I am giving advice on Levimir - but i dont know much.

[Charlotte & Prop]

My cat prop was on caninsulin for 4 weeks 10 months ago and became dietcontrolled and fortunately still is. At that time I started my own homepage www.sukkerkatten.dk to let people in Denmark know about how to treat diabetes differently from what pretty much every vet in DK suggest. Several people have through my homepage contacted me and the first to, caninsulinusers I helped get in remission in a very short time, but this last one Pelle is more difficult. So here is what has been going on since they wrote to me the first time til now, day 2 on levemir.
November 10. th. they wrote me an e-mail asking for help. Their male cat Pelle had diabetes and the vet said he didn't respond at all to insulin and he ate and peed alot and got skinnier and skinnier, all classic signs of uncontrolleddiabetes. I wrote back about wetfood and hometesting and they told me they were going away for a few day and didn't want to change before they were back home. They contacted me again on saturday the 19.th of november and told they had desided to put Pelle to sleep. The vet said that it was probably a tumor there was the reason for the cat not to react to the insulin. I pretty much begged them to give me a chance for a week to see if he would react to insulin. And they desided too
At that time they gave him 1 unit of this one twice a day:


I told them to get rid of the dryfood and only feed wet low carb.Not a problem. They were pretty open to hometesting but it was and still is very difficult for them. They have to be two to do it, one to hold the cat and the other one to test. After the food change Pelles AMPS and PMPS on this insulin was around 252. At nadir he was between 144-216. The pen could only give 1 unit at the time and since I at that time didn't know how to get insulin out in smaller doses I suggested to get them back on caninsulin where you can deside the dose yourselves. It might soud crazy, but the vet in Denmark is actually not allowed to give you anything but caninsulin, therefore it was not an option in my mind.

On caninsulin we started him on 0,5 unit and that did not make any difference at all, in fact his number began to rise. They talked to the vet who actually suggested levemir, I told them to get it right away. They got it friday, it looks like this:

The vet told them to start with 1 unit once a day. I told them to do it twice a day (was I wrong here?) The first day prior to his first dose his pmps was 313 and he was 238 at +5. Saturday yesterday at amps he was 266 and they gave him 1 unit again. I told them to test during the day at least at +3 so we could see how it worked, but it is not really their favorite thing to do. They came home at +6 and did the first test there and he was on 48. They called me and I told them to give sirup and thes in 30 minutes. He was up a bit after 30 minutes and I told them to test in another hour, at that time the suger had stopped workin and he was down to 54. Sugar again and after a while he slowly began to rise. He was only at 100 at pmps, so no shot that evening. This morning 24 hours after the shot he was at 252. Since he no longer should have 1 unit there was some problems, because they didn't have the right syringes, and not any syringes that could messure only .5 unit. The lady shot 1 unit out in a steril dish and then only took about half up in a syringe, but precisely how much it is is hard to tell, but no were near one unit. I convinced them to test at +3 to see how his reaction was and at that time he had rised to 306. I told them to chek again at +5, but they didn't since only one of them were home and they cant do it alone. At + 12, before pmps he was at 216 and they called me to ask me what to do. Since I didn't know if he was on his way up or down I told them not to shoot after he came so low yesterday. We talked about them shooting after he ate, but since they have the wrong syringes it is really difficult to even know how much they are giving him.

So that is where we are now. What do I need to know to give them good advice. Believe me I am telling them to test a lot more than they are doing, but it is an older couple and the cat pretty much hates it, so do they.
Few questions:
- is shooting once or twice a day - asking because yesterday his numbers didn't start to rise until after +12, but maybe it was because of to high a dose.
- Should the levemirpen be in the fridge after opening?
-Microdosing is really difficult, how do the rest of you messure such small amounts?
-Anything else that would be good for me to know about?

Thanks for you answers and sorry for the long post

Charlotte

 

[Vicky & Gandalf (GA) & Murrlin]

So that is where we are now. What do I need to know to give them good advice. Believe me I am telling them to test a lot more than they are doing, but it is an older couple and the cat pretty much hates it, so do they.
Few questions:
- is shooting once or twice a day - asking because yesterday his numbers didn't start to rise until after +12, but maybe it was because of to high a dose.
- Should the levemirpen be in the fridge after opening?
-Microdosing is really difficult, how do the rest of you messure such small amounts?
-Anything else that would be good for me to know about?

