks when he gets thirsty enough.
now that's not to say i didn't bang my head on my desk a few times after reading some of your posts! :mrgreen: :mrgreen: :mrgreen:

it's good to see chip doing so well! :mrgreen:

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You're a nice women, Jill. Thank for that. And for not holding grudges. Chicago women vent and get over it. *LOL*
Suze

Suze, thanks for letting me hijack your condo, and Dale, thanks for your good questions too. I love a good discussion!

As I said (way, way above), my biggest concern is that people on the Lantus TR board are too willing to suggest dose increases after a certain number of cycles, because that is what protocol says, but protocol doesn't take a lot of pertinent information into consideration. Like, has the cat dropped below 50 on the current dose? And, at what cycle of the current dose did the <50 reading occur? And is the cat in question still clearing a bounce.

Click to expand...

You're right, it's easy to become reliant on what the protocol says vs. what the spreadsheet and Whole Cat Report say. It's never a bad idea to question something you don't understand, or to put your own thoughts out there for feedback (which you do).

Also, Suze, the protocol is not etched in stone. It's an extremely useful set of guidelines, but it won't address every question or situation. If it did, it would have more pages than War and Peace
As you've seen in this condo, people can look at data and see more than one course to follow. Experience, your experience, will ultimately be your best teacher. But it sure doesn't hurt to have years of others' experiences to help you along. And at least there IS a protocol that works pretty darn well.

Carl

Libby and Lucy said:

Suze, thanks for letting me hijack your condo, and Dale, thanks for your good questions too. I love a good discussion!

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I'm glad you do.

You'll never know how much we appreciate Jill and yourself stopping in here with words of wisdom and hard earned experience.

So thanks much! :smile:

I have another interesting and related question. With a cat (patiently waiting for the numbers to come?) still heartily bouncing yellow and pink, how do we know when a reduction has failed or not? With Chip it's more straight forward, if he loses regulation (starts/keeps bouncing?) the reduction has failed and I take him promptly back to the last good dose (and hopefully) back to regulation.

I know and agree there should be no New Dose Wonkiness (NDW) with a reduction, but how can one ever tell the "Wonkiness" from the "bouncing", from the ever creeping pink/yellow Insulin Resistance/Glucose Toxicity?

I see so many bouncing cats earning reductions but frankly besides that single dive that went (barely) too far, I can't really detect any appreciable difference in the numbers before or after. Sienne must usually come along and remind them to increase. ;-)

How do we sort out all the various pinks and yellows or worse after the (mandatory) reduction?

Jill & Alex said:

i can't speak to the accuracy of the Bayer Contour as i haven't used it. however, i've used both the arkray vital and a couple of the relion meters. i have to agree they do seem to read low on the low end.

Click to expand...

The Contour is a consistent and reliable meter and apparently the human glucometer used by Roomp/Rand to set the glucose thresholds for Tilly TR.

The blood glucose values were based on using portable glucose meters (Ascensia Contour, Bayer,
Leverkusen, Germany; Accu-Chek Aviva, Roche Diagnostics, Basel, Switzerland)

Click to expand...

The most commonly used glucometers were the Ascensia
Contour (Bayer, Leverkusen, Germany; 37/52;
71%) and the Accu-Chek Aviva (Roche Diagnostics,
Basel, Switzerland; 10/52; 19%).

Click to expand...

It may be nice to have the extra safety factor with the Arkray Relion meters (reading low on the low end) however it may require more flexibility with the reduction thresholds to avoid taking (failing?) reductions that weren't in reality earned. There is always the 20% factor but these Arkray meters may be beyond that.

I get around this issue by using the Bayer Contour meter to check lows. I would use the Contour for everything if I could afford enough strips, DCIN can only provide a basic allotment, so I'm using Vital/Prime.

