I have given first Levemir dose

Okay, so tomorrow morning will probably be Pixie's first Levemir injection. He was diagnosed last Tuesday and has been on ProZinc since then. The vet had his dosage way too high so I had to adjust it myself... for the last couple days his numbers have ran about 260+ in the morning. I feed him and give him 1 unit of ProZinc and I am pretty sure it peaks around 60'ish at that dosage based on some random tests I've performed over the last couple days (I am only 3 days into trying to regulate him after the vet ignorantly and negligently prescribed him 4 units twice a day :roll: ). The second feeding time is 12 hours later and for the last couple nights he has not needed a dose (he's usually 100+ at this time). His BG levels then seem to slowly rise again throughout the night (I got a 130+ reading around 1:30 AM), until it gets around the 260-270 range by the next morning, so I repeat the process. This exact procedure has happened for two days in a row.

Now I'm switching to Levemir, so what I'd like to know is should I start the dosage at 1 unit like I did the ProZinc since that is seeming to work pretty well? Or should I back it off to 1/2 a unit? Morning dose time is 9:30 AM, but I will not be home from 11AM until around 5PM and will be unavailable to monitor him or his BG level. I'm kind of nervous about using a new insulin for the first time with a 6-hour window when he is "on his own" (but I don't have any more syringes to do one more day of ProZinc and from what I hear I want to get him on Lev ASAP to promote remission).

Thanks!

-Mike 'n' Pixie

 

Re: Questions about first Levemir dose

You have U100 syringes, right? You should not use the U40 ProZinc syringes with Levemir, OK? They need to be U100 and preferably with 1/2 unit markings to help give small doses of Levemir. You can, however, use the U100 syringes with Prozinc. Please see this conversion chart: http://www.felinediabetes.com/insulin-conversions.htm
So 1U of U40 insulin would be 2.5U on a U100 syringe.

I suggest using the U100 syringes with the Prozinc until you can be home to test the first few cycles on Levemir.

Otherwise, it might be better/safer to do only .25U (one quarter of 1 Unit) of Levemir if you can't be home to test him mid-cycle. From our experience, 200s are close enough to normal that it usually does not take very much insulin to bring the cat down to normal range. Just ask Sheila, who kept trying to give Beau .5U and he ended up needing less than half that and going OTJ soon after.

Less is more with insulin, truly. We see this time and again on the boards, newbies coming on starting at 3 or 4U of their given insulin. Vets are so used to other "drugs" being dosed by weight, for example, and that cannot be done with insulin.

 

Re: Questions about first Levemir dose

Never mind, had to try 1 unit. I wasn't expecting a nighttime high reading, but he was 241 for some reason.

Will be up a while longer to monitor him.

Thanks.

-M

 

Re: Questions about first Levemir dose

Will stay up late and monitor him closely. Thanks for the advice.

-M

 

Re: Questions about first Levemir dose

Oh. So you gave 1U of Levemir tonight? Hmm, do you drink coffee?

We really only worry about low numbers on Levemir when it gets below 40mg/dl and that also depends when it happens in the cycle. Early in cycle, like +3 or +4, isn't so good and needs intervention such as extra low carb food or medium carb foods.

His preshot BG was 241? Well, 200 points to go on a new insulin before you get to trouble area. Should be fine. I can stick around for a while and Sheila is on later in the evenings usually. Check him in 2 or 3 hours if you can. What brands/types cat food do you have in the house? Any with gravy in them?

I'll round up some more eyes. Please confirm that this is 1U of Levemir. Thanks, Mike. No harm done. Levemir is a gentle giant and rarely, unless it's an extreme overdose, produces severe hypo symptoms. Pixie will be fine.

 

Re: Questions about first Levemir dose

Yeah, it was one of those situations where I wasn't expecting to have to give him any insulin and currently have no U40 syringes. Forgot you could convert it. Yes I am using U100 syringes with the Levemir, and yes I am confirming that he was given 1 unit with a 241 reading at about 9:30 PM (I actually had a 260+ reading also because I tested twice before giving the insulin to make sure he was really that high because he was only 60+ at 5:30 PM). It was too late to back off the dose by the time I saw your reply. I've been an insomniac for most of my life so staying up late will not be a problem (and I don't have to be in to work until 11 AM tomorrow).

