1/2 Michelangelo AMPS 350, PMPS 324 - Lantus vs. Levemir ?

Previous Condo. What a busy end-of-year I had! Things should be quieting down now and I should be back to posting regularly again.

First things first, I've been keeping a close eye on Mikey these past couple of weeks because he's been seeming a bit "off." It first started with him eating less than normal. He's been holding steady at about 8 pounds for the last month or so and he's still on the double-calorie intake amount for kittens, which equals out to about 2 5.5oz cans or 3-4 3oz cans a day for him (~325-375 calories/day). Then, right after I got back from my business trip on the 19th, he suddenly wasn't finishing his meal every time and he'd go for HOURS without eating (he usually only goes about an hour or two before he's wanting more food). He's still consuming the same amount of calories every day, but I think that may be because I'm just increasing the amount I feed him each meal to compensate for the meals he's skipping. He is hitting 9 months old soon, so it may be that he no longer requires as many calories as before and is just needing a calorie decrease?

His numbers have been elevated, but not too bad and I'm increasing his dose today to 1.25u anyway. I'm in the office today and not able to monitor him so I wanted to hold off the full increase until tonight's dose, but since his AMPS was higher than normal, I still decided to give him a little preliminary bump this morning with 1.15u.

He's also been overly skittish and is hiding out in my room, including under the bed, and not coming out every time I call for him, which is rare for him. He's like a little puppy dog that comes running whenever you call for him or, in my case, whenever I leave the room he's in. So, it's been pretty noticeable to me not having my constant shadow following me around like normal. He's been sleeping a lot more and seems more lethargic. He's always had about 4-6 bursts of energy/activity per day since I first got him and even before the insulin. Now, he's down to only about 2-4 times a day. He doesn't seem to be in any pain or having any elimination issues and there's not really any other signs other than I know he's "off." I'm thinking of taking him into the vet tomorrow just for a check-in to see if there's a reason for this or if it's just him transitioning from a kitten to an adult?

Next order of business: I've noticed a recurring theme with me and Mikey where I decrease his dose only to have to increase it again shortly thereafter. I think this dose increase/decrease/increase thing might be related to the same issue that had me skipping shots about once a week back when he was first tentatively diagnosed and before I started home-testing him. It seems that about once every week to two weeks, he has this steep drop into borderline hypo for a few cycles till I decrease his dose. Then, he'll remain high (like an extended bounce) till I increase his dose back again. He'll stabilize and remain relatively normal for a few more days/weeks till he drops too low again. Rinse and repeat.

I have been speculating that it might be related to the Lantus Depot. The reason for this is that I've poured over his numbers for when he's gone low and the results of me lowering his dose and I've discovered a seeming pattern to it. Not sure I'm using the right terminology, but I'll try to explain what I'm seeing: His nadir(?) seems to expand slightly each cycle until he reaches a point where his nadir continues on across the cycle and right into preshot time. The closer his nadir encroaches into preshot times, the higher the chance of him hitting a low number at peak/+6 and/or me having to skip a shot multiple days in a row, resulting in a dose decrease. Then, for a few days, it's like he's not even getting insulin (his numbers remain pretty stagnant from preshot to peak) until I increase his dose back again. At this point, it's like his depot is wiped clean and we start again with either no nadir, or a short, normal nadir at around his +6. And then the cycle repeats itself in a week or two. This seems much more extreme and prolonged than the normal 36-hour Lantus Depot window. Perhaps this is specific to Michelangelo and it's just his pancreas sporadically working? Maybe this is specific to kitten diabetics and the way they metabolize insulin? Anyone else ever see this or notice this? Am I seeing patterns that don't exist? I think I need to figure out how to create a pivot table in Google spreadsheets, unless someone here already knows how and can instruct me?

On top of that, since he first went on Lantus, his skin-twitching is getting progressively worse and more frequent and there's this aggressiveness that seems to correspond with the twitches. Basically, I see his skin twitching and shortly thereafter, he'll have these spurts and bursts of energy. If they're prolonged, it turns into a play session, but if it's short-lived, it ends up with him getting the ears-flat, annoyed look and swiping at anything or anyone near him and him chasing after me and attacking any of my extremities he can access. The twitches and aggression coincide when his numbers are anywhere from >300 to <100 and at any point from +1 to +11, so there seems to be no rhyme or reason for this based on his BG numbers at those times. The only correlation is that it continually increases in frequency till I drop his dose due to the low numbers/skipped shots as mentioned above. Then it clears out (almost like the Lantus depot), back to happening only once or twice a cycle before gradually occurring more and more often till the next dose decrease/increase.

