60 days on Lev - need advice

[dosgatos]

Hi everyone,

My cat Akane has been on Levemir for 2 months but I am not doing well for him. I would be happy if you could look at his numbers and give me your feedback!

His brief history. 13 yrs old, neutered. Has been diabetic for 3.5 years. Previously on BCP-PZI 40U 3.5 years but only 1 static dose per day without home-testing during the first 2.5 years as that was our vet's instruction.. His pre shot number was around 400 and it went down to around 100 after 11 or 12 hours whenever I took him to the vet for blood test.

Experienced hypo seizure in the 2nd year while suffering from pancreatitis for months (received no treatment) and developed into DKA a few month later. He was almost dying but survived...

I started home testing and switched his diet from prescription dry food to low carb wet and home made raw. And started tight regulation by Dr Hodgkins and dosed him 2 or 3 times a day as needed. His condition began to improve dramatically and he gained his weight again (from 2.2 to now 3.6kg or 7lb? He is a small cat.) and his fur shines.

He is now on Fortekor (benazepril), Covalzin (toxin binder) and Ursodeoxicol for his kidney and liver. His USG is still within normal range. He is quite active and he often runs after his brother. His water intake has increased a bit since changed to Lev...

He was doing fine on PZI with the support from Diabetic Cat Care forum members but we switched it to Lev as it is getting harder to import it due to BSE issue. His dose of PZI was tiny and he usually received 0.4u to 0.6u each shot. Now his current dose is 0.3u skinny - or that is what I think! I draw to 0.5u and expel 2 drops and a tiny bit.

I have read the stickies in the forum and information on Petdiabetes wikia, micro-dosing pictorial guide, and visited Tilly's page. I am aware that I changed dose too often too soon. I am learning.. I have recently looked at some Lev cats' progress and noticed that sometimes reduction could work amazingly. I would like to learn about it as well as how everyone is managing micro-dosing. I seem to be doing it poorly so he may be receiving inconsistent dose.. I am using Monoject 3/10cc for U100 with half unit markings.

I would appreciate any thoughts and input from you! :smile:

Mami

ETA ---6 Feb 2011
Changed syringes to BD as of end of Jan. His water intake and peeing increased.

 

[Melanie and Smokey]

Lev is an insulin that liles consistant dosing on a 12/12 schedule so changing times or dose could have consequenses. I would recommend the Lantus ISP, I think many of the Lev users hang in there and the dosing advisers in there are the best.

 

[Vicky & Gandalf (GA) & Murrlin]

Hi Mami,

And welcome to FDMB. Thank you for the very comprehensive details of Akane's status.

The drop method to achieve consistency with microdoses works very well. I will alert other members who have managed it. Perhaps they can post here so others can learn as well.

I see you had a 25 the other night on .3U! That means .3U is too much, as you probably suspected. It is not wise to continue with .3U following that low although the numbers are now higher. That is a pretty extreme number on Levemir and unless there was another factor causing it, such as not eating any food, the dose most definitely should be lowered.

Lowered to what, you're probably asking. When dealing in microdoses, it's easier to think in percentages. I think 50% decrease to .15U is reasonable when the dose is this small and he had that drastic of a drop. The higher numbers you've seen since are a reaction to that low. Have you read about rebound or what we sometimes call bouncing?
http://petdiabetes.wikia.com/wiki/Somogyi_rebound

He came up quickly - did you use syrup or just high carb food?

Other than that, you're doing well and he's getting some good numbers. A lower dose might actually level the blood glucose out. His diet is excellent - have you ever tried taking him off insulin completely, although it's not recommended to do that even when at these small doses. Often times they still need a little help to keep numbers in normal ranges.

You are also correct that consistent dosing, both in unit measurement and time, is necessary to help Levemir work its best. Hopefully others will reply to help with the microdosing methods.

 

[dosgatos]

Thank you, Melanie and Vicky for your prompt responses!

Vicky, yes, the drop from 154 to 25 in 1.5 hours was totally unexpected! :shock: He was sleeping but woke up and ate his usual wet food (no carb) and a bit higher carb one a lot.. I have no idea. The dose could have been a bit more than I intended even though I measured it so carefully.. Or could it possibly be a hot water bottle he usually sleeps with on his back that might have affected the speed..??? I have read somewhere that heat, sub q fluids, brushing, etc. any stimulants on skin could affect its reaction, though this was about Lantus.

Yes, I have read the somogi effect. He usually comes back from rebound very soon so I was thinking higher numbers last 2 days were not a reaction from 25.. I was hoping that if I can manage to dose him 0.3 skinny consistently, he would go down to lower range..as other doing great kitties.

Even though his condition improved very much compared to the time when I was only blind dosing, I think damage caused by long period of pancreatitis and severe DKA may be significant and that is why, I think, he can not get a longer duration anymore even with PZI. He is a low dose cat but I do not think he can go without insulin..

 

[Sheila & Beau GA & Jeddie GA]

Hi, Mami, and welcome to you and Akane!

