1/17 Yum 1st R test AT2 AMPS 602 +1 617 +2 598 +3 531 +4 508 +5 500 +6 552 +8 540 +10.5 453

5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531

 

Here's your yesterday's condo. Good luck with the R!

 

Ha! I just came back to add yesterday's condo. Thanks.

 

Thanks for the new thread. Keep us posted on the progress!

 

I hope the R is just what Yum needs to start heading in the right direction and that you see good results soon!

 

5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531
+4 508

 

nice gentle slide down, just what we would like to see. .25u looks like a pretty good dose for now when giving at AMPS. There might be a little overlap between the lantus and R insulin which helped contribute to the drop. She has dropped almost 100 pts since AMPS, you don't want her to drop more then that from the R. It can start that bounce/dive rollercoaster if she drops too much too fast.

Let's see some red today Yum, that would be a good start to your journey to lower numbers.

 

Right now I'm not convinced the R has done anything. I will form an opinion after her +5 and +8 measurements.
Then I have to decide my next step.
My goal is to get her into reds asap.
1. should I give her .25u R again tonight or just see if there is a carryover effect? I think I've been advised to skip R the first evening.
2. I really want to increase her Lantus to 8.5u tomorrow morning.
3. If I increase her to 8.5uL tomorrow morning, should I also give her .25uR, then try .5u with 8.5uL the following day if supported by the data?

 

I was always told not to increase R & Lantus/Lev on the same cycle. But I did lose my patience pants and may have bent the rules a bit to get Bronx out of steady blacks/reds. Once I got my first yellow...and then a first blue, I did get more conservative. ECID, especially when it comes to R.

 

You can't tell if the R has done anything or not because you don't have any +1 and +2 and very little (none in the am cycle) +3 data to compare it to. The number was dropped 100 points over that time, which is exactly what you want the R to do, it's meant to give the Lantus a lower number to take hold of since Lantus isn't made to bring down high numbers quickly.

I would also say you need a different experiment on a pm cycle because they can be so different. Increasing Lantus while you are trying to get acclimated to R is not advised. It would be a great idea to review your past few condos regarding R and reread what Jill, Marje, Wendy, Sandy and Wes wrote and write down bullet points somewhere or print it out, listen to what they are suggesting with R and make yourself very familiar with those guidelines.

Given how it went perfectly today to drop 100 points on .25, I'd say increasing right now to .5 is not even a consideration at this point. Hopefully all those experienced R users will be along at some point to add to your condo.

Glad Yum is seeing some movement in the right direction, baby steps, but she will get there.

 

That's perfectly fine when first starting out. It takes some time to find the right dose and with R you start small due to its potency.
I would not give R tonight just in case there is carryover, this is your first day on R so caution is prudent.

I know the high numbers are discouraging, but increasing the lantus while starting R means you have 2 different insulins in play and makes it harder to see if the R is working.
I would hold the Lantus dose the same for now and give .25u R tomorrow, maybe .5u if Sandy/Marje/Wendy think it is safe, I'm not comfortable with saying yes or no to an R increase this soon.

As they say, FD is a marathon not a sprint, with some patience Yum will get into those better numbers.

 

Please slow down!!!!!

I’m sorry to be so blunt but experienced members, including Jill, have advised you to slow down on the L increases when you are using R. You are also worried about the vial and, if it is bad, switching might drop her numbers. Why increase the L dose if that is potentially the issue?

As Sandy said, we know this is a serious concern....these high numbers. But you just can’t throw caution out the window. R will not “fix” things overnight.

When I first started using it with Gracie to control bouncing, it took 2-3 weeks before I saw the overall curve coming down. Yes, I saw lower numbers after the first few times but in terms of bringing the entire curve down it took a bit of time.

One step at a time or you will have no idea what is causing the changes. If you want to try the old vial tonight, I would suggest you do not shoot R. I would also stick with this 0.25u dose of R the next time you use it. I found that 0.1u with Gracie did nothing the first time or two and you did see a response.

Here is a “review” of cautions and tips for using R. Please heed them.

