Is it normal.....

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Charlotte & Prop

Charlotte & Prop

Member Since 2011
Hey everybody

As I have told earlier i am helping this couple with their cat Pelle.
They startede him on 1 unit and he went from the 250 to around 40 in a couple of hours. Then we went down to .4 unit. That was ok for a few days and his numbers remained stable around the 220. Then his numbers begang to slowly raise to around the 300. We changede the dose to .6 units and again he dropped and remained stable. But now again his numbers are raising at amps and pmps and in a few days we will have to change the dose again.
Is this normal? Than the first reaction to a dose can be really good, but only for a few days? Does it take some time for the cat to get used to the dose and when that happens he could need more? It is a bit confusing.
I will try to upload the spreadsheet they are doing in an excell dokument.



Thanks you guys :)
 

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If I understand levemir correctly, it is longer lasting than Lantus - 14 hours or so - and you need to hold a dose for 3-5 days to get a stable ongoing level. It also has a nadir which tends to be later than +6, even as late as +12.

Based on that, and looking at the spreadsheet, I'd suggest going back to the 0.5 unit dose and hold it there for 5 days UNLESS the glucose during the middle to end (between +7 to +9) of the cycle goes below 50, which earns a dose reduction.

When in doubt, follow the instructions in the stickies ;-)
 
Going back to 0.5 is to get a stable shed/carry over so you can see what it is really doing. I thought 0.5 because of the initial response. One unit got you down to an earned reduction on a single dose (2.7 * 18 = 48.6).

Think of the carry over as a sort of rolling average which smooths out sharp day to day fluctuations. It starts low, and each dose leaves a little bit unused, which adds to the next, and so on. I'm thinking that 1 unit would have too much carry over.

The important thing is to hold the dose for the 5 days to see how things work with an ongoing shed / carry over.

Caveat: I am not a Levemir expert; this is based on what I've read in the Levemir stickies and what I've recalled of folks comments on using Levemir. When in doubt, go with the stickies!

More experienced folks should be on in a few hours, (evening, US time).
 
Charlotte, I noticed there have been several dose changes recently. 6 in the past 11 days and that is just with the AM preshots. That is why you are seeing higher numbers now, not because the dose needs raised. My recommendation would be for them to continue with the .6U for at least 3 more days and see where he is after that. They have seen progress on the .6U, so going back to .5U is not productive because they have not used .6U consistently enough to see how .6U works.

BJ, I don't know exactly to what info in the stickies you're referring to, but I don't think it's in my Levemir stickies. Levemir has been promoted on the board as being like Lantus because it is a longer acting insulin and maintains a storage depot, but that's where the similarities end, IMO. On the Lev ISG we have learned that at doses below 1.5U, Levemir works better when dosed in tiny incremental changes, less than .25U and ideally .1U. I believe this is why some people who switch from Lantus to Levemir don't have success with Levemir because they try to dose it like Lantus/Tilly protocol. If the cat truly needs more than 1.5U dosing in .25U increments may be fine with Levemir, we have seen that here as well, but at smaller doses .25U changes can be too much.

But just like Lantus, Levemir does not like frequent changes. So you're right that doses should be held for a minimum of 3 days. Some cats need the dose held for longer than 3 days however.
 
I agree with Vicky - although I know they reduced the dose to .2u on the 18th because that was such a low PS. I think that is OK to do as you don't know how he is going to react yet. It is good that they gave some insulin and did not skip the shot. I think he could have had more insulin, maybe .4u on that low PS as the .2u allowed his "shed" to be depleted somewhat. And that could explain the higher numbers the next night.

You are working to find the dose that allows things to be stable. That means no big variances between PSs or nadirs - so, something like 200-250 for PSs and 80-150 for nadirs.

Was the shot skipped on the night of the 16th? If that is the case, and then 36 hours later he was at 5.3 for a PS, it is possible that .6u is too much, but lets see if things even out a bit over the next few days.

For what it is worth, Beau had a very strong response to his first few shots of lev, dropping from the 300s to 95 on the 1st shot and into the 30s on the 3rd shot - then back up to the 300s. His first shot was .5u and I now know that it was too much, but it took me a while to figure things out (about 6 weeks). For a long time it seemed like .4u wasn't enough and .5u was too much. He was rebounding on both doses and what I saw in terms of numbers was 300s with no good lows on .4u because it was enough to cause a rebound, but on .5u he dropped into the 30s because it was enough more to overcome the rebound (of course, he rebounded high from that too, but it was the real lows that helped me figure it out). I think when I got down to .3u his numbers started to improve. After that I kept reducing and his numbers kept getting better until he was off insulin all together.

