Jessica & Conan
Member Since 2016
Previous post: http://www.felinediabetes.com/FDMB/...-insulin-degludic-update.194584/#post-2179735
http://www.felinediabetes.com/FDMB/...-insulin-degludic-update.194584/#post-2179735
At the time of my last update, about a month ago, we were at 2.5U twice a day, and not having great results. I continued to increase Conan's dosage in .25U increments every 6 cycles or so, and gradually started seeing improvement, first some yellows and occasional blues, then some more blues, and then some greens (I have altered my spreadsheet so it shows green from 50-119, since I think this is accepted as an ideal range), until we were at 3.75U.
At this point it was clear that the dosage was successfully lowering Conan's BG to a fairly good level - but that it was not lasting anywhere near a full 12 hours. By the time of PMPS (always very close to 12 hours), he was always well back into the 300s. And since it takes a solid 4 hours for the Tresiba to really take effect, he was spending about half the day out of an ideal range (about 1-2 hours before each shot and maybe 4 hours after). This is exactly what happened to him with Levemir - in terms of duration of action at least; the Levemir never had such a consistent effect for him.
I decided to experiment for a few days and see what would happen if I dosed him every 9-10 hours. I only did this for two days or so. At 9 hours he was often still only in the yellows - but once he is in the yellows, it moften means he's on the upward slope, the insulin is wearing off. Dosing him at this point may be too late, because it's going to take 3-4 more hours for the shot to take effect, so he's going to keep going up, possibly even into the pinks, before he comes down again. It actually isn't quite that simple - also depends on how recently he's had his steroid, and other mysterious cat factors that I don't understand - but 9-10 hours did not lead to reliable control.
So I gave up and accepted that I was going to have to push the doses even closer and go back to TID dosing. So since about May 10, Conan has been getting his insulin 3 times a day. I've experimented a little with the timing (I also bumped his dose up to 4U to see if that helped with duration). 3 times a day, equally spaced, is every 8 hours. But it seems like 8 hours is actually too long. The dose definitely lasts for 8 hours. But because of the delay of onset of action, he needs to get the next dose while the previous dose still has a solid period of effectiveness left, so there is a generous overlap. Otherwise, the next dose has to work to bring him back down, rather than simply maintaining him at a good level.
As I understand it, humans generally dose Tresiba 1x/day, even though the duration of action is about 40 hours. So there's a really large overlap - each dose is well inside the effective period of the dose before. This I think is what is necessary for it to keep BG levels consistent all the time.
So ideally, to keep him solidly in the greens and sometimes blues all the time, I believe Conan needs to be dosed more frequently. If the duration of action for him is about 10 hours, he needs to be dosed maybe every 7 hours, well before the first dose has even begun to lose its effectiveness. I suspect in that case he wouldn't need quite such a high dose either, because it wouldn't have to work to counteract rising BG levels, during the first part of every cycle.
Of course, dosing every 7 hours is just about impossible to keep track of or maintain. I've thought about trying every 6 hours, which at least fits into a 24-hour day. The problem is that I simply can't do that every day - in fact there is almost no day in which he could get a shot in the AM and another shot 6 hours later. It's often hard to get his midday 8-hour shot. But I might play around with this when I have time, and to see what happens. Maybe 6 hours will turn out to be too much anyway.
But from a larger perspective, all this is nitpicking. His current spreadsheet looks incredibly good, especially when compared to how it used to look. Mostly blue, but also lots of green, some yellow. An occasional pink here and there, or a red, usually on days when I'm gone all day and not able to do TID dosing at all. This is by far the best he's ever been controlled.
So my thoughts about Tresiba at this point:
- BG levels are very consistent, even with the steroid. No spiking, no plummeting BG (at least during its duration of action). Far fewer weird inexplicable numbers than the other insulins I've used.
- It's more forgiving of "early" dosing than the other insulins I've used - but no more forgiving of "late" dosing (in the sense that once it wears off, it wears off).
- Onset is delayed. It works best and BG levels stay most consistent when there is significant overlap in dosing cycles; i.e., the next dose is given well inside the duration of action of the previous dose - earlier is better (see previous point). This means that the dose must be given when BG levels are still quite low (and indeed, I've dosed when Conan has been as low as 81, with no issues).