• Aim for a dose that lowers the BG through the duration of R by about 100 mg/dL.
• Avoid overlap of the nadirs of the basal and bolus insulins
• Don’t give when a bounce is due to break
• Avoid giving R on a basal insulin increase cycle
• Monitor every hour for 4-5 hours to see onset, nadir, duration; once the cat’s patterns on both insulins are very clear, monitoring every hour can be decreased to those times the cat is typically most active during the R cycle.
• Be aware that R can appear to have an effect on subsequent cycles. It is likely the effect of the L insulin grabbing onto the R and the BG lowering in response to the longer effects of the L.
• After initial uses, determine the curves of the two insulins so you can see other safe times to give.
• Developing an R dosing scale is handy for long-term use. As an example, if kitty’s PS is 300 and on the rise, 0.1u might be appropriate; if kitty’s PS is 400 and on the rise, 0.25u might be appropriate. This is ECID and should be done after full knowledge of kitty’s onset, nadir, duration of both the basal and bolus insulins.
• Be fully present and focused when preparing syringes and shooting. Develop a double check system.
• Patience is required. Activity from the R is often not seen every time it is given. Don’t increase the dose of R just based on one cycle. The amount of R given should be tied to the current dose and the BG.
• Knowing when not to use R is as important as knowing when to use it.
• There are also some cases where R might be used for a period of time and then, if the cat's situation changes, it might not be appropriate to use it anymore. One mustn't think that using R always is routine.

IMHO, she had a good response this morning because she dropped about 100 mg/dL and her +4 didn’t go back up.

I can’t overstress the importance of you understanding the onset, nadir, and duration of both insulins so you can safely and effectively use them.

I also want to stress, again, what @Stacy & Asia said about marking the bottles. She linked Ole’s condo but that is not the first time we’ve had that happen and these were very conscientious members. It can happen. (BTW, I am the guilty one of putting my meter in the microwave ) I wouldn’t rely on the different colored tops and, believe me, it’s easy to get the syringes mixed up once you draw them so even though her L syringe will have much more insulin in it....double check before you shoot.

You do want to store R in the frig....mine lasted until the expiration date on it which was almost 1-1/2 years.

Please understand we’ve been doing this for years. The cautions we give are based on our knowledge and things we’ve seen happen. We are just supporting you to keep Yum safe.

ETA: you’ll want to continue to test hourly to see what kind of duration she might be getting. Once she heads up, you are good to stop. You are collecting data again at this point.

 

5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531
+4 508
+5 500

 

5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531
+4 508
+5 500
+6 552 possibly food influenced by small meal at +5

 

Thank you! You can give her a break. You might want to get a +10 just to see whether she drops into PMPS or not.

What is your plan for this evening.....trying the old vial or shooting 0.25u R again? If the latter, you will need to be able to stay up and test, if the numbers require, but you will want to test hourly from PS through, at least, +4.

 

5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531
+4 508
+5 500
+6 552 possibly food influenced by small meal at +5
+8 540

 

Plan for tonight and tomorrow

What will I do about Lantus?
Today is Yum’s 3rd day at 8 units.
I think a .5 unit increase in Lantus would probably give me more than a .5 unit dose of R, and with less risk for inducing a bounce.
I will increase her to 8.5 units of Lantus tomorrow. If you guys weren’t watching, I would increase her to 9uL. Her BG is too high by more than 400!!!
I see no way a 12.5% Lantus increase would drop her that far. But I will hold off.

I have reexamined her spreadsheet. I don’t believe anything is wrong with this new vial of Lantus.
However, I will probably shoot her with the old vial on Friday, the morning of day 2 at 8.5uL. My vet will be open, the ice will be long gone, and there is a nearby ER.
Of course this would interfere with R testing. So not sure.

What will I do about R?
What did it buy me today?
Yum’s onset today was at +3, the same as her historical onset for Lantus only.
Her nadir was at +5, her historical nadir for Lantus only.
[However, this month she seems to nadir at +5 for small drops from AMPS and at +8 for large drops from AMPS. See below.]
There is no smoking gun R footprint for .25uR, but see below.

It’s a pity she was anomalously high yesterday afternoon and evening, so I couldn’t compare today to a “usual” pattern.

