just a few comments on some of the statements made in this thread...
Dale 'n' Chip said:
BTW Dr. Hodgkins didn't say much about Levemir, I assume she hadn't used it. But the same flawed study had nearly the same remission rates for Levemir. My thought is that a larger proper scientific study would show both of them lower than that.
there's a little history here that you appear to be unaware of.
that first study had 8 cats on lantus in it. a copy was available on this site somewhere, but i just looked for it and couldn't find it. that doesn't mean it isn't hiding around here somewhere. the results were the basis of the
first "Rand" Protocol (not to be confused with the more recent study in which our current TR protocol is based on). the Dr. Hodgkins quote you mentioned above was in reference to that very first study:
Treatment of newly diagnosed diabetic cats with glargine
insulin improves glycaemic control and results in higher
probability of remission than protamine zinc and lente
insulins
RD Marshall BVSc, MACVSc
1,2, JS Rand BSVc, DVSc, DACVIM
1*, JM Morton BVSc, PhD, MACVS 1
1Centre for Companion Animal
Health, School of Veterinary
Science, The University of
Queensland 4072, Australia
2The Cat Clinic, 189 Creek Rd, Mt
Gravatt 4122, Australia
Glycaemic control and remission probabilities were compared in 24 newly
diagnosed diabetic cats treated twice daily with either glargine, protamine zinc
(PZI) or lente insulin and fed a low carbohydrate diet. After day 17, the
probability of remission was substantially higher for cats with lower mean 12 h
blood glucose concentrations on day 17, irrespective of insulin type.
Glargine-treated cats had lower mean 12 h blood glucose concentrations on day
17 than PZI- or lente-treated cats, and all eight glargine-treated cats achieved
remission compared to three PZI- and two lente-treated cats. The probability of
remission was greater for cats treated with glargine than cats treated with PZI or
lente insulin. In newly diagnosed diabetic cats, twice daily treatment with
glargine provides better glycaemic control and higher probability of remission
compared to twice daily treatment with PZI or lente insulin. Good glycaemic
control soon after diagnosis is associated with increased probability of remission
and should be the goal of insulin therapy.
Date accepted: 12 May 2009 2009 ESFM and AAFP. Published by Elsevier Ltd. All rights reserved.
the study was finally accepted for publishing in may 2009 by Elsevier, but the study was done years earlier... typical of most studies. it often takes years before something is published.
i believe what you're calling the "same flawed study" refers to remission rates in a
second study involving 55 lantus kitties and 18 levemir kitties. the details of this second study can be found here:
STICKY: LANTUS & LEVEMIR - TIGHT REGULATION PROTOCOL.
more on the subject...
J Feline Med Surg. 2009 Aug;11(8):668-82. Epub 2009 Jul 9.
Intensive blood glucose control is safe and effective in diabetic cats using home monitoring and treatment with glargine.
Roomp K, Rand J.
Department of Computational Biology and Applied Algorithmics, Max Planck Institute for Informatics, Saarbrücken, Germany.
Abstract
Human diabetic patients routinely self-adjust their insulin dose using a protocol and home monitoring, and perform equally well or outperform physician directed adjustments. The objective of this study was to report the outcome of home monitoring of diabetic cats by owners using a protocol aimed at achieving euglycaemia, using ultra-low carbohydrate diets (< or =10% metabolisable energy) and the insulin analogue glargine for >10 weeks and/or until remission was achieved. Fifty-five cats diagnosed with diabetes mellitus, whose owners joined the online German Diabetes-Katzen Forum, were included. An overall remission rate of 64% was achieved in the cohort. Significantly higher remission rates were observed if good glycaemic control was achieved soon after diagnosis: 84% for cats started on the protocol within 6 months of diagnosis went into remission, and only 35% for cats that began more than 6 months after diagnosis (P<0.001). Only one mild clinical hypoglycaemic episode occurred observed despite tight blood glucose control. In conclusion, intensive blood glucose control is safe and effective in diabetic cats using home monitoring and treatment with glargine.
