Please share experience on Levemir use_Very concerned w/NPH

Status
Not open for further replies.
Re: Please share experience on Levemir use_Very concerned w/

Feeding the higher carb is good for now. And retest.

If you ever need immediate help, post on Health where there are more eyes.
 
Re: Please share experience on Levemir use_Very concerned w/

I see you shot .75u on that 456. That was probably ok. The 456 is rebound from the low last night. She just isn't used to those numbers and it is possible that she was lower at +3. Bouncing to 456 is a huge response to a low number. Did you give her any syrup last night? That adds to the bounce effect.

Now, the thing is to stop the roller coaster ride for her. What you shoot tonight is really important in that respect. If she doesn't drop lower than 150 today, probably .5u will be ok. But is she drops lower than that or is lower than 150 at tonight's preshot, then going to .25u would be a good idea.

You want to stop these swings, even if it leaves her in the 200s. Once you get flatter numbers, you can slowly raise the dose (in something like 20% amounts) to bring the entire curve down together instead of creating deep valleys and high peaks.

Lev is a much gentler insulin than NPH so it's action is slower. It's onset is later, duration longer and it overlaps with the next shot. That is how it can maintain overall lower numbers. One shot is wearing off as the next begins to effect things. There is never a "zero amount of insulin" in the blood stream. So seeing those rapid fall-offs in BG in the first few hours is a really good indication that the dose is too high. So .75u is too high a dose, It worked today where you had really a high rebound BG that needed to be brought down. However, this is not the best way to dose this insulin. Making dose changes based on the preshot number works only for fast insulins like NPH and vetsulin. With lev and lantus you have to find the dose that shot consistently keeps the BG in a low, shallow curve. That is the difference in using long duration versus short duration/fast insulins.
 
Re: Please share experience on Levemir use_Very concerned w/

I shot something inbetween 0.5 and 0.75u. It is very subjective to say exact due to so small lines/space available plus plunger seal seams to be not ideally horizontal. Additionally, air buble always present and we had a hard time to get rid of it.
We did not give her any syrup last night when we saw 50. We gave her canned food with higher carb content than her low carb diet. Just one tea spoon plus fed her additionally with low carb wet food (another tea spoon). Just measured BG at +8. BG=74.
 
Re: Please share experience on Levemir use_Very concerned w/

Since you shot late tonight, make sure tomorrow am is also 2 hrs later (12 hours after tonight's shot).

Moving shot times earlier with lev (and later) is not as easy as with NPH because of the overlap. In general, shooting late = and dose decrease and shooting early = a dose increase.

Will you be trying to move her shot time back to what it was for Tuesday morning? You can do that, but would need to decrease her dose a bit to shoot earlier than 12 hrs. It's hard to say how much without data to show how she is tending to respond to lev. Just don't skip a shot if you can avoid it as that messing up the numbers for several cycles.

I will be interested to see how she handles the .25u shot later . Hopefully you won't have really high numbers again tomorrow - and no real low tonight.
 
Re: Please share experience on Levemir use_Very concerned w/

We'll try to go back to the same schedule, also, worried about reaction to low dose and morning #s
There was no need to inject at +12 tonight but later BG started to move up again.
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila.
BG was 282 at +4 and BG=274 at +8 (after 0.25u shot). What do you think?
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
we injected 0.5 u earlier at +10. Dose was not lowered. We need to get back to work week timing. BG at +10 was 341 at the time of shot.
 
Re: Please share experience on Levemir use_Very concerned w/

Vitali,

I know you are new to this insulin and don't yet have a good feel for how it works. This is why I am trying to explain the reasons for my suggestions.

It is really important to drop the dose to .25u and shoot that on a 12/12 schedule no matter what her numbers are (assuming they are above 100-120). Lev works by keeping the numbers lower. So last night, when she was at 129 there WAS a reason to shoot insulin. It was to keep the numbers lower. And remember, that was supposed to be .25u so it was already a big decrease from the previous dose. If you are hesitant about giving insulin below 180 from you experience with NPH, that is normal, but there needs to be a plan to address the situation as you learn a new way of using insulin.

While it is yet an unknown to shoot a full dose on JJ when her numbers are lower, if you are home you can go ahead and do it and monitor, feeding if needed on a number that drops below 50-60. If you won't be home, then reduce the dose a bit. You can reduce a bit if you are really uncomfortable with the number she is at - until you have data showing that it is safe. Always, if you skip the shot you lose momentum. and BGs may stay higher for a few cycles.

