4/3 Teddy dose? Insulin?

[Minty]

Hello, I apologise if I’ve missed information or written the wrong things, I’ve always struggled with how forums work!

Anyway Teddy is 10, soon to be 11 neutered male. He was diagnosed October 2023.
He’s been on caninsulin which had very short duration, prozinc was similar, lantus stings and he reacts to the injections due to hyperesthesia and levemir he’s not really found a pattern or using it as would normally be seen.

I have a couple of questions the first maybe easier, do you have any insight on his dose? I’m thinking he needs to increase and the lower numbers were just a wonky settling dose. I’m trying to be braver with dosing on lower numbers but I am reliant on lifts to the vets so we are now over an hour from them if he has a bad hypo I can’t fix and due to my own health staying up through the night and testing is very difficult to do. But he doesn’t have a typical levemir pattern so I’m not certain increasing is right.

My second question, in the UK levemir stocks are due to run out at the end of the year. I currently have 2 pens in the fridge and a prescription for 5 more, and I could ask my vet for another prescription before the end of the year so I potentially have access to a year+ of levemir (depending on expiry dates on the pharmacies stock).
However I’m not sure it is suiting Teddy as well as it could. I have an appointment with my vets coming up soon to discuss what to do going forward, and what we might change insulin to.
I could go back to prozinc, but I feel we will go back to the same pattern of very high preshots and the depot of levemir/lantus is what has kept preshots some what lower.
I could try toujeo and maybe the smaller quantity would sting less than lantus did, but dosing with u100 syringes would restrict how small a dose I can give (I’m using calipers).
I could try tresiba but in the UKs Facebook group we have no one on tresiba so I don’t have any information to go on with what to expect curve wise, duration etc I’m leaning more to this as it’s a neutral base so shouldn’t trigger Teds hyperesthesia in the same way the acidic bases do.
But I’m very unsure what might be best!

He’s never had ketones or DKA, he takes gabapentin to manage the hyperesthesia and this makes him very hungry. He is not drinking or weeing excessively and appears to manage well with a higher blood sugar. He’s a quiet nervous boy whose body is quick to raise blood sugar if he’s scared/excited/lower than normal.
We are also currently waiting for another dental as more teeth need to come out, he’s taking onsior to help with the pain and gingivitis inflammation, and has a gel called dentihex to use every few days as a antiseptic.

In the spreadsheet I’ve made a tab in my/dl to help you in America. Thank you for any ideas you have!
Teddy and Olie

 

[Wendy&Neko]

Hello and welcome. I've moved your post to the Feline Health forum as that's where we ask people to post first. The Lantus/Levemir forum is a busy one and there are a few things people will need to see before they will help over there. The first thing is what dosing method you would like to use: Sticky Dosing Methods: Start Low, Go Slow (SLGS) & Tight Regulation (TR) I've linked the Sticky Note on the Lantus/Lev forum. You should read through and decide which one you'd like to use. You are feeding all low carb, so you can chose which ever one suits you based on your life style and goals for Teddy.

You will note that with both dosing methods we change doses by 0.25 units at a time. There are a few exceptions if following TR and all in high numbers or on quite high doses - which Teddy is not. Fat and skinny dose changes are not appropriate at this point of Teddy's journey.

The two dosing methods would have you increase after different periods of time, SLGS after a week, and TR after 3-5 days depending on nadirs or the low points. From what data I do see, I think Teddy needs an increase to 1.25 units. He's held this dose long enough.

It's really important that we try to figure out how low a particular dose is taking Teddy, as that drives all decisions we make on doses. I see that there are few tests done in the PM. Is it possible for you to get at least a test 2-3 hours after his P shot every night? We call that the before bed test. Many cats go lower at night, so we need to see if that is happening. Alternatively, some Levemir cats (like mine was) have a very late nadir so getting a test a couple hours before AMPS provided more data. The night of Feb 21st, that would have been a better test, as an example.

