Day 2 Levemir Simba...

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Theresa and Simba (GA)

Theresa and Simba (GA)

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We have joined the Levemir group! I have added my 2 latest posts to update you, we have been doing good, but slacking here at FBMB learning to navigate the new board etc.. We have started a new spreadsheet too. Simba has never liked being BG tested so we do the best we can without upsetting him too much. I test his UG every day. Always about the same at .5 to 1 and never ketones. He was previously taking 5U Vetsulin. Due to really high numbers, I decided to raise the dose today. His numbers have been high all week due to insulin changes. The Vet predicted that he would need 2U or more.

http://spreadsheets.google.com/pub?key= ... utput=html

viewtopic.php?f=9&t=13108

viewtopic.php?f=9&t=13289

Thank you for your interest.
Simba - 12 year old male.
Diagnosed 3-09 Diabetes
also has a congenital diaphragmatic hernia.
Receives regular Veterinary care and is
otherwise in good health for his age.

Vetsulin last dosings were at 5U, kept him controlled. Not regulated. Vetsulin has been recalled, so we had a good opportunity to make a switch.
After 2 days trying Humilin we decided to switch to Levemir and quit fooling around.
 
Hi Theresa and Simba!!!

Welcome to Lev - we're thrilled to have you here (wow, look at me speaking for every one here :-D ). We're a close little family who all use Lev and are very happy with it. Welcome to the fam!

First off - well done at the vet's office!! Proud of you! When i told my vet i didn't think PZI was effective for my Molly and i wanted Levemir, she also pushed me to go with Lantus as she was more familiar with that insulin. I am fortunate she was willing to give it a try.

I think your starting dose of 1u is right on. I would suggest holding it for at least 3 days or 6 cycles. Let's see how Simba does.

How is the paw testing going? Do you mind if i ask why you said he has bad ears? Bad as in he doesn't want you touching them?

Others will be along shortly to say hi - Welcome again!! -Michele and Molly.
 
Hi and welcome Theresa!
Levemir is a whole different insulin from Vetsulin. It works by building up what you may have seen referred to as a "shed." Whereas Vetsulin would be completely out of the system by 12 hours after the shot, Levemir can maintain blood glucose longer at lower levels because of the shed, so we don't see that severe curve like occurs with Vetsulin or even PZI.

I'm curious as to what documents you've read so far on managing Levemir? Vital to understand how to achieve the optimum dose is the Tilly Protocol, http://www.tillydiabetes.net/en_6_protocol2.htm

It may take a few days for his body to acclimate itself to Levemir, so it's probably best to remain at a starting dose for at least 3 days. Since you've moved up to 1.5U, try to hold that dose for at least 2 more days and see what happens.

I'm also curious what you mean by "controlled," as opposed to regulated. Did his excessive peeing/drinking cease or would he have periods where it occurred while on Vetsulin? Did you have the vet do fructosamine tests while on vetsulin? What did those show while on 5U?

5U of Vetsulin is rather high unless there are other disease factors such as acromegaly. We have a member, Sheila, who previously used Vetsulin and I'm pretty sure she will tell you the same thing. She may not be on this weekend though because she has a family health issue she's dealing with. Her cat Beau went off insulin after switching from Vetsulin to Levemir within 3 months, and had used Vetsulin for 2 years prior to that!

Achieving remission should not be the goal - the goal should be to maintain blood glucose levels as near to normal as possible for the better course of each cycle. That in itself is what leads to remission for some cats.

I love how you phrased the comment that you decided to "quit fooling around" and made the switch. Bravo!

Don't get too anxious if his glucose remains high for a few more cycles. What we need to see is some movement of the numbers. It's best not to expect immediate results with each dose - it takes a few cycles to respond.

Please read the Tilly protocol and reread if you've already read it. Take notes for yourself. Then come back and ask questions! I'm sure Simba will do fine. He must be very pretty with a name like Simba - is he orange?
 
