Do Some Cats Not Respond To Levemir?

[Anonymous]

Is it possible that some cats don't respond to Levemir?
When Buddy was diagnosed with diabetes on 11/19/10 his bg was 454. My vet prescribed 3 units of Humulin 2x/day. His #'s came down to 127 and his highest number was 264 and at that time he was still eating dry food as well as wet Fancy Feast (which is what he was fed all of his life). It was suggested that I switch to Lev because of the high remission rate, etc. My vet was not familiar with Lev but agreed to work with me and support me. He said that due to his unfamiliarity with Lev he would not suggest a dosage but since I was working with those who've had great experience with Lev he would go along with it.
We started out on Lev for 10 days at 1 unit 2x/day and his numbers kept climbing thru the 300 & 400's (plus I eliminated dry food at that time too). His overall personality spiraled downhill. Buddy and I were really a "bonded" couple. He was always with me, slept with me, etc.,. But since I started on the Lev and home testing he became extremely stressed; he hid from me, would never even stay in the same room with me and stopped sleeping with me (first time in 8 years).
I took him to the vet and he said to increase dosage to 3 Units 2x/day and DO NOT TEST FOR ONE WEEK. Very quickly, his personality came back, slept with me, his water intake finally decreased, became playful again, all very positive things. I eased back into the testing at mid-point during the cycle and now doing a test at pm preshot, his numbers are not improving.
I know I'll be getting a lot of flak about needing additional numbers throughout the day, but after 27 days on Lev, at a low dose, then a high dose, shouldn't signs of lower numbers be appearing?
My only question is ... "has anyone heard of a cat NOT responding to Levemir"?
I'm at a loss. My vet also said he's not liking what he is seeing. What must I do?
Thanks in advance to anyone willing to offer advice.

 

[Sue and Oliver (GA)]

I think any given cat can respond to or not respond to any given insulin. I am not sure you have given Lev a chance, however. It is never a good idea to increase by 2 units (from the 1 to 3 units), with any insulin. If one unit is not working, the next dose increase would generally be to 1.25. After that is tried for awhile, then another .25. If you don't move in slow increments, it is very possible to go over the ideal dose and end up in high flat numbers.

This is true for all the insulins, not just Lev. And all the insulins require a mid cycle number as often as possible. It's the only way to see what the insulin is really doing. You don't have to test constantly, but those 2 numbers are vital= the 2 preshots and the midcycle number as often as you can get it.

 

[Venita]

Hi Bel and scritches to Buddy,

I am so sorry to hear that you are getting nowhere positive on the Levemir. I take that back. You are getting somewhere. Buddy is back to being a happy cat.

I wouldn't say that Buddy's doesn't respond to Levemir. It was dropping his BG levels on most of those days in January when you were testing pre-shot and mid-cycle. It just wasn't dropping him low enough and the way he was feeling "spiraled."

After a couple cycles with mild dose increases, the vet tripled Buddy's starting dose and gave him and you a testing vacation. The good news is that you got your bonded Buddy back. The bad news is that we really can't tell you whether the 3U is too high or too low a dose for Buddy. We could all have our guesses and suggestions for the next step, but we cannot point to carefully gathered information to support our positions. We would be shooting in the dark.

I probably shouldn't say that either. There may be people here who have been through this scenario who can make a good, educated guess about next steps, so let's wait for them to chime in.

I know that one of the concerns you have with increased BG testing is that it will drive Buddy to avoid you again. That may or may not happen. When you were testing him at PS and mid-cycle before, he wasn't feeling well. Now that he is back to being Buddy, perhaps he will tolerate it better. How is he doing with the tests you are taking?

There are ways to test urine for glucose...either a test stick or a confetti product for the litter box called GlucoTest. However, those may not work for you given that Buddy mostly pees outdoors.

In looking closer at your post you said:

after 27 days on Lev, at a low dose, then a high dose, shouldn't signs of lower numbers be appearing?

If Buddy was my cat, I would likely try one thing that you haven't tried with the Levemir...a dose between the 1 and 3 units. You had Buddy on 1U for about 9 days. His mid-cycle tests were between the mid-200s and mid-300s. The tight regulation protocol here would say that you should have increased him by .25 or .5U. I would have increased by .5U because he had more mid-cycle 300s than mid-cycle 200s. But he is clearly doing better purrsonality-wise on 3U than he was doing on 1U. So I would likely reason my way to a change to 2U.

Another option would be to increase the dose. If that is the way to go, I would likely go up .5U because high midcycles were more common.

The last option I can think of is to change his insulin. I know your vet is accustomed to Humulin N. However, N isn't known to be a blue ribbon insulin for cats. But there are past and present Humulin N users here, and we will support you should you decide to go back there. We won't stop asking for preshot and midcycle tests though, and you will likely hear suggestions for starting back at N at 1U BID. You could also decide to try Lantus. I believe you mentioned that your vet had or is working with that.

I completely understand your frustration Bel. I usually suggest that people give an insulin two months before claiming failure. Your Buddy is very important to you and you want to see him well NOW. I get that, and support you in whatever you and your vet decide to do.

 

[Anonymous]

Hi Bel and scritches to Buddy,
Hi ... thank you so much for your advice. I'm going to give it at lot thought tonight as to what direction to go.
I came home from work just long enough to test and when Buddy saw me laying the supplies out to test, I reach to pick him up and he "growled" at me.
I'm not having a good day ....now I have to go back to work. Thank you for your time and advice.


