Tidus will be starting Levemir

[miso00]

Hi All,

Tidus has been on Lantus since the end of May. He is pretty steady in the 200's (there was a short time he was steady in the 100's) but that was about 2 months ago. I am constantly increasing his dose and his numbers don't want to budge. He was up to 6.75u and I spoke to Venita (Tidus is a DCIN foster) and we decided to try him on Levemir.

I an a fairly new bean, it's been a year since I've learned how to treat an FD kitty. Mikey was my first and he was on Lantus and is now OTJ.

Any advice on what I should do to switch Tidus is appreciated. I usually shoot at 11a/11p.

Do I keep the same SS that I have used for Lantus?

Thanks! Looking forward to learning something new!

 

[Laura and Harley (GA)]

Hi Jenn & Tidus, Welcome to the Lev ISG!

Before we can advise on the switch, can you refresh my memory on if Tidus has any other concurrent health conditions that may be affecting his numbers? I recall when he first came to you he was not doing well and had GI issues. Have they resolved themselves? Is he on any other medications besides the insulin? We tend to look at the whole cat picture in this group as many times other health conditions affect the BGs and can impede regulation. Also when do you want to change him?

I think you and Tidus are really going to like Levemir once you get going. I've used both Lantus and Lev and I prefer Lev. My kitties do too. Lev is not as thick as Lantus and I found it is much easier to draw up into the syringe which makes for more accurate dosing. When I was drawing up Lantus for Vinny, it was like drawing up Jello which resulted in more air bubbles than I've ever seen before plus I found I was wasting a lot more insulin because with Lantus you cannot inject the insulin back into the pen. With Lev, if you overdraw insulin you can inject the excess back into the pen without worrying about damaging the molecules. Plus some cats do not like being injected with Lantus. There are others here who can tell their stories of how their cats just didn't feel good when on Lantus but became much more happy and agreeable once changed to Levemir.

You can continue to use the same spreadsheet if you want. When I switched my cats, I just inserted a blank line, shaded it with a pastel color and noted the change of insulin to Levemir. If you are a visual person, like me, feel free to check out Vinny's spreadsheet below in my signature for an example.

Looking forward to seeing how Mr. Tidus like his new juice!

 

[Sheila & Beau GA & Jeddie GA]

Hey, Jennifer.

You can switch "right away" meaning no need to skip a shot or anything. What you do need to do is figure out your starting dose. I am think 1u. You will see the suggestion of ~70% of the lantus dose, which would be 4.5u. I just think that is too high. I have seen some dramatic responses to the 2nd or 3rd shot of lev in many kitties here. Beau and Cami both had strong responses in those early shots and they were both started on .5u.

I noticed that he has not had insulin in a few days. Why is that? Still, he is holding himself in the mid 200s. Also, did he not get insulin while at the vet in Aug.? Seems like in both cases giving insulin bumped him into the 300s. Granted that is a low 300 and he could have been hitting that at times you weren't testing on other days. It just makes me think he might be getting too much insulin when he is over about 2u. He was getting some pretty decent numbers starting out at .75u and 1u. I think the increases after that might have been too fast.

Generally, we suggest holding a dose for 3-5 days. I always look for still settling (lowering) numbers. When that stops, then I would raise the dose - or if all numbers are still pretty high (using the Tilly protocol numbers as a general guideline) I would raise on day 4 or 5.

I hope he likes lev and does well on it. Ask any other questions you have.

PS - Cami seems to finally be "getting it" - that she is safe, will have enough food, etc. She got up next to me on the sofa last night and toughed my arm with her paw. Then she got on my lap and purred for a little while. Her numbers have been really good since the second week, and she is on .25u now (although I may need to increase that a bit after I get some spot checks).

 

[Carl & Polly & Bob (GA)]

Hi Jenn,

A few days ago, you noted this on Tidus' SS: KETONES W/ METER "LO"
It also looks like he hasn't had any insulin for the past 3 days? Are you continuing to check for ketones?

