10/6 Oberon PMPS 359/3.3, +1 342, +2 357, +3 319, +4 330, +6 371, 3rd R trial 0.5 U

Lisa & Oberon

Lisa & Oberon

Member Since 2020
Yesterday (first R trial in the evening, with Wendy's help): https://www.felinediabetes.com/FDMB/threads/10-5-oberon-9-327-amps-351-5-8-3-346-6-25-312.236390/

Finally got some Humulin R and Oberon had his first trial last night. BG dropped maybe a tiny bit by R+4, but not much, but this morning he's got the lowest preshot number (302) he's had in a while. So I'm starting a second R trial, and he got 0.25 U of R along with his morning Lantus (6 U). Hourly checks now until at least +4. (I'm home all day and can check after that, if necessary, in between my classes.)
 
JaxBenji said:
lol, true! Though did you find it weird you can get R OTC? I was just went down a rabbit hole on OTC insulins lol.
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Took me this long to get it because I was so convinced that it just couldn't be possible to get it OTC, and I was waiting for the vet...

329 at +2... R onset is supposed to be around +2, so it looks like maybe we're not at an effective dose yet. We'll see what happens in the next couple of hours.
 
Best:bighug:! Will be curious what your IM says on Wed Re: not only the test results, but what else they currently/now use to mange these situations. I remember you mentioning that when you asked her about adding R they said they have other options they use.
 
Me too! The other option she mentioned was Humulin 70/30 (or 80/20), which is a mix of 70% Humulin N and 30% Humulin R. N is a medium-acting insulin. I'm not sure what the advantage of that would be over just using R + Lantus, but I'd be interested to hear about it. Right now it feels like adding in an additional variable that may not be necessary, especially if part of the point of using R is that it can be stopped quickly if the cat starts to break through the resistance and come down. Having a medium-acting insulin doesn't help with that as much.
 
I’m sure she will be happy to explain. I’m also curious about constant rate infusion (CRI) as it’s becoming standard of care for DKA, but maybe only for cats who are ill vs high ketones but all else is stable?

I found an interesting and informative review of current Insulin Protocols for managing DKA. It includes mention of supporting studies and some info from each study along with advice that when there are multiple MDs managing a case, which often happens, they should pick one protocol and stick with it vs switching it around——Good point and good to know that could even happen!

Anyway, with respect to CRI they note:

“The rationale for IV insulin during DKA is that because of poor perfusion and consequently variable absorption of drug from the SQ or IM space IV CRI of insulin allows for reliable and rapidly titratable dosing.

The rationale for co-administration of SQ long-acting insulin along with IV or IM short-acting insulin is that this combination more closely mimics the activity of the functional pancreas.”

Here is the link for the entire piece-
https://eccvetmed.com/2018/07/18/insulin-protocols-for-managing-dka/

I would be curious as to why they wouldn’t utilize CRI to get the BG stabilized & ketones under control quickly and safely & then move to the next step? It would seem to be the most reliable and safest way to accomplish both. Again, maybe reserved for symptomatic DKA? I would like to think it could be done proactively before ending up there but only the specialist is able to answer that question. I do know one other issue that may come into play is a facilities ability to do it, including having staff to monitor the process.
 
I agree that 0.25 R doesn't seem to be it, next try is 0.5 units. I'd like to be around then - when do you think you can trial it? I do want to make sure it's safe to give R when you trial. For the moment, no R under 300. Over time, our goal is also to build an R scale. Basically a scale will tell you how much R to shoot at a given R preshot. It can also vary over time as things change in the cat. A great example of an R scale is in Black Kitty's spreadsheet, check out the R scale tab. You might also be interested in looking at his BG data, as he was also a high resistance IAA cat. And just because it's fun - take a look at his OTJ video.

DKA + IAA is less common combo and possibly needs a somewhat nuanced treatment than managing just DKA by itself.
 
I’ll definitely be asking some endo thought leaders to inquire about what they are currently doing/finding with treatment that is similar as well as unique with IAA. Good info to know.

Just an FYI, and some people are uncomfortable asking but should not be, you can always ask the current IM if she would reach out to someone like Dr Hess at UPenns Diabetes Center to do a consult.
They do remote consults vet to vet & it’s really nice to have someone like her with her vast amount of experience and years working with feline DM, to offer some additional thoughts/recommendations.
Just a thought if you find yourself wanting more info along the way but can’t get to a U setting :)
 
Wendy&Neko said:
I agree that 0.25 R doesn't seem to be it, next try is 0.5 units. I'd like to be around then - when do you think you can trial it? I do want to make sure it's safe to give R when you trial. For the moment, no R under 300. Over time, our goal is also to build an R scale. Basically a scale will tell you how much R to shoot at a given R preshot. It can also vary over time as things change in the cat. A great example of an R scale is in Black Kitty's spreadsheet, check out the R scale tab. You might also be interested in looking at his BG data, as he was also a high resistance IAA cat. And just because it's fun - take a look at his OTJ video.

