Using Humulin R—help

Howiesmom

Howiesmom

Member Since 2020
It has been suggested on the IAA/acromegaly forum that I start using Humulin R in addition to levemir. Howie is An IAA kittie and is up to 16 units twice a day and only lives in yellows and pinks despite following TR. he’s only seen blues 3-4 times since Oct. 16. Are there folks experienced in using this who would be able to help me get started and can guide me? If there are online resources you can direct me to as well, that would be great so I can start reading about this. Thanks!
https://www.felinediabetes.com/FDMB/threads/iaa-kitties.239499/
 
First step for using R is to find someone experienced with it to help you out. What time zone are you in, and what time is your shot time? We'll want someone who is around at that time.

Out of curiosity, I see the blood work for acromegaly/IAA was done on 9/17. When did Howie start insulin? I know you are supposed to wait at least 73 days after starting insulin before doing the IGF-1 test.
 
Wendy&Neko said:
First step for using R is to find someone experienced with it to help you out. What time zone are you in, and what time is your shot time? We'll want someone who is around at that time.

Out of curiosity, I see the blood work for acromegaly/IAA was done on 9/17. When did Howie start insulin? I know you are supposed to wait at least 73 days after starting insulin before doing the IGF-1 test.
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I’m in CST and do shots at 7:30am/7:30pm. He started on insulin on 6/23.
 
Thanks. That rules me out for morning help (am on PST), but still could do nights. Typically we get people to shoot R (to start) the same time as the L and get hourly tests for 4 hours to start. Would you be up to staying up that late?

Also, let us know when/if you get the R. I've put out a call to see if I can find other experienced people to help.
 
Wendy&Neko said:
Thanks. That rules me out for morning help (am on PST), but still could do nights. Typically we get people to shoot R (to start) the same time as the L and get hourly tests for 4 hours to start. Would you be up to staying up that late?

Also, let us know when/if you get the R. I've put out a call to see if I can find other experienced people to help.
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I can certainly do this until I go back to work (out of the home) starting in January again. I can work from home 2days/week once I start back up, but the days I work in the office, I can’t get 4 hrs of tests in the day.
I’m still confused...do I need a prescription for it in the States? I thought I read you don’t in Canada but the States might be different, I appreciate all the help!
 
I got it at a CVS in New Jersey without a prescription.

Also, because it's short acting and you're not trying to build and maintain a depot, you can pick and choose when you use it. So on a day you have to go to work, you could just skip it. It's always optional.
 
@Wendy&Neko
@Sandy and Black Kitty
@Lisa & Oberon
It does not look like I can get the Humulin R anywhere locally so am going to have to order it online. I also need to consult with my vet about this to keep him in the loop. I will post when I’ve got the Humulin in hand so I can connect with anyone who is able to help me get started. The good news...despite spending a good chunk of yesterday in pinks, I was happy to test him at 154 for AMPS! He hasn’t seen that number since early November! Maybe something is kicking in! But I won’t hold my breath either.
 
It's bizarre you can't get R locally. It's used all the time by human diabetics so should be available at most pharmacies. Another trade name is Novolin R.

Yeah for blues!
 
Howiesmom said:
@Wendy&Neko
@Sandy and Black Kitty
@Lisa & Oberon
It does not look like I can get the Humulin R anywhere locally so am going to have to order it online. I also need to consult with my vet about this to keep him in the loop. I will post when I’ve got the Humulin in hand so I can connect with anyone who is able to help me get started. The good news...despite spending a good chunk of yesterday in pinks, I was happy to test him at 154 for AMPS! He hasn’t seen that number since early November! Maybe something is kicking in! But I won’t hold my breath either.
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Have u tried Walmart
 
wow, just looked at Howie's spreadsheet. I feel for you... Looks like you are raising doses as needed he just doesn't want to budge. Since he gets used to the new doses so quick you may want to raise every 3 - 4 cycles rather than waiting for 6-8 cycles. My cat is Acro and that's what I did when her numbers were on the moon. I have no experience with Humulin, but i'm definitely here for moral support. What did your vet say about using it? Like did he/she say to inject when numbers start climbing to pink?
 