My point being that you have to gather data and really look at the numbers. Make very small, slow dose changes. (again, I can't fault them for reducing on that low PS the other day). And hold doses dose a minimum of 3-5 days unless you get a number below 40-50, then you can reduce a tiny amount.
 
Ok we are staying on 0,6 unit.

He woke up this morning with a really good number 214 and got 0.6 units levemir. They tested him at +5 and by then he was 275, wich is really wierd. He eats at the two shot times and the two other times. At +5 he has not been eating for 5 hours. And he is not getting into anything else, so not really any reason for the rise.
 
If you look at the bigger picture of the whole cycle, he is staying within the 200s, which is good, even if there is a rise. Did they check him later in the cycle, +9 or +10?

It is best not to focus on one BG at one point in the cycle in order to judge how well a dose is working. Levemir is designed to hold blood glucose more level. I prefer to see BGs in the 200s over the early course of a cycle than a beginning 214 and a drop to 80 within 5 hours on Levemir.

I suspect the rise they saw today was due to the dose still settling since there have been so many changes in a short period. I know they seem like very small changes, but in percentage terms, they are pretty big. From .4U to .6U is a 50% increase.

They may need to raise the dose again after the .6U has settled and been able to show us what it can do. Patience is important with Levemir.
 
He was at 331 at pmps so there his numbers have raised 117 from amps to pmps. But it make sence to keep the dose stable at 0,6 u for a few more days and then we will ask here before any changes. And you are right, the dose in just the last week has gone from 0-0.2-0.4-0.6 and back a few times.
Thank you so much for you help, we are so happy to be able to get your advise on everything :)

And this cute kitty is Pelle
 

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OMG, look how cute he is in his Santa hat!

Thanks for sharing that, Charlotte. I love his little white, butterfly-shaped mustache. What a doll.

And I just noticed you have a photo avatar of Props (with a Santa hat too!). He is a very cute boy too. Is he tabby and white?
 
Thanks Sheila :)
I don't really know what tabby means when it comes to color, but she is mostly white, and then with a cape of grey/brownish stripes.

Pelles numbers are still a little up and a then a little lower. Tonight he gave us a good number, but usually when he does that, then his numbers are higher at +5, but we will see that later tonight. The updatet spreadsheet is here:



Thanks for you help
 

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Pelle is giving us really good numbers tonight, he is at 155 at +4. I suspect his number to be lower than normal tomorrow morning and need a bit of advise. How low should he be before we consider to lower his 0,6 units. His mom will be home with him but cant test his bg, so they need to shoot a dose that Wont take him to low. Any suggestions on how low his amps Can be for still shooting 0,6?
 
CharlotteDenmark said:
Pelle is giving us really good numbers tonight, he is at 155 at +4. I suspect his number to be lower than normal tomorrow morning and need a bit of advise. How low should he be before we consider to lower his 0,6 units. His mom will be home with him but cant test his bg, so they need to shoot a dose that Wont take him to low. Any suggestions on how low his amps Can be for still shooting 0,6?
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Do they have any other BGs from later than +4? Because of the time difference between Europe and the US, I assume you mean his +4 was after his PM shot tonight. It's not on the spreadsheet, which is why I ask.

I would really like to see them give the .6U if his preshot BG is between 150-200. I am afraid if they don't give .6U, they are going to have a repeat of the 18th when they gave only .2U since the preshot was 95, which resulted in the cycle ending higher.

If BG is below 150, they can lower the dose, but not as low as .2U. I suggest trying .5U if he is below 150, but I understand if they want to do less than that since she can't test by herself.

Did they get the new syringes yet?

I have a lot of faith in Levemir that it does not cause serious hypoglycemia unless there is a considerable overdose (such as when someone gives 10U instead of 1U). I don't know if that will reassure them or not. 155 at +4 after a 223 preshot is a nice steady drop that is not too fast. I would like to have seen how low he went this cycle, but that's OK.

