? 3/31 Asia AMPS 204 Thoughts/ideas how to extend duration

http://www.felinediabetes.com/FDMB/threads/3-28-asia-amps-167.193259/#post-2159445

Houseguests are gone! It was sad to see my niece go, she lived with us for awhile and she is very attached to my girls.

Overslept by an hour, accidentally turned off my daily am alarms, don’t recall doing that or why.

This new food experiment is very interesting, I’m getting pretty spot on predictable numbers, at least for AMPS: 167, 161, 143, 139, 167, 167, 204, 204. It’s like she does the same thing for 2 days and then switches it up. I’ve changed her dose from 1.25s to 1 to a fat 75 in that time as well. PMPS might be more predictable too, but many of the PMPS numbers were bounce influenced, so I can’t say. She’s also predictably taking a dive in +4 both cycles.

Not sure where all this lime green is coming from, it’s happened even with reductions. I didn’t take a reduction from yesterday’s am cycle because it was way too close to the previous one.

The reductions are keeping the middle numbers low (too low in these cases) but raising the bookends significantly. Don’t know what the heck to do about that! She has a solid 3 hours pre and post shot where duration is just lost. It’s about 12 hours in green and 12 hours in higher numbers.

I very briefly considered what TID dosing would look like and as much as I’d like to try it because I’m very curious, I think it ultimately would just be a huge PITA for me and I have other things I need to do besides nurse this beautiful cat 24/7. I would like to see SSs of TID dosing with Lantus and Levemir to quench my curiosity, but it seems nobody has done it here for many years (and those old SSs don’t come up in google sheets anymore). So how do you get/extend duration? That’s the million dollar question. These yellow bookends are unacceptable.

 

Wow. she even hit lime on .75 and it was the second cycle of the reduction. She is really be bouncy girl right now.

What is the new food experiment.

 

I’m reading the Dr. Bernstein book and he seems to think you can reliably and accurately get the same BGs (in humans) with a regimented and controlled input (exacting amounts of food and exacting amounts of glucose to bring up lows an exact amount). He doesn’t say it only works with type 1 diabetics, but I’m assuming it can only be that predictable and exact when you are certain no endogenous insulin can crash the party. I have been precisely measuring Asia’s meals (instead of eyeballing it like I did before) and feeding her at consistent times am and pm (instead of on demand, loosely at the same times) to see if it makes any difference. I wish there were a test to see if she makes any of her own insulin.

 

With her hitting the 30’s I would’ve taken the full reduction. When ever there is food/ schedule changes it can mix things up for a bit. I use to blame the weather when Doodles decided to change his pattern. Hopefully she’ll get back to nice surfing soon.

 

What is TID dosing?
IMHO I would take the reductions as Asia earns them. If she is hitting lime green regularly then she is getting too much insulin. You can always go back up if she fails the reduction

 

I did take half of a reduction from that, but she hasn’t held reductions well, and double that for back to back ones, I just made a judgement call because I knew I could test her often enough. I didn’t put too much stock in that number or cycle being entirely accurate because I wasn’t home and my daughter was watching/feeding/testing her and she’s had trouble getting enough blood for the tests recently, which I find always gives a lower than accurate reading with my meter and strips. I recorded them, as they were the numbers she got, but skeptical of the accuracy. I’m pretty confident there was a lime green there, but I’m not certain it was really in the 30s, had her go overboard and give 2 rounds of .8mL Karo anyway, which is way more than I would give Asia if I were home.

It’s hard to make heads or tales of the food experiment with all the sudden dose changes (the AMPS is the only thing that stood out), I hope she settles down soon and I can see what’s happening.

 

It’s 3 times a day, or every 8 hours. You would give a lot less at each dose, so instead of say .75 every 12 hours, it would be more like .5 every 8 (or likely even less than that because of overlap). She would for sure get better coverage, but I just know it would drive me bonkers as there would be no time I could ever leave, sleep, human etc. and feel she was safe unless the even coverage would make her super flat, but even then, it would only take one off cycle to throw a wrench in the works. I wouldn’t have the same support I have now as there aren’t another group of cats doing TID to work out the kinks, and committing to every 8 hour dosing would be too exhausting and difficult. Humans use a bolus insulin to cover the times where their basal is falling short, but no way is that an option for Asia that I would feel remotely comfortable with, and that would be even more obnoxious shooting and testing wise than trying TID Lev.

I’ve had the duration question for a long, long time and asked it more than once. There doesn’t seem to be an answer I could try that I haven’t (they are all food carb/amount/timing related). The only thing that seems to give her longer duration is larger amounts of insulin, which, obviously, is not an option. Just trying to figure out something that works for Asia.

I know I can always go back up, I’m just a lot more worried for her kidneys and I’m really hesistent to knowingly insult them, as she hasn’t held reductions that well, that’s exactly what I feel I would be doing. I would take the full reductions each and every time if I weren’t able to test as often as I do. When she has had reductions, it’s not super obvious, now there’s suddenly pink everywhere let’s increase again, it’s there’s that one green, let’s hold the dose and see if she does it again, oh she did one more green again let’s hold it longer...meanwhile, every other number around it is creeping up (and likely 50% or more of her cycles are then over renal threshold).

 

I've never heard of that for a cat! I have a good friend who is diabetic; she is on 2 different insulins. She uses faster-acting ones during the day (I believe a shot at each meal) and then I think she uses Lev before bed.
The duration is something a lot of us struggle with but I really don't know whether more insulin is the answer because with Lantus and Lev the cycles should overlap so that AM cycle is ending just as PM cycle kicks in. I think trying to stop the bouncing helps but that's not always easy to do either!

 

Yes, that seems to be how most humans do it, but they are also often compensating for larger meals, carbs and other variables we have better control over with cats. They are actually supposed to calculate carbs, proteins, fat and calories for their meal to determine how much rapid insulin to inject each time to cover their meals and snacks! Talk about complicated.

More insulin isn't the answer for her, as she can't tolerate more, it's just been my observation with Asia that the stretch of greens in the middle extend out further on either side with a larger dose and shrink smaller with a lesser dose. I don't think the insulin is going completely kaput like an in and out insulin, as her bookends would likely be pink, red or black if left to her own devices... but it peters out rapidly around +10/+11 and much more rapidly/numbers climb faster at the 11th hour the less insulin dose she is on.