On 1/14 (day 2 of 7.5uL) she started anomalously high at 604 and she nadired with a drop of 103 to 501 at +8.
Today 1/17 (day 2 of 8uL + new .25uR) she again started anomalously high at 602 and she nadired with a drop of 102 to 500 at +5: same drop but steeper.
On 1/8 (day 1at 6.5uL) she started at 631 and nadired with a drop of 61 to 560 at +5
On 1/9 (day 2 at 6.5uL) she started high at 639 and nadired with a drop of 225 to 414 at +8.
I need to plot all this stuff.

It’s possible .25uR caused a steeper drop.
We want to see R facilitate Lantus reaching a deeper nadir not a steeper nadir. Should I have shot her with .25u again at +6?

Yum has had so many ear pokes today.
I will skip R tonight. I am still deciding if I should continue with .25uR tomorrow morning.
I want to test multiple .25uR doses or .5uR, but not on the day I increase Lantus. A morning .25uR would be a continuation of today, but a single good Lantus dose would be so much easier.

 

There are many comments I’d like to make and will come back to do so when I have a bit more time but a couple thoughts for now.

The increase to 8.5u in the morning is warranted.

You have a great opportunity to shoot another 0.25u of R at +10 today and see if the L can latch onto it at L+2 tonight and give her a better evening cycle, especially in light of a dose increase in the morning (again, we would suggest no R with an increase for her tomorrow morning).

Are you willing to do that, even though you said no R tonight due to the tests she had today? Can you test tonight as long as need be in case the R brings her to a better number, the L grabs on, and we see some improvement?

 

I got this post too late for +10 but shot +10.5 with .25uR.
I had fed her maybe 50 kcal in the preceding hour because of her begging.
I tested her immediately after shooting her: she was at 453---a red! I also gave her another 20 or 30 kcal of food.
Do we attribute the 453 to the morning R or not? We don't know. She has been coming down late in the day frequently this month.

5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531
+4 508
+5 500
+6 552 possibly food influenced by small meal at +5
+8 540
+10.5 453
.25uR @ +10.5

 

These large numbers probably have a lot of variability due to accuracy limits.

 

Please be sure you test every hour. Try not to feed and I say that assuming she isn’t going to drop to 68 by shot time (anti jinx).

 

I can feed her at Lantus shot time, right?

 

A small amount of LC because you don’t want to stop the action of the R too much.

 

I apologize that I couldn’t make a detailed response earlier.

It’s now water under the bridge but please don’t shoot any insulin, much less R, without testing first. While it might turn out to not be an issue today (I hope), in the future, it could very well be. This is something we try to teach you all from the very first day (test before every shot); it is even more so important with using an L insulin and R in combo. The time it takes to test is very short and it won’t hurt to delay the shot by that much. Please also note that I asked you to test her at +10 in post #15 and you made two replies after that.

I completely understand how these numbers are driving you crazy. We all do. At one time or another, all of us helping you with the R have seen black and red numbers.

But, we have to somehow earn your trust that what we are suggesting to you is based on our knowledge and experience. Is there something that we are doing that discourages your trust in us? What would it take for you to be able to trust us? While you might feel you understand Yum’s patterns, you don’t understand how Lantus works with R and how the patterns of the two of them work together.....based on one shot.

This is your decision but quite honestly, I don’t think it’s the vial. She was going up into black and red before you switched vials.

Yum’s R onset today was at +2. Her R nadir was at +4 and then she was flat. 508 and 500 are the same number. I am not trying to be flippant at all, just honest, but you don’t have enough data in the last two weeks to tell what her Lantus onset is. We don’t typically look too much further past two weeks but even if I do, you didn’t historically test at +1 or +2 to know if she onset then. I’m also not seeing enough numbers to say she nadirs with L at +5. I understand that with these high numbers, you don’t want to be poking the heck out of her. I get that. I do see she’s been a little bit lower at +8 on a few cycles but not enough to call it a pattern.

I’d just like to make the point that you don’t know the nadir was at +5 because you didn’t test at +6 or +7.

No, the goal is not to see R facilitate Lantus reaching a deeper nadir. The goal is for R to slowly help the Lantus bring down the overall curve. It does that slowly, we hope, by giving Lantus a lower number to grab onto over time each time you use it. As I said before, this doesn’t happen overnight and it took Gracie a few weeks for me to start seeing an overall better and lower curve....not just lower nadirs. Because if the nadir drops but the rest of the curve doesn’t, you are in a dive/bounce cycle.

