2/5 Crystal - advice on "R" please, vet appointment Monday - Update

Hi everyone,
Crystal is still running very high, AMPS 371 and then a 430 at +3 but she came back to 344 at +7. Another dose increase planned for tomorow morning.

I popped into my local pharmacy this morning to enquire about the "R" insulin. I had a feeling it wasn't going to be easy, much head scratching and general confusion until I said the magic word "rapid" - voila, we then got somewhere. Apparently here in France the equivalent (I think, but needs confirmation) is NovoRapid insulin aspart, which is known as Novolog in the US. Comes in the pens, the same as Levemir. I've done a quick internet check and is says it onsets after 15mins, with the peak action 45-90 minutes and a duration of 3-5 hours. Is this the right insulin to be using in conjunction with the Levemir? Would be grateful for any comments before I talk to my vet. In all the confusion I stupidly forgot to ask whether I need a prescription for it (think I probably do) but I need to see my vet anyway to bring her up to date on the recent change to Levemir.

Suki & Crystal

 

don't have an answer... but bumping you up

 

Thanks Rhiannon and Suzanne for bumping and tagging the experts. (Bet it's a lot cheaper at Walmart, 41 euros for the 5 pens - wonder if they will sell me just one as I need such a small amount?)

 

It never hurts to ask. I think my vial at Walmart was $35.

 

There are rapid acting insulins and short acting insulins. The R people use here is the Regular insulin (Humulin or Novolin). I found a table that lists some of the different products. Maybe it's best to ask your vet. He/she should know what insulin they would use to quickly bring down a cat's blood sugar. Or if there is an animal ER clinic, they would know what's used in France.

 

Thanks for attaching the table Wendy, looks like it's a different type of insulin altogether. Now that I have the names that R goes under, I can check again at the pharmacy and/or my vet. As far as I know there aren't any animal ER clinics, the vets just do out of hour emergency consults as required. I'll speak to my vet tomorrow, if she's around (doesn't work every day).

 

I'm glad Wendy found the information for you. I think asking your vet is a good idea. There are a lot of products that are different in N. America than elsewhere.

 

Novolog is definitely a different insulin from Humulin R/Novolin R, also called Humulin or Novolin Regular.
It lasts about 4-6 hours in the cat.

 

Crystal

I also think it's a good idea to be sure you get the correct insulin since Humulin/Novolin R is what we have experience with. I'm going to ask Jill if she can contact Kirsten Roomp with the German Katzen Forum and see what they use in Germany because if they can get it there, you can possibly get it in France.

 

Thanks Julie, BJ and Marje for looking in and for your suggestions, I hope to contact my vet later today (only 06.00 am here at the moment) and will let you know what she says. Back to bed for a couple of hours.
Suki

 

Here are images of the Humulin R box, a picture being worth 1,000 words.

And Novolin R.

And there's a website for Humulin R 100 here.

 

BJ you are an absolute star, thank you. That will make my quest so much easier. Now why didn't I think of that?

 

I sent Jill a PM. Hopefully she can get hold of Kirsten in case your vet is not sure.

 

Please keep in mind that packaging can be different in various countries. The generic name is "regular insulin" whereas the trade name is Humulin R or Novolin R. Ask for the generic.

 

Thanks for looking in Sienne, what's the difference then, why generic? I called my vet this morning but am still waiting for her to phone me back to talk about about using the R insulin. In the meantime is there a preference amongst members here between the Humulin R or NovolinR?

Edit
My vet has just phoned, I will call in on Monday to collect a prescription for the R insulin so if there is a preference for one or the other, would be grateful to know which one. She also mentioned using Arnica homopathic tablets for Crystal's stiff leg - anyone heard of that or used it in the past.

 

I think they're the same, just a different brand name.
I know there is a big difference in prices, so it pays to shop around, at least here in New Jersey. My local grocery store pharmacy wanted $80 and I could get it at Walmart pharmacy for $20 something.

 

They are the same but, as Dyana said, the price difference is substantial due to the generic vs not generic.

Jill has sent an email to Kirsten to confirm what name Regular insulin goes by in Europe. Hopefully by Monday, we'll know so you can give that name to your vet. In the US, "R" insulin does not require a script but not sure about in Europe and it might differ even by country.

 

Thanks Dyana and Marge (and Jill) I'll be very interested to see what Kirsten recommends. In the meantime i'll pop out tomorrow to the pharmacy to see what they have in the way of insulins, and generic versions (which they are very keen on here) so I can make an informed choice on Monday.
Thanks to all for your help and advice.

 

I have not heard from Kirsten yet, but in the meantime, I did a little research on my own.
However, it would probably be a good idea to wait for a confirmation from Kirsten before purchasing.

