2/11 Sid relatively new to Prozinc- question about using R

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Lydia & Sid & Jake(GA)

Lydia & Sid & Jake(GA)

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Sid was dx Nov 2011 and started on lantus. It was very hard to get his numbers stable and at the end of December, he was hospitalized with DKA. Long story short, he has been hospitalized 3x with DKA in about 6 weeks. He has been diagnosed with small cell lymphoma (intestinal), IBD, and possible pancreatitis. He was on 2 antibiotics - baytril and 3 rounds of clavamox. He may have had a kidney infection that has since resolved. He is now on prednisolone (5mg/day), cerenia, famotidine, b12 injections (weekly), iron supplement (19% anemic), chlorambucil (leukeran) (2x week), 80 ml SQ fluids/day. He has a feeding tube but typically eats on his own, usually about 1 can/day - he weighs 4#.

He receives 1U Prozinc 2x daily through IM. He was not responding at all to SQ injections - my vet thinks because he has lost so much muscle mass that he could not absorb the insulin. Sid is really skin and bones right now :sad:

My question concerns using a bit of R - such as .25. First, if anyone else does this, what kind of needle do you use for R that makes it easy to see a .25 dose?

Second, looking at Sid's SS (which I have updated but is not completely UTD yet), at what hour would you give a bit of R? yes, I know I have to be very careful using R because his numbers can shoot down, etc, but if I dont' lower his numbers, he is going to develop ketones and become acidotic again.




yesterday's Lantus condo http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=63365
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Sounds like he's been going through a LOT. Wish I could offer some advice, but will have to defer to the experienced folks. Meanwhile, I'm asking the question for some of us newbies... what is "R"?

Our Best to Sid and his recovery.

Grayson & Lu-Ann
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Wow, Lydia, you and Sid have a complex situation. We don't have anyone at the moment who is using a R booster. BJ did for a while but doesn't anymore.

We do have a member who doses TID. Would that maybe work for Sid? Kim and Kitty (member name kse) have been doing it a long time. Kitty has been a very complex cat, but TID has worked for them. You might check out their spreadsheet and send her a pm, if you think TID is a possibility.
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Lu-Ann,

Humulin R is a very short acting insulin that is typically used only in the hospital when cats have DKA episodes. They typically use it IV along with a dextrose drip. some people, especially those on lantus or levemir might give a VERY small amount of R every so often if a cat runs high in order to bring the cat down a bit. I have to stress that R can bring a cat down very fast - Sid has been known to drop 100 points in 15-30 minutes so I only give him the tiniest amount and test him like crazy (every 30 minutes to hour).

Sue, thank you for the advice. I will look at her SS and PM her.
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

I forgot about Nancy and Payne. She doesn't post often, but Payne has had DKA several times. Her spreadsheet looks like she did use R for a while. Maybe not now, but she definitely has in the past. Glad you thought of her, Robin.
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Hi Lydia,

I'm sorry to hear about the hard times you and Sid are going through. It sounds like you're already completely aware of the huge respect that R demands, regarding its ability to yank down numbers quickly, without taking any prisoners. Actually, it sounds like you have way more R experience than I will ever have, but I wanted to share a couple of tid-bits with you.

Marilyn and I are new to ProZinc. She started throwing me higher than "her normal" ketone numbers after switching from Lantus to ProZinc. I haven't been able to come up with a reason for this...but I do know it threw me into a panic, and I broke out the R. A very wise woman instructed me to practice with the u100 syringe (I use Relion u100 syringes with 1/2 unit markings), she said to, "Take a used syringe, draw-up 0.5u in water, then twist the plunger to push out one drop at a time. Ultimately, you want to get to the point where you are able to squeeze out 5 drops from that 0.5u". I think the point was that you want to become an expert at 0.1u increments when dosing R.