I have his Purina DM canned food (am switching him to Wellness next week when my local pet store can special order it for me). I have left-over Cat Chow, Whiskas, and 9-Lives dry food that the other cats currently eat (I'm switching them to canned also when I get the Wellness). I also have pancake syrup that I think he will lick off my finger or out of a spoon (tried to give him honey once and he would not eat it).

I will test him around 12:30 AM and post results.

Thanks again!

-M

 

Re: Questions about first Levemir dose

I didn't think to ask... wow I feel negligent now myself...

there are never any adverse reactions with combining insulin (specifically Levemir, because ProZinc has been fine so far) and antibiotics, right? Because he has been on Antirobe Aquadrops (clindamycin hydrochloride liquid) for over a week now for an infection he had in his mouth (he had a tooth cut out at the vets last Tuesday).

-Mike 'n' Pixie puff

 

Re: Questions about first Levemir dose

You are soooo on the ball!! Wish everyone was this prepared. And not going in to work till 11AM??? That's fortunate.

The board is 24 hours with members from around the world and other insomniacs! Post on Health though if it's 2 AM and you get a 40. Make sure you mention it's on 1U of Levemir so people won't freak out. A 40 on Levemir is different than a 40 on PZI or N. The best thing to do is feed more regular low carb food, then test in 30 minutes. As long as BG has not dropped further, he's fine.

Also, watch his behavior. We see cats "park" at the bowl if they get low on Levemir. Gandalf does that if he goes down to 30s. It's how I can shoot on preshots of 95 like tonight and leave for work for 10 hours. I know he will eat if he happens to go too low. He has also awoken me in the middle of the night if his timed feeder didn't go off and he needs food. One time he bit my nose to wake me.

Will check in in the AM to see what you got for an AM preshot. Even if it's 200s, please consider doing only .5U or less since you will be gone.

To answer question you just asked before I got this posted - nope, I also give Gandalf Clindamycin, no problems using it with insulin.

 

Re: Questions about first Levemir dose

Hi, Mike.

No matter what insulin you're using, there may be an effect from the use of antibiotics. Many people seem to think that giving antibiotics will cause higher glucose levels. With my Scruffy, I usually saw his levels - which tended to be high anyway - go lower once he was started on antibiotics. (He had chronic ear infections and really lousy teeth, so we had a lot of experience to feel that that was his pattern.)

When you were using the Prozinc with clindamycin, did you notice anything that would seem to indicate that it was having an effect on Pixie's BG? That's one of the many reasons that a spreadsheet is helpful - you can look over the period before, during, and after the antibiotic use and get information that can be helpful in the future.

I'm glad you're able to stay up tonight to monitor; starting a new insulin can be nervewracking, as you're probably finding out.

 

Re: Questions about first Levemir dose

Where I don't have canned food in stock (aside from the Purina DM), I don't leave food out so he has no food dish to go to. If I put the DM food out, the other cats will eat it (they get jealous at feeding time because right now Pixie is the only one getting canned food LOL)... so I think I may leave his dish in the floor empty and watch for him to sit at it for a prolonged period.

Oddly enough he likes to hang out in rooms by himself sometimes (the bathroom or the laundry room... I think he likes the tile floor), but I've coaxed him back into the living room with lots of love (that he can never get enough of) so I can watch him.

Thanks again for the support.

-M

 

Re: Questions about first Levemir dose

His antibiotic schedule is also twice a day, so my daily routine has been one of the following:

1. give dropper of antibiotics 2. check BG 3. feed 4. dose if applicable

or

1. check BG 2. feed 3. dose if applicable 4. give dropper of antibiotics

I did not think they affected BG so I haven't kept track of which days I gave them before or after. Although, now that I think about it, he REALLY does NOT like the taste, so if he is stressed out from having just taken his medicine, could that make his BG read a little high even though I test him directly after (within 5 minutes after giving the antibiotics anyway)?

-M

 

Re: Questions about first Levemir dose

And I don't currently have a spreadsheet, but am keeping track of daily results by hand using the ReliOn logbook that came with my Micro glucometer.

-M

 

Re: Questions about first Levemir dose

He is now in one of his favorite spots on my girlfriend's computer desk with his eyes closed. He sleeps there often, so I'm pretty sure the first hour is A-OK, but am considering testing him anyway because of his tiredness.

