? 1/7 Pearl - Thinking of switching to TR?

Hi all!

Pearl is a new diabetic and on Lantus, you can find her BG spreadsheet link in my signature. Her BG numbers have been flopping around, and I'm so confused. At first (and some cycles even now) they are even and more straight line, and some cycles she is swinging between 200 points.

Can someone help me with advice or at least knowing/reading what is going on? Her diet is controlled. I try to feed her 2 mini-meals in the first 5 hours of each cycle, and after that only occasional snacks. She gets Wellness Core Turkey and Duck (5% carbs) for food and snacks - Fussie Cat Tuna/Anchovies (0 carbs) or Origen Lamb treats (0 carbs).

I was thinking of upping her dose by 1/4 unit this weekend - but would like advice on that given her flopping numbers. She is on Day 2 of 1.25 units (previously 1 unit).

Her other meds are: Flovent 250mcg BID (asthma), Pred 2.5mg every third day (weaning off or as low as we can go, for IBD and asthma), Gabapentin 25mg BID, Cerenia 6mg, Pepcid 5mg

Thank you for your help and input,
Margaret (and Pearl!)

 

Hello!!!

It looks like you are following SLGS, which means that you would hold the dose for 7 days before performing a curve and deciding upon adjusting the dose at that time - unless kitty shows a BG under 90 at any time, which would entail an immediate 0.25 reduction.

I would recommend getting a test before bed at +2 each night. Many kitties go lower at night and getting a +2 can give you an idea of (potentially) where she is headed. Similar to last night 1/6, where you saw a drop between PS and +2 and then you tested again a few times overnight. There are some evenings where you don’t have a +2, so it is hard to tell how low the dose could be taking her.

A normal reaction to a number she isn’t used to yet is called a bounce, where you see kind of like a rebound to a higher number. Some of the am red preshots ( like this morning) could be bounces, but hard to tell without some of the data. This is the livers natural reaction to what it perceives as a threat to the system, where it facilitates the dump of glycogen from its stores into the bloodstream to bring BG back up. While the BG that initiated the bounce may not be unsafely low...fast drops, large downward changes and lower than the kitty is used to can initiate a bounce.

as for the bounce itself, there isn’t anything you can do other than wait it out. Kitties bounce, until they don’t, and some bounce right into remission.

For your thought on increasing, you will want to wait the 7 days, then perform a curve (a test every 2 hrs for 12 hrs, or every 3 hrs for 18 hrs). The data you are collecting from now until then will help determine the next course of action. Again, you would reduce by 0.25 at the next shot for any number under 90. (119 isn’t that far from 90).

Keep asking questions! We are here for you and Pearl

 

Thank you for your response! Since we are just starting out, I chose SLGS but could do a modified TR version. I am nervous about her hovering in those high numbes for so long. If I am testing as much as I am, and can add in 1-2 nighttime cycle tests, would the TR just entail changing doses more quickly?

I am open to TR if that means getting her regulated more quickly, and since I can do the testing (my vet had encouraged me not to just b/c she is not a fan of home testing - that is where I got the SLGS).

Thanks for your advice - if you recommend TR for a kitty like Pearl who jumps, I am happy to do it.

PS - about her last night cycle. What i reeaaaly don't understand: at +10 she was like 232, then 2 hours later 460! Why would her body want to bounce at those numbers?

Thanks again so much!
Margaret and Pearl

 

In the below link you will find the details to SLGS. I re read them all the time

https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/

 

Yes I"ve been reading the guidelines, thanks. To me, it sounds like I do more of a TR tracking on her spreadsheet, don't I? (the gaps 2 weeks ago are for when my vet had me convinced to stop testing). I mean, with SLGS, you don't test much. I am happy to be doing the testing. To me, at this point that looks like the only thing differentiating the two methods for Pearl. If I wanted to do TR, what do I need to change in my current spreadsheet? I give timed meals, I test throughout the day (and now in the night 1-3 times). I am always at home. I think TR sounds more like what I am looking for, yes?

 

This is the livers natural reaction to what it perceives as a threat. Yesterday, my guy Cosmo had a lovely blue surf going then, jumped from 166 at +8 to 353 at PS

It is involuntary, kind of like an adrenaline rush (fight or flight). Her body senses a 119 and thinks...”Hmmm, I don’t have as much sugar in my blood as I normally do. I don’t recognize this number. I need to make sure all important organs and brain has what it needs, so I need to release some glucose storage to make sure we have enough”.

Now eventually, as she spends more time in those pretty blues, her liver learns that 119 isn’t a threat to her system, but it doesn’t have the data to support it yet

 

I understand now, thanks so much for that explanation. So, her increase actually started hours BEFORE the +9, when she was at the 119. Makes total sense. Do you have any advice for me transitioning to TR instead of SLGS? I think we may prefer it, unless her chart to you looks so wonky you would not recommend it.

