STICKY: Levemir® 101 ~ basic user info

Levemir® 101

As you may have read, Levemir (insulin detemir) is recommended by current users for:

• ♦ cats that have been diabetic for a period of time without seeing stable blood glucose results on their present insulin
  
  ♦ cats on other insulins seeing results which vary widely during cycles
  
  ♦ newly diagnosed cats.

These results are determined through home blood glucose monitoring.

Please speak with your vet to determine if changing your diabetic cat's current insulin regime might help.

See the Sticky Levemir Prerequisite to provide further basic information. Levemir 101 is intended for those who have made the switch and wish to learn how best to manage Levemir's unique action.

So, you have your vial, cartridge, or pen of Levemir. Now what? If you have not used a flexpen, please see Flexpen photo and Flexpen with syringe use. You do not need to buy the pen needles. [Note from Steve: the pen needles make good cheap hand lancets, though.]

Starting dose:

The current recommendation is to start with less than 1U unit BID (twice daily), preferably .5U. Getting to the best Levemir dose requires a step-up approach, so it is better to start at a lower dose than too high.

Doses should be spaced as close to 12 hours apart as possible. The beginning dose should be maintained for 3 days while evaluating action. By cycle 6 (three days at 2 cycles per day) you may see an overall decrease in blood glucose result.

The following graph compares Gandalf the Grey's previous blood glucose results on PZI Idexx, to his blood glucose results on Day 3 and Day 16 of Levemir use:



Note that although the BG nadirs or peaks at a desirable number on PZI, the overall curve is fairly steep and duration is lacking. Even by day 3, Levemir was preventing this swing between high BGs and normal BGs.

Not every Levemir user will achieve results so soon. Do not get discouraged by higher numbers after switching from another insulin. There can be several reasons for that, including rebound. Raising the dose too quickly may cause the liver to overreact to normal blood glucose levels and dump glycogen into the blood stream. BG of 400s and 500s can result.

Unless the blood glucose tests below 150 mid-cycle (anywhere from +3 to +10), raising the dose by .2 or less increments is most likely safe. Increase amounts should be considered in percentages rather than unit measures, so the smaller the present dose, the smaller the increase. 10% increases if present dose is below 1U are recommended. Up to 20% changes can be made above 1U, however some fine tuning of dose may be necessary to level the cycles optimally. Levemir users have been regulated on .4u, 1.3u, etc. not always half, whole or even quarter units.

If you're unsure how to dose in tenths, visit these pictures. Also the drop method works well for doses of under .5U: drop method pictures,drop method instructions.

The Tilly Protocol also has guidelines about raising the dose, however, we do not recommend increasing by .5u because the optimum dose could be surpassed.

Please note this discussion on the previous FDMB regarding zero line inconsistencies between syringe brands; you may wish to use a syringe brand which is not as prone to inconsistencies if you dose less than 1U or in tenth of units.

When you've reached the optimum dose you may see a curve like this:



Welcome to a happier, healthier Levemir kitty! Owners have remarked how their cat's behavior resembles that of past years, especially if the cat had been poorly regulated on another insulin.

Maintaining regulation:

Levemir operates best when dosed every 12 hours as regularly as possible at a consistent dose. One of Levemir’s unique aspects is the need to dose at otherwise normal blood glucose levels, at or below 100 mg/dl. It can be given at normal blood glucose levels because of its generally long onset, and its habit of “surfing” or “hanging” – staying at a fairly even level – for long periods of time. The overlap created by giving Levemir at lower glucose levels helps to maintain steady numbers.

Testing data from +1, +2, and +3 hour readings will help you feel more confident that:

• 1) the pre-shot blood glucose level will most likely rise until the onset of the new dose and
  
  2) you will not put your cat in danger by dosing at those levels.

There will be occasions when you should wait for the glucose level to begin to rise prior to shooting. Test again in ½ hour to make sure the BG is rising before administering a dose. Testing data will determine safe shooting levels for your cat.

Once you begin to see lower than usual blood glucose readings for your cat during a cycle or at pre-shot, a dose reduction may be needed. A blood glucose reading of 40 or below at any point in a cycle means the dose should be reduced. If you increased in small increments, reducing in small increments is also advised.

Caution is also advised when below 40 blood glucose occurs because it is considered a hypoglycemic number. However, a Levemir cat may not exhibit hypoglycemic symptoms.

Your Hypo Tool Kit should have some high carbohydrate (18% kcal) Fancy Feast grilled varieties.

Feed a small amount (tablespoon or less) and re-test in 15 minutes. You should see a rise, even as much as 50 points, if not, feed another tablespoon and re-test. Above 70 should be safe, but be aware blood glucose could drop again, especially if the low numbers was early in the cycle. The Feline Diabetes Health Forum is excellent at helping your cat recover from a low if you feel scared or unsure. Please type Levemir in subject line to alert current users, most of whom have experience in treating low numbers.

Alternative Technique: Using Bolus Insulins with Levemir

Due to Levemir's sometimes slow onset, using a fast acting bolus or booster insulin such as Humulin R may help reduce blood glucose quickly or counteract food spikes to give Levemir a lower starting point at onset. Using boosters with Levemir is an advanced technique not recommended without strong testing data on Levemir's cycle in the particular cat or without specific knowledge of the action of the booster insulin in your cat. Achieving the proper dose of Levemir should eliminate the need for bolus use, but it can be a temporary solution to high blood glucose readings.

A Few Final Words:

Levemir is the newest prescription human insulin in use for cats. Each owner using Levemir is gathering data for future Levemir users and should not take that responsibility lightly. Levemir has great potential which is as yet unrecognized by the veterinary community at large, therefore each Levemir user is a pioneer in Feline Diabetes management.

We thank you and your cat thanks you.



Last edit: VC Jan. 19, 2011