First, a few notes and caveats:

1. This forum is not a high-traffic forum. Time-sensitive questions likely won't get answered quickly -- please post them to the health forum instead.
   
2. The quality of advice may vary with each person's individual experiences and research.
   
3. This FAQ is a work in progress and will change. Nothing written here is gospel truth. We're here to learn more and debate about unusual cases, not necessarily to form a consensus.
   
4. Comments and criticism for the FAQ may be discussed here in the TR forum.
   

Q1. What is Tight Regulation?

Regulation of a diabetic cat is an attempt to bring that cat's blood glucose within safe levels and keep it there, using scheduled insulin shots and maybe scheduled feedings. So let's start with our FAQ's definition of that.

The FAQ question 6.1 defines regulation in terms of blood sugar range and clinical signs:

• Not treated [blood glucose typically above 300 mg/dl (16.7 mmol/L), poor clinical signs]
  
• Treated but not regulated [often above 300 (16.7) and rarely near 100 (5.6), poor clinical signs]
  
• Regulated [generally below 300 (16.7) with glucose nadir near 100 (5.6), good clinical signs, no hypoglycemia]
  
• Well regulated [generally below 200-250 (11.1-13.9) and often near 100 (5.6), no hypoglycemia]
  
• Tightly regulated [generally below 150 (8.3) and usually in the 60-120 (3.3-6.7) range, no hypoglycemia, still receiving insulin]
  
• Normalized [60-120 (3.3-6.7) except perhaps directly after meals -- usually not receiving insulin]
  

So to begin with, Tight Regulation is an attempt to achieve the Tightly regulated range. It's a more difficult but (many believe) healthier goal. With the more difficult goal comes more work and extra care.

Some of the techniques used to achieve tighter regulation include:

• choice of a specific insulin and diet well-suited to that cat
  
• more frequent blood tests and insulin shots, either 3 or 4 times daily, or as needed
  
• feeding at specific times to match the specific insulin's known action profile
  
• use of a well-tested combination of insulins (slow/fast or basal/bolus) at specific times
  
• change of insulin dosage based on current glucose levels (aka "sliding scale")
  
• change of insulin dosage based on recent readings and experience
  

See also Janet's Beyond BID document for further techniques.

Various "protocols" or sets of rules have been developed for dosing diabetic cats. Some, including Dr. Rand's protocol for Lantus, Tilly's protocol for Lantus and Levemir, and Dr. Hodgkins' protocol for PZI, call themselves "Tight Regulation" protocols -- their first goal is to keep blood glucose close to non-diabetic normal ("euglycemia").

Q2. Why make this attempt?

Dr. Rand and Dr. Hodgkins both claim that with Tight Regulation, it's also possible to bring a large number of newly-diagnosed diabetic cats into remission, meaning they stop needing insulin injections and require only a diabetic diet. No large-scale studies have shown just how many cats can achieve this goal.

Even in cases where remission is not achieved, keeping the cat's BG levels as normal as possible ("euglycemia") is much healthier for the cat long term, shown to drastically reduce complications in humans, and will almost always bring back the cat's old personality and activity level. Insulin requirements will often decrease too.

In some cases even euglycemia can't be achieved. In those cases "Tight Regulation" refers to using similar methods of frequent monitoring, food measurement, insulin choice, and frequent injection just to keep things as comfortable as possible for a difficult cat.

These good potential results should be balanced against the downsides and the risks.

Q3. What is the downside? What are the risks?

The downside is that you may be spending more time (and possibly money) monitoring glucose, measuring food, doing curves, and on some protocols, shooting insulin more often.

The risk includes giving insulin before the previous dose has worn off ("overlap"), so you may need to watch the cat for hypo more often.

Q4. Why is this not the standard protocol, and should it be?

The typical for-and-against arguments can be summarized like this:

Tight regulation is riskier
Moving the goals toward lower blood sugar ranges may increase the risk of hypoglycemia. Dr. Rand agrees but states that she thinks the risk is justified. Note that Dr. Rand's first study, unquestionably successful, had all her cats monitored, 24 hours a day, by experienced people. In her case, it would be easy to note a cat approaching hypoglycemia, and immediately correct the situation. If your cat isn't monitored 24 hours and you're not as experienced, your risk is higher.

Loose regulation does further damage
Being too afraid of causing hypo can itself cause damage too, though. Inadequate insulin dosage leaves your cat at risk of DKA, an even more serious emergency than hypo. (Hypo caught early can usually be treated at home -- DKA usually cannot.) High blood sugar itself causes damage over the long term too.

In particular, high blood sugar suppresses the cat's own insulin production.
Dr. Rand states that anything that causes very high blood sugar over 3-7 days will suppress the pancreas.

In addition, high blood sugar can permanently damage the pancreas through amyloidosis. This means that poor regulation, or even good regulation that's not tight enough, may in the end make the cat permanently diabetic.

Tight regulation may help heal
In contrast, in some cases Tight Regulation can jumpstart the cat's suppressed pancreas by removing the toxic high glucose conditions that keep it dormant. Dr. Rand concludes in her study that diabetic remission is a realistic goal for newly-diagnosed diabetic cats. This is possible in some percentage of uncomplicated type-2 diabetic cats, 64% in Dr. Rand & Kirsten's study of 55 uncomplicated diabetic cats.

