Getting Started Using R

http://www.felinediabetes.com/FDMB/threads/using-r.202058/#post-2248239

I plan on starting R tomorrow with the help of so many of you here. I am quite nervous, but know that this is the only way out for Merlin. He is just not feeling well at all, but still eats, drinks and poos nicely. He has no other interests except sleeping. No QOL. Too long at these high numbers with no relief.

His Internist suggested Bupe at a range of .1 to .2 BID. I feel he is in pain, or at the very least uncomfortable, most hours of the day. I had a vial of bupe so we started him the end of last week at .1. Monitored him to see if he needed a second dose. The past two days were at .1 in the morning. Yesterday's dose brought him down; he looked awful. He started coming out of it 8 hours later. And for the first time in quite a while, he had soft poo. I am not giving this to him again any time soon and will be in touch with his Internist today to get another recommendation for pain (Gabapentin?). I'd appreciate anyone chiming in with opinions/suggestions.

So, in starting R tomorrow, I'll need some guidelines. Right now Merlin is on 5U Lantus. Take a look at his spreadsheet; where do I start? How does this work? I do know that I may have to switch to Levemir as dosage increases.

Also, does he need a full belly? He eats a lot (11 oz a day/328 cal). Is it imperative that he eats right before R? He's never failed me yet, but sometimes he eats a little and then comes back 10-15 min later and eats more. With Lantus being a deposit, we're safe. One of the hardest challenges for me is not having him eat 2 hrs. before shot time. He is so pathetic I want to give in.

Thanks for any and all help. This is appreciated more than you know.

 

Gabapentin is an alternative that works for some acros, it didn't for us. For Neko it was bupe at 0.22 ml, she was a bigger girl. Bupe is constipating so not the cause of the soft poo. I eventually added acupuncture for arthritis pain.

I fed Nrko several small meals in the first half of the cycle, and that worked fine for R. I will let Marje guide you in starting R as I am about to go off grid. If you aren't starting R this morning, you could have increased the L. Just don't increase L on a cycle using R.

 

I will be back in just a bit to give some guidance for starting R tomorrow.

 

Ok, Merlin and Cynthia....you got this.

Use your U100 syringes for the R. This is what 0.25u looks like:


I want to repost the guidelines for using R that I gave you before so you don’t have to go search for them.

Goal in using R:

• Aim for a dose that lowers the BG through the duration of R by about 100 mg/dL.
• Ultimately, the goal is to give R in a manner that slowly brings the BG down so that by onset of the L insulin, you are shooting a lower BG than you would have without the R.

Cautions:

• It’s best to shoot R in the scruff do to the potential differences in absorption rates. Shots in the scruff usually absorb more slowly.
• 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
• Be fully present and focused when preparing syringes and shooting. Develop a double check system.
• Monitor every hour for 4-5 hours to see onset, nadir, duration; once the cat’s patterns 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.

Going Forward :

• 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 400 and on the rise, 0.25u might be appropriate; if kitty’s PS is 500 and on the rise, 0.5u 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.
• 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.

Tips for shooting R

• Try and create a scenario where BG at the time of L onset is lower with R than without. That way the L has an easier job.
• For bounce control, think of it as placing a ceiling over the upcoming bounce to limit the severity. Timing can be tricky.
• R is also useful for damage control after a fur shot (in cases where ketone development is feared).
• R can also be used at the beginning of a bounce, or after the cycle passes nadir and begins to rise, or at the end of a normal L cycle (+9/+10/+11/+12 ish with Lantus)

Specific to High Dose Kitties

• High dose cats will usually need a higher starting dose (e.g. 0.25u) and larger increases.
  
  
• If a high dose CG finds they are not needing to use R anymore, that often means a downward trend in dose is coming. It could be IAA breaking, cabergoline doing it’s thing, after effects of SRT, or just plain old tumour ebbing. In those cases, R gives you that buffer against the overfull large depot.
  
  
• With a high dose cat and a caregiver who cannot monitor every cycle, it can be safer to use basal/bolus dosing instead of just trying to get the basal dose up to a dose that can do some good (when the basal is a depot insulin). Let's say your cat is doing fairly well on a dose of 10u Lev and 2u of R (R given at PS). The R starts pulling the numbers down, the Lev takes over and continues pulling down slightly and holds on until close to the end of the cycle. The Lev dose isn't quite enough to give a good cycle on its own, but in conjunction with R, the BG looks fairly good. Then if you are faced with a much lower PS than usual, and you can't stay home to monitor, you can give the 10u Lev and skip the 2u of R. Instant dose reduction without depleting the Lev depot by skipping or BCS-ing.