I don't think you ever want to start out with 0.25u of R, unless you already know what that dosage does in Sid's case, and you also know the nadirs of both Sid's ProZinc, and the R. I have given Marilyn less than 0.1u of R to cut through her high food spikes at shot time...and I only gave it because her ketones were starting to concern me. Less than 0.1u only showed in her numbers once. It's a hard dose to give; nothing is in the barrel of the syringe...you're really just pushing hard on the plunger to squeeze out the little drop that's in the needle. The next time I feel she needs it (hopefully, there will be no next time), and I am certain I can stay awake to test, I will probably give a full 0.1u (see how brave I am?), since the other dosage (or non-dosage as the case may be) is pretty much hit or miss, as to whether she's actually getting any.

In regards to Sid...at only 4 lbs...I think you would really want to talk to an "R expert" first. I was advised to try the 0.1u of R "a few times" (not in the same cycle, but on different cycles/occasions), since some cats can drop like a ton of bricks on 0.25u. In Sid’s case however, I’m hoping TID ProZinc dosing will work, and there will be no R in his future. I understand the huge issue with his DKA history, and that R could be a life saving tool to keep on-hand, but I'm worried about his size, and all of his other problems...poor little baby. My heart breaks for you both. Have you discussed R usage with your vet?

Lastly, I wouldn't have given R to Marilyn beyond her ProZinc's shot time, or at most, beyond her +1. Of course, this all depends on the ProZinc's, and R's, onsets and nadirs...and the ECID factor. R can stay in the system up to 4 to 5 hours. If the R was still acting, when her ProZinc's nadir was kicking-in, I could have gotten her into trouble....or, worst case scenario, the two nadirs could have collided had I given it later in the cycle. I've easily pulled her out of many low number/hypo situations...but with R involved...I just don't know. Hopefully, someone else will come along with more knowledge and experience. I wouldn't consider using < 0.1u as having any experience!

I hope this helps...even if only a little. Good luck to you both.

Deb
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Hi Lydia,

My Kitty was complex at best, and was impossible to regualte or get into any type of "good" numbers on bid dosing. With suggestions from the group here, I tried everything to get Kitty into better numbers with bid dosing. When I finally found a dose (5 units) that would drop her enough for a decent nadir, it just accelerated the bounce. She would go from the 200s to 500s in less than an hour. It was a vicious cycle and very frustrating.

So, 5 months into the dance, we tried tid! She is now doing great. It still took some time to get her into a good pattern, but immediately her numbers improved.

Normally, when starting tid, you take the amount of insulin that a cat is receiving daily (ex-- 2 units dosed bid= 4 units daily) and divide it by 3 to get a starting dose. So, the tid dose on that would be 1.3 units tid. BUT, due to the possibility of insulin overlap, we normally advise to drop the initial dose back a little further. Just like with bid, it is better to be safe and start slowly.

What I found with Kitty was, that by cutting off 4 hours of the bid cycle, I was able to cut off the high numbers and big swings. One point of caution with tid dosing is to ALWAYS, be sure you are shooting into a rising number. I feel comfortable now with Kitty, but when I first started, I would always test around +6 of the cycle and then test at her preshot of +8, to be sure the +8 number was rising.

I hope this answers some of your questions, if you decide to try tid-- post here and we will help you get started. TID is not for everyone, but it has proven invaluable for Kitty.

Bookworm, Lisa, has also dosed tid and might can add some thoughts.

Good Luck!
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Thank you everyone for the valuable advice!
I'm glad that with Prozinc I can start over with a clean slate each day. I think that was part of the problem I was having with lantus. One day he would be super high and the next day low and I could never get a handle on his levels. Jake (GA) was on lantus along with some other insulins during his 8 year sugar dance and I never had these problems. The vets believe Sid's underlying conditions are making his situation so complex.

Deb - that is really good advice advice about how to get 5 drops out of the syringe. I also use the Relion syringes with the 1/2 marks. My vet is onboard with the R - in fact, his advice is to only use R and to give him 1U at at time. No way am I doing that. My vet "has not had good luck" with the longer acting insulins and so he advocates Humulin N or R in Sid's case. However the specialist Sid has seen wants him on the longer acting and he prescribed Prozinc, which is what I agree with so that is what's he's on.

As for nadirs, I think I have figured out (hopefully) that Sid's peak with R happens within 2 hours. It is typically out of his system within 4. With Prozinc, I believe his nadir is about +6 range but I am still data gathering.