I really, really, *REALLY* wish that insulin didn't speed through Conan at such a rate- I was so hoping to at least be able to achieve BID dosing on the Tresiba, if not the once-a-day advertised for humans. That being said, I'm pretty pleased with the results we've been able to achieve so far. His spreadsheet has never looked even close to this in two and a half years of treatment.
http://www.felinediabetes.com/FDMB/...-insulin-degludic-update.194584/#post-2179735
At the time of my last update, about a month ago, we were at 2.5U twice a day, and not having great results. I continued to increase Conan's dosage in .25U increments every 6 cycles or so, and gradually started seeing improvement, first some yellows and occasional blues, then some more blues, and then some greens (I have altered my spreadsheet so it shows green from 50-119, since I think this is accepted as an ideal range), until we were at 3.75U.
At this point it was clear that the dosage was successfully lowering Conan's BG to a fairly good level - but that it was not lasting anywhere near a full 12 hours. By the time of PMPS (always very close to 12 hours), he was always well back into the 300s. And since it takes a solid 4 hours for the Tresiba to really take effect, he was spending about half the day out of an ideal range (about 1-2 hours before each shot and maybe 4 hours after). This is exactly what happened to him with Levemir - in terms of duration of action at least; the Levemir never had such a consistent effect for him.
I decided to experiment for a few days and see what would happen if I dosed him every 9-10 hours. I only did this for two days or so. At 9 hours he was often still only in the yellows - but once he is in the yellows, it moften means he's on the upward slope, the insulin is wearing off. Dosing him at this point may be too late, because it's going to take 3-4 more hours for the shot to take effect, so he's going to keep going up, possibly even into the pinks, before he comes down again. It actually isn't quite that simple - also depends on how recently he's had his steroid, and other mysterious cat factors that I don't understand - but 9-10 hours did not lead to reliable control.
So I gave up and accepted that I was going to have to push the doses even closer and go back to TID dosing. So since about May 10, Conan has been getting his insulin 3 times a day. I've experimented a little with the timing (I also bumped his dose up to 4U to see if that helped with duration). 3 times a day, equally spaced, is every 8 hours. But it seems like 8 hours is actually too long. The dose definitely lasts for 8 hours. But because of the delay of onset of action, he needs to get the next dose while the previous dose still has a solid period of effectiveness left, so there is a generous overlap. Otherwise, the next dose has to work to bring him back down, rather than simply maintaining him at a good level.
As I understand it, humans generally dose Tresiba 1x/day, even though the duration of action is about 40 hours. So there's a really large overlap - each dose is well inside the effective period of the dose before. This I think is what is necessary for it to keep BG levels consistent all the time.
So ideally, to keep him solidly in the greens and sometimes blues all the time, I believe Conan needs to be dosed more frequently. If the duration of action for him is about 10 hours, he needs to be dosed maybe every 7 hours, well before the first dose has even begun to lose its effectiveness. I suspect in that case he wouldn't need quite such a high dose either, because it wouldn't have to work to counteract rising BG levels, during the first part of every cycle.
Of course, dosing every 7 hours is just about impossible to keep track of or maintain. I've thought about trying every 6 hours, which at least fits into a 24-hour day. The problem is that I simply can't do that every day - in fact there is almost no day in which he could get a shot in the AM and another shot 6 hours later. It's often hard to get his midday 8-hour shot. But I might play around with this when I have time, and to see what happens. Maybe 6 hours will turn out to be too much anyway.
But from a larger perspective, all this is nitpicking. His current spreadsheet looks incredibly good, especially when compared to how it used to look. Mostly blue, but also lots of green, some yellow. An occasional pink here and there, or a red, usually on days when I'm gone all day and not able to do TID dosing at all. This is by far the best he's ever been controlled.
So my thoughts about Tresiba at this point:
- BG levels are very consistent, even with the steroid. No spiking, no plummeting BG (at least during its duration of action). Far fewer weird inexplicable numbers than the other insulins I've used.
- It's more forgiving of "early" dosing than the other insulins I've used - but no more forgiving of "late" dosing (in the sense that once it wears off, it wears off).
- Onset is delayed. It works best and BG levels stay most consistent when there is significant overlap in dosing cycles; i.e., the next dose is given well inside the duration of action of the previous dose - earlier is better (see previous point). This means that the dose must be given when BG levels are still quite low (and indeed, I've dosed when Conan has been as low as 81, with no issues).
I really, really, *REALLY* wish that insulin didn't speed through Conan at such a rate- I was so hoping to at least be able to achieve BID dosing on the Tresiba, if not the once-a-day advertised for humans. That being said, I'm pretty pleased with the results we've been able to achieve so far. His spreadsheet has never looked even close to this in two and a half years of treatment.
