4/23 Should I hold reduction? Plus concerns

249 AMPS
269 +3.5
265 +6
279 +9

Mia's dose was reduced from 1.5u to 1.25u this morning due to a 66 reading last night. (http://www.felinediabetes.com/FDMB/threads/4-22-pm-6-5-66-at2-meter-dose-reduction.194537/)

Should I hold this reduction for three days or is it safe to go back up sooner if these higher numbers continue?

Since starting Lev, Mia has been laying around more than normal, and I am concerned that she might not be feeling well. (I have been able to get her to play with me for a few minutes each afternoon.) Her eating is off. I have had to go get her for some meals which is highly unusual, and she is not eating near as much as normal...which makes it really odd that her weight went up. Today, she weighed in at 12.06 lbs which is higher than expected. Did anyone have any of these issues with Lev? If so, did they pass after awhile?

 

I think that those yellows look like a bounce (she is staying flat and yellow) of the lime green last night. I'd wait to see where she lands when she clears the bounce before taking her up.

If you start to see the numbers creep up, then you could call a failed reduction and take the dose back up, but I would not base it just on this mornings cycle.

I'm sorry she seems off her food, and is perhaps a little lethargic, have you checked for ketones today? Might be an idea to check seeing as you feel she might be a bit off. If she has Ketones, then you may need to consider taking the dose up. Please post for help if you do find she has ketones.

Something I noticed with George's appetite was that when he stopped seeing pink and reds he was less hungry, and his weight started to come back on. Another thing that triggered his appetitie was fast drops. I'm wondering if Mia not eating as much might be related to her BG seemingly being a little flatter and better overall for Mia since she has started Lev.

 

Because it's so early in your Lev trial I'd chalk it up to her body getting accustomed to a new insulin with a very different mode of action. Give it some time. She was quite accustomed to a deep-ish curve each cycle and that hasn't happened the last two days.

 

A couple of weeks back I would have voted for a dose reduction after the 66 last night, but after hanging out on the Diabetes-Katzen forum recently I think I would have held it, because all the other numbers are way higher. You're testing, you know how to react, and can monitor. I'm assuming she was acting "ok" at 66?

I would be quick to backpedal on the reduction if the numbers don't seem to be going in the right direction these few next cycles.

 

I thought about a bounce. She has a bouncy history, so I am pretty familiar with those. However, she had gotten to where she was not quite as bounce-prone. For example, she went to 64 on 4/6, and the cycles after that continued to reflect a curve; likewise back on 3/31 when she went to 60. This seems like an odd question to be asking but, do you think changing insulin type could make her more bounce-prone again? I am not sure how many cycles to expect it to take for a bounce to clear on this insulin.

I have not checked for ketones. I will do that when I do her next BG test. I will tell everyone in advance that I may go a bit cuckoo (and feel really guilty) if she has them, because she has never had them.

Even though she was not spending a lot of time in pinks and reds, it makes sense to me that the fact that she was in them at all may have increased her appetite a bit, and I had not thought of the steep curves possibly increasing hunger. As long as she continues to consistently eat 'some', I will not get too alarmed. I really do not want her to gain much weight though. She has done well at putting back on weight. I do not want to go too far and have her become overweight. I have made sure the calories she is fed are appropriate for where her weight needs to be.. and she is not even eating them all, so it is odd that she is gaining. I read somewhere among the stickys or links from within them that Levemir can actually help with preventing excess weight gain. So, hopefully, it is not going to go the opposite direction with my girl.

Thank you for your help

 

Thanks, Kris. I know Teasel is bouncy. If/when he bounced on Lev, did you find that it took longer to clear than on ProZinc? I realize ECID and even the same cat can have different experiences from day to day, but I have no frame of reference at all for how long a bounce would take to clear on Lev. So, any comments on that would be helpful.

 

I really did not want to reduce. I have learned to hold doses if at all reasonably safe on ProZinc, BUT I do not know anything about how Mia will respond to things on Levemir, so I did not want to disregard the guidelines. I have read that it can take up to 6 cycles to see the full effect of the depot. So, I was not sure that she would not continue to go lower if I held the dose. (She was fine at 66 and has gone a little lower in the past and has been fine.)

What are your thoughts on how many cycles should be held before going back up.. assuming the numbers continue to look as they do now? Thanks, Stephanie.

 

I would say that Teasel's bounces could often take quite a while to clear on ProZinc, Lantus and Levemir. My observation is that he sometimes bounces less and they're shorter lasting if I'm dosing closer to the edge as I call it - ie., when a dose produces lime greens. There's a good example on my SS from 16 - 20 Apr. However, from 07 - 14 Apr he had a lot of yellow AND dark green even though the dose range was similar. In other words, sometimes he bounces a long time and sometimes not - typical erratic Teasel.

