2/15 CRYSTAL ready to go on R - Comments on result please

[BJM]

From " Canine and Feline Endocrinology and Reproduction

By Edward C. Feldman, Richard William Nelson
Elsevier Health Sciences, 2004

This one did use diabetic cats.

 

[Marje and Gracie]

In order for a study to have validity, speaking from my profession as a biologist who has done research, one would need to know if there were controls, if there was an appropriate sample size, the parameters of the study, etc. The data in both of these is also pretty old especially the 1995 information.

 

[BJM]

Ditto from my profession as an epidemiologist. The point is, I had seen the duration for R in cats given as 4-6 hours and have found different citations reporting that.

Typically, those initial studies are going to be on 'normal' specimens, observational in nature, and descriptive in reporting results, rather than experimental.

I'm going to guess there isn't a lot of research on high dose cats and their onset and duration for various insulins. I would be very surprised if the reported onset and duration numbers for normal cats or even normal diabetics were applicable given the rate of insulin use in high dose cats.

 

[Jill & Alex (GA)]

Thanks for the info but a sample size of seven cats does not convince me of anything. I'd more likely go with the ECID approach.

The info is all very interesting. However, having seen more cats than most simply by virtue of "being here" longer than most... we typically see a duration of 4 hours when using R with diabetic cats... high dose or not. Although, I do recall a single cat... a high dose kitty with acromegaly... experience almost 6 hours duration from R. I do want to note that was one cat out of many I've seen since joining the board in 2006.

Like Marje, I prefer the ECID approach...

 

[Jill & Alex (GA)]

@BJM perhaps you could publish Spitzer's and your Gracie's SSs to the web...

O/T - I've often thought everyone offering advice should have their own spreadsheets open for viewing, but that's just a personal opinion.

 

[Marje and Gracie]

O/T - I've often thought everyone offering advice should have their own spreadsheets open for viewing, but that's just a personal opinion.

I agree with this for a variety of reasons including there is always something which we can all learn from another cat's SS. That is one of the important roles of this forum..... learning.

 

[suki & crystal (GA)]

Well, while I was blissfully sleeping looks like a slight difference of opinion has occurred. I think in the end you will just have to agree to disagree, I can't even pretend to understand some of the scientific stuff referred to. (BJ, I was particularly saddened to read of the circumstances surrounding the loss of your Spitzer, it must have been truly awful for you). Having said that, I am extremely grateful for all the amazing support I have received here, especially last night while conducting our first ever R trial, so thank you to everyone who watched and offered their advice and opinion, even it they were not entirely in agreement. Some interesting thoughts though and I hope we can all learn something from Crystal's experience.

Getting back to Crystal .... would appreciate your comments on the effects of the R on her BGs and what should be my plan for going forward? I managed to get a +10 in last night and she was steadily climing to this morning's PMPS of 387.

 

[Sandy and Black Kitty]

Good Morning

I think you could safely try .5u at your next opportunity.

Provided that all Ps are present, ketones are negative and Crystal has a good appetite, my thinking is if you are able to monitor, hold the L dose for 6-8 cycles and at the same time be a bit more aggressive with the R , shooting AM and PM for a few cycles.
Then re-evaluate.

What do you think?

 

[suki & crystal (GA)]

Hi Sandy, I appreciate your comments, makes sense to me. Crystal seems well enough in herself, haven't been able to check poo output as she usually goes outside but showing no signs of constipation so would think all is okay. I usually manage a ketone test pretty regularly so will carry on with that. Good appetite, always looking for more so no problem there. I've been only holding the Lev dose for 4 cycles (as previously advised because of her acromegaly) so you are suggesting holding it now for 6-8 instead but to increase the R frequency, sounds a good idea, perhaps my acro "mentors" might like to comment as I'm still very inexperienced with all this (@julie & punkin (ga) @Wendy&Neko @Suzanne & Cobb(GA)

At the moment I don't think I can shoot both AM and PM for a few days as I am out every afternoon until Thursday. However, if I start at 06.00 I will be able to monitor until +6 or +7 anyway before going out and be back in time for 18.00 PM shot. I'm in every evening this week so no problem monitoring the PM cycles. Thursday would be my first full day and evening in when I could do both. So, would it best to wait until I have a couple of consecutive days at home to do both cycles, or is it be okay to do either cycle, here and there? The only downside to all this would be poor Crystal's ears!

 

[Marje and Gracie]

Suki

One of the beauties about this forum is it is a peer-review forum. We have a lot of members with a lot of different experience. If you only got input from one person, you might wonder how much you could trust it. But having several members offer input allows you, as the Caregiver, to inform yourself and make the decision for your kitty.

