New to Lev and numbers all over the place

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tye

tye

Member Since 2010
Hi, I have started 18 year old Tye on Levemir almost 3 weeks ago. He was previously on Caninsulin (2 units twice a day) but I wanted to get him off of it as he would go up to 20-22 (ie 400+) before his shots and I didn't think the big swings were good for him.

Well if you check out his chart (in my signature) he is still a bit all over the map. I've been only giving him 1 unit twice a day for the past 3 weeks but his numbers (while lower) are still not consistent.

Is this normal for Levemir?

(In the past 2 days I also started introducing wet food just FYI but he's not been consistent about eating it all up)

Can anyone advise what I should do - keep the same dose / change it / something else I'm not doing? I haven't upped his dose as I feel like I just can't predict where his numbers will be from day to day...

Thanks,

Michelle (Tye's Mom)
 
Hi Michelle and Tye,
I am a newbie on Lev myself, so I don't have any advice...just wanted to say hello and the more experienced users should be along...

Would it be possible for you to get some mid-cycle tests in? That will really help to see if Tye needs an increase or decrease.

Marcy & Klinger
 
Hi Michelle ( with 2 L's! - we have a Michele, too, with 1 L ;-) )

Welcome! Glad to have you here on the Lev board!

I have some questions that might help fill in the bigger picture....I see you are introducing canned- assuming then you are feeding primarily kibble? Can you tell us what kind? Also, what type of canned are you introducing?

There is a chart around here called Janet&Binky's food chart http://www.felinediabetes.com/diabetic-cat-diets.htm where you can find foods with low carbs...carbs help to keep BG's HIGH, so the lower the carbs, the lower the BG's generally. Generally suggested is to feed foods with under 10% carbs, however many have larger success with under 5% carbs.

Also, Marcy is very helpfu in suggesting mid cycle tests( see Marcy- you DO have something to offer!). It helps us to understand better how the Lev is working. You don't have to o it every day, but a few days a week would be good...even if you need to get a +5 one day and +8 the next and so on...

One thing difficult to switch our brains around to is that on Lev or other long acting insulins, we need to base dose changes on the LOWEST number in the cycle, which generally is around +8ish or so I believe, not the pre shot value, which are the readings you have the most of.

If we can find out when your sugarsnack's lowest number ( peak) is, and how long he hangs there or doesn't, it is easier to help with dose suggestions.

I suspect the food might be keeping BG's higher however, and you may find with a food switch you'll have lower and steadier numbers on the 1u or less....just a hunch.

Let's see...also, could you tell us if there are any other illnesses or medications and how long has your sweetie been diabetic?

That's all from me- others will be along shortly, I'm sure. It is the weekend, however and it tends to be a little slower then. If you have any emergencies, you'll find more traffic on the health forum...otherwise, hang in there 'till the rest of the folks get up and moving! :-D
 
Please read the stickys that will give you info about this insulin - on your ss, you have only the ps numbers, but dosing for Lev is based on the nadir, so the ps blues suggest you may be having some really LOW numbers at mid cycle and then Tye's bouncing up higher again.

Tight Regulation Protocol
Lantus & Levemir – Insulin Depot –AKA- Storage Shed
Lantus & Levemir – Data Ready to Shoot Low Numbers
Here's a bit from the protocol:
"General" Guidelines:
--- Hold the initial starting dose for 5 - 7 days (10 - 14 cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 cycles).
--- Each subsequent dose is held for a minimum of 3 days (6 cycles) unless kitty earns a reduction (See: Reducing the dose...).
--- Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.

Increasing the dose...
--- Hold the dose for 3 - 5 days (6 - 10 cycles) if nadirs are less than 200 before increasing the dose.
--- After 3 consecutive days (6 cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
--- After 3 consecutive days (6 cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

Reducing the dose...
--- If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further.

--- If an attempted reduction fails, go right back up to the last good dose.
--- Try to go from 0.25u to 0.1u before stopping insulin completely.

Random Notes...
Because of the cumulative nature of Lantus and Levemir:
An early shot = a dose increase.
A late shot = a dose reduction.

A "cycle" refers to the period of time between shots. There are 2 cycles in one day when shooting twice a day.

Sometimes a dose will need to be "fine tuned" by adding some "fat" or "skinny-ing up" the dose.