Metabolism or how fast her body breaks down the depot to release the insulin surely plays a role here too. With Lantus, she was super early onset, and with Lev that can sometimes be true as well (+2/2.5 which is an earlier onset than many on Lev, closer to the onset of Lantus for most). Wish I knew why so I could figure out how to manipulate it more.

Logically, earlier onset could mean it doesn't last as long to extend to the next shot. Obviously the depot is in play, but I don't understand enough how it works to say if it will pull more insulin later in a cycle if needed, it wouldn't seem so other than Lantus double dip. Seems like some little insulin fairy goes to the depot, makes the daily withdrawal and then sprinkles that set amount insulin all over the place for a few hours until it runs outs, he gets tired and goes back to his insulin fairy home. His quitting time is nadir and everything after that is just a rise, well before the next shot takes hold for Asia, roughly 6 hours on either insulin. Almost every green preshot she's had is on the end of a bounce clearing, and that's more like a shift right of the duration hours rather than an extension on them.

 

Here’s what I did with Gracie although it is aggressive and I wouldn’t recommend it to anyone who doesn’t know their cat well and isn’t there to test. But you do and are

I increased the carbs to 8-10% and raised the dose. It got her into green and kept her there most of the time but it takes a lot of work. You might not have that latitude because of the CKD and finding a low P food.

Shooting tid is easier with PZ.

For any readers: this is advice for Asia only. Please do not follow. I know Stacy knows Asia’s patterns really well and is there to test.

 

I was hoping to find Michelle and Doodles Lantus spreadsheet, but it appears to have disappeared down the Google drain. Michelle shot Lantus TID for a long time and made it look effortless! Doodles ss was a work of art! I asked her about it once. She said it worked once she developed a routine that worked for her.

I looked for the spreadsheets of several others who dosed Lantus/Levemir TID, but couldn't find any who used the Ls. It's a shame to have lost them. Another vanishing technique that has worked so well with stubborn kitties!

The only other method I know of to increase duration is to get as much insulin into the cat by manipulating the curve with food as I did with Alex. I'm sure you've seen the basic write-up I did a long time ago: Using Food to Manipulate the Curve. You'd have to figure out a method that works for you based on Asia's carb sensitivity.

 

Thanks, Marje! As much as I'm happy to have Asia needing less insulin, I don't like when I'm trading a lower dose for higher numbers overall, and that feels like what is happening right now.

Theoretically, I could just dump Karo in all of her radcat meals (assuming she would eat it that way) to up the carb content without messing with the phosperous, it's just the same in her body as flour, corn, potato or whatever else they put in cat food to make it carbilicious...but it still just seems so wrong to intentionally sugar up a sugar cat?

It's not unlike what I'm doing right now to hang on to this dose (this dose with yellow bookends!), except only Karo meals in the middle and the rest, where numbers are higher, without it. It is a lot of work because I have to keep hyper vigilant over her eating or I know she will go under 50! I'm not sure if that's a great day to day solution, but I won't count it out.

Easier with PZI because when it's out, it's out and I could give myself a break if I needed to be away/delay shots, etc.? But if I did that, she'd likely be in reds and blacks so I could go to a show or something. I know that even if that were an option, I wouldn't do it to her and I'd be stuck slaving away and stressing out on an 8 hour schedule. I just know that's what I'd do. I'm also not very impressed with the Prozinc SSs I've looked at, by and large. It seems like the old bovine PZI was great for cats and maybe ProZinc is not as ideal? It's different somehow, I read about it, I don't recall the finer points. And then I wonder, if L&L are supposed to be 12 hour + duration and PZ is even less, I could only be so lucky to get 8 hours from it?

 

Thanks, Jill! I looked for some too, and all the SS links were dead. It is a shame to have lost them. Seems some of the advanced techniques have been lost on the PZ board too. When I'm no longer on the front lines with cat diabetes, I will gladly volunteer as an archivist here!

I have been trying to manipulate the curve, and I've seen your post and shared with others. I've figured out that if the insulin is pulling her down, it takes big guns to make a dent where I want it to...except when it just looks like the insulin is pulling her down, well before nadir, and it actually isn't, so my efforts abort the cycle. There seems to be no telling which one I'm dealing with! So my approach has been more conservative at first and then fire all cannons once I know, except by then, all I'm really doing it barely keeping her out of or getting her out of lime green...and I just wait for the postprandial response.

Rarely is there a bounce on her SS that wasn't preceded by a round of Karo. I think very few of her bounces are actual biological panicky liver responses, most of them instead, I think, are delayed food spike reactions to high carbs. The orange dog ears on her SS cells are when I give her Karo so I can see, visually, the impact it has. So she is sensitive to them, but no so much in the immediacy when I want her to be. The more force I use to get her out of unsafe numbers, the more she pays for it later, it must be done, of course, but it sure is frustrating! If she's in a dose that just barely gets her to greens, I can get her numbers up as high as I want to in no time flat with almost zero effort...but that's not the type of curve that needs manipulating.

 

I totally agree and the method I used did not involve even MC food. I used a higher LC food but it was still LC.

Asia has some challenges that I did not have with Gracie. Gracie loved to eat no matter when I fed her and if you are going to manage the curve with food so you can get as much insulin in as safely possible, the kitty needs to eat.

PZ can have a good duration and it wouldn’t be out within 8 hours or maybe not even 12 but it doesn’t have a depot as the L insulins do. With the L insulins, once you have data for your cat (as you do), you can see whether delaying shots or shooting early really has an effect on her BG. With Gracie, really, within two hours, I didn’t see a big issue but ECID. But, I do believe PZ gives more flexibility overall with TID dosing. My intent was not to suggest that you switch insulins (I LOVE Levemir and didn’t want to switch) but it was just a statement that it’s a little easier with PZ. I don’t think PZ is as good as the bovine PZI and I wouldn’t get PZI compounded due to chance of contamination.

I can completely identify with that! It can be a challenge and I’ve completely overcarbbed cycles and aborted them by accident until I found a food that really worked in slowing down the drop but keeping the nadir up a little bit. Since I wasn’t feeding raw or dealing with CKD, I also had more flexibility on finding that food.

Again, you have challenges that I didn’t have with Gracie in that when the dose got lower, if she went low, it didn’t take as many carbs to bring her up (or kill her duration....karo certainly would) and what worked better was giving her a larger helping of LC food. But she’d happily eat it. If you could get Asia to do the same, it might address what you have observed.

