6/24 Henry PMPS 355

Discussion in 'Lantus / Levemir / Biosimilars' started by John & Henry, Jun 25, 2022.

  1. John & Henry

    John & Henry Member

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    https://felinediabetes.com/FDMB/thr...-saga-amps-317-1-5-308-2-25-313-3-336.265025/

    Alright, Mr. Henry was living in the red almost the whole last cycle. Last ketone check we were at .8, down from .9 the check before. I think the .25U R really helped with the 100 point drop, that quickly rebounded a couple hours later, but kept us from getting up to the 400s.

    Fingers crossed for some blues and yellows this cycle. Maybe even a green or two. No more red!

    Would love your input @Wendy&Neko
     
  2. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    Hi John, Wendy will be sound asleep for the next several hours. But you got the 100 point drop with the R which is what Wendy was looking for.
    How are you feeling? you must be tired. You can’t keep going on like this without some sleep. You won’t be any good for anyone, least of all Henry.
    Are you OK to monitor for the next 4 or 5 hours?
    That is good that the ketones have stayed down.
     
  3. Bandit's Mom

    Bandit's Mom Well-Known Member

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    Hi John, is the PMPS 255 or 355? SS says 355 and title says 255 unless I'm seeing things wrong!

    ETA: did you up the L dose to 2U?
     
  4. John & Henry

    John & Henry Member

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    That was a typo sorry for the scare. It's 355. Yes, after all the red and the ketones I went with 2U L. I'd rather deal with potential hypo than ketones
     
  5. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    John, that was really not a good idea to increase the dose of Lantus to 2 units. Please, please do not do increases on your own at the moment, especially when you are just starting R.
    Henry dropped to 34 last night on 2 units and his dose was dropped to 1.75units. The 34 indicates that the dose was too high.
    Hypos can be a lot harder to manage than you think.
     
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  6. John & Henry

    John & Henry Member

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    Yes, I'll be OK. Got a couple hours this morning when he was running good. 45 minute "eyes closed" sessions in between readings (it takes me usually at least an hour to actually fall asleep, so, I'm not really "sleeping" per se). The libre is great for waking me up when things go south, and Henry sleeps right next to me, just I've just been scanning him periodically. The libre is basically useless in the reds tho. It just reads 400 or HI. I'm very happy about the ketones and the clear 100 point drop right after the R dose. Hopefully that will be good information going foward.

    Do either of you know if certain brands of syringes are more or less prone to bubbles? I've been having a hell of a time with bubbles and dosing out that R. He may be getting a bit less than I intend.
     
  7. Bandit's Mom

    Bandit's Mom Well-Known Member

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    I know the multiple DKAs have been scary but dosing is based on nadirs and not preshots or bounces. There is only so much you can do to prevent bouncing...unfortunately. And numbers will be flat and high in bounce cycles. Lantus is a depot insulin, so dosing based on a bounce cycle can cumulate and give you hell when the bounce clears. Especially with R in the mix as well.

    Which brand are you using? Try pressing the plunger hard and keeping it pressed and insert into the pen/vial and see if that draws less air? Sometimes it is a real pain in the ar$e to get the air bubble out.
     
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  8. John & Henry

    John & Henry Member

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    Yes he did, but when that 1U dose was given his BG was only 70 and it had dropped from 80. I know we thought it was going to shoot up at some point so I understand why you wanted to shoot at 70. I just see a big difference between shooting at 70 and shooting at 355. Maybe I made a bad choice tonight. I guess we'll find out soon. I just keep thinking back to the day he was given 2U and then proceeded to stayed in the 400s the whole cycle til he ended up in the hospital. I'm trying to avoid that repeat at all costs.
     
  9. John & Henry

    John & Henry Member

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    I guess I just figured the vet had been giving him 2U (well, she actually gave him 3U at one point which probably caused a lot of this bouncing in the first place) and he's really had mostly 2U for 5 or 6 days now with the exception of last night and this morning. I see what you're saying tho. I guess we'll have to see how this cycle goes. I guess I'm just traumatized from the last 3 hospitalizations. I wish wendy would have had a second to look at his SS and give an opinion.

    I'm using UltiCare VetRx 3/10 29g U-100 syringes. I've tried everything I can think of and can't get rid of every last damn bubble, it's near impossible. It's gotta have something to do with the brand. So he's probably getting less than we expect. I have been pushing the plunger and drawing very very slowly and it may help a little, but it's bubbles that seem to stick around the top of the syrine and you can't even really eject them out, they get like hung up on the plastic or something.
     
