? 24March2020/Maxi/AMPS302/Introducing Humulin R Questions

Last thread: http://www.felinediabetes.com/FDMB/...pdate-on-cabergoline-etc.227429/#post-2547456

@Sandy and Black Kitty @Wendy&Neko

Last 2 posts:

(I don't know why that "1" is there and can't get rid of it.)


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

------------------------------------------------------------------------------------------------------------------------

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

 

Short answer, no. R is powerful stuff. We learn by being coached by experienced people. We haven't written down a "protocol" as truly ECID so there isn't one, and we don't want someone just reading this and deciding they can go alone with it. Just last year we had someone "go it alone" and posting irregularly, and I saw by his spreadsheet he had given 3 units of R then no more tests that night. He was lucky his cat survived.

Your goal with testing R now is to do it frequently so you can figure out the onset, nadir and duration. Once you've figure out the onset, you can test at onset. For example, if onset is +2, you could start skipping the +1 tests. I'm not saying to skip the +1 now, cause we don't know when onset is yet for Maxi. So for the moment, we still need tests during the first part of the cycle.

 

While I am REALLY GRATEFUL for your help, I do need some kind of guideline to follow. For example, I haven't tested during this AM cycle. Because last night nothing really happened. I have been keeping a close eye on Maxi, and I was planning to test him at +6. I at least need to know how often and when I'm supposed to test for each next cycle because you and Sandy are not available every hour. I'll test him now.
Thank you

 

AMPS +4: 278

 

You really, really need to test the frst 4 hours after you give R. To not curve during the R dose is asking for trouble. R is exceptionally powerful and can slam numbers into the dirt. I would like to not have you dealing with a symptomatic hypoglycemic event which is why we have you start low and work the dose upward while testing every hour.

 

OK, here is some guidance. If the PMPS is over 300, give 0.5 units R. Test at +1, +2, +3 and +4 so we can gather data on how R is working.

This will be a different R dose than last night. Because of what is happening with the underlying L dose (depot building), you can't say that because something didn't happen last night, it wouldn't next time. And now we have no data about what happened with 0.25 units this morning. It was a wasted experiment. As I said above, don't step down the testing until we know when the R onset and nadir is.

 

What do I do if his number is under 300? No R? 0.25 R?


Not completely wasted if we have +4 number of 278.


If we can't predict what will happen based on previous tests, why is the testing data so precious? Of course we have to monitor the effects of the insulin to watch out for hypo, but if the past data doesn't predict future data, why is there an emphasis on creating and recording data?

Thank you!

 

Do I need to test every hour the first 4 hours after giving R every time I give it forever?

Thank you

 

No. You do, however, need to do so initially and with dose changes in order to understand how your cat responds to R. What you did today was dangerous. Look at how often you were testing regularly with Lantus when you first started out. Given that R is short acting, you need to get a feel for how it's affecting Maxi's numbers especially in conjunction with Lantus. Lantus tends to "latch on" to lower numbers better than higher numbers given it's gentle nature. You haven't seen a cat's numbers plummet with Lantus. I've seen Lantus take Gabby's numbers from the 400s to the 40s and back to the 400s. Just think what could happen if R was in the mix. Please listen to Wendy and other experienced R users. R is the most powerful insulin you can use and we're trying to prevent a heartache.

 

No, as I said previously, you need to do that until you know R's onset, nadir and duration. We don't know that yet.

You can't predict based on ONE experiment. You need additional data.

Sandy will be along in a while with some more thoughts.

 

I am trying to listen and heed (appreciated) instructions but there are gaps in the instructions. When I'm told not to do anything until further instructed, and then no further instructions appear, there's nothing to listen to and heed. This morning no instructions came. It wasn't clear (to me) that I should keep testing every hour. I still don't know what I should do tonight if Maxi's number is under 300. No R? 0.25 R?
That said, I can't expect you advisors to be on standby at every moment, so I need to know what to do by myself. I at least need clear and complete instructions about each forthcoming cycle. Without that, mistakes happen.
Thank you!

 

Maxi's IAA result arrived:

Maxi's IAA is 1. Normal is below 20.

He doesn't have insulin antibodies making him insulin resistant. Acromegaly diagnosis is supported.

The lab that performed the test would not offer Maxi's vet treatment recommendations.

Someone (@Judy and Freckles , @Sandy and Black Kitty , @Wendy&Neko ?) asked me about the details of Maxi's cabergoline: $120 for 2-month supply/60 mls, concentration is 30 micrograms, dose is 1 ml per day with food, compounded into liquid with chicken flavor.

I will get the cabergoline in a few days. Please advise me on when to start Maxi on it. I agree about what you (Wendy?) said about holding off since we started the R so as not to have too many moving parts.