 

Oh, and @Judy and Boomer this is for you, Toki likes boxes of all kinds, even the ones with invisible walls, Asia couldn't be bothered with such nonsense, she's not so easily fooled!

 

I love it!!!!

 

When Meme first diagnosed and before i found this forum, i registered in a fourm where they do TR in different way than here, they give insulin every 10 hours and they dose it based on the BG numbers, they do not give same dose every 12 hours, less or more every 10 hours and they have a lot of OTJ but i found it hard to do it every 10 hours and make dose judgment as o was just new to that.

 

Wow! This is a discussion! I hope you find the best solution.

 

I've heard of that too. No wonder you found it hard to do! Every 10 hours sounds like torture, honestly. At least with every 8, it can be the same time each day like every 12. With 10, you'd be shooting any hour of the day or night! It would be a lot to keep track of and the chances to make a mistake (from dosing at the wrong time to dosing the wrong amount because it's 4:00 in the am and you're brain is still sleeping) would go up exponentially.

 

I think you were away when this most recent development came about, but one of Asia's nicknames is "Poof" (what my DD decided to call her as a preschooler for some reason) and we've started calling her "Piggy Poof" because she has been suddenly eating her food all up in one sitting for weeks now! It was so unusual, I had them test her thyroid in the last labs because I was certain it was a symptom rather than an about face at age 21 (high end of normal, but still a grey area for older cats, apparently).

She has changed in that regard for whatever reason and will pretty much inhale her food when I put it out. At +7 I tried to give her a double helping to slow the drop (2 tablespoons) and she ate half and then walked away. So she does get full and doesn't seem to be interested to gorge herself, but just eating her regular sized meals at once instead a bite or two every 20 minutes is a huge difference and has allowed some level of surfing she wasn't capable of before.

 

Catching up on the thread and before reading Marje's comment above, I was thinking "hmmm... maybe give food with slightly more carbs so you can shoot higher doses"...

So that's definitely the direction I would lean!

 

Oh, something else I was wondering: does she have glucose in her urine? I hear you're worried about her kidneys with the yellows but as such those numbers don't seem that alarming. Renal threshold varies from cat to cat, so are you basing your kidney worry on the numbers you're reading or on the fact there is actual glucose in her urine?

 

Stacy, have you tried canned wet food to boost when needed. I feed Bubba raw also and when he is dropping usually another small meal of raw will bring him up. If it doesn't or if it's night time and momma wants to sleep, I give him a tsp or so of FF Classics. Just 3% carbs will bring him up by 10-15 points. I only gave Bubba corn syrup a couple of times and it shot him to the moon and I think it upset his tummy. Corn is horrible for humans and animals. Just a thought.

 

I’m assuming she does, I have yet to narrow down exactly the number for her because it’s not easy to do. The urine glucose could be reflective of a number that happened a few hours before it, the best way to test would be on a flat yellow cycle and I try to catch them, but they don’t happen often and I need to combine that with the fact that I would need to be home that whole time and stalking her to the LB. As it were, when she is running higher, I leave the house and get stuff done!

The reason I assume she is still spilling some is because all of the pee clumps were sticking horribly to the LB when she was first diagnosed, because of the sticky sugar! So when I see a sticky pee clump, which I do not too infrequently, I make that assumption.

 

A small raw meal will bring Asia up as well, except for when it doesn’t. When it doesn’t is on some cycles when the insulin is trying to pull her down before nadir. Believe me, I’m not crazy about the corn syrup, but it was a concession I had to make. I didn’t want to feed her other foods because for the last 2 decades, she has been an eat the same kind of food every day cat and she’s not typically keen on trying new things. I was mostly concerned if I did find another food she would eat, that she might prefer it to the raw and refuse the raw. I chose her diet long ago and it had nothing to do with diabetes, I want the benefit to work with diabetes, but extend holistically to the other things I was addressing when I picked it. I’ve seen the frustrating food merry go round many people on here ride when they don’t know from one hour to the next what their cat will or won’t eat. I don’t want to buy tickets to that ride!

I started out with honey, because like you said, corn, ew, no thank you! Honey did little to nothing as far as bringing numbers up. I do use FF gravy and other brands of gravy cat food that are 20% carbs if not more as a conduit to get her to eat the Karo. If we assume Karo is the big gun, and a drop or two can send other cats to the moon, obviously, Asia needs something more akin to a rocket launcher. It will have a larger effect on her in the cycles where I don’t need to steer, but the ones I do, it takes a good bit to move the needle a hair (my standard amount that I give her is .5mL or .6mL of Karo which is roughly 8-10 fat drops)! Sometimes I have to give .5 mL more an hour later. If that much corn syrup does little, eating some higher low carb wouldn’t seem to have much of an impact either.

I’ve tried Karo alone which should induce a rapid response, I’ve tried it with food which should make the carbs take longer to metabolize and would mimic higher LC/MC/HC? food. It makes little difference in the moment on those cycles I’m referring to. When I need to get her numbers up right now, both do the job rather poorly comparing to what I see with other cats here “I just show Snowball a photo of French fries and her BGs go up 40 points”.

I don’t know what makes them carb sensitive, but one hypothesis is that cats that got diabetes through whatever process that included a high carb diet pre-diabetes, might very well be more reactive when those things are reintroduced post diagnosis, assuming a change in diet made a big difference to their insulin response/regulation. That wasn’t the case for Asia at all. I don’t know why she got diabetes, but I suspect it was from pancreatitis, so it’s plausible that she has very few to no working beta cells since the pancreastitis went undiagnosed and unmanaged for a good bit of time.

It does make a difference in humans how your treat diabetes depending if they are type 1 or type 2, yet we treat every cat here as if the process which made them diabetic doesn’t matter...with the huge exception of acro/IAA/cushing’s kitties. Your cat may be capable of making his own insulin (a likely truth, considering he has gone OTJ before) my cat may not be, that should be a consideration in treatment. Even if we can’t difinitively say, there are educated guesses, and if one set of rules generally works for the insulin makers and your cat doesn’t get with the program, there could be alternatives to the cats of a different category to try. Might a cat that can make his own insulin, even if only a little bit and some of the time, use that bonus to get better “duration” or have flatter cycles than one who can’t make any, at all, ever?

