Info New Dose Wonkiness (NDW) and Failed Reductions

The Tight Regulation Protocol with Lantus or Levemir describes what we've fondly dubbed "New Dose Wonkiness" (NDW) here in the Lantus, Levemir, & Biosimilars ISG:

"Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations."

You might also see this happening while following the Start Low, Go Slow Method.


NOTE:

• NDW usually lasts for less than 24 hours and is usually seen in the second day following a dose increase.

• The concept of "New Dose Wonkiness" is NOT applied to higher numbers which may be seen after a dose reduction.

• There is no "NDW" following a dose reduction nor do we hold a reduced dose 6 cycles (as done with dose increases) to "fill the insulin depot".

• "Settling time" does not apply to dose reductions. We don't wait for a reduction to "settle".

• For those following the Tight Regulation Protocol: "If the cat will not stay in the normal range after a reduction, immediately increase the dose again to the last good dose."

Hope this helps...

 

Re: New Dose Wonkiness (NDW)

when you increase a dose of lantus, you would expect the BG numbers to go lower, right? that's logical. more insulin = lower numbers. only there is a lag time sometimes - increase the dose and for some reason the numbers go higher. that can last a day or so, and then suddenly you start seeing those lower numbers you expected. we call those higher numbers "New Dose Wonkiness" or NDW.

this is the reason we wait following each dose increase to let it settle and see what it's really doing.

now not every cat does that, of course. ECID. sometimes you increase the dose and you immediately see lower numbers. the point of this post is to say that IF you increase a dose AND you see higher numbers, give it a couple of days for things to settle down and then you can assess the dose to see what it's really doing.



the second part of the post is saying that this doesn't apply to a cat when you DECREASE a dose. let's say mookie drops below 50 today and you decrease the dose. if you see higher numbers following the dose decrease, that's not NDW. NDW only applies when you're increasing a dose. higher numbers following a dose decrease can be from one of two things. one possibility is that it simply isn't enough insulin. another possibility is if the cat dropped quickly, or if the cat dropped into a lower range of numbers than it was used to, that can cause a bounce.

BOUNCING

Here is an example of a bounce from someone's recent condo:

you can spot a bounce this way (this only took me 6 months to learn and a bunch of people explaining it! i'm a slow learner!)

yesterday morning you had a 215 - then it went 235, 271, 270, and then 308 this morning - basically straight up. no curve. and then look backwards in the ss and the night before was that sweet little 148 12 hours earlier.

if you imagine that night-time cycle, starting at 148, kitty probably went down in a nice little curve, hitting something under 100 mid-cycle. that lower-than-usual number would've shocked her body. they get accustomed to whatever range they're in, and any sudden dip lower can set this off.

"HELLO WE"VE GOT A 911 HERE- KITTY'S GOING DOWN!" yells Mr. Liver. Fortunately, mr liver has a storehouse of counter-regulatory hormones and stored sugar (in case kitty needs a little nommy sweets in the middle of the night) and when Kitty gets into a range of numbers lower than usual, Mr. Liver lets loose with the sugar and the hormones and sends Kitty on a rocket to the moon. this is the cat's body's protective mechanism to keep the cat from becoming hypoglycemic. unfortunately, mr liver doesn't seem to know that anything above 40ish isn't a crisis and it will do this regardless of the range of numbers, even at 200 if the cat has become accustomed to 400.

A second cause of a bounce is if a cat drops very quickly. 100 points in an hour, for example, regardless of the range the BG number is in, can cause a bounce as well.

So, what to do now? don't increase the dose because of these higher numbers. once this bounce clears, which can take up to 3 days of high numbers if mr liver is super-active, then if you had increased the dose, it would be too high. you are entering the phase of treatment that we say requires "Patience Pants." when you think you're seeing a bounce, you have to wait it out, then you can see what the dose really does. You will know the bounce has cleared when you start seeing numbers you were seeing before - like that 148 again.

edited for clarity.

 

bump!

 

This is great info, thanks!

 

What does the word "bump" mean in Jill and Alex's post above? I got that same directive last night and didn't know what it meant. Still,don't.

 

"Bump" the post to the top of the forum. The most recent post are listed first.

 

Doesn't that happen automatically?

 

A post will only get moved to the top if someone replies (so there's something new for people to read). As far as I know (no idea how - someone must have told me at some point), the original meaning was "Bump Up My Post" but anything you type as a reply will have the same effect.

 

Many thanks for the explanations everyone. Every day I learn something new from you.

 

Ohhhhhhhhhhh! I'm sure I will have for ead this 24 more times but right in this minute I understand it! Lol Thank you!!

 

GREAT explanation of a bounce!!

 

bump

 

bump

 

Bumpity!

