23March2020/Maxi/AMPS306/Update on Cabergoline, etc.

[bambinaki]

Last thread: http://www.felinediabetes.com/FDMB/...ust-increased-to-5-units.227375/#post-2547135

Hello!

Maxi's vet has been great. She reads what I send her. She supports giving R in addition to Lantus. She has ordered cabergoline.

Thank you all for your help. I'll have more questions...

 

[Ti-Mousse (GA) Pepe (GA)]

Very good news!

 

[Wendy&Neko]

Carrying on yesterday's conversation:

Oh, really? @Wendy&Neko , do you think I should sothat (increase Lantus every 2 days instead of 3)?

I ordered R from Mark's Marine Pharmacy in Canada. I haven't been able to find a price close to $40. And I sure don't want to go to Walmart (self isolation for safety). I just hope I get it, and get it soon. They, like everyone else, are backed up.

I spoke with a Walgreen's pharmacist who said Humulin R lasts only a month. But maybe it's like Lantus - it lasts a lot longer if stored properly. Do you rest of you (@Wendy&Neko) agree that I can keep Humulin R for months in the fridge? How many months?

I only ever bought one vial of Humulin R. I kept it in the fridge. Used it for over a year and it was still effective at the end.

No on the fast tracking - that's an option if kitties are only seeing numbers above 300. Maxi is showing some yellow. Your next increase will be by 0.5 units, so that will help.

Great news on the cabergoline and your vet being so prompt! Are you getting it compounded? Most people get a script and get it compounded as a liquid at one of the on line pharmacies.

 

[Olive & Paula]

Glad Wendy corrected regarding the fast tracking. I did not know there was a start point for it.

 

[bambinaki]

Carrying on yesterday's conversation:

I only ever bought one vial of Humulin R. I kept it in the fridge. Used it for over a year and it was still effective at the end.

No on the fast tracking - that's an option if kitties are only seeing numbers above 300. Maxi is showing some yellow. Your next increase will be by 0.5 units, so that will help.

Great news on the cabergoline and your vet being so prompt! Are you getting it compounded? Most people get a script and get it compounded as a liquid at one of the on line pharmacies.

Thank you, Wendy.
OK, so, I could get the giant vial of Humulin R and keep it for a year.
I'll increase Lantus by 0.5 after every 6 doses if numbers don't go down enough. I just received 5 more Lantus pens. I'm wondering in these circumstances how soon I should re-order, and if I should get Lantus or Levemir...?
Yes, the cabergoline will be compounded by a local pharmacy. $120 for a 2-month supply. Good price or not?

 

[Wendy&Neko]

From tilleydiabetes.net, the site of the German diabetes forum where Tight Regulation started:

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. Alternatively, if the cat is continuously producing moderately elevated BGs (nadir always >=200 mg/dl), increase the dose every 2-3 days by 0.25 IU ( if the cat is getting a low dose) or 0.5 IU (if the cat is getting a higher dose).

There may be some room to increase faster if Maxi remains with just high yellows, but I'd like to see what he does with the first 0.5 unit increase. We also don't want to combine fast tracking, trying R and cabergoline at the same time. Too many moving parts.

 

[Olive & Paula]

Thank you, Wendy.
OK, so, I could get the giant vial of Humulin R and keep it for a year.
I'll increase Lantus by 0.5 after every 6 doses if numbers don't go down enough. I just received 5 more Lantus pens. I'm wondering in these circumstances how soon I should re-order, and if I should get Lantus or Levemir...?
Yes, the cabergoline will be compounded by a local pharmacy. $120 for a 2-month supply. Good price or not?

For 60 day supply that is great. Can you give me the particulars on this, where, concentration, etc? I pay that for 30 days.

 

[Wendy&Neko]

The other thing to consider with reordering is the weather. Not now, but in May it'll start to get warmer here (I am 25 minutes drive away from Marks pharmacy). Even if you got to 10 units, or 20 units a day, that 1500 units you have now will last 75 days. You are probably still OK weatherwise ordering in May, but I wouldn't wait much longer. I don't know if mail service is going to slow down, but cool packs only last so long. Lantus or Levemir is your call.