Carl

 

[Marje and Gracie]

Jenn

I very respectfully disagree with Sheila on the dose. With a cat that has shown ketones and has persistently been in yellow numbers on lantus as you've increased the dose per the protocol, I would dose at 70% of your current lantus dose and monitor closely. Yes, a few cats have shown a quick response to lev in the first few cycles and then they settled in. But other cats have not shown that propensity to go low the first few cycles.

While we don't know what Tidus will do, giving him 70% of the lantus dose should help.

I also think lev is a great insulin and Gracie's numbers a very different on lev because it flattened her out. Tidus is already flat....so I'm. OT sure if you will see alot of difference. But lev does have its pluses and no stinging at higher doses is one. It can also have really nice duration.

Also...do not inject lev back into the pen just like you don't inject lantus back into the pen. From the sticky on proper handling and storage of lantus and levemir

Do not inject air into cartridges or pens. Cartridges and pens are designed to work on a negative pressure principle.

If you draw up too much insulin in the syringe... squirt excess either into the air dramatically like they do on TV or into a paper towel... anywhere but back into vial/cartridge/pen. There is a silicon coating inside the syringe. It may contaminate the insulin vial with silicon (this is probably what makes "floaties", it forms a white precipitate). Better to waste a drop than ruin whole vial, cartridge, or pen.

Please be sure and read what Libby wrote on your 11/5 Condo in LL.

 

[Sheila & Beau GA & Jeddie GA]

I have been injecting lev back into the pen for over 3 years with no problems. I always use the pen to the very last drop - and this is with doses no larger than 1u, and usually less than .5u.

I always overdraw and inject back (without removing the syringe). Insulin remains clear and potent to the last drop some 6-8 months later.

 

[hmjohnston]

I thought if you injected the insulin back into the syringe the lubricant in the syringe to move it smoothly would contaminate the pen.

Then again, i am usually very careful on drawing the insulin to the right mark in the first place :lol: .

Welcome to Lev Jenn and Tidus!

 

[Sheila & Beau GA & Jeddie GA]

I have to believe that it does not effect lev. Even if it does effect other insulins.

I have predrawn lev and used it up to 15 days later if no issues.

 

[Marje and Gracie]

It's not a risk I'm willing to take but it comes down to a personal decision, I suppose.

 

[Sienne and Gabby (GA)]

FWIW, I called the College of Pharmacy where I work. I spoke with a PharmD who works in diabetes care. She indicated that insulin dispensed from any of the pens (e.g., Levemir, Lantus, etc.) should NOT be reinjected into the pen. The pens are designed to work on a negative pressure system and you risk damaging/cracking the glass. I also asked about pre-drawing the insulin and she stated it is not recommended. I have a great deal of faith in PharmDs. As a rule, they are a pretty amazing group of professionals and the issue of reinjecting back into the pen or pre-drawing are not specific to humans or cats. It is not a recommended means of handling the insulin.

 

[Laura and Harley (GA)]

Thanks for the information Sienne. Fortunately both Sheila's and my cats have suffered no ill effects from insulin injected back into the pen. Maybe it's the difference between Lantus and Levemir, maybe it's our cats and maybe it's just plain luck. Fortunately all of the information is here in this thread so JennF or any other reader can make an informed decision. As Marje says:

It's not a risk I'm willing to take but it comes down to a personal decision, I suppose.

 

[miso00]

We had some DCIN cats that were on high doses of Lantus that once taken off didn't even need insulin. I was hoping that would happen with Tidus-but it did not. When I hear some people take a "break" before switching I thought days not just one dose. LESSON LEARNED! I have a ketone testing monitor that tests ketones with a blood sample. The meter is pretty cool. It will say HI or Low or also the number. If lower than 0.1 mmol/L display is "LO" if higher than 8.2mmol/L displays "HI" anything in between will display the number 1.0, 2.0 etc. It also has a test solution to use to determine if the "LO" is correct, I did that too just to be safe the monitor was working properly.

