Jill
I switched Gracie to lev after a year on lantus. She still bounces but she has done so much better on lev. As Sienne said, there's no predicting which cat might do better on one insulin or another but the important thing is the best progress is made when you stick with the protocol as closely as possible.
First, I would have started Charlie at a higher dose of lev. Usually the starting dose of lev is 70% of the lantus dose. So her starting dose of lev would better have been .5u based on her lantus dose. I do think her lantus dose was too low. But that's in hindsight and we don't base the lev dose on what the lantus dose "should have" been. It's just a general observation.
Second, when we switch between lantus and lev, the TR protocol allows you to increase faster than if Charlie were newly dx and this was her first insulin.
The TR protocol from the Tilly webpage states:
If the cat received another kind of insulin previously, the starting dose should be raised or lowered by taking this information into account. Cats that have a tendency to get ketones and/or who are getting relatively high flat curves after the switch should have their dose raised earlier (after 24-48 hours)
I would have raised Charlie's dose after 48 hours. So I think we have a couple things compounding her lack of progress so far:
- starting dose held too long
The skipped shots almost put you back to square one. I'd raise her dose to .5u tonight and if she isn't progressing, I'd increase it after six cycles.
Lev onset is "typically" +4 and nadir is +8 to +12 depending on the kitty. I emphasize "typically" because ECID. You will have to test to catch her patterns on lev. It can be quite different than lantus and you won't know what it is without the testing. If she does onset at +4, it will allow you to shoot the lower PSs because you'll have time to be sure she is headed up before she onsets again. However, lev is known for it's ability to give really good duration. When I get Gracie's dose correct, she often nadirs at +15 which means she is nadiring from the previous shot three hours after I give the next one. I still shoot the low PSs to keep her flat.
Lev can result in really nice, long, flat curves if the dosing is correct but I think you need to work to follow the protocol a little closer. I don't like to make blanket statements like that without giving examples so please bear with me because I want Charlie to do really well on lev and since you asked for examples, I'm happy to just give you a couple so it will help with the lev dosing. We know you are doing the best you can but if you can see where there might be some other paths to take, it might help. Of course, since we don't know how Charlie will do on lev, we might see some different patterns (e.g. she might not clear bounces so radically but I did find Gracie did it on lantus and she does it on lev).
If you look back on 1/21/13, she earned a reduction in the PM cycle and you reduced to 1u the next morning. Very good! But then you shot a BCS on the fourth cycle on a BG that is, what most of us who've been here a while, would consider to be relatively high. Then two more cycles at 1u and she got to 50 and you reduced to .75u. You gave her another reduction on 1/29/13 and another on 1/31/13 so that was three in a row that she hadn't earned. And then there was some additional dose switching after that. The other thing I note is that Charlie likes to be a drama queen when she is clearing a bounce ;-) (P.M. cycle 2/4, P.M. cycle 2/6, P.M. cycle 2/10). One of the most valuable tools for lantus users is the +2 test and I bet you would have seen her dropping at +2 so you could have controlled those dives to prevent her going so low and bouncing straight back up. Unfortunately with lev, there is not really a specific test across the board for most cats that will give you that info. BUT Charlie will tell you what to watch for if you look closely; we can also help you find her patterns.
Levemir is like lantus....it really likes consistency in dosing. I know you work and travel and we understand you have a life to live. I'd try though, as much as you can, to be more consistent in the dosing with lev. When she starts getting into some better numbers, I think
initially you'll want to test a bit more when you can (weekends or days off) so you can pick out her patterns on lev because that will help immensely. And while the patterns might seem unpredictable.....there's usually some predictability in them.
We are here to help you....just let us know how we can best achieve that.