See below.... you will need to do some curves in order to find out just how well or poorly this Lev dose is doing.
Maybe try on a weekend to test at amps, +3, +6, +9, pmps, +3 .... to get an idea how Tye's really doing.
How to do a Curve
Example of a typical curve:
+0 - PreShot number.
+1 – Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number.
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 – Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (may dip around +10 or +11).
+12 - PreShot number.

Once you know Tye's pattern - if his nadir is around +4 or +6 or maybe even later like around +10, you will better be able to know how the insulin is working and how Tye will handle his shots.

edit to add:
Binky’s Food Lists
Feeding Your Cat: Know The Basics of Feline Nutrition
 
Hi and welcome, Michelle,

Gayle is right that it's virtually impossible to tell how Levemir is working without midcycle numbers.

We have found that cats who switch from Vetsulin or Caninsulin seem to need far less Levemir than they did of the faster acting insulin. Levemir may be slower acting, but it is no less powerful. I call it the Gentle Giant.

The quirky thing is that if you get a curve of numbers which are high and flat, that could be because he has rebounded on a dose which is too high, meaning he needs less insulin rather than more. The tight regulation protocol is a good tool, but it does not work for all cats. Like Gayle, I suspect Tye needs less insulin because he had several preshot 100s.

We have begun recommending that cats who come from the faster acting insulins start with .5U rather than 1U because we have seen several cats need so much less Levemir. Beginning at a low dose and working up yields more success than backing down from a dose which might be too high. The way the insulin builds up in the system is the main reason that going up seems to work much better.

A frequent question we see on Health about dropping the dose is if it's OK to do that suddenly. Yes, it is. There is no need to go from 1U to .75U to .5U - you can go right from 1U to .5U.

However, since you're just starting out, it might be helpful to us if you try to get a curve before going down to .5U. And, do you have ketone urine test strips? It would be a good idea to check his urine periodically with those, particularly if he's had or is prone to any infections like oral or urinary.

It really does get easier. Levemir is a marvelous insulin, just takes some study to get the hang of, especially after using an insulin like Caninsulin, so you were right to switch.
 
Wow, thank you for all the responses! I will attempt the curve test today (at 1 unit Lev).

Tye was diagnosed almost 3 years ago... he is 18 now (we think - not sure of exact birthdate). No other illnesses - just got full bloodwork done in the fall and aside from cataracts and a slight heart murmur vet says he is fine.

Re: his food - he has been on dry food his whole life but will eat bacon, turkey, chicken, beef if I give it to him (I don't do it too often but he LOVES when I do so he can't be *that* fussy).

The wet cat food is a different story. Usually he will just lick up the juices in it so it has been a struggle - although two days in a row this week he finished an entire can within 24 hours (given with his morning shot). I don't know if it was just the flavours or what because now he seems to be back to just licking what I give him. He will go to his bowl immediately when I open the can and seems very happy with licking but then never goes back to finish it. Weirdo.

I have tried experimenting with pate vs. marinated and he will have nothing to do with the latter. Have also tried taking away his kibble to see if that makes a difference... I was too nervous to not leave it out overnight. (Although the two nights this week when he licked his wet food bowl clean, he did have the *choice* of wet or dry.... which leads me to believe he liked those flavours.) So I am going to buy more of the 2 flavours he ate (Whitefish and Chicken & Liver) and do a test with that.

Oh and I have been feeding Fancy Feast, the meat only kind... he doesn't seem to like Friskies and will not even touch the special vet kind that the vet promised me *cats love*. So much for that. But I'll have a look at the food chart to see what other options there are, thank you.

I don't have urine test strips (although he's never had any urinary infections, just some kind of tooth infection last fall that seemed to go away pretty fast... although it was a hypo episode when he wasn't eating on antibiotics which led me here). Anyway do you buy these strips at the vet or do drugstores carry them? How do you use them - do you have to catch him when he pees before it hits the litter and clumps?
 
Nothing to add except I switched Beau from vetsulin (caninsulin) to lev with a starting dose of .5u (he was getting about 1u or 1.2u of vetsulin) and it took me a long time (6 weeks?) to figure out it was a bit too much. So, you may find that .5u will give you better numbers. I do agree with Vicky on getting a curve in before dropping the dose though.

And I would also like to know what food he has been getting. I switched Beau from mostly dry food to all wt food when I started home testing him (6 mos after diagnosis). His BG was probably being raised about 100 points by the dry food, but it could have been more. He was also getting too much insulin so I was decreasing the dose (of vetsulin) during that same time (from 7u sid to 1.5u bid). He went from 400-500s to 200s.