Jill & Alex said:

dale, thank you, but an apology is not necessary. you had different ideas and thoughts, but that was about protocol. over the years, those of us who have hung around here to help when they could have been off doing other things all come to the same conclusion: "you can lead a horse to water, but you can't make them drink."

the horse always drinks when he gets thirsty enough.
now that's not to say i didn't bang my head on my desk a few times after reading some of your posts! :mrgreen: :mrgreen: :mrgreen:



it's good to see chip doing so well! :mrgreen:

Click to expand...

It's too bad someone couldn't get through to me sooner. ;-)

There's such vastly differing opinions and when we arrive here we have no way to know "who" is "who" out of the gate. Julia was finally able to get me back on track by directing me to (the same) basic Tilly Roomp/Rand flowchart and also importantly she advised me to pay close attention to Sienne and yourself. That latter bit of advice may have come a bit late for me to just start a condo. But I did the next best thing, I revisited and soaked up Pumbaa's famous condos which were chock full of amazingly comprehensive advice and formed the basis for teaching myself TR. So just know all the effort and attention put into those was put to good use. :thumbup

Poor horse, or should I say poor Chip, he was certainly flat pink for weeks longer than he should have been.

But fortunately he's since made up lost ground and is now thriving. You could say the horse got pretty darn thirsty. :mrgreen:

Carl & Bob said:

That day Hershey and Oreo decided to mess things up. But the other bounces weren't caused by dry food. Hershey's always been a bouncy boy. And definitely a deep sea diver. You know Pumbaa's Friday Night Adventures? Libby's had quite a few of those too, but not on a schedule like Pumbaa. Hershey's much more random :lol

Click to expand...

Pumbaa's scheduled Friday night dives were bad enough! *LMAO* We all knew they were coming and we all still have no clue how Pumbaa knew when it was Friday night! These deep sea divers are a nightmare to any caregiver, that is for sure!

Suze

Libby and Lucy said:

You're right, it's easy to become reliant on what the protocol says vs. what the spreadsheet and Whole Cat Report say. It's never a bad idea to question something you don't understand, or to put your own thoughts out there for feedback (which you do).

Click to expand...

Thank you! I love you for saying this! But sometimes, I feel like I am not doing Pumbaa justice because I am hesitant to follow protocol based on his history. But, today 12/20/12, he had excellent numbers at 3.0U. Hindsight says I should have just left him at 3.0U instead of increasing him. That was my gut feeling, but my gut feelings have been wrong in the past.

And, until you brought it up recently, I had no clue that FD cats could go down the dosing ladder when they were still bouncing. That has really changed my outlook on how to dose and feed/steer Pumbaa, and I appreciate that input so much you have no clue!

Suze

Carl & Bob said:

Also, Suze, the protocol is not etched in stone. It's an extremely useful set of guidelines, but it won't address every question or situation. If it did, it would have more pages than War and Peace
As you've seen in this condo, people can look at data and see more than one course to follow. Experience, your experience, will ultimately be your best teacher. But it sure doesn't hurt to have years of others' experiences to help you along. And at least there IS a protocol that works pretty darn well.

Carl

Click to expand...

Carl, I adore you for all of the help that you provide to all of us, but...you have also stated that you think we should follow protocol to a "T".

As you said, and as I have questioned, protocol doesn't cover every circumstance. And, when protocol doesn't cover something, aren't we just relying on opinions to make the next move? As in the conflicting comments I was receiving about increasing/decreasing during the same insulin dose? That is the hard part. Listening to recommendations, and trying to follow protocol, and trying to take our unique cat into consideration, all at the same time. That is why I have said before that the TR boards are stressful, because too many people just suggest dose increases because that is what protocol calls for. *sigh*

Suze

Dale 'n' Chip said:

But I did the next best thing, I revisited and soaked up Pumbaa's famous condos which were chock full of amazingly comprehensive advice and formed the basis for teaching myself TR.

Click to expand...

Obviously, I have missed a lot! :YMSIGH:

I've learned a lot, but I have also missed a lot.

Suze

Dale 'n' Chip said:

I have another interesting and related question. With a cat (patiently waiting for the numbers to come?) still heartily bouncing yellow and pink, how do we know when a reduction has failed or not?

