3/17 Munchie-Lantus to Lev switch Dosing advice

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ewest

ewest

Member Since 2011
Hi Levemir users: My cat Munchie has been on Lantus for 6 months and has not regulated yet with it (more highs than anything and with increases tends to dive). I mentioned Levemir to my vet and she sounds open to it but hasn't used it before. Some folks are saying I could continue to try to increase Munchie's insulin dose on Lantus...or decrease her dose to below a unit to see if she's getting too much. Just wanted to see if there's others out here who've switched from Lantus to Levemir and what folks think in terms of Munchie's SS numbers for that. If I stay on Lantus with her I'm trying to get more details on figuring out which way to go to try to get her in a better range as soon as possible :)

Thanks so much.
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

Hi, Elizabeth. So sorry you are having trouble getting stable numbers with Munchie. Here's some things I am wondering:

Was she diagnosed with any other health issues when she had DKA/Pancreatitis? How are her teeth? What were here BGs when she was diagnosed? How old is she and how was her health before the diagnosis?

It is odd that she would become diabetic on the raw diet, so I am wondering if an infection, like pancreatitis, caused her BGs to rise and also caused inappetance and then the DKA. Treat the original infection and the BGs should come down. Could she still have pancreatitis or IBD causing increased, and unstable, BGs? There is evidence that something is going on with the continues vomiting.

Do you know about triaditis? It is an inflammation that involves the pancreas, intestines and liver - the infection can easily migrate from one area to the next as they are all linked together. She could have developed a food allergy to the raw diet protein. Have you tried switching proteins, or brands.

So, that is one issue, finding the source of the inflammation and treating it.

The other issue is managing her BGs. I do see evidence that she has gotten too much insulin. Going back to her BGs at diagnosis, I wonder if they were high then from the infection and DKA and vet stress, but have dropped much lower since she no longer has DKA and is at home. All of those times that she dropped to the 30s and 20s mean too much insulin.

You do have to be very careful because of the DKA and it looks like she is still having p-titis or IBD issues from your SS notes (vomiting, etc.), but I think she needs less insulin. You could try dropping her to .5u and monitor her BGs AND test for ketones very carefully. She has already had some days in the 500s and has many 300s and 400s, so trying a lower dose is a risk you can take - her BGs can't get much worse.

I hope that helps. I have not used lantus, but it is very similar to levemir. I'd like to see you try the lower dose on lantus before switching in case that is the problem here. I do think that that sometimes either lev or lantus is the better insulin for certain cats, so changing insulins may or may not make any difference.
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

Hi Sheila,
Thanks so much for your response. Munchie had liver inflammation at diagnosis and they did ultrasound as well but I don't recall any conclusions from that (in other words, I don't think they saw anything definitive). I didn't remember her glucose at diagnosis but just went over her chart and it looks like it was 388. That actually suprises me that it wasn't much higher. Well, that somewhat depresses me. If I took her off completely, would her numbers be the same??? Her most recent blood test also still showed elevated liver levels and she had elevated WBC's so they put her on antibiotic to treat infection. I do believe she still has pancreatitis and my vet is coming out for next check-up on Wednesday to recheck her levels for that and everything else. Her health before she was diagnosed had been good. She will be 18 years old in April. So, yeah, she didn't develop diabetes due to diet or weight but aging and body functioning just getting poorer. I make her food (consulted with nutritionist on diet) and have added a new meat for variety. The 1wbu on her SS is about a .5 unit. For awhile she seemed to do okay with that, but then after 8/2 her numbers got worse on that dose and I didn't get any recorded lows around that time (recorded maybe being a key there?) so we started the upward journey. I just talked to my vet and she wants me to stick with the 1.25 for tonight and we'll check-in tomorrow am. Munchie did get in yellow today and I'm glad for her time in that. My vet is doing consult with endocrinologist hopefully on Monday to get advice on her. Her best time recently seems to have been 11/16PM-11/26 where she had more blues than for awhile. She did get 300 and 400's with the blues too, though.

Thanks.
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

Your vet comes to you? Cool.

OK, some other ideas. Have you read the Tilly Protocol? It is linked in the Levemir 101 Sticky at the top of the forum. The information in that sticky is helpful also, even for lantus users. The main thing that may help you there is the dose changing guidelines. Specifically, reducing after a low (below 40). It does seem like you have done that, but then the dose get increased again at the next higher number.

Doses should not be changed based on one PS, but really based on the nadir. You have to look at the entire cycle, really. When making a change, you should hold it for 3-5 days, but some cats take up to 7-10 days to settle on a dose. Get spot checks during that time and then run a curve before deciding on a dose change. I think a lot of us tend to react to one number and increase/decrease without seeing the big picture.

How are you treating the pancreatitis? How is her appetite? Any chance the lows that are recorded on her SS coincide with lower appetite?

There are several people here that have (or currently are) dealt with p-titis. What helps is anti-nausea meds, pain killers, sub-Q fluids and syringe feeding if they aren't eating enough. There is a lot of information in the "Klinger at the ER" thread. You might give that a look over before the vet visit as it might help you discuss things with the vet.

