? 1/9 Yum AMPS 639 +5 570 Start Novolin R?

[MJW]

Yesterday's condo: 1-8-yum-amps-631-5-560-8-587-take-her-back-to-6.189325

It's not safe to increase a long acting insulin like Lantus faster than every 2 days.
Yum clearly needs a much larger dose.
It's not safe to leave her at these high BG numbers.
I've asked her vet to prescribe some Novolin R, so I can layer a short acting insulin on top of the Lantus.
I don't know if the vet will agree.
I don't know if the forum will agree.
I need to do something.

 

[MJW]

Vet wants me to try different AM and PM doses, maybe going down to 5 units and 3 units, before resorting to short acting insulin.
I don't see that working.
I could try an 11 hour/11 hour schedule.

 

[Sienne and Gabby (GA)]

I would not recommend using R. First and foremost, you are not routinely testing during the PM cycle and you have been increasing the dose at a rate that is not supported by the TR protocol. You will need to run curves every hour at least over a 4 hour period from when you give a dose of R. If no one has pointed this out, R is rapid acting, and if you give too much or overlap the nadirs of R and Lantus, there is an exceptionally high risk for hypoglycemia or worse. It is not a bolus insulin to be used lightly and you would need to work with someone who is experienced in it's use so you don't inadvertently kill your cat.

It looks like something changed when Yum was boarded. Whether your cat picked up some sort of infection, the vet was using old, ineffective insulin, etc. It could be a dental issues -- who knows. Have labs been done to rule out anything medical? Yum was in blue and green numbers until boarded. There are lots of nasty bugs that are in a vet hospital. Unless Yum is throwing ketones, at least to me, I don't believe R is indicated. Does your vet have an explanation for Yum's low WBC? This can be related to FIV, FIP, or potentially, pancreatitis. If the latter, the pain could be a reason for high numbers. A low WBC (leukopenia) will leave your kitty open to infections. I think you need to explore some of these reasons, along with being a bit more consistent before you contemplate using R.

As for differing AM and PM doses, dosing different amounts is not indicated with Lantus. It disrupts the depot and if you think Yum's numbers looks less than desirable now, they will look worse.

 

[Jill & Alex (GA)]

I understand why you've increased the dose after 4 cycles (2 days). You're following the suggestion in the TR Protocol for when nadirs are greater than 300:

"However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU."
http://www.tillydiabetes.net/en_6_protocol2.htm

However, if I may make a suggestion based strictly on experience...
when you're increasing the dose rapidly because of high numbers, push and then pull back. In other words, increase after 2 days a time or two and then pull back to increasing every 3 days (if necessary). Pulling back allows numbers to settle down. You'll be able to get a clearer picture of what's happening than if you constantly push the dose increases. I hope I'm explaining this well.

I've asked her vet to prescribe some Novolin R, so I can layer a short acting insulin on top of the Lantus.
I don't know if the vet will agree.
I don't know if the forum will agree.

If you and your vet decide using R as a bolus is the way to go, then you'll want to stop increasing the basal dose (Lantus) so rapidly. One doesn't want to rapidly increase the Lantus dose when one incorporates the use of a rapid acting insulin such as R. It's one or the other, but not both. I used R with Lev, but never with Lantus. I'm sure others will offer advice specific to Lantus with R use. Like Sienne has already mentioned, using a bolus will require a lot more testing. I don't know if you have that availability???

Vet wants me to try different AM and PM doses, maybe going down to 5 units and 3 units, before resorting to short acting insulin.
I don't see that working.

There are other web sites that dose Lantus successfully using other methods including sliding scales, frequent dosing, or inconsistent dosing. However, we dose Lantus consistently when following the protocols used on the FDMB. It just seems to make the most sense given the depot.

I could try an 11 hour/11 hour schedule.

An 11/11 hour schedule will eventually give you shots times that travel round the clock. It starts out ok, but then it quickly becomes real old when you're tied to your cat at all hours of the day and night.

Whether your cat picked up some sort of infection, the vet was using old, ineffective insulin, etc. It could be a dental issues -- who knows. Have labs been done to rule out anything medical? Yum was in blue and green numbers until boarded. There are lots of nasty bugs that are in a vet hospital. Unless Yum is throwing ketones, at least to me, I don't believe R is indicated. Does your vet have an explanation for Yum's low WBC? This can be related to FIV, FIP, or potentially, pancreatitis. If the latter, the pain could be a reason for high numbers. A low WBC (leukopenia) will leave your kitty open to infections.

I agree with Sienne. No matter what, medical issues should be explored and taken care of/ruled out.

Just a quick comment, take it for what it's worth...
If you end up incorporating R into Yum's treatment plan and you're looking for help from the forum, you might want to switch to a human meter. I only make that suggestion because the TR protocol was written for use with a human meter, those offering advice are most familiar with the use of human meters, and frankly using R can be dangerous if not used properly. The use of a human meter would keep everyone on the same page.

Just some thoughts to ponder...