-M

 

Re: Questions about first Levemir dose

Mike, we're OK here without spreadsheets. Most of us are from the days before spreadsheets. Oh, it's helpful though to post numbers in this format:

AMPS XXX ~ how much insulin given
+3 (how many hours after shot) XXX and if you fed something
+5 XXX
+7 XXX
+9 XXX
PMPS XXX ~ how much insulin given

That's how we did it in the days before SS!

Another Levemir note - you do not have to feed prior to giving Levemir. Test BG, yes, but since Levemir is a longer acting insulin it takes longer to get going so we consider it a good idea to feed right after giving insulin, rather than before. Feeding too much before giving insulin can make it take longer for the insulin to begin action.

 

Re: Questions about first Levemir dose

The only days my work schedule permits me to adhere to that hourly checklist is on Saturday and Sunday unfortunately. I'd definitely be interested in that type of intensive analysis on one of those days though. The curve and whatnot. I think I'm getting the hang of this LOL.



-M

 

Re: Questions about first Levemir dose

You don't have to test that often. I was just using that as an example. Most of us test only preshots and at various hours when we can. We have to have lives outside of FD!

 

Re: Questions about first Levemir dose

Mike, a couple of things....

First, the curve day is after the dose settles for 3-5 days. Otherwise, just get the preshot tests and spot checks. A test at +4 is good and/or +6.

I do think that 1u is probably too much. Can you feed him a snack at +4? Just a tablespoon or so of the DM is ok. And maybe again at +6 or 7. Because you don't know how he will react to levemir, I would be conservative and give no more than .5u for now. And between 150 and about 225 you might want to drop to .25u.

Here is what I am seeing and know can happen. Your boy had a dental and a tooth (teeth?) extracted. He is on antibiotics because he probably had an infection going along with that. Infections can raise blood glucose (BG). The ABs will clear up the infection, and his BG will drop some amount. He was eating dry food. It causes elevated BG. You have changed the diet to DM canned which is much better and lower carb and his BG will drop from that as well. You will be changing him to Wellness, an even better and lower carb food and his BG will drop some more.

Now, have you read/know about rebound hyperglycemia? That is where the BG raises because of too much insulin. It is caused by the liver releasing stored sugars to prevent a hypo situation. It can happen from a BG drop that is too fast, too far or too low. Examples: A 200 point drop in less than 2 hours; a drop from 500 to 100; a drop to 50 or below - or any low number the body has not been used to for a while. Even 80 could do it until he is used to it.

I see a pattern with the PZI numbers you posted where he is dropping to 60 and is too low to shoot at +12, but then back toward 300 at +24. This is not "normal" insulin cycle activity. Cats metabolize insulin very fast so they need it every 12 hours unless they are starting to not need it. Yeah, I know, that sounds like nonsense. It is better to give less so you can shoot every 12 hours and get full coverage.

From what you are posting I think Pixie has a very good chance of going into remission and being diet controlled. But I also think he is experiencing a little rebound from the drops to 60 which may possibly be going lower.

All of that is why I suggest the lower dose of lev. You don't want him dropping low and bouncing high from that. You want to bring him down slowly and gently and keep him in lower numbers. Every cat is different, but my Beau could drop to the 30s after just .05u of lev - that's a 20th of a unit. Some people didn't believe me, but it is the truth. You are supposed to be able to give a full dose (whatever your cat is getting) of lev on a preshot of 100 - like Vicky does, but I could not give Beau insulin, even .05u, below 130 and eventually below 150. That isn't usual, but it can happen.

So, long story short - please start lower on the lev with the next shot. You are doing great, BTW!

 

Re: Questions about first Levemir dose

Thank you very much I appreciate the encouragement.

I read your reply very closely. I understand what you are saying. So I need to actually take steps to AIM for him getting his shot every twelve hours? Only having one shot a day is not good for a cat because of their metabolism is what you are saying? Yes, I think I get it.

So if nadir is 60 and he is not in dosing range at the following regular dosing time, but his BG is too high and needs dosing at the NEXT dosing time, I should back off the dose and try not to bring him so low down to 60 so that he can be up high enough again for another shot in 12 hours?

Is that it?

Thanks,

-M

 

Re: Questions about first Levemir dose

Just saw your other thread with question about storing lev in the fridge.