PMID: 19592286 [PubMed - indexed for MEDLINE]
edited to add lev abstract:
This abstract was presented at the 2009 ACVIM Forum:
ABSTRACT #41
EVALUATION OF DETEMIR IN DIABETIC CATS
MANAGED WITH A PROTOCOL FOR INTENSIVE
BLOOD GLUCOSE CONTROL.
K Roomp1, JS Rand2.
1. Max Planck Institute for Informatics, Germany. 2. Centre for
Companion Animal Health, Uni of Queensland, Australia.
There are no reported studies of long-term use of detemir in
diabetic cats. The aim of this study was to report outcomes
using detemir and a protocol aimed at intensive blood glucose
control with home monitoring in diabetic cats, and to compare
the results to a previous study using the same protocol with
glargine.
Eighteen cats diagnosed with diabetes mellitus were
included in the study. Cats diagnosed with acromegaly were
excluded. Data were provided by owners who joined the
online German Diabetes-Katzen Forum, and followed an
intensive blood glucose regulation protocol for a minimum of
5 months or until remission was achieved. Detemir was
administered twice daily and a low carbohydrate wet food diet
was fed. The insulin dose was adjusted aiming to achieve
euglycemia (50-100 mg/dL as measured using a portable
blood glucose monitor calibrated for human blood). Owners
performed an average of 5 + 2 blood glucose measurements
per day in the stabilization period, and supplied spreadsheets
recording daily insulin dosages, blood glucose concentration
and clinical information.
Seventeen cats in the cohort were initially treated with
another insulin type (16 with porcine lente insulin) for a
median of 9 weeks, but failed to achieve remission prior to
switching to detemir. Most (15/17) of these cats were fed a
low carbohydrate diet while on the other insulin.
The overall remission rate was 67% (12/18). For cats that
began the protocol within 6 months of diagnosis, the remission
rate was 81% (9/11) and for those that began 6 months after
diagnosis, the remission rate was 42% (3/7). The median time
to remission was 1.7 months after beginning the intensive
protocol (range = 10 days to 5.3 months). Nine cats of 12 cats
(75%) achieving remission remained off insulin, and the
median duration of remission was 12.3 months (range = 6.4
months to 2 years). Three cats (25% of remission cats)
relapsed and required insulin again. Only one of these relapsed
cats achieved a second remission.
Six of 18 cats (33%) in the cohort required insulin
throughout the study to control blood glucose concentrations
and did not achieve remission. The median length of time on
the protocol was 10.3 months (range = 5.4 months to 1.2
years). The majority (83%; 5/6) of long-term diabetics were
considered well regulated with a median blood glucose
concentration of ≤150 mg/dL and 17% (1/6) were moderately
well regulated (median blood glucose ≤200 mg/dL). Clinical
hypoglycemia was rare, with only a single event in one cat
which had mild signs. The median maximum insulin dose
administered to cats in the study was 1.75 IU twice daily.
These results are comparable to those of the glargine study.
No significant differences were identified between outcomes
for glargine and detemir, with the exception of a lower
maximal dose for detemir (p-value = 0.045). The median
maximum glargine dose was 2.5 IU (range = 1.0 to 9.0 IU)
compared with a median detemir dose of 1.75 IU (range = 0.5
to 4.0 IU).
http://www.acvim.org/websites/forum/File/docs/2009ACVIMForumAbstractsFinal.pdf
Dale 'n' Chip said:
But almost everyone agrees Levemir is a better choice all other things the same, provided albumin is normal. We'll see and try to have realistic expectations this time. But if you look even the TR so called experts are using Levemir. So there must be some reason for that.
no, not everyone agrees levemir is a better choice.
the "best" insulin is the insulin that works for YOUR cat. over the years, we have seen cats do very, very well on
each and every insulin available.
i've never considered myself an "expert" at anything much less insulin, but i can tell you why "i" currently use levemir after starting out with lantus. alex did very, very well on lantus when she was diagnosed in 2006. she went OTJ after 3 months on lantus. if i knew then what i know now, her time on insulin may have been shortened. she stayed OTJ for almost 3 years. a simple case of gingivitis knocked her out of remission in 2009. then and now, we helped/help many, many levemir kitties in what's now called the Lantus TR ISG.