 

[MJW]

I would not recommend using R. First and foremost, you are not routinely testing during the PM cycle and you have been increasing the dose at a rate that is not supported by the TR protocol. You will need to run curves every hour at least over a 4 hour period from when you give a dose of R. If no one has pointed this out, R is rapid acting, and if you give too much or overlap the nadirs of R and Lantus, there is an exceptionally high risk for hypoglycemia or worse. It is not a bolus insulin to be used lightly and you would need to work with someone who is experienced in it's use so you don't inadvertently kill your cat.

It looks like something changed when Yum was boarded. Whether your cat picked up some sort of infection, the vet was using old, ineffective insulin, etc. It could be a dental issues -- who knows. Have labs been done to rule out anything medical? Yum was in blue and green numbers until boarded. There are lots of nasty bugs that are in a vet hospital. Unless Yum is throwing ketones, at least to me, I don't believe R is indicated. Does your vet have an explanation for Yum's low WBC? This can be related to FIV, FIP, or potentially, pancreatitis. If the latter, the pain could be a reason for high numbers. A low WBC (leukopenia) will leave your kitty open to infections. I think you need to explore some of these reasons, along with being a bit more consistent before you contemplate using R.

As for differing AM and PM doses, dosing different amounts is not indicated with Lantus. It disrupts the depot and if you think Yum's numbers looks less than desirable now, they will look worse.

Yum's WBC isn't low. Her RBC is low, probably because she has CKD. She was going higher before she was boarded at Thanksgiving, supposedly due to a urinary tract infection. Then she had a bad reaction to the antibiotic and I boarded her again at Christmas. I'm sure the gaps in TR while she was boarded didn't help the situation. They used my insulin.

 

[MJW]

I understand why you've increased the dose after 4 cycles (2 days). You're following the suggestion in the TR Protocol for when nadirs are greater than 300:

"However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU."
http://www.tillydiabetes.net/en_6_protocol2.htm

However, if I may make a suggestion based strictly on experience...
when you're increasing the dose rapidly because of high numbers, push and then pull back. In other words, increase after 2 days a time or two and then pull back to increasing every 3 days (if necessary). Pulling back allows numbers to settle down. You'll be able to get a clearer picture of what's happening than if you constantly push the dose increases. I hope I'm explaining this well.


If you and your vet decide using R as a bolus is the way to go, then you'll want to stop increasing the basal dose (Lantus) so rapidly. One doesn't want to rapidly increase the Lantus dose when one incorporates the use of a rapid acting insulin such as R. It's one or the other, but not both. I used R with Lev, but never with Lantus. I'm sure others will offer advice specific to Lantus with R use. Like Sienne has already mentioned, using a bolus will require a lot more testing. I don't know if you have that availability???

There are other web sites that dose Lantus successfully using other methods including sliding scales, frequent dosing, or inconsistent dosing. However, we dose Lantus consistently when following the protocols used on the FDMB. It just seems to make the most sense given the depot.

An 11/11 hour schedule will eventually give you shots times that travel round the clock. It starts out ok, but then it quickly becomes real old when you're tied to your cat at all hours of the day and night.

I agree with Sienne. No matter what, medical issues should be explored and taken care of/ruled out.

Just a quick comment, take it for what it's worth...
If you end up incorporating R into Yum's treatment plan and you're looking for help from the forum, you might want to switch to a human meter. I only make that suggestion because the TR protocol was written for use with a human meter, those offering advice are most familiar with the use of human meters, and frankly using R can be dangerous if not used properly. The use of a human meter would keep everyone on the same page.

Just some thoughts to ponder...

Thank you for all these good suggestions. I feel so helpless and sometimes panic stricken with Yum stuck in these high numbers.
She is my top priority: I can and will do whatever I can to make her better.
The push pull advice does make sense.
I am thinking about Levemir, although all her patterns would change and we would have a new learning curve.
So far my vet won't prescribe the fast acting insulin. I understand it is more dangerous and tricky than I've been thinking.

Yum finally gave me some hope with 400's this afternoon, so I will plod along the standard course another day.
I will do some extra tests tonight to decide whether to hold the 6.5 units for a 3rd day or a new 7 units for 3 days.

 

[Sienne and Gabby (GA)]

Sorry -- my office computer is having issues with font sizes and it's making some documents difficult to read.

 

[Jill & Alex (GA)]

So far my vet won't prescribe the fast acting insulin. I understand it is more dangerous and tricky than I've been thinking.

I won't withhold information from you. You don't need a prescription for Novolin R in the States. You can pick up a vial for around $25-$30 from Walmart.

However, the first few times it's used, we suggest having an experienced R user available online to lend a hand. When using a bolus insulin in addition to a basal insulin, it's just as important to know when NOT to use it as it is to know when to use it. An experienced R user can help you with that. Initially, a 4 - 5 hour curve will be done so the caregiver can learn the onset, nadir, and duration of the R. There are more stipulations and points to cover... things we can go over if you decide to incorporate R into Yum's treatment plan.

Our number one priority is to keep all our kitties safe. Therefore, if you decide to go this route... PLEASE do not attempt to use R without guidance. Once you get a handle on Yum's response to R you'll be prepared to fly solo, but not in the beginning. Make sense?

 

[MJW]

I won't withhold information from you. You don't need a prescription for Novolin R in the States. You can pick up a vial for around $25-$30 from Walmart.

Aha. Thanks. I only saw this today. The forum and my vet and Yum's numbers have all been getting me down.