I would not put it on the top shelf. It could freeze there if that is where the cold airflow from the freezer comes in. I store unopened lev in the box it came in in the meat drawer. And the opened lev on the second shelf. I suppose if you opened the meat drawer a lot that would not be a good place for it.

 

Re: Questions about first Levemir dose

Gotcha will make that fridge adjustment and thank you very much for the heads up.

 

Re: Questions about first Levemir dose

At the risk of sounding corny, this board is a great comfort and a blessing in a pretty scary time for me. My girlfriend is really great about helping out with him (we merged our two sets of animals when we moved in together, but Pixie was originally mine), but the whole blood testing and needles etc. aspects of his treatment really freak her out. She does it when she has to when my work schedule does not permit me to do it, but she much prefers me to do it. So I've taken on most of the responsibility of coming up with proper treatment procedures since my vet wasn't worth a flip for feline diabetes. After paying the first vet and realizing I paid for nothing, I don't have the money to go to another vet who may be more knowledgeable. This is a great disappointment for me, also.. as I really like my vet because he seems to genuinely care about the animals. All this responsibility and trying to cram every single fact about a very complicated disease in CATS no less into my head and learn everything and basically attempt to become an expert in less than a week is very mind-numbing!

I'm so thankful for this board.

-Mike 'n' Pixie

P.S.
Pad Thai noodles in microwave... OMNOMNOM!

 

Re: Questions about first Levemir dose

OK - you just asked the million dollar question. My answer is: sort of.

The trick is that getting a good cycle or response happening consistently takes time and tweaking. While 60 is a great nadir, it may cause rebound. But lev works differently than PZI in that it builds up in his system and you are working for a constant level of it where you may get PS numbers in the mid 100s and nadir of 60 by shooting every 12 hours on a dose of .75u (for example). If you skip shots, the storage shed (yep, that's what they call it) of insulin depletes so the next shot - now 24 hrs later - has to go toward partially refilling it and his BG will climb during that cycle. You get out of balance and it takes several cycles to get back to equalibrium. It is always better to find the dose that you can shoot consistently every 12 hours. This will keep a flatter, lower curve (BG levels) which is better that a roller coaster ride of ups and downs.

Also, some cats like 45 as a nadir and others prefer 80 or 90. You just have to find what his best nadir is and the process really can't be rushed.

Does that make sense?

 

Re: Questions about first Levemir dose

Yes, I think it does. Start low, go slow. Heck, I haven't even got his permanent food yet. So I hope I am doing a good job of trying to manage things until I can start working on preciseness.

So when I first came to the board (before I learned anything) and was told 200+ was the magic number to shoot or not to shoot, is that number different for Levemir? That seems to be what you are saying.

For example, I need to shoot at a 150+ reading instead? And try to keep that number pretty constant at dose time by backing off the dose a hair or increasing it a hair to get it consistent?

I think I'm getting this Levemir stuff...

Another question is though, how is remission achieved using this protocol?

-M

 

Re: Questions about first Levemir dose

I think it just hit me.

Because of Levemir's 12-hour smooth cycle (half of 24 hours in humans because cats metabolize twice as fast), it is best to try to shoot JUST when the blood sugar level is ABOUT to get into "too high" levels (around 150)... so as to bring it down to a level that is also safe (50-90) so that the cat's BG level never goes too high or too low.

*whew*

Is that it?



-M

 

Re: Questions about first Levemir dose

Yum! I love Pad Thai!

I know what you mean about this board - and about vets. I really like my vet, but boy the FD advice I was getting was terrible! Beau was on vetsulin one shot per day and I was taking him there once a week to be tested. He got up to 7u in one shot - and then hypoed while at the vet for a curve. Dose was dropped, then it was raised, then it was dropped.... in the mean time he was not regulated and was still having symptoms, looked like he felt like crap, etc. They discouraged me from home testing and said diet wasn't important until after he was regulated.

I remember standing in the kitchen after six months of this with the syringe in one hand, vial in the other and having been told the day before to raise the dose again, thinking "He needs LESS, not more". It was right after that that I came here and started learning all I could - and home testing him. I took him to the vet for one last test and they told me to raise the dose again. I just nodded and walked out planning on lowering the dose and starting to give two shots a day - and phasing out the dry food. I had him regulated in a month. Now he is diet controlled. He is a Lev miracle because he was on another insulin for over two years, but still went into remission after switching to lev.

