Thinking of switching Lantus to Levemir

[nepenthe]

my 12 yr old has been diabetic since June 2010. He was first on 1 unit of Lantus BID and then he got an attack of pancreatitis in Jan 2011. Since then, until a couple of weeks ago he was on prednisolone (low dose, 5mg eod) and we've gotten numbers all over the map.

Since that time, he's gotten 2 units BID Lantus.

Now that the pred is gone, we are still getting numbers all over the map (100-400 pre shot #'s) On December 3, he was dx'd with pancreatitis (fPL = 6.4). I am suspecting that this could be one underlying cause of his erratic glycemic response to the insulin - but am also thinking that it might be the type of insulin. (I've come across numerous threads where users were also reporting erratic #'s until switching to Levemir.)

I am wondering if my cat is one of those who stopped responding to Lantus and might do better on Levemir?

Question: If he is currently getting 1.75-2 units BID, how would you switch the insulin?

Would the dose be the same?

Would one just give 2 units of the new insulin (assuming the pre-shot #'s are ok)?

(in case it is a low-level chronic pancreatits that's causing this, I am also going to throw B12, 75ml/day sub-q's and pepcid at it- and some transdermal codeine; he isn't eating that great and spends most of the day in my bed. That way I can alleviate some of the possible pancreatitis's contribution to the elevated BGs he's been getting. Also, he just had an ultrasound, and the ultrasonographer is very good apparently. The ruled out IBD, Lymphoma, and said that there was no calcification in the pancreas but slight inflammation there - either "resolving or beginning chronic pancreatitis". He said the liver looked ok. But what worried me, is there are some signs of very early renal disease, ie "medular rim sign", which we think is due to the transient hyperglycemia we've seen over the past year.)

 

[Blue]

my 12 yr old has been diabetic since June 2010. He was first on 1 unit of Lantus BID and then he got an attack of pancreatitis in Jan 2011. Since then, until a couple of weeks ago he was on prednisolone (low dose, 5mg eod) and we've gotten numbers all over the map.

Since that time, he's gotten 2 units BID Lantus.

Now that the pred is gone, we are still getting numbers all over the map (100-400 pre shot #'s) On December 3, he was dx'd with pancreatitis (fPL = 6.4). I am suspecting that this could be one underlying cause of his erratic glycemic response to the insulin - but am also thinking that it might be the type of insulin. (I've come across numerous threads where users were also reporting erratic #'s until switching to Levemir.)

I am wondering if my cat is one of those who stopped responding to Lantus and might do better on Levemir?

Question: If he is currently getting 1.75-2 units BID, how would you switch the insulin?

Would the dose be the same?

Would one just give 2 units of the new insulin (assuming the pre-shot #'s are ok)?

(in case it is a low-level chronic pancreatits that's causing this, I am also going to throw B12, 75ml/day sub-q's and pepcid at it- and some transdermal codeine; he isn't eating that great and spends most of the day in my bed. That way I can alleviate some of the possible pancreatitis's contribution to the elevated BGs he's been getting. Also, he just had an ultrasound, and the ultrasonographer is very good apparently. The ruled out IBD, Lymphoma, and said that there was no calcification in the pancreas but slight inflammation there - either "resolving or beginning chronic pancreatitis". He said the liver looked ok. But what worried me, is there are some signs of very early renal disease, ie "medular rim sign", which we think is due to the transient hyperglycemia we've seen over the past year.)

Pancreatitis will likely contribute to higher BG numbers / higher insulin dose, so switching when treating pancreatitis would likely have people to suggest a lower dose.

When switching from Lantus to Lev, it's often said to go with about 70-75%.
Because of the differences between the two insulins, you'll have the 2 sheds.... one dwindling as the other is filling. if you wanted to go with safe, you could switch and give 1u BID of the Lev.

For the pepcid AC, you could try to give at least 30min before the main meals as it may help to settle the stomach before food's given. Maybe you could talk to the vet about an appetite stimulant; give every few days to nudge him to eating. You could also ask if something stronger than pepcid would help for a few days?

The fluids are a great help and the 75ml daily should help, but you can also add a bit extra water into the food as he may be more inclined to lap up some of the watery food.

I had been using transdermal gel/codeine on my Shadoe's ear tip but she HATED IT! My other cat loved it as she would lick it off Shadoe's ear! See if you can talk to your vet about getting buprenex as it's a bit better i have found than the ear gel pain relief.

If your vet thinks the pancreatitis may become a recurring issue, ask your vet about B12 shots to help with the pancreas inflammation. Within a month of my starting to give Shadoe her B12 shots, she no longer had any of her 'pancreatitis' type issues. None, but one minor day .

With Levemir, you should see a more level curve, and also a bit of a later nadir; my Shadoe who did have quite erratic BG numbers on Lantus started to level out quickly after switching to Lev. She was also very tense on Lantus but not so when on Lev.

I wish you well on the switch.