How do we sort out all the various pinks and yellows or worse after the (mandatory) reduction?

Click to expand...

Excellent question! Would love to hear input on this.

My guess would be that you would have to wait for the bounce to clear, entirely, and see if the cat in question settles back down into low numbers or not. Pumbaa didn't clear his last bounce until the 6th cycle, so being patient would be key. At the same time, you don't want to wait too long to bring them back up to a higher dose if necessary, so being patient would be difficult.

Also, Marje brought up something in a different thread, which I thought about trying this morning, and that is not taking the reduction in the cycle immediately following the cycle where the reduction was earned if the numbers look like the cat is going into a bounce. If I wasn't going to be tied up in meetings this morning (and unable to test frequently), I would have kept Pumbaa at 3.0U for another cycle.

Suze

Carl, I adore you for all of the help that you provide to all of us, but...you have also stated that you think we should follow protocol to a "T".

Click to expand...

Damn, you're gonna make me search for where I said that, aren't you? ;-)
C

Okay, I did the grunt work, and I think you are referencing this:

As one who used to be "fearful of the protocol " (as anyone who was around this time last year might recall), I'll say it was because I didn't understand it. I never followed it, and it overwhelmed the hell out of me. A year later, not so much. Still haven't used it, but when I look back on the treatment routine I used on Bob, it was a lot more scary than TR. A year later, I actually think that following the TR protocol, to the letter, makes dealing with this condition much easier. How awesome is it that you have this document that tells you "if this happens, then you do this"? I would have killed for that with PZI

Click to expand...

.

Then I also said this:

My point is, that only after seeing in black and white that following the protocol to the letter wasn't always working, you tweak it based on what you know - YOUR cat. But until you know for sure the protocol isn't working, the best way to deal with this is to stick with it. And bounces be damned. In my mind, I'd let Bob live on a freaking trampoline if it meant he'd go OTJ and I could get him below the renal threshold as quickly and as often as possible. What's better, living in the yellows and blues, or taking the occasional pink that will go away within a couple of days?

Click to expand...

You'll notice that there are "qualifiers" in those quotes. There always are. I never used Lev or the protocol so I'd have to be an idiot to not make any advice conditional. If you notice, I said only after proving to yourself that it isn't working, then you tweak things. And obviously, there's things that bother you, like bouncing, that wouldn't concern me as much.

But please keep in mind that I was arguing that you follow the protocol to a T, in a discussion where I felt that the protocol indicated that you needed to reduce, while most of the discussion was about you increasing? So yeah, in this case I felt the protocol, as I understood it, need to be adhered to.

Carl

Also, Marje brought up something in a different thread, which I thought about trying this morning, and that is not taking the reduction in the cycle immediately following the cycle where the reduction was earned if the numbers look like the cat is going into a bounce. If I wasn't going to be tied up in meetings this morning (and unable to test frequently), I would have kept Pumbaa at 3.0U for another cycle

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Yes, the concept is "shooting through the bounce", and it's just one of many tricks of the trade I have learned about from the amazing folks that have "tutored me" in the past several months of my education here. I had to turn off my PZI brain to grasp that one :lol:

Carl

Pumbaa said:

Dale 'n' Chip said:

I have another interesting and related question. With a cat (patiently waiting for the numbers to come?) still heartily bouncing yellow and pink, how do we know when a reduction has failed or not?

How do we sort out all the various pinks and yellows or worse after the (mandatory) reduction?

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Excellent question! Would love to hear input on this.

My guess would be that you would have to wait for the bounce to clear, entirely, and see if the cat in question settles back down into low numbers or not. Pumbaa didn't clear his last bounce until the 6th cycle, so being patient would be key. At the same time, you don't want to wait too long to bring them back up to a higher dose if necessary, so being patient would be difficult.

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I don't believe they should bounce when the reduction is successful. The protocol stresses that the cat must remain in normal numbers after any reduction. Or you return to the last good dose. Or you continue increasing until you reach a good dose. Normal numbers in this case are 50-200.