Lastly, assuming she has few to no beta cells and I want to heal them (pipe dream), giving her sugar in whatever form would, in a non diabetic cat, send an alarm for the body to release massive stored insulin and then to produce more. I think I’m murdering those weakly few beta cells she may have every time I carb her up because I’m taxing an already exhausted and depleated system. Yet if I don’t want to do that, I’m inviting blood glucose levels for several hours of the day that are unacceptable for the rest of her organs, including, but not limited to, her kidneys. It’s a sick cycle.

I’m sure that’s way more of a response than you bargained for, Bobbie, but this stuff has my brain going and I’m just mostly thinking out loud.

 

It has got to be very frustrating to say the least. But, I did enjoy your response. You could very well could be on to something about the pre diabetic diet in the sugar cats and with the reintroducing of certain foods. It can make us crazy for sure. But, whatever the reason she reacts or doesn't react to the carbs given to her to boost , I hope will stop because I know it's got to be frustrating.

 

That is a lot of karo! I didn’t realize it took so much to bring her up. Typically a drop would work with my baby girl. But you are struggling with the same issue I had....giving sugar to a diabetic. What I “tried” to do, which worked sometimes but not others, is stop the drop before she got so low that she needed karo intervention. Of course, I wasn’t doing that even within the first year....it was something I eventually learned to do. I think you are ahead of where I was at the same point into the dance but also, back then, karo was widely used without a thought.

Point well taken on the difference between Type I and Type II human diabetics. There hasn’t been enough research done on cats but most of what I’ve read indicates Type I in cats is rare. I really wonder about that, though, because we’ve had some really young cats....even kittens....here with FD. Gracie was very young as well.

I also hear you on the food (and I’m glad Miss Piggy Poof is in the House!). I wouldn’t want to move away from raw and I sure wouldn’t want to mess with a 21 year old cat that is happily eating.

On the tid dosing, it just seems to me that’s a lot to take on with all you have going on with your girls and how busy they are. OTOH, perhaps it will flatten her out but you’d have to spend a good deal of time available to test until you could get into a rhythm and see how it worked for her.

I don’t have any proof for what I’m about to say but I’ve often pondered if I didn’t see better results because, early on, I was so frightened of the low numbers that we just reached for the karo instead of letting Gracie’s body learn to deal with it and surf. I’m not talking about really low numbers but I still wonder if I reached for the karo too much which shortened her duration and once she was up, she had to come down and she’d do it fast which put us in that whole catch 22. When I did up the % carbs to a higher LC, it worked but I felt we were testing her too much because she could go from flat green for hours into the 30s out of nowhere.

I would go back and study her SS but it’s still just too painful for me . I can take quick glimpses of it but if I look at it very long, I just get mired in the loss of my heart and soul. I need to put on my big girl panties one of these days. @Doodles & Karen and I call it FD PTSD.

I wonder if you can get to a better dose by fine tuning it a little more. I also found this helped when I started dosing in smaller increments as one dose could be too much and another too little even with 0.25u changes. For us, the calipers made a huge difference because I could dose in 0.1u increments reliably and consistently. I don’t remember if you are using calipers? There are some people here who can dial in a consistent dose without them but I never could plus Mike was also dosing and when two people are drawing doses by eyeballing it, you aren’t ever going to get the same dose. Add in the inaccuracy in the syringes.....cumulatively it became an issue for us.

 

It takes that much to bring her up right away. She’s very old, maybe it just takes longer for everything to get through her system (except the insulin which seems quick enough)? I recall her first below 50s and the “test every 15 or 20 minutes” I quickly realized there was little point in doing that, because the number would only be lower or the same, it often takes 30 minutes to see the beginning effect of the Karo I give her and several hours more to really see it.

We purchased movie tickets last night in advance, something we rarely do anymore, but shot time +3 hours is uneventful 99% of the time. Well last night, she goes and gives me a green preshot, of course! So I gave her .4mL Karo when she was at 116 and then again a couple hours later as well as food in the autofeeder available on the hour. .8mL of Karo total when she didn’t need it, but I needed the peace of mind to leave...well you can look at today’s cycle and see what that looks like several hours later! That’s a good example of a cycle where she doesn’t need it, when she does, I could give double that and her bounce or postprandial response is way less dramatic (see 3/29 that was 1.6mL of Karo given, height of bounce was likely less than 290, 267 is the highest I caught).

I have tried to anticipate the drop, did it often with Lantus. It worked to bring the number up to drop from, but it seemed like she had a destination and was going there no matter what I did or didn’t do, often it required more Karo at later points, many times it killed her cycle before it started, and sometimes it almost masked what was really going on and then she would drop more drastically and I wouldn’t see it coming because of the Karo inflated number. What it didn’t do was help her surf on her own after that! I helped her surf, with Karo and frequent intervention.

In reality, there are more than type 1 and type 2 in humans, but they typically boil down to the two because what separates them in oversimplification, is the ability to produce some insulin, or not. I’m sure there could be many subcategories of diabetes for cats, relating to how they get it: autoimmune/attack your own beta cells, pancreatitis, obesity/system abuse, drug (steroid) induced, etc. I’ve also heard type 1 is rare for cats (don’t they say that about acro too, though ).

While it is probably far less common, for sure there are some cats that do not make their own insulin anymore and may never be capable of it. That would look more like type 1, treatment wise, even if the root cause of the beta cell destruction was different. I doubt there will ever be enough research, in cats, unless it’s a byproduct discovery of doing an animal study for a human purpose. In the meantime, valuable strategies and insights made on forums like this can continue to improve the lives of cats afflicted with FD where funded research science fails us. Gracie was so young to get it , did you happen to know or find out if any of her litter mates ended up with FD?

The thought of TID seems like a possible working solution, the thought of actually doing TID kind of makes me want to cry. I really don’t think it would be a good fit, and in the short term, I could try it just to say I tried and it failed...but if it worked out really well, I’d hate myself to not continue and I’d hate my life if I did continue!

I understand what you’re saying about reaching for the Karo too soon and it causing high numbers that she’d need to dive down from. It is a vicious cycle. I’ve wondered, what if 48 is just Asia’s jam (I really doubt it, but have considered). I don’t have to guts to find out. I also wonder if, in an effort to get numbers up immediately, I’m giving way too much Karo. Would she come up with the initial amount, some food and a little more time? Again, too risky to find out, because if she’s still dropping when I try that, we are in trouble. I kind of test this theory when it’s later in the cycle, like the 50 yesterday, regular food and she went up to 57 in an hour (or stayed the same, but she wasn’t going down which is what I needed to know), it’s a lot less risky to test it out later in the cycle as opposed to an early drop, for my cat.