DKA + IAA is less common combo and possibly needs a somewhat nuanced treatment than managing just DKA by itself.
Click to expand...

I could do it tonight if you're around then. 7 pm ET shot time (so 4 pm for you).

Tomlin said:
I’m sure she will be happy to explain. I’m also curious about constant rate infusion (CRI) as it’s becoming standard of care for DKA, but maybe only for cats who are ill vs high ketones but all else is stable?

I found an interesting and informative review of current Insulin Protocols for managing DKA. It includes mention of supporting studies and some info from each study along with advice that when there are multiple MDs managing a case, which often happens, they should pick one protocol and stick with it vs switching it around——Good point and good to know that could even happen!

Anyway, with respect to CRI they note:

“The rationale for IV insulin during DKA is that because of poor perfusion and consequently variable absorption of drug from the SQ or IM space IV CRI of insulin allows for reliable and rapidly titratable dosing.

The rationale for co-administration of SQ long-acting insulin along with IV or IM short-acting insulin is that this combination more closely mimics the activity of the functional pancreas.”

Here is the link for the entire piece-
https://eccvetmed.com/2018/07/18/insulin-protocols-for-managing-dka/

I would be curious as to why they wouldn’t utilize CRI to get the BG stabilized & ketones under control quickly and safely & then move to the next step? It would seem to be the most reliable and safest way to accomplish both. Again, maybe reserved for symptomatic DKA? I would like to think it could be done proactively before ending up there but only the specialist is able to answer that question. I do know one other issue that may come into play is a facilities ability to do it, including having staff to monitor the process.
Click to expand...

Really interesting link, thanks! One of the things I'm learning in my reading is that there's a differences between ketosis (elevated blood ketones) and ketoacidosis (DKA, compromised pH as a result of elevated ketones; Bad Things happen). The study that validated one of the home ketone meters found that cats under 2.4 were never in DKA, while those above 2.4 were sometimes in DKA but sometimes not. They suggested there might be differences in how well the cats were able to use blood buffering systems to mitigate the pH changes. So 2.4 is the "take action" number where the cat should be evaluated by the vet to determine whether they're in DKA or not. My vets are telling me that so long as he's eating and not vomiting he's "fine." I'm skeptical, but so far so good, I guess.
 
Tomlin said:
I’ll definitely be asking some endo thought leaders to inquire about what they are currently doing/finding with treatment that is similar as well as unique with IAA. Good info to know
Click to expand...
Thanks for looking into this Amy. I'd love to know what they say. All we have is the data from the few cases we've seen here. Plus we don't have all the data results on Oberon yet, so don't know if it's just IAA we are dealing with.
 
Really interesting link, thanks! One of the things I'm learning in my reading is that there's a differences between ketosis (elevated blood ketones) and ketoacidosis (DKA, compromised pH as a result of elevated ketones; Bad Things happen). The study that validated one of the home ketone meters found that cats under 2.4 were never in DKA, while those above 2.4 were sometimes in DKA but sometimes not. They suggested there might be differences in how well the cats were able to use blood buffering systems to mitigate the pH changes. So 2.4 is the "take action" number where the cat should be evaluated by the vet to determine whether they're in DKA or not. My vets are telling me that so long as he's eating and not vomiting he's "fine." I'm skeptical, but so far so good, I guess.[/QUOTE]

I was thinking the same when I was reading about how some types aren’t even picked up on meters. “types” of ketones....something new to learn.

I was told the same about ketones. It has to be in context.

I am hopeful you will continue to get the info needed between the IMs and your own deep dive into the literature & be able to formulate a solid plan sooner vs later once you have a definitive diagnosis.
 
Wendy&Neko said:
Thanks for looking into this Amy. I'd love to know what they say. All we have is the data from the few cases we've seen here. Plus we don't have all the data results on Oberon yet, so don't know if it's just IAA we are dealing with.
Click to expand...

I will definitely ask when I have the opportunity to do so. I wish the U settings/thought leaders would put out a monthly or even yearly bulletin on what they are learning and doing differently (if anything) in respective specialities. It takes SO long for it to get to conferences, journals and then books. Frustrating :(
 
Tomlin said:
I was thinking the same when I was reading about how some types aren’t even picked up on meters. “types” of ketones....something new to learn.

I was told the same about ketones. It has to be in context.