As far as Tidus and his IBD/IBS issues...he is currently eating raw food mixed with FF. It's next to impossible for him to not eat any FF unless I keep him locked up all day in the bathroom and I don't want to do that. His poop is pretty solid (no more liquid poo) as long as he eats more raw than FF. I noticed when he gets too much FF it gets softer. The amount of poop has not changed, I can still measure it my the cup full. He was retested for B12 and thryoid and both were normal. He is still drinking a lot (although I think less frequently than before) and peeing a lot when he goes but less frequently. He has gained 5 pounds since May. He was 9lbs now 14lbs. and it's all in his belly! If he was human it would be a beer gut :lol:

He did receive insulin while at the vet but only once a day and only 2u if he was at 200 or over. If he was under 200 they did not give insulin.

I'm excited to start him on Lev. I will keep the same SS and just skip a line and note Lev. was started.

I'm going to start him tonight at .5u.

I'm very happy to see so many familiar faces here

 

[Laura and Harley (GA)]

We had some DCIN cats that were on high doses of Lantus that once taken off didn't even need insulin. I was hoping that would happen with Tidus-but it did not. When I hear some people take a "break" before switching I thought days not just one dose. LESSON LEARNED! I have a ketone testing monitor that tests ketones with a blood sample. The meter is pretty cool. It will say HI or Low or also the number. If lower than 0.1 mmol/L display is "LO" if higher than 8.2mmol/L displays "HI" anything in between will display the number 1.0, 2.0 etc. It also has a test solution to use to determine if the "LO" is correct, I did that too just to be safe the monitor was working properly.

Good thought to do a "no insulin" check. We've seen some pretty insane doses and then boom, OTJ. What's very interesting with his no insulin numbers the last few days is that they are virtually the same as when he was on insulin. It makes me question if perhaps his Lantus had lost its potency. Good thought to test for ketones while trying this experiment. After Mikey's scare the last thing you and Tidus need is a DKA. And now that you've explained the ketone meter reading my heart can slow down a little. ;-)

As far as Tidus and his IBD/IBS issues...he is currently eating raw food mixed with FF. It's next to impossible for him to not eat any FF unless I keep him locked up all day in the bathroom and I don't want to do that. His poop is pretty solid (no more liquid poo) as long as he eats more raw than FF. I noticed when he gets too much FF it gets softer. The amount of poop has not changed, I can still measure it my the cup full. He was retested for B12 and thryoid and both were normal. He is still drinking a lot (although I think less frequently than before) and peeing a lot when he goes but less frequently. He has gained 5 pounds since May. He was 9lbs now 14lbs. and it's all in his belly! If he was human it would be a beer gut :lol:

I'm so glad to hear Tidus's GI issues have calmed down. Yes I've tried to transition my brood to 100% raw and they are resistant so about 50% raw/50% Fancy Feast is the best I can do. We do what we can.

I'm going to start him tonight at .5u.

For what it's worth, I'm going to throw in my dosing $0.02 for consideration. I think starting at 0.5u is a great choice. Starting low is safe and prudent and will guard against overdose if Tidus is one of the cats who shows a dramatic first response to Levemir. Please continue to test for ketones during the switch. (I know you know, I'm just throwing that in for the benefit of the lurking reader. :idea

I also support the advice that Sienne, Libby and Marje have given in LL to the point that Tidus may turn out to be a higher dose kitty. If his initial response to 0.5u Lev after at least 6-8 cycles is the same as on Lantus e.g. continued flat yellows, then I recommend rapid cycle dose increases. The Romp/Rand TR protocol calls for dose increases after 6 cycles or 3 days. If and only if you are going to be home and able to get consistent pre-shot and spot checks, I would suggest dose increases after 3-4 cycles if his nadir is still above 200 to get him up the dosing ladder quicker. If you are not comfortable with a "start low, go fast" approach like this and cannot test frequently, then sticking to the TR protocol would be a safer course. Once you start to gather data on how Tidus responds to Lev then a more customized approach may be needed. Sheila has a great gift of being able to review a SS and find and interpret patterns in the numbers. Me, less so, I tend to shoot insulin based upon both the numbers and on intuition. For me the sugar-dance is more of an art form, which makes treating my own kitty easier than treating a kitty from afar because the personal interaction is lost with distance.

Fortunately FDMB is a peer-reviewed board and you will receive other dosing advice besides mine and in the end I know you'll do what's right for Tidus.