It is odd that you could not find R locally.

I’ll be able to help with your AM shots once you’re ready to start- I’m on the East coast.
Regarding your vet, don’t be surprised if he/she is opposed. Mine was.

Today’s AMPS is great. It does however raise the question- was he coming up or down at AMPS?

Try and sprinkle the occasional test from PM+5-PM+11 ... the “zone of the unknown BGs”. A PM+ 6 one night, a PM+ 10 another night, a PM+8 another... that way you will have a better idea of what is going on and not be making dosing decisions with barely 3/4 of the full picture.
 
Sandy and Black Kitty said:
It is odd that you could not find R locally.

I’ll be able to help with your AM shots once you’re ready to start- I’m on the East coast.
Regarding your vet, don’t be surprised if he/she is opposed. Mine was.

Today’s AMPS is great. It does however raise the question- was he coming up or down at AMPS?

Try and sprinkle the occasional test from PM+5-PM+11 ... the “zone of the unknown BGs”. A PM+ 6 one night, a PM+ 10 another night, a PM+8 another... that way you will have a better idea of what is going on and not be making dosing decisions with barely 3/4 of the full picture.
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It is not uncommon for his nadir to be at +12, so it is quite likely he was coming down at AMPS. I will do my best to get more nightly tests. With being the only person in my household and working full time, major alterations in sleep wreaks havoc on my body. I'm waiting to hear back from my vet. He was out of the office since last Thursday and just responded this morning that he'll get back to me. Thank you for being able to help me out! Howie & I really do appreciate it!
 
JanetNJ said:
wow, just looked at Howie's spreadsheet. I feel for you... Looks like you are raising doses as needed he just doesn't want to budge. Since he gets used to the new doses so quick you may want to raise every 3 - 4 cycles rather than waiting for 6-8 cycles. My cat is Acro and that's what I did when her numbers were on the moon. I have no experience with Humulin, but i'm definitely here for moral support. What did your vet say about using it? Like did he/she say to inject when numbers start climbing to pink?
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I guess I hadn't considered raising him after fewer than 6 cycles. I'm certainly open to ideas/opinions! I'm still waiting to hear back from the vet as he had been out since last Thursday. He responded this morning that he'll get back to me. I know he doesn't have any experience with this, but he is very good at doing research and providing his best professional opinion or talking to colleagues in the vet world. When Howie was diagnosed with IAA, we did talk about adding in a fast-acting insulin, so I know he is aware of the practice. By the way, when I first started testing Howie's BG, it was your video that taught me how to do it! THANK YOU!
 
Howiesmom said:
I guess I hadn't considered raising him after fewer than 6 cycles. I'm certainly open to ideas/opinions! I'm still waiting to hear back from the vet as he had been out since last Thursday. He responded this morning that he'll get back to me. I know he doesn't have any experience with this, but he is very good at doing research and providing his best professional opinion or talking to colleagues in the vet world. When Howie was diagnosed with IAA, we did talk about adding in a fast-acting insulin, so I know he is aware of the practice. By the way, when I first started testing Howie's BG, it was your video that taught me how to do it! THANK YOU!
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I'm glad you found it helpful. I think raising faster may help.
 
You'll often find with Levemir that you will get later onset and subsequently later nadirs, where it can sometimes be just before or at preshot. You've gotten stuck with +3 tests ;), at night, it might be time to mix it up. I have been caught by surprise a few times around +10 so I agree with Sandy, I think some spot checks to fill in some of the missing spots would be helpful before thinking about increases. TR is already aggressive in the ability to increase every 6 cycles based on nadirs under 300, so I don't know if I would be comfortable in increasing faster, especially since you just saw blues.

Just my 2 Canadian cents.
 
Since you have seen blues, I would not raise any faster than every six cycles at this point. That might work on Prozinc, but not Levemir - you do need to give the depot time to settle. You might be able to try slightly bigger increases, 10% of total dose. So go to 1.5 unit increases now and up to 2 unit increases should you need to give 20 units.