Thanks for your replies, today at 1.5 is a little better. We'll hold it there for a few days and see how it goes. I did read the Tilly Protocol and it is why I'd upped the dose a little. It recommends raising dose a small amount after 24-48 hours of too high numbers on a larger dose cat. You had asked about his ears, he has one that is a 'cauliflower' ear from an old hematoma surgery/cat fight. His other ear is good, and although the vet and everyone else says to test there, Simba says "No way Jose"! Of course, he is the perfect angel at the vet. We use his toe pad and he does fine , just harder to get it to bleed, Simba gives us 1 hassle free shot at it. I also check his urine glucose daily. His behavior has been good, he has food on demand and water intake/urine output is average today. He eats 4 3.5 oz servings of food a day and has a snack here and there. This is the norm for him. He is 10.5 lbs. I have checked into the acromegly and he has some similarities, he doesn't have the muscular look though.

Now it would seem to me, with the overlap, it would take awhile to find the actually nadir time. What have you learned about this? Thanks ttyl!

http://spreadsheets.google.com/pub?key= ... utput=html
 

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Theresa and Simba said:
Now it would seem to me, with the overlap, it would take awhile to find the actually nadir time. What have you learned about this? Thanks ttyl!
Click to expand...

Glad that he's doing OK with the routine.

As for nadir, it is simply the lowest point of blood glucose during a 12 hour cycle. It is true that some cats experience this low point AT the 12 hour mark. A bit disconcerting for those who discover their cat experiences this extended duration because it means shooting insulin at normal blood glucose levels, but it's necessary to keep them level.

Levemir has shown nadirs usually after the 7 hour mark, anywhere between 7 and 12 hours. The average is about 9-10 hours after the shot. And it's usually consistent, occurring within the same hour span each cycle.
 
Hey, Teresa, it's been a long time...

I just tried to open your (Simba's) SS, but Google was having some issues or something.

My gut reaction is that 5u was a lot of insulin and I wonder about rebound. Would like to look over his numbers before commenting further though. I seem to recall we posted back and forth about it when he was on vetsulin.

I would encourage you to not raise the dose too quickly (on lev). It really is a completely different insulin and you sort of have to throw out all your previous thoughts about dosing and how Simba reacts to insulin. Beau, for instance, was started at about half of his vetsulin dose and by the third shot he dropped into the 30s. I dropped the lev dose, but still didn't get good numbers so I raised it back up and got worse numbers. For a while it seemed like a half unit was too much, but .4u was too little. Turns out they were both too much.

Anyway, as long as you are testing for ketones, don't raise the dose without letting it settle at least 3 days (5 would be better) AND getting a curve done so you know how low he is going. With lev, dose changes are made more on the nadir, whereas with vetsulin changes are often based on PS numbers.

Welcome on board the Lev train!
 
Hi Sheila, I see you have added a Jeddie! Simba is doing ok , I just got in and he was ready for food so we checked him and he is in the 400's at +7 . This has been consistent from the start which is a sign that he will be needing a little higher dose soon. I doubt rebound because it has been the same every day at the +7. He was on 5U of Vetsulin. i will leave the dose for another day or two, but, I won't let his numbers stay that high for long. So nice to hear from you!
 
HI Theresa,

Welcome to the Lev board!

Wanted to mention/reinforce about Lev being a very different insulin than Vetsulin. We used vetsulin the first time around ( PK was OTJ for 6 months from it) and when we started the L's ( Lantus first, then Levemir) it was a pretty steep learning curve after being steeped in vetsulin mentality for so long.

SInce you pretty mich get one pass at the blood testing, do you think maybe you could vary the hours in the cycle that you get that number?

If you can collect a +3 one cycle, then a +9 another cycle, then a +5 or +8 and so one, after a week or so you should be able to identify Simbas's peak time.

It is that peak number that you really want to focus on and adjust doses by....not the PS. Of course in PK's case, his PS and peak are one in the same- he is a late nadir kitteh.

It is advisable to note when he eats as well, so you can identify food spikes as opposed to just high BG's in general. ( I think I read you are testing ketones, right?)

Also- since Lev seems to build over time and needs a decent settle time, it is advisable to let doses settle for a minimum of 3 days ( 6 cycles) however I find that PK continues to settle through day 6 ( 12 cycles).