  10. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    John, the reason we shot at 70 was because he needed to get some insulin into him. Today was different. Lantus dosing is based on the nadir as Bhooma said, not the pre shot BG. You have given him the increase based on the pre shot and you have given 0.25 units of R as well

    He was not eating well that cycle, and he was drinking a huge amount and the previous cycle had been skipped and he was unwell. This time he is eating well, he is getting sub Q fluids, no skipped doses and he is getting R. There is a big difference.
    We can’t help you unless you help us help you. If you want to do something please ask us first.we will always discuss it with you. But if you go ahead and do increase without telling us, it is very hard to help you.
    I know you are tired and that is the worst time to be making decisions on your own.
    We only want what is best for Henry, believe me. :bighug:
     
  11. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    I totally get you are traumatised after three admissions. I would be too.
    Let’s draw a line in the sand and move on. :bighug:
    Not sure when Wendy will be back online. But I’m sure she will be popping in here to see how Henry is going. And hopefully Sandy will as well.
     
    Last edited: Jun 25, 2022
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  12. Bandit's Mom

    Bandit's Mom Well-Known Member

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    We all know and understand how traumatic this has been for you. 3 DKAs, almost back to back, would freak anybody out. We have to find a balance between DKA and hypo. Both are dangerous and potentially fatal and can send him back to the ER.

    This seems rather illogical but a preshot is not always an indication of how the cycle will play out. We like to say "Shoot low to stay low" because Lantus is very good at giving beautiful flat cycles when you shoot a low preshot. You can have cycles where you start in the 400s or 500s and nadir below 50. Especially in bounce breaking cycles where there is additional downward momentum.

    2U took him down to the 50s on 6/20 and if you had shot on the AM of 6/21, it's possible he might have dropped below 50 and earned a reduction. You will get a good idea of what a dose is doing when you shoot the same dose consistently for a few cycles and see how low he goes when a bounce clears. There is only so long you can prop a cat's numbers up with higher carbs when the dose is higher than it should be. If the depot gets overfull, it's like standing in front of a speeding train. There was a sticky somehere with an actual example of a CG who didn't take an earned reduction and spent a cycle strugging to bring the cat up from the 20s. A cycle like last night is also not something you want.

    Wendy usually checks in every day but unfortunately she's tied up this weekend. I'm sure she will peek in at some point, but might not be able to do so as often as she usually does.

    I guess you must already have tried this, but do you flick the syringe with your finger to try and get the bubble to the bottom of the needle so that you can squeeze it out?
     
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  13. John & Henry

    John & Henry Member

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    I guess the way I'm looking at it is we actually did a decrease because as I said, he had been at 2U for 5-6 days, now we're seeing high numbers and we would no doubt be in the 400s right now with more ketones if I had followed the advice to not to give the .25U R because wendy wasn't around. I get that R is different than what everyone is used to using and everyone is reluctant to give advice because they don't have experience with it and don't want to be responsible for a hypo event. I get it. I'm also not thrilled about getting blamed by the vet for not following her instructions, but I realize this is your area of expertise and I'm trying to defer almost everything to the knowledgeable people of this board. Henry's been hypo a couple times now, its been pretty easily dealt with. he's had no symptoms of hypo and if he did I'm less than 5 minutes away from an ER and dextrose and hypo is rarely fatal, but another DKA would be for him at this point. I also think both of these glucose meter are garbage. The nova may be better, but with the faulty batch of strips it seems I was using, who's to say he was even under 50 at all? we just don't know for sure. I feel like I'm trying as hard as I can to keep him alive, and I do appreciate everything you've done to help. :bighug:

    I'm also exhausted and don't want to argue as I can barely spell and I've been trying to type this short message for 20 minutes now.
     
  14. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    You are doing everything possible to help Henry. And it’s wonderful to see someone love their kitty as much as you do!

    No one is arguing, we just want what is best for Henry. And I get that you are totally exhausted.
    I am happy you gave the R tonight. Who said not to?
    I am just concerned that the Lantus was increased.
    However we are going to move on and I am hoping Henry has a really good cycle, eats well and the ketones stay down.
    it must be time for +1?
     
  15. John & Henry

    John & Henry Member

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    Yes and although it takes some effort I can usually always get the bottom bubbles. Its the bubbles that get caught on top that are the problems. You'd think they would get ejected out when I push, but it's like they're stuck on the plastic or something and no amount of flicking or trying to eject them till get rid of them. It's gotta be the brand of syringe. These syringes are also not uniform. Some of them the plunger goes all the way to the zero line, some of them it's back as far (or further) than where the plunger should be for a .1U dose. It's very frustrating and makes gauging small doses very difficult. The trick that wendy talked about with just doing it over and over on to a piece of paper to try and get a uniform drop is the best I can do, but it's still not easy at all.
     
  16. John & Henry

    John & Henry Member

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    Yeah we're almost to +2 actually. The libre was still reading HI half an hour ago. let me poke him. He's had 4+ full cans of food today so yeah, I'd say he's been eating well.
     
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  17. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    That’s great.
     
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  18. John & Henry

    John & Henry Member

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    So we're not down much 335 @ +2
     
  19. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    But it is going in the right direction.
    Can you get some sleep for 1 hour?
     
  20. John & Henry

    John & Henry Member

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    sleep? probably not, but just lying in bed with my eyes closed helps. I'll be back and check him in an hour.
     