Keep us posted on how Munchie is doing. And ask questions. That is what we are here for.
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

You might try giving her Denamarin for her elevated liver issues. Also ask your vet about ursodial. I am sorry can't give a link right now (on my phone). It works will for bile duct issues - sounds like this could be triaditis like Sheila mentioned. You might google it. Let us know how she is doing. So sorry about her brother. :(

Where do you live ?
 
Re:Munchie-Advice

Hi All - Hope ok to revive this thread. Munchie's numbers are not good recently- please be gentle with feedback as hard to have been going at it this long without great results. She does have chronic pancreatitis which complicates things.

If a cat has too much insulin, would they have an okay response some of the time on a dose and more of a bounce on the same dose at others? She had cycles on this dose with greens and then a yellow after which is good for her...and then others (like last few days) with a stronger bounce- but she may be having a bit of a panc. issue going on at moment too. I did try a brief reduction but I can't say that had significant results (unsure if too short). She was on 1 unit for awhile early Feb to try lower dose but really didn't get greens on that and had her on .5 unit back in September and she got lotta reds. Her beginning numbers at diagnosis are hard to use as reference because she was coming out of dka and being on IV fluids and all.
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

Are you using Levemir or is she still on Lantus?

2U looks very much like too much insulin in either case. 500s at preshots are generally a rebound from either having gone low in mid-cycle or BG dropping too quickly. I would say the latter is certainly what happened yesterday. 590 to 187 in 6 hours is a 400 point drop, that's harsh.

Please read the Pet Diabetes Wiki about rebound.http://petdiabetes.wikia.com/wiki/Rebound
Here's an additional webpage http://www.indulgedfurries.com/petdiabetes/somogyi.htm
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

I'm actually surprised she didn't do better on 1u when you tried that earlier this year. That is what I would have suggested as a possible good dose.

One thing that I think happens with too much insulin is that a little bit too much shows as slightly elevated numbers because of insulin resistance and/or rebound hormones as a chronic defensive mechanism, but if you increase the dose a little you see some better numbers, but deeper swings. Increase a little more and you get really low numbers and really big swings because there is enough "extra" insulin to force down the numbers even against the rebound response.

I also think that 2u is too much. I wonder if even less than 1u, but more than .5u (.75u, for instance :roll: ) would give better results, but also, it could be the insulin if you are still using lantus. From what I have been reading here, some kitties just don't do well on it and swing all over the place. Mel's Musette had that trouble with lantus. I think if you switch you will need to reduce the dose on lev. I haven't made a lantus to lev switch, but there are several threads here that discuss it and I seem to recall a post that said to go to 70% of the lantus dose. You might want to start a new thread asking that question if you plan to switch.

Pancreatitis will mess with numbers. In my experience it lowered them, but that was because Beau was not eating much. I remember having to decrease his dose a bit until he was feeling better and eating more.
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

Thanks Vicky and Sheila- Do you use bounce and rebound interchangeably? If the dose isn't too much, are there cats who sometimes still have higher numbers (pinks, reds)? What I'm hearing is a little too much insulin can cause higher, flat numbers- but not enough would as well, right? How does one judge this--do you always take the dose down if you see higher numbers AND a lower number (?) and see if they have better numbers in response?

Munchie is still on Lantus but I'm basically back to something needs to be changed with her dose or I need to switch to Lev. On the 1 unit she really didn't get greens but did still gets pinks and reds- so I hadn't been thinking that was too much insulin (?) and the other option was the bouncy colors could mean not enough insulin. With her current dose, it is breaking through a bounce and getting greens and so I had been wondering about too much and tried the brief decrease- maybe too short or not enough, but she really didn't get greens on any lower dose recently (1unit through1.75)- it wasn't until the 2 that she got any green.

What I'm set with now is where to go from here...I tend to change her dose by no more than .25 unit at a time because she has been sensitive to changes. If I started to decrease her dose by .25, it would take 12 days to get to .75 unit...and if that entails her being in higher flat numbers for that whole time that doesn't seem great...but she has gotten blues on some of the lower doses so maybe she would be able to do that. I would be happy for yellows. Trying to weigh things...Maybe both are needed- do wonder how her behavior would be with Lev too..
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

Yes, "bounce" means less of a response and has factors which distinguish it from rebound, but for the most part a bounce is still caused because of the hormones involved in Somogyi rebound. Munchie is out and out rebounding most times.

Sheila makes a good point about Lantus vs. Levemir. The fact is some cats just don't do as well on a particular insulin. I had Gandalf on PZI for 2 1/2 years before I realized that his lethargy was due to constantly going from high to low BGs and not from UTI's, which the vet always seemed to find although we weren't diagnosing those correctly.

So, the next step would be to help your vet understand why Levemir is worth a try. We can help with that. I don't have time to provide the links just now, but will be back later tonight.
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

In the "old" days we used to talk about a 'rebound check' by cutting the dose in half and seeing if the numbers got better - or starting over at a reasonable starting dose and seeing if the numbers got better. That was with faster acting insulins. When people started moving to lantus (and lev, but lantus was the big favorite) they said there was no need for rebound checks because rebound was unproven in cats. Yeah, right.