What we do here is called "Paying it forward". Enjoy your dinner!

 

Re: Questions about first Levemir dose

Pretty much. I would say you are shooting when the BG starts to rise (usually). Really, you are trying to keep as constant a BG level as possible. Lev works differently than PZI, which is why the different "no shoot number". And part of those numbers is a comfort level and part is a "data to back it up" thing. Just as Vicky knows she can shot Gandalf at 85 and he won't go too low, I know that Beau could not have insulin below 130 - because we had the data to back that up. It just takes time to gather that data.

 

Re: Questions about first Levemir dose

Once you are able to keep the BG in the normal range for most of the day, they pancreas actually can heal the beta cells and begin to take over the insulin production/regulation again. You will see that referred to as the pancreas sputtering or some pancreas action going on. The pancreas in a cat responds well to reduced glucose toxicity by healing and sort of "re-boots" itself.

Not all cats will achieve remission, so it is not a first goal. The first goal is regulation using diet and insulin. Then tight regulation - if possible keeping the BG between 60-120. If the pancreas can heal, it will in those conditions.

Generally, the sooner the regulation happens the better the chances are for remission.

Does that answer your question? If you want more technical info I might be able to get a link for articles on it.

ETA: And now I am off to get ready for bed. Make sure you get some spot checks in before too long.

 

Re: Questions about first Levemir dose

No I think this info is at the perfect knowledge/intelligence level for me. Don't need more technical but definitely don't need less technical either.

Okay, he went back to the spare bedroom (where I store some of my stuff from where I lived before moving in with my g/f back in Jan. or Feb.) and was laying down in my closet floor (I left my closet door open apparently). This is not necessarily abnormal behavior for him as he does things like this often enough, but it made me antsy anyway so I decided to test him a half-hour early.

at 12:05 AM he is at 188.

So basically, this is what we have so far tonight:

9:30 PM 240-260 (took two readings) - 1U of Levemir administered
+2.5 188

So this is good, right? A steady drop, so I obviously didn't give too much?... need further tests in a couple hours though to be sure he is going low enough? Or could he still drop too low if I'm not careful? Had a little trouble with the ear prick this time, so he had a few pokes (still trying to master this also... need cotton balls... and the things to test ketone levels... it's the only 2 things I am missing, I think). I just forgot to get the cotton balls, and the pharmacy was out of the ketone strips. Poor guy. He is a champ though. He hardly ever even tries to run away anymore... just whines a little when I have to poke him extra times. Should I possibly get 29-30 gauge lancets instead of 31 to prevent having to re-poke? Is this more a cat-specific thing than a generalized thing (i.e. whatever works best for your cat)? Also, I hear that with time the ears "learn" to bleed... so should I just give it more time?

-M

[Edit]I just double-checked... the lancets I have are 30-gauge, not 31. My syringes are 31 (1/3cc U100 31g 5/16" needle) the optimal syringe finally!.. after buying only one incorrect box! LOL...[/Edit]

 

Re: Questions about first Levemir dose

[Update]

9:30 PM 240-260 (took two readings) - 1U of Levemir administered
+2.5 188
+4 cat was asleep & stretched like he always does indicating he was relaxed and comfortable and breathing was normal so opted not to test
+5 (see +4... plan on testing at +6 even if I have to wake him up)
+6 155 (had to wake him up)

[/Update]

[Edit]I am already impressed with Levemir's consistency. I am very happy with my +6 number so I may try to get some rest for work tomorrow. Thanks to all![/Edit]

 

Awaiting morning's report! He did really really well on first shot.

BTW, Mike, love your avatar!

Thank you, Sheila, for all the detail explanations. I am saving this thread for future reference.

 

That is a great photo! It wasn't there last night was it? How could I have missed it?

On ear sticks - are you using anything to heat his ear a little? A rice sock? It is a thin cotton sock with raw white rice in it, knotted off. You heat in microwave for about 30 second and hold over the ear edge for about 15-30 seconds. That will help dilate the vessels. I use one on all but the hottest days, so when I am testing them in their sleep (lol!). Their ears seems to be nice and warm when they are sleeping.