 

[Marje and Gracie]

Jenn

I am still extremely concerned about your decision to start him in such a low dose of levemir. Consider that his numbers are what they are without insulin because of the large depot you have with a 6.75u dose. The depot can affect several subsequent cycles and the larger the depot, the longer it would affect subsequent cycles. His BG was higher mid cycle today so you be starting to see the effects of the depot diminish.

I don't understand the thought behind stopping his insulin. You followed the protocol; if the protocol is not followed, then there is a greater likelihood that the dose might be too much. But not when you follow the protocol as you did.

If you are set on this course of starting so low, the TR protocol states this:

In many cases, the starting dose of Lantus or Levemir has been 0.25 IU per kg of the cat's ideal weight and is always dosed BID (two times a day, 12 hours apart). If the cat received another kind of insulin previously, the starting dose should be raised or lowered by taking this information into account.

Cats that have a tendency to get ketones and/or who are getting relatively high flat curves after the switch should have their dose raised earlier (after 24-48 hours).

I added the bold above to be sure you understand that you should not wait 6-8 cycles to raise the initial dose.

 

[Sienne and Gabby (GA)]

Jenn:

This is information from a long time FDMB member, Sharyn, whose kitty, Fiona had problems with ketones. She ran comparisons of the blood ketone readings with ketostix.

Precision Xtra Readings for Cats

**'Normal' for cats is 0.0-0.3 (Fiona's normal is 0.1, D & Shadow's normal is 0.3)

**3.0 is approximately when ketones start showing on urine ketodiastix strips at a trace - at least that is the case for Fiona.

The Lo reading on your meter may be inconsistent with the Ketostix reading. The brand of Ketostix I use read either negative, trace, small, moderate, etc. I would think that a reading of Lo, would be consistent with negative or maybe trace. A reading of Small ketones would be of concern since I've always suggested that this would require veterinary intervention. It may be the brand of ketostix you're using have a different "calibration." In any event, if ketones are present, no matter what the amount, I want to go on the record and state that for Tidus' safety, reducing the dose to 0.5u is dangerous. One of the most effective tools you have at your disposal to combat ketones is insulin.

The Romp/Rand TR protocol calls for dose increases after 6 cycles or 3 days. If and only if you are going to be home and able to get consistent pre-shot and spot checks, I would suggest dose increases after 3-4 cycles if his nadir is still above 200 to get him up the dosing ladder quicker.

This information is not entirely correct. The following is from the Tight Regulation with Lantus or Levemir for Diabetic Cats (aka Tilly version of the TR protocol):

However, if the cat is producing continuously high BGs (nadir always >=300 mg/dl), only hold the dose for 2-3 days before increasing it by 0.5 IU. Alternatively, if the cat is continuously producing moderately elevated BGs (nadir always >=200 mg/dl), increase the dose every 2-3 days by 0.25 IU ( if the cat is getting a low dose) or 0.5 IU (if the cat is getting a higher dose)

The TR protocol is aggressive with respect to dose increases. I would encourage you to stick with the protocol and increase no sooner than after 4 cycle/2 days. Increasing before 4 cycles has no research data to support being quite that aggressive. In the situation where you're combating ketones, a more aggressive approach may be necessary. I'm not sure whether Laura was speaking about dosing in general or specifically with respect to ketones.

 

[miso00]

I'm a little confused. I know all of you, some from DCIN and some from FDMB, and you are all here. So is it better for me to be in the Levemir board or the Lantus/Levemir. I've worked with Sienne and Marje for so long and I feel comfortable with them but I know you are all awesome and know Tidus' issues.

I'm not going to lie I just thought I was choosing a new insulin. I wasn't prepared for the different dosing advice or that I could have stayed in LL.

 

[Libby and Lucy]

posting my response to your PM here. Hope this helps!

You can post where ever you feel most comfortable. There are Levemir users in both forums. You're right, the advice is very different between the TR and Lev forums, so it can be confusing to try to post in both. Most people end up choosing one place to post.

read this (especially the symptoms) and see if anything sounds familiar:
High Dose Conditions: What We Know

Weight gain and potbelly are pretty big signals of acromegaly. I think you should do the test. I also think you should reconsider the dose of 0.5u. You arrived at your dose in a safe, methodical manner, so his current dose is NOT too high.