Lastly- I am not sure if this is b/c he is unregualted and his body just isn't using food properly, or something else- but what you wrote here really stands out to me- He eats 4 3.5 oz servings of food a day and has a snack here and there. This is the norm for him. He is 10.5 lbs.

Most cats eat about 5-7 ozs A DAY....from what you write, he is eating about FIFTEEN ozs a day! This may be one reason for high BG's- too much food to process at one time, overwhelming the body/pancreas... I am assuming you are offering a LOW CARB food?

Is hyperT a consideration for this kitty?

Thanks for sharing your Simba's Lev journey with us- look forward to reading your future posts!

(((hugs)))
 
Melissa asked some very good questions. I agree with observation about how much food he eats, I thought that was a lot myself. And Hyper-T is also something older kitties should be tested for, especially those with a chronic medical condition.
 
Was finally able to open the SS. Not really enough numbers yet, and too early in the switch to see any patterns. A couple of things that come to mind are - again - you have to let the lev dose settle. The Tilly protocol is a guideline, but in application it is our experience that a dose needs to settle for at least 3 days and should not be changed without knowing what the nadir is. Nadir time may be different on lev than on vetsulin.

Also, when I see 500s, I always think rebound if the cat is not a dry food eater. So it makes me wonder if he came into lev with rebound from vetsulin. What kind of numbers did you get on vetsulin? (average PS's and nadir).

Yes, that is a lot of food for a 10.5 lb cat, so I wonder about hyperthyroid as well. And, sis you ever have an acromegaly test done?
 
Hi Sheila, we may have messed things up a bit when we made the switch... at first, I thought we would try the Humilin and the vet gave us a few doses to try while I thought about his offer to try Lantus. I did some research here and checked on some friends here who had used Levemir and Lantus . The smoother curves and good results for others swayed me in the direction of Lev. I also liked the Lantus results but the strict testing with Lantus could be hard for us to achieve. So, he has had 3 different insulins within a one week period. The dosage was dropped way back for the Humilin using 2U as a start up dose, which sent his numbers up, the vet did a curve that first day. Neither of us was impressed by the results and so we discussed the other options. Nadir of 388. ( granted the dose was lower.) I went back and he gave me the Lev script, so again we had to start over which lead us to where we are at today. I did not do any additional testing for acro or anything mostly due to the cost. I agree that we need to hold this dosage until things settle down a bit.

His Vetsulin results were average over the last year with small dose increases needed throughout the year. At 5U Vetsulin he seemed to be doing pretty well. Nadirs in the low 100's and sometimes even under 100's. We usually just randomly checked nadirs at home. UG test done every day. I use toilet paper in his litter box making it simple to get a sample. Dose increases were determined by fructosemene tests. When his UG is consistently high we take him in for the fruct. test. We found the fructosemene tests to be the most accurate and cost effective.The vet thinks the food consumption is diabetes related, due to him never really being regulated for long, just controlled. I assume that excessive eating also interferes with his BG results?? We will do another fructosemene test at the end of this vial. With more home testing, I hope to have him under control by then. The vet was not as knowledgeable on Levemir as he is Lantus so he was concerned about my decision. I know we can get this to work with the guidance we are receiving here. Thank you, I appreciate the support.
 
Hi again -

Just wanted to comment real quickly on the paw testing,,,,while i am more familiar with ear testing, with both ear and paw testing they need to "learn" to bleed. Yeah, i know that sounds a little insane and the first time someone said that to me i thought they were off their rocker but yup, it's true - the area really does need to learn to bleed. It will only get easier, i promise!

Proud of you, you're doing great!! -Michele and the Molly
 
Welcome Simba and Teresa!

I too wondered about the large amount of food and if there was a possibility of HyperT (GMTA Melissa) :). Tigger eats about 7 ounces of food per day and he is 15 lbs. But of course ECID. You mentioned you are feeding grain free but maybe I missed exactly what kind...just curious.