Thanks for you answers and sorry for the long post

Charlotte

Hi Charlotte,

Wow, that is very amazing how you are helping diabetic cats in Denmark! Thank you for asking here for advice on Levemir. It is a very very good insulin for cats, as you and Pelle's owners are finding out!

Let me answer your questions first, then we can discuss further.

1. Yes, Levemir should be given twice a day for cats. Cats metabolize insulin faster than humans and all insulins should be administered twice per day, even the longer acting ones.

2. Yes, all Levemir pens should be refrigerated, even after opening. A pen will last to the last drop if refrigerated, 3 months or more.

3. Please see these pictures and description of how one member here does it. Pictures: http://felinediabetes.com/FDMB/viewtopic.php?f=10&t=34424#p360982
Description: http://felinediabetes.com/FDMB/viewtopic.php?f=10&t=15637#p156967

They are using separate syringes inserted in the rubber tip of the pen, correct? If they have 3/10cc syringes, those work best with this method and should also have .5U/half unit markings, such as shown in the pictures.

4. Other notes - I would not shoot insulin out and try to suck only half of it back up in the syringe, even if it is a sterile dish. I would be afraid that may somehow affect the insulin simply because it's being exposed to air. Normally we draw the insulin a bit past what we think is .5U, then just slowly twist the plunger up and squeeze out drops. They could also take a stiff piece of paper and mark with a fine point pen where they think .5U would be on the syringe and push the insulin out until they get to that line. Most ink pens would not mark on the syringe itself, so I suggest the paper. I also used a device called a micrometer as an external measure. http://www.qcinspect.com/images/Micrometer.jpg That worked very well for me, but I am very mechanically inclined for a woman ;-)

Hope this helps and please ask any other questions. Do I understand the owners are not online? We could help them directly if they are. It is so good of you to help in this way!

 

[pamela and tigger]

Good for you Charlotte helping other diabetic cat owners. I couldn't read your blog since I only speak English!

So I take it they only have U40 syringes left over from using the Canninsulin? Can they not get U100 syringes like Vicky mentioned? It would make smaller doses so much easier.

Are you sure they have completely eliminated the dry food? I hope they know that even just a little bit will raise the bg levels. Please tell them that because he went so low on such a small dose he could be a good candidate for going off the juice. I wonder though, did he get enough to eat that day?

One other thing...when we were first starting out with Tigger it took two of us to test him. Until my hubby had to go out of town, I was forced to do it alone. It worked out much better. I think Tigger didn't feel ganged up on then, and he relaxed more. Ask them what size lancets they are using too.

Please keep coming back with questions. I know there is a time difference. Post on the Health forum if you don't get answers in a timely manner. Tell them to hang in there!

 

[Sheila & Beau GA & Jeddie GA]

Ah, I gotta jump in here..

Vicky, I think they don't have any syringes? And they are using the pen auto inject ability? That's just a guess.

Charlotte, do they have the syringes for Canninsulin? And are they shooting 1u from those syringes - 1u as marked on that syringe? That would actually be 2.5u of levemir. That is a pretty high dose and it does sound like he is getting too much right now. You would want him getting a lower dose every 12 hours to stop the swinging blood sugar levels.

A drop to low numbers will cause a "bounce" to higher numbers. It is what has happened in the past few days where he has gone from 300 to 48 and back to 300s (approximately). Also, this is probably what was happening on canninsulin that made it look like he wasn't responding to insulin.

Back to the syringes. They do need to find a source for u100 syringes. They will need to get 3/10cc ones in order to get half unit markings (ask for half unit markings, not all come with that). That is the smallest size of u100 syringes and they should be able to give 1u or less - especially using the guide that Vicky posted. I think they might need a prescription to buy them where you are.

If they have to use the u40 syringes, I would have them practice drawing 1u and twisting the barrel slowing so that a tiny drop forms on the tip. Flick it off and repeat. Practice until they can get 5 of the same sized drops. They should be about the size of the zero at the end of the dosing window on the levemir flexpen - just trying to use something they will have access to for comparison. If they can do that, those drops are each a half unit of levemir. So, if they draw the 1u on the u40 syringe and exspell 4 drops they will have .5u left. Exspell 3 drop and they will have 1u left - and so on. That is for in a pinch if they can't get u100 syringes.