Question: I've heard that Levemir can be smoother/more gentle than Lantus for some cats and am wondering if this might help with all the above dosage/depot quirkiness he's exhibiting?

Would Levemir help with this skin-twitching/aggression thing as well?

Finally, if Levemir might be a good choice, is there a specific protocol or procedure to follow for switching insulins?

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

The nadir is a point -- it's the lowest point in the cycle. What you are seeing are flat cycles. This kind of flat cycle is typical of Lantus and Lev. It's also very common for you to need to change the dose. You need to add or subtract in order to get the results you want. What was a good dose last week, may not be doing the job this week.

I don't know what you mean by a "normal 36-hour depot window." It might help if you gave specifics (the date and times of what you're referring to). The protocol suggests you hold a dose for 3 days/6 cycles in order for the depot to stabilize. Is that what you mean?

Mikey's SS doesn't look all that unusual to me. What it does look like is that Mikey needs more insulin.

Lev may be better. There's no way to know. The skin twitching may be due to some cats experiencing Lantus as stinging when you inject. Both insulins are equally gentle. The biggest difference is that the onset and nadir for Lev are both later. If your schedule can accommodate the later times, then it may be worth trying.

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

Some cats just twitch when they get amped up for stalking mode or as Sienne said it could be from the Lantus stinging a bit. One other difference in Lev is that it doesn't sting like Lantus can (although that is usually only at high doses.) Lantus forms a shed by forming micro crystal due to the change in ph when it is injected into the body. Lev binds into complex molecules either w/ itself or albumin in a liquid state and there is little sting compared to the ph reaction of Lantus.

Very often a Lev nadir will be at or beyond the +12 point, with everything happening much later it can be challenge to monitor Lev cycles. It would meann really changing you schedule.

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

thats a long post! But its great to see you back.. here are my thoughts.

1. Mikey is an unknown entity being a kitten so anything could be going on with him - that applies to food intake, behaviour/energy levels, and the reason for the dose going up and down.. however the dose changes is common with adult cats too ie Tiggy.
2. Mikey isnt holding reductions well. In future maybe wait on reductions until he has 3 drops under 50 (or one drop under 40) instead. Maybe just skinny the dose at that point too.
3. the once weekly skips arent helping the depot or the pancreas
4. the shivers happen to Tiggy too, just before he gets a burst of energy and runs around. Time to play! Aggression could be just Mikeys way of releasing his energy.. try and play with him at those times to wear him out. But stop the game immediately if he bites or anything behaviour you dont like.. and walk away to teach him not to do that.
5. Tiggy's skin crawls a little sometimes when I give him his shot. Have you tried letting the filled syringe sit out for a few minutes to warm up first? Also where are you injecting on his body? sometimes he feels it if I inject too close to certain spots. He has preferred spots.

Happy new year!
Wendy

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

Sienne and Gabby said:

I don't know what you mean by a "normal 36-hour depot window." It might help if you gave specifics (the date and times of what you're referring to). The protocol suggests you hold a dose for 3 days/6 cycles in order for the depot to stabilize. Is that what you mean?

Click to expand...

That might be what I'm meaning, but I can't find the "feline translated" version I read before where it discusses the injection site depot as equating out to approximately 36 hours for felines, but here is the original human study on Lantus. From page 10:

Absorption studies performed following subcutaneous injection of insulin glargine indicated that after
24 h approximately 50 % of the dose still remained at the site of injection. After 48 h the amount of
insulin glargine at the injection site was still about 20 %. Given the method used for the quantification
of insulin glargine, these amounts do not reflect the exact amount of active substance present at the
injection site. This is supported by findings that injected insulin may be metabolised locally, resulting
in a disproportional relationship between the measured amount and the actual amount remaining at the
site of injection.

Click to expand...

I've also discovered that kittens have varying rates of insulin metabolism from day to day from the two other people on the planet who had diabetic kittens that grew into diabetic cats (vs. diabetic kittens that went into remission once the underlying cause was cleared up). One of them had to leave her kitten at the vet for SIX WEEKS just to get him regulated enough until it was safe to come home (this rescue kitten also had/has a lot of other health issues, so I think the diabetes is just one of many things this wonderful owner had to deal with). The other kitten had a feline diabetic specialist monitoring her unique case and determined that caninsulin was necessary for the first year or so because of its fast onset and ability to give multiple times a day. Not sure how this ties in with Mikey, but that's one of the reasons why I was wondering if Levemir might be a better option for him, at least for the first year or so until he's a bit older and more stabilized and able to handle the Lantus better.