No, we don't always all agree but we all understand that we agree to disagree. While it might seem like arguing to the new member, it's just a presentation of info we all have. I know it makes it difficult for the new CG to sort through and figure out what to do and I'm sorry for that. But look how much you learned!

I think the take-home from this is that we've observed from the many R users in this forum (and Jill probably taught a great many of them how to use R...including me and likely Sandy) that R typically lasts about 4 hours but there are some cats, e.g. high dose, where the duration can be longer. Now you are aware of that potential, you can see if Crystal is one of them.

As far as when you can be available to shoot and monitor an R cycle, I know you've seen Cobb's SS to see how Suzanne did it while working although I think she started back to work after she had started using R. You might also want to look at Jazzy's SS.

Scroll down to 11/18/10 when Libby switched her to lev. Libby worked and shot R and Libby is another of our extremely experienced members (also helped me learn to use R). I am certain you can also learn from that SS.

It is absolutely fine to shoot just one cycle a day if the numbers warrant and you'll be there. just let us know when so we can make sure one of us is around. When you are able to shoot both cycles as Sandy suggests, also just tell us. There is usually one of us around or can be available if we know ahead of time. I definitely want to leave the R dosing to Sandy, Julie, Suzanne, Jill, Libby (if they are around). Wendy is also a great resource for the lev dose for high dose kitters.

 

[Suzanne & Cobb(GA)]

Hi Suki,

If you're going to do R again while on this dose, I wouldn't change your Lev dose too quickly. I, personally, wouldn't hold it longer than 6 cycles though. Just so you know which insulin is doing the work.

Some have noticed the cycle AFTER the R is given is more active than the cycle when it was. Why? I don't know. Just something to look out for.

I do agree with upping the dose to .5u. I think you'll end up with a higher dose anyway, but best to increase the R one shot at a time instead of dramatically increasing it.

Regarding R while working, I did get to the point where I would shoot and leave. But...I had a good amount of data before I did that. Several months of data. And I was still pretty nervous doing that.

Looks like your first R trial went well! I'm sorry I wasn't around. We had an unexpected trip out of town yesterday morning and then took a nap that was lovely, but ended up being WAY longer than I had anticipated!!!

~Suzanne

 

[suki & crystal (GA)]

Hi Marge, thanks for clarifying the debate, as you rightly say, you have to make an informed choice from all the info submitted and there is still so much for me to learn. When I logged on this morning, I just didn't expect that many posts and got a bit bogged down in the detail. I just feel sometimes as if I will never get the hang of all this though, especially interpretating all the data about dosing. I will really be in trouble when, and if, Crystal comes down to low numbers and having to decide whether to shoot, stall, feed or not, give insulin or not. Anyway, going by her resistence so far, it might be a while off and hopefully I will have got more confident by that stage. It was a big thing for me to do the R but I'm glad I've started that course of action and as long as I have help, I will manage.

Looking at the SS's I notice that other peope don't monitor that excessively, which I suppose comes with experience, but I certainly can't do 2 cycles and take her BG levels every hour, she's normally very cooperative but I think she would soon get very irritable and fed up with that amount of tests. So what would be a safe testing regime, say if I started at 06.00? Also, because of our time differences, is there anyone experienced around at that time who would be able to help? (I'm at GMT + 1 hour). Perhaps my evening cycle, which would be a morning/early afternoon in the US might be better? I could probably manage one, if not both, cycles this Thursday as I am around all day, let's see what others have to say.

 

[suki & crystal (GA)]

Hi Suzanne, looks like your post crossed with mine. Thanks for checking in on us, don't worry about not being around yesterday to help out, I was in excellent hands. I have actually changed the Lev dose this morning (which I did before logging on) so I'll hold this for the 6 cycles which takes me to Wednesday. However, as I said in my post above, I think I can do another R session on Thursday (my AM) , if it can be arranged with you guys. Alternatively, I could try again tomorrow night if it's not too much short notice but Wednesday is going to be more difficult. I think it was marvellous how you managed to look after Cobb so well while still working, I still feel nervous leaving Crystal for any length of time, let along dosing R and going out the house!

I'm just going to update her SS now.

 

[Marje and Gracie]

I'm sorry it got overwhelming; when i read back on it, I realized that it probably did. Rest assured that when we work dropping or lower numbers, most members are extremely respectful of those couple of people that might be helping you. if they post, it's only to give support but if numbers are low for the first few times, the members that have been here a while, at least, understand that the focus needs to be the numbers and the feeding/testing and not an information dump or social chit chat.