 

There isn’t a modified TR and that isn’t recommended, especially since TR is a more aggressive method towards regulation. The safeguards and parameters are in place to keep kitty safe, while helping the pancreas to heal. There are a few differences, in monitoring requirements, no kibble allowed, lower reduction points and ability to increase faster, etc. It’s true, that TR has more success in remission, but ECID (every cat is different).

What type of food does Pearl eat? Can you be home to monitor according to the TR requirements?

If you look at a few SS of other kitties that follow TR, like @JaxBenji @Butters & Lyla @Golf2015 you can see the level of commitment you can expect to ride the surf safely.

I see Pearl is also on steroids. Is that right? We have often seen steroid induced diabetes, which can resolve fairly quickly once the steroid is reduced.

I follow SLGS because Cosmo has some other conditions that require him to eat a special diet that is not low carb, but I wouldn’t discourage anyone from TR Have a read through and decide whether you want to switch.

 

Hi again and thanks for all this information.

Pearl eats Wellness Core Pate Turkey and Duck (5% carbs). Snacks are Origen Lamb (0 carbs) and Fussie Cat Tuna/Anchovies (0 carbs). No kibble in this household. I give her 50g mini meals at shot time and then 3 hours after shot time. She grazes until it's gone, and then there is either no food for her until the cycle is over, or I give her a small carb-free snack now and again.

I work from home so I am home ALL THE TIME. I am a highly educated researcher, so it's in my DNA to be monitoring closely and I really do know every single little detail of what is going on or WANT to know it (it was REALLY difficult for me when my vet told me not to test her, and I don't see the logic in that...I mean, you would test yourself or your child). I am/want to be highly attuned to the ebbs and flows of what is going on with Pearl, and I think by nature anyway I am doing TR type of monitoring.

Pearl is on steroids - which I hate. But she has historically had bad bouts with asthma (yes we do Flovent etc). I am down to Pred once every 3 days. I do not know if I will ever be able to get her off of them, but that is my goal. Is TR still ok to do with her on steroids?

When I read through - the SLGS has less monitoring I see, and perhaps that is why the increases/decreases are not as frequent. But I do lots of monitoring (and can do 1-2 also middle of night). So I think it's worthwhile for us to do TR. What do you think?

 

Love your desire and experience for facts and knowledge!

It sounds like TR could be a good route for you! If you would like some more opinions, specifically on switching to TR, you could update your thread title to something like “1/7 Pearl - Thinking of switching to TR” Selecting the question mark from the drop down will draw attention to your thread.

After that, we are always here to help! Many post daily and format our daily threads like this:

example:
1/7 Cosmo AMPS 200, +2 187, etc.
in the body of your post, you’ll want to link your previous post for continuity and information for helpers and advisers. We often go back a few days in posts to gather previous data and information. Sometimes it isn’t just BG related information that is relevant, but also clinical signs, eating habits, energy, etc.

 

FWIW, I test MORE than needed for TR. I don't want to scare you away from TR with my ear pokes Per Romp and Rand (summary here)

Intensive blood glucose control requires dedicated owners that are willing to monitor their cat’s blood glucose concentration a minimum of 3 times per day (on average 5 times per day).

I think people following TR here, aim for at least four tests a day (each preshot and then at least once more each cycle). Additionally, you have to be ready to test more frequently in lower numbers (e.g., a dip below 50 requires testing every 20-30 minutes until kitty is up to a safer number).

I think vets think caregivers don't want to test and/or the cat won't allow it. I started testing Jax before I found FDMB because I knew that if I was a diabetic that I wouldn't inject insulin without knowing my glucose. My vet never suggested testing for safety reasons (nor did the ER vet where Jax was diagnosed) BUT my vet was happy to hear I was - though mostly because Jax is fractious at the vet and there was no way I could take him to the vet for a curve (and my vet knew this ).

 

Hi and thanks for your message. Yeah, I think TR is right for us. My vet knows I am on top of every medical case, so her resistance here I think is just b/c no testing and then curve on 10th days is what she knows to do. I told her I am not interested in diabetes management, but am going for eradication as much as is possible with her co-conditions But yes I agree totally - if I wouldn't inject myself or my child without knowing what is going on (and the trends) with my blood sugar, I sure as hell wouldn't blindly inject Pearl either.

Your spreadsheet doesn't scare me. I don't think I would check every hour, but you can BET I would be on top of swings and dips. I don't take a backseat approach to anything about Pearl's health so can't see myself being casual about testing and what the numbers say either. It would make my anxiety SO MUCH WORSE to not test than to actually test.