OK - see you answered some questions:

Try crushing some dry food and sprinkling that on top of the wet food. Beau was tough to transition so I pushed about 6 kibbles into the top of the food so they barely showed. He has to eat the wet food to get the dry pieces. If you feed people food (meat/poultry) as treats make sure it doesn't have salt, onions or garlic in it. I boil chicken breast in plain water for 10 mins as a treat for my cats. They love it and it is no carbs.

Stick with Fancy Feast Gourmet or Classic Pate flavors, they have the lowest carbs. No gravy ones! Not sure about those marinated ones? Do they have wheat gluten in them? That usually means too many carbs for a diabetic.

For ketosiks, to test urine for ketones, you can buy them at any pharmacy. They work best to hold in his urine stream as he pees, but you can dip immediately into the puddle before it totally sinks into the litter. Once it clumps, its too late though. Ketones are a byproduct of their body burning muscle tissue for fuel and can happen when they aren't eating enough, don't have enough insulin to get the glucose into the cells and, usually, when there is an infection present. It's just a good idea to check for them regularly while the BG is in the higher numbers all the time.
 
When you are picking foods, try to pick ones that are listed as carbs under 10%. Many stick to lower like 3% or 5%, but I would say if it's under that 10% line, you're just fine.
Be sure to get a few cans of the high carb (HC) like 18% or something. They are going to be your grilled or gravy ones... they are the yummy ones that will need to be given if Tye goes really low and you need to bring his numbers up. I keep all my HC cans in a separate place from the regular LC foods; I don't want to be grabbing the wrong can and then wondering how come I got such high BG numbers!

The ketostix can be picked up at any pharmacy. If Tye's getting into the higher BG numbers, you want to be testing once a day, just to be sure that no ketones are registering in his urine. When you test, if you see the stix register even a trace, please post here as any ketones are a matter that need to be addressed. Some cats never have problems with them, but some do, so it's best to know which side Tye is on.
 
I read back on your first posts on Health. Is Tye living with you all the time now?

Everyone has mentioned the importance of getting him completely off the dry food. And now while he is on only the one unit of Levemir would be a good time. If you were to continue to raise the dose to combat higher numbers then you would have to start all over again once you did get him off the dry. I hope that makes sense.

Boy, do I know how hard it is to make that transition with a stubborn dry food addict. I think everyone on this site has gone through the drudgery of having to do this. Some cats are harder than others for sure.

Have you tried sprinkling parmesan cheese over the top? The one that comes in the green can. You can also use Romano cheese in the same way.

I think someone already mentioned to you to try Fortiflora on your Health thread. You sprinkle just a small amount. Recommended by Dr. Lisa for picky eaters.

http://www.amazon.com/FortiFlora-Feline ... 850&sr=1-1

Also, if you can find dried chicken treats. I can't find it right now, but Sheila has a good link for these.

Also, these pouches from Wellness are a big hit when Tigger is off his food. They are a little pricey if you have multiple cats though.

http://www.wellnesspetfood.com/products ... t=cat&ft=4

Keep at it and hang in there. You will get there and when you have him off the dry food completely you will see such a difference in his numbers and his regulation. :)
 
Here is a link to the freeze-dried chicken treats I use. They are made for dogs, but chicken is chicken.
http://www.petsmart.com/product/index.jsp?productId=4406466

I get them from my local PetSmart. There is a cat version called Halo that are, basically, the same thing, but cost more. The difference that I have found is that the dog ones sometimes have hard chunks in them, but since I always either crumble them over food or tear off pieces to feed as treats, I can feel those and either break them up or throw them out. Really, it might be 2-3 pea-sized pieces per bag that I have to toss. I just don't want my cat's to hurt their gums on something too hard. But they love these so much that if I get out ANY other crinkly plastic bag (my cereal comes in one), they come running and pester me for treats. Like you said, wierdos.
 
Michelle, I just noticed on Tye's spreadsheet for today that he dropped down to 40 at +6.

So my question would be if he got any dry food today? Did he eat normally? Because if that is with the dry food then that would be very odd that he would get a drop like that.

ETA what time do you normally shoot?
 