At each newly reduced dose, try to make sure the cat is still stable in the normal range before reducing the dose further.

If the cat will not stay in the normal range after a reduction, immediately increase the dose again to the last good dose.

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And you shouldn't be stacking failed reductions either, if a reduction fails then you return to the last good dose. A good dose is one where the cat remains between 50-200.

I don't see any allowance for bouncing in there. The zen approach of waiting for the numbers to come must predate Tilly, because I don't see any case where you wait more than 7 days before the next increase when the cat is still bouncing above 200.

As far as going all the way down the scale, I believe those are cats which were stable and regulated at 0.25U but started bouncing again when they were reduced to 0.1U?

If not then l'd love to hear the explanation for that. I sincerely doubt many cats go OTJ without first reaching regulation and normal numbers i.e. remaining between 50 and 200. And of course they aren't/shouldn't be OTJ unless they remain in normal numbers. The only brass ring here is regulation and remaining in normal numbers (well before any pipe dream of OTJ) and the dose at which that occurs may vary widely for each cat. Some 0.5U, some 5.0U, some 50U (high dose acro), we shoot whatever it takes to make it happen, only of course after reaching such dose in a methodical organized manner using the protocol. Remaining as close to normal numbers as possible is the most important objective here.

I suppose for Chip's sake it's a good thing I just doggedly/blindly followed the flow chart and didn't try to over think it.

okey-dokey, here's my take. I know I won't address all of your points because I'm feeling a little scatterbrained today, but let's see how I do. :lol:

First, recognize that our protocol in Lantus ISG is a modified version of the Tight Regulation Protocol for Lantus and Levemir. The modifications are minor, and are based on anecdotal evidence after years of observation of the cats that have gone through LL. In some ways we are more aggressive than the published protocol (for example, allowing for fat and skinny doses, and not really allowing for decreases of 0.5u or 1u), and in some ways we are less aggressive (some people think we shoot low, but take a look at some of the older spreadsheets on the German forum! Though they do seem to be getting more conservative about low preshots lately. I think they also tend to be more aggressive calling a reduction "failed," but here we have found that in most cases it is best to wait for the bounces to clear). Our adaptations are based on what we have seen that works in most cases.

In the modified protocol, we state that "Adjustments to dose are based on nadirs with only some consideration given to preshot numbers." Tillydiabetes.net states "When the cat first begins to have daily nadirs in the normal range of a healthy cat (50 to 80 mg/dl) and spends significant amounts of time in this range each day, stop increasing the dose and switch to Phase 3. It doesn't matter when you measure these lower BGs, it can be at pre-shot or sometime between shots." and '"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.(emphasis mine). It doesn't say they have to be under 200 ALL the time, just as much as possible. The published version also focuses primarily on nadirs.

Yes, cats can continue to bounce after reductions, and some cats continue to bounce until right before they go OTJ. Here is Alex's first spreadsheet, which Jill has labeled as pre-TR. This was when she was first working with Kirsten and learning about TR - shooting that low almost got her kicked off the board! Luna tried to drive us crazy by continuing to bounce on the tiniest dose of insulin. And then here is the famous Riggs, who bounced like crazy even when he wasn't receiving ANY insulin!

It is important, too, that while it would be nice if the path to OTJ was working up to a good breakthrough dose and then down to nothing, in truth most cats have to take a few attempts at getting there. Lucy went from 4.25u to 1u and then back up to 4.25 again before going OTJ. Many cats go up and down in dose for quite a while before one day they finally hit the moment that we call "The Snap" and they hit all blue/green. It happens overnight usually, and is a thing of beauty. Lucy finally snapped at 2.25u on her final trip down the dosing ladder.

So, how do you know if a reduction has failed? Primarily by nadirs - when any bounce has cleared, does the cat manage to get back down to a nice green nadir? If yes, hold the dose. If no, increase the dose. We do recommend waiting out the bounce because we've seen too many times that people increase too quickly and the cat ends up bottoming out. Does that mean there aren't people who increase sooner? Nope, as people get more experience they will tend to do whatever works for their own cat. It does remove the "safety net" that is built in to the TR protocol and we don't typically recommend things like that in condos because this is the internet and you never know who might be reading.

