10U BID Lantus- Acro?? - Levemir??

Hi all,

This may end up being a double-posted subject by yours truly and Debbie and Bryce but quick question....

Bryce is on 10U BID of Lantus and we are in the process of going forward with a work up for acro.

My question to you guys is a pretty general one - have there been many cats that seem to be resistant to Lantus but do much better on Levemir?

It seems like they are such similar-action insulins so I was wondering if anybody has been beating their head against the wall with high doses of Lantus but then had Levemir work wonders. (Non-acros, of course.)

I realize that this question really needs to be split up into acro or non-acro and I am probably jumping the gun by posting it (prior to an acro work-up) but I would love some input from those of you who have switched from Lantus to Levemir.

Come to think of it...I probably should post this in Levemir so I will put a link there also.

Thanks for any help!

 

Hi Dr. P!

Jojo recommends that all high dose cats switch to Lev, but I'm not completely sure why. The doses are generally the same and I don't think one actually works better than the other. There is speculation that the higher doses of Lantus sting and that Lev doesn't.

Considering that acro isn't really that "rare" anymore, I would think that any cat that could handle 10 u should be tested for IGF-1 and IAA.

The Lantus forum includes many Lev users (and none of the high-dose kitties post in Lev).

ETA: Shelly & Feeburt did switch to Lev recently and really like it: viewtopic.php?f=9&t=14574#p146141

 

Hi Heather,

Thanks so much for responding on both boards. I know that it gets confusing when posting on different boards!

Regarding the IAA (Debbie - we chatted about that ....antibodies to insulin) I had - rightly or wrongly - taken that off the list because Bryce has never responded to Lantus - even from Day 1 and I would think that any IAA cat would have at least an initial response *before* developing antibodies to the insulin.

She also never responded to Vetsulin even though I think that the highest dose was only 2.5 units but still...her BG did not move.

I am having both the IGF-1 and the GH run on Bryce, in addition to a cardiac work-up due to an enlarged heart.

Thanks again and I am so glad that Boo is still OTJ!!

 

Dr. P - Following this closely....thanks, Doc!

Heather - As I said on my other reply..nice to meet you and Boo. We're huge fans of Dr. P...have a ways to go with Bryce, but I know we're heading in the right direction.

 

PS - I assume that Dr. Lunn is still wanting GH in addition to IGF-1?

I know that we have a better idea of what IGF-1 values mean but I think that we are all still of the mind to study the GH in these cats as well?

I think that GH has to go to Univ of Minn....I need to find out about the handling of the sample. Do you know if it needs to be frozen and go next day? I can go to VIN to look this stuff up but you are so 'up' on so I thought I would ask you first. :>)

My MSU lab book states that IGF-1 "requires no special handling". I think in the other thread you mentioned frozen, next day air but maybe I am mistaken...will have to go back and read what you said.

I will also check the MSU website.

 

In addition to what Heather said, I think I've heard that Lev is "less fragile" than Lantus. We're still using Lantus. There are several people that have experience with both, but I'm not one of them.

There are some recent threads on the High Dose board concerning the tests an where/when to have the vet send them.

Dr. Lunn does want GH measured, as well as IGF-1.

 

I am sending Debbie links for the handling of these tests..days that they are run, etc so that she can copy them for her local vet...which is always helpful for us!

 

Unfortunately, Jill isn't around this weekend and she may be the best person to respond to your question. Aside from her knowledge of FD and both insulins in general, she's used both in treating Alex. From what I recall, the dose if Levemir is slightly less than Lantus (30% is what's sticking in my head but I won't swear to that). If this is the case, for someone who is shooting a substantial amount of insulin for treating an acro or IAA cat, over time, this could make a differences in out-of-pocket expenses. Also, as Nina pointed out, Levemir does not seem to be quite as fragile or have as short of a shelf life once opened as Lantus.

Beyond that, I honestly don't know enough about issues with protein binding and depot formation and whether they would make a difference in Lantus vs Lev. My understanding is that Lantus is derived from e. coli vs. Lev is based in yeast. The latter binds to albumin in forming the depot and is slowly dissolved from the albumin bond. I don't know if the pharmacodynamics and pharmacokinetics would make a difference in choosing one insulin over another in an acro or IAA cat.

 

You guys have give me a lot of help. Thanks!

It really does not seem like we need to switch to Levemir right now, as Heather pointed out in the other thread, so we will just sit tight with Lantus for now.