 

[Sheila & Beau GA & Jeddie GA]

I'm sorry your boy isn't feeling well. It sounds like you have a good handle on treating the ptitis. I would also second the B12 shots as it is better absorbed that way - plus the pepcid is negatively effecting the B12 if given in tablet form. Also, if he has ptitis there is a possibility of some intestinal inflammation and/or lack of pancreatic enzymes so his intestines aren't operating at full potential making absorbing a tablet form harder.

When Beau had ptitis flares I gave pepcid 20-30 mins before trying to feed him and "chased" it with a little warmed plain Greek yogurt - about a tsp. He loved it.

If his PS values are ranging from 100 to 400 starting lev at 1u is probably a good idea. You want to stop the BG swings and reducing the dose a little will probably help with that.

Are you getting tests mid-cycle? Spot checks any time during the cycle will tell you what the dose is doign better - and dose changes with lantus or levemir are based on the nadir (lowest point) not the PSs.

 

[nepenthe]

thanks,

The first thing I did last night was to go to the pharmacy and get a 10ml vial of b12. He got 250mcg. Will dose him with that ever 5-7 days for the first few weeks and then maybe scale it back to 1x a week.

This aft I gave him 1ml of transdermal codeine which he did very well with before when he had that bad attack and also gave him 100ml sub-qs. Will do both, along with the B12 and 2.5mg pepcid, every day for a few weeks and then re-evaluate.

I've even heard that B12 in itself is an appetite stimulant.

The big question for me is now that the prednisolone variable is removed, is - is it the ongoing pancreatitis, or the insulin, or that the pancreatitis has damaged his pancreas so that these "wonky numbers" are the new normal.

Based on what I've read from many people on here, literally dozens who also have diabetic cats with chronic pancreatitis, is that they have had cats go into tight regulation or at least well regulation, even after recurrent bouts of nasty pancreatitis attacks. So, I am not leaning towards the last suspicion above - that his pancreas is permanently messed. (especially since the ultrasound showed nothing abnormal in the pancreas other than very mild inflammation. The vet and ultrasonographer both said his pancreas looked pretty good.)

My whole strategy is to get the pancreatitis flare-up under control, (by using the big 4 things against it: sub-q's, pain meds, pepcid, B12) and then see if I am still getting wonky numbers in a few weeks.

If so, and he is still losing weight, getting high unstable numbers despite not showing signs for pancreatitis (and esp with testing negative on an fPL), then I will really lean towards the theory that this insulin (Lantus) just isn't cutting it for him anymore.

I feel encouraged by reading about others who've posted that their cats got better, more predictable numbers after switching from Lantus to Levemir. This might be a relatively new phenomenon that veterinary science just hasn't caught up to yet, as these are relatively new insulins (and esp with Levemir not being studied in feline use much at all)

what is really interesting is the reports of behavior/mood changes for the better after moving to Levemir.

 

[nepenthe]

Are you getting tests mid-cycle? Spot checks any time during the cycle will tell you what the dose is doign better - and dose changes with lantus or levemir are based on the nadir (lowest point) not the PSs.

yes, and that's where I can tell something odd is going on. Yesterday he was 235.8 amPS and at +6 he was 416. At +12 pmPS, he was 410.

This amPS he was 226.8 and then this aft at +6 he was relatively unchanged at 221.4.

I am going to make an SS this Sunday and post in it all the daily reads I have on him for the past month or so.

 

[Sheila & Beau GA & Jeddie GA]

Do not give up on regulation or even remission - that's all I can say. I have seen too many miracles on this board to say that a certain situation will prevent regulation or remission. Yes, there are "the odds" to deal with, but still.

Beau was first diagnosed with pancreatitis at age 3. It was so severe that he was touch and go for 48 hrs. He was a feral and did not allow me much contact with him so I did not notice the developing symptoms. He also had HCM that was diagnosed at the same time (same ultrasound). He was on pred for 2-3 years (weened very slowly because he relapsed the first time we cut back). Diabetes was "expected" if he lived long enough (prognosis 2-5 years). He was diagnosed with FD just after that 5 year mark and was on insulin 2-1/2 years. He has been diet controlled and off insulin for over 3 years now.

I know of another cat with chronic ptitis that was well regulated for over 5 years before dying at age 18. And yet another cat that just went into remission after, I think, 8 years who had some serious liver issues.

Anything is possible. We know so much better how to care for these diseases for the long haul and there is so much knowledge on this board in dealing with almost any disease state and diabetes.

I have also read that injected B12 is also an appetite stimulant. I am planning on asking my vet about it for both Cami and Beau. Cami is 12 and came to me with some digestive issues. Beau is now 14 (6 years past his prognosis date) and he can't put on weight. I have had him tested for everything with no results and his hyperT is regulated with meds. He gets digestive enzymes, probiotics and omega oils. I am hoping that B12 might help both of them absorb nutrition better. Older cats can have pancreatic insufficiency - not enough enzymes produced. That is why I add enzymes to their food.