Please let me know if this concentration and dosing looks right to you.

Thank you!

 

The cabergoline question came from @Olive & Paula

Thank goodness for no IAA, that will make things less complicated.

If you have no instructions about a case (ie, preshot under 300), that means do nothing for the moment. If it helps to be more explicit, the current R scale is:
under 300: no R
300 and over: 0.5 unit R and test every hour for 4 hours.

Am I missing any cases you can think of?

 

Thank you!

I can't think of any missing cases to be prepared for.

Sorry for my OCD + slow to catch on.

And thanks for remembering it was Paula who asked about cabergoline.

 

OK, I do have a question about no R if number is under 300. We've added the R because the Lantus isn't cutting it. Why not then give R to bring numbers below 300 since the Lantus isn't?

 

The foundation for success in safely treating FD is to "Know Thy Cat "
That takes time and experience; patience persistence and perseverance.

No protocol exists. It's tribal knowledge passed along by those with experience.

Neither am I. Its just too soon to safely take that step right now.

What you propose above makes no mention of Lantus. The goal is to use R to keep numbers in a reasonable range while at the same time methodically increasing Lantus until reaching a dose that does the trick without the use of R. Ideally The R covers the time between when L is shot and when L onset occurs. its like a 2 person relay where the first runner is a sprinter running the first 1/3 of the race and then handing the baton to a long distance runner who runs the rest of the way, Once you reach a Lantus dose that can carry the whole cycle without the benefit of R you reserve using R for covering fall out from fur shots or skipped shots or other situations that result in unwanted highs. R becomes a tool in your toolkit.

When in doubt, always err on the side of caution, particularly when you arre dealing with a high dose kitty.
High Dose = High Drama
Better a day too high than an hour too low.

Great news on the negative IAA results! That eliminates one layer of complexity

Hang in there. In time you will be able to sense which way to go and when.

 

What you propose above makes no mention of Lantus. The goal is to use R to keep numbers in a reasonable range while at the same time methodically increasing Lantus until reaching a dose that does the trick without the use of R. Ideally The R covers the time between when L is shot and when L onset occurs. its like a 2 person relay where the first runner is a sprinter running the first 1/3 of the race and then handing the baton to a long distance runner who runs the rest of the way, Once you reach a Lantus dose that can carry the whole cycle without the benefit of R you reserve using R for covering fall out from fur shots or skipped shots or other situations that result in unwanted highs. R becomes a tool in your toolkit.



Thanks, Sandy.

I made no mention of Lantus because I thought it went without mentioning that I should continue to follow the Lantus protocol. If I should now practice a different methodology for using Lantus, I need to know what it is.

 

So caber is 30 mcg per 1 ml ? You will give 1 ml correct? I know it comes in different concentrations based depending on what form you use.

 

Hi Paula-

I can't say that Maxi's cabergoline is "30 mcg per 1 ml." But that's the way it sounds. This is exactly what they told me: concentration is 30 micrograms, dose is 1 ml per day. So, the concentration would be the same for 1 ml or 60mls. If the bottle contains 60mls, any ml coming out of that bottle will have the same concentration.
Anyway, this is very different from what you told me about Ollie's cabergoline (concentration: 100mcg/ml, dose: 0.84-0.9ml). What do you think of this difference? My vet didn't know about cabergoline as a treatment for acromegaly. I don't know how Maxi's cabergoline got to have this concentration and this dose. Please advise!
Thank you.

 

What does Maxi weigh? Dose is based on weight. There are different concentrations, so higher concentration could be lower amount given and still equal larger amount given that is lower concentration.

I have to look up what starting dose would be. Do you know what the base of the suspension is? Oil, Water? Don't know if that makes a difference or not. What Pharmacy was it ordered from? Let me look it up and get back to you.

 

Maxi weighs 13.5 pounds.

I don't know what the base of suspension is.

It's ordered from Taylor's Pharmacy in Winter Park, Florida. (It's not a nationwide mail-order place.)

Since this is new to me, new to the vet, and probably new to the pharmacy, I'm very nervous that they might not get it right.

Many thanks!

 

I think the caber studies all did 5 μg/Kg.

Maybe vet discussed with pharmacist and decided the dose...........

I know I asked someone to do the calcs for me (back in Oct 2018) since I'm so bad at math. I can not find the posts. Ollie is 13 pounds and her dose started at 0.6 ml. I don't know how much mcg that would equal. I don't think you have to worry its to much though. It seems low to me but again I'm not sure of the calculation. I bet Wendy would know. When you get it, see what the bottle says.

I think Wendy stated the dose when you first found out but I can't find that post either.

 

This is all I could find from this (Feline Diabetes) website:
A quote on current RVC dosing: "We are currently only managing the trial in the UK but have been in contact with others outside the UK who wish to try it. We use a starting dose of cabergoline of 10 micrograms per kilogram by mouth once daily..."

