? ? New to Levemir dosing questions

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Vicki and Jerry

Vicki and Jerry

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I have just gotten Jerry's Prescription for the Levemir flex touch pens. He is still using Humulin NPH and I test with the AlphaTrak2.( he eats FF classic canned) If you see his SS you will see why I needed to make a change. I already have the 1/2 marked U1oo syringes and of course the Hypo kit ready to go. Jerrys weight is 10 lbs. Vet wants to do a resting glucose number so he needs to fast for twelve hours. He wants to see if it is above or below 360 MG. If over the 360 mg he suggested starting at 2.25 U BID. Jerry now takes 2.25 U of Humulin NPH ( varies with his numbers)
Questions are do you need to do the resting glucose number? I do intend to use the SLGS method.
I do understand to keep Jerry very closely monitored but I just don't want to start at to high of a dose since it sounds like you need to try and keep the dosage the same for the 6 cycles. Like everyone just scared of the Hypo. He has gone thought it once at the very beginning of his insulin treatment and do NOT want to go though that again. I appreciate any input to get Jerry and I started with the Levemir. TIA
I will be using the Relion Micro Meter when I change to Levemir
 
Welcome to Lantus & Levemir Land!!

I don't know what to tell you regarding starting dose but I can bump the thread up to the top :) You can also edit your thread title and put in the ? icon and add your starting dosing question to the tread title.

We started out on ProZinc in May and switched to Lantus in July, dropping from 4u to 1u and were told that we dropped too far. We are switching next week to Levemir (when it comes in from Canada -https://rxcanada4less.com/ much less expensive than US prices but takes about 1 week to get to the US east coast) and the vet wants us to drop 50% but the board recommends giving 70% of old dose when switching between Lantus and Levemir) We will probably split the difference :smuggrin:

If you have not already read the sticky about Depot insulins (http://www.felinediabetes.com/FDMB/threads/lantus-levemir-what-is-the-insulin-depot.150/) you should. They are different than the NPH he has been getting. They build up over a few days, so his first response will not be his "typical" response. You should keep the dosage the same (day and night) for 6 cycles (3 days) to get a feel for how it will work for Jerry. Obviously, if he goes low (below 90 for SLGS and human meter) you would give a reduction. We use the same meter (the Micro) and you can get a great deal on strips here (http://www.adwdiabetes.com//product/arkray-glucocard-01-sensor-test-strips-50bx-buy-4-get-1-free_4050.htm).
 
Since you're switching and already using 2+ units, you might want to start around 3/4 or so of what you're giving. (The experienced users will undoubtedly chime in on this)
It works very differently - slower, gentle onset, often a later nadir. And you've got to be patient and let the effects build up over 5-7 days starting out, before increasing. Its kind of like pouring water in a funnel - too fast and it flows over, too slow and flows right through, just right and a small pool is in the funnel while you pour in from the top and drain from the bottom.
Do read over the sticky posts at the top of this forum section.
 
When switching from an insulin other than Lantus-Lev (between those 2 insulins) it is common that the cat will need about the same amount of insulin as they needed before. Switching between Lantus and Lev (either direction) we suggest dropping the dose to 70% of the current dose on the current insulin. Since you're currently using Humulin N, that 70% reduction wouldn't apply to your situation.

Looking at Jerry's spreadsheet, I see he got to green numbers (78AT) on 2.25u - which on an AT is right below the reduction point for those following SLGS (90). So I would probably start at 2.0u. As you said, hypos are scary, although with these longer-lasting insulins, it's not common to have symptomatic hypos in those who are hometesting and following either the Tight Reg protocol or the SLGS dosing method. It's easier on the nerves to end up needing to increase the dose slightly, although you don't want to start too low and have him in high numbers unnecessarily long. That's why I'm thinking 2.0u.

I think the black numbers and other highs you are seeing is because the insulin is wearing off before the next shot takes effect. Levemir is great for lasting a long time and holding blood sugar flat - I suspect you're going to be pretty happy with it.

But let's see what others suggest as well.

and by the way - welcome to the group! Ask as many questions as you have - we all remember what it was like to be starting out and how confusing it can be. We're glad you're here!
 
Thank you for your replies!! I will start the Levemir on Monday when I can keep a close eye on him and monitor his BG levels. Right now I still dont know if I need to do the resting glucose test or not. What I have read I have not seen this be a method to come up with the dose amount. Still lots of questions before I start. I will continue and read the sticky notes until my brain wraps around them!!!
Thanks!!
 