 

Yikes! PMPS was 372. Based on what happens with this PM cycle, I may be going back to 1.5u in the AM.
Oh, and no ketones.

 

Yay for no ketones! It’s easy enough to call a failed reduction and go back up, but because Mia has never been on a depot insulin, I think it’s wise to take the reduction and see what happens in the next couple cycles. That 66 was pretty random, unexpected, and a large drop. So we know she’s capable of that. If you were going from Lantus to Lev, that would be one thing, but this is all so new for both of you.

 

One additional consideration. Typically, you do not need to reduce the dose when switching from Prozinc to Lev. You dropped Mia's dose by 1.0u when you switched. My best hunch is that she may not be getting enough insulin. Once the bounce clears, you'll be better able to evaluate if this is a good dose or if you need to increase. This is clearly a bounce off of those green numbers.

That said, I'd encourage you to decide if you want to follow the Tight Regulation Protocol or Start Low Go Slow. I'd likewise encourage you to stick closely to whichever method you choose so you have a strong baseline for how Lev is working for your cat. Lev and ProZinc are very different and what you learned to expect on ProZinc may not apply to how Lev works for Mia. Further, there's more than one difference in how Lantus and Lev are used on the German Katzen forum. None of us are conversant with the ins and outs of what they do and we will be very limited in terms of helping you with dosing if you opt to pick and choose what you do based on that forum.

 

This is still early days for Mia and Levemir. Throw out all ideas of what she did on Prozinc. Even switching from one depot insulin to another, Neko still changed the rule book. I felt like a newbie all over again.

For now I would hold the reduced dose and gather more data. She may need to go back up, or maybe not. You just don't have the data yet on this insulin. So for now, pick one of the two dosing methods we use here, and follow what they say.

 

Interesting that you indicate that I did not need to start at a lower dose than she was on with ProZinc, yet on the reduced starting dose, she was low enough to warrant a dose reduction after her fourth cycle. If 1.5u resulted in a 66, would not a unit more have been potentially dangerous as a starting point?

 

The TR protocol says to take a reduction if you get a reading of less than 68 using an AT2, so I did. They are not clear, in my opinion, on how long you have to hold that reduction which was the reason for this post in the first place.

Excerpts from Phase 1: Generally the starting dose is kept for 3 days. 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). It is extremely rare that a cat will need to have its dose reduced in the first 3 days, but if the cat falls below 50 mg/dl, reduce the dose.

So, normally your starting dose is held 3 days, but if you get relatively high flat curves you can raise after 24-48 hrs or if you get below 50 (68 on AT2), you drop right away. Nothing there tells me how long the reduced dose has to be held. Since the starting dose should 'normally' be three days, does the reduced dose get held that long? Or, because there is some indication that you can raise sooner during phase 1 if there are 'high flat curves', could going back to the previous dose be warranted if the 'high flat curves' continue for 24-48 hours?

So, you see, I am attempting to follow the guidelines!!!

 

A specific time period is not spelled out, it's your call when a failed reduction happens. The only trick is since Mia hasn't been on this insulin for very long, it might be hard to see numbers trending upwards as opposed to a bounce that will clear and show downward momentum. If you make the call and it does turn out to be a bounce, you would have to very closely monitor as the momentum from the bounce and the failed reduction increase combined could make things a little crazy. Hope that helps.

• If an attempted reduction fails, go right back up to the last good dose as soon as you see kitty's numbers trending upwards. You don't have to hold the reduced dose for a certain number of cycles before taking the dose right back up. The guidelines listed under the topic "Increasing the dose" do not apply to a failed reduction. Please use common sense in this situation. The "last good dose" is not the dose that just dropped kitty into the 20s or 30s. You want to resume momentum by finding a dose in-between the dose that dropped kitty too low and the reduced dose.

 

The guidelines for a reduction are to hold the reduced dose until he's cleared the bounce. If kitty doesn't see green after the bounce clears, then the reduction has failed and we go back up. Bounces can take up to six cycles to clear, but over time that can decrease. So the time you wait is specific to your cat. If in doubt, use six cycles. Also, you don't have a depot built yet, and some cats have a strong initial reaction to the insulin switch. Often that strong reaction doesn't sustain and kitty needs an increase. Only time will tell. You will have so depot by the time the bounce is over.

 

Some cats will have a marked response during the initial cycles of an insulin switch. It's hard to predict if that may happen -- most cats don't have a marked response. What is likely to happen -- a possibility, not a guarantee -- is that you will be in the process of building the depot over the next week. As a result, the numbers may be a bit higher until the depot has formed.

 

Can't find a more recent condo, hate to comment on an old one, but was wondering how you and Mia are holding up?