I do feel like any “good” dose Asia works is always a slightly overdose one. What I mean by that is if I didn’t steer with Karo, she would go below 50 (earning reductions) quite frequently on a “good” dose. If she’s on a dose where I don’t need to do that, it’s a couple hours in green at best and messy everywhere else.

No need to study Gracie’s SS on my account. The SSs seem like just a bunch of numbers to most people, but it tells a story, for sure, and it’s very much tied to emotions when it’s your cat and those numbers take you back. I can only imagine what FD PTSD feels like. I don’t look forward to joining that club.

Yes, I have been fine tuning and I do use calipers. The most recent really good dose for her was 1.25S which is exactly between 1 and 1.25, you can see on her SS prior to the most recent run on that dose, 1.25 was too much, 1 was not cutting it. I doubt any adjustment finer than .125 would make a difference.

 

Thanks for this discussion, Stacy (and others)! I'm also trying to figure out about intervening with sweetener. Felix's situation isn't as complex as Asia's, but I'm asking myself the kinds of questions you're asking, and I appreciate seeing this all articulated. [Bookmark.]

 

It can be tricky and I encourage you to try different sugars if you aren’t getting the result you’re looking for: honey, Karo, (real) maple syrup as they have different compositions and you may find one works better than another. I also tried just using drops at first but there was no consistent way to measure, one drop could be twice the size of the next, which is why I started using an oral syringe instead (way less messy that way too).

I really enjoy discussion threads like this, there’s always a lot of different ideas and perspectives and it helps me more than thinking these things to myself.

 

Hi Stacy
As you already know, I used TID dosing with my cat Alex and as I told you he was a high dose kitty, his numbers were MUCH higher than Asia’s, I was shooting much higher doses so I had more room to play around with the dose and I worked from home so I was/am always here. I would not have tried it with Asia’s numbers I’d never have gotten any sleep. I’d have celebrated numbers like that...I didn’t see them even with TID dosing.

What I might suggest in lieu of that to extend the dose is split shots. I don’t know if it will work but can’t hurt to try again it’s such a small dose so it’s hard. What you’d do is give about 3/4 of the dose at regular time then the rest at about 2 or 3 hours into cycle. There is no set rule but most people do it like that. The guy you see on the left , my sweet Sebastian, another hard to regulate kitty,went into remission that way.
I hadn’t adopted him yet but that’s what I’ve heard.

 

Karo was working well enough for once in awhile, and I've just started experimenting with honey (probably not any better for his teeth, though). The honey is proving a little more manageable glopwise, but the syringe is a good idea. Fortunately, I haven't had with Felix the struggles you've had bringing Asia's numbers up--he has come right up, but especially since I'm going to start intervening earlier and more often, I'd like to fine tune things so I don't just abort his cycles.

I've focused on feeding in the first three hours of his cycles for quite awhile, but his usual food (canned Core, 8% carbs) isn't always enough. Since Felix doesn't have an open mind about wet cat foods, I have to get more deliberate about this do-it-yourself medium-carb and high-carb based on what he will eat. Like you said: "It can be tricky"!

 

Thanks for sharing. I do realize some people would be envious of Asia’s numbers, it’s all relative. There are people here that get upset with a slightly blue preshot. We can only play the hand we are dealt as best we can.

I don’t think I could easily or reliably split a .75, even with calipers, or try to inject just part of the .75 and save the rest. It’s an interesting idea, but it wouldn’t be unlike shooting 4 times a day instead of 3 or 2, just not even number of hours apart or even shot amounts which sounds an awful lot like chaos if you ask me. That is great that it worked for Sebastian though.

TID is already a split dose, as is BID. BID is a a daily dose split in half, TID in thirds. If the daily dose was 6 units, the BID dose would be 3 units every 12 hours and TID dose would be 2 units every 8 hours. That’s simplifying it, of course, if you had overlap, the dose would probably go down further.

Thanks for stopping by and sharing your experience.

 

Actually when I started I think I changed the dose a little

 

And a black for PMPS, seriously, Asia? If only it were an April Fools joke! Looks like how a furshot would look, but I don’t think it could be, I see skin every time and the needle goes in. What on earth, this cat sometimes!

 

So, this reminds me of the infamous (don't beat me!) Hodgkins argument that a healthy liver will prop the cat up from low numbers. Now, I'm NOT advocating that one shouldn't prop up a low cat with carbs, but I have been wondering for a long time about the impact of adding "fast sugar" into the mix like this (cf. some "old" --now-- discussions on Quintus's condo).

Just to say I'm with you here, wondering if maybe the karo is indeed sending her in a vicious circle, and maybe she's actually more "ok" than we think in these scary numbers.

A thought, as this is a case where we're focused on "a number": I can't remember if you have an alphatrak lying around? It might be interesting to test her with the AT when she's "low" to put those numbers into perspective.

Also, I hear you very concerned about her kidneys, and wondering exactly how bad the number of yellow hours she's getting really are. I'd personally try and test for glucose to confirm your "sticky pee" assessment, and try and get data on exactly how damaging that much time above renal threshold is, and put that in the balance with the karo and short duration.

Other than that, I completely agree that "why" the cat is diabetic isn't taken into account enough. You and I have talked about this, and I think Quintus was a really good example. Reading these definitions, I'd put Quintus in type 3, and seriously question the general assumption that most cats have type 2 (insulin resistance?) rather than type 1 (we talk about the pancreas starting to work again... so type 1, no?)

 

Her method was/is responsible for killing cats, period. There are current members here that were witnesses to that. Because forums that use her method are not transparent and open to the public like this one, it's really hard to assess what her version of TR looks like in action, that's a problem. If there's really nothing to hide, why is it all hidden? Without free access to those forums and unedited/uncensored data, everything she purports is academic at best, as we already know of cases where her theory failed more than one cat.