Dosing TID might be the ticket for us too. Thanks for the advice about calculating the dose and how to space it out.

Today I got up at 3:30 am (PMPS +9) and he was Hi. I gave him a small amount of R - probably somewhere between 0.25 and 0.1 - it is really hard to tell with the syringe. I got up at +1.5 he was 486. Then I gave him 1.25 of Prozinc. I just upped his dose by .25 because yesterday he did not go below 300s.
At AMPS +2.5 he was 231 and at 3.5 he was 225.
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Good morning Lydia,
Yes, I have been where you are ..... complex cats leading to DKA, hopefully we can keep Sid at three and no more! My Payne did the same thing as Sid. She was Dx. and then went into DKA almost immediately, which she did 2X more in the first 3 months .... I feel your pain. The last DKA happened almost a year ago when my vet wanted to change her from PZI to Lantus and she wasn't getting enough insulin which yes, led to DKA and we finally came back to PZI with my vet's blessing!

I still haven't read everything about Sid, I will as soon as I get my family moving and get back with my ideas.
Off the top of my head because he can go into hypo range, R would need to be used sparingly. From what I have learned about what causes DKA is ketones+ (infection, too little insulin, ????) BUT, you need the ketones to get it started.

It has taken me forever to regulate Payne and stop the DKA's BUT what I had better, was Payne is a big gulper who is on TID and gets about 12u a day. When I was using R daily she could go up to 15u! You don't have that luxury and it will be harder but not impossible to regulate. I did some reading but don't remember about ketones, does he always have them? Ketones are your enemy and controlling them is the real important part.

After Payne's third DKA I started adding R with every shot of PZI .... 3u pzi, 1uR, 3x a day. On bad days I would give extra R but I am lucky because Payne never goes low. Adding weight helps also. Payne is a good size cat and in the beginning went down to 6 pounds. Her last check-up she weighed in at 15 pounds!! Vet said she looked amazing!! and his thing is, just keep doing what you are doing!

I know you work but I would consider TID because it keeps insulin in them constantly, keeping the ketones at bay. Kim had a hard time with Kitty and TID has leveled her out also but she is also a big gulper!!

PZI is very easy to use with complex cats and using with R much easier. As I said I gave the shots at the same time and that worked for us, you use U100 needles with R. Let me know about his ketones, does he have always, do they go away completely? then come back? I will watch for your answer and then read the rest of Sid's postings. Good luck and this can be figured out!

Nancy and Payne ......
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

So today at +7 he was Hi so I gave him 0.5U of R. At both +1 and +2 he was still over 500 so I gave another 0.5U of R. Within 30 minutes he was down to 323. I hate those spikes but I really want to keep him below 300 all the time. Whenever he goes Hi, I give him a bit of R to bring him down. I think that he either 1) didn't get the first dose of R because there was none or not enough in the needle. Sometimes I cannot draw up the R without getting a bubble no matter what I do and go through multiple syringes to try to get rid of it OR 2) my R is bad. Does anyone else have the experience of R fizzing? Is that normal? My R also seems thicker than the Prozinc.

I was so happy to test his ketones today and see Negative. the day after we returned from the hospital (2/4) He had moderate to high ketones (!!!) so I doused him with R every 4 hours along with SQ fluids. The next day he was down to trace and then for 2 days after that he was down to trace. He develops ketones very quick if allowed to stay Hi too long. I can also tell by his behavior and appetite that he's feeling OK today. He's been walking around a lot and scratching his scratcher and eating - been grazing at the food bowl a lot. I have a really hard time withholding food from a cat as thin as him. does anyone have any ideas about what to do with spacing out his meals? I've been feeding Max Cal and he seems to eat that. I want him to gain some weight.

Here is a short video I took of him during one of our visits together last time he was hospitalized. He is such an awesome little cat. :-D http://www.youtube.com/watch?v=BMTlyOMMtnE&list=UUFHwVIT60NlHW3tXdPCjhMg&index=1&feature=plcp
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

My feeling on food is, feed him whatever he wants (only good stuff) now while he is so thin and unregulated.
When I started concentrating on putting weight on Payne and staying on top of the ketones, that helped a lot. Using R to keep ketones at bay I found to be the most helpful and it seems as if you know how to do that. Remember if he doesn't have ketones, he can't DKA ....