  21. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    Do try because you have not slept for ages. :bighug:
     
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  22. John & Henry

    John & Henry Member

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    We're at 298 on the nova for +3. The libre is actually updating again and its at 370 and will start screaming at me if it gets low. I'll be back in another hour since everything isn't crazy right now
     
  23. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Yellow!
     
  24. Tina Marie (GA) and Jan

    Tina Marie (GA) and Jan Well-Known Member

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    John, it is beautiful to witness your love for Henry (precious), your quick learning on his behalf, and your very good attitude along the way. I hurt for you over the expense, and your lack of rest.

    I am glad you pushed for using R. You also accomplished giving subQ fluid (a big yes on those 20g Terumo needles @Suzanne & Darcy / and maybe somebody else, mentioned). They slide in easily with the long sharp, slender opening at the tip. I could give 100 ml in just over 2 minutes.

    I deeply "feel" for Henry, as I have taken insulin for 43 years (currently Levemir and Humalog, which is faster acting than R). I know what highs and lows feel like, and I remember DKA too when I was 18. One of the first cats I gave insulin, was a beautiful black boy named Henry:) Having a scale for R is very helpful, after you discover just what works, which you are in the process of doing.

    Big hugs and peace:bighug::cat: you are a great cat daddy!
     
    Last edited: Jun 25, 2022
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  25. John & Henry

    John & Henry Member

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    ....and back to red :( 336 @ +4 the Libre is reading HI again. I really don't understand what is going on here. So strange. Situations like these are why I was suspecting my Lantus had gone bad or something. Well, looks like we don't need to be afraid of hypo anymore. The libre should beep at me if it drops anywhere near scary terrority. Can I try to actually sleep for a few hours and I'll try and catch a +8 or something? Hopefully it doesn't go back up too much. /sigh
     
  26. John & Henry

    John & Henry Member

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    Thank you for the thing words Tina:bighug:. I'll have to look into those needles. I'm glad Henry's a good boy I was afraid he wasn't going to like it after seeing those needles. I'm sorry you've had to experience this. I actually lost a (human) friend to DKA a little over a year ago. Diabetes is such a devastating disease. I hope your able to manage everything ok? Another diabetic Henry, eh? I've seen 3 different Henry's (including mine) here on the Lantus board alone. Must be a popular name for diabetic cats.

    Thanks again for all the encouragement :bighug:
     
  27. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    Yes, I think you can get some sleep. Were you thinking of giving R again at +6? We need to see what the +6 is first.
    He is bouncing at the moment from the run of low greens yesterday. That is why you are seeing the higher numbers.
    Have you got a urine sample to test for ketones at all?
    I’m not commenting on the R dose moving forward at all, I’ll leave that to Wendy and Sandy, but with the Lantus dose, I think you should go back to 1.75 units in the morning, because when he breaks the bounce he could drop low and we know that 2 units took him down to 37.
     
  28. John & Henry

    John & Henry Member

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    Yes, I was actually just thinking that right after I got up about doing the R at +6 so I'll be back then for .25U.

    edit: should conditions continue to permit. Have not been able to catch a urine ketone yet.
     
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  29. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    Get some sleep between now and +6
     
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  30. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    I’m heading to bed now John. I’ll ask @Bandit's Mom to help you.
    See you tomorrow. I hope you can grab some sleep.
    You are doing a great job under difficult circumstances :bighug:Henry is one lucky kitty to have you.
     
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  31. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    I was sorry to see he is back in pink - although it’s not a huge change from the 298. It’s so frustrating to see so little change from AMPS.
     
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  32. alio

    alio Member

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    Hi John, I've only partly been following Henry's story, but I just wanted to pop in and say what you are doing for Henry is very heroic, I can only imagine how stressed and exhausted you are. Henry is very lucky to have you!

    With the bubbles in the syringe, I too struggled with that for a while. What worked for me (most of the time):
    * hold the syringe with the needle up and flick the bubbles to the top
    * still holding it upright, draw in more air to make a big gap of air at the top
    * still holding it upright, slowly depress the plunger til the air is gone

    It seems counter-intuitive, but, for whatever reason, the big air bubble likes to stay together when it gets expelled, whereas the tiny ones just seem to get stuck up the top.

    The times this hasn't worked for me, is when there is insulin somehow above or on the side of the big air bubble, but, you can normally flick it into place. Sometimes it takes a couple of tries of redrawing more air.
     
  33. John & Henry

    John & Henry Member

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    So holding steady still at +6 333 Ketones back up to 1.1 :( Just gave what I hope was .25U R (the plunger barely moved when I pressed it, so hopefully there was enough R in there to do something. Will check BG in an hour. Thank you for the tips @alio will practice later. back to bed for an hour
     
  34. Sandy and Black Kitty

    Sandy and Black Kitty Well-Known Member

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    It’s critical you understand that what makes Lantus long lasting is that it’s slow acting. The reason Lantus dosing decisions are not made based on pre shot value is that Lantus onset, unique to every cat, is generally +2-+3 ish and is the number you are actually shooting at.