However well intentioned she may be, she was misguided in the notion that cats cannot clinically hypo (and die) if they have access to low carb wet food. Even if it were true of most cats, you can't categorically claim it won't happen if it can; that is where her credibility went out the window for me. I know your take is to not throw the baby out with the bath water and I see your point there, but at the same time, if one piece of information is so horribly flawed, it does make you wonder how accurate the rest of it is. I might feel differently if she had a mea culpa and revised her method and wording, but as far as I know that hasn't happened.

The very reason she is wrong has, in fact, been extensively studied and published in medical journals, particularly in humans. Two words: hypoglycemia unawareness. Frequent dips in unsafe numbers can make people more sensitive to and less aware of future hypo events, not just consciously unaware of them, but systemically unaware such that counter regulatory mechanisms fail, especially true the longer one has been diabetic. I believe something similar has been observed in cats on this board.

It makes sense when you think about what we do here. Cats come here with their bodies fully convinced that 524 is the perfect and normal level their blood glucose should be and we have to, essentially, desensitize them to lower and lower numbers and retrain them to what is normal. It fits with all the bouncing from lower numbers that aren't really that low, but much lower than what is perceived at the time by their body to be normal. Bounces typically lessen the more time they spend in lower numbers. Some cats go into lime green and just don't bounce perceptively, to this point:

Indeed, some of the lime green numbers could be perfectly okay and their body treats them as such. The problem being with exogenous insulin in the picture, it's risky to find out how low is that number. The number 50 was designed as a cutoff, not because below 50 is hypo for a cat, but because there needed to be a safety buffer built in that accounts for meter variance, ECID and is marginally higher than what really would be a hypo number.

I agree with you, for sure the Karo or any carbs that raise their BG contribute to this cycle of bouncing, but I just don't see a viable alternative. I certainly wouldn't trust for a second that my cat could eat her way out of a hypo, she can't even eat her way out of a below 50 the majority of the time without the assistance of Karo and it isn't because she won't eat but rather her body response is slower than the rate at which the insulin is pulling her down.

Perhaps there is some magic number that would elicit a counter regulatory response without the high carb intervention, but, if the insulin is continuing to pull them down when that happens, and the response doesn't happen faster than the rate the insulin is dropping them, it won't matter and it won't work and now the cat is having a seizure or worse.

This happens even in humans (being self aware and very experienced with managing diabetes). I have a family friend that was type 1 and died from a hypo, despite whatever she was trying to do to get her numbers up. I have a family member that is type 1 and has gone unconscious from a hypo on a few occasions and was only saved from a terrible fate by being found by police on the side of the road in his car or being around his wife when it happened so they could give or get him help.

I do still have my AT, just don't have any strips left for it. Asia having several blood draws since diagnosis, I have taken readings with my human meter at the same time her blood was drawn to know it's pretty close to the lab number. AT would only tell me the low number is higher and would be confusing because IMO AT is no more accurate and has the same flaws as any other meter. Besides which, since I don't use AT all the time, one number from it would be rather meaningless. If I had insurance paying for all of Asia's testing supplies, absolutely I would research what is the most accurate compared to lab meter out there and use that one. Something tells me it wouldn't be an AT either.

Sticky pee is as good as confirmed for me. I have an automatic litter box that rotates 360 degrees to empty the waste, when I say sticky pee, it literally sticks to the base, even when upside down, and I have to manually pry it off unless the pee clump is large enough that gravity does it for me. This never happens in days of blues and green. I would still love to zero in on the threshold with diastix and I'm trying, but not wishing for the several flat yellow cycles it would take to do so.

How bad and how much damage is done are things we may never know with precision for humans or for cats. What is known is that hyperglycemia does major organ damage over time, hypos kill fast, hyperglycemia kills slowly. If that's all I have to go on, I'd rather her spend zero time in yellow or worse. Her time is running out because of her age and many of her organs are in various states of harm already, so I don't want to put kerosene on the fire by allowing her to spend hours each day in harmful numbers.

The Karo issue is more my hang up in this instance. Her chance of remission is slim at this point, with all she has going on. If she were a lot younger, the Karo and beta cell damage would be of much greater concern to me. I bring up the point because it's a point that should be made and discussed, but pertaining specifically to Asia, of the two, the higher numbers will do her greater damage at this point than the Karo.

I would put Asia in type 3 as well, if I had to guess, but I would categorize her as a type 1 from a treatment perspective as I'm assuming she doesn't make insulin. I do think most cats have type 2 as well, I just don't think something closer to type 1 is necesssily as rare in cats as we are led to believe (meaning less that all the cats have an autoimmune disorder, and more that the cats do not and will not make their own insulin any longer). Type 3 would fit the bill, but even in that category you have stuff you can right the ship from (like steroid induced), and stuff you're not going to bounce back from, which is why the make insulin/can't make insulin categories make more sense. Pancreas working again definitely type 2. Type 1 is autoimmune and the beta cells are attacked and destroyed by the immune system. Type 2 you are taxing the system, but very much still making insulin; if it goes on for too long, however, you can destroy the beta cells because they can't keep up with the constant demand and end up very much like a type 1, although it technically isn't. Acro cats would be another type 3, but you would treat them as type 2.

Thanks for furthering the discussion, good stuff. I'm bookmarking my own thread.

 

Very interesting discussion!

 

I’m wondering if shooting early for a limited time, to create some overlap might help. I have a distant memory of D and Noisy shooting
early, until working the schedule completely around the clock. Unfortunately Noisys ss is no longer accessible. I have no idea how the strategy works or if it would be appropriate for Asia, however when stepping outside the safety guidelines of TR a solid knowledge of your kittys onset, nadir and duration is an absolute must as is very close monitoring. It may also require dialing back the dose some.

@Jill & Alex (GA) may recall cases and circumstances where shooting early helped and if it may be appropriate to consider for Asia.

 

Thanks, Sandy. I’d be curious to the particulars, I’ve shot early a few times before, on Lantus, when she was bouncing to the moon and I’ve shot late (on accident, because I’ve overslept). I’m not sure how it would look on a regular cycle. She got some decent overlap this morning because of a very ill timed bounce that kept me up clear until her next shot! We will see how it plays out.