To keep Payne healthy she takes 5mg. Pred. daily in 2 doses and she gets SQ fluids 100ml. every other day. She eats FF pates and gets treats a lot and she is on 12u PZI TID. Her numbers stay in the high 100's low 200's, which I think is great! This works for her, we need to find what works for Sid.

I would say Payne is finally back to how she was pre-Dx. but we still watch her ketones like a hawk and test daily and I only use R if I see them but we haven't had to use in a long time. When my company leaves I will read all your posts on Sid but you seem to know what you are doing but just be careful of the hypos with R.

Nancy and Payne ......
when I was fighting ketones one of the more experienced members told me to feed the ketones, I think that was one of the best pieces of advice I have gotten.
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Hi Lydia,

You are so wonderful for adopting Sid...and he is awesome in the videos...what a trooper. It looks like Nancy (and Payne) are the perfect "partners in crime" for you and Sid.

Lydia & Sid & Jake(GA) said:
Deb - that is really good advice advice about how to get 5 drops out of the syringe.
Click to expand...
I was thrilled when it was shared with me. I need that kind of detail in order to wrap my head around the big picture. I see you're giving 0.5u of R lately...but the 5 drop method could come in handy someday.

Lydia & Sid & Jake(GA) said:
Sometimes I cannot draw up the R without getting a bubble no matter what I do and go through multiple syringes to try to get rid of it OR 2) my R is bad. Does anyone else have the experience of R fizzing? Is that normal? My R also seems thicker than the Prozinc.
Click to expand...
Your R shouldn't be "fizzing". Do you push air into the vile before you draw the insulin? If so, is the vile standing upright when you push the air in, or are you pushing the air into the insulin while holding the vile upside-down? The only way I can picture an insulin fizzing, is if air was pushed from the syringe, directly into the insulin, while the vile was upside-down. Does that make sense?

I did an insulin comparison test. Here are my very unscientific observations: :lol:

I always thought that Lantus was thicker, almost sticky, in the syringe (and it is, but only compared to N). When I compared Lantus to R, which are both clear insulins, they behaved about the same, and both had their share of bubbles to deal with...which is maddening when you're dealing with clear insulin, and clear bubbles. With ProZinc, and N, which are both cloudy insulins, the bubbles aren't quite as maddening, since you can at least see them...but even though they are both cloudy insulins, they don't compare in the bubble department. I started with N, and never had any bubble issues. It seems "thinner" than the other insulins, and it doesn't act as "sticky" in the syringe. When I switched from N to Lantus, bubbles weren't something I was used to dealing with...and the Lantus bubbles made my head explode. Now, it's the ProZinc, and the R, bubbles making my head explode. I forgot to test the "thickness" of R, against ProZinc, at Marilyn's shot-time...but I wouldn't worry about this comparison too much. They are...what they are...unless of course, one is "fizzing"...then just dispose of it properly. Did you call "Lilly" to see what they had to say?

Humulin R, and N, are good until the expiration date on the vile...unless they start to look funky in any way. The R package insert states not to use it past the expiration date on the label, or if it has been frozen. So hopefully you don't have it in an extra "cold spot" of your fridge, where it might start freezing at times. The insert also states, "Do not use Humulin R if it appears cloudy, thickened, or slightly colored, or if you see particles in the solution. Do not use Humulin R if you notice anything unusual in its appearance." Okay, so they do use the word "thickened", but still, I wouldn’t drive yourself crazy comparing its thickness to ProZinc in the future. Just start out fresh with two new viles of R (it's cheap enough to keep an extra on-hand), and you'll always have peace of mind, if one vile seems questionable, or in case you drop one and it breaks.

Deb
 
Re: 2/11 Sid relatively new to Prozinc- question about usin

Thanks for the advice and unscientific observations about the insulin :-D
My vet asked me to bring it to the clinic tomorrow because he wants to see the bottle. It will be interesting to see if the thinks anything is wrong.
 
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