In North America we're accustomed to using Humulin R or Novolin R when using a bolus insulin with Lantus or Levemir insulin.

It appears Insuman Rapid is an equivalent to Humulin R:
Insuman Rapid is Aventis' brand name for its r-DNA/GE/GM short-acting insulin[2] in its Insuman line of products[3].
Like all R or neutral insulins, nothing is added (suspensions) to alter the insulin's action or speed[4]
Other brands of the same type of insulin are: Humulin R[5] and Humulin S[6][7][8] by Eli Lilly--Actrapid[9][10] and Novolin R by Novo Nordisk.

It appears Actrapid is an equivalent to Novolin R:
Novo Nordisk's brand of fast-acting insulin[2][3][4], known as Novolin R in North America.
Comparable insulins made by others are: Humulin R[5] and Humulin S[6][7][8] by Eli Lilly, and Insuman Rapid[9][10] by Aventis.
Like all R or neutral insulins, nothing is added (suspensions) to alter the insulin's action or speed[11]

 

Jill, a wealth of info there which I'm going to print off and study before going to the pharmacy. Thank you for all your research, I must admit I'm way out of my depth with all the choices available and my vet doesn't seem to know much more than me!

 

I've only used Arnica personally for bruises, ie. recent injuries. And that was applied externally. But in that form it's not supposed to be good to ingest. If you Google arnica for felines you get a range of answers. Did the vet ever X-ray the leg?

 

Hi Wendy, I asked about possible painkillers for Crystal's leg (stiffness comes and goes) and that's what she recommended, I thought it was only for bruises too but apparently not. I'll check it out - my list of things to query with the pharmacist is getting longer. Crystal hasn't had an x-ray yet, was hoping a visit wasn't necessary as she gets so stressed out but not so sure now, will see how she is on Monday and take her then if necessary.

 

@Jill & Alex (GA) @Suzanne & Cobb(GA) @Wendy&Neko @julie & punkin (ga) @BJM @Marje and Gracie @Sienne and Gabby @Dyana
Sorry to tag you all but just wanted to make sure you got my update as I would like to start the R next week if possible. I went to the pharmacy this morning armed with my paperwork from all your suggestions and research, (thanks so much for all your help) as well as my own investigations. Apparently the only regular insulin I can get here in France is Actrapid, which comes in the 5x3ml cartridges. The pharmacist checked the product info for me and it peaks between 1.5-2.5 hours after injection and last for 2-5 hours duration. Looks like this is my only option (there is no generic version available, unfortunately), and she was willing to let me have it without a prescription. According to Jill's research it's the equivalent of NovolinR so on that basis, would members be happy talking me through the first doses sometime during next week? Also, before I meet up with my vet on Monday, would it be possible for someone to let me have a rough outline of the dosage protocal as my vet is naturally concerned that I'm going this alone as she she's not familiar with the usage of R insulin. I've told her I will receive expert guidance from experienced people used to administering R but it might be a good idea to have something to show her if that's possible.

Thanks once again to everyone for their input.

Suki

 

You will test a tiny dose - maybe even just a drop, up to 0.25 units.
You test every hour to observe the curve (no depot) and monitor response.
Be prepared with Karo/high carb food, just in case it drops him like a rock.
Given the amount of time it lasts, I would pick the 5 hours when he is normally rising and highest, to test the dose. This will cover the period when the Lev is not doing as much. You will shoot at the beginning of this period.

Edited to add: this should be near the end of, or the beginning of the shot cycle, so it doesn't overlap the nadir of Lev, as Suzanne mentions below.

 

You want to make sure the nadir of the R won't coincide with the nadir of the Lev. My suggestion would be to give it at the same time as a high preshot.

Ultimately you'll develop a R scale. So, for example, if Crystal's BG is 350-400, you might shoot 1.5u of R, whereas of she's between 300-350, you may shoot 1u of R. The scale would be developed after you see how she responds to the R. Those numbers are just examples...not a suggestion.

 

Looking at the spreadsheet, I don't even see a nadir. How about you Suzanne?

 

I can't get Crystal's SS to open.

 

Its all pretty much purple recently, and very flat to my eyes.

 

Without looking, if there is no nadir, I would probably still start with shooting at preshot. The R might pull down the BG enough to let the Lev work at onset.

 

Given that Levemir generally nadirs later, that sounds like plan to me.
Suki, what do you think?

 

So are you both saying starting the R at PS (in my case, either 06.00 am or 18.00 pm, which is best?) , then what? do I use the levemir or not? if so, when? (Currently she is on 17u BID and I'm increasing every 4 cycles). sorry for so many questions, just scared I might do something wrong that would have dire effect on Crystal. Just to confirm she has been running high and flat for quite a while, especially yesterday when there was hardly any change all day.