I am so sorry to hear that you are getting nowhere positive on the Levemir. I take that back. You are getting somewhere. Buddy is back to being a happy cat.

I wouldn't say that Buddy's doesn't respond to Levemir. It was dropping his BG levels on most of those days in January when you were testing pre-shot and mid-cycle. It just wasn't dropping him low enough and the way he was feeling "spiraled."

After a couple cycles with mild dose increases, the vet tripled Buddy's starting dose and gave him and you a testing vacation. The good news is that you got your bonded Buddy back. The bad news is that we really can't tell you whether the 3U is too high or too low a dose for Buddy. We could all have our guesses and suggestions for the next step, but we cannot point to carefully gathered information to support our positions. We would be shooting in the dark.

I probably shouldn't say that either. There may be people here who have been through this scenario who can make a good, educated guess about next steps, so let's wait for them to chime in.

I know that one of the concerns you have with increased BG testing is that it will drive Buddy to avoid you again. That may or may not happen. When you were testing him at PS and mid-cycle before, he wasn't feeling well. Now that he is back to being Buddy, perhaps he will tolerate it better. How is he doing with the tests you are taking?

There are ways to test urine for glucose...either a test stick or a confetti product for the litter box called GlucoTest. However, those may not work for you given that Buddy mostly pees outdoors.

In looking closer at your post you said:

after 27 days on Lev, at a low dose, then a high dose, shouldn't signs of lower numbers be appearing?

If Buddy was my cat, I would likely try one thing that you haven't tried with the Levemir...a dose between the 1 and 3 units. You had Buddy on 1U for about 9 days. His mid-cycle tests were between the mid-200s and mid-300s. The tight regulation protocol here would say that you should have increased him by .25 or .5U. I would have increased by .5U because he had more mid-cycle 300s than mid-cycle 200s. But he is clearly doing better purrsonality-wise on 3U than he was doing on 1U. So I would likely reason my way to a change to 2U.

Another option would be to increase the dose. If that is the way to go, I would likely go up .5U because high midcycles were more common.

The last option I can think of is to change his insulin. I know your vet is accustomed to Humulin N. However, N isn't known to be a blue ribbon insulin for cats. But there are past and present Humulin N users here, and we will support you should you decide to go back there. We won't stop asking for preshot and midcycle tests though, and you will likely hear suggestions for starting back at N at 1U BID. You could also decide to try Lantus. I believe you mentioned that your vet had or is working with that.

I completely understand your frustration Bel. I usually suggest that people give an insulin two months before claiming failure. Your Buddy is very important to you and you want to see him well NOW. I get that, and support you in whatever you and your vet decide to do.

 

[BJM]

Aside from the dosing issues, you may want to do some work to desensitize Buddy to the testing process.

Some of these may help:
* Use an antibiotic ointment with pain reliever on the ears to reduce discomfort before and after testing. If before, give it a good 5-10 minutes to numb things a bit, then wipe off before testing so it doesn't contaminate the results.
* Provide a small treat any time you try to test (even if unsuccesful)
* Make it less of a production - leave some of the testing stuff sitting out at all times to be ignored while playing, petting, grooming, or other activities Buddy likes
* Check your lancet and aim - if you get right on the edge, with a 26 gauge (or higher) lancet, it is a quick, small poke. If you are using a lower gauge lancet, ie. larger, it will be more uncomfortable for him.

Additional stress relief for both of you - play sessions of 15-20 minutes twice a day may help relieve some stress, kick up a few endorphins, use some of the glucose, and help him and you relax a bit. Done before a feeding, it simulates a hunt, then eat pattern.

 

[Vicky & Gandalf (GA) & Murrlin]

I will only speak to your initial question - do some cats not respond to Levemir?

I see no reason why any diabetic cat would not have any response to Levemir, they simply may not respond the way we or our vets expect or want them to.

As a longer acting insulin Levemir may take some more fine tuning with dose than fast acting insulins like Humulin N which produces a more predicable BG pattern. Because of that, Levemir doses should be based on nadir BG numbers, the lower or lowest point in a 12 hour cycle, not preshot BGs.

Ideally Levemir produces a flattish "curve." To achieve this affect you must determine how a particular dose is working - does it bring BG down? If it does, but does not bring BG down below renal threshold (perhaps 250mg/dl), then dose is probably not enough and should be raised incrementally by percentage, not simpy unit value.

Say for example you are currently giving 1U. The lowest point in cycle after several days on that dose (should be no less than 3 days) is only 270. You want the nadir to be lower, so you should raise dose. If you raise 1U to 1.5U you are raising by a whopping 50%!! If you raise it from 1U to 1.25U you are only raising it by 25%, which is more desirable as you are less likely to overshoot the optimum dose.

Going from 1U to 3U is a 200% increase. If that makes it sound scary, it should!

Most likely Buddy's is doing better because the 1U was not enough. 3U could very well be doing a good job at getting him down off the ledge and helping him feel better, but if it's too much Buddy could get in to trouble and experience a low.

Venita laid out some very good reasoning as to why you might consider a compromise on the 1U vs. 3U dose by dropping to 2U. Get as many midcycle tests as you can and we'll go from there. Does Buddy have any health complications, such as prone to urinary tract infections, tooth problems, etc which might affect his use of insulin? It's also a very good idea, especially when switching insulins, to get ketone tests of their urine as often as possible. Make sure he is eating well also.

Hope that helps give you some more confidence in Levemir! It is a wonderful insulin and worth the time and trouble it may take to determine a good dose.