I hope some of that helps. Tell them to hang in there with Pelle. He may just need insulin for a short time, but they are learning to test and it does get easier. Have them give treats after each testing attempt - mine like boiled chicken breast. Pretty soon, the cat actually likes testing - or at least doesn't fight you over it.

 

[Vicky & Gandalf (GA) & Murrlin]

Charlotte, both Pamela and Sheila have brought up excellent points about the syringes, which I overlooked, chiefly regarding the U40 vs U100. Levemir is a U100 insulin and Caninsulin is a U40, so syringes for Caninsulin CANNOT be used with Levemir.

You just received guidance from 2 of our most senior members on Lev ISG. Good thing they're on the ball.

Pamela & Sheila, "senior" is in regards to your years on FDMB and experience with FD, only. You each have sharper minds than I do today since I missed the syringe distinction. ohmygod_smile

 

[Charlotte & Prop]

Wow thanks all off you for your answers
I know the difference between the U40 and U100 and I know that caninsulin wich they used to use is U40 and that Levemir is u100. I also know there is a difference in how much one unit is if it is U40 and U100. So he has not recieved 2,5 unit u100 insulin. Wow cant even imagine how that would end

No the problem is really the syringe. Since the one unit in the pen is to much and they only have u40 syringes there is a problem. And with the wrong syringes and since ½ a unit of u100 is such a small amount it is very difficult for them to draw it out of the pen, I can't even imagine since i thought it was difficult with Prop when she was on her way in remission.

The cat is not getting any dry food what so ever, and since he is not regulated he eats about double up in food. I have told them to feed him alot since he is so skinne after the vet has failed for 2 months.

The couple are very stressed out about the situation and i think i stress them even more out. I guess it was easyer with the vet, because he just had them blindly shoot him twice a day. But they can see the cat feeling som much better now after they have contacted me, but they are stressed and feels like they are failing bacause of the time at the vet where he just got worse. The couple are not on this forum and I don't think they use the internet to things like that.

I have told them to get these syringes from an internet store today, they will probably have them in a few days http://www.reamed.dk/Insulinspr%C3%B8jt ... l.136.aspx These are the only ones i can find in Denmark that are small enough. Until then i can tell them about the dropmethod and see if that will work for them.

Thank you guys, i will return shortly with updates and cross my fingers the he will be a remissioncandidate, that would be a real christmasmiracle for this family, after he was nearly pts a few weeks ago.

 

[Darlene & Jack]

Wow, Charlotte!! Keep up the great work in Denmark! That's wonderful that you are helping out with this kitty...best of luck on getting him under control and maybe in remission. It sounds like you are doing wonderful work over there. :thumbup

 

[Vicky & Gandalf (GA) & Murrlin]

My Danish is no good, but from the picture and the ,3 and the 1/2U I see on the box I take that to mean they are 3/10cc with 1/2 unit markings, so yes, those should be correct!

Please tell the couple that everyone experiences this stress in the beginning. We promise it will get easier and I'm glad they are seeing improvements since contacting you.

Charlotte, I'm wondering if you are familiar with the German Katzen diabetes forum online? They created the Tilly protocol for Lantus and Levemir insulins in cats.

 

[Vicky & Gandalf (GA) & Murrlin]

Oh, Pamela sent me this link to the Pet Diabetes Wiki on insulin pens. A lot of good info here: http://petdiabetes.wikia.com/wiki/Insulin_pen

 

[Charlotte & Prop]

0,3 ml i believe means it contains 30 units of u100 insulin and then i guess the ½ unit markings do the trick

I am not familiar with the German forum and Tilly control and I am affraid that my german is pretty much as bad as your danish Most people in denmark have german i school from 7. th grade (we have english from 3. grade) but I choose frence in stead

Pelles amps was a pretty high 318 since he didn't have any insulin last night. He got around .5 unit this morning. The couple are at work all day but I have asked them to try and get a bg number before pmps so we have an idea of he is going up or down, since we don't know if even .5 is too much.