 

You would shoot both the R and Lev at the same time. Two syringes.

You would then get a test every hour for 4-5 hours to see how she is responding to the R.

 

Thanks Suzanne, sounds as if it would be best for me to start at my PMPS in view of the time difference (time here now 16.45 for reference), that would give me all evening to monitor her from 18.00. Any luck with my SS yet? She's just gone up into the 400's @ +10.

 

Crystal

It's important that you take R dosing advice from people that have used it: Suzanne, Dyana, Jill, Libby, Julie, Sandy, and me right off the bat. There are a few others but the ones mentioned are regular posters. R should be used with extreme caution.

• First, you need to know Suki's onset, nadir, and duration. The timing of the R is critical and it's important to know those three things so you can lay an R curve over a levemir curve. As Suzanne said, you do not want to overlap nadirs and if Suki onsets fast from levemir (as my Gracie often does), then we need to take that into account as well.
• Second, I would start with only 0.1u of R because we don't know how Suki will react to it. The first few times you give it, you will need to monitor hourly. Eventually, you will be able to see how she reacts to it (when her onset, nadir, and duration on R are). For example, I know when I give it to Gracie that she's typically not going to start showing much change until R+2 and then she will be quite active with it from R+2 to R+3. By R+4, she's often done.
• Third, keep in mind that even once the R duration is complete, the R "can" knock back the numbers enough that the basal insulin (levemir) can do it's job. Many times, after I use R, the next cycle will be very active.
• It is very, very important that you draw the doses separately. When I give R, if I'm giving it at the same time as Levemir, I always draw my lev dose first, put the lev pen away, and only once my lev dose is drawn do I even take the R out of the frig and draw the R dose. We have had members accidentally draw the lev dose with R (one member accidentally shot 10u of R one day). It is really crucial that you develop a plan and a repeatable method so you make sure you don't accidentally draw the L dose with R.
• R should only be shot in the scruff because of the rate of absorption in other places of the body. While I will shoot chest, side, and flank with levemir, I would never shoot R there. Absorption is typically thought to be slower in the scruff so be sure the R dose is only given in the scruff.
• Also as Suzanne said, you will want to develop an R scale once you get a little more experience with it and see how she reacts. Suzanne, Julie, Sandy, and Libby have all used R with acro and/or IAA kitties and they can best advise on how much you want to increase the R by and help with a scale. My experience is limited to giving very small doses of R to Gracie (never more than 0.1u) because she is not acro/IAA and I would not feel comfortable advising on larger doses of R with the levemir. Suzanne has a good example of the R scale she developed for Cobb.

We are here to support and help you but, again, I encourage you to take advice on using R from those that have used it and the first time you use it, one of those people should be on the board with you. I wouldn't give anyone advice on using PZI because I've never used it so just keep that in mind.

Questions?

 

Hi Marje, Suki here (Crystal is the kitty, don't worry, easy to confuse with names like ours and I can't seem to alter our avator name). Thanks so much for all the detail. Can you access Crystal's SS ? only Suzanne was having difficulty checking it. If you can, you will see that she's pretty high and flat and I'm not sure on her latest figures when exactly the onset, nadir and duration is. Re the suggested dose of 0.1u I read somewhere how many "drops" make up one unit but can't find it, was it maybe 10? I will need to practice getting it that small, any tips? I have half unit syringes. No problem with monitoring hourly, I often stay up to her +7 or +8. Good point about not getting the two insulins mixed up, I will follow your advice and do one at a time, I am very aware of the dangers involved, that's why I'm a bit scared by the whole thing. I only shoot Crystal in the scruf, mainly because she puts up a real fight if I try the flank and she can get to me and bite and then we end up with a fur shot. Stomach area is out as she has the acromegaly "pot belly" and there isn't any loose skin there, so it will definately be the scruf for dosing.
If I aim for some time towards the end of next week that gives me plenty of time for making arrangements with one of the experienced people to watch our progress.

 

Hey Suki,

Marje has made some excellent points.

Yes, there are 10 drops in 1 unit. Some people use food coloring so they can see the drops more clearly when they practice measuring out that small of a dose.

You should be able alter your name. Robert posted a how to in one of the top sections yesterday.

I'll do the time calculation. Let us know when you're ready to do a trial and we'LL make sure you have several people around to help.

 

Hi Suzanne,
Okay, I have to see the vet, get the insulin, have a hospital appointment next week so looking for a clear late afternoon and early evening before PS so it looks like Wednesday or Thursday might be best, starting at my dose time of 18.00. Looking at your post it was 34 minutes ago which was approximately 18.45 my time (now 19.15). I'll check the name change to avoid any further confusion and thanks for confirming 10 drops to 1 unit, what would I be starting at so I can have a practice. She's at 17u Levemir and going up after every 4 cycles, increase to 18u tomorrow morning.