Are you sure your vet said a "resting" blood glucose (BG) test? The term is usually a fasting BG test. Either way, most of us don't do it. I'm not sure you'd want to fast your cat prior to giving a shot of insulin. I'm also not sure how you can get a resting BG test with a cat unless you are planning on testing when Jerry is sleeping. With Lantus and Lev, if you were just starting out on either of these two types of insulin, the initial dose could be based on your cat's weight if you were going to use the Tight Regulation Protocol or with SLGS, you start out at 0.5u. Given that Jerry has been on NPH, the starting dose of Lev should take your current dose of NPH into account.

 
Think I should of said fasting BG test. I did not do the total 12 hours of fasting to test him but did do a test of seven hours of fasting before I gave him his food in the morning.( which is given 2 hours before his shot )and it was 427. Vet suggestion was if over the 360 mg at test time he should get 2.25 units but he is not very familiar with Levemir at all.
So still a little confused on his amount of units he will need. I give 2.25 U now on Humulin NHP and I had a suggestion on 3/4 of that for the Levemir ( which what in units would that be? Around 1.70u?? ) Math ugh .. and a suggestion of 2U for the Levemir. I am going to use the SLGS. Any other suggestions or am I on the right track of giving him 2U for the SLGS? Sorry for all the questions but still knid of new at all of this and your help is very much appreciated!
 
A full fast shouldn't be necessary, but we usually take up any leftover food 2 hours before preshot test, to get a non influenced number. I think a starting dose of 2u would be safe. You must remember though that this same dose should be maintained until the shed had a chance to be filled, for SLGS that is 1 week, unless the cat goes below 50 (about 68 on an AT?). You won't see the actual effect of the dose until then. A very important point to remember is that once the shed is established DOSING IS BASED ON THE NADIR (that's the lowest that a cat goes in the cycle) NOT ON THE PRESHOT TEST.

Since Levemir is a very long lasting insulin it is not necessary to wait to shoot after eating, unless there is some problem getting Jerry to eat. We usually test, feed, shoot within a few minutes, often while the cat is still eating. Onset for Levemir is often 3 to 4 hours after the shot and the nadir can be as late as 8 hour even up to 12 hours after the shot. It will take some getting used to.:rolleyes::bighug:
 
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The suggestion to start at 3/4 of the NPH dose is incorrect. If changing between Lantus and levemir, we start st 70% of the dose but not with other insulins. When changing from other insulins to Lantus or levemir, we look to see what dose got the kitty into safe, normal numbers. If kitty hasn't gotten there yet (Jerry has), we would consider the dose that got kitty into the best numbers.

Good luck with the switch.
 
Made the switch from Humulin to Levemir today 11/10 His AMPS was 220 on the Relion micro. (266 on the Alphatrak) which is lower than it has been running. I gave him 2U. I will test him several times today to see his BG but what I have read is it takes about a week to build up his depot and then do a 12 hour curve. Am I correct?
 
It can take 5-7 days for the depot to build. You can use this time to do spot checks around different times in the cycle to try and figure out when his onset and nadir might be. I'd also test a bit more often today and tonight, just in case Jerry is one of those few kitties that respond quickly.
 
Vicki and Jerry said:
it takes about a week to build up his depot and then do a 12 hour curve. Am I correct?
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Partially....the part about the depot taking 5-7 days to build is correct, but as Wendy said, some kitties don't read the "rules" so getting tests sprinkled throughout the day (and night!) is a good idea

The other decision you'll need to make is which dosing protocol you want to use...that will determine how often you make dose changes. The Tight Regulation Protocol gives the best chance at remission and is backed up by a published protocol in a veterinary journal. Dose adjustments can be made as often as every 3 days which can keep better control of the blood glucose numbers...therefore allowing the pancreas to heal sooner and hopefully get the cat into remission. It's an aggressive protocol though and not for everyone. Reductions are earned when the blood glucose drops below 50 (on a human meter). It requires the cat be on low carb canned or raw food only and a minimum of 3-4 tests per day. Always before shots, and if at all possible a mid-cycle on the AM cycle and a "before bed" test on the PM cycle (although most of us test more often than that)

The other method is the Start Low Go Slow method. With this method, doses are held for 7 days and then a curve is run to determine what dose to use the following 7 days. Reductions are earned when they drop below 90. This isn't as aggressive, but we've had cats go into remission on SLGS too. This is used more by people who can't test as much or for whatever reason aren't comfortable with the TR protocol

It'll be important for you to decide which way works for you and Jerry...but if you choose one way and decide later it's not for you, you can always change!!
 