If she were mine, I’d increase the dose to 8.5u Lantus in the morning and then look at where she is at PMPS tomorrow night and decide if it warrants shooting 0.25u.

I see she was up a bit at +11.8. I’d advise testing her at L+1 and L+2. It will put you just past when we would normally test for R but I’d like to see what she does at L+1 and L+2.

 

One other thing I’d like to add.

The last week of Gracie’s life, she went up into numbers we’d never seen before. I had been using R very successfully for many years by then. I still turned to Jill and Libby for help with the R doses and times to give them because I had to take the emotion out of my decision and put the trust in those two ladies. They could see things that I was just to close to the situation, and everything else that was going on with Gracie, to see.

Sometimes, we think we see something on a SS or it appears to be a pattern but we’re so close to all that is going on, that we really can’t step back and see it clearly. That’s why experienced, knowledgeable, and unbiased eyes are so helpful.

 

When she was getting dangerous greens, her nadir usually looked to be at +5 (+-1). It's been my impression that her low point is drifting around lately. I'm not comfortable poking her every 1 to 2 hours to chase a shifting daily nadir, unless I have to. She's not running away yet (probably because she is starving for a post test treat), but that could change and her ears do have some polka dots today. She free feeds or steals food a bit too: might that interfere with her exact nadir? Do you think 0 carb food affects her BG? I've seen her have a flat nadir lasting a few hours. Before R I was more interested in the value than the onset.

. Sounds good. You would advise the R at +12 and not at +10?

 

I value and respect all the advice I get here. Yum would perhaps have died a while back without it. R is very tricky. I hope it is a short term solution.

 

5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531
+4 508
+5 500
+6 552 possibly food influenced by small meal at +5
+8 540
+10.5 453
.25uR @ +10.5
+11.5 515
L PMPS +1 501

 

And Yum ends the official R test for the day in the red! Woohoo! I will test her one more time before I go to bed, but this will probably be my last post.
I am very grateful to everyone for their advice today, especially @Marje and Gracie. The 480 after the time offset R is a pleasant end to the day.
5:50 AM 8u Lantus, .25u R
AMPS 602
+1 617
+2 598
+3 531
+4 508
+5 500
+6 552 possibly food influenced by small meal at +5
+8 540
+10.5 453
.25uR @ +10.5
+11.5 515
L PMPS +1 501
+2 480

 

That’s some progress! I hope the numbers slowly change color for in the following days and weeks.

 

I'm not Marje, but how about seeing how things go before making a decision about giving R tomorrow? Giving R @ +10 may or may not be a better option than @ PMPS time. Who knows? You may not need it. Please open a new thread tomorrow. Post her numbers as you get them and watch the forum for suggestions, comments, and advice.

It's often hard to plan when one will use R. All too often it's getting a BG number, analyzing the cycle and where one is at in the cycle, and then making an informed decision whether to give R or not. Since several of us have experience with R, we can help you with that.

Good day today. As Marje mentioned earlier, always test before you give any insulin... especially before you give R. It wasn't a big deal today, but it might be the next time.

Since you're in data gathering mode, I would get a before bed test. It should give you an idea if she needs further testing tonight.

Nice work everyone!

 

Thank you @Jill & Alex (GA) for getting back to MJW with a response. I had to go off the board for a bit.

MJW.....to summarize what we suggest:

• Get a before bed test tonight
• Increase the L dose to 8.5u with the a.m. shot
• Don’t worry about shooting the old vial of insulin
• No R in the morning but see how the cycle goes tomorrow and tag either Jill, Wendy, or me regarding when to use R some time in the a.m. cycle which might vary anytime from midcycle to PMPS. I want to urge you to not shoot R tomorrow without some input on the best time to do it.

Nice day! Let’s hope she sees some pink

 

Always keep in mind that there is no way to know what the numbers may have been had you not used R.

Working with 2 insulins can be very nuanced.Take it one cycle at a time and watch closely for the development of new trends.


IAA and Acro each have their own mechanisms that influence BG. Knowing if there is IAA and/or Acro on the scene will help you safely fine tune dosing.