So, here we are. And I will start the TR. So looking at my spreadsheet this means I give the current dose about 4 more days to sort itself out before increasing yes? And do you generally recommend to be posting daily and asking before I go ahead and do the increase?

Thanks so much for your input.

 

Congrats on the switch to TR!

TR thinks about it more in terms of cycles, rather than days. You would hold the dose for 6 cycles (3 days) before making dose adjustments, unless Pearl drops under 50, then you would take a 0.25 reduction at the next available cycle.

I post daily, but some do not. I personally find that one gets the most out of the FDMB experience by posting daily, asking questions, and also checking out others SS and posts to gain knowledge. I learn so much from other posts and have many condos (what we call threads) bookmarked.

 

yup, same!

You'll do great at TR and you can always switch to to SLGS if you ever feel the need. As for dosing, per TR, you hold the initial dose 5-7 days (to build the depot) - which you have done with your 1unit dose and then you increase every 6 cycles (3 days). Looks like Pearl is on cycle 3 of 1.25u so you have 3 more cycles at this dose (unless she asks for a reduction ). Sometimes we hold a dose longer when kitty first starts seeing blues and greens - see the section in the dosing method sticky about increasing the dose.

Looks like @Bandit's Mom stopped by in your previous condo - she can weigh in on dosing (I'm merely just restating what is in the TR sticky ).

And here's the link to your previous conod - https://www.felinediabetes.com/FDMB/posts/2712950/ - we also link to them for continuity.

Lastly, how often you post is totally up to you. I post daily - some post just as they are getting their footing, some post when their schedule allows. Personally, I'd post whenever you can (and are comfortable with) so that the experienced folks can look back for any history if needed.

 

Hi Margaret, I see you have swapped to TR. ...that’s great.
With TR you increase every 6 cycles if warranted.
If you are new to seeing blue BGs, it is recommended to hold the dose for at least 8 to 10 cycles before increasing. I can see Pearl had some blue BGs yesterday and is bouncing today.

Posting daily is a good idea if you can. It helps us to see how you are going and you will get support from others.

 

Hello Margaret and Pearl,
Welcome to Lantus and Lev board and welcome to TR.
Your comments tickled me, I would have gone nuts if my vet said I shouldn't test George, not testing him would have definitely given me more anxiety.

As others said you reassess the dose every 6 cycles (unless she earns a reduction with a drop under 50 on a human meter).

She got to blue on cycle 2 of the 1.25u dose, and she is new to blues, and new to insulin, so you would be looking at holding this dose a little longer than 6 cycles, at least 8 or possibly 10. She may stay in those yellow and pinks bobbling about with no significant curve for up to 6 cycles when she is bouncing, though she may clear it more quickly. If you spot a sudden dip, into a very low yellow or blue be sure to follow it up as that can often signal the start of the bounce clearing. If that happens just as she is due a shot and you shoot, the cycle can carry quite a lot of momentum, this is not a problem but you might need to monitor more closely.

Ready how you like to know what's going on and understand her cycles and their nuances, I would recommend you make not of what you are feeding and when, that helped me when I first started out, it helped others help me, but I could also look back and adjust what I was doing to better help George.

I would also point you in the direction of the New to the Group sticky you will find a lot of reading material there as well as links to further reading.
From that sticky here is the answer to your question as well as some other things you will probably want to start thinking about, to help you understand pearls reactions better.

A full understanding of the following concepts will go a long way in helping you regulate your kitty's blood glucose when using Lantus/Basaglar or Levemir:

• Carryover - insulin effects lasting past the insulin's official duration
• Overlap - the period of time when the effect of one insulin shot is diminishing and the next insulin shot is taking effect
• Insulin Depot - a "spare tank" of insulin, which has yet to be used by the body
• Lantus, Basaglar & Levemir: What is the Insulin Depot?
• Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

Don't be afraid to ask if you have a question, happy reading and look forward to seeing you on the board

 

Hi Gill and thanks for your message. It was really helpful. When you say to follow up a blue as it can start the bounce clearing - what does follow it up mean? What does clearing mean? I'm excited and nervous about TR but I think it's the only way for me to go - since yes it would drive me NUTS to NOT know the details of what my cat is dealing with or paying sharp attention.