I would try to always get a test in the pm cycle. So many cats have their lowest numbers at night, and since your dosing decisions are made by how low the dose takes the cat, it becomes important to know that. Many people get a test right before going to bed.

Looks like Jerry is having a nice response for his first day.

You doing ok, Vicki? Any questions so far?
 
I will try and get some numbers tonight. The change so far has been pretty smooth but like everyone says they are very unpredictable and Jerry is no different!
Thank you @julie & punkin (ga) for asking! So far so good but I am sure there will be lots of questions from this newbie!! Thank you all!!
 
You got some good testing in today! It's early days yet, but looks like those tests in the +6 to +9 time frame will be key. Tomorrow maybe try a few tests on the odd number hours. Maybe try a +3 or +4 tonight if you are up that late as seeing where he is after onset often gives a clue what the cycle will look like.
 
Wendy&Neko said:
You got some good testing in today! It's early days yet, but looks like those tests in the +6 to +9 time frame will be key. Tomorrow maybe try a few tests on the odd number hours. Maybe try a +3 or +4 tonight if you are up that late as seeing where he is after onset often gives a clue what the cycle will look like.
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Jerry second day on Levemir. his AMPS number is 162. Just wondering to shoot or not. I am using the SLGS method and he is on 2U
I just don't have enough data since this is only his second day to see how low he goes. I can test all day since I am home. Thanks
 
Normally 162 is a shootable number, especially on Levemir with a later nadir. You can get nadirs near preshot, which it looks like Jerry did last night. In that case, you do have to shoot lower. But they keep going up until onset.

If you have to stay on this schedule, your options are to give a token dose or skip. Since you are home all day, some insulin would be better. If you have flexibility in your schedule, you can feed and wait a couple of hours to see what is number is then, and possibly shoot when he's at a number you are more comfortable shooting.
 
Wendy&Neko said:
Normally 162 is a shootable number, especially on Levemir with a later nadir. You can get nadirs near preshot, which it looks like Jerry did last night. In that case, you do have to shoot lower. But they keep going up until onset.

If you have to stay on this schedule, your options are to give a token dose or skip. Since you are home all day, some insulin would be better. If you have flexibility in your schedule, you can feed and wait a couple of hours to see what is number is then, and possibly shoot when he's at a number you are more comfortable shooting.
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If I give a token dose do you know what that would be of 2U? If I feed and wait a couple of hours to see his numbers would be ok too but just wondering how you would get back onto schedule I do the 9 am and a 9 pm shot time and that works for me. I hate to skip since it seems like he is responding to Levemir. Jerry, Jerry ,Jerry , what to do??:rolleyes: Thanks @Wendy&Neko for your help!!
 
Jerry ate at 6:30 am + =9.5 AMPS 162 ate 1/4 can FF thirty minutes after AMPS and eating 159 +1 at 134 Looks like he is still going down so thinking no shot or token.
 
Lev can nadir late, even about the time of pre-shot, however the dose could still be too high for him
Unless you can be home to monitor and intervene, I'd go with the safe option of skipping and starting again at night, since you haven't got but 2 doses in him so far.
And maybe the Lev is working better for him than the NPH and he might be better off with a 1 unit dose ... if he's even high enough to shoot ... until you have some data to see how he handles it.
 
BJM said:
Lev can nadir late, even about the time of pre-shot, however the dose could still be too high for him
Unless you can be home to monitor and intervene, I'd go with the safe option of skipping and starting again at night, since you haven't got but 2 doses in him so far.
And maybe the Lev is working better for him than the NPH and he might be better off with a 1 unit dose ... if he's even high enough to shoot ... until you have some data to see how he handles it.
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That makes sense to me BJM! I just tested Jerry for his +3 and he is at 126 his +2 was 122. I just fed him 1 1/2 ounce of FF after his +3 test So with these late Nadir numbers your suggesting that the dose of 2U was to high? I would agree with skipping his dose and shooting him tonight at his regular 9 pm time. I will set my alarm for tonight and get some data. Just hard to understand all this with not much to go on since its his second day. Maybe good news is that the Levemir IS working better on Jerry than the NHP!! Thanks @BJM
 
Are all of the tests in the spreadsheet done on the relion? Just making sure there isn't a mix of AT and human meter reporting.

Yes, Lev is probably better for any cat than a nondepot insulin. Cats metabolize insulin quickly and longer control is better.