Remember that you are building data and learning now and so you might need to do more tests at first. When we started R, I tested every single hour until we figured out what we could expect. Now, based on the preshot number that I shoot R and the amount of R I shoot, I won't test until R+2 and sometimes R+3. There are some cycles with R that I only test once. So yes, it comes with experience but early on, you'll need to test more during the R cycle just to understand what she will/can do.

We'll put our noggins together again and see who will be around. 0600 Thursday is Wednesday @ 2200 here and 2100 on the West Coast. Julie has been really sick and i try to get in bed by 2300 or so on Wednesdays but we'll check with Sandy....it would be even later her time but she is sometimes a night owl.

 

[suki & crystal (GA)]

Hi Marje, Okay, I'll be fine with testing regularly but perhaps it might be best to start with just the one cycle, otherwise it will be an 18hr marathon from early morning until midnight, In which case perhaps we are best to do a PM start for me and a morning start at your end, rather than get people to sit up into the wee small hours, especially if they have to work the next day, what do you think, shall we go with Thursday PM which will be the same time frame as Sunday? I will fit in with whatever cycle is most convenient at your end and thank you for organising everyone, no mean feat.
Sorry to hear that Julie is poorly, if you speak to her, please pass on my best wishes for a speedy recovery.

 

[Tiger(GA) and Ruth]

Wow Suki- you had a pretty intense day yesterday- congrats for getting through it and I hope you got a good night's sleep! No advice here, just had to smile when I read your post the day before on Valentines Day and how Crystal got her shrimp treats! A cat after my own heart! My favorite way to eat shrimp is fried in Tempura batter from my favorite Japanese restaurant, it is so not healthy however, so now we only have it on New Year's Day as part of the celebration. Sorry, for the OT

Good luck on your next day of using R- I hope Crystal gets the response that you are looking for! And thank you for providing us all an opportunity to learn!

 

[Sandy and Black Kitty]

So, would it best to wait until I have a couple of consecutive days at home to do both cycles, or is it be okay to do either cycle, here and there? The only downside to all this would be poor Crystal's ears!

Either cycle here and there is fine, particularly while you are working on finding a dose that provides just the right amount of action. Once you do , like Marje said hourly testing will not be needed (unless the numbers say otherwise).

Alternatively, I could try again tomorrow night if it's not too much short notice

If that is Tuesday 02/17 18:00 Paris/12:00 Baltimore I am available.

Julie has been really sick and i try to get in bed by 2300 or so on Wednesdays but we'll check with Sandy....it would be even later her time but she is sometimes a night owl.

I am indeed . Since I retired I can just go with the flow

 

[suki & crystal (GA)]

@Sandy and Black Kitty Just logged on at PMPS (06.00) to read your post, that really is very kind of you to offer your services again, I really appreciate it. Let's go with tonight then, approx 12 hours from now, I'll post about 15 minutes before to say I'm ready.

Thanks Ruth for checking in, mmm, tempura prawns = food heaven. yes we did have a pretty intense first trial - and we get to do t all over again tonight, but I'm sure each time will become easier for me, paws crossed.

 

[Sandy and Black Kitty]

Pardon the second post -(I clicked 'post reply' accidentally on the previous one and it's easier for me to continue rather than edit)

It was Jojo who taught me about using R and it was an 'initiation by fire' since the reason for R was that BK was in serious crisis.
I'm glad Crystal is not in a crisis situation. Much easier to learn all this without the sword of Damocles hanging over your head.

I will really be in trouble when, and if, Crystal comes down to low numbers and having to decide whether to shoot, stall, feed or not, give insulin or not. Anyway, going by her resistence so far, it might be a while off and hopefully I will have got more confident by that stage.

It may be a while an it may not - ECID. FWIW It was 1 year before BK had his first taste of HC food. However long it takes for Crystals numbers to start to move you will build confidence with every cycle and you will get the hang of this. If you ever find yourself uncertain and there is no one around to assist - always err on the side of caution. "Better a day too high than an hour too low" If your instincts tell you to skip for safety sake, just think of it as a 'fur shot'

My $0.02 :

Information regarding IAA in felines in our day was nonexistent. Not much better for IAA in humarns.
Sadly it's still the same. No scientific studies or journal articles for felines.