 

Hi Margaret, Gill probably won’t be online for several hours now as she lives in Spain so I’ll explain what she means.
Clearing a bounce means that a kitty has come to the end of the bouncing and is going to start to come down to more normal numbers again, or down to where they usually are if still unregulated.
Gill explained bouncing in the previous post, above. Some cats when they are clearing (or coming down) off a bounce, can drop quite quickly and keep dropping until the end the cycle and sometimes into the next cycle....so there is no nadir in the middle of the cycle and then a gradual rise in numbers, but just a continuing drop in numbers, sometimes down into low greens.

eg they might start the cycle like this and go on to clear the bounce....
AMPS 400, +2 370, +5 250, (big drop here so I’d feed her and be aware the bounce may be clearing) 7+145 (a blue number so be alert), +8 100, +9 70, +10 60, +11 55, PMPS 55
You can feed during the drop to slow it down. And the lower the BG the more frequently you would test. But don’t feed for the 2 hours preshot unless she drops under 50.

If you get a clearing bounce, and you have a low preshot, you stall and see if the BG is rising and test again 20 minutes later. It probably will rise because it is the end of the cycle, but post and ask for help. You may need to skip, depending on how much the BG rises and how low you have been shooting. But we can help you.

So what Gill is suggesting is, if you see Pearl with a blue BG when she has been bouncing, followup and test again during the next several hours to see if she is coming off the bounce and is continuing to drop. These drops can be managed with food, so don’t be concerned. Does all that make sense?

 

Hi Bron!

Thanks for all that! Let me repeat what I understand and you tell me if I have everythign straight, ok?

So, I have been noticing that Pearl does not have a NADIR many times on the 1.25U dose. Her BG continues to go down during a cycle. It comes up again kind of for the next cycle PS reading. What you're saying is...if this gradual/quick decline gets down into the blue and doesn't start coming back up for the PS reading of the next cycle, then DONT SHOOT and post here asking for help. Is that right?

Also, that decline thing is called "clearing a bounce". Yes? And if the bounce is going too quickly (how do I determine what too quickly is?) then I feed it to slow it down. Yes? Do I feed it while she is still in a yellow or only when clearing the bounce gets into blue numbers too quickly?

Can you look at Pearl's chart for 1/06, her PMPS. Should I have not shot that, given that she was continuing to decline from the bounce? And tonight - if her PMPS has not risen but has declined further (even if over 200), then I should not shoot and wait 20ish min to see if she is continuing to decline or starting to rise?

Thank you for all the help!!!

 

The nadir is the lowest BG in the cycle. The nadir can move around.... sometimes early in the cycle, sometimes in the middle and sometimes at the end of the cycle.
Sometimes there are flat cycles where the BG stays around the same BG. Insulin is a hormone and works differently to something like an antibiotic. And ECID (every cat is different) so there are lots of variables.
So looking at Pearls SS she does mostly have a nadir somewhere in the cycle.
You can shoot any number that is above your "no shoot"(or stop and think about this number) number as you are learning to shoot lower numbers. As long as you can monitor the cycle, you can shoot any number 150 and above. Gradually as you get more data as to how Pearl manages shooting the lower numbers, you will be able to shoot lower than 150. If you get a number under 150, you stall, don't feed and test again in 20 mins and post and ask for help.
With a 'coming off the bounce' cycle that is strong, the numbers often drop into the lower greens and that is when you also stall, don't feed and ask for help.

yes

Yes. If Pearl is dropping more than about 70-100 points in an hour, that can trigger another bounce. You need to slow it down. I found that if Sheba dropped more than 70 in an hour she would bounce. But ECID so gather the data. Yes feed a drop. Just a teaspoon of low carb is usually enough.

If you see a drop of more than 70-100 in an hour I would feed that drop. Ideally you will learn from gathering data when Pearl mostly has her drops and can feed before the drop.

She was still above 150 so was fine to shoot.
As you gather data and learn to shoot lower numbers you will find that Pearl will hopefully (if she has read the rule book) start to stay in lower healing numbers. We have a saying here...shoot low to stay low. Cats on lantus, when given insulin in lower numbers usually don't drop as fast as they do from higher numbers so they get nice flat curves.

If she is over 150 you are fine to shoot. If you are concerned or in doubt, post and ask advice.
Remember you are testing and have the necessary food to bring the BGs up if needed so you are in control.

 

Thank you for your reply, and especially for this new information. She has been swinging way more than 70-100 points in a given cycle! So maybe that is why she keeps bouncing! I am not positive my low carb food will stop clearing a bounce if today AM +2 332, food at +3, then +4 241 is any indicator. But if I get in the habit of doing this, perhaps it will work then. I will start marking where all the food is given so the pattern becomes clearer.

 

It is 70 to 100 points in an hour not a cycle that can trigger a bounce.
You can put what you feed in the remarks column of the SS. That will help you and help us.
If you can work out when the big drops happen... it is often around onset and the next few hours... you can feed a good snack before the drop to slow things down. Sheba was a champion diver and bouncer and I found if I could stop the big drops by feeding before they happened I had better numbers. It is all trial and error and a lot of patience is needed!