Ann & Tess said:

Lev binds into complex molecules either w/ itself or albumin in a liquid state and there is little sting compared to the ph reaction of Lantus.

Very often a Lev nadir will be at or beyond the +12 point, with everything happening much later it can be challenge to monitor Lev cycles. It would meann really changing you schedule.

Click to expand...

Yes, I think it's this "sting" that keeps increasing as his cycles start going "flat." When he hits that "flat" point right around where I usually end up having to decrease a dose and/or skip a shot, even though his numbers look pretty great for the most part, his twitching and aggression/hyperactivity become almost constant. I hate to say that I rather prefer him when he's at 300 and is calm and seemingly normal and even playful vs. at 150 for an extended period where he's twitchy, jumpy, skittish, cowering, fearful, running around and into things like a bat outta hell, aggressive, and just plain irritable.

Besides being able to monitor Mikey quite often throughout the day and night and the fact that he now seeks out BG testing (especially when he's hungry or wanting a treat), I also have no problem changing my schedule as needed (for the most part) if the Levemir would help with this. Other than that, my brother has turned out to be quite a valuable resource for me with this, so the days I'm not at home, he can always pick up the slack. :lol:

Wendy&Tiggy said:

thats a long post! But its great to see you back.. here are my thoughts.

1. Mikey is an unknown entity being a kitten so anything could be going on with him - that applies to food intake, behaviour/energy levels, and the reason for the dose going up and down.. however the dose changes is common with adult cats too ie Tiggy.
2. Mikey isnt holding reductions well. In future maybe wait on reductions until he has 3 drops under 50 (or one drop under 40) instead. Maybe just skinny the dose at that point too.
3. the once weekly skips arent helping the depot or the pancreas
4. the shivers happen to Tiggy too, just before he gets a burst of energy and runs around. Time to play! Aggression could be just Mikeys way of releasing his energy.. try and play with him at those times to wear him out. But stop the game immediately if he bites or anything behaviour you dont like.. and walk away to teach him not to do that.
5. Tiggy's skin crawls a little sometimes when I give him his shot. Have you tried letting the filled syringe sit out for a few minutes to warm up first? Also where are you injecting on his body? sometimes he feels it if I inject too close to certain spots. He has preferred spots.

Happy new year!
Wendy

Click to expand...

A long post because there's been a lot I've been thinking about as I've observed him these last couple of weeks and no chance to post any of it here until now! :lol:

1. It's comforting to see that the dose changes are fairly normal for other cats as well. I was starting to think, "what the hell? Every time I decrease his dose, I just have to increase it again?!?!"
2. Great idea! I'll try skinnying up the dose the next time that happens. This last time, the main reason I dropped him from 1.25 to 1u was because I was going to be gone for three days and I'd rather have his caretaker(s) giving him a lower dose than one too high and having to deal with a hypo episode while I'm gone. The fact that he continued to show low numbers even on 1u and had a couple of skipped shots because of this was actually quite a surprise for me and I ended up dropping him even lower to .75u. He's now going to be back up to 1.25u tonight, which I was expecting would happen when I first dropped him from 1.25u to 1u back in mid-December.
3. The skipped shots are based on low PS numbers. I've now gotten fairly comfortable shooting under 200, but not yet ready to tackle shooting under 150.... Maybe if it happens on a day when I know I'll be around, I might do it, but I'm a bit of a scaredy-cat (har-har!) when it comes to hypos since he's never had one before and I don't ever want him to have one. I'm sure it's not a matter of "if," but "when" he'll have his first hypo and after that, I'll probably not be as terrified any more, but in the meantime, I keep the "start low, go slow" mantra running through my head.
4. Yes, this is definitely what occurs simultaneously with the twitching. I usually try to get him to play if I can and sometimes I'm able to engage him and we have a great play session. Other times, he has NO interest in whatever toy I'm waving about (even his beloved mouse) and just wants to be mean and bite something to death, namely my hands and feet, sometimes even my knees and elbows. At night, if I'm sleeping and this happens, he'll even burrow under the covers to get at them! Not a pleasant wake-up experience.... :?
5. Never had a problem with injecting him yet. He's always been pretty much unfazed when I shoot him and just continues eating. The closer he gets to that bi-weekly dose decrease, however, the more wary he becomes during his "Shot" meals and keeps me in sight out of the corner of his eye till I start to give him his shot. Then, he'll sometimes shift around his food bowl a bit, presenting me with whichever side he's wanting me to shoot (usually he doesn't care), pause in his eating, and wait for me to inject before he resumes eating again. Not really anything remarkable, but it's one of the signs I look for that lets me know I'll start seeing some pretty low numbers soon.