I have two diabetic cats, one is in remission (Beau) and the other is on levemir. Beau was on another insulin before I switched him to lev. He ended up being a micro dose cat and I was giving doses like .2u, .1u and, at the end, .05u before he went off insulin.

Maybe you read my method for getting the small doses over on the Levemir ISG (Insulin Support Group)? It does need to be practiced:

The drop method I use is to practice with a used syringe and water or expired insulin and draw up .5u, then twist the barrel (clockwise if the needle is pointed away from you) slightly until a drop forms on the end of the needle. It will be about the size of the end of a straight pin. Flick it off and twist to form another one. Practice until you get 5 drops that size from a half unit. Those would be .1u drops, so you can dose fairly easily in any increment of .1u. If you want to perfect that, try for a drop HALF that size. Those would be .05u drops.

I suspect that Akane may need .2u or .15u as Vicky suggested.

Something that might be easier (long explanation - bear with me): I looked really closely at my syringes and found that the width of the top of the stopper - the flange part - and the width of the lines were the same. When the top of the stopper flange is just meeting the bottom of the zero line (needle pointing up) the bottom of that flange is just touching the top of the half unit line. That means it is measuring .16666u (I just call it .15u). Maybe that will work for you? Make sure that your zero line is actually printed at zero (no part of the stopper can fit above it). I have had syringes marked so far off there was .25u above the zero line.

Also, Beau has a long history of pancreatitis and was on steroids for it from the age of 3 to the age of 6. He also has cardiomyopathy and hyperthyroid. He was on a fast acting insulin (vetsulin) for over 2 years. All of those things should have made it very unlikely for him to go off insulin, but he did. So never say never! If you look at his spreadsheet from Aug to Sept 2009 you will see how his dose decreased and his numbers went down. I did try to skip insulin, but his BG would creep up. He went without insulin for a week when I was out of town and I felt it was safer given his very low dose and occasional drops to low numbers. He could bring himself down, but would still go back up again so he got his .05u dose "as needed" for about a week.

 

[dosgatos]

Thank you very much, Sheila! Beau's story is wonderful and very encouraging! Yes, I read your method and practiced a lot that way but .. I can never be sure if this amount is the same as the last one! Are you using the same syringe?

Today he was good and his number was 147 at +12 so I reduced to 0.25. A bit scared to dose 0.3u skinny to that number..

So two of you suggest lowering the dose to 0.2u or 0.15u for Akane but why ? What is the logic or.. what is the mechanism of Levemir? I know he dropped to 25 with 0.3u but not always. And he did not do very well with 0.25u at the beginning. Where do I need to look at in his data to suspect that he may need 50% reduction? Can I learn it?

Edited to add
He is now 278 at +3.5. :shock:

 

[Sheila & Beau GA & Jeddie GA]

Mami, the answer to the dose reduction is in the basic Tilly Protocol - if they drop below 40, reduce the dose.

Now, every cat is different (ECID), of course, and when you have enough data you can make a decision based on your cat - how you predict he will react, will you be home to test/watch him, etc.

Because you are fairly new to lev and don't have a lot of data, dropping the dose is the safe thing to do. If he went low because of other things, like shooting early (less than 12 hours), didn't eat as much, exercised more, had some stressful event, then the numbers will show you that you need to go back to the last working dose.

However, because of rebound issues, you need to let a few cycles (up to a couple of day) pass before making that decision (to raise the dose back up). The high 200s and 300s he had the cycle after he dropped to 25 indicate rebound. Then he settled after that - more or less. Earlier today was looking good. Now with the dose reduction, you have to let that settle as well. It is not unusual for the first cycle or two to show a bit of increase before settling back down.

You have read the Somogyi Rebound section of petdiabeteswiki, right? Link: http://petdiabetes.wikia.com/wiki/Somogyi_rebound

That was what finally clued me in to the fact that Beau was rebounding and I started reducing his dose. I had read it many times, but it finally clicked for me. It is very hard to tell the different between rebound and not enough insulin. The BG will be high in both cases.

Learning to analyze the numbers just takes experience and a familiarity with YOUR cat's response to different doses, foods, schedules, etc. I look for patterns: Does a 300 always follow a low number? How low was the number? Are the numbers high and flat with rare drops to below 50? (that would indicate rebound and too much insulin) Are the numbers high, with a decent drop, but only to upper 100s? (that would indicate not enough insulin) What is the overall drop and how fast was it? How fast did the BG go back to the PS level?

Unfortunately, working with hormones like insulin is not "logical". :mrgreen:

Lev works by binding and unbinding, repeatedly, to albumin in the blood stream. The insulin can only be utilized in the unbound state, so that gives it a sort of "time-release" mechanism. Once the optimal dose is found, the level of insulin has built up in their system (the "shed" people refer to) and is fairly constant (or should be) and the BG should be low most of the time. That means you will be shooting a full dose on a "normal" number. In my experience with Beau, he would range from 60-170. Anything higher, or lower, than that indicated rebound to me and I reduced his dose again. It was very subtle. I know people here will shoot 1u or more on an 80 or even a 60. That still scares me, but they know their cat will rise a bit from there and won't drop too low because they have the data to support that.