5/27 Shakespeare - start tonight

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dmartini4

dmartini4

Member Since 2010
Hi everyone!
Well it looks like I am going to start the levemir tonight
He is doing very poorly on the PZI so I am not going to finish the bottle as planned.
He is currently on 3 units on PZI....when I raise the dose, his numbers go up, when I lower the dose
his numbers remain very bad....
SO...my vet recommend that I start Shakes on .50 unit.
because it is a stronger insulin...any opinions on that?
I think I will be shooting around 5:30 tonight
Thanks for any input

denise and shakes
 
Hi Denise,
I think you should look at the fact that Shakespeare has been running such high BGs for a while now and take that in to consideration regarding starting dose.

I would be uncomfortable agreeing with the vet about starting at only .5U because of the constant high BGs Shakespeare has experienced. We have seen too many times a cat who was not responding to their previous insulin go in to DKA when switching primarily because of the lowered dose. Normally I'm fine with .5U, given how we've seen some cats do well on less than 1U of Levemir.

I don't consider Levemir a "stronger" insulin, it simply works differently than PZI. Because it takes a while to build up in their system, the "shed" or "depot" effect, it essentially is weaker in the beginning and that fact could contribute to why some cats develop ketones after switching.

This topic of which is riskier - hypo or DKA - was brought up in Think Tank recently and it's one that we have bantered back and forth about over the years. Low BGs are easier to catch if you're home-testing and although low numbers certainly happen on Levemir, the possibility of symptomatic, need-to-get-to-the-vet-now hypo is lesser than it would have been on PZI. Because of that aspect, starting Shakespeare at 1U or 1.5U is safer than starting too low and risking DKA, IMO.

I would really like to know in what way the vet considers Levemir to be "stronger." Stronger is not a term we use to describe the different insulins in comparison to one another. We use "longer-acting" for Levemir and Lantus when comparing to PZI or ProZinc. To call PZI a long-acting insulin is incorrect in my experience with it. It is moderate acting. PZI peaks at 5 to 6 hours, compared to Levemir's 8-10 or longer.

That fact may be all Shakespeare needs to bring his BGs down.
 
My suggestion would be 1u to start and get some spot tests, particularly on cycles 2 and 3, if he isn't dropping significantly on 1u, then you can go to 1.5u on the 4th cycle. Test for ketones is always good when they are in higher numbers.

My reasoning is that IF they are going to react more strongly to lev you will know in the first 3 cycles. Beau was one who did that hitting the 30s in the 3rd cycle on a dose that was about half his vetsulin dose.
 
Hi Vicky,
Thank you so much for your input, I was thinking of starting him at one unit.
The only thinkg I vcan think of, was she was thinking stronger because it is a U100 isulin,
compared to PZI which is a U40...that is the only thing I came up with
Also I think she was thinking lower because the more we tried to raise Shakes the
more his numbers wentup...
I dont know but I think I will start at oneunit
Abaout how long am I supposed to hold the dose? maybe 5 days?
how long does the shed take to fill? He was on lantus for a few months and I never was able to understand the shed
thanks
 
If you start at 1U, give it 3 days before considering whether to increase. You want to be able to check mid cycle BGs beginning +6 or so on that third day. You may consider the 3rd cycle as Sheila mentioned too, but I don't know that I'd base a dose increase on 3rd cycle BGs. 3rd day or 6 cycles, yes because more likely the shed will be filled by then and the dose will show what it can do.

The shed or "depot" concept comes from the idea that Levemir and Lantus make a store of insulin. Think of it like a storage shed. You keep excess things in a shed, Lantus & Levemir need excess insulin around to work properly. Unlike other insulins, such as PZI, they don't run out at the end of a cycle, there's a little left over. This is very simplified, but then with every shot a little more is left over each time. What wasn't used by the body during that cycle stays in the shed. In order for the insulin to work properly, the shed has to be full so there's a continual supply of insulin going to the cells, rather than the constant depletion and refilling we see with PZI or Caninsulin. The shed concept is why Lantus and Levemir are able to create more shallow curves.

Not scientific, but it may help you understand. Another unique characteristic to Levemir and Lantus is that the response to a dose doesn't show up sometimes for 3 or 4 cycles. That is also due to the shed because the body is drawing from stored insulin, so to speak. If the dose is not big enough, the body will use up the shed faster so when you increase the dose it has to fill the shed first for the body to get the full effect from it.
 
I gotta say that I don't like the term "shed" or even "depot".

These insulins both work by having a "usable" amount and an "unusable" amount. What happens to both is a process of breaking down "storage" or "unusable" insulin into insulin monimers (usable insulin molecules). If the body needs more insulin it uses up the usable insulin before more is available and BGs run high. Conversely, having more insulin results in more available and if the body doesn't have enough blood sugar circulating the BG drops low. Getting the right dose means injecting the right amount of insulin to keep the balance for that particular cat. You want to start lower than is probably needed and slowly step up so there isn't a sudden large amount of usable insulin in their system - hence the "building up" of the "shed".