Since you and your vet rely a lot on fructosamine values this might be another reason to rule out whether or not he is hyperT. I just ran across this article the other day about fructo values being possibly unreliable in hyperT cats. Maybe copy it out and run it by your vet?

http://www.vet.uga.edu/VPP/CLERK/Bates/index.php

"Feline hyperthyroidism: Hyperthyroid cats may have decreased fructosamine levels, despite having normal serum protein levels.10 It has been proposed that the decreased glycosylated protein levels can be explained by an increased protein turnover rate (decreased protein half-life) due to increased thyroid hormone levels.10 In hyperthyroid cats with decreased fructosamine concentrations that were treated with radioactive iodine (131I, a common treatment for hyperthyroidism in referral centers), the fructosamine concentration increased and throxine (T4) concentration decreased following treatment.3 Thus, the rise in fructosamine concentration after 131I treatment is thought to be due to normalized or decreased protein turnover.3 Serum globulin concentrations also increase after treatment with 131I and globulins have a greater affinity for glucose in cats.3,9 Because hyperthyroidism decreases fructosamine concentration, serum fructosamine levels should be used with caution in the diagnosis and monitoring of diabetes mellitus in cats with underlying hyperthyroidism.3"

Also do you have a profile from the old board? You can link to it here. Or set it up in Google docks. Let us know if you need help.

I am sure you are going to love levemir like all of us do. Check out my spreadsheet to see our journey. Tigger is on 3 units BID and doing fine. :)
 
Thanks for the info Pam, he had his senior profile since this started , don't think they do thyroid on that but I will see if they did. I think his problem now is not enough insulin. We just have to work our way back up up slowly. I see Tigger needs 3 units to maintain and I figure Simba will need 2-3 units too. The Vetsulin was just too short acting to regulate him. Fingers crossed for Levemir. Lately, he has been eating whiskas new wet food, he likes it a lot . We also feed FF and sometimes friskies canned turkey and giblets, meats from the table too. etc. He used to eat some Evo, but he has started losing teeth and can no longer eat it. He does bleed ok he just doesn't like being held ... ever. He is not a lap cat. He bit me tonight and we ended up with a high reading. We are testing more right now than we usually would. Most of his BG results are probably elevated from his squirming. We have been going thru this for a year now. I find that the UG is pretty effective, for general monitoring, even though the results are delayed. It gives us a good idea how his day/ night has gone. It is just cannot be used for dosing adjustments, because it is not exact. Would love to see a glucose free UG stick one day.
 
Theresa,
Are you considering an increase today? Sure looks like he needs it. He's just sitting in the 400s.
I'm sorry he bit you! It's difficult because he doesn't understand it's all part of helping him.
And a note about your vet being uncomfortable with your using Levemir - it works the same as Lantus, so his familiarity with Lantus should serve you just as well.
 
Thanks Vicky, I gave him a heavy 1.5 just a tiny bit more. Want to give it one more day... may go up .25 tomorrow and slowly pushing towards 2. It is very hot here now and he seems a little more relaxed today. He has had 2 servings of food so far. He did not finish his lunch. He did not do his usual pee this morning, which may be a good sign. Just couldn't get a UG reading. Just got home and DH had let him outside to potty. Simba is calm and napping, would love to test him right now but, he is so content, I am going to leave him alone for the moment. He needs the rest. When he is calm and not begging I know his BG is better. He is at +5 now. I will test when he becomes active again. Fingers crossed.
 
Theresa, I read on the lantus posts that you were given "needles" to stick him with that worked better than the lancets.. I was wondering if you have tried BD Ultra Fine II lancets? They are the only ones I will use on my guys - all others, frankly don't work - I can't get the drop of blood. Really, it feels like the darn lancets are dull or something. The BD ones work beautifully. I don't know about on paw pads, but it might be worth a try?

Also, did you get u100 syringes with half unit markings? That would help over the ones without them. I order mine from Hocks, linked above - the GNP ones. Hocks also sells the BD lancets.
 
Re: Thanks Sheila and Vicki

yes, we do have the U100s with extra markings.They are 3/10 3G. I didn't care for the needles the vet gave me much so we are using the lancet again. I will keep the BDs in mind. (I also have a stash pack of BD UF needles and syringes that were given to me). Vicki, I did up his dose tonight to a skinny 2U. Thanks.
 
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