Once you get some R, I think that'll be the biggest help. Good to hear your vet already has thought about it. I've seen it's use documented in papers about dosing acrocats, but no one has ever published anything about dosing IAA. So that leaves those of us with experience with it to help you out.
 
Wendy&Neko said:
Since you have seen blues, I would not raise any faster than every six cycles at this point. That might work on Prozinc, but not Levemir - you do need to give the depot time to settle. You might be able to try slightly bigger increases, 10% of total dose. So go to 1.5 unit increases now and up to 2 unit increases should you need to give 20 units.

Once you get some R, I think that'll be the biggest help. Good to hear your vet already has thought about it. I've seen it's use documented in papers about dosing acrocats, but no one has ever published anything about dosing IAA. So that leaves those of us with experience with it to help you out.
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I did find out that the reason it looks like I can’t get R locally in MN is because I must have a prescription for it. I confirmed that with a friend who is a pharmacy tech today. So I have to hear back from my vet to even get that. If I order R from Marks, do they require a prescription? It’s cheaper to get it from there but obviously have the shipping time.
 
I've seen people get R from Walmart at about the same price as here - I live 25 minutes drive from Marks. I wouldn't bother with Marks for R.
 
I’m looking for Humulin R U-100, right? That’s what I was told to get on the other forum and what requires a prescription here in MN (verified by a friend who is a pharmacy tech). I can’t find it cheaper than $96.75 and that’s with the GoodRX app. Marks is selling it for $41. I would love to find it for $25!
 
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Howiesmom said:
I’m looking for Humulin R U-100, right? That’s what I was told to get on the other forum and what requires a prescription here in MN (verified by a friend who is a pharmacy tech). I can’t find it cheaper than $96.75 and that’s with the GoodRX app. Marks is selling it for $41. I would love to find it for $25!
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I used Novolin-R which I believe is the same thing as Humulin-R? @Wendy&Neko

NJ is pretty strict with prescriptions, but did not need one for Novolin-R. Walmart has it in the pharmacy section behind the counter in their fridge.

R was the catalyst that got Bronx out of the reds & blacks. Great addition to have in your "tool box".
 
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Bronx's dad (GA) said:
I used Novolin-R which I believe is the same thing as Humulin-R? @Wendy&Neko

NJ is pretty strict with prescriptions, but did not need one for Novolin-R. Walmart has it in the pharmacy section behind the counter in their fridge.

R was the catalyst that got Bronx out of the reds & blacks. Great addition to have in your "tool box".
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I just called our Walmart about Novolin R and they have it and don't need a prescription! So I'm glad I called about that and didn't just ask about Humulin R. Thanks so much for the tip!! I'm still just waiting to hear back from my vet but am relieved I don't have to spend $96.75 for it! More to come soon! He just stared 18 units BID today :(
 
Howiesmom said:
I just called our Walmart about Novolin R and they have it and don't need a prescription! So I'm glad I called about that and didn't just ask about Humulin R. Thanks so much for the tip!! I'm still just waiting to hear back from my vet but am relieved I don't have to spend $96.75 for it! More to come soon! He just stared 18 units BID today :(
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Glad to help!

Bronx was at 37 units BID of Levemir at his highest:eek:

If you look at his SS back in 2017, you can see how I used R. Also, one of tabs in the SS is an R scale that made things easier. Just make sure you put red tape all over the R vial so you don't mix up that with any other med! I also learned never to use R twice in the same cycle, it seemed to have a delayed reaction and too much of a drop.
 
@Wendy&Neko
@Sandy and Black Kitty
@Bronx's dad (GA)
@Lisa & Oberon

Update on Howie...I finally talked to my vet and he is all on board with trying Novolin R on top of levemir and I will go to Walmart today to get it. What do I need to know to get him started? Dosage, timing with food and levemir, etc? I saw on @Bronx's dad (GA) SS a dosage chart from 2017. Is that what I should follow? My vet had said it’s a 1:2 ratio so he would get 6 units R and 12 units levemir since he currently is on 18 units levemir BID. But he never has had a patient actually do this so that is just his research. I will follow your practitioner advice! Any other things I should know/be aware of getting started on this?
 