What is your goal for him? Are you hoping for remission or simply controlled blood sugar?
 
julie & punkin (ga) said:
Are all of the tests in the spreadsheet done on the relion? Just making sure there isn't a mix of AT and human meter reporting.

Yes, Lev is probably better for any cat than a nondepot insulin. Cats metabolize insulin quickly and longer control is better.

What is your goal for him? Are you hoping for remission or simply controlled blood sugar?
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Yes all the tests in Jerry's Levemir SS are done with the Relion Micro meter. While he was on Humulin all his testing was done with the Alphtrak.
Yes remission would be wonderful but what I am up against is I will be leaving Jerry in the near future with a pet sitter and thought it might be easier for her and her schedule if Jerry was on the SLGS for now. At least until I get pass the learning curve of Levemir and its response to Jerry.
(His last test at +4 was 242 but if I shoot now then his schedule will be 1 am to 1 pm for me and would take me a long time to get back to the 9 am 9 pm )
 
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How soon in the near future?

I'm thinking the dosing guidelines (in regards to what to do with a lower preshot) were written for Lantus curves, and those using Lev sometimes have to get used to giving the shot at the nadir of the cycle. Dosing decisions are primarily made by the nadir of the cycles - how low the dose takes the cat, with less consideration given to preshot tests.

I think it was fine to stall or skip this morning, but it is something you'll want to begin to notice as you give shots. If his nadirs are around the preshot time, then shooting lower becomes important in order control the rest of the cycle.

This is really a pretty ideal cycle he's got going on - he's in very safe numbers, but not too high. But if it unnerves you, you could drop the dose a little. Personally, I wouldn't cut it by 50% however. That seems too much to me. Even 0.25u changes in dose can make huge differences. I think this dose looks pretty good, but if you want to decrease the dose, I'd just do it a little, maybe 1.75u or 1.5u. Dropping it too much, just like starting too low, can cause a cat to be in high numbers unnecessarily.

However, that said, this is simply my opinion. You hold the syringe and need to make the choice yourself.

Have you dealt with low numbers before? I looked at the NPH spreadsheet but can't really tell. If he drops below 90 (since you're following SLGS) you would give him a little bit of high carbs and then retest in 20ish minutes. There are exact guidelines in the SLGS sticky.
 
Almost forgot - one little "trick" to help a cat "surf", ie, stay in the range they are in, is to dole out a little bit of low carb food every 30-60 minutes or so. Jerry isn't plummeting - he's got such a nice blue surf going right now, I'd give him some low carb to help him stay there.
 
Sorry, I keep thinking of other things to consider. With the Lev, it can be 4 or more hours til the onset of the insulin's action. With NPH you saw an almost immediate onset - looks like an hour or so - and it was done by about 5 -6 hours.

So it will be a little bit different for you since the new Lev shot won't onset for so much longer after the shot compared to the NPH that you're used to.

By the way, something for you to consider that might be helpful for those of us helping you - most people keep the same spreadsheet when they switch insulins or meters. They put in a noticeable horizontal row and say something like "Levemir & Relion meter below" and then add their numbers below the line. I'm switching back and forth between your NPH ss and the Lev one - because the data on both is important - and thinking it would be easier if you kept the same one. If you want to do that, now would be the time since there isn't much data on the new ss yet.
 
I would not get too panicky on the dose yet. These are really good numbers and it might be a perfect dose for him. If you absolutely are worried, I agree with Julie that I wouldn't reduce more than 0.25u. But I don't think you started at too high of a dose and I would give the 2u time. Remember I told you that some cats will see some action early on the switch...they don't always read the book on how long it takes to fill the depot.

If you need help with the SS....making it as Julie suggested...I'd be glad to help. I've done this for several members. Just shoot me a PM.
 
julie & punkin (ga) said:
How soon in the near future?

I'm thinking the dosing guidelines (in regards to what to do with a lower preshot) were written for Lantus curves, and those using Lev sometimes have to get used to giving the shot at the nadir of the cycle. Dosing decisions are primarily made by the nadir of the cycles - how low the dose takes the cat, with less consideration given to preshot tests.

I think it was fine to stall or skip this morning, but it is something you'll want to begin to notice as you give shots. If his nadirs are around the preshot time, then shooting lower becomes important in order control the rest of the cycle.

This is really a pretty ideal cycle he's got going on - he's in very safe numbers, but not too high. But if it unnerves you, you could drop the dose a little. Personally, I wouldn't cut it by 50% however. That seems too much to me. Even 0.25u changes in dose can make huge differences. I think this dose looks pretty good, but if you want to decrease the dose, I'd just do it a little, maybe 1.75u or 1.5u. Dropping it too much, just like starting too low, can cause a cat to be in high numbers unnecessarily.

