5/15 Fred AMPS 443

[Purrberry]

https://www.felinediabetes.com/FDMB/threads/5-14-fred-update-breaking-that-bounce.247360/

As predicted, he bounced from breaking the bounce.

I just don't understand why he seems to bounce more from yellow than he does blue. I've scoured my spreadsheet, and that really seems to be the pattern. I just don't know how I get him to any kind of consistently good numbers without risking another hypo...and we are NOT going through that again!

His neuropathy is getting worse, and his personality fades by the day. I'm so sad I'm sick over it.

I wrote my vet and requested Levemir this AM. Whether or not I'll have the courage to fill it, or that she will agree to fill it, I don't know. The late nadir will be a problem for me, especially in the PM cycle.

Sorry. I'm Debbie Downer today.

 

[Wendy&Neko]

I rather think he's still bouncing from the greens, not a new bounce. It can take six cycles to clear a bounce, and numbers can wobble around during that time. Hopefully at the end of those six cycles he'll come down.

 

[Suzanne & Darcy]

I am so sorry that you are sad. I TOTALLY understand about how it feels to see them change in their personality and how it makes you sad. Fred is getting pretty high up in dose. Have you thought about getting him tested for Acromegaly or IAA? Have you had other recent bloodwork/vet visit lately to see if there is anything else going on? Sorry if you've already mentioned this in previous posts.

Also, what are these crisps you are giving Fred? To me, crisps are potato chips. Surely you aren't feeding him those although they are certainly high-carb (darn it, because they are so tasty!)

 

[Purrberry]

Have you thought about getting him tested for Acromegaly or IAA

Thank you. It just sucks. I did have him tested for both, and he was negative. No worries on not seeing that...it's hard to keep up with everyone! So his numbers are a mystery for the time being. There has to be SOMETHING going on.

His "crisps" are short for crispies/dry food. He gets a 75-25% mix of Young Again LID Mature and Dr. Elsey's. I've cut those out down to a trickle of what he used to eat, but that's as low as I can get him. He will not eat any commercial wet food (I make them raw), so it has to be dry in the timers when I'm out/overnight. And it's Mom who also loves potato chips...or as my Aussie husband calls them, "chippies".

I also just heard back from my vet. She's willing to prescribe Levemir, but I can already tell she's not versed in it. She said she's only had one canine patient on it, so I'm not blaming her. But she said she'd want him OFF insulin for 24-48 hours to clear out the Lantus, and would want to start Fred all over at 1-2u BID. That does not sound right AT ALL to me...a recipe for DKA or wrecking his kidneys. I know the advice on here is to start at 70% of the Lantus dose...is that correct?

I just don't know what the right thing to do is. I'm really afraid of having to start a brand new learning curve and risk something going wrong.

 

[Purrberry]

Oh...and she also said Levemir only comes in pen form? Is that correct?

 

[Suzanne & Darcy]

Yes 70% at startup when switching ... just to make sure ...

 

[Suzanne & Darcy]

The pens are very convenient, but I believe it also comes in a vial. The internet at least has photos of vials if you do a search for Levemir vial...

 

[Suzanne & Darcy]

Thank you. It just sucks. I did have him tested for both, and he was negative. No worries on not seeing that...it's hard to keep up with everyone! So his numbers are a mystery for the time being. There has to be SOMETHING going on.

His "crisps" are short for crispies/dry food. He gets a 75-25% mix of Young Again LID Mature and Dr. Elsey's. I've cut those out down to a trickle of what he used to eat, but that's as low as I can get him. He will not eat any commercial wet food (I make them raw), so it has to be dry in the timers when I'm out/overnight. And it's Mom who also loves potato chips...or as my Aussie husband calls them, "chippies".

I also just heard back from my vet. She's willing to prescribe Levemir, but I can already tell she's not versed in it. She said she's only had one canine patient on it, so I'm not blaming her. But she said she'd want him OFF insulin for 24-48 hours to clear out the Lantus, and would want to start Fred all over at 1-2u BID. That does not sound right AT ALL to me...a recipe for DKA or wrecking his kidneys. I know the advice on here is to start at 70% of the Lantus dose...is that correct?

He was diagnosed in December and you had him tested when? I'm just wondering when you had him tested? I have heard Wendy say that sometimes if they are tested too soon after diagnosis that there can be a false negative test. I sure hope that is not the case with dear Fred.

I just don't know what the right thing to do is. I'm really afraid of having to start a brand new learning curve and risk something going wrong.

 

[Wendy&Neko]

I also just heard back from my vet. She's willing to prescribe Levemir, but I can already tell she's not versed in it. She said she's only had one canine patient on it, so I'm not blaming her. But she said she'd want him OFF insulin for 24-48 hours to clear out the Lantus, and would want to start Fred all over at 1-2u BID. That does not sound right AT ALL to me...a recipe for DKA or wrecking his kidneys. I know the advice on here is to start at 70% of the Lantus dose...is that correct?

You are right - your vet is not well versed in Levemir. Not surprising, might wasn't either. You do NOT clear them out. Just start the Levemir the cycle after the last Lantus dose, but pick a time you can monitor closely a couple cycles. And you start him at 70% of his existing dose, so about 5 units of Levemir. There are a small handful of cats who have switched that have had a strong reaction the first cycle or two, that's why the reduced dose. Most cats end up on close the dose of what they were on for Lantus.

Lev comes in vials or pens (or cartridges in Canada). I never bought a vial, pens/cartridges are much more convenient, and you can use them to the last drop.