Anyway, this is still a safe thing to do - immediately cut the dose by half, or some other large factor. You can go down to 1u or .75u in one step and give it time to settle - testing for ketones as you have been doing because of her DKA history. I am guessing that she may need several days (up to 7) to settle on the new dose before you see improvement. And if you were switching to lev I would suggest starting at .5u.

Increases, when needed should be only about 10-20% of the dose. You are right about that, especially if the cat is insulin sensitive. I think Jeddie is very insulin sensitive and I have very slowly and painstakingly increased him with long settle times (2-3 weeks). After over two years I think I might be making progress! (except last night's PS was 97 and this morning he was 250. Sigh) The smaller the dose the smaller the increases should be. And also decrease if you know you are near best dose and are fine-tuning it. But for a rebound check, you can make that big step down all at once.

With lev, and I would assume with lantus but don't know for sure, it seems to help to come in under the best dose, let things settle and stop swinging even if that means a flat curve in the upper 100s to lower 200s and then slowly raise the dose to bring the whole curve down. BG swings seem to have their on momentum.

I think when you are seeing 400s and 500s as well as numbers well below 100 you have rebound. On a low carb diet you just don't get those high numbers without rebound (unless there are other health factors involved like acro). I also think these guys get very good at pumping out the rebound hormones to fight the insulin and can ward off low numbers for a very long time until the dose is high enough to "break through" those defenses and drop the numbers.

Yes, it is very hard to tell too little insulin from too much. You have to look at patterns and clues. When steadily increasing the dose results in no better numbers or the only way to achieve "greens" is a dose that also gives reds and blacks, then rebound has to be suspected. (IMO)
 
Re: 12/16 Munchie-Advice on possible switch to Levemir

Thanks for the feedback everyone. I feel pretty set on going ahead and trying Levemir. I had asked my vet about it before and she doesn't have experience with it but was open to it. I do feel Munchie is more lethargic lately and all those swings could likely do that. Am wondering if I should also reduce Munchie's dose down some (.25 unit) tonight- she's having a flatter cycle today with yellows so far which is nice and I don't want to further mess things up. Hoping I can switch her over to Lev this week.

Do folks know a formula for determining how much to give when switching to Levemir from Lantus?

Are there other differences with Levemir I should be aware of? Seems some are saying the onset or nadir may be different- have folks found this?

Thanks.
 
Hi Sheila- I didn't see your post when I was putting mine out---so you're saying you think it's okay to drop her down to 1 unit all at once (like tonight's dose)? I could try that as well...just trying to understand any adverse affects of reducing insulin like that? I could allow that to settle and then see about Lev- still feeling pretty good about wanting to try Lev as well...

"With lev, and I would assume with lantus but don't know for sure, it seems to help to come in under the best dose, let things settle and stop swinging even if that means a flat curve in the upper 100s to lower 200s and then slowly raise the dose to bring the whole curve down. BG swings seem to have their on momentum."

If Munchie had a flat curve in the upper 100s to lower 200s on a regular basis, that would be a great goal met let alone a stepping stone. :-D
 
I am not sure how it applies to smaller doses but usually it's said to go with 70% of your Lantus dose when switching to Lev. If you are at 2u Lantus, a 1.5u dose of Lev may be good, but if you are looking to lower the dose to get a more level curve, may 1u dose of Lev would be good.

My Shadoe did need less Lev, but Oliver was about the same dose. I did switch both starting with the 70% less.
 
There won't be any adverse reactions to lowering the dose. Her numbers might spike the first few cycles, but then settle. It isn't like doing the opposite and raising by 1u all of a sudden and risking a hypo.

My only concern is that you tried 1u and didn't get better numbers - still had some swings from lows to high. That is why I was thinking .75u. Your call, of course.

And with a lev switch maybe you would wait to see how she is doing on a lower lantus dose before deciding what dose to start lev at.
 
Here are the Levemir links to help your vet feel comfortable about it:

http://www.diabeteshealth.com/read/2007/07/17/5316/lantus-and-levemir--whats-the-difference/

ACVIM 2009 abstract http://www.felinediabetes.com/phorum5/read.php?15,1778958

Dissertation done by a University of IL vet https://www.ideals.illinois.edu/bitstream/handle/2142/16049/1_Gilor_Chen.pdf?sequence=3

FYI, insulin "detemir" is Levemir, the latter is the trade name.

http://felinediabetes.com/FDMB/viewtopic.php?f=10&t=681

http://felinediabetes.com/FDMB/viewtopic.php?f=10&t=682

The last 2 links are from the stickies which are at the top of the main Levemir ISG page. They contain vital links for you and your vet as well.

And despite the usual 70% of current Lantus dose recommendation, I would start Levemir at .5U. We have seen numerous strong results with it and .5U may seem conservative but the best way to determine dose is to start BELOW what may be the cat's optimum dose on Levemir. Lantus as well as far as that goes.
 
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