Thanks again. :>)

 

Univ of MN just states "next day air" and to use with frozen gel packs. It does not mention actually freezing the sample.

Growth Hormone
Fee: 50.00
Specimen:

1 ml serum

Shipping Container:

plastic tube

Coolant:

frozen gel packs

Days Tested:

call lab for schedule

Turnaround Time:

test done on monthly basis

Comments: Send next day delivery. Do not use heparin. Include time of day sample was taken.

 

Hi Dr. Lisa,

Both the IGF-1 and the GH can be frozen, that is the way I send Milo's samples to Dr. Lunn.

We changed from Lantus to Levemir when Milo was at 9u because the Lantus shots were bothering him (stinging). When we switched we went from 9u Lantus to 9u of Lev. If you take a look at his SS his numbers seemed to improve immediately.

Now that Milo's insulin requirements are much lower we are going to switch back to Lantus for a change - I have about 1 weeks worth of Lev left.

 

Hi Wendi,

Thanks for the info.

Out of curiosity, why are you switching back to Lantus? I can't remember....is it cheaper than Levemir? I always thought that they were similar in price.

 

hi dr. L! quite a few peeps have noticed a longer duration with levemir.

you might want to add the test for IAA while you're at it. i think it's only another $12.
take a look at sandy and black kitty's ss: http://spreadsheets.google.com/pub?key=pj18WeQTVaWmyP-SWuUD1Ew. BK never really responded to lantus from day 1 either. once BK was diagnosed with IAA, sandy dosed aggressively using both lantus and R. her hard work paid off. BK is now OTJ!

 

Not really sure why, lol

Probably shouldn't be changing since we are having some really nice numbers lately, but a change may be good, too. Since I've already purchased the Lantus and can't return it, we'll give it a try and see.

The Lantus is a bit cheaper.

 

Hi Jill,

Since I love numbers/data so much, we will go ahead and test for IAAs since the test is not that expensive. Thanks so much for your input!

(Debbie...do you like the way that I spend your money?? :>) )

 

One comment that I'd like to share is that I started Maddie on Lantus and switched to Lev. Right before the switch, at 20u, Maddie's numbers started getting much better. If I had switched from Lantus to Lev just one week later, I would absolutely have sworn that Lev worked magic for her. (If you look at her SS for early October 2008, you'll see what I mean.)

I

 

I am sure that you did not intend to rule out all us acro moms by saying that. LOL

I have used both Lantus and Levemir in my acro cat and know many other acro moms who have used both. Levemir seems to present a more shallow curve and gentle cycle as well as increased duration, all of which are highly desired in resistant cats. Levemir is only slightly cheaper than Lantus and in some areas it's more expensive, however, I save approx $30 a month on Levemir over Lantus in my area.

Here's some data for you. Jen's Milo (acrocat local to me) is still not regulated but he's getting there.. and his dose is dropping. See what happened when he switched from Lantus to Lev on March 30th 2010 http://spreadsheets.google.com/pub?key=tYXurtGG1oRckXQGfzc-qKg&output=html

What Joan says is true, in many cases it is like magic insulin LOL.. it is quite often that a switch to Lev results in a report that the acrocat is doing better suddenly, even with little to no change in the numbers. Leo's numbers did not come down but he DID visibly feel better when I switched him. Immediately.


PS: Gosh I can't keep a single thought in my head. :mrgreen: Finally... NO STING. At large doses, Lantus can be very uncomfortable because it can sting. No such animal with Levemir.

 

It looks like Jen kept pretty much the same dosage for the first shot of Levemir.

Realizing that every case is different, when you guys are switching from lantus to levemir, are most of you going with the same dosage or cutting it down a bit?

 

No we do not reduce dose on crossover. The action of the two insulins is extremely similar, and usually at the time they are switched, their resistance is not yet broken, so there is no real need to reduce. Even if they are fairly regulated, and Jen's Milo was working on it but not there yet, we'd switch straight across. What you see from him is not UNcommon, but it's not common either. In some cases we will see that it almost appears the acrocat was "fighting" the Lantus and the introduction of Levemir caused immediate dose reductions.

In the case of an acro getting numbers too low, we might recommend a reduced dose, or even a skipped dose to let the shed drain, because we'd want to prevent the cat from going too low for that very reason. (It's not advisable to aim for the same numbers with an acro that you do with a "normal" FD.) Most of the cats who are switched are switched early, when the basal insulin dose is still climbing.

