Using R to give Levemir a jumpstart

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Bronx's dad (GA)

Member Since 2016
The goal of using R insulin is to only lower the blood sugar by 100 or less points. Depot insulins do great at holding blood sugar flat but less well at pulling high blood sugar down. By using R to lower the blood sugar a little bit the Lev will be able to do its job a little better. We don't want to drop his blood sugar too much or too fast, so initially we'll start with a tiny dose. After you give it, you'll test hourly for the following 4 hours so we can see what effect it has. It's not uncommon for the first trial not to do too much. We're starting with a tiny dose because some cats do react. Even when Punkin was getting more than 10u per shot, I usually didn't use more than 0.5u with the R.

Thanks Julie! This seems like the next logical step for Bronx if #s are still flat and high using Levemir after a week or so (just switched from Lantus to Lev yesterday) . I will try to find the best place to get R (probably walmart pharmacy?) and get a hypo toolbox together.

previous post: http://www.felinediabetes.com/FDMB/...r-an-unregulated-acrocat.170519/#post-1859707
 
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I had suggested two weeks yesterday to wait to start R because I knew I wasn't going to be around and I needed to check with Wendy and Julie to see if they would be. After discussing with Julie, we both think if he's on lev for a week, she will be available to help you with the R.
 
I had suggested two weeks yesterday to wait to start R because I knew I wasn't going to be around and I needed to check with Wendy and Julie to see if they would be. After discussing with Julie, we both think if he's on lev for a week, she will be available to help you with the R.

Sounds like a plan Marje. I will wait till next week to start. So I can plan ahead, how many days in a row will I be using R and need to be home to closely monitor?
 
Sounds like a plan Marje. I will wait till next week to start. So I can plan ahead, how many days in a row will I be using R and need to be home to closely monitor?
Be sure you tag or check in with Julie or Wendy before you start as we really like an experienced R used to be with you online the first few times. There are others around, too, who have used R but I just don't know their schedules.

You can't really plan on how often you will use R. You have to take it a cycle at a time. Julie and I both often observed that it seemed to have a residual effect a cycle or two later but the goal is to use it effectively so the preshots are gradually lower and it gives the levemir a better starting place to work its own magic.

Sometimes it works like that, sometimes it doesn't. You have to learn when it's appropriate to use and when you're better to lay off. You can start a viscious bounce, dive cycle with it if you aren't careful.

We can post some general guidelines for you. I've got to run right now but will come back later and post some of them.
 
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So I can plan ahead, how many days in a row will I be using R and need to be home to closely monitor?
Let's see if anyone on east coast time is available for Saturday morning (I've put out the word to see). If we do it Saturday with his pm shot, then I would probably not want to do it again on Sunday. Just depends on how he reacts to it. I wouldn't want to use it both Saturday pm cycle and again on Sunday am cycle. As Marje mentioned, it's not uncommon to see the next cycle be lower after using R. This is yet one more of those "play it by ear" scenarios.
 
Let's see if anyone on east coast time is available for Saturday morning (I've put out the word to see). If we do it Saturday with his pm shot, then I would probably not want to do it again on Sunday. Just depends on how he reacts to it. I wouldn't want to use it both Saturday pm cycle and again on Sunday am cycle. As Marje mentioned, it's not uncommon to see the next cycle be lower after using R. This is yet one more of those "play it by ear" scenarios.
I can work from home, so a weekday is fine too next week if that is better for my "coach".
 
Are you ok doing a pm cycle? It would be from pmps to +4 - probably not more unless there was a more marked response than we expect. Again, hard to plan.
 
Are you ok doing a pm cycle? It would be from pmps to +4 - probably not more unless there was a more marked response than we expect. Again, hard to plan.
Yes, I could do a 730p-1130p cycle next week, no problem. Closest vet would be closed at that time but a 24hr one is only about 15-20min away if things go bad. What is the worst-case scenario shooting 0.5 of R? I would have my hypo toolbox ready to go.
 
Yes, I could do a 730p-1130p cycle next week, no problem. Closest vet would be closed at that time but a 24hr one is only about 15-20min away if things go bad. What is the worst-case scenario shooting 0.5 of R? I would have my hypo toolbox ready to go.
Numbers can drop really fast and by a lot. When we give R, the ideal is to see about a 100 mg/dL drop over four hours.

When we use R, we:
  • Avoid giving it so that R and L nadirs overlap
  • Test hourly the first few times you give it until you are familiar with how it affects the BG keeping in mind it can change
  • If he bounces, be sure you don't give it as he starts to clear a bounce
  • Be aware that after the R has reached its duration, you might see lower numbers again the next couple of cycles
Those are just a few things to consider.
 
How do I properly measure 0.25u?
025unit-1.jpg


Just following the thread and helping there and there. The above picture shows what .25u looks like. It's found in the Syringe & Info Handling, Drawing Fine Doses sticky at the top of the L&LL page.
 
Numbers can drop really fast and by a lot. When we give R, the ideal is to see about a 100 mg/dL drop over four hours.

When we use R, we:
  • Avoid giving it so that R and L nadirs overlap
  • Test hourly the first few times you give it until you are familiar with how it affects the BG keeping in mind it can change
  • If he bounces, be sure you don't give it as he starts to clear a bounce
  • Be aware that after the R has reached its duration, you might see lower numbers again the next couple of cycles
I have not seen any real sign of a predictable nadir time since Bronx remains just flat and high & has has no pattern. But since Lev normally nadirs later in the cycle with most cats, sounds like I should use R at around +1 or +2?
 