Link to have blood sent for IGF-1 testing:

For the USA and Canada – costs vary depending where you live: http://www.animalhealth.msu.edu/Bin/Catalog.exe?Action=Test&Id=1401
UK (free test): http://www.rvc.ac.uk/CIC/Current/Internal.cfm


In the US – a result > 100 is considered + for acromegaly; in Great Britain a result > 1000 is positive.

Link to have blood sent for IAA testing:
http://www.animalhealth.msu.edu/Bin/Catalog.exe?Action=Test&Id=1494
A result > 20% is considered positive for IAA.

If you're going to do the acro test, you might as well do the IAA test at the same time because you can save postage by sending them together. The IAA test itself is inexpensive, shipping blood overnight is not.

edited to fix links.

 

[Carl & Polly & Bob (GA)]

Sorry to intrude but I'm perplexed on the entire dose amount issue.

Tidus was on nearly 7u of Lantus, right?
What's the rationale of going all the way down to next to nothing? I'm not getting that. I want to grasp this stuff in case I ever have to answer this type of question in the future and none of you wonderful beans happen to see it or aren't around to answer it...

I understand that normally it is recommended to reduce to 70% of the current dose, and sometimes down to 50%. I don't get how we got all the way down to about 6%. Especially when "ketones" comes into the conversation.

Jenn said she tried something that worked with other DCIN cats - stop insulin and see what happens. That seems to have failed, although Marje did point out that there still might be depot draining that would affect the cycles, more so because of how large his dose had been.

Sheila said that she just felt the 70% reduced dose was still too high? Why? Why is even 50% too high?

My logical brain isn't getting past that point, and I don't understand reducing by over 90% when 100% was such an obvious failure. Why would a few drops be expected to succeed?

The other thing I can't get past is what happens if ketones appear quickly? That endangers Tidus, and could require ER care and the subsequent expenses. I guess I don't see how that risk is somehow less than starting at 3 or 4 units.

If it turns out that he needs at least that much Lev, even using aggressive increases, how long is it going to take to get from .5 to there. And how many ketostix or ketone meter strips is Jenn going to need before the concern of ketones from insufficient insulin is no longer a cause for concern?

I'm not trying to be a jerk, I just want to understand.

Carl

 

[Sheila & Beau GA & Jeddie GA]

I made the suggestion to start at .5u because Tidus has had the same numbers on all doses tried so far - 100s and 200s for the most part with a smattering of 300s. There were more 100s on lower doses and the few 300s seem to be on the higher doses.

I know from experience that starting too high is harder to figure out than starting below the optimal dose and increasing. I have also seen cats, including Jeddie, need a lot longer than 6 cycles to settle on a dose.

Yes, weight gain and big bellies are a sing on acro, but when you have a severely underweight cat finally getting enough food and some insulin they will gain weight. Does that warrant a test for acro and IAA? That is for Jennifer to decide.

Granted, my 'technique' is more conservative (slower/smaller increases) than others and I think smaller doses work better. They certainly have for my cats. I am only sharing my experience so Jennifer can make decisions about her Tidus.

 

[Carl & Polly & Bob (GA)]

Sheila,
I wasn't questioning your experience. You have a lot more than I have. I just didn't understand the logic.
Thank you,
Carl

 

[Marje and Gracie]

I also do not understand the logic and I've switched my kitty from lantus to levemir.

I'm not sure if you read Libby's post in LL, Sheila, but I think it is extremely important. Not only has she used both insulins but she has had an acro kitty.

The fact that his numbers have been the same on any insulin dose so far, including no insulin, strongly suggests that he just has not yet reached a dose where the insulin is even touching him. I'm sure you've seen me note over and over again that with Lantus kitties the response we usually see is NO response - the numbers don't change at all, dose increase after dose increase, until all of a sudden a breakthrough is reached and the numbers start to move a lot. He hasn't even really started to move, so I would say he's just not up to his dose yet.

