7/4 Papaya AMPS 594 +4=274 PMPS=328 +4=110 +6=58

Yesterday

I did a pre-bedtime check and yikes, Papaya was at 40. I fed her LC mixed with 17% carb FF and set the alarm to check for two hours later, at which time she was already up to 160. So a high preshot number again this morning, but dropping pretty quickly already by +4.

Some followup on yesterday's advice:

Sienne and Marje, you both suggested yesterday feeding a higher-carb-low-carb food. What percent carb are you suggesting - I assume still below 10, but higher than the FF 4%? Are you suggesting feeding that all the time, or should I try something like the low-low carb at preshot and then the +1.5 and +3 feedings of the higher-low-carb? I may experiment with both of these. The +3 feeding does seem to have helped a bit, so I think this is a good suggestion. As I am about to go into in detail, I don't think I have a lot of room for changing dose, so adjusting food is probably a good option, thank you.

Sienne, you're right, I wasn't differentiating between below-40 and below-50. I will take that into account in future.

Marje, I'd like more information on what you said, "I think if you really tried to get Papaya either on the TR protocol or the Start Low Go Slow Approach, you might see her doing better. I don't think you are using this insulin to its maximum potential to benefit Papaya." In what specific ways, based on the numbers RIGHT NOW (not months ago when I was still figuring this out) Papaya's spreadsheet, would you suggest change?

Is the reason you state I am not "using this insulin to its maximum potential" because I do not decrease as soon as I see a 50?

TR sticky says: "The suggested "guidelines" in the Tight Regulation Protocol are just that... guidelines. Not hard and fast rules.
The Tight Regulation Protocol is a great place to start, but once you gain experience and knowledge of YOUR cat's response to insulin you may find yourself in need of tweaking and refining your approach to treating your cat's diabetes. "Every cat is different" is not just a slogan. Following suggested guidelines is a great place to start, but some kitties will force us to think outside the box."

If you look at the SS around December, I reduced every time the numbers according to the protocol told me to reduce. We worked our way right down to 1 unit, and I ended up with a cat in high pinks and reds, with bloodshot eyes, drinking water like it was going out of style and lying there looking miserable. And in the middle of all that she would still occasionally pull a green out of her hat. So no, I do not take reductions quickly and there is a very good reason for that. I have been waiting until dropping to 50 or so is clearly a pattern and not a freak event.

Or do you think I should be increasing? TR sticky says:
"Increasing the dose:
Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
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."

Am I missing something? I don't see where Papaya's nadirs call for an increase. Yes, the preshot numbers are insane, but isn't it nadirs that determine the dose? Even if we give more consideration to the preshots, what would happen if I increase the dose in a cat that can go from black to green in one cycle?

I wasn't familiar with SLGS so I looked it up:

"The curve should be evaluated by someone experienced at interpreting feline blood glucose curves, in order to check for signs of rebound and other possible problems. If no rebound is present, follow these guidelines for dose adjustment (smaller adjustments may be appropriate for cats on PZI or Lantus):
a) If the lowest point of the curve is above 150 mg/dl (8.3 mmol/L), increase the dose by 0.5 unit.
b) If the lowest point of the curve is between 90 and 149 mg/dl (5.0 and 8.2 mmol/L), keep the dose the same.
c) If the lowest point of the curve is below 90 mg/dl (5.0 mmol/L), decrease the dose by 0.5 unit."

Even that doesn't call for an increase at Papaya's current numbers, does it?

Can you understand my frustration here? I see new people come on the boards, all freaked out that their cat is diabetic, having to learn to home-test and everything, and then a couple months later their cat is off insulin. I am basically in financial ruin from the expenses treating my cat has already incurred, and getting sick all the time no doubt due in no small part to the completely screwed-up sleep schedule I have been subsisting on for months and months. My cat just doesn't follow the expected behavior, and telling me that it must be because I am not following protocol or not testing enough is not helpful when her numbers are just not falling into the pattern of more "well-behaved" cats.

As to testing, it would be nice if I could stay at home all day, every day, with my cat and test every hour, but there's this little thing called "work" that is necessary if I want to be able to feed myself, the cat, and buy all those test strips (which in Canada are $0.75 per strip, by the way, and it's not always possible to make a border run). So yes, there are times when she's dropping and there are no further tests on the SS. That means I gave her HC, left more out, and hoped for the best because if I miss ANY work I won't be able to pay the rent.