Why isn't that happening with JJ today? Because you double increased the dose on her. Remember that shooting early = a dose increase. You increased from .25u back to .5u and shot 2 hours early - double increase.

Please try to forget everything you learned about using NPH. Lev does not work the same. I know, I had this problem with the switch from vetsulin to lev. Vetsulin is very similar to NPH in how it works.

You, and JJ, are going to have to weather some higher numbers (like those nive, even yellow last night) to let the rebound hormones leave her system and the lower dose settle. She will stop swinging from high to low if you stay with .25u for about 3 days.
 
Re: Please share experience on Levemir use_Very concerned w/

Hi Sheila,
Just measured BG at +8. BG=79. We tried to follow your suggestion: shoot earlier = dose increase. If tentative for +12 was supposed to be 0.25u, we've dosed the shot at +10 from 0.25u to 0.5u. Did we do it wrong?
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
it is easy for us to forget NPH. we had no time to learn it.
here we're at +12 (8-00pm) and BG =143. Do we monitor more?
 
Re: Please share experience on Levemir use_Very concerned w/

You have data now that she climbs from +11 to what would be +1 - so shoot .25u at +12. Youalso know that the +11 is a climb from +8. That means it is safe to give her insulin even on a 143 or 129 because her BG is on the way up.

She is going to be all over the place until you are shooting consistently at +12. Every dose change (in amount or timing) effects her entire cycle. When you shoot late like you did again tonight it gives her BG a "head start" in climbing higher. Then you shoot too high a dose (.5u) and she will drop again - probably lower than she did two nights ago - and that will cause a climb to higher numbers by the morning, just like on the 26th.

Please do not shoot more than .25u in the morning even if she in in the 400s. I know it will be a +11 shot because of work schedules. Let that earliness work on the higher BG and let things settle out - or she will just keep swinging like this. Right now you WANT nice even (flat) numbers in the 200s to stop the swings.
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
just measured at +6 and BG=182. Just looking at the previous cycle, do you think 0.5u in the morning would be a better choice than .25u?
Thank you
 
Re: Please share experience on Levemir use_Very concerned w/

No. .25u. I hope that is what you gave her this morning. I am afraid to look.

She is on a BG roller coaster ride because of too much insulin. The only way to stop that is reduce the dose and let things settle.
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
We gave 0.5u. at +4.5hr BG=175
Compared two syringes. 0.5u from ReliOn=0.25u from BD. Scarry....
 
Re: Please share experience on Levemir use_Very concerned w/

Wejust filled each of them up to the 0.5u markand released the content on a flat metal surface, drop by drop, side by side and BD was consistently a drop or 1.5 drop more.
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
if we introduced the air in the levemir pen, is this pen wasted and we need to through it away?
nerves and getting tired...
 
Re: Please share experience on Levemir use_Very concerned w/

One more thing, do we need to warm up in hands the insulin dose prior injection? I've seen somewhere that is needs to be room temperature when injected?
Also, what is typical shelf life for the pen in use? thanks
 
Re: Please share experience on Levemir use_Very concerned w/

Don't worry about the air. Those pens have a second stopper that moves with the decreasing insulin quantity to hold a vacuum in the pen. I had a pen where that failed and the insulin was still good until I finished it up even though there was a lot of air inside.

Refrigerated you can use the pen until it is empty. I think I posted about that before.

You don't need to warm it. You are shooting such a small amount - it probably hits room temp immediately anyway. The guidelines that come with the pens are for human use with large doses using pens that last 2 weeks or less because they are used up.

As for the syringes, if that is the case, pick one brand and stick with it. BDs are NOT the best. They get lots of air bubbles. Not sure about the Relions.
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
Thank your comments on Levemit pens. What syringes that you've used draw the minimum or no air? We noticed that ReliOn draw some air as well.
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila & Beau & Jeddie (GA) said:
This is the kind I get (and where I order from):

http://www.hocks.com/diabetic-suppl...edle-1-2-unit-markings-gnp-brand-100-box.html

One thing I always do before drawing the dose (and before sticking the syringe into the vial or cartridge) is to pull the plunger down and push it back up to zero. That kinda gets it "unstuck". The other thing is to twist the plunger with very slight pressure on it to fine tune the position.
Click to expand...
I posted that on the first page of this thread.

Vitali, please start a new thread (new topic). This is getting too long now.
 
Re: Please share experience on Levemir use_Very concerned w/

Welcome Vitali!