I am hopeful you will continue to get the info needed between the IMs and your own deep dive into the literature & be able to formulate a solid plan sooner vs later once you have a definitive diagnosis.
Click to expand...

Yep, I read about that, too. There are three main ketones that can be involved in DKA. The urine strips detect one (and maybe a second; I can't remember now), and the blood meter detects a different one. That one gets more elevated than the first two during DKA, so it's possible that the readout on a strip would underestimate the severity of an incident. Makes me glad I got the meter.
 
@Wendy&Neko let me know if this evening works for you. (No rush; I can make the decision right up until shot time at 7 ET.) I'll be in class from 2:30-5:00.

341 at +6, BTW... once again someone needs to tell Oberon that "tight regulation" doesn't mean keeping his BG in the mid 300s!
 
Lisa & Oberon said:
Yep, I read about that, too. There are three main ketones that can be involved in DKA. The urine strips detect one (and maybe a second; I can't remember now), and the blood meter detects a different one. That one gets more elevated than the first two during DKA, so it's possible that the readout on a strip would underestimate the severity of an incident. Makes me glad I got the meter.
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Ok, so we would be dangerous together .
Nothing like “All things Ketones” as a light read!
The blood ketone meter was fun to find last year due to all the people on Keto diets.....:banghead:

Best with the trial later tonight :bighug:! You and Wendy will hopefully find that nice dose that moves things in the right direction :cool:
 
I can be around - though may or may not be exactly on time. I have workers in the house starting before then, but hopefully they won't need me around all the time. Oops, they just arrived 3 hours early. I should be OK.

We've had a saying around here - flat as a pancake or visiting IHoP. :rolleyes: Seriously though, I'm toying with another idea of moving to faster L increases - something we can do if cats are perpetually over 300. Though he was darn close to under the line this morning.
 
Wendy&Neko said:
I can be around - though may or may not be exactly on time. I have workers in the house starting before then, but hopefully they won't need me around all the time. Oops, they just arrived 3 hours early. I should be OK.

We've had a saying around here - flat as a pancake or visiting IHoP. :rolleyes: Seriously though, I'm toying with another idea of moving to faster L increases - something we can do if cats are perpetually over 300. Though he was darn close to under the line this morning.
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No problem, I can get the party started without you if necessary. Probably won't be much happening for the first couple of hours anyways. So the rule right now is to skip R if under 300 at preshot, right?
 
Correct, no R if under 300, 0.5 R if above. We'll work on making into a scale at some point once we've started to see movement in the numbers.

Don't know if you like seeing these things, but I've been combing through the vault for spreadsheets of IAA only kitties. This one is for Doodles. He almost went OTJ before his numbers started increase. They did a major increase 3/16/16 when he was diagnosed with HCM (enlarged heart). Karen finally managed to find a vet who would test for IAA and it was 72. And started R around that time. Not long after she switched to Levemir, and you can see the difference. Another reason I wanted to bring this up is that she had a hard time finding an IM vet who thought there was value in testing for IAA, so you are definitely one step ahead there.
 
Thanks! The R scale was especially helpful to see, so I have a feel for what we're aiming for.

I pushed for the IAA test; the vet wanted to wait until we ruled other stuff out, but I argued that so long as we were taking blood and some of it was going to the same place for IGF we might as well get it done now. Glad I did. (Thanks for pushing me to do that!) I'd really be interested to know more about what triggers it in some cats but not others. Also wondering whether the Lantus he took for 2 weeks last December could have something to do with it- did it prime his immune system to react when it was exposed again in July? Guess I have more research to do. Not that it changes what I'm doing; I just like to understand what's happening.
 
OK... 359 at PMPS (and ketones 3.3, so that's better). Off and running with 6 U of Lantus and 0.5 U of R on board. I'll check back at +1.

Aargh... just remembered I forgot to do his fluids earlier. I'll wait until +4 or later so it doesn't mess with the trial. No big deal.
 
Neko didn’t onset her R until +3. Which is quite unusual, most do + 2.

Sorry for the late catch up, had an emergency with DH towing a trailer with seized brakes. All good now.
 
Wendy&Neko said:
Neko didn’t onset her R until +3. Which is quite unusual, most do + 2.

Sorry for the late catch up, had an emergency with DH towing a trailer with seized brakes. All good now.
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No worries! All's well here.

Thinking ahead... assuming we want to run a trial at 0.5 again I could do it tomorrow morning. I can't do one in the evening because he's scheduled to get a Lantus increase (from 6 to 6.5) then, unless he surprises me somehow tonight and I have to extend his time at 6 U. I think that's very unlikely.
 
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