I'm sorry this sounds like such a rant, I'm just finding it frustrating that Papaya is so hard to regulate and really don't see how I can be following the protocol any better. I do appreciate the food suggestion, and will do some experimenting in that regard. If you can tell me SPECIFICALLY how I need to be following protocol better to adjust Papaya's current dose, keeping in mind what I have observed about how Papaya does with too-hasty decreases, please tell me and I will see if I can do better and if that will make a difference.

And please, please, PLEASE, if there are people reading this who have bouncy cats and have found anything that helps, don't feel that you are not allowed to offer your thoughts just because you are not one of the two people on this board who are relied on to give advice. Your cat might be more like mine and what you have found to make even a bit of difference might be what Papaya needs.

Thanks again!

Edited to add: Sorry, forgot to address the suggestion to "feed the curve" - don't worry, I do. I just had stopped putting details of food on the SS since I wasn't posting here very much any more, so was not transferring all the details from the handwritten notebook I have at home. I usually give a teaspoon of something high carb hourly if the low numbers are early in the cycle, a mix of LC and high or medium carb if it's midcycle, or a bit of LC only if it's late in the cycle already.

Re: 7/4 Papaya AMPS 594 +4=274 caught a 40 last night

Dear Amy, I always read papaya's ss, because my dumdum is the same as papaya, they both have colorful ss. :smile:
I have the same problem with you, I read ss here every day for these few months since I joined FDMB, and I realize that most sugar cats here with Lantus, they do have good reaction to Lantus and get the low and flat curves in 1-3 months. I'm not going to describe how confused I am, I'm pretty sure you have the same feeling with me. I just want to provide my vet's suggestion today, she is famous for diabetic cats in my country. I've translate protocol to my vet and discuss with her before, and she told me I can use this protocol to adjust the dose, but in her opinion, we'll have to do adjustment depends on what their curve shows after we get more information about his reaction to Lantus , because every cat is different, not like dogs, they are so different in each one that in fact it is hard to find regular rules can be used by every cat. That's 2 months ago I first time met her.

Today I bring Dumdum's ss to her with my question : what else can I do to get his numbers better? I'm thinking of change insulin or change the rules I adjust the dose. In fact I would like to changing insulin more, I think what I've followed should have been make Lantus to shows all it can do, than maybe is just not suitable for Dumdum.

My vet is not agree with changing insulin, she said that it's true sometimes some cats' ss look like this, no matter use which kind of insulin. Changing insulin may not bring better result than now, and due to we are so familiar with Lantus, she think we should keep on use it.

Than the next question will be how to adjust. Here will be different from protocol. I have to say that I'm not sure will this work or not, but since there were two vet told me this way (the other one told me to do so last month, but I told her I'm going to try another month), I'll give it a try. You can try it or not, it depends on you. In their opinion, the curve can be see as in two circles (sorry that my English is not so well, I'll try to explain more, please ignore the wired grammar), that means due to Lantus will work more then 12 hour, so different dose at AM and PM shot will be OK, but not keep on changing dose, the regular dose should be maintain. Just shot different dose at AM and PM. For example, shot 2.25u at am shot, and shot 2u at pm. Also, in their opinion, adjustment in 0.25 won't affect depot's stable. The dose still should maintain more than 3 days. What I mean is if shot 2.25u at am and 2u at pm, it still need to do so at least 3 days to see what will happen. To them(my vets), the huge bounce(they all know what is the bounce) and huge drops also affect his own ability to stable the numbers, and also hurt his brain in long-term, so avoid huge bounce is important the same as lower numbers. This way will provide them still have overlap between circles, but better fit the Lantus's working time.

The other way the vet said last month, I think will be much more difficult to achieve, is shot every 18 hours. Even I always at home, I still don't think this is a easy way. This is because since we can see their circle is obviously longer than 12 hours, than the 12/12 shot is clearly not suitable for their needs, so just make the circle longer to fit their body, but this way will have another shortcoming that is his number will go back to peak than come down, the effect of Lantus won't be overlapping.

This are two ways my vet suggests me. Since taking care of sugar baby will be a long journey, I think I'll give a try to find the best way for him. If there is anything I didn't explain well, please let me know. Or any opinions to these treatments.