Another thing to keep in mind if you are watching the people who give advice in condos - I freely admit that I give different advice to different people. Somebody who has been posting a while and who I know will watch their cat for as long as it takes and I trust them to come back with updates will usually get more specific/aggressive advice than someone who tends to post questions at PS time then disappear for the evening, and I don't trust them to follow through. True. I refuse to be the one responsible for a cat being put into danger. I "advise" based on what I know is safe, but I will support people who want to be more aggressive than that. Does that make sense?

oh good. libby was able to get back here before i could! i agree with her on all counts. i'm another one who may offer advice based on the caregiver and/or the response of a particular cat. so yeah, a reader could think i'm offering conflicting advice if they happened to be following my posts.

btw, i don't *think* i was in danger of being kicked off the board for what was considered shooting low numbers back then (120 - 150). a couple people asked me privately not to put my preshot numbers in the subject line in my posts! :roll:

one of the first caregivers in the ISGs to follow the TR protocol to the letter was tracey/george. tracey was beside herself trying to get george regulated. i spoke with her about TR several times and she decided to go for it. you can see what a HUGE difference following TR made on george's spreadsheet. tracey began following TR in november 2006. the protocol was a little different back. doses were generally held for a week before increasing. tracey stopped posting much during this time to avoid criticism from those who were against tight regulation. it took a whole lot of encouragement to get her to start posting again so that others could learn from example.

we've come a loooooooooooooong way in a few short years in learning how to use lantus/levemir!

about meters...

The Contour is a consistent and reliable meter and apparently the human glucometer used by Roomp/Rand to set the glucose thresholds for Tilly TR.

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yes, it was. however, a little known fact... or at least discussed on the fdmb... is over the last few years the test strip manufacturers have been changing the methodologies used in their test strips to test blood glucose. the changes have been made to weed out properties in the blood which could affect the readings shown on the meters (make the result appear higher) in order to get a "true" BG reading.

i've been doing some research on the subject, but (1) so much of this is over my head, (2) it's hard to find much on the internet on the subject, and (3) getting info from strip manufacturers has been like pulling teeth. i've included the little bit of information i could find on the tab labeled Strip Comp on alex's ss.

based on a limited amount of research, as well as the allowable +/- 20% variation in meters, the fact that you can take 2 readings moments apart and get different results, not to mention differences between any 2 meters will be much greater at high numbers... my conclusion is there aren't any meters which reflect 100% accuracy. and trying to compare them is a bit like repeatedly hitting your head against a brick wall. even the manufacturer of alphatrack test strips recently changed the methodology used from GDH-PQQ to GDH-FAD. incidentally, the new GDH-FAD methodology used in the alphatracks is the same methodology used in the freestyle "butterfly" strips which has been totally discredited by some members of this board. :shock: :shock: :shock:

100% accuracy no longer matters to me. what i look at is ranges... and conclude alex is "somewhere" in that range. i'm good if she's running in the normal range. i don't like ultra lows as much as i don't like high numbers. i try to make adjustments accordingly instead of getting hung up on particular numbers.

Yes, the concept is "shooting through the bounce", and it's just one of many tricks of the trade I have learned about from the amazing folks that have "tutored me" in the past several months of my education here. I had to turn off my PZI brain to grasp that one

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carl, we stole that concept from the PZI group several years ago! :lol:


a note about clearing bounces...
we're all familiar with the statement, "it can takes up to 72 hours for a bounce to clear." well, guess what? it *can* take longer than 72 hours to clear a bounce! look at tucker's spreadsheet for an example. it took 4 days for tucker to clear a bounce. i've always suspected it could happen, but have never seen such a clear-cut example. ECID. the longer i stick around here the clearer this point is driven home. :mrgreen:

about failed reductions...
it's all about nadirs. if kitty is remaining high, go back to the last good dose.



just some thoughts...