 

[Olive & Paula]

I write the date on the pen when I start it. I think when Ollie was 7.75 units a pen lasted me 3 1/2 weeks.

Current pen in use I started 3.7.20 and there is 75 units left. Ollie on this pen has been using between 4.5 and 6.5 units twice a day.

If your on the east coast in the states, you want to order no later than end of May to get you through the summer. Marks ships according to temperature of destination. It can be delayed.

Same for the winter. Order in November enough to get you through the winter.

 

[bambinaki]

For 60 day supply that is great. Can you give me the particulars on this, where, concentration, etc? I pay that for 30 days.

I'll do that for you when I receive it. Please remind me.

In the meantime, the pharmacy is Taylor's in Winter Park, Florida. I don't know if they ship.

Gosh, I hope it's the right concoction.

 

[bambinaki]

The other thing to consider with reordering is the weather. Not now, but in May it'll start to get warmer here (I am 25 minutes drive away from Marks pharmacy). Even if you got to 10 units, or 20 units a day, that 1500 units you have now will last 75 days. You are probably still OK weatherwise ordering in May, but I wouldn't wait much longer. I don't know if mail service is going to slow down, but cool packs only last so long. Lantus or Levemir is your call.

Well, if you could just reconfirm for me that I have / Maxi has nothing to lose by changing to Levemir, we'd appreciate it. I want to go ahead and order some in these uncertain times. Levemir lasts as long as Lantus if refrigerated, right?

The CVS here would not give me Humulin R without a prescription. The clerk was also surprised. She said the computer system wouldn't let her without a scrip.

Thanks

 

[bambinaki]

From tilleydiabetes.net, the site of the German diabetes forum where Tight Regulation started:

There may be some room to increase faster if Maxi remains with just high yellows, but I'd like to see what he does with the first 0.5 unit increase. We also don't want to combine fast tracking, trying R and cabergoline at the same time. Too many moving parts.

Thanks for your logic!

As for the Humulin R, I should be getting some today.
Should I give it to him tonight?

The vet said give Lantus as I have been while he is eating, and then immediately after give him 1 unit of R. Does that sound right to you?

 

[Olive & Paula]

Lev lasts just as long

 

[bambinaki]

Lev lasts just as long

Excellent. Thanks, Paula.

 

[Wendy&Neko]

The vet said give Lantus as I have been while he is eating, and then immediately after give him 1 unit of R. Does that sound right to you?

Absolutely not! That is waaaaaaay too much R to start with. @Sandy and Black Kitty You are fine to give R after the Lantus as the vet has suggested, but we start low and go slow with R. When you give R, you have to test at +1, +2, +3 and +4. At least until you have a better idea of R's onset and nadir with Maxi. You never give R on the first cycle of an L increase, so tonight would be fine. I'll ask Sandy, but I think something like 0.1 or 0.25 units to start.

Maxi has nothing to lose by changing to Levemir, we'd appreciate it.

Correct. The only thing to consider is that onset and nadirs are a couple hours later than they are with Lantus. That doesn't work with some people's schedule. It was great for me, because Neko's nadir was often close to or around preshot time, and I was generally home for that. It did mean for me that my usual before bed test didn't always tell me what the cycle was going to look like. But I learned how to use that plus the AM +9 test to figure it out. I wouldn't start Lev until you have a good handle on R. Sounds like you have enough Lantus for a while anyway. We'll also have to figure out the cabergoline timing.

 

[Olive & Paula]

Cabergoline timing? Is this a concern? I didn't know it could be.

 

[bambinaki]

Absolutely not! That is waaaaaaay too much R to start with. @Sandy and Black Kitty You are fine to give R after the Lantus as the vet has suggested, but we start low and go slow with R. When you give R, you have to test at +1, +2, +3 and +4. At least until you have a better idea of R's onset and nadir with Maxi. You never give R on the first cycle of an L increase, so tonight would be fine. I'll ask Sandy, but I think something like 0.1 or 0.25 units to start.