i saw a golden opportunity to get some hands-on experience with levemir... so i seized the moment and asked my vet for a script for levemir. had to spell it for him because he never heard of it. i just told him to trust me... and he did. alex spent 8 weeks on levemir before going OTJ a second time. she remained OTJ for approximately 5 months before an episode of severe liver and acute renal disease of unknown origin in 2010. when it was clear she had to go back on insulin, i reached for the levemir
because it's what i had in the refrigerator. she remains on levemir to this day. it's easier to refill/renew a prescription than get a new one.
there are others who have switched insulins for a variety of reasons. when caregivers are not seeing the results they desire and
are using their insulin of choice properly... no matter which insulin... we often suggest trying another insulin. after all, some kitties do better with one insulin than another.
over the last 6 years i've been a member of the FDMB, i have seen kitties switch from lantus to levemir, from levemir to lantus, from pzi/prozinc to lantus, from pzi/prozinc to levemir, from humulin N to lantus or levemir, and from lantus or levemir to pzi/prozinc. there's no "best" insulin. again,
some kitties do better with one insulin than another. fortunately, we have several kinds of insulins to choose from!
Dale 'n' Chip said:
It's gentler, more durable, less risk of hypo, more even dispersion and it's ph neutral so it doesn't sting like Lantus. :smile:
not necessarily so. it depends who you ask. :lol:
when lantus and levemir are handled properly, we've seen caregivers get about the same mileage out of both. members of the german-katzen forum found about the same to be true. personally, i've had some levemir go bad (crystal formation) before my lantus went south and vice versa.
not sure where your "more even dispersion" claim is coming from. please share any documentation you may have. i love learning about the insulins we use... especially when it comes to lantus and levemir.
humans have reported feeling a "sting" after injecting lantus. you have to keep in mind humans inject much larger doses of insulin than what *most* of us inject into our cats... the exception of course being kitties with high dose conditions. when my husband was in the hospital last year, the doctor started out with injecting 10 units. from what i hear, human diabetics may inject upwards of 5 times that amount. while there may be a momentary sting at high doses, after you inject lantus into kitty's subcutaneous tissue, the acidic solution is neutralized by the body to a neutral pH. fwiw,
my cat has flinched more times (causing fur shots) when injected with levemir than lantus... and i know she's not the only kitty who this has happened to. frankly, it hasn't seemed to be much of a problem so i've stuck with levemir.
as far as hypos go, i think it's important to note kitties can and some do experience hypoglycemic episodes after receiving any of the insulins available to us. we've seen/heard of symptomatic as well as asymptomatic hypos from every one of the insulins. just a few months ago i was made aware of a levemir kitty who had experienced a
symptomatic hypo... "staggering, unable to walk, glassy eyed, and trembling"...
on a dose of 0.1 unit! this is why we promote hometesting.
Dale 'n' Chip said:
The onset and nadir may be a bit later but with Lantus (as you can see) there is no set time. The Nadir can be anywhere, shifting around. Even at AMPS and/or PMPS. In looking at Levemir SS's I don't see it shifting around like that, so it might (should) be more predictable. Seems like Levemir might not have quite the same problem of "dumping the shed" so it should be safer for hypo.
there's no set time with levemir nadirs either. nadirs can and do change... whether you're using lantus or levemir. alex has had lev nadirs anywhere from +6 through +12. nadirs change. she's currently going through one such change.
Pumbaa said:
My only problem with the Levemir is if the onset is really about an hour later, which, to me, would also make the nadir later? Which would mean more frequent 1 am & 2 am testing times? Ugh!
ECID is not just a slogan. "when" onset occurs when using lantus or levemir can vary depending on the cat. same thing with nadirs. generally speaking, you'll see action from lev later in the cycle than when using lantus. actually, this seems to be a primary reason why some caregivers of long-term diabetic lantus kitties do not try levemir. their schedules don't allow it.
sorry. somehow this turned into a novel. :mrgreen:
fwiw, just my thoughts..