Wendy or someone more experienced will be able to give you a more detailed answer, but that's definitely not how we handled it when I tried it. You don't want to mess with the Lantus depot, so you keep that dose the same and just add in R at very low doses until you see how Howie responds. With Oberon, we started at 0.25 U and gradually worked up to 1.25 U (don't use my dosing; ECID). The goal is to get to a dose that lowers BG by no more than about 100 points at +4 or so. And definitely wait to start until you have someone here able to stand by while you do your first few trials.
 
Howiesmom said:
My vet had said it’s a 1:2 ratio so he would get 6 units R and 12 units levemir since he currently is on 18 units levemir BID.
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NOOOOO! This really is ECID. We start low and go slow. Neko never got above 0.5 units at all and that was with 7 units Levemir. We had one cat on 30 units of Lantus who never needed more than 0.5 units. Typically we start with 0.25 units and see how he does with a couple cycles of data where we get +1, +2, +3, and +4 tests. We need to figure out the R onset and nadir and duration. Give the Levemir and R at the same time, but different locations. Make sure you have a routine that absolutely ensures you do not mix the two insulins up. Yes, we've seen it happen. :eek:

You don't give R on the same cycle as an L increase - in case there is a strong reaction. You are trying to limit the amount the BG goes down to no more than 100 points.

Let us know when you have the insulin, and either Sandy or I will "hang out" with you on line at the time.
 
Glad to hear your vet is onboard :cool:

Question-How did you discover Howie was diabetic?

Gotta get ready for a yoga class. Will be back around 8pm eastern.
 
ECID when it comes to R. I was a little impatient, well a lot lol, and was probably too aggressive with R. So do not follow my SS too much. But you can see on the SS that R doesn't not work the same every time on every cycle. One thing I did learn was to never use R twice in the same cycle, it seemed to have a delayed reaction in the following cycle causing a big drop in the middle of the night and just lucky to get up and test him. Start with .25 and have one of the pros here guide you. I am definitely no pro but will help you the best I can. Sandy and Wendy are pros. Your vet is way off with that 2:1 ratio, that is for sure.
 
ECID on using R twice in a cycle. Lisa's done a great job with Oberon, and that includes sometimes giving R a second time in the cycle (after nadir). But we'll start you out with just R shots at preshot time.

It is true that for some cats, the impact of R are seen more in following cycles.
 
Definitely ECID on using R more than once per cycle. I shot R every 6 hours around the clock for about 5 weeks straight at one point.
I felt that the impact of R definitely stretched into subsequent cycles with BK.
 
A few important things to know and keep in mind-

With IAA injected insulin first gets bound to the antibodies. Any insulin that does not get bound goes toward metabolizing sugars and delivering energy to the cells of Howies body. How much goes to antibodies and how much goes to metabolizing sugars is anybody’s guess and a moving target

IAA can retard the initial rise of available insulin after an injection.

IAA can lead to an increase in the half-life of free (unbound) insulin in circulation because some bound insulin gets released into circulation. The increase in half-life can lead to prolongation of action.

Most importantly when it does break, the release of insulin from the antibodies can happen at inopportune times.
 
Some important housekeeping items-
  • Please use one thread for all your comments and questions you have that day This will keep all activity pertaining to your cat together everyday.
  • Start your daily thread with the date, kitty's name, and AMPS
 
BTW, I wonder whether part of ECID here has to do with the antibodies themselves and how they're targeting the different insulins. R and Lantus have slightly different structures, so the antibodies may bind/release them differently. But also, different cats' antibodies could be targeting different parts of the insulin molecule, which could also lead to greater/smaller differences between R and L binding. So for some cats R and L might interact similarly with the antibodies, and for others one might bind more tightly than the other. Just one more complexity to think about. (Doesn't affect anything about the procedures here; I'm just sort of thinking out loud. Always trying to figure out more about what's going on under the hood.)
 