A lot of human diabetics shoot weird with L&L. Like before bed and when waking which can create something like a 9/15 cycle. Many also shoot different amounts in the am vs pm. The weird thing is I’ve rarely come across any knowledge of the depot when humans are talking about it. If it is mentioned, it’s just a thing, the depot, a big squishy pool of insulin under your skin. No talk of this banking system where taking an uneven withdrawal will create an imbalance. They also have different circumstances than our cats in that they are fasting (and sleeping) at night and use bolus insulins in the day the cover their meals or any duration gap before the next shot, so all they really need from the basal is a relatively flat background in safe numbers. I have found a couple where their doctors say shoot exactly 12 hours apart the same amount, but they are the exceptions and they also don’t know why, they are just following doctors orders.

By far the most interesting thing I’ve discovered about human diabetics is that many of them don’t understand the particulars of their treatment at all, the doctors tell them which insulins to use and how much (for basal), and then the doctors make the dosing adjustments often times rather than the people. Not unlike some of the vets that tell you to shoot blind and bring him back in a month for a curve and adjust the dose that way! Well, with the exception that human doctors wouldn’t dream of telling their patients to shoot blind.

 

Some acrocats have perfectly working pancreases, some don't. I have always seen vets refer to acros as just type 3. It's not that an acros cells don't respond to insulin, but rather the IGF-1 is blocking the insulin from getting into the cells. Of course, acros can also have pancreatitis, glucose toxicity and some elements of type 2 as well.

 

Just a few comments on what's already been said...

I also had that mindset for a long time, but it's not true. The schedules are the same and even though the Ls and the Ps are different insulins, the thinking behind dosing/reasons for making dose adjustments are the same whether you're dosing BID or TID. More on that coming below.

Lookee, lookee, lookee... I did find it! Doodles ss: https://docs.google.com/spreadsheets/d/11dkxMOCwPyaj4bGG1T9xT_xMR2s_WYKWB4TEgLnbfCE/pub?gid=14#. How about that!

When dosing TID, what we are forgetting in this discussion is we're dealing with cats who lack duration... no matter the insulin used. That's why there's no need to worry about the overlap and carryover which is normally associated with use of the Ls. The depot action becomes relative to the amount of the TID dose (one third of the total BID dose). To put it simply, with the Ls, usual BID action may be apparent for 12 - 14 hours because of the depot. When dosing TID, the action may be for 8 - 10 hours because of the decreased dose. So whether one is using the Ps or the Ls, it's really not all that different.

Something else that has not been mentioned... shooting TID is usually a method used to achieve longer duration. In other words, most kitties who are shot TID eventually start experiencing longer duration... stretching to the point where the caregiver is able to go back to shooting BID once again (not all, I think Nancy/Payne shot Prozinc on a TID schedule for around 3 years). We say shooting TID is shooting every 8 hours, but it's not etched in stone. On some days OR at some point it may be shooting at +9, +10, or +11. Remaining flexible is important no matter which no matter the insulin used, the dosing frequency, or the method used to achieve regulation used. Members should think in terms of "guidelines" rather than "rules". Every method geared to achieving regulation used on the FDMB has a set of guidelines, not rules.... regardless of insulin type.

To answer your question: Shooting TID is not a lifetime sentence for a multitude of reasons. Some caregivers (especially P users) would only dose TID going into and on the weekend. Dosing TID can be used while on vacation if that's what works for the caregiver. It's simply a method where one hopes to achieve and maintain duration.

Yes, shooting every 10 hours using a sliding scale can be rough, especially when one is new to the whole routine. Although, as with other methods, oftentimes duration lengthens to the point that kitty may only need shooting BID.

I'm so glad this was brought up for another reason. Lantus/Lev is used best when dosed every 12 hours as well as when dosed consistently (same doses for AM & PM cycles). Right? Wellllllllllllll, we're overlooking what should be included in the statement. This is what we should be saying,"Lantus or Levemir is used best when dosed every 12 hours as well as when dosed consistently when following either of the protocols commonly used on the FDMB... TR or SLGS."

There are FD boards and protocols used by vets out there that employ different methods than used here... methods that are successful. Just because they're different doesn't make them wrong.
Stepping down from my soapbox...

A little bit OT, but worth mentioning for those using human meters...
Depending on what literature one reads or which vet asked, "renal threshold" is often to be measured at 200, 225, or 250 mg/dL. Those are lab values (measured on a blood chemistry serum analyzer). Pet-specific meters are supposed to measure the closest to lab equipment, but we know human meters will read lower.

For example: Because sugar in the urine shows up some time later than when you're obtaining a blood glucose reading, it's next to impossible to come up with anything close to being precise when trying to determine renal threshold for your cat. The closest I could come up with after extensive testing was Alex's renal threshold was around 150 - 180 mg/dL range using a human meter... and that's a rough estimate.

Yes, at that time karo was running freely. I remember offering links to medical info as to why that wasn't necessarily a good idea to some of the advice givers at the time. Wish I still had them.

Being frightened of low numbers is natural. It takes a little time to overcome that fear and instead develop a healthy respect for low numbers. IMHO, the most common made mistake among new caregivers is ignoring sage/tried and true advice because their thought is their cat "is different".

Exactly the thought behind tight regulation. Unfortunately, many cats follow other paths and manipulating the curve with food is about the only way they're able to hang onto a dose.

Hi Caryl... long time no see! I had forgotten about split dosing. Glad you brought it up!

Split shots: They've been used in a few different scenarios that I know of... two of which were intended to increase duration... one to allow shooting a lower than usual preshot number.

• Some caregivers using Lev in the old Lev group would occasionally administer half the shot at the normal shot time and the other half at +2 when they knew the next shot would be late. They'd resume a normal 12/12 schedule at the next shot. This method usually worked well that day, but it seemed to mess with the numbers over the next few days (depot draining?).

• (the method Caryl was referring to) Venita gave Sebastian half the shot at the normal shot time and then the other half somewhere between +1 and +3 to increase duration. It worked very well with Sebastian and like Caryl said, he eventually when OTJ. I've been looking for Sebastian's spreadsheet. Haven't come up with it yet.

• an alternate suggestion outlined in the TR Protocol guidelines as written on the tillydiabetes web site for when presented with a lower than usual preshot number, "A third alternative is to split the dose: feed the cat, give most of the dose immediately and give the remainder 1 to 2 hours later when the BGs start rising." <---- Personal observation: This is a temporary solution. In most cases it doesn't work long term.