Hope both of our sugar babies will be fine, live long and prosper.

Re: 7/4 Papaya AMPS 594 +4=274 caught a 40 last night

Amy --

For me, it always helps if I understand the rationale behind what an experienced caregiver is doing. You're right -- the protocol is a guideline and you've been at this a while and understand your cat. It's fine to modify. Unfortunately, when any of us look at a SS, the reasoning behind what someone is doing isn't always evident. All that's there are numbers and the assumption is that someone is or isn't following TR (or sometimes, SLGS). We don't always know (or remember) what you've tried or what modifications you've made. I'm happy to brainstorm with you as I'm sure Marje is.

What I can tell you is what I've done with Gabby. I don't think she was quite as bouncy as Papaya but she could certainly bounce. Jill helped me to come up with a strategy that works for us. Fundamentally, I try to not allow Gabby to drop low enough to get a reduction. I'm fortunate in that Gabby has an early nadir so you'll see on our SS that I test a lot early in the cycle. If I see that numbers are heading downward, I try to buffer the drop by feeding HC. Usually, Gabby will surprise me with a number below 40 and I shave the dose. If you're going to handle the numbers this way, you do need to be vigilant. It's an aggressive strategy and by shaving rather than taking a full 0.25u reduction, you could end up working very hard to prevent numbers from tanking. I also front load the cycle with food. Gabby gets meals at pre-shot, +1, +2 and +3. This helps to offset her fast, early drops.

The strategy did not work immediately. It took several weeks for me to begin to see changes on Gabby's SS.

Using food to manipulate the curve is a trial and error process. By all means, try one approach for a couple of weeks. If you get the results you want, great. If not, try a different approach.

Re: 7/4 Papaya AMPS 594 +4=274 caught a 40 last night

Many of the folks over on PZI/Prozinc also have steep curves. The tactic of deliberately feeding a bit of medium to high carb food around +3 to flatten the drop is one that was suggested as a way to postpone a reduction. It usually results in a higher nadir and flatter curve.

If you've got a feeder or could freeze a few teaspoons of the medium or high carb to thaw and be nibbled later, you might see how that worked for you on a day when you could monitor.

There are some things that will cause steep curves regardless of insulin type. An insulinoma is one of them (DebH's XuXu was believed to have had this.)

Re: 7/4 Papaya AMPS 594 +4=274 caught a 40 last night

Thanks, akilo, for your long and thoughtful reply. I do understand the concept you're talking about with the "circles". Papaya and I used to live in Taiwan (Banqiao) so if I was still there I would go to your vet! I used to put her in my backpack for rides on the scooter :lol: I have sometimes wondered if shooting on a shorter schedule would work with Papaya - like a smaller amount every 8 hours to keep her numbers from shooting up before the next shot - but I think it would be very difficult to schedule this. I think I am going to try changing her feeding schedule and type of food a little first.

Sienne, thanks for explaining what you do with Gabby. I have always wondered why your spreadsheet always shows HC at +1, +2, +3 rather than taking reductions, but I may have to try that and see if I can flatten the curve a bit. There is no way I can do the hourly feeding considering I already have to do the shot at 4:30 AM to know where the cycle is going before I leave the house . . . getting up at 4:30 and 6:00 before actual get-up time of 7:30 is already nuts, I just can't squeeze another sleep interruption in there! But I will try a bit higher carb food perhaps at the 1.5 or 3 mark and see what happens.

BJM, thanks for your input as well. Papaya for some reason will virtually never eat unless I am home offering her the food. I always leave some out, literally a foot from where she is hanging out for the day when I leave, and it is untouched when I come home. I hope that if she was dropping low enough to actually hypo she would have the instinct to eat it, which is why I leave it out, but it's not a strategy I can really rely on. I will try to flatten the drop with MC around +3.

I realize the Americans here are having a holiday weekend so thanks for stopping by anyway on your day off . . . enjoy the weekend.

Re: 7/4 Papaya AMPS 594 +4=274 caught a 40 last night

Amy

It was not my intent to frustrate you and I tried to give you some examples instead of just saying "you aren't following the protocol". Take a look at Gracie's SS and click on her Lantus tab. She never bounced as high as Papaya but she was pretty well known around LL as being difficult to regulate. And I was working and juggling a million other things as well.