Correct. The only thing to consider is that onset and nadirs are a couple hours later than they are with Lantus. That doesn't work with some people's schedule. It was great for me, because Neko's nadir was often close to or around preshot time, and I was generally home for that. It did mean for me that my usual before bed test didn't always tell me what the cycle was going to look like. But I learned how to use that plus the AM +9 test to figure it out. I wouldn't start Lev until you have a good handle on R. Sounds like you have enough Lantus for a while anyway. We'll also have to figure out the cabergoline timing.

Oh wow, I'm so glad I checked with you about the R dose!

-Is it ok to start the R tonight, right after Maxi's 4th dose of 5 units of Lantus (at the start of his 4th cycle on Lantus)? (I'm double-checking)
-Should I give 0.1 or 0.25 of R? I'm not sure I can manage 0.1 even with the 1/2-unit-marked syringes I have. (@Sandy and Black Kitty)
-Do I gently roll the Humulin R vial in my palms before taking the dose out?

Since I am working from home now and for the foreseeable future, I'll be able to manage any and all monitoring/testing. If things normalize and I go back to working away from home in a couple months, I'm not sure how to handle that. I think Maxi is like Neko. It seems his nadirs (the few nadirs he's actually had) tend to be after +6.

Thank you, lifesaver!

 

[Wendy&Neko]

I've talked to Sandy, and we are thinking 0.25 units. I never rolled the Humulin R. How many hours until PMPS?

Cabergoline timing? Is this a concern? I didn't know it could be.

I just meant that when she starts cabergoline, we'll have to be mindful that it might start having an impact which sometimes means a drop in dose. In which case we'd go conservative and possibly not use R at that point.

 

[bambinaki]

I've talked to Sandy, and we are thinking 0.25 units. I never rolled the Humulin R. How many hours until PMPS?

I just meant that when she starts cabergoline, we'll have to be mindful that it might start having an impact which sometimes means a drop in dose. In which case we'd go conservative and possibly not use R at that point.

...or maybe drop

I've talked to Sandy, and we are thinking 0.25 units. I never rolled the Humulin R. How many hours until PMPS?

I just meant that when she starts cabergoline, we'll have to be mindful that it might start having an impact which sometimes means a drop in dose. In which case we'd go conservative and possibly not use R at that point.

PMPS is 1 hour and 15 minutes from now

 

[Sandy and Black Kitty]

...or maybe drop




PMPS is 1 hour and 15 minutes from now

So, 9:30pm eastern?

 

[bambinaki]

So, 9:30pm eastern?

Yes

 

[Sandy and Black Kitty]

Great! I’ll be around and available.
(please keep in mind I’m a painfully slow typist)


A word of caution-

I can’t stress enough the importance of being 110% present when preparing the syringes. No multitasking. Develop a system with a cross check. The last thing you want is to accidentally shoot .25u Lantus and 5u R instead of.25u R and 5u Lantus. It has happened here before, on more than one occasion.

 

[bambinaki]

Great! I’ll be around and available.
(please keep in mind I’m a painfully slow typist)


A word of caution-

I can’t stress enough the importance of being 110% present when preparing the syringes. No multitasking. Develop a system with a cross check. The last thing you want is to accidentally shoot .25u Lantus and 5u R instead of.25u R and 5u Lantus. It has happened here before, on more than one occasion.

Thank you, Sandy. (@Wendy&Neko)
Thanks for being around and available, and thanks for the caution.

I will PMPS test Maxi at 9:25.
At 9:26 I will feed him.
While he is eating, I will inject him with 5 units of Lantus.
Immediately after the Lantus shot, I will inject him with 0.25 unit of Humulin R. (Do I need to roll/gently mix the insulin?)
I will test him at +1, +2, +3, +4.
At this point I need you to tell me what to do. At +1, if his glucose is at least what number is everything OK? If it's below that number, what should I do? Same question for +2, +3, and +4.
If at +4, if his glucose is above the OK number (whatever that is, which I hope you will tell me now), can I go to sleep until his AMPS? Or should I test more through the night?
If you would care to give me your phone number in a personal message, that would be fine.