 

I'm bumping this up because the explanation here about the famous bounce and the concept of new dose wonkiness is helpful to me today and may help others too.....

 

Bump

 

I gave my kitty .50 units and she bounced to 245. . I am using Alpha Trak 2 meter and strips and Lantus. She has never been that low at 90. She went down to 90 at +4. She is now at 151 at +10 and I usually dose at +10. So, now it is dosing time do I give the .50 units or reduce to .25 units??

 

Can I ask that you start a new thread giving some details about your cat, the dose you've been giving and when (giving Lantus at +10 is fairly unusual) and some kind of history of her numbers? This thread was started quite some time ago and it's likely that not too many people are looking at it right now apart from those of us who are getting notifications because we've commented on it at some point.

 

bump

 

bump

 

So how long do you wait to see if they get back down to greens after a reduction? It seems it does take Gizmo a few cycles to level out.

 

My rule of thump is, if they go steadily up after a couple of days, go back up to a bit less of a dose that caused the reduction. It seems to me that when they are bouncing, the numbers wobble around higher, lower, higher again. If it is a failed reduction, the numbers seem to go steadily upward with no downward movement.

 

That makes sense. Hard with working to see his nadir in the AM cycle. We will see what he does tonight.

 

So Rudy got a reduction of .25 today since his bg was under 90 yesterday. I'm confused as to how long to hold this reduced dose. Is it a full week? Or is it reevaluated as we go?

 

You'll want to hold the dose:

• until Rudy falls below 90 and earns another reduction, or
• unless the reduction has failed (if you see his BG numbers trending upwards after any bounce clears... you'll want to take the dose up, or
• if nadirs are greater than 90, but less than 149.

Make sense?

 

It says to hold the dose if nadirs are between 90 and 149. What if he's greater than 149? Then what do I do?

 

That is for SLGS Correct? Do the same nadir numbers apply to TR?

 

Then post for help. If his numbers are trending upwards, you'll probably want to increase the dose.

 

He just had the reduction today. He's probably clearing a bounce today.

My question was about part 3 of the list you posted - what do you do if the nadir is above the 149 mark? Then how long do you hold it? Or what do you do then? The instructions for this part do not make sense unless you fall in that range.

• if nadirs are greater than 90, but lessthan 149.

 

Nope. When practicing TR you're looking to bring kitty's numbers down to that of a normal cat (50mg/dL to 80mg/dL) and under 100 overall. Therefore, when following TR you'll want to hold the reduced dose:

• until kitty falls below 50 mg/dL and earns another reduction, or
• unless the reduction has failed (if you see BG numbers trending upwards after any bounce clears... you'll want to take the dose up), or
• for at least a week (stabilize the cat) if kitty's numbers maintain that of a normal cat (50mg/dL to 80mg/dL) and under 100 overall.

Make sense?

 

That wasn't very clear! Sorry.
When nadirs are greater than 90, but less than 149 you'll want to hold the dose... maybe a week... maybe longer. It all depends on the cat. At that point you want to make sure he's stable in that range before deciding if you want to try to bring the entire range down a bit. Some caregivers are happy with those numbers. Others want to push for remission by gradually lowering the reduction number. It's an individual decision...

 

Ok. Again I ask - how long do I hold his dose if his nadir remains higher than 149?

 

Sorry, I had to take a phone call.
If his nadirs are higher than 149, it would mean a failed reduction. Right? Some might wait a week. Others will take the dose up as soon as they feel confident the reduction has failed.

Here's the thing I think most (not you personally) are missing...
every caregiver really needs to get a handle on their kitty's onset, nadir, duration, how long it usually takes kitty to clear a bounce, how long it appears to take for the insulin depot to deplete, how much of a bump in numbers they'll get from a couple teaspoons of LC, MC, & HC. In other words, a caregiver needs to learn their own kitty's response to insulin and food.

Once a caregiver "knows thy cat", they'll understand what they're looking at... they'll know when to increase, decrease, or hold the dose.

Here are some basics that might help everyone (from the New to the Group? sticky)...

Learn how YOUR kitty is responding to insulin:

• Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose
• Peak/Nadir - the lowest point in the cycle
• Duration - the length of time insulin continues to lower blood glucose

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

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

Hopefully I've answered your question. If not, let me take another shot at it.

I'm also hoping the rest of the info info will help everybody... no matter which protocol they're following. The suggestions in the protocols are guidelines, but not every cat reads them. When the caregiver truly knows their cat, they know what they have to do to achieve regulation and maybe even achieve remission.

 

Makes sense now. Thank you for clarifying.

 

Bump cuz it's a great explanation!

 

This is great. Glad to get such a good explanation!