    The effects of Lantus are commutative and can sneak up on you. That’s why it’s important to string together the recommended number of consecutive cycles at the same dose
     
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  35. John & Henry

    John & Henry Member

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    So the R seemed to have minimal effect, we''re at 306 @ +7. I'll be back for +8 reading. Will respond to some of you than later today, just sooo tired right now Thank you for the comments. <yawn>
     
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  36. Liz & Minnie

    Liz & Minnie Well-Known Member

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    Hi John, just caught up on Henry's latest hijinks. Glad you are getting some sleep, and please don't feel that you have to respond to this.

    I would also return to 1.75u L next cycle and keep following your R dosing rules. Don't be tricked by how little the plunger moves with the R!!

    Generally per the rules for increases under TR and assuming his nadir remains in the 200s you will keep at 1.75u for 6 cycles before increasing to 2u.
    <100 - hold for at least 10 cycles before increasing
    <200 - hold for 6-10 cycles, incr 0.25u
    200-300 - hold for 6 cycles, incr 0.25u​
    I think you re-set the count so next 1.75u shot is cycle 1 - can someone else confirm this?

    Also - to help your peace of mind, not for dosing guidance - I looked back at my s/s from when Minnie was hospitalized last year with back to back DKAs and the feeding tube. Don't look at the dosing, but in April 2021 you can see how she went green almost every time they sent her home followed by several cycles of pinks and she still had some ketones.

    If you can get some urine ketone tests too that might help your peace of mind too (I never managed to catch her pee, I just kept not much litter in the tray so there were puddles I could dip into) because for Minnie at least, even when the novamax is showing ketones increasing up in the 1+ range it showed as negative or maybe trace with the urine test. It didn't change how I managed her at all but it helped me to 'not panic'.

    You have the tools to fight the ketones - food, fluids and R - and hopefully he is still eating well. You just need to get a decent few hours of sleep!
     
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  37. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Sorry the R has seemed have minimal effect. We don’t really know where he might be without it. I’m concerned about when this bounce may start to break at the same time as having 2 units of Lantus and .25 R. Well, rest up now! Hopefully he will come down slowly from the high numbers and not do anything too dramatic.
    I would give fluids again today(see my tips on Terumo needles/fluid warming, etc. from the previous thread.). Also - the higher you hang the bag, the faster it will flow. Only 60 mL should not take long at all.
     
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  38. FrostD

    FrostD Well-Known Member

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    Since it is the weekend and not everyone is always around in time - my two cents for tonight (and the next few cycles) is to definitely wait for R advice as long as you can. There is a possibility he will break the bounce, and experienced eyes may be able to help pinpoint that trend early enough. Given the 2U this morning + past data + his onsets of L and R, the R at shot time could add some serious fuel to the fire of a bounce break if it happens.

    If nobody is around to advise, I would go more conservative on the R and possibly even skip. Then if by midcycle he's not showing signs of a break, can rethink it then and hopefully buys you some time for someone to come around.

    @Liz & Minnie how did you handle not knowing if a bounce was coming? Skip the R at L shot time and re evaluate mid cycle?
     
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  39. Sandy and Black Kitty

    Sandy and Black Kitty Well-Known Member

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    To best manage this situation you need to find a Lantus dose that you can shoot consistently. Then you need to spot time of onset, nadir and duration. Keep in mind these are not fixed- they can and do shift. You then need to look for the R onset, nadir and duration. with that information you will be able to judge the best timing for R.

    R is a double edged sword. It’s easy to become trapped on “the R roller coaster”. It goes something like this-

    You see a high number and grab the R to shoot it down. If the drop is too fast and or too far, the counter regulatory hormones are released and up the numbers go. So you grab the R…

    before you know it you’re trapped in a self perpetuating loop of endless ups and downs.
     
  40. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    [QUOTE="FrostD, post: 2968065, member: 30207"
    There is a possibility he will break the bounce, and experienced eyes may be hopefully buys you some time for someone to come around.

    Melissa, I don't know that there's anyone around here who is better at predicting when a bounce break is coming than you. I've seen you do some good spotting in that department. Anyway, maybe you should share your methods with John and alert him to what he should be looking for :) But I agree with what you've said here, that's what I was trying to express concern about in my post above.
     
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  41. FrostD

    FrostD Well-Known Member

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    May 27, 2020
    In much better with ProZinc and Vetsulin ;)

    Last night I mentioned that about the only trend I could pull was that the cycle before the break Henry tends to dip into yellow, then come back up and stay flat pink the rest of the time. Now of course it's all a little fuzzy with hospitalizations and doses but that's best I can do.

    @John & Henry I see he was pretty flat coming into AMPS and you still have 0.25U R at 319...Wendy's advice was 0.1U in that range so please do be watchful. I don't think he'll break the bounce that quickly on you, but if he starts to slide down towards midcycle - I strongly suggest no R unless one of the experts says otherwise.
     