Shooting early is a practice to address a couple situations. Years ago, many of us (D and Noisy was one) who had flexible schedules would occasionally shoot an hour or two "early". The thinking was if kitty was on their way up either due to a lack of duration or the beginning of a bounce, why wait til they got higher? Didn't make sense to wait. We'd shoot at +10 or +11 to get a jump on things. Flexibility is a must because the next shot time was "due" 12 hours later.

Another scenario is the case of high flat numbers for a prolonged period of time (often seen in kitties with high dose conditions). You could what I call "push and then pull back" meaning shoot early a couple cycles in a row and then go back to shooting 12/12 to see if kitty's numbers were coming down at all. If not, repeat the technique... always making sure you took the time needed to properly assess what was happening with kitty.

A third scenario is shooting early by "shooting on the rise". D and Shadow was probably the best example I could give, but again, Google appears to have poofed the spreadsheet. Shadow was the most ketone prone cat I've ever seen. The Ls weren't the best choice for Shadow. Jojo had D switch from Lantus to Vetsulin and then helped D learn to shoot as soon as Shadow began to rise. The action could almost be likened to using an insulin pump today.


As far as to whether I think shooting early would benefit Asia...
Since she can dive early, if I were to try the technique... I think I'd only try shooting early at the beginning of a bounce. JMO.


Just my thoughts based on the discussion thus far...

 

This is a really fascinating condo, and I hope we can capture it somewhere for future review. Maybe when it's done it can be added to the Where Can I Find ______? For now, like many of you, I'm bookmarking it.

 

The appropriate place for a discussion like this is Think Tank because the techniques apply to all insulins. As the discussion winds up here, one of the moderators will flag and edit the thread for TT where it will remain open for further comments.

 

Agreed on the discussion that followed this but with PZ, as I understand it from discussions of old with Libby, there is a little more flexibility in varying the dose from shot to shot. While consistent dosing is beneficial, although not required, for both insulins, if Stacy had to vary the dose over two to three shots in a row due to some personal needs, she’d likely see less impact with the PZ. And yes, I’ve seen the other forums that shoot Lantus, in particular, with sliding scales. If Stacy elected to do that here, she certainly could but there are limited people who could help her with that. Whereas shooting a sliding scale or a variable dose with PZ is not unusual.

 

But when dosing TID and adjustments had to be made one would vary the time between shots rather than alter the dose itself... probably revert to dosing BID. That's what others have done whether they're using the Ls or the P insulins.


Edited to add: Look at Doodles 2009 ss (2/2009) where Michelle was shooting TID. You'll see a good example of how timing was adjusted Shooting as early as +6 and as late as +8) while shooting a consistent dose without messing much of anything up.

 

Thank you, thank you for finding that! So interesting to see. My, it does look exhausting, even 4 times a day in some parts. But she did get tighter numbers, it seems, although still not very flat, which did surprised me.

A good bit of flexibility does seem to be required, but it also increases the chances of mistakes, shooting the wrong amount, shooting at the wrong time, forgetting to change your alarms, it's really a lot to juggle. Of the 2 TID L/L SSs I've seen, both cats had ketones. If it did the job of keeping that in check, it's a risk worth taking IMO because it's a huge payoff. I'm enormously thankful Asia hasn't had ketones thus far, touch wood!

Yes, this is why it's been hard to nail down for me, I'd have to have a flat yellow or flat high blue cycle to reliably get a range since the urine could reflect numbers hours before. I wasn't even considering as low as 150 I hope Asia's is higher than that. I stopped giving her fluids because of her heart, so I'm already taking more risks for kidney damage I so want to keep over renal BGs out of the picture.

What about Karo might not be a good idea? Is it that it's corn based or a sugar? Or something else? Once in the body, Karo is really no different than bread, potatoes or other starchy veggies, etc. However they add carbs to higher carb cat food, it's all sugar at the end of the day.

Doesn't apply to Asia, but would for some high dose cats. When you mentioned splitting the dose it reminded me. I've read humans have better luck and absorption on high doses if they split the dose and inject smaller amounts in different places, say the dose is 15 units, 5/5/5 not in the same spot (but given at the same time). I wonder if any high dose cats have tried or had success with that. Do you know @Wendy&Neko ?

Yes, I'm not really comfortable or confident about shooting early unless I really need to for non FD reasons or the number is going way up, like last night which I should have shot early. The times I've needed to outside of a bounce, adjusting shot time by 30 minutes or shooting an hour early because of an appointment, I didn't see value in it other than to my own schedule and in fact it just made me more anxious as it added another layer of unpredictability ala "an early shot can act like an increase".

 

Dosing TID: Ha! You asked for thoughts/ideas on how to extend duration and that's what you're getting. TID is just one of them. Deviating from the norm is almost always more labor intensive.

Renal threshold: I wasn't surprised by the 150 - 180 mg/dL range I found when looking for Alex's renal threshold because years ago, Steve & Jock, member and fellow moderator authored a post in TT which linked info that discussed the possibility of renal threshold being as low as 140 mg/dL. Unfortunately, I can't find it. It looks like the thread was lost in cyberspace on one of the old FDMB boards (we've been through several since 1996).

Using too much karo: There was a discussion on the original YDC message board (now offline) authored by an RN about possible damage to the brain from using glucose/karo during a hypoglycemic event. I sent the linked information in the thread to a select group of members who were offering advice in the forum then known as the Lantus ISG. I don't remember enough to carry on an accurate, let alone half-way intelligent conversation about it.

Splitting a dose to shoot in more than one location: Not Wendy, but yes, that practice has been around for quite a long time. I believe some caregivers of kitties with high dose conditions have found the method beneficial, others not so much.

Shooting early: I understand. Given Asia's history, I don't think I'd shoot early unless it was clearly the beginning of a bounce.

 

I hate that, it happens to me all the time too "I remember this not being such a good thing, but I don't recall the particulars". The info that sticks is "proceed with caution here" and the why is lost over time.

I'll have to add this to the things that make me go hmmmm... category. Human diabetics use glucose for low numbers and it's been the standard of care for decades (which of course doesn't make it infallible, but there would be an awful lot of data to link sugar with brain damage if it were a remotely common thing). An actual hypoglycemic event can cause brain damage because the brain is without sugar, I'm not sure how one can point the finger at one type of sugar, or any sugar being the cause of the brain damage.

I don't think I've come up with a solid solution for Asia, possible things to try but no clear winners. None the less this thread has been very interesting and enlightening. I'm sure it can be helpful for a lot of people (and cats).