They have the evidence of what happened when they gave .2U on a preshot of 95. His BG went up within the first hour and that is normal. Then it went a little lower, but the .2U was definitely not enough because then the BG kept climbing after that. I hope that helps them understand that lowering the dose so much on a lower than normal preshot is counter-productive.

I hope I explained this well enough. Please ask for clarification if you aren't sure.
 
His didn't fall to low i guess since his morning number was at 277 :) But it is ok, then the dose is still the same :)

No they didn't get the syringes, because they think it is a lot easier to count the drops. 1 Unit have 5 drops, so .6 unit is 3 drops. They have vacation now for a week (I have 2 weeks :D) so they will be able to test a bit more at different times the next week.

Pelles still eats a lot and is very hungry. I suspect that even though the food is low cards (between 3,3 and 5,5 %), then the amount of it probably uses some of the insulin, wich prevent him from dropping more. When he is more regulated and eats less i guess the .6 could be to much.
He eats 14,1 oz (4x 3,5 oz) a day, 6 hours apart and two of the meals at shoot time. He i still very much underweight so it would be difficult not to feed him when he is so hungry.

His spreadsheet updated and all:


Thank you so much for all your help :)
 

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I would not restrict his food in order to get better numbers right now. He is underweight and not yet regulated so he will be famished all the time. Beau was like that - like couldn't fill him up. He was eating close to 12 ozs a day. After he was regulated on caninsulin for a few months his appetite slowing went back to normal. Now he eats 6-8 ozs a day. Jeddie was also very hungry, but I don't think he ate quite as much as Beau did in the beginning. They both had lost a lot of weight. Beau went from a hefty 14 lbs to under 10 lbs and Jeddie went from 13 lbs to under 9 lbs and was 9-1/4 when I adopted him. Both eat normally now and have put back some of the weight, but not all of it. They are healthy and their coats are good so I don't worry.

That will be good if they can get more tests in at different times during the cycle.

On the drop counting method they are using, what syringe are they counting the drops from? I thought they had u40 syringes (from the caninsulin). If they are using those, 1u as marked on that syringe is equal to 2.5u of u100 insulin (levemir). That would mean that at 5 drops per "unit" on those syringes, each drop is .5u. I just want to make sure we are all talking about the same thing here :roll:
 
She is using the u40 syringe, but she shoot 1 unit from the levemir pen into the u40 syringe in the top and then she does the dropping from there.
Pelle is just under 8 pounds and he i probably a 10 pound cat, so he need a few pounds to being back to normal.
Sheila I think one of you asked at onepoint how long he was on steriods for. It was actually a pretty long, I think several months. He had some itching issues and from what I remember the vet had them give him medrol everyday and just leave him on it. The vet denies that the medrol could cause the diabetes, but several other vets says it is probably why he got the diabetes in the first place.
 
The steroid Depo Medrol is probably the worst to be given to cats! Gandalf had it about 3 times per year for 7 years! I blame the steroid plus the dry food I fed him for causing diabetes. It's well known here that steroids affect blood glucose levels and can trigger diabetes.
 
Pelles owner just wrote to me. She says that Pelle before he got his diabetes had been itchin a lot and scratching so much that he had o lot of wounds. The vet told them to give medrol for 40 days and at the same time give antibiotics for 40 days. When the 40 days were over, Pelle had diabetes. Have you ever heard of a 40 day treatment? That seems like way to long.
 
I would HOPE it was a very small amount! I had a cat with nasal lymphoma on depo shots and she got them every two weeks - for 9 months. I wonder what her BG was toward the end. We never thought to check it since we knew her situation was life limiting and were just trying to make her comfortable as long as possible.

As for the itching, that would be horrible to make him go through just to not give steroids - if there were no other alternatives. It would be important to find the source of the itching and stop that so he did not have to be on steroids. In my experience, itching is either from fleas or an allergy to something like an ingredient in his food or a cleaning product or something. Don't know if carpet deoderizers and cleaners are popular over there (they are here), but they are full of chemicals that get on the cats feet and either get ingested or spread around by grooming.

Jeddie has an allergy to dried egg product in canned food that I though was causing some itching. It's worth reading labels for something that isn't a normal part of their diet and maybe eliminate it for a while and see it his itching improves. Also make sure he is getting enough fat in his diet - and water right now while he is peeing more so that his skin isn't drying out and itching.

Thanks for the syringe/drop/dose explanation - that makes sense and is pretty clever! Good for them coming up with that method.
 
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