It should be noted that dose reductions are not uncommon with acro's and can not always be blamed on the old insulin or the new insulin, as their insulin needs are driven by fluctuating hormonal balances, so we can guess as to why, and we can assume things are or are not coincidences, but we are chasing hormones, not pancreatic issues.

 

Exactly and, at the risk of stating the obvious, this is what makes acro cats harder to deal with.

FD, in general, sometimes has little rhyme or reason but then through in fluctuating hormones and the issue gets even more complicated.

Great info here! Thanks mucho.

 

Here's another example of the Lantus -> Lev sudden response. This is Shelly's Feeburt. You can see the wall of red and pink shatter when Levemir was introduced (4/23/10), resulting in some rather startled beans LOL
http://spreadsheets.google.com/pub?key=trORNTIAnGY_JbgUrjaeQxg&output=html

Harder? Only if you have trouble keeping your balance on a moving floor while dodging large swinging wrecking balls. :mrgreen:

 

Yea...."harder"....a mild understatement.

 

Just another thought to add to the mix:

Heather/Jasper was on Lantus for well over a year. Jojo suggested Heather switch to Lev-mainly I think on cost and longevity. Maximum a year later and he was OTJ!

He's swinging a bit at the mo but had his first CP flare and that may be the reason for this. She's just giving him the tiniest bit and he's dropping through the floor!

She did switch foods (to Felix) and stopped giving him milk-no idea if this contributed.

I couldn't get Lucky regulated on Caninsulin but beautifully regulated on Lev-I swear like Joan, if she hadn't got P'tis and a rubbish vet she'd still be with me and a good chance OTJ :sad:

 

Thanks, Kate.

We are going to definitely switch to levemir asap....just as soon as we can get Bryce's local vet to write a script.

 

adding simply because i didn't see this mentioned: the pH value of levemir is supposedly closer to a human/cat's, too, which may explain why in larger doses this becomes even more noticeable. i've seen flatter curves with lev, too. i think the fragility or lack thereof of lantus is a nonissue these days,* but the fact that lantus can sting for some kitties/humans is why i'd try lev first for a high doser. plus that whole cancer connection with extremely large doses of lantus.


*i stopped treating lantus as a fragile insulin when i became broke (LOL). from what i've seen i think it lasts just as long as lev and stays effective just as long, too. initially we were told to toss the lantus at day 28 but it lasts to the last drop for cleo (9-10 weeks). only time i "damaged it" i had it right next to an active heat vent all day. i've mistreated my lantus just as i mistreated PZI: dropped it many times and keep forgetting to put it back into the fridge; despite this, cleo had a 59 nadir today from a lantus cartridge just starting its 9th week.


disclaimer, of course, i am not in vet science and am just a layperson so i'm only reflecting what i've read and seen here and by reading outside research in the past 2.75 years.

 

That's a very pretty number. Tell Cleo to talk to Bryce.

 

Sorry for my late arrival.

Shadoe's a weird one, but you can see her numbers in signature, and I have scanned all her b/w and results from IGF-1 and IAA tests if you need them.

We started on Caninsulin and her numbers show you how well THAT worked!
We then moved onto Lantus and the numbers improved but the dose kept going up , up. Eventually we tested her for both above and results showed only 7 for IAA (negative) and a low but positive 120 for acro test.
We switched her from Lantus to Lev because of the mention of doses increasing and sting and fragility, etc. Also, who knew if it would be more to her liking?

Unfortunately, it's tough to tell what caused her free fall because we had dental and u/s of organs, and insulin switch, and then pancreatitis shortly before all the changes, so she dropped down from 14u to 2.5u.
She had dental on 3/19 with 1 extraction, and I switched to Lev 2 days later.
I sure can't sort out what was the magic, but today, Shadoe has a wickedly silky coat like long ago and seems to be doing quite well now. We are also up to 6.5uLev and looking at an increase shortly.

Oliver is a bit different. I don't have his test results yet, only his reg b/w from pre-adoption and last week, but he is currently at 13uLev and needing help from R to keep his numbers decent, for him. He did start on Lantus, but I decided to switch him over to Lev as well, for the same reasons as for Shadoe and also for convenience and sanity. It's been hard enough to keep track of different doses for each and also her earlier nadir and his super late one, then remembering how much R for which and at what times. There was no way I wanted to toss into the confusion Lantus for one and Lev for the other.
His test results should be available this coming week; the draws were shipped to msu last week. If you need to see his ss and lab results, I can make them available for you. Let's just say that our vet was doubtful about Shadoe, but not so for Oliver. His appearance, and dosage and even his