 

[Purrberry]

@Suzanne & Darcy I had him tested at 70 days...3 days shy of the one study that said 73 days was best. That does haunt me. His acro number was 56, so with a number that low and just a few days short, we're hoping it's for real. I tend to feel that he CAN respond to insulin, but he is such a supreme bouncer that his body never has a chance to adjust.

You are right - your vet is not well versed in Levemir.

When I pushed back a bit about "clearing him out" and also having to start from a low dose, she pushed back. She said Lantus has about an 18-hour half-life, so it would be at least a day without insulin. Then she said they start from scratch with any change in insulin because every insulin acts differently in the body. Finally, she said she read obese cats can have higher incidences of overdose with Levemir. ("so being careful is important")

Now when he was 20lbs, Fred was obese. Now that he's hovering at 17, he definitely is not. He is a big cat...he's truly a large animal. He has the waist indent now and everything, and frankly looks downright skinny to me.

I would trust the experience of those on this board more than someone who has put one animal, a dog, on Levemir. But God forbid something go wrong. I feel trapped in this..damned if I do and damned if I don't. I also WOULD have trouble ever getting a PM nadir with my schedule, unless it were to be at AMPS.

With the pens, can you do .25 dosing? Does it make a "click" sound?

I just don't know.

 

[Suzanne & Darcy]

@Suzanne & Darcy I had him tested at 70 days...3 days shy of the one study that said 73 days was best. That does haunt me. His acro number was 56, so with a number that low and just a few days short, we're hoping it's for real. I tend to feel that he CAN respond to insulin, but he is such a supreme bouncer that his body never has a chance to adjust.


When I pushed back a bit about "clearing him out" and also having to start from a low dose, she pushed back. She said Lantus has about an 18-hour half-life, so it would be at least a day without insulin. Then she said they start from scratch with any change in insulin because every insulin acts differently in the body. Finally, she said she read obese cats can have higher incidences of overdose with Levemir. ("so being careful is important")

Now when he was 20lbs, Fred was obese. Now that he's hovering at 17, he definitely is not. He is a big cat...he's truly a large animal. He has the waist indent now and everything, and frankly looks downright skinny to me.

I would trust the experience of those on this board more than someone who has put one animal, a dog, on Levemir. But God forbid something go wrong. I feel trapped in this..damned if I do and damned if I don't. I also WOULD have trouble ever getting a PM nadir with my schedule, unless it were to be at AMPS.

With the pens, can you do .25 dosing? Does it make a "click" sound?

I just don't know.

No. I believe the pens only dose whole units. But you don't use the pen itself to dispense the insulin (that's the way the humans do it.) You take your insulin syringe and insert it into the pen and draw back the insulin just like you would with a vial EXCEPT that you do NOT inject any air into the pen. The pens work on negative pressure so you just draw out the dose without first injecting air. It took me a while to get used to the and I have to admit to forgetting and occassionally inserting air into the pen. Also... when I did this... nothing bad happened (so don't worry if you do it) except that I had a little air in the pen... so when I got to the end of the pen I had to be careful to not draw air into my syringe.

 

[Suzanne & Darcy]

Well, I'm not the expert on the timing of the testing... but @Wendy&Neko is and she can tell you about the 73 days (I see you already researched it and kudos to you... but she can tell you more about the experience of people on the board who had to re-test).

 

[Wendy&Neko]

When I pushed back a bit about "clearing him out" and also having to start from a low dose, she pushed back. She said Lantus has about an 18-hour half-life, so it would be at least a day without insulin.

In humans maybe, not cats. I have never seen a problem with a cat starting Lev the cycle after Lantus, and that's several dozen more cats than she has experience with.

Then she said they start from scratch with any change in insulin because every insulin acts differently in the body. Finally, she said she read obese cats can have higher incidences of overdose with Levemir. ("so being careful is important")

Yes cats can react differently to a new insulin, but that's no reason to start from zero. That's just irresponsible in a higher dose cat, potentially dangerous if ketones. I'd also love to see the citation where she read that obese cats can have higher incidences of overdose with Levemir. Maybe ask for the name of the paper? I did a quick search and couldn't find anything. In dogs there is a big difference when switching to Levemir, they are much more sensitive to it. Cats are not dogs. And there is a big difference between a starting dose of Levemir if kitty is new to insulin, vs. one that has been on insulin for a while like Fred.

 

[Bron and Sheba (GA)]

or as my Aussie husband calls them, "chippies".

Yes.... Affectionately known as chippies!

Kathleen, it is normal practice when swapping to a different insulin, to do it at the next cycle. Stopping insulin for 24-48 hours then starting over again at 1 to 2 units when the dose is 7 units is just opening the door and inviting ketones in.
Most of the cats here that are on Levemir were on Lantus first and did the swap over at the next cycle at 70% of their current dose.
That is what I did with Sheba when I swapped to Lev and had no issues as all. I found Sheba was happier on Lev.

 

[Purrberry]

Thank you for all of your replies. I feel much more confident in how the switch would be done, and that it (the switch) has been successful in other cats. I just can't believe she'd want Fred at such a risk of ketones, given his numbers WITH insulin!

It really is my hope that Fred would be happier on Levemir. I don't think the Lantus has agreed with him from the get-go. It seems to suck the life out of him. Or, perhaps that's just a result his numbers. :-/ I guess the last remaining hurdle is the late nadir. I can catch it in the AM cycle, but likely not the PM.

Maybe ask for the name of the paper?

I'm going to see if I can do so--good idea.

In dogs there is a big difference when switching to Levemir, they are much more sensitive to it. Cats are not dogs

So very true. As kind as she is, and always open to the suggestions that I know seem out there to her, she is much more versed in dogs than cats. It is unfortunately often the case at most practices.