However, that said, this is simply my opinion. You hold the syringe and need to make the choice yourself.

Have you dealt with low numbers before? I looked at the NPH spreadsheet but can't really tell. If he drops below 90 (since you're following SLGS) you would give him a little bit of high carbs and then retest in 20ish minutes. There are exact guidelines in the SLGS sticky.
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Ok . When I was reading how to handle low preshot numbers it did refer back to Lantus. Just need to get though my brain that Lev will nadir so much different than his NPH. Am I right that his last cycle his nadir was at +14 the 122 number? So If I were to of given him his shot he would of not dropped to quickly? but rather carry on with those nice blue numbers and if he did drop below 90 I could of given him some high carb food to take his numbers back up. I have dealt with a Hypo in Jerry at the very beginning of his insulin treatment. I did like his reading yesterday and thought the 2U were going to work for him. Would like to keep his blues going if possible. And also next month Jerry will be having a petsitter.
 
Marje and Gracie said:
I would not get too panicky on the dose yet. These are really good numbers and it might be a perfect dose for him. If you absolutely are worried, I agree with Julie that I wouldn't reduce more than 0.25u. But I don't think you started at too high of a dose and I would give the 2u time. Remember I told you that some cats will see some action early on the switch...they don't always read the book on how long it takes to fill the depot.

If you need help with the SS....making it as Julie suggested...I'd be glad to help. I've done this for several members. Just shoot me a PM.
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I agree I love the blues esp. after being on NHP and all was so drastic!!! If 2U helps Jerry and maybe makes Mom a little nervous guess its worth it.
Jerry might just be one that reacts soon to Lev. I DO need help in the SS . I was wanting to keep the same ss but could not figure out how to change the cells in the spreadsheet to
make the horizontal line for my reference info on changing to Levemir and the Relion meter. Also how to do add more information in the cells? When you say PM does that mean conversation on this site? Sorry so many questions but I really do appreciate all the help!!
 
Looks like you got the spreadsheet figured out.

Pm means a personal message. If you click on anyone's profile picture, there's a place that says something like "start a conversation". That's what marje was talking about.

I've closed his ss, but I think you've got it right, his nadir from last night's pm cycle was this morning. The nadir is simply the low point. If he'd had the shot this morning, it would have onset a few hours later and might have kept that blue streak going. No way to know for sure. You'll have another chance and Jerry will recover from the skipped shot.:D
 
My Spartacus was on N when I got him - 11 or 13u - and eating dry kibble. We changed food immediately, he "de-toxed" for 2.5 days, then started at .5u Lev. He responded beautifully. He's never been above 1.25u Lev. I think you'll be pleasantly surprised what a difference the new insulin will make. Good luck!
 
Improvement showing up already. 2u may be just a tad high... and his body will be adjusting to seeing such nice numbers. You're doing a great job testing. I know it's hard to shoot a blue number... it was for me as well. But once you get accustomed to Lev, you'll find it's much easier to predict their response. Just think how much better he must feel!
 
Grayson & Lu said:
My Spartacus was on N when I got him - 11 or 13u - and eating dry kibble. We changed food immediately, he "de-toxed" for 2.5 days, then started at .5u Lev. He responded beautifully. He's never been above 1.25u Lev. I think you'll be pleasantly surprised what a difference the new insulin will make. Good luck!
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Wow sounds like Spartacus has done very well on Lev!!! I already am very pleased with his numbers compared to his NHP ones. Like you said it will take some getting use to shooting on the low numbers.
 
My "do not shoot" number for Grayson on ProZinc was 250... but I rarely saw even that much movement. Once I got the insulin resistant dx, it became so much clearer! Grayson "Swam in a sea of pinks" for most of the first 4 months. He needed more juice, and NOT to get into the Tupperware canisters of dog & cat kibble that were in the cupboard. He was quite committed to sneaking food. The ravenous appetite of an Acro cat didn't help either! One of my favorite stories was when I found the poor, starving, carb-starved boy riding on top of my canned & boxed goods in my (pantry) lazy susan base cabinet... his face in a torn-open bag of egg noodles!!!
 
Just checking your dose here - can you describe or take a picture of what you mean by 0.2 units? Most folks with that low of a dose are using calipers or eyeballing between tick marks on the syringe. Are you doing that?
Or are you using a 3/10 mL U-100 syringe and lining up with a specific tick mark?
 
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