Sandy and Black Kitty said:
Some important housekeeping items-
  • Please use one thread for all your comments and questions you have that day This will keep all activity pertaining to your cat together everyday.
  • Start your daily thread with the date, kitty's name, and AMPS
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Sandy, Since it sounds like you’ll be my AM guardian angel and @Wendy&Neko will also help me in the PM, do you want me to tag you in the AM posts? I usually test him around 7:20AM CST so he gets his shot around 7:30AM while he is eating (same as PM times). So should I test him, post his #, and start feeding him while waiting for a response on a recommendation for an R dose? Or should I wait to feed until I get a response? He hit another blue tonight at his PMPS! Second one this week! Thank you for all your help!
My vet is very curious how this will go as he’s suggested it to a previous patient, but they wouldn’t take the time or energy. I’m his only patient in 26 years of practice who has taken home testing, monitoring, and trying new things to hopefully reach OTJ so seriously (and then mix in IAA!). I’m not sure what vet journal the 2:1 ratio came from, but I knew it didn’t sound right!
I am planning to start R on Saturday as I’m working tomorrow and Friday. Plus, Saturday will be day 2 at 19 units BID (so not first day of new dosage.)
 
Sandy and Black Kitty said:
Glad to hear your vet is onboard :cool:

Question-How did you discover Howie was diabetic?

Gotta get ready for a yoga class. Will be back around 8pm eastern.
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I knew something was up when Howie was drinking a ton of water. At first I thought he was hot because it June and he loved sleeping in the sun. But Mama’s gut knew something else was up! My previous kittie Simon had some similar symptoms but he turned out to be CKD. I hope yoga was good!
 
Howiesmom said:
Sandy, Since it sounds like you’ll be my AM guardian angel and @Wendy&Neko will also help me in the PM, do you want me to tag you in the AM posts? I usually test him around 7:20AM CST so he gets his shot around 7:30AM while he is eating (same as PM times). So should I test him, post his #, and start feeding him while waiting for a response on a recommendation for an R dose? Or should I wait to feed until I get a response?
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I'll look for you but go ahead and tag me when you open your condo.
Howiesmom said:
So should I test him, post his #, and start feeding him while waiting for a response on a recommendation for an R dose? Or should I wait to feed until I get a response?
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The first few days will be a series of trials, to see how sensitive (or not) Howie is to the R. So Saturday morning you will prepare your L syringe and a seperate syringe with 0.25u R. Always give your full attention to preparing your syringes. Once his head is in the bowl give him his L and follow it with the R in a slightly different location. After that you test every hour for 4-5 hours.
Howiesmom said:
He hit another blue tonight at his PMPS! Second one this week!
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Nice :cool:
Howiesmom said:
My vet is very curious how this will go as he’s suggested it to a previous patient, but they wouldn’t take the time or energy. I’m his only patient in 26 years of practice who has taken home testing, monitoring, and trying new things to hopefully reach OTJ so seriously (and then mix in IAA!). I’m not sure what vet journal the 2:1 ratio came from, but I knew it didn’t sound right!
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You are very fortunate to have a vet who you can work with on this. That's interesting about the 2:1 ratio. Before the IAA broke I got to the point where I was shooting 26uL (AM plus PM) and anywhere from 10-16uR in a 24 hour period
 
Sandy and Black Kitty said:
I'll look for you but go ahead and tag me when you open your condo.

The first few days will be a series of trials, to see how sensitive (or not) Howie is to the R. So Saturday morning you will prepare your L syringe and a seperate syringe with 0.25u R. Always give your full attention to preparing your syringes. Once his head is in the bowl give him his L and follow it with the R in a slightly different location. After that you test every hour for 4-5 hours.

Nice :cool:
You are very fortunate to have a vet who you can work with on this. That's interesting about the 2:1 ratio. Before the IAA broke I got to the point where I was shooting 26uL (AM plus PM) and anywhere from 10-16uR in a 24 hour period
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Do I do anything to prepare the R (i.e., roll vial on the counter, etc)? Thanks!
 
R is much more durable than Levemir. Just make sure you mark it well so no chance of mixing up the vials with any other med! I can't stress that enough. I accidentally used R instead of Adequan when I was half asleep, Bronx ended up in the ER with a BG drip. Scary as hell seeing him fall over and the meter read "Lo".
 