Since you started in the Levemir forum, I didn't see you join us. I've found you now! :smile:

In general, we want the glucose level of a cat on insulin to stay above 50 mg/dL for safety reasons. Please do not increase the dose based on the pre-shot test you get. He is going too low.

Levemir is a slow and steady insulin. It is like steering a big cruise ship - make a little turn of a few degrees, and a few days later, you're going in a different direction. Similar concept using Lev - make a small dose change, and 3 or more days later, see the full effect.

My signature link Secondary Monitoring Tools, has some other assessments you might wish to note on your spreadsheet, such as the 5 Ps (also called the "Whole Cat Report").

I see you are in Ohio, as am I.
 
Re: Please share experience on Levemir use_Very concerned w/

Hi BJM:
thank you for the tips. Should the dose be decreased if a pre-shot test is below certain BG level so we would not to put BG's into very low numbers and what is the BG level? Based on what you see on JJ's SS, are we high on the dose should level it down?
 
Re: Please share experience on Levemir use_Very concerned w/

Hi Vitali

We recommend you not give insulin if the pre-shot is < 200 mg/dL until you have enough data collected in the middle of the cycle to show it is safe to do that.

When the pre-shot is < than your no shot level (currently 200), without feeding, wait 20 minutes and re-test to see if the glucose is rising. This is called 'stalling'. If it is rising, it may be safe to shoot. You may want to post a request for feedback at that time in the main Feline Health forum with the question icon selected as the Levemir forum doesn't have as many folks checking it.

And, we usually ask new members to post an introduction in Feline Health, so everyone gets to meet you and say Hello.

There is a Tight Regulation protocol developed for using both Lantus and Levemir described in the sticky posts in the Lantus TR forum. You may find it helpful to read that over if you haven't done so yet.
 
Re: Please share experience on Levemir use_Very concerned w/

Vitali, a quarter unit only. (unless she is below about 130 at PS or, on a quarter unit, drops below 50 during the cycle).

I disagree about using 200 as a do not shoot number at this point. I think you have data showing she rises from +11. However, that suggestion is based on only shooting .25u. I think a safe do not shoot number is 130, but certainly 150.

Why are you not dropping the dose to .25u? That is the ONLY WAY to stop these swings from 400s to 30s. The only way.
 
Re: Please share experience on Levemir use_Very concerned w/

I wrote 200 as a no shoot number because there is not much data at the same dose and I am concerned because of Lev's longer action and build up. I tend to be on the cautious side.

You hold the syringe, Vitali. Up to you what you want to set as your no shot number.

I do agree about sticking to the 0.25 dose. You won't really know how Lev is going to work if you keep switching the dose.
 
Re: Please share experience on Levemir use_Very concerned w/

Thank you for your comments.
Our vet's initial recommendation was 1 u. That where we've started.
We could not hold to that dose because BG dropped to double digits too quick in day 1...
We decided to stick with 0.5 u and try to hold the dose (as per TR protocol recommendations) till BG #’s tells us otherwise. Today in the morning BG was 543. It could’ve been a fluke because it is not easy to assure the exact amount of insulin in syringe (we’ve wasted 5 syringes yesterday in trying to pull the less than 1u dose). It’s almost impossible to get rid of all air bubbles within such a tight dosing and it’s possible we’ve injected less than targeted. We very afraid that 0.25u will keep JJ in triple digits for sure all the time from what we’ve seen on the second run and question is what does more harm those swings or constant high BG’s. Since it is day 6 of levemir use, based on TRP (on FDMB) we are in phase 2 holding stage. Based on University of Queensland or Tilly’s we are in increasing dose scale. Our preshots are over 200 but nadir drops to double digits. Where do we go at such conditions? We do not see the match in either protocol. Should we stick to 0.5u dose and watch her for another 3 days? We can do additional BGs’ at +6 and can try to do more frequent tests over weekend, say every 3 hrs.
 
Re: Please share experience on Levemir use_Very concerned w/

Hi Vitali,

I don't know the answer to your question. I think Sheila may be at work so I will post over in the ISG Lantus TR and see if another experienced Levimir user is around to give some advice to you.

Sheila has been doing a fantastic job advising you so far. She knows a ton about the Lev.
 
Re: Please share experience on Levemir use_Very concerned w/

Would you please keep the dose consistent? Last night you gave 0.5, this morning and yesterday morning you gave 0.75. Unless and until the nadir goes high, keep it the same. Your dose adjustments are based on the nadir, not the pre-shot. If your nadir goes below 50, you earn a dose reduction, never mind the pre-shot levels.