Another thing is lancets - I use ONLY BD Ultra Fine II lancets (white, orange and green box). No others of same gauge, and supposed quality, work as well (I have tried about 6 different brands). I poke twice very quickly and just next to each other, wait a beat and then gently milk the ear. It's really more like "pulsing" my fingers on the ear below the pokes. And I use a fold piece of facial tissue to blot off, put a little pressure on the site after the test while the meter counts down (mine is 10 seconds). I take about four tissues, lay them open and cut into 3 strips than cut those into 3 "squares". I keep them in my testing basket with everything else I need - it's one of those plastic cubes with a handle you can get at Target or similar places - good for corralling everything.

 

No you are correct, the avatar was not there last night lol I got bored staying up late so I uploaded all my recent pictures from my phone. Have a SS now (link is in my signature). I also posted a link to my cat photo album in the community forum
Click here for album

I'm probably just being too sensitive about the lancet poking. I am wanting/trying to only poke once (using ReliOn ultra thin lancets)... I'm just going to have to get used to it and poke twice because every time I do I get enough blood the first time. Plus I'm not using anything to heat the ear (forgot about that optional step that when I was studying testing procedures). Where do you get those rice bags? Are you talking about the kind used for weddings (LOL)?

Haha, he is poking around in his diabetes treatment case rubbing his face on it. Guess he knows it's his! Uh-oh, he just knocked it in the floor... he's upset because I am here posting on a message board instead of feeding him.

Anyway, results are very good this morning! AMPS 179

Probably only going to give him a half unit this time because I must leave for work soon and won't be able to test him for a while.

I'll be able to test him around +7 though, and will post results when I have them. It will be my first time measuring half a unit. I still need to be flicking syringe to be sure there are no air bubbles, right?

-Mike 'n' Pixie

 

Forced myself to be more confident and quick. Boy, it was the difference of day and night! Smoothest injection yet! He did not even verbalize any objection at all (there's still a slight whine at test time, but we are working on that!). Everyone is eating now, and I have to get ready for work! Later!

-M

 

Air bubbles in syringe - it depends on the syringe. Some are worse than others, the BD brand is especially bad at bubbles and they are difficult to remove. I sent those syringes along with Gandalf when he was admitted at a vet school teaching hospital and the attending vet even told me they were very bad and explained that the bubbles displace how much insulin you're actually giving, which isn't so bad with higher doses, but when you get below 2U, the percentage difference is greater.

Flicking too hard can create more bubbles in my experience.

Here are the syringes I've had the best luck with, except for inconsistent markings: http://hocks.com/Merchant5/merchant.mvc ... e=syringes

If you go to their site via the Hocks.com link near top of the message board pages, FDMB gets an 8% commission. Then search for insulin syringes.

Sheila has a very good method for getting very small doses. Let me email her and see if she can get you a link. I searched but can't find the post.

 

Mike, here is info on getting "micro" doses - meaning something other than .5u, or even .25u or .75u, which are possible to eyeball (maybe with a good pair of reading glasses?).

Also, it might be helpful to think of dose changes in percentages of current dose. In other words, a change from .5u to .6u is a 20% increase. A 20% increase is probably fine so if you are giving .5u it is .1u more, but if you are giving 1.25u it is .25u more. To me, that makes more sense than set increments of a quarter or half unit regardless of current dose. Make sense? (left that in from another post because it might come in handy very soon for you)

To get those small dose amounts - like tenths of a unit, I practiced with used syringes and expired insulin (actually my old vetsulin) by drawing up 1u and twisting the plunger until a bead of insulin formed on the tip of the needle - like screwing in the plunger rather than pushing it in. I practiced getting 10 beads from 1u and 5 beads from a half unit. THEN, I practiced getting beads HALF that size for the .05 amounts. Good lighting and powerful reading glasses are helpful! To me, the .1u beads were about the size of the head of a straight pin.

You have half unit markings right? You should be good for now, but practice so you can get .4 or .3 as you may need them soon. You can practice with grape juice or something too, so you can see it better.

THe rice sock is something you make. Get socks at Target, just make sure they are mostly cotton. Fill the toe with rice and tie off (I cut off the extra sock above the knot). No, don't use a wedding rice bag, lol!

You might want to start a new thread as this one is very long.

 

Thanks, Sheila! I bookmarked the post for future reference.