Still, each dose has it's own "building up" and "using up" stages. It isn't like you can fill the pantry for the winter and just use what you need when you need it. It's more like a newspaper subscription - the next one is going to arrive on your doorstep whether you read the previous one or not. So you better subscribe to the right sized newspaper you can finish in one day.

Lantus forms a sort of clump (precipitate) under the skin that breaks down into smaller (heximers) and smaller (diamers) clumps and finally to monimers that can penetrate the capillary membrane. Levimer binds to albumin under the skin and in the blood stream making it unavailable, but (if I remember correctly) it is a weak bond that forms and unforms repeatedly. Insulin is usable in the monimer/unbound forms.

I think it is really more helpful to just think of it as a long acting insulin that peaks, levels out, and then fades with each dose - in time lengths of 10-14 hours (total effective time). Where there is overlap of dose action is where you have to be careful and "find the balance". If you wait too long, the previous dose is all gone and the new dose takes time to "get up to speed" leaving a window of opportunity for BGs to climb. Also, if you shoot early you are creating a longer overlap so there is a potential for that dose to peak before the previous one has faded enough and risk lower than desired BGs. There isn't really a shed to fill or empty, but an overlap of insulin action to balance.

We were so used to the insulins that were completely and totally out of the cat's system long before 12 hours that these long acting insulins just make it seem like there is something else going on.

I suggested waiting only until the 4th shot to increase the dose because Shakes has been sitting in higher numbers and may not need the dose decreased so much. I think that if 1u is near the best dose, and certainly if it is too much, there will be a definite strong response to the insulin by the 3rd cycle. You wouldn't suddenly jump to 2u or something, but increasing to 1.25u or 1.5u would probably be fine.
 
Thank you for all that information
I gav him his first injection of one unit...
question though, I let the shot warm up before injection but he jumped like
it had hurt or stung
does levemir sting at the injection?
I will be watching him over the next couple of days...if he is not doing well I will increase dose
 
Hi Denise and Shakes!

I just wanted to drop in and tell you that I hope this does the trick for Shakespeare. I've watched and tried to help for about a year with you and him, and I totally get your switching, because he just wasn't responding consistently to Prozinc. Wishing you nothing but the best!


Sheila,
I wanted to thank you for that explanation of the "shed". Not a huge fan of the word itself either! I've been here for about a year, and although I used PZI and not one of the L's, I've done a lot of reading in LL. But I never quite "got it" on the shed/depot. Your explanation was the first one I've seen that made it "click" in my old brain. :lol: Many thanks!

Carl
 
dmartini4 said:
Thank you for all that information
I gav him his first injection of one unit...
question though, I let the shot warm up before injection but he jumped like
it had hurt or stung
does levemir sting at the injection?
I will be watching him over the next couple of days...if he is not doing well I will increase dose
Click to expand...

Levemir should not sting. You don't even need to let it warm up because it's such a small amount they shouldn't notice. It is possible to inject in a sensitive area and get a reaction from the cat. Are you using 1/2 inch or shorter needles? Insulin needs injected just under the skin, not the muscle or any layer beneath the skin. I would pull up a small bit of skin and inject while holding the needle almost parallel to the body.

Sheila, that's an excellent explanation of how the body processes Levemir and Lantus. I always have a hard time relating a more scientific explanation, so I try all these analogies. I think that's where "shed" and "depot" come from, the attempt to put it in layman's terms. I'm not fond of using those terms either, but they've been bandied about so much on the board that to say something else I'm afraid no one will know what I'm talking about!
 
Lev won't sting. You probably just got a sensitive area. Jeddie hardly ever reacts, but every once in a while I must hit a nerve or something and he reacts.

I am really happy that my explanation helped someone else understand these two insulins. A while back I did some research online, mostly because I didn't think that "shed" was correct or really explained what happens. I found some, relatively, simple info and copied it into a Word doc with the idea that I would work on a "better" explanation. Today, it just sort of happened.

Guess I better copy what I wrote for future reference.

Denise - paws crossed for Shakes liking lev and doing well on it!
 
Hey Denise...

Something I read - in this or the Lantus info, said when switching to one of the "Ls" that you should should start at a dose about 50% less than the dose you were giving. Don't know that I can put my hands on that document, but it's here somewhere. I know the same document said for Acro cats you didn't need to hold it for quite as long before doing an increase. Having said that, perhaps the info was on the Acro/IAA site. Worth a peek regardless.

Good luck to Shakes - see you here soon!

Lu-Ann
 
Hello Denise and Shakespeare!

Don't forget to check ketones- when I switched Sneakers she went from negative to trace to small in about 3 days, but then started to go down again. But I know Sneakers and she throws out ketones when there isn't enough insulin in the first place.

Good luck with the switch!

Heather
 
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