After you are stable at the same dose for the 3 full days or more, then we can look at ways to address large swings. Some cats may have large swings between pre-shot and nadir. This may happen due to bouncing (reacting to a fast drop, or a lower than usual level, or too low of a level). Some cats just do that. There are some finagles that may be tried after you've kept the exact same dose for at least 3 full days/6 shots, if that is still ocurring. Many cats swings level out as you continue with the same dose.
 
Re: Please share experience on Levemir use_Very concerned w/

Will try 0.5u over weekend, starting tonight. BG=49 at +6
 
Re: Please share experience on Levemir use_Very concerned w/

Vitali, if you do not have u100 syringes, 3/10cc with half unit markings you need to get them. Drawing .5u is a piece of cake - the line is right there. Even drawing .25u is easy when you have a zero line and a half unit line - you aim for right in between. stay away from the BD syringes - they are terrible for air bubbles. You might try getting Walgreens house brand - again: 3/10cc u00 with half unit markings. I used to get those and they were fine. They will sell you a 10 pack without a script (if your state requires one). Yes, more expensive per syringe than a box of 100 at W-mart, but you need the right ones.

It sounds to me like you have syringes that have only whole unit markings - and possible are for more total units than 30 (3/10cc is a 30 unit syringe). If you have a 5/10cc for 50 units max dose those lines are really tiny - and I think they are 2unit markings? Not positive as I have never used them.

JJ's nadirs are consistently telling you that .75u is too much. I am sure that .5u is too much as well, which is why I keep suggesting you shoot .25u.

Swings are bad. They make her feel crappy. High numbers are bad. They make her feel crappy and can allow ketones to develp. They don't do real damage (barring ketones, which are very bad) until a lot of time has past.

The thing is, if you drop the dose to .25u, you stop the swings AND stop the extreme climbs to 400s and above, maybe even to the 300s and above. Flat 200s would be better than 543 to 49 to 400-500s again. It is the insulin that is causing the high numbers right now.

As for you vet's dosing recommendation, it is useless. You vet is not looking at these numbers swinging from 500s to below 50 and back. Your vet is not managing her 24/7 and there is a good chance s/he has NEVER managed a diabetic cat 24/7. Vets are not taught to think in terms of unit fractions, especially not less than a half unit. When Beau was first diagnosed, he was started at 2u, increased to 3, than 4, than 4.5 and up to 7u. I was not testing him at home. He got ONE blood sugar test a week at the vet's office. It's a wonder I didn't kill him with doses like that. The only thing that saved him was the dry food I left out all the time.

When I started testing him I dropped his dose to 2.5u. His BG was in the upper 300s to over 500 all the time, sometimes higher. But after a month his dose was below 1u, his BGs were in the 100s and 200s and he was eating only canned food. My vets thought I was a crazy cat lady. They aren't laughing now though since he is off insulin and has been for over 3 years.
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
I use ReliOn 3/10cc syringes 31 G with 0.5u marking. Still the space (in my opinion) between 0.5 and 0 lines is too tight. It's only a guess that 0.25u is measured when the plunger is half way between the marks. Plunger itself is not parallel to the bottom. Also, I looked at Beau's SS, and noticed you've started with 0.5u as well. We will try to inject slightly less than 0.5u over weekend and take some more measurements. Thank you for sharing your experience!
 
Re: Please share experience on Levemir use_Very concerned w/

Yes, Beau started levemir at .5u - and dropped to 37 on the 3rd shot. I then reduced the dose to .3u. What I found over the next few weeks was that his 300s were from too much insulin, not from too little. What I did, eventually, with his dose was NOT what I was being told here and not what the protocol said to do. It was out of pure frustration at having .5u drop him into the 30s and .4u leaving him high and flat as if it wasn't enough. I figured out that he was rebounding on BOTH dose. They were BOTH too high. So I started reducing his dose. And it worked. I have been trying to share that experience with others here since then, especially when their cat's patterns so closely mimic Beau's, like JJ's does.

If you look at Beau's SS you will see that I raised him back up to .5u - and that that was wrong because he dropped into the 30s again. If I had dropped him to 3u and stayed there (or .25u) I think his numbers would have come down even faster. I am trying to prevent you and JJ from repeating my mistakes and frustrations.