I found this article, which I think is linked somewhere on this site too: http://www.scielo.org.co/scielo.php?script=sci_abstract&pid=S0120-06902017000400316
and the article says: Oral cabergoline at 10 µg/Kg every 48 h was administered.

But none of this is helpful if the concentrations vary.

I really don't know what to do now about the caberline. It's too expensive to buy the wrong concoction, and MUCH more importantly, I have to find the right, safe concoction and dose for Maxi.

 

After one of our members asked RVC, Chris from RVC said "10 microgram per kilo dose once daily". Half their 6 cats in the study got 5 mcg/kg, the other half got 10 mcg. Apparently they didn't notice a difference between the two, but their study also wasn't long enough. At 13.5 lbs, Maxi is 6.14 kg, so a dose of 60 mcg/day would be the upper end, 30 would be the lower end. Some people here started low and increased it. Sounds like your vet prescribed the lower end to start.

Good luck with the R trial tonight.

 

I did see that dose for every 48 hrs. So the 5 µg/Kg daily would be the same.

Anyway, all is not lost. I just saw Wendy's post. I was thinking same thing. Vet is starting low. My vet messed up the first bottle also. But we recalculated it. So its an option in the future.

Here are some tips, if its an oil base, do not put it in the fridge. It needs to be protected from light. Mine comes in an amber bottle and I keep the bottle in a probiotic box. I only get 2 syringes from pharm. They get gunky quick, pharm said I could rinse and reuse. I do. I also bought a box of 100 ct 1 cc syringes without needles to use if I need to.

 

Thanks, Wendy.

You used mcg to refer to dose. The pharmacy (my pharmacy here) used mcg to describe the concentration, not the dose.

You said the dose was from 30 to 60 mcg per day. The pharmacy said the concentration is 30 mcg, and the dose is 1 ml per day.

???

 

Thanks for the tips, Paula

 

The concentration should be 30 mcg per ml. Therefore 1 ml has 30 mcg in it. The concentration is always described per amount of liquid. 2ml would be 60 mcg.

 

Wendy, first I should say that you deserve sainthood for dealing with me. Now... if the medicine in the bottle is of a certain concentration, then isn't any amount of liquid taken from that bottle of the same concentration? Maybe I'm misunderstanding the concept of concentration. For example, if I put pure alcohol in a bottle, the concentration of alcohol in that bottle is 100%. If I take 1 ounce of liquid from that bottle, the concentration of alcohol is 100%. If I take 2 ounces from that bottle, the concentration of alcohol is still 100%. But if I then add water to that bottle, the concentration of alcohol is decreased; let's say it's now 90% alcohol and 10% water. If I take liquid from that bottle, no matter what amount of liquid I take, the concentration of alcohol is always going to be 90%. This is why I don't get how the concentration of the medicine, compounded cabergoline in liquid form, would change depending on the amount of liquid taken from the bottle. ??

 

Looks like you are seeing some movement at +2 again. What do you think Maxi's Lantus onset time was? Good to know of what you are seeing is the Lantus and/or the R lowering the numbers.

Cabergoline is not alcohol. Plus if you take an ounce of alcohol out of that bottle and drink it, then you take a second ounce of alcohol out of that bottle and drink it too - you'll notice you've just consumed more alcohol! Think of the concentration as how many parts per ml. There are 30 parts (or mcg) per 1 ml. So there are 60 parts (or mcg) per 2 ml. Assuming the medicine is shaken or evenly distributed amongst the liquid.

 

So, it's the word "concentration" that's confusing me. The concentration is the same; the amount of alcohol consumed increases as more liquid is taken, but the concentration of alcohol doesn't increase. It's still 9 parts alcohol, 1 part water. So when Maxi takes 1 ml, he gets 30 mcg of medicine, and if he takes 2 ml, he gets 60mcg of medicine.

In any case, what the pharmacy told me about the concentration (30mcg) and the dose (1 ml per day with food) sounds appropriate to you, right?


I'm inclined to believe that Maxi's Lantus onset time is late-ish in a cycle.

 

¥es, 1 ml of liquid is starting on the low dose but still sounds OK.

Lantus onset is typically +2 to +3.

From the New to the Group Sticky:

• Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose
• Peak/Nadir - the lowest point in the cycle
• Duration - the length of time insulin continues to lower blood glucose

 

Thank you.

I would like guidance on when to start the cabergoline. (I know we need to hold off so as not to confuse things because of the introduction of R.)

Relative to the norm, I think Maxi's onset is late-ish, I think his nadir is late-ish, and I think the duration is less than 12 hours. But I really have no clue. His numbers are always really high with very few marked drops.