Some who have successfully regulated their cats years ago believe that they were using forms of "Tight Regulation" from day 1, and some add that it need not be difficult or stressful. Tight regulation under the supervision of an experienced vet may be just as easy as any other kind. Others believe that tight regulation is too difficult and dangerous for caregivers to attempt at first.

Q5. Should I try Tight Regulation?

After you've found a good diet, a suitable insulin that lasts until the next shot time, and approached Regulation, this is something to consider.

Dr. Hodgkins and Dr. Rand, on the other hand, emphasize the limited time window after diagnosis during which remission is possible, and urge that cats be on tight regulation protocols from day 1.

Your own schedule may prevent you from trying these methods. People who work from home or are at home most of the day are the best candidates for this type of regime, since monitoring and injections sometimes go on a very frequent schedule.

Steve and Jock recommends people not begin attempting Tight Regulation until:

1) They have adopted a low-carb diet successfully.
2) They have an insulin that works well for their cat. (Recommended are PZI insulins, or Lantus (glargine), or Levemir (detemir)).

Q6. Is this a vet-approved goal?

Two vets in particular, Dr. Elizabeth Hodgkins of California, and Dr. Jacquie Rand of Queensland University, recommend it. Their approaches are different but they both seem to agree on their conclusions, which include:

* Good glycemic control is best obtained using long-acting insulins and low carbohydrate diets

* Early intervention with good glycemic control reverses beta-cell glucose toxicity and facilitates early remission.

* Achieving diabetic remission is a realistic goal for the veterinary practitioner, and remission rates are high when good glycemic control is obtained soon after diagnosis.

* The goal of therapy has changed from controlling clinical signs to curing diabetes.

Q7. Okay I'm game, I really want a healthier diabetic kitty, and to try for remission; how do I start?

Once you've considered the factors in Q4, please start by making sure you know as much as possible about your cat's reactions to insulin. Know what dose it takes to get to a good BG level, and how long it stays good. Make a target blood sugar range for your cat and write it down.

If you can, through experimentation, determine exactly how much insulin reduces Blood Glucose by some fixed amount, say 100mg/mL, you are halfway there. If you know how soon that insulin works and for how long, this will help tremendously.

Some people use one of the established "Tight Regulation" protocols (all of which customize themselves to the cat over time). Others start elsewhere with their vet's assistance.

Some protocols include a "sliding scale", that is, shooting differing doses of insulin depending on the current meter reading. There is no standard sliding scale -- you need to figure out what works best for YOUR particular cat. Steve and Jock believe the sliding scale approach works best with faster-onset insulins like PZI, and very poorly with slow-onset insulins like Lantus and Levemir.


Next steps may include:

• Determine what kind of shooting schedule would keep your cat's BG numbers in the normal (non-diabetic) range for most of the day.
  
• Determine what you will do when and if your cat's liver/pancreas objects to these lower numbers with a rebound.
  
• Share your results so we can help each other out.
  

Q8. What protocols/procedures are out there for my insulin?

* Dr. Rand's protocol for Lantus: (See Dr. Rand's Protocol page: [www.uq.edu.au] ) Dr. Rand's protocol is specific to Lantus (glargine) insulin though she's starting to mention that Levemir should work just as well. Dr. Rand's protocol is more aggressive at the beginning, assuming that monitoring for hypo at all times is possible. If that's not possible, modify by starting at a lower dose.

On the other hand, Dr. Rand's protocol is less tight in other ways -- the upper blood sugar limit is 180 (10.0), and she allows a few days to go by between blood tests once initial regulation is established, which doesn't go down well with the FDMB's "test then shoot" philosophy.

* Kirsten and Tilly's Tight Regulation protocol for Lantus and Levemir Is a tighter-regulation Lantus and Levemir protocol developed by the German Feline Diabetes group.

* Dr. Hodgkins' protocol for PZI: (See Dr. Hodgkins' page: [www.yourdiabeticcat.com]) Diet and insulin type are extremely important to this protocol. It is specific to PZI insulin and low-carb canned or raw food. Dr Hodgkins no longer offers direct advice on this forum (or not often).

* There are no known Tight Regulation protocols for Caninsulin or Vetsulin, and Steve and Jock and Kirsten and Tilly believe that this insulin will not ever be suitable for Tight Regulation in cats, due to the large drops in blood sugar and short duration of its action.

Q9. Is this going to be a lot of extra work?

The cats on Dr. Hodgkins' protocol with PZI insulins usually are tested 3-4 times a day, at least at first.

The other protocols above usually require twice-daily shots and testing only 2-4 times daily.

Changing to a low-carb diet can be tricky but you shouldn't begin these protocols until that's in the past anyway.

You don't need to begin Tight Regulation as a big change. You can work your way gradually tighter, too. The alternative of normal regulation can always be gradually tightened down by lowering dietary carbohydrates, spacing shots a bit tighter or increasing dosage, or changing insulins to get more duration. That said, many people have found that once they achieve numbers in the cat's normal (non-diabetic) range, the cat seems to "like" it there, and it's not as easy to return to the higher ranges while remaining predictable.



Edited 39 times. Last edit at 08/19/08 08:17AM by Steve and Jock.