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  42. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Here's my data dump on bounce clearing: If you see a bounce happening, with numbers high and maybe wobbling around a bit or just high and flat -- and sometimes it seems like there's just little to no response to the insulin -- then there some ways to spot a bounce breaking. If you see cycle where they are sliding down the entire cycle, that's a sign of a breaking bounce. However, sometimes a cat will do an unexpected rise in the cycle before the bounce break. I've heard Wendy call this the "high before the low." Of course, you will eventually learn how long it takes Henry to clear his bounces and be aware of it. Every cat is different in this respect.
     
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  43. John & Henry

    John & Henry Member

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    May 24, 2022
    So a got a few hours sleep in between tests last night & feeling better, (I did dream about feline diabetes the whole time tho!). I'm still extremely concerned with the current situation. The ketones crept up overnight, reading 1.1 @ PMPS +6. Atleast they didn't increase anymore at AMPS and stayed at 1.1. While the R at PMPS +6 seemed to do very little in regard to bringing the BG down much, maybe it helped fight off the ketones from rising anymore? His eating has been ravenous and he's suddenly been very interested in drinking this morning. We've seen this happen before with high BG & ketones-- he starts pounding the water, hopefully this isn't a sign of bad things to come. I went back to the 1.75U L dose based on everyone's suggestions. I do hope to not regret it and have it lead to higher BG/Ketones. Last hospitalization he started getting sick when ketones hit 1.9. EDIT: interestingly even though the nova didn't register much of a change after the +6 R shot, the libre stopped reading HI or 400 and has been showing in the high 300s ever since. Again, I'm questioning the accuracy of both of these meters.

    This is a good explanation. So the counter regulatory hormones are released from a fast drop and not just a low drop? How much of a fast drop? I've read 100 is ideal. What about going from 450 to 250 in a couple hours, is that too fast? I do like how you explain why (counter regulatory hormones), sometimes I have a hard time accepting things deemed to be canonical without an explanation as to why. Especially in non-standard situations like Henry's.

    I'm totally on board with line of thought. I'd be thrilled with some yellows at this point.

    So one thing that really concerns me with not explicitly following the vets instructions is what happens if he needs to be hospitalized again? Do I tell her what his doses have been? Do I include that information in my reports to her? She got really annoyed when we did the increase from 1U L to 1.25U L even though it actually improved the situation at the time and probably should have been higher. If he goes DKA again and I say "Yeah, I've only been giving him half the R dose you prescribed and 1.75U instead of the 2U you wanted " she likely isn't going to be happy about that. At this point shes made 3 major errors and I don't really want to have burden of guilt shifted back on me. When she called me out on the increase to 1.25U L before she said, "How can you even dose that? 1/4 units aren't even a thing"

    I'll be responding to other comments too, but I just wanted to get this posted.
     
  44. Liz & Minnie

    Liz & Minnie Well-Known Member

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    Feb 4, 2021
    I still can't spot when a bounce is going to break!

    When I was in a similar situation to John last year, I started the R under the vet's instructions (0.5 or 1u) and then was told here afterwards that the vet had me giving too much R . I'm looking back again at last year, I think I just followed the rules pretty much based on BG reading at PS and and ~+6 (I'm using Levemir, not Lantus). I couldn't even spot her nadir at that point. I do remember posting and asking others for advice/if they thought the bounce was breaking. @Marina & Chico is also very good at analyzing s/s data.

    Shorter answer - if the BG was high enough and the ketones high (fresh out of DKA), I think I gave the R at L shot time in the absence of other guidance. Knowing that you only want a drop of 100 over 4 hours means that if there was a steep drop after hour 1 or 2, I could give higher carb food.

    This is all just me answering the question about how I handled it. Not giving advice. I can rarely spot bounces breaking (Minnie right now being a case in point, I have no idea what's going on)
     
  45. Liz & Minnie

    Liz & Minnie Well-Known Member

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  46. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    I hope he won't drop more than about another 50 in the next hour. Keep a close eye on him for sure. I was excited to see yellow though. Are you feeding him now, or what?
     
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  47. FrostD

    FrostD Well-Known Member

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    May 27, 2020
    "fast" really depends on the cat. Typically, if they drop about 1.5-2 color ranges in the sheet that's enough to do it...some are more sensitive than others.

    As for the vet...I would explain the long hypo you had (which I think you already did) and you took an L reduction from that because that's just not sustainable. As for the R, that's up to you. You can tell her you did some reading and wanted to start a little more conservative. I personally don't think she needs to know that many details in the event of a hospitalization because the R doesn't have much bearing aside from when it was last given - they'll do their own thing in the hospital anyway
     
  48. FrostD

    FrostD Well-Known Member

    Joined:
    May 27, 2020
    Ok +1 tells me very likely no R midcycle and that you might be looking at a bounce break on this cycle...hoping for a long slow slide down once the R is out of the way.

    That, or this is the cycle before he clears.

    If the +1 to +2 drop is more than about 50 points I'd consider mixing some LC and MC...Liz and Suzanne, thoughts?
     