The number now at +11 is 237
The number at pmps +12 is 212, so he is still falling a bit.

I har told her to try the drop thing that one of you wrote about and then only give him one drop for the night and then check his numbers before bedtime. She can get 5 drops of the same size out of one unit, and she is giving him one just to be safe tonight. So tonight only .2 unit
I can't believe how much he is reacting to this insulin.
Is it normal for numbers to still drop at +12 or is it a sign of dose still to high?

 

[Sheila & Beau GA & Jeddie GA]

We say here "Every Cat Is Different" (ECID) - so yes, some can still be dropping at +12. It would be good if they can test at about 3 or 4 hours after the shot, at least in the evening - we call that a before bed check". That might tell you if he continues to drop or starts to climb after the shot. My one cat (I have two diabetics, one in remission) tends to stay flat for the first two hours after a shot or climb a bit before starting to drop again, but he is usually not dropping at +12.

Tell them not to feel bad about the two months with the wrong insulin and not testing. My first diabetic, Beau, went 6 months before I started testing and his canninsulin dose got up to 7u! He was also still eating dry food during that time and it probably saved his life, but once I started testing, I lowered the dose and changed the diet. No more dry food now!

 

[BJM]

Use Google Translate to get an approximate translation of the Danish. It works fairly well.

Here's the page

And its a really nice page, too!

 

[pamela and tigger]

Use Google Translate to get an approximate translation of the Danish. It works fairly well.

Here's the page

And its a really nice page, too!

Thanks BJ! That is really helpful. Yes, it is a nice page Charlotte!

 

[Charlotte & Prop]

Thanks - the site is very relaxed. I don't know how may people uses it without contacting me, but three owners have mailed me through the site and asked for help.

Pelles has been getting 0.4 units since yesterday morning now. He is pretty much the same amps and pmps around 225, the few bg numbers they have taken at +3 and +5 shows a drop of only around 18, but they will keep the dose of .4 til this weekend where they will try .6 unit and then do a test at +5 and +7. We have no idea what time his nadir is and how low he goes, but since around 200 has been the lowest at +5 i don't think he gets to low on the current dose.
Does that seem like a good plan or do you guys have any suggestions?

 

[Vicky & Gandalf (GA) & Murrlin]

Hi Charlotte,
That sounds like a good plan. One thing to keep in mind is that when close to a good dose on Levemir, BG values may not move very much. They may be in the 200s, but they don't bounce around. I actually recommend their next step be to only .5U, not .6U. A .2U increase is a 50% increase in dose! That matters when the dose is so small.

Would it be possible for you to create a Google doc spreadsheet for their numbers? Or you can report them here the "old way,"

AM Preshot BG, Units insulin
+2 BG
+4 BG
+6 BG
+9 BG
PM preshot BG, Units insulin

That's how we did it before the spreadsheets! I don't expect you to go to all the trouble of a spreadsheet, so listing them would be fine. Thank you for converting them too!

 

[Charlotte & Prop]

Does that mean that it is ok he hangs around 200-225 all the time?

They are dosing him by the dropmethod because they dont have any syringes that is good enough for them. Each drop is .2 units, and there is 5 drops in 1 unit. But I guess they can try to remove 2,5 drops so the dose is .5 unit from saturday.

This morning they could not chek his bg. He had been out all night and his ears vere really cold. He was actually biting one of them when they tried. So they gave him the .4 unit. I think it will be ok since he has not been dropping on that dose, but i really hope they will get a number tonight.

I dont think a spreadsheet will work for them, but i can post the numbers here:

12.12.11
Amps 319, dose 0.5 unit. But he had no insulin the night before because we didn't know if his numbers were going up or down.
+11 1238
pmps 212 dose 0,2 unit
+5 220
12.13.11
amps 263 dose 0.4 unit
pmps 232
+3 216
+5 212
12.14.11
amps % dose 0.4 unit

 

[Vicky & Gandalf (GA) & Murrlin]

Does that mean that it is ok he hangs around 200-225 all the time?

Well, not if we are aiming for remission, but it's better than going from 400s to 60s, for sure. Human diabetics say that feels awful!

Sounds like he is feeling better if he was outside all night!