I attribute her current regulation to switching to levemir and us figuring her out a little more. We've had to try different things as well to see what worked best for her including different dosing and feeding plans and using R to minimize the bounce when she started it. She still befuddles us sometimes but it's gotten alot better. Jill and Libby have both been instrumental in us getting to where we are with her. I know if you look at her SS right now, you would wonder what I could possibly know about dealing with a difficult to regulate cat. Well....I do totally empathize.

What I would like to do is exactly what you have asked for but, because today is a holiday and we have guests coming over for a BBQ, I will need to do it for you tomorrow when I have lots of time to go over her SS much closer and give you examples. Again, you might peak at the ones I gave you again as a starter.

So I hope you will not mind if I do this tomorrow for you. Try to relax today and enjoy the holiday. Good catch last night!

Re: 7/4 Papaya AMPS 594 +4=274 caught a 40 last night

Amy --

You're correct. There are some people who have gone to an every 8 hour shot schedule. If you work, it's exceptionally hard to do especially if you are the only caregiver. I have some flexibility with my work schedule so I can get those early meals in. The bottom line is to try a strategy, keep really, really good notes, and give the approach enough time to see if it works. Don't expect an overnight change.

Re: 7/4 Papaya AMPS 594 +4=274 caught a 40 last night

Marje, please just enjoy your weekend and don't feel you have to spend ANY of it going over Papaya's numbers. She's been on a rollercoaster for most of the year, and I am going to try a few things with food, so it can certainly wait! I realize you're not trying to frustrate me. Just don't lump me in with people who bemoan their cat's numbers while all they're getting is maybe high yellow or worse preshots and not doing any midcycle testing at all or changing the dose all year. I just hate when I reach out for any ideas for a non-standard cat and the first response is "oh, you're not following protocol well enough" or "you're not testing enough". I do have to economize somewhat on the testing and I try to remember that testing does not FIX her BG at that moment. It adds information, which can be used over the long run, but sometimes I just have to say that I know she is safe right now, so I am going to have to save this strip that I could have used on getting a tiny bit more information for tomorrow when I may really need it to save her life. But overall I think I am testing quite a lot - I almost always get midcycle numbers, either early so I know where she's going, or before bed, or around what I think nadir will be. Yes, there **may** be times when she went lower than I realized, but unless a cat somehow has a BG monitor hooked up to their circulatory system, I think that can be said for any cat, right? Sometimes she coasts downhill all night for a low preshot. I can't stay up 24 hours a day testing hourly, obviously. So rather than looking back to try to pick out a possible error months ago, I would be more curious what you are suggesting for right now. Are you advising increasing, decreasing, or staying at this level? At what point would you increase, decrease, or hold, if it is different from what I understand the protocol to say?

Sienne, the only thing that stops me from trying an 8-hour schedule is the need to feed in the early hours. I could, just barely, do it because I actually work a 7-hour day. (Guess I really better work on getting my Etsy shop going so I can just stay home and knit lol). Right now it would mean shooting and immediately leaving, which I just don't think is safe. I wonder, though, if the early feedings would still be as important on a lower/more frequent dose of insulin. Do you recall any of the users that have tried that schedule? I'd like to look at some spreadsheets if there are any around. Oh, also, and if you don't happen to get back to this thread to read the question I'll try to remember to post it in Gabby's condo next week, how much (proportionately to the whole day or cycle) are you feeding Gabby at each meal? Is it split up evenly or more weighted toward the preshot, or towards the +3?

Again I'm just posting this because it's part of the ongoing conversation but please don't worry about answering in detail right now - enjoy the weekend (I'm in Canada, we had our long weekend Monday already) and we'll continue to discuss this in the coming weeks. Thanks.

I decided to start trying the feeding higher-low carb tonight, but since I have only low carb and quite a bit higher carb, I mixed them.

PMPS: low carb
+1.5: mixed averaging to 7.5% carbs
+3: mixed averaging to 10% carbs

I guess it's good I started this already since by +6 she was still down to 58. I fed her 17% carb mixed with LC at this point and will retest again at +7.

Amy --

This is the one kitty's SS that I remember where there was three times per day dosing: Doodle. Look in he date column for how often Michelle was shooting since the SS is organized a bit differently.