  49. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    I agree with this!
     
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  50. Liz & Minnie

    Liz & Minnie Well-Known Member

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    Feb 4, 2021
    Yes, same thought! You want him to drop but not too much too fast.

    And (paws crossed) if he is still in the yellows by mid-cycle, you wouldn't give R anyway if you're following the rules.
     
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  51. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Blue! You need to slow the drop with higher carb food.
     
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  52. Liz & Minnie

    Liz & Minnie Well-Known Member

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    Feb 4, 2021
    Yes, agree...though I am sure it feels counter-intuitive. You want to keep him about where he is and not let the R pull him down more.

    Somewhere here I read, the L works better on lower numbers so the R has done its job to bring him to a better range for the L to work with. (I know someone can explain this better!)
     
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  53. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    Feb 21, 2015
    Hi John, I just wanted to let you know that I have spoken to Wendy and she is really caught up this weekend and is not sure she will be able to pop into the thread or not, but she is aware how things are going.
    She said don’t expect the R to work the same each time, and that R doesn’t always reduce the numbers every time but that keeping a lid on the bounce is a good reaction.This variability means we need to try a dose several times before tinkering with the R dose. Data gathering is needed before changing.
    Also Lantus is a depot insulin. The dosing method works. so you need to be patient.

    I can see you gave 0.25 R with the last two BG under 350 instead of giving 0.1 R
    Please follow Wendy’s suggestions on dosing of R. I think it is a good idea to say online what you are going to give with the R so someone can check with you, while you are so tired.

    Yes this is correct.
    I can see the R has dropped the BG ny more than 100 by +2. I would also feed a little higher carb. We don’t want it to drop too much and cause another bounce.
     
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  54. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Jun 4, 2020
    Yes. Wendy always used to explain it to me that the R would bring down the numbers and give the Lantus (or Levemir) better numbers to “work with.” This makes sense since these depot insulins are not good at shooting down high numbers.
     
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  55. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    As Liz and I know only too well, a cat’s response to R is definitely variable, i.e., same BG , same R dose different response.
     
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  56. John & Henry

    John & Henry Member

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    May 24, 2022
    He's eating right now, and I'm going to test again at +2.5
     
  57. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    I'm happy he's eating, but I hope it's higher carb food. MC at least (over 10 percent) 15% would be good to try.
     
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  58. John & Henry

    John & Henry Member

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    May 24, 2022
    The downward momentum has slowed at +2.75 to 172 on the nova and 242 on he libre. I do wonder how much my measuring skills play into this as I've spent a couple of hours now trying to be able to nail .1U and .25U doses, and it's very very hard. Maybe its because I don't have enough experience yet, but there are time when I "think" I got a .1U dose and when I hit the plunger nothing at all comes out on the paper. Also as I've said before these syringes are not manufactured uniformly. In some the plungers don't go all the way to the zero line, but others do. Makes it difficult for dosing such small amounts. I try to do a test shot on paper for each new syringe first. Anyway, I'm happy to finally be out of the reds and hopefully ketones go down now. In previous R doses we usually see a tick back up by +3 or +4. I expect we'll see that soon.

    edit: In the FAQ it says it possible to dilute insulin, although the sanctioned dilutants aren't sold commercially anymore, but that sterile water can be used as a dilutant. Seems like being able to dilute the R would make for more accurate measuring.
     
    Last edited: Jun 25, 2022
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  59. Sandy and Black Kitty

    Sandy and Black Kitty Well-Known Member

    Joined:
    Dec 31, 2009
    Depending on the cat the release of counter regulatory hormones can be triggered by a drop to a number lower than the cat’s body is accustomed to, a fast drop or even the length of time spent in the lower than accustomed to numbers. ECID. The important thing is to “know thy cat”

    Our situation was about as non standard as they come.

    Sometimes you have to take a leap of faith. :cool:


     
  60. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Jun 4, 2020
    I do not have experience with diluting R. @Sandy and Black Kitty ?
     
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  61. Diane Tyler's Mom

    Diane Tyler's Mom Well-Known Member

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    Sep 21, 2018
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  62. Diane Tyler's Mom

    Diane Tyler's Mom Well-Known Member

    Joined:
    Sep 21, 2018
    [​IMG]

    [​IMG]

    You probably saw this already
     
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  63. John & Henry

    John & Henry Member

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    May 24, 2022
    I have and I'm ordering some of those syringes right now. Thank you!
     
  64. Sandy and Black Kitty

    Sandy and Black Kitty Well-Known Member

    Joined:
    Dec 31, 2009
    I’ve never diluted insulin or known anyone who diluted insulin. I see no reason to do so.

    Do the best you can. Your 0.1u is your 0.1u. The important thing is to be consistent.
     
  65. Sandy and Black Kitty

    Sandy and Black Kitty Well-Known Member

    Joined:
    Dec 31, 2009
    What’s the WCR (whole cat report)?

    All Ps in place? (peeing, pooping, playing, preening and purring)

    Appetite good?