Thanks again

 

[Sandy and Black Kitty]

No rolling required

 

[bambinaki]

No rolling required

OK

Thank you

 

[Sandy and Black Kitty]

Make sure you always have plenty of test strips on hand as well as plenty of HC food. Should you find yourself needing to bring numbers up fast, Karo syrup, honey or maple syrup will work so keep one of those on hand as well.

At this point I need you to tell me what to do. At +1, if his glucose is at least what number is everything OK? If it's below that number, what should I do? Same question for +2, +3, and +4.

I'll be here for the +1 (and the +2, 3, 4) ...one test at a time
Ill also be posting additional important information as we watch this first trial unfold.

 

[bambinaki]

Make sure you always have plenty of test strips on hand as well as plenty of HC food. Should you find yourself needing to bring numbers up fast, Karo syrup, honey or maple syrup will work so keep one of those on hand as well.

I'll be here for the +1 (and the +2, 3, 4) ...one test at a time
Ill also be posting additional important information as we watch this first trial unfold.

+1: 350

 

[Sandy and Black Kitty]

See you at +2

 

[bambinaki]

+2: 329

 

[Olive & Paula]

I've talked to Sandy, and we are thinking 0.25 units. I never rolled the Humulin R. How many hours until PMPS?

I just meant that when she starts cabergoline, we'll have to be mindful that it might start having an impact which sometimes means a drop in dose. In which case we'd go conservative and possibly not use R at that point.

Oh. Sounds reasonable. I thought maybe you meant when in relation to giving insulin and the nadirs.

 

[Olive & Paula]

Great! I’ll be around and available.
(please keep in mind I’m a painfully slow typist)


A word of caution-

I can’t stress enough the importance of being 110% present when preparing the syringes. No multitasking. Develop a system with a cross check. The last thing you want is to accidentally shoot .25u Lantus and 5u R instead of.25u R and 5u Lantus. It has happened here before, on more than one occasion.

This is when one insulin being a pen comes in handy.

 

[bambinaki]

+3: 302

 

[Sandy and Black Kitty]

Moving in the right direction

The goal is to gather data on how R works with your cat. You must determine the onset, nadir, duration and impact. Remember, the desired result is for the R to lower BG by about 100 mg/dL from R onset until the end of R duration. This information will go a long way in helping you make your best dosing decisions going forward.

Being armed with onset, nadir and duration info for both Lantus and R, you want to make sure to time any R shots so as to avoid overlapping nadirs as that could result in unexpected lows. Likewise shooting R when you expect a bounce will be breaking could also result in unexpected lows.

In terms of continuing up the dosing ladder with Lantus while using R we generally recommend you do not use R on the first cycle of a Lantus increase to avoid boosting a cycle that may already be in for a boost from the new Lantus dose. However if you come discover or already know, via data collected, that your kitty never sees action the first cycle of a Lantus increase, but cycle 2 or 3 or 4 act accordingly.

See you at +4.

 

[bambinaki]

+4: 308

 

[Wendy&Neko]

All good data. It takes a number of experiments to figure this out. Be interesting to see where he is in the morning.

 

[bambinaki]

All good data. It takes a number of experiments to figure this out. Be interesting to see where he is in the morning.

Doesn't the R last only 4 hours? It seems that tonight his nadir from R was +3, if it can even be called a nadir. Are you saying that the R might still have an affect on his morning number?

 

[Sandy and Black Kitty]

Congratulations on completing your first R trial!

The next step is to try 0.5u R either tomorrow AM or PM as long as PS is still pink (or higher).

Any idea when the IAA results will be available?

 

[bambinaki]

Thank you.

Wait -- aren't I trying to get Maxi's glucose below 300? I don't understand why I wouldn't give him R in the morning even if his number is less than 300.

When I spoke with the vet early this afternoon, the result was still not in. I think it's expected in a day or 2.

I'm going to have a +5 test result in a couple minutes.

Please let me know about the morning dose (or no dose) of R.

Thanks again!

 

[Wendy&Neko]

Are you saying that the R might still have an affect on his morning number?