Regarding hypos, is there a reason your spreadsheet says the take action/hypo number is 4.4? For those who don't read metric, that's 79. That's not a number we use here for pet meters. Shooting lower numbers can be scary at first, but with Levemir kitties, they really do have a lot of lower numbers at shot time due to the later nadirs. As long as you can closely monitor, have plenty of test strips, and high carb food and/or syrup around, you can typically manage lower numbers on your own. People here are more than willing to dive in and help when you first see lower numbers.

I suspect one of the main problems you are having difficulty getting Teddy regulated is his bad teeth. Is there a plan for dealing with them soon? Onsior isn't supposed to be used for more than 3 days at a time, it even says that on the manufacturers website.

On your question of insulin choice, I loved Levemir for Neko. I suspect your problem is that you aren't at a good enough dose for him yet. That combined with him needing a dental. Our Tresiba forum is also quiet, been a while since anyone posted there.

By the way, the World version of our spreadsheet (used by us not in the US) has a mmol/L tab that automatically converts to the US mg/dL. More detail on where that's found in this post: New? How You Can Help Us Help You!

 

[Minty]

Hi Wendy, thank you for your reply and putting my post in the right place!

I think I was doing a loose form of start low go slow, so we’ll go with that one I think to had been suggested we use the fat and skinny doses to see if his pattern wasn’t typical because 0.25u was too much of an increase at a time. I think I’m going to have a lot of unlearning to do, in the Facebook group levemir is held for 10-14 days which is why I’ve been holding longer. And that’s where the hypo number for a pet meter has come from too. The PetTest manual has 4.2mmol as the low end of normal blood sugar.

With testing I will try to get evening/early morning ones but it isn’t going to be regularly. +3 is 1am with where I dose and my health make mornings very difficult which is why I dose later.
When we’ve used the libre he hasn’t historically been lower overnight but I understand things can change and patterns change.

I suspect it is his teeth too, although every time he’s had some removed we’ve expected better numbers and that’s not happened. It’s likely he will come out this time with just his incisors and bottom canines, he’s empty on the top apart from one back small molar and incisors, and empty of molars of one side at the bottom. The last dental was November and they took all the teeth they could without risking his jaw bone, and they will do the same this time. He has an appointment with the head vet in 2 weeks to get that booked in and onsior and dentihex until then.
I think the UK must have different licensing for onsior (like we do for senvelgo) the leaflet I have says 6 days for acute disorders and chronic disorders clinical response is seen within 3-6 weeks, it should be stopped if at 6 weeks there is no improvement and if being used long term liver bloods need monitoring.

I’ll leave my spreadsheet as is, I know my formulas are a bit wonky to copy the data into a new one, I can just x18 and pop it into the mg/dl page manually


I guess I need to sort teeth and then decide if I try and get him sorted on lev knowing eventually it will run out and I’ll have to start again. Or just start again now rather than pushing to get this to work to do it again. Teeth first the pictures here are a week apart and only a couple of days of onsior, not a huge change but a little change and he’s not pawing at his mouth anymore or licking his lips so much

 

[Wendy&Neko]

I think the spreadsheet evidence is that Teddy needs 0.25 unit changes. My Neko was incredibly sensitive to small changes in dose, but I used those smaller changes when decreasing, not increasing. She also had a couple secondary endocrine conditions which made dosing more complicated.

Do what you can for testing overnight. Lots of people have limits there. I actually found that if I got a AM+9 and a PMPS, I could get a clue what Neko was going to do overnight. Mind you, that took a lot of looking at data to figure that pattern out.

Levemir is not different from Lantus, no need to hold more than 7 days. I followed TR and could increase after 3-5 days.

Interesting to know the Onsior dosing is different in the UK. Here is the US website for the manufacturer.

Good luck with the dental. It would be good to try being a little more aggressive (but safe) with Levemir dosing once he's had his dental, and see what that does for him.