His dose isn't really that high yet, so I might be all wet, but honestly almost every time I have noticed a cat who is still this flat as the dose starts to get into this range, it turns out to be acromegaly. I know that's not something you want to hear. Testing might be worth it because then you will know. It was kind of a relief for me when I got Jazzy's positive acro result because then at least I knew I wasn't doing anything wrong and she just needed more insulin. Look at Jazzy's spreadsheet and I think you'll agree that most of it looks a lot like Tidus's.

I think you will find that none of us in LL are quick to jump on the acro bandwagon but when we see a SS where the kitty has been taken up per the protocol as Tidus has and the dose goes over 6u, then we look a little closer. There have been some kitties that have gone over that 6u dose and aren't acro.....Randi's Max for instance. So it's still an ECID issue but I think what Libby is saying makes more sense.

I do think you have valid points....there are alot of cats (including mine) who need longer to settle into a dose. And in some cases, it is easier to start lower and increase per the protocol. But not when a cat has been slowly taken up and is at 6.75u and still in the mid 200s and showing ketones.

 

[Venita]

Hi folks. I am Tidus's DCIN case manager. DCIN case managers do not give dosing advise, but as a somewhat experienced FD caregiver (on FDMB since 2005 and working with Levemir since it became available from Canada in 2006) I feel I have some useful information about this situation.

I have asked JennF to start Tidus on 1U Levemir, and to closely watch his ketones. Tidus is a curious case, staying in the 200s whether on 6.75U of Lantus, 0U Lantus, or 4.5U Levemir. I would prefer that Tidus start on a "start low, go fast" protocol than overshoot a good starting dose by following the 70% rule (that frankly I was unaware of). I also have asked JennF to stay in the Levemir ISG for the time being.

I am available here, by PM, and email at Venita@dcin.info.

Thanks to all!

 

[Sheila & Beau GA & Jeddie GA]

Sheila,
I wasn't questioning your experience. You have a lot more than I have. I just didn't understand the logic.
Thank you,
Carl

As far as I know cats don't follow logic - ever :lol: But it is the best place to start for us humans and that makes something like the Tilly protocol very attractive and, usually, useful. However, I have seen so many cats that "don't agree with" that method. Mostly, I think that the settle period is too short, or maybe its that there isn't any guideline on how to determine YOUR cat's optimal settle time. I learned with Jeddie that can be up to 10 days. I do think that gathering data and watching for the pattern in the numbers will give you clues to what works best for your cat.

What I see in Tidus' SS is that early on, at .75u and 1u, he was still settling, but on the very first slightly higher number, his dose was raised. Then he seemed to be raised after 4 cycles, 6 at the most. I just don't think that is long enough - and those first higher numbers can be a response to the first lower numbers their body experiences in a long time, even if that "low" number is 180.

Once the optimal dose is passed over, it is really hard to figure out what is going on (too much insulin? not enough?) and you end up backtracking. It's just easier to "start low, go slow', collect data and make decisions based on that data.

Without the data on the lower dose, it's really hard to figure out what is going on - heck, it's hard enough with that data!

With Tidus it is going to be important to test for ketones daily, make sure he is eating well and is well hydrated.

 

[miso00]

I did give Tidus the 1u this morning. I will check for ketones and since I have had him there is never really a time he won't eat and he drinks cups of water every day.

I updated his SS and will start a new condo for today in the LEV board.

 

[Sienne and Gabby (GA)]

Jenn --

Please continue to test for ketones and compare your blood ketone and ketostix readings. You will need to calibrate the numerical readings from the meter with the ketostix so you have some idea of what the numbers mean for Tidus. I am very nervous about the advice you've received to reduce the dose this drastically in the presence of ketones.

 

[Venita]

I am very nervous about the advice you've received to reduce the dose this drastically in the presence of ketones.

Sienne, JennF tells me there are no ketones. She tells me the blood ketone meter reads "LO," which is the lowest reading it has, equivalent to "NONE."

 

[Venita]

If Tidus were showing ketones, he would be at the emergency vet getting BW and fluid and AB treatment. DCIN definitely cannot afford a full-blown DKA at this time.