I'm no scientist however I suspect many cats receiving exogenous insulin develop some degree of IAAs.
It also seems to me that the range for a 'normal' IAA result (1-19%) is pretty broad and that a result on the high end of normal could offer some resistance.
That being the case since you are unable to confirm IAA in Crystal and being she has not yet seen blue, I think it's prudent to consider the possibility. @Wendy&Neko can offer first hand experience with an Acro/IAA combination and is an excellent resource. Your R experiments will shed some light. Close attention to onset and duration (a tall order when faced with a relentless and seemingly impenetrable sea of pink, I know) may contain clues as well.

When you do break through, which you one day will, step back and re-evaluate the whole picture.
I say this because the one thing we do know is that IAA is self limiting, lasting approx. 1yr.
That is great news but at the same time a double edged sword. When it comes to an end, any insulin that was bound to the IAAs is released into the bloodstream.
A sobering thought at high doses.

Although during our journey I was referred to as having the biggest BOS in LL, the thought of the resistance breaking and previously bound insulin being released into BKs bloodstream made me weak in the knees. I was hyper vigilant about watching for signals that BKs IAA had run it's course and that hyper vigilance served me well.

Today in L&L Land we have an example in BK; knowledge we can build on . IAA kitties don't have to navigate in completely uncharted waters as we did.

Although just one example, not backed by science and very anecdotal, his story demonstrates how dramatically things can change.
It gives hope.

 

[Sandy and Black Kitty]

I'm happy to help.

Many were the nights Jojo and/or Jill (who back in the day were affectionately referred to as 'The J Team' ) held my hand and helped us safely navigate.
As a result BK not only stayed alive, he thrived.

See you Tuesday 02/17 at 18:00 Paris/12:00 Baltimore

 

[suki & crystal (GA)]

Hi Sandy, thank you for sharing BK's history. What a marvellous job you have done with him, it must be so rewarding to have him OTJ and thriving and worth all the late nights and worry, you certainly did have those BOS! I hadn't thought about the possible effects of IAA when it breaks, it is indeed a very sobering thought at Crystal's numbers. If it did break I suppose she would then be in an overdose situation? what exactly would be the signs just so that I am prepared? Also, when did BK have his crisis so I can look at the relevant part of your SS and study it. Sorry for so many questions.

Crystal has started the day well, just on the borderline yellow at +3 @ 299 so perhaps that is an indication she may go lower. I shall carry on testing throughout the day to get some data (I will be out for 2 hours this afternoon at my art class between +8-+10 but will test either side) and keep her SS up to date.

Check in with you later Sandy.

 

[Peg and Toby]

I didn't know either that once you get a break through that all that insulin is released into their system at once. Toby is now on 16.5 units and getting a lot of blues and some greens.
Does this mean he's getting close to a break through? I didn't mean to steal your condo but,
Just wanted to know what to do in case it did. Peg and Toby

 

[Marje and Gracie]

Glad you all got the times set up. I was going to work on Setting up Thursdsy today.

@suki & crystal ...after today, let me know when you want to try again or if you want me to go ahead and see who is available for you for Thurs 1800 your time, which would be 0900 for Julie(she will be working), 1000 for me, and 1200 for Sandy. I'm not sure of my schedule yet.

 

[suki & crystal (GA)]

Hi Peg, haven't had an answer to that one yet but hopefully later someone will drop in.

Hi Marje, I would like to do Thursday but can I just hold off until after tonight to see how it goes and let you know tomorrow, would that be okay? Thanks for putting people on standby, I can't tell you how much I appreciate everyone's help.

I'll be starting a new post for tonight's R but I'll check back here to see if there are any more comments.

 

[Suzanne & Cobb(GA)]

I didn't know either that once you get a break through that all that insulin is released into their system at once. Toby is now on 16.5 units and getting a lot of blues and some greens.
Does this mean he's getting close to a break through? I didn't mean to steal your condo but,
Just wanted to know what to do in case it did. Peg and Toby

Hi Peg,

No, it does not all release at once. It may release faster than you want it to, but no, not all at once.

You can see on Cobb's spreadsheet when the IAA started to break after we switched to Lev. We came down the dosing ladder quickly, but it wasn't like we went from 20 units to 2 overnight. You can see our R usage dropped dramatically after the insulin switch. I think Cobb's IAA was insulin specific. Not that he didn't require that much insulin, but he showed a marked improvement when we switched from Lantus.

 

[Marje and Gracie]

Hi Marje, I would like to do Thursday but can I just hold off until after tonight to see how it goes and let you know tomorrow, would that be okay? Thanks for putting people on standby, I can't tell you how much I appreciate everyone's help.

Perfect. just let us know.

 

[suki & crystal (GA)]

Will do, over on the new post now if you are interested.