    Caloric intake at 1.5x what’s required to maintain ideal weight?

    results from today’s ketone tests?
     
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  66. John & Henry

    John & Henry Member

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    May 24, 2022
    Ha! Hadn't heard about the Ps yet. Finally caught him in the box and got a ketone test. Its reading "trace", two poops, I wouldn't say he's acting particularly bright like he was after he had just came home, several months before the first DKA he had stopped grooming himself (I should have taken that as a sign in retrospect), he started grooming for about 2 days after he came home after the first DKA, but hasn't done it since. The vet says they stop to conserve energy and since he's mostly just a skeleton with skin at this point, he may still be trying to conserve energy. He's always a purrer whenever I pick him up except when he's really sick/lethargic/won't eat, and even then he'll usually do a few very quiet purrs if I love on him a bunch.

    Appetite is ravenous as always, he's had about 2 1/2 cans in the past 7 hours. Last blood ketone test was at PMPS +6 and it was 1.1, urine ketone trace. Think I should do another blood ketone soon? I'm not as worried now that he isn't in the 300s, hopefully they'll come down now. I was planning on one at PMPS tonight unless his BG gets real high again. Doing AMPS +5 reading right now.

    edit: for some reason he's been lying on the welcome mat at the front door since last night. This isn't a normal spot for him to hang out. Maybe he misses all the vet techs? They all seemed to love him (or maybe they just tell that to all their patients parents)
     
  67. John & Henry

    John & Henry Member

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    May 24, 2022
    So we're still going down to 126 @ AMPS +5. Maybe the bounce broke? Hopefully the fall won't trigger it again. Should I try some MC food?
     
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  68. Liz & Minnie

    Liz & Minnie Well-Known Member

    Joined:
    Feb 4, 2021
    I think @FrostD called it at +1, bounce is breaking. Impossible to tell how much of the drop due to breaking bounce vs impact of the R.

    What have you been feeding him up to now? LC or mix of LC/MC?
     
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  69. John & Henry

    John & Henry Member

    Joined:
    May 24, 2022
    Yes, he's had 2 cans of FF LC and about half a can of DM. I think offering him the LC/MC mix right now would be a good idea, huh?

    edit: he just loves the FF more than anything now. I'm afraid he'll just his nose up to his former favorite Friskies which is 18%
     
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  70. Liz & Minnie

    Liz & Minnie Well-Known Member

    Joined:
    Feb 4, 2021
    Yes, I would mix LC/MC now. As you said a couple of messages back, we don't want to trigger another bounce. For future reference, I would have started mixing the LC/MC as soon as he had such a steep drop at +1.

    Which DM do you have - pate or savory selects (chunks in gravy)? The pate is 6% and savory selects is 10%.

    ETA - Minnie loves the FF too so I keep these on hand (can usually get both at Walmart and the HC beef is almost everywhere)
    • HC 20%: FF Gravy Lovers Gourmet Beef Feast
    • MC 12%: FF Grilled Chicken Feast
    • MC 12%: Prescription Hill's ad (you can buy a few cans at the vet to see if he likes it then get it a bit cheaper from chewy)
     
    Last edited: Jun 25, 2022
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  71. John & Henry

    John & Henry Member

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    May 24, 2022
    Thank you for those tips Alio! I've tried all of that and yes, it seems its the tiny bubbles that get stuck at the top, even after pulling in air. It's like they're stuck on the edges of the plastic. I've ordered a different brand recommended by @Diane Tyler's Mom
     
  72. John & Henry

    John & Henry Member

    Joined:
    May 24, 2022
    Hmm, yeah, it's the pate, so not that many carbs. I'll try some friskies now

    edit: He's happily eating the friskies, half way through the can already
     
    Last edited: Jun 25, 2022
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  73. Liz & Minnie

    Liz & Minnie Well-Known Member

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    Feb 4, 2021
    You can mix it in with the FF.

    I keep these on hand. The HC beef is in most supermarkets, the grilled chicken I found at walmart. Re-writing this since I added to an earlier post after you read it :)
    • HC 20%: FF Gravy Lovers Gourmet Beef Feast
    • MC 12%: FF Grilled Chicken Feast
    • MC 12%: Prescription Hill's ad (you can buy a few cans at the vet to see if he likes it then get it a bit cheaper from chewy)
     
  74. Liz & Minnie

    Liz & Minnie Well-Known Member

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    Feb 4, 2021
    Hurrah!

    What % is the friskies?
     
  75. alio

    alio Member

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    May 10, 2022
    I wonder if it's something about the coating that particular brand uses inside the syringe that attracts the air somehow. Hopefully, you have better luck with a different brand!
     
  76. John & Henry

    John & Henry Member

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    May 24, 2022
    Thank you. I'll pick some of those up ASAP. He really loves the FF.
     