All that I posted above about vet recommendations and Beau's starting doses was in regard to his vetsulin dose after he was diagnosed and then after I found FDMB and started testing and taking control of his treatment, but it doesn't matter what insulin it is. Vet's just don't know enough about treating this disease "in the trenches". Most of what they know is probably learned from treating dogs and applying that to cats as if they were small dogs. They are not.

It's just what I have been reading here time after time from dozens of people over the past 5-1/2 years.
 
Re: Please share experience on Levemir use_Very concerned w/

Just eyeball it as best you can.

You might take 1 syringe and mark it to use as a comparison reference to help you be consistent.
 
Re: Please share experience on Levemir use_Very concerned w/

Bough new syrineges at Walgreens. Will check if they any better than ReliOns.

Just measured BG at +12 (pm), BG=49?!!
scary to think were she was at +6 or +8. I came home at +7 but JJ behaved normally, nothing unusual.
Will need to pick up another BGmeter to double check if one we use doing good measurements.

Sheila:
What Great Choice flavours are you using now while OTJ? Are you using any dry food at all?
Thank you
 
Re: Please share experience on Levemir use_Very concerned w/

I think we need to drop that dose again to 0.25U. What does Sheila suggest?

Looks to me like he is still bouncing from some very low numbers. We usually give a mandatory 0.25U dose reduction if the BG drops below 50 on a newly diagnosed diabetic cat. New is diagnosis date less than one year ago.
 
Re: Please share experience on Levemir use_Very concerned w/

Please do another BG test ASAP. I want to know if the number is rising or falling.

You did not give any insulin right?
 
Re: Please share experience on Levemir use_Very concerned w/

no, we did not. We're out of test strip. will have to go to pick more up. JJ is doing ok. Ate 1/2 can of Chicken feast.
 
Re: Please share experience on Levemir use_Very concerned w/

I'm concerned that JJ could drop even lower than that 49 you got. Do you have some high carb food, something with gravy in it to help raise the numbers a bit?

Can you get more test strips tonight?

ETA: good , very good that you did not give any insulin tonight.
 
Re: Please share experience on Levemir use_Very concerned w/

This is how Levemir and Lantus can act because they build up in the body.
Levemir builds up more slowly and takes longer to dissipate.

You will need to check about every 30 minutes to make sure he is rising and not continuing down.
If you get a two or more rising in a row, he is likely on his way up.
Once he is gets above 100 or so, you can relax.
 
Re: Please share experience on Levemir use_Very concerned w/

Wow! He popped back up really fast, in only 2 hours.

Did you feed him some food?
 
Re: Please share experience on Levemir use_Very concerned w/

Could be a bounce from getting really low.

Maybe he doesn't need insulin? Or Prozinc might work better because of the lower concentration and lack of depot?
 
Re: Please share experience on Levemir use_Very concerned w/

vgriguil said:
Sheri:
What Great Choice flavours are you using now while OTJ? Are you using any dry food at all?
Thank you
Click to expand...
Do you mean me?

I use their pate flavors, mainly Turkey & Giblets and Poultry Platter. Really, any pate one is ok, but I stay away from fish flavors except Wellness Turkey & Salmon. The only dry food they get is as a treat once a day and no more than 12 kibbles. I use PetSmart Simply Nourish Kitten Cat food. But some cats are very sensitive to carbs and even 12 kibbles might be too much.

Now for JJ's numbers: I bet she was down below 49 earlier and that caused the very fast rebound bounce to the 300s. She may be high again tomorrow morning, but don't increase the dose. Lev needs consistency to work and she needs to come off the rebound hormones. Really, her numbers are classic for rebound on long acting insulins. If you haven't read about rebound, this page has good info:

http://petdiabetes.wikia.com/wiki/Somogyi_rebound

I had to read through it many times before it really made sense, but the BG patterns are high numbers punctuated by drops to very low numbers - sounds like JJ, right?

BJ is right, she may not need any insulin, or may need very little - even less than .25u. When cats are heading OTJ, they sometimes just need a little assist and only when above 140 or so. Something like .1u shot when they go above 130-150 (depends on the cat).
 
Re: Please share experience on Levemir use_Very concerned w/

Sheila,
Sorry for typo! We're trying to stay with 0.5u dose for another day. 0.25 was injected late yesterday. This morning BG was again up to 427
Will do more measurement during the day
 
Re: Please share experience on Levemir use_Very concerned w/

Hi Sheila,
We've done some testing over weekend. Results are posted in SS. What do you think?
thank you
Still having a kick measuring those microdoses and trying to move the cyringe plunger to where the dose should be at.
 
Status
Not open for further replies.
Back
Top