Again, this is a cycle by cycle thing. There might be some cycles where, if you can monitor, you might want to shoot it twice (not at first but after you see what it does). I also used lev and would shoot it later in the cycle so the PMPS would be lower. Gracie was not acro and was on a fairly low dose of lev but I used R to nip the bounce when it started so it couldn't get a hold.

It often works well with lev to shoot it at AMPS or, as you said, +1 or +2, depending on when Bronx actually onsets so you can take advantage of the R pushing the numbers down a bit so the lev can work from a lower number at onset.

Once you see how it works, you can develop an R curve that you overlay the L curve with and can see where it might be best to shoot for Bronx. We can also help you develop an R scale so for a certain BG with lev, you'll shoot a certain amount of R.

It would be helpful, too, if you studied two SSs of acro cats where the mom's became very skilled at using R.
Cobb's SS
Crystal's SS
 
Yes, it can be. I have seen higher lev doses, though.

But Suki did a wonderful job with Crystal. I think her commitment to Crystal and getting her numbers down helped Crystal immensely. Unfortunately, there was no place in France where they could get SRT which can also help very, very much with the BG and the symptoms.

We are extremely blessed that Wendy and Julie have done so much research on acro. Take every chance you can to pick their brains. Suzanne (Cobb's mom) is also a great resource but she doesn't post much anymore and, of course, Suki is as well. She does post from time to time.

BTW, we start a new condo every day so these don't get too long so you might want to do that and link this one. Thank you!!
 
I have not seen any real sign of a predictable nadir time since Bronx remains just flat and high & has has no pattern.
When numbers are high and flat, one can pretty much give R at any point during the cycle. I think that thought is probably behind Julie's suggestion to initially administer R in the latter half of the cycle ... well, that and having someone available to help when taking your AM shot time into consideration.
But since Lev normally nadirs later in the cycle with most cats, sounds like I should use R at around +1 or +2?
Yes, shooting R at amps, +1, or even +2 may work out well. Collecting R data will go along way in making these kinds of decisions. Also, Like Marje mentioned, once you see movement (being able to define onset, nadir, and duration) and depending on the onset, nadir, and duration of both the Lev and R... you may be able to shoot R twice in a cycle... once early in the cycle to help give the Lev a lower number to "grab onto" and once later in the cycle to either take the edge off a bounce or hold numbers flat going into the next shot time.
Wow, Crystal was at 60u of Lev & 20u of R. This is scary stuff.
Yes, it looks scary, but also notice how she got to those kind of doses. It's a gradual process of working up to the right dose. All dosing is supported through data collection.


 
You can check Jack's SS to see how I have been using R with him(still not as experienced as some though). He is a little different since he has IAA. The IAA seems to delay the effects of the R. I frequently don't see much initial reaction, but do see an effect during the next cycle. The big one with R is not to overlap the nadirs of the lev and R. There is a lot of trial and error with finding the best time to shoot R and also how much is needed. Depending on the nadir's some folks would shoot R after the nadir but before PMPS, around +10.

I've shot 5R one day with little effect, and the next day 3R is a little too much. It can get a little confusing at times. This is compounded since now there are 2 different insulins working on their own timescales. Sometimes it can make seeing trends a little more difficult.

You definitely want to start on a small dose to see how Bronx responds. We started at .25R and have used as much as 6R.

I would think about sticking with just the Lev for a little bit so you can start to get a feel for the onset and nadir with the change in insulin. From the few data points, it looks like his nadir is pretty late on the Lev which is pretty typical.
 
It can get a little confusing at times. This is compounded since now there are 2 different insulins working on their own timescales. Sometimes it can make seeing trends a little more difficult.

I have looked at a few different charts and it is very confusing! I get ECID, but even the same cat responds totally different from one cycle or one day to the next like Jack. I will start low (.25u) probably by the weekend or next week and do not expect any big swings but it is just a starting point. Got the R today and getting hypo kit together. As far as a karo syrup mixture for a needle-less syringe, how much do I dilute the syrup? 50/50? Can I prefill the syringe with the mixture and leave it indefinitely?
 
The typical R onset is around +2 and and nadir round +4. Neko was not a "typical" cat. She did things in her own time.:rolleyes: First time I used R with her I tested every hours for four hours and saw no change, went to bed with her in high numbers and woke up to green. :eek: Her R onset was late compared to most. It also meant I didn't like giving R later than +1 because the big R drop could coincide with her Lev onset where she sometimes did a big drop. I preferred giving R at preshots or before. ECID. I have a math background, and used to think of laying the L and R curves on top of each other, and trying to time things to avoid combined big drops.

As for the karo question, I have rarely seen someone have to resort to it in a syringe. I did once, at Neko's parting PJ party. With acros, you can usually put a bit of it on food and the cat will inhale it. I didn't dilute it and just filled the syringe when I found she wouldn't eat it.
 
Wow, Crystal was at 60u of Lev & 20u of R. This is scary stuff.
Yes it was, sometimes I just felt I was hanging on by the seat of my pants .... but eventually it worked, and Crystal was pretty well regulated for her last few months. But I couldn't have done it on my own, my vet had never treated an acrocat and was horrified at the high dose; I took all my advice from the acro experts here, mainly Wendy, Julie and Suzanne, and others guided me on the use of R. So don't give up, you are in safe hands.
I hope the Lev makes a difference for Bronx, I shall be watching how you both get on with interest.
 
Karo likes to solidify once it's out of the bottle, so it will probably just ruin a syringe if left sitting around in one. I suggest just drizzling it on food, or mixing it with gravy, on an as-needed basis. In an emergency situation, you can always pour some out onto a plate or bowl, and suck it into the syringe from there.
 
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