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  77. John & Henry

    John & Henry Member

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    May 24, 2022
    18%
     
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  78. Liz & Minnie

    Liz & Minnie Well-Known Member

    Joined:
    Feb 4, 2021
    Will be interesting to see what his next BG is. Let us know the time between finishing the friskies and his next BG. (It should take about 20min for the food to have an effect)
     
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  79. John & Henry

    John & Henry Member

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    May 24, 2022
    Looks like it's been almost 30 minutes and we just tested 125 for +6, so looks like we're leveling off. Let's hope we can just stay in the blues til PMPS in 6 hours.
     
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  80. Liz & Minnie

    Liz & Minnie Well-Known Member

    Joined:
    Feb 4, 2021
    Hold off the MC. We don't know if he's at nadir or if the MC bumped him back up.

    No mid-cycle R, that's for sure!
     
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  81. Sandy and Black Kitty

    Sandy and Black Kitty Well-Known Member

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    Dec 31, 2009
    How often are you giving sub q fluids?
     
  82. John & Henry

    John & Henry Member

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    May 24, 2022
    60ml/day. Haven't given them today yet, but was just thinking about doing it as much I hate poking him with that needle.
     
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  83. John & Henry

    John & Henry Member

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    May 24, 2022
    Yep, definately not doing anymore R. I'd say he ate about 1/3 of that friskies can about 45 minutes ago. I'll put the rest away.
     
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  84. Diane Tyler's Mom

    Diane Tyler's Mom Well-Known Member

    Joined:
    Sep 21, 2018
    Just giving you more choices of med and high carb foods
    Fancy Feast Gravy Lovers Gourmet Beef Feast in Gravy 20% High Carbs

    Fancy Feast Gravy Lovers Gourmet Chicken Feast in Gravy 15% Med Carbs

    Fancy Feast Gravy Lovers Turkey Feast in Gravy 15% Med Carbs

    Fancy Feast Gravy Lovers Chicken and Beef in Gravy 15% Med Carbs

    Good idea to mark the cans with magic marker how many carbs
     
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  85. AbbottTheCat

    AbbottTheCat Member

    Joined:
    May 12, 2022
    I had a hell of a time with the BG syringes initially, now I realize it's less about the brand and more about the method. After some trial and error (and a bit of wasted juice:)) I have developed a technique where I'm getting maybe one or two, (sometimes zero) tiny bubbles that can be easily flicked up. I should mention I'm using a pen. The first bit is setting up a hands free rig:
    https://www.felinediabetes.com/FDMB/threads/pen-syringe-hands-free-technique.264986/

    As for the syringe priming method here's what I do:
    *pull plunger most of the way out and move up and down (lubricates plunger)
    *push plunger all the way in and WHILE PUSHING twist a couple times. (lubricates the area between zero and .5 where most of the bubbles hang out)
    *KEY- while holding plunger pushed in, insert syringe into pen all the way. (no risk of contamination since syringe is empty)
    *release thumb off plunger (this will instantly fill the area between zero and .10 (with zero bubbles if done correctly)
    *then draw up your dose

    All of this is much easier to do with the hands free method I posted I'm sure, although I have not dosed with one hand holding pen so can't speak to that.
    Give it a shot! pun intended;)
     
    Last edited: Jun 25, 2022
  86. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

    Joined:
    Jun 4, 2020
    Well, Henry is holding steady in blue! I feel good about that. I’ve been watching, and letting Liz take the lead for our team. Since I am on Eastern time and it’s after midnight, I am going to bed.
     
  87. John & Henry

    John & Henry Member

    Joined:
    May 24, 2022
    Thank you for all that. I have been trying to push in on the plunger before drawing, but didn't think about rotating to lubricate, that's a good idea. I just started moving it in and out to lubricate in the last day or two. I'm using a pen too. I'll check out the hands free rig. Excellent info!
     
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  88. John & Henry

    John & Henry Member

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    May 24, 2022
    Thanks for all the guidance Suzanne! Very appreciated!
     
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  89. Sandy and Black Kitty

    Sandy and Black Kitty Well-Known Member

    Joined:
    Dec 31, 2009
    Please do.
    Flush those ketones out.

    I’m not sure if you have learned the basic how’s and why’s of ketone development and DKA but the way DKA happens is that when there is not enough energy from food making it into the cells, the body will breakdown fat and protein to try and fulfill the need for more metabolic energy. The excessive breakdown of these stored reserves creates a toxic by-product - ketones. As ketones build up in the blood stream, the resulting pH and electrolyte imbalances can very quickly develop to life threatening levels , a state of DKA.
     
  90. John & Henry

    John & Henry Member

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    May 24, 2022
    Oh, I have. I've even been reading academic papers on it, and the number of chemical processes occurring is enough to melt my brain. Such a delicate balance with many variables. I worry Henry has very little muscle and fat left to be used as energy. He's a skeleton with fur at this point. We thought in the week or two after the first DKA he may have gained a little tiny bit, but that's all gone now. I'm trying very hard to fatten him back up!

    This thread is getting a bit long so I made a new one: https://felinediabetes.com/FDMB/thr...5-2-198-3-163-4-151-5-126-6-125-7-133.265070/
     
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