Howiesmom said:
Do I do anything to prepare the R (i.e., roll vial on the counter, etc)? Thanks!
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Nope :cool:

You must make sure you are fully present
You don't want your mind to wander off to other concerns while you are preparing syringes, testing and shooting and then later not be able to recall what exactly you shot so think about some sort of cross check method to employ; something you will do each and every time. Doing so greatly reduces the chances of a mixup. You don’t want to accidentally pull an R syringe in the amount of your L dose. It’s happened more than once in the time I’ve been around here. My chest feels tight remembering those incidents.
.

As you figure out how R works with Howie your “R scale” will develop. The R scale is based on the data you collect from the trials. It functions as a guide. Also, an R scale is not static As your cats reactions change so does the R scale... Check out the R scales tab on BKs ss for examples of a couple of his last ones. Unfortunately I lost the earlier ones in a hard drive crash.:mad:

keep asking questions ...
 
Howie reminds me of our kitty Junior (shown below) in his younger days.

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Sandy and Black Kitty said:
Nope :cool:

You must make sure you are fully present
You don't want your mind to wander off to other concerns while you are preparing syringes, testing and shooting and then later not be able to recall what exactly you shot so think about some sort of cross check method to employ; something you will do each and every time. Doing so greatly reduces the chances of a mixup. You don’t want to accidentally pull an R syringe in the amount of your L dose. It’s happened more than once in the time I’ve been around here. My chest feels tight remembering those incidents.
.

As you figure out how R works with Howie your “R scale” will develop. The R scale is based on the data you collect from the trials. It functions as a guide. Also, an R scale is not static As your cats reactions change so does the R scale... Check out the R scales tab on BKs ss for examples of a couple of his last ones. Unfortunately I lost the earlier ones in a hard drive crash.:mad:

keep asking questions ...
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Luckily he is on levemir flex pens, so I can’t mess up vials. But I’ll have to figure out how to keep the syringes separate! Thanks for the tips. I’m a bit nervous trying this!
 
Bronx's dad (GA) said:
R is much more durable than Levemir. Just make sure you mark it well so no chance of mixing up the vials with any other med! I can't stress that enough. I accidentally used R instead of Adequan when I was half asleep, Bronx ended up in the ER with a BG drip. Scary as hell seeing him fall over and the meter read "Lo".
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Ugh...that sounds awful. Luckily my levemir is in flex pens.
 
Two different coloured sticky notes, one with L on it, one with R for the separate syringes? I always shot L first. Got the Lev cartridge out, loaded and shot it, put it back in the fridge and got the R.
 
I nearly had the opposite problem yesterday. Shot Lantus and set the used syringe down next to the loaded R syringe (0.25 U). Then had to look really really carefully to make sure I used the loaded R syringe and not the empty L syringe for the R shot!
 
Once BKs L dose got upwards of 10u or so Fur shot frequency increased. I just wasn’t fast/steady enough and he would move. So I split t he L dose into 2 syringes. So with the R that made 3. I would place 3 post it notes on the counter and on each one write the amount each syringe was to contain followed by an L or an R. I would first fill the L syringes, placing eac on the appropriate note and put the L back in the fridge, then I would prepare the R syringe, place it on the appropriate note and put the R back into the fridge. It was a bit elaborate however I never second guessed what I had shot which was the goal.
 
@Sandy and Black Kitty , @Wendy&Neko
Howie has had diarrhea for the last 2 days and is lethargic. He eats his meals fine but has to be prompted to eat his snacks. He’s been on s boulardii forever so i was trying to ween him off but immediately put him back on the emergency 48 hr dose. I checked ketones and he is fine there. Any reason to not start the R tomorrow?
 
Given you are starting with a 0.25 unit dose of R, there is probably little risk to starting the R experiment. The biggest issue is if it drops him a lot and you want to slow the drop with food.

Has Howie ever had his B12 levels (cyanocobalamin) checked? S. boullardi doesn't work well for cats with low B12.
 
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