 

Hi Suki.
I took out the Levemir and drew that dose and put the Levemir away, and shot that insulin, and then took another syringe and took out the R and drew that dose and put the R insulin away, and shot that insulin.
I also kept the two insulins in two separate places in the refrigerator, so as to never get confused should I be extra tired, stressed, in a hurry, or just barely awake when getting the doses ready.
I think the number of drops depend upon how big the drops are and what syringes you are using.
I called 0.10 unit when the plunger was just touching the bottom edge underneath the zero line. I also gave lesser doses than that, and 0.10 unit was about as high as I shot. And I too, found that the cycle following a cycle when I gave R would often be extra active.
Good luck, you will be fine, with all of us watching you. I was scared too, to try R, but finally did with the eyes of experience helping me along.

 

Suki, you'd be starting at .1u. The dose of Lev won't correlate to the R dose So don't worry about going up on Lev and how it will affect the R dose.

 

Suki

I'm very sorry. Obviously not enough this morning. I think I was thinking of another kitty we had here whose name was Suki but, again, that could have been lack of caffeine

Jill has some info for you and will be posting it.

eta: sorry to not answer the other question. Yes, she is high and flat now and it's hard to tell her onset, nadir, duration. But I'm hoping that by the time you start using R, a pattern will develop especially if you are continuing to increase the dose with the help of our experienced acro/IAA members.

 

Very interesting I'll be watching To see how to give it to Toby. Have been giving .25 and that didn't do much so went to .5 don't know if I'm doing it right or not. So maybe can learn with you. Peg and Toby

 

I realize the conversation has moved on, but for the sake of continuity and posterity, I want to add this info here:

I heard back from Kirsten (tillydiabetes.com) in regard to short acting insulins used on the German-Katzen Board. She said a few have used Insuman Rapid, especially those who have kitties with acromegaly.

Alternatives can be found here: Activity profiles of the insulins (I used a translator I have installed on my laptop).

Normal-Insulin (Alt-Insulin)
- Insuman Infusat
- Berlinsulin H Normal
- Humaject Normal
- Huminsulin Normal 40
- Insulin Actrapid HM
- Insuman RAPID

 

Hi Dyana, Suzanne, Marje, Peg & Jill. I think my best way forward is to draw up a little plan for myself with all the vital info condensed on it (which I can also show my vet on Monday) and have a good practice with eyeballing the 0.1u with my syringes and get that sorted so I'm confident that I've got that right. Jill, thanks for taking the trouble to contact Kirsten on my behalf. One of the insulins I asked for today was Insuman but as I said earlier, there is a very limited choice here and it appears to be Actrapid or nothing, which is a bit of a bummer as I don't think anyone here has actually used that. Having said that it's supposed to be the equivalent of NovolinR which members are familiar with and no doubt I will have many eyes watching over this particular episode, thank goodness.
Should I start a new thread, say on Tuesday, as this one is getting a bit long now or is it best to keep all the info in one place? I'll be around for about another hour or so, if not I'll check back tomorrow morning.
Thank you all for your advice and moral support, I really appreciate it.

 

I'm sorry I haven't responded sooner, Suki, I've been sick.

It would be good to start a new condo/thread tomorrow and include a link to this one. I would also bookmark this one for yourself so you see the info that has been here - it's a lot of good info.

The number of drops in 0.1u can vary depending upon the size of your needle and syringe. The important thing with measuring the dose is that you can be confident you are able to repeat the dose again and can increase it. It's ok to eyeball it. Notice where the plunger line is - the measuring lines are often different between one syringe to another, so it's a good idea to take a used syringe and decide with colored water what you think 0.1u will be, then save that syringe and use it to compare when you draw up the dose.

I'm thinking you could increase by 1.5u increments at this point, meaning you could go to 18.5u in the morning. That's still less than 10% dose increase and following the protocol, most cats are getting 25% increases. I'm concerned that we start seeing some movement on Crystal's ss. What do you think about that, Suki?

 

Hi Julie, sorry to hear that you have been sick, I thought I hadn't seen your posts for a few days. I do hope it was nothing serious and that you are feeling much better now.
I suppose proportionately a 1.5 increase makes sense on such a large dose anyway so I'll give it a go. luckily you caught me just before I'm off to bed @ 1 pm especially as I don't usually check in at AMPS, just test, feed, shoot and go back to bed!
I will start a new thread tomorrow as you suggest. Just going to get a +7 from Crystal, who is snoring rather loudly at the moment. Night night.

 

nighty night! sleep well.

 

Thanks, you too.