Right now, because you aren’t using R to help control bounces, then you have more latitude. You also are seeing really high, flat curves so you will also have the ability to shoot R a little more often until the numbers start to come down. Tomorrow, you’ll want to give his shots at roughly the same time (in other words, both at AMPS). As indicated above, you need to develop a method right from the get go to keep from mixing up the insulins (believe me, this has happened more times than I care to remember). Keep the insulins in separate places in the frig and always draw one insulin first and then the second one in the same order. If it helps you, you can draw the L dose first and then give it and go back and draw the R dose and give it. Check and double check and then check again.

Feed him as you normally would; however, if, for any reason, you think he might not want to eat, then I would suggest you feed him right before you give the insulins just so you know he’s eaten. You don’t have to get a lot of food in him before you shoot the R.

As stated before and you know, test every hour and feed as you normally would. You might not see any change at all the first time you shoot R. I wouldn’t recommend you increase the R dose immediately if you don’t see any changes after the first dose. It might take a couple times to start seeing the numbers move a bit and we will help you decide when to increase the R dose.

IMHO, you should start out with just shooting R once a cycle just to let you get the feel of it but then we can possibly increase how many times a cycle you give it if you are available to test.

You will also get familiar with how his R curve runs. For example, by testing hourly when I first started using R in Gracie, I knew that if I got a good drop by +2, I’d need to test at +3 and +4. But if things were slow by +2, I might not test again until a little later in the L cycle. I would not suggest doing this until you are familiar with his R cycles and can lay them over his L cycles to see when the very best time to shoot R is and at what times you will need to test. As his numbers come down, the flexibility in when you can give R will decrease because you’ll start to see L nadirs and you don’t want them overlapping. Often, giving it at PS is a good time but I also like giving it at +10 for Lantus because just as it is waning, the next dose of Lantus is taking hold at +2 of the next cycle.

Once you switch to Levemir, you’ll have to develop a new strategy for when to give R but most of us that have used R are well versed in using R and Lev so don’t worry....we will help you.

I’m going to see if @Sandy and Black Kitty will be up at 7 PDT so she can be around as you get started. I’ll be up by about 8 PDT so I can check in with you.

Questions? Just remember to breathe. The first time might be a little scary but it will be ok. The most important thing to remember is getting the correct L dose in one syringe and the correct R dose in the other. Once you got that, then just do your regular shooting, feeding, testing and let’s see where he goes.

 

Whoa! Lots to digest. I cannot thank you enough. I have soooo much to learn, but if this can help Merlin feel better, I’m all in. He is the love of my life. I am patting his butt with one hand and trying to type a message to you with the other.

I do have a question with the R insulin. On the box it says do not refrigerate an open bottle. I opened it today to see what it looks like and how to get the cap off, but I do not have it in the refrigerator now. This is the R insulin from Walmart. What should I do?

I copied this message to my notes and I will printed out tomorrow. It’s a lot of information and I really want to study it.

Thank you from the bottom of my heart.

 

You’re welcome!

Refrigerate it. I used my R until it expired and I left it in the frig. I would go really long times without using it.

I’ll check back in later tonight in case you have questions.

 

Got it!

 

Sandy said she’d be here in the morning to get you started and I’ll check in when I get up

 

I’ll look for you just before 7am PDT

 

You guys are the best!

 

I’ll be fine. I’ll send a message when I’ve dosed. The nerves are kicking in now and I’ve still got an hour. Thank you!!!

 

Eating like a champ! About to dose in a minute. Yikes!

 

Great!
Please start a new post for today. See you there

 

Dosed! He’s fine; I’m shaking. The hardest part is getting the .25 in the syringe. Of course the first needle was bent at the plunger and I couldn’t understand why I was looking at it like I was. I had it over the sink and was expressing drops and counting. When I finally figured it out, I got a new syringe and was good. I even used a magnifying glass ;-)

 

@Cynthia and Merlin Because you're in a unique medical thread there might not always be someone here for you. I just wanted to make sure you were set up with tagging, has it worked for you yet? As you can see you just got an alert when I tagged you. I don't use the e-mail alert feature, not completely sure how that works, so if you were to tag me when I was out of the site for 72 hours your tag would go unnoticed.
Apologies for stating what might be obvious;
>Once someone has added to a thread they will get an alert if anyone else has responded to that thread at any time. That's how all the people that have helped you so far keep tabs on you if they so choose.
>There is no "board" here in the way some people have thought there is a 24/7 Help Desk, it's all just volunteer.
>It's not medical but you may find it a morale boost to follow someone. When you log on anyone the avatar of anyone you follow will pop up and the same works in reverse. Following is not stalking, creepy or overly personal. To follow anyone click on their profile, then click on follow.
>The PM system is not meant for dispensing medical advice.
Hope something in there helps, best wishes for you and Merlin.