Also, can you explain the comment on yesterdays line - what shot was delayed till +14?
With Lev, you need the shots to be 12 / 12, so if you delay to +14, then the next shot should be 12hrs later.
If your shots are at 8am/8pm, and you delay a shot to 10am, then the next shot should be given at 10pm.
If you give a shot late, and then the next shot at the regular time, it's like giving a dose increase and that would explain the low 40 .
 
Hi, yes the 40 (2.2) at +6 happened on wet food. Right now I am giving 1 small can of wet food per day to see if he eats it and yesterday he finished the whole thing - so I assume no dry food was eating in between the PM and AM shots.

So I think that explains how he got so low. (The previous day when I waited until +14 to shoot happened in the AM, so there wasn't any overlap by 24 hours later... we are now a bit off track at 12 noon / 12 midnight so I'm trying to go back by 30 min a day)

Anyway the 40 (2.2) number scared me a bit yesterday so I only gave 0.5 Lev for his PM shot... now this morning he is up to 322 (17.9)! But he also didn't seem to like the wet food I gave last night (marinated kind which I understand isn't as good as the low carb pate ones anyway).

Ugh so it seems Pamela is right, now is the time to sort out his food situation as I don't think I'm going to see consistent numbers without making this change.

Tye is still living with my parents but as I've been sick (and have the flexibility to work from home) I've been staying here since Christmas in order to tackle the cat situation and get my dad trained up on how to measure BGs. (I think he has gotten the hang of how to do it now - too bad the BGs are swinging so much though)

I will try the suggestions re: putting dry food on top of the wet and the parmesan cheese. Will look into ordering the other brands too.

For now what should I do about the dose? I shot 1 unit today since he was at 322 (17.9) (and seemed to have eaten dry)... but I am nervous to do this when he has the wet and numbers go more to the 160-200 range (and 40 at nadir!!). Should I only give 0.5 when they are that low?

I am not sure if having 0.5 one day and 1.0 the next is good for him but I feel like until he consistently eats the wet food I would have to change my dose accordingly.... do you agree?
 
Michelle, it doesn't work with this insulin to keep changing the dose in response to a PS (unlike the faster acting insulins). Lev works best at a consistent dose shot every 12 hours. Also, you should make dose changes based on the nadir number, not the PS number and, unless there is a really low nadir, don't make a change based on one number.

Because he is being transitioned to all wet food, and he dropped to 40 yesterday, a dose reduction is a good idea. He may need a little more than .5u though. I would suggest trying .75u and let that settle for 6, or more, cycles (unless he drops below 40 again).

The higher PS this morning could be a bit of rebound from the 40 yesterday, but it could just be a response to the lower dose and needs to settle out. I would try .75u tonight and let that settle for several days.

Make sense?

PS - good plan on the food transition and getting that sorted out now. My vet told me to wait until Beau was regulated before changing his diet... which makes no sense at all. Beau was not regulated at all until I changed his diet.
 
tye said:
Anyway the 40 (2.2) number scared me a bit yesterday so I only gave 0.5 Lev for his PM shot... now this morning he is up to 322 (17.9)! But he also didn't seem to like the wet food I gave last night (marinated kind which I understand isn't as good as the low carb pate ones anyway).
Click to expand...

Yeah, they do like those gravy flavors but they are higher in carbs and should only be used to bring up a very low number. So please put those away for emergencies as well as the dry food. As long as he knows there is something more tasty around he won't eat the less exciting/tasty foods. angry(2)_cat

You might want to add that to your spreadsheet that he got gravy wet food last night which could have been the reason for the high number this AM as well as rebound from the 40 yesterday.

tye said:
For now what should I do about the dose? I shot 1 unit today since he was at 322 (17.9) (and seemed to have eaten dry)... but I am nervous to do this when he has the wet and numbers go more to the 160-200 range (and 40 at nadir!!). Should I only give 0.5 when they are that low?
Click to expand...

I saw Sheila suggested .75 - I agree and was going to suggest that too. Remember you are there to monitor and have the tools to bring him up if he goes too low. You just need to find a dose that keeps him in a nice range and where you are comfortable shooting the full dose.

Since you are home try to get in a +10 and/or a +11 test. Then when you test him at preshot time you will see if the number is higher or not. If he is on the rise you should feel more comfortable shooting a lower preshot.

Nice your Dad is getting the hang of testing. Good for him!! Does he get on the computer much? If he has any problems and you are not around can he post here?
 
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