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

Wendy&Tiggy said:

2. Mikey isnt holding reductions well. In future maybe wait on reductions until he has 3 drops under 50 (or one drop under 40) instead. Maybe just skinny the dose at that point too.

Click to expand...

For what it's worth, I don't think you're at a point where you need to do this yet. All I see on your spreadsheet is one failed reduction - when you reduced from 1u to 0.75u, the reduction didn't hold. The protocol calls for going right back to the last good dose. By waiting so long, you allowed some glucose toxicity to set in. In these cases, it is pretty common for cats to have to go back ABOVE that good dose to get another breakthrough. No big deal, onward and upward and now that he is back to 1.25 (he will be at 1.25 tonight, right?) you'll probably see another breakthrough soon.

One failed reduction doesn't mean a cat doesn't hold reductions well. Most cats have a few false starts before they really can start holding reductions. I only see one other reduction on your spreadsheet, the one from 1.25u to 1u, and that one held fine (probably would have done even better without the skipped shots, but it is what it is.). I would stick with the protocol, reduce for under 50 until he proves he can't maintain that.

Lantus vs. Lev - it can't hurt, if you want to give it a try. Some cats do better on one, some the other. There is a difference in pH and that might matter to Michelangelo. I do remember one of our old-timers (Jojo andbunny) who switched to Lev because her cat always went crazy and tried to bite when being shot. She switched, only to realize Settles was going crazy and biting just because that's who he was. He did the same on Levemir. :lol: So who knows, but there's no harm in trying. Usually we suggest starting Lev at a dose about 30% lower than the cat's good Lantus dose. This is mostly because we have seen some cats have a pronounced response to Lev in the first couple of cycles. They may or may not hold onto that good response, but for safety's sake it makes sense to back off on the Levemir dose for the first few days just in case your cat is one of the ones who responds quickly.

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

Weren't you thinking about getting a second cat/kitten? That might give him better exercise and something to playfight with that isnt your body parts. Wiggling body parts under the covers are SO much fun to attack!!And if they squeal its even better!

I think if I were you I would stick with the Lantus a little longer, get used to it and get consistent with it. Stick to the protocol rigidly. Hopefully now that Xmas is over etc you can get more control over things... get experienced and comfortable with shooting low (although the last 2 times you skipped were because you were away not because he was low) Dont skip unless you really have to... stall instead if you can. And I agree, dont hold the dose as long.

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

Kay --

The link you provided isn't to a study. It's a report. It's also from the meeting of the European Medicines Agency. I have no idea how difficult or easy it is to get a report of this type accepted at a conference or whether papers accepted at the meeting are peer reviewed. Basically, the report is a review of the literature. It is a bit concerning in that there are no references provided; I tend to not trust documents that don't provide citations to the research. It's also likely that the information is dated. The report is from 2005. I have no idea how old the studies it reports on are or what the quality of the research is.

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

Libby and Lucy said:

Wendy&Tiggy said:

2. Mikey isnt holding reductions well. In future maybe wait on reductions until he has 3 drops under 50 (or one drop under 40) instead. Maybe just skinny the dose at that point too.

Click to expand...

For what it's worth, I don't think you're at a point where you need to do this yet. All I see on your spreadsheet is one failed reduction - when you reduced from 1u to 0.75u, the reduction didn't hold. The protocol calls for going right back to the last good dose. By waiting so long, you allowed some glucose toxicity to set in. In these cases, it is pretty common for cats to have to go back ABOVE that good dose to get another breakthrough. No big deal, onward and upward and now that he is back to 1.25 (he will be at 1.25 tonight, right?) you'll probably see another breakthrough soon.

One failed reduction doesn't mean a cat doesn't hold reductions well. Most cats have a few false starts before they really can start holding reductions. I only see one other reduction on your spreadsheet, the one from 1.25u to 1u, and that one held fine (probably would have done even better without the skipped shots, but it is what it is.). I would stick with the protocol, reduce for under 50 until he proves he can't maintain that.