Been known to do that in some IAA kitties. First time I tried R, Neko went straight from pinks to red four hours later so I went to bed, I woke up to yellows.

 

[bambinaki]

+5: 277

 

[bambinaki]

Been known to do that in some IAA kitties. First time I tried R, Neko went straight from pinks to red four hours later so I went to bed, I woke up to yellows.

OK, so now it's gone back down (to 277).

So, Wendy, why shouldn't I give Maxi R tomorrow (or at any AM or PM) if his glucose is higher than it should be?

 

[Wendy&Neko]

You do give R if his AMPS is over 300. Over time and experience, you might give a lower dose of R if his numbers are high yellows, but not yet. But we are still in early days in data gathering.

 

[bambinaki]

You do give R if his AMPS is over 300. Over time and experience, you might give a lower dose of R if his numbers are high yellows, but not yet. But we are still in early days in data gathering.

OK, I get it about it being early days, but if his numbers don't go below 300 after these early days, shouldn't I be working on getting them below 300 (and below 200) with the 2 insulins? Maxi has already gone so long with these high, harmful numbers.

Thank you and Sandy very much for your guidance!

 

[Sandy and Black Kitty]

Wait -- aren't I trying to get Maxi's glucose below 300? I don't understand why I wouldn't give him R in the morning even if his number is less than 300.

R is strong stuff. Ive seen kitties who ended up on an express elevator down to the lowlands from just .01u. You have just started on the path to building your R scale. Tonight's trial was .25u with a PS of 341. The question now is what might .5u have done to that pink start? We want to have a similar start for comparison, and we want to have plenty of room for unexpected lows

OK, I get it about it being early days, but if his numbers don't go below 300 after these early days, shouldn't I be working on getting them below 300 (and below 200) with the 2 insulins?

You are working on getting his BGs below 300.

Maxi has already gone so long with these high, harmful numbers.

The high numbers have become his "normal" . If you bring the numbers down abruptly you risk triggering a bounce, one that you will want to counteract with some R which if you do can trap you in a continuous loop of creating high numbers and trying to shoot them down. The only way out of that trap is to stop R and let things settle down and that can be painful to watch. In the end its a huge waste of time.

R is seductive. Unlike Lantus, R provides instant gratification.
Knowing when not to use R is as important as knowing when to use it.

 

[Sandy and Black Kitty]

Doesn't the R last only 4 hours? It seems that tonight his nadir from R was +3, if it can even be called a nadir. Are you saying that the R might still have an affect on his morning number?

Like Wendy said it can with certain IAA kitties. It did with BK.

 

[bambinaki]

Good morning @Sandy and Black Kitty and @Wendy&Neko !

AMPS: +302

I will now feed and give 5 units of Lantus and 0.25 of R. --->EDIT: Maxi pulled away before I got the last drop of Lantus in.

Do I need to test +1, +2, +3, +4? Or is there another testing schedule for this cycle that I should follow? (Maybe a less aggressive one?)

Thank you

 

[bambinaki]

Also, would it be possible to give me a protocol for R?

I do understand what you're saying about going slowly, and I want to go slowly and be careful and do this right, but I'm not convinced that I shouldn't go ahead and give 0.25 R even if his number is lower than 300 since our goal is way lower than 300. You know much more than I do, so I'm open to being convinced, but I need some kind of protocol for moving forward.

What about this:

This PM: 250 or higher, give 0.25 R (Test at +5)
Tomorrow AM: 200 or higher, give 0.25 R (Test at +6)
Next PM: 250 or higher, give 0.5 R (Test at +1, +2, +3, +4)
Next AM: 200 or higher, give 0.5 R (Test at mid-cycle)
Next AM: 250 or higher, give 0.75 R (Test at +1, +2, +3, +4)
Next PM: 200 or higher, give 0.75 R (Test at mid-cycle)
Next AM: 250 or higher, give 1 unit R (Test at +1, +2, +3, +4)
Next PM: 200 or higher, give 1 unit R (Test at mid-cycle)
Keep increasing R and testing like this until numbers go below 180. (or lower?)

Please advise.

MANY thanks