 

[Charlotte & Prop]

Sounds like he is feeling better if he was outside all night![/quote]

That was exactly what I said this morning And is is kind of cold her, around 40, but I guess Pelle dont care.

Well the goal is remission, that would just be so amazing for them, but since they don't test that many times a day i know it can be hard.

 

[Sheila & Beau GA & Jeddie GA]

Do you know about the rice sock? If they have a microwave oven, they can put some raw rice in a cotton sock, knot the end and heat it in the micro for about 20 seconds (depends on the micro - you want it hot, but not burning). Hold it over the edge of the ear for about 5-15 seconds. It warms the ear and dilates the blood vessels. You can also use a washcloth (face cloth) run under very warm water and placed in a plastic bag. Just make sure it doesn't drip on him.

As far as the BGs in the 200s - that is better than swinging from 400s to 40s - and it is the first step in reaching the best dose. Stop the swings, wait for the numbers to settle (can take 2-10 days, but usually about 5), then do a curve (test every 2 hours) and adjust the dose accordingly.

I keep forgetting to mention that dropping to 40 is probably not going to be dangerous. Both of my cats have been down to the 30s (and I think Beau went as low as the 20s once, but that is a guess). Anyway, just feeding regular food and retesting in 30 mins should be fine. Feed higher carb food if worried. I don't break out the syrup until the low 30s, but I have cats that allow me to test without trouble. So, make that decision based on the comfort level of the testers. It's just that giving syrup can contribute to the higher numbers.

Lows like the 40s to 60s, even the 70s, if he has been in the 200s can cause a rebound high BG swing just because he isn't used to them. That is why you want to stabilize the numbers, even in the 200s, before slowly increasing the dose to bring the numbers down - it allows him to get use to the new lows.

 

[Charlotte & Prop]

Yes I know about the ricesock, I use it on my own cat prop when i test her every two weeks. I have told them about it and they are doing it and find it a lot easier when they use it, but I guess this morning was just bad, maybe he was hungry from being out all night. He is still really hungry and eats a lot more than what he should be, but I guess it has only been a few days with these numbers, so it is probably going to be better soon.

It seems like a good idea to stable his numbers like we are doing now, and then after 5 days make small changes. The 0.5 unit dose are starting this saturday.

 

[Charlotte & Prop]

12.12.11
Amps 319, dose 0.5 unit. But he had no insulin the night before because we didn't know if his numbers were going up or down.
+11 1238
pmps 212 dose 0,2 unit
+5 220
12.13.11
amps 263 dose 0.4 unit
pmps 232
+3 216
+5 212
12.14.11
amps % dose 0.4 unit
pmps 248
12.15.11
amps 272 0.4 unit

His numbers begin to rise, is that normal?
They are changing his dose allready tonight to .5 units.

 

[Phoebe_TiggyGA_NortonGA]

BG numbers 200-225 are ok.

"Renal Threshold" is when the sugar in the urine reaches a level that starts to do some damage (small damage that adds up over long time) ---- for cats this is ~240-250

So controlling BG be stay under that level is more safe for cats than going too low and becoming HYPOglycemic.

To some extent that is the difference between "Tight" regulation and "Relaxed" --- Tight means very frequent testing and trying to keep the cat under 150 nearly all the time.

For "relaxed", we try to stay below 240 and not test as often because the kitty is less likely to go down below 50 (hypo).

 

[Sheila & Beau GA & Jeddie GA]

Phoebe, I would say that those number should be a little lower for the definitions:

Tight regulation being at or near normal (non-diabetic) numbers - so 60-120 or so. I have seen a lot of 50s over in the TR lantus ISG, And, as you mention, having to monitor closely so that the cat doesn't drop too low.

For "relaxed" regulation, my thinking would be below renal threshold and as near 100 as possible - so 100-220. I have read that renal threshold in cats is 220-240. I think you can tell be if your cat is drinking water a lot or not.

We have found that with Lev, and I would guess with lantus, dropping to 40 is safe, but not desirable. I, personally, never aim for lower than 80 and that gives some wiggle room if he is going to drop a little lower.

As a first step, getting the numbers to be stable at 200-250 is good. It stops the swings and bounces and then the whole "curve" can be lowered slowly with small dose increases of 10-15%, which is NOT usually .25u or .5u unless the cat is getting more than 2u already.