Lantus vs. Lev - it can't hurt, if you want to give it a try. Some cats do better on one, some the other. There is a difference in pH and that might matter to Michelangelo. I do remember one of our old-timers (Jojo andbunny) who switched to Lev because her cat always went crazy and tried to bite when being shot. She switched, only to realize Settles was going crazy and biting just because that's who he was. He did the same on Levemir. :lol: So who knows, but there's no harm in trying. Usually we suggest starting Lev at a dose about 30% lower than the cat's good Lantus dose. This is mostly because we have seen some cats have a pronounced response to Lev in the first couple of cycles. They may or may not hold onto that good response, but for safety's sake it makes sense to back off on the Levemir dose for the first few days just in case your cat is one of the ones who responds quickly.

Click to expand...

There was also a failed reduction back in November, but in that particular case, I think the reduction failed moreso because he gained around 4 pounds in that month alone vs. not taking to the reduction well. In December, he only gained a little bit of weight/size, starting out at ~7.5 pounds to where he's at now at ~8.2 pounds. That might have played a part in this dose reduction failure as well, but I don't think it was a significant enough growth spurt to be the full story.

Thanks also for the dosage information about Levemir. I don't think Mikey has a biting personality because his aggressive biting only seems to present itself when the twitching, rolling skin starts, and even then, it's only about half the time. The other half of the time, he's willing and wanting to play.

Wendy&Tiggy said:

Weren't you thinking about getting a second cat/kitten? That might give him better exercise and something to playfight with that isnt your body parts. Wiggling body parts under the covers are SO much fun to attack!!And if they squeal its even better!

I think if I were you I would stick with the Lantus a little longer, get used to it and get consistent with it. Stick to the protocol rigidly. Hopefully now that Xmas is over etc you can get more control over things... get experienced and comfortable with shooting low (although the last 2 times you skipped were because you were away not because he was low) Dont skip unless you really have to... stall instead if you can. And I agree, dont hold the dose as long.

Click to expand...

Yes! Still looking for that second kitten, but it seems that most cats don't have kittens till the springtime around here! :roll: I've tried a few rescue places and the few kittens they have available, every time, the cat is already in its new home by the time they get back to me. Because of all the chaos these last few weeks with work trips and family and friends out to visit and people ending up in the hospital and the holidays, I haven't been as proactive about it as I should have been, but I'm hoping to have a new furry creature by the end of this month. My brother has also made mention of getting another rabbit (his last pet rabbit died shortly before Michelangelo's arrival into our house), so we'll see how that goes as well. We might end up with two new additions to our household! Either way, I don't want Mikey to end up with Only Cat Syndrome and be unable to play well with others.

"...although the last 2 times you skipped were because you were away not because he was low..." I know, and that's one of the reasons I held off on increasing him too quickly because I wasn't sure how the skipped shots were playing into his high numbers. The other reason is that I want to be able to monitor him the first day or two on the new dose in case it's too high and he ends up with a hypo, so I hold off on increasing a dose until I know I'll be home to do so. And yes, he'll be at 1.25u for tonight's shot. :smile:

I'm planning on sticking with Lantus at least until this batch runs out (another three months or so, I'm guessing). I like to prepare for the worst (but always expect the best), so if this vial breaks or there's a sudden loss in potency, that's a lot of aggravation and urgency that'll end in probably at least 2 skipped shots (if it doesn't happen on a weekend) before I can get him a new prescription and have it filled. So, at the very least, if I end up taking him into the vet tomorrow anyway, I was thinking I want to get a new back-up prescription then as well. Even still, I think I'll hold off on asking for a new prescription for a bit longer until I figure out if I want to stick with Lantus or try out the Levemir.

Re: 1/2 Michelangelo AMPS 350 - Lantus vs. Levemir ?

Sienne and Gabby said:

Kay --

The link you provided isn't to a study. It's a report. It's also from the meeting of the European Medicines Agency. I have no idea how difficult or easy it is to get a report of this type accepted at a conference or whether papers accepted at the meeting are peer reviewed. Basically, the report is a review of the literature. It is a bit concerning in that there are no references provided; I tend to not trust documents that don't provide citations to the research. It's also likely that the information is dated. The report is from 2005. I have no idea how old the studies it reports on are or what the quality of the research is.

Click to expand...

Yeah, I'm still looking for where I originally found that 36-hour thing for felines mentioned, but I had the EMEA one saved in the same spot I thought the other would be, so I was just assuming this one was referenced by it (based on the way my "filing system" works). Maybe they removed the web page? Maybe I never saved it? But I'll keep looking and won't give up till I find it again!