 

[nepenthe]

Do not give up on regulation or even remission - that's all I can say. I have seen too many miracles on this board to say that a certain situation will prevent regulation or remission. Yes, there are "the odds" to deal with, but still.

Beau was first diagnosed with pancreatitis at age 3. It was so severe that he was touch and go for 48 hrs. He was a feral and did not allow me much contact with him so I did not notice the developing symptoms. He also had HCM that was diagnosed at the same time (same ultrasound). He was on pred for 2-3 years (weened very slowly because he relapsed the first time we cut back). Diabetes was "expected" if he lived long enough (prognosis 2-5 years). He was diagnosed with FD just after that 5 year mark and was on insulin 2-1/2 years. He has been diet controlled and off insulin for over 3 years now.

I know of another cat with chronic ptitis that was well regulated for over 5 years before dying at age 18. And yet another cat that just went into remission after, I think, 8 years who had some serious liver issues.

Anything is possible. We know so much better how to care for these diseases for the long haul and there is so much knowledge on this board in dealing with almost any disease state and diabetes.

I have also read that injected B12 is also an appetite stimulant. I am planning on asking my vet about it for both Cami and Beau. Cami is 12 and came to me with some digestive issues. Beau is now 14 (6 years past his prognosis date) and he can't put on weight. I have had him tested for everything with no results and his hyperT is regulated with meds. He gets digestive enzymes, probiotics and omega oils. I am hoping that B12 might help both of them absorb nutrition better. Older cats can have pancreatic insufficiency - not enough enzymes produced. That is why I add enzymes to their food.

I feel pretty encouraged today, he has some nice low numbers again, with a +7.5 of 81 (on the AlphaTrak meter) after an am dose of a fat 1.5 Lantus. I am going to test hourly until his pmPS to see where the nadir ends up.(I typically don't test until mid-cycle because he responds so slowly to the dose, unless I'm doing a full curve.)

Based on this number, the Queensland Protocol tells me that I should reduce his dose by .25.

This is a scary time for me as he came off prednisolone 11 days ago, and his pancreatitis is resolving. Until coming off the pred, he'd been getting 2U BID and now the insulin requirements have been wavering as the effects of these two contributors to hyperglycemia wear off.

Yesterday I began with 100ml sub-q and today he seems much better. I think there are many on here who have also mentioned that sub-q can lower BG values.

As to those other cats who got remission after chronic pancreatitis - I really think that many vets don't understand the role that low-level, subclinical pancreatitis can play in making a cat hard to regulate. Even my vet three weeks ago confirmed pancreatitis with an fPL and ultrasound, but seemed more convinced that it was the pred that was making him hard to regulate and didnt advise me anyway to addressing the pancreatitis. Even after being off pred for 10 days, I was still getting wonky numbers. Now that I am throwing codeine, sub-qs, B12 and pepcid at the pancreatitis for the past 2 days, he is eating better, seems better, and is getting some low numbers. I hope its a trend.

 

[Blue]

When pancreatitis flares, you may well see higher numbers that require higher doses. Then, when the flare passes, you will be seeing numbers that dictate a dose decrease.

I hope you have the good luck I had with Shadoe when giving B12 shots... her attacks stopped, and also the Lev gave her level numbers.

 

[Sheila & Beau GA & Jeddie GA]

You are probably right that the decreased BGs reflect the pred leaving his system and the pancreatitis easing up.

I actually saw the opposite with Beau - when he had a flare he ate so much less that his insulin needs dropped. He also never acted like he was in much pain, so I wonder if his experience was more nausea than pain. You just have to let the insulin follow the needs as governed by the other health issues they have.

Good to see he reached a decent nadir. I don't think you want to decrease the dose if 80 was as low as he got mid-cycle. That's actually a great nadir number.

 

[nepenthe]

Good to see he reached a decent nadir. I don't think you want to decrease the dose if 80 was as low as he got mid-cycle. That's actually a great nadir number.

Oh, the reason that I decreased by .25 at 80 at +7 is that I am using the AlphaTrak meter and that Roomp/Rand/Queensland Protocol calls for that. With a human meter, the number seems to be 50.

This morning he is around a 200 for the 6th cycle. I think its the 100ml sub-qs (lactated ringers) that are making the difference. Must be something with the sodium/potassium that sorts out his electrolyte balance. His appetite was great yesterday.

 

[Sheila & Beau GA & Jeddie GA]

Gotcha.

I have heard from several people here that subQ fluids help to lower the BG. Maybe they help with absorption of the insulin - easier when well hydrated for the chemical reactions to take place?

Great appetite is good too!

 

[nepenthe]

For some reason that protocol uses higher numbers. Maybe its just using higher numbers to be safer.

I think that sub-q's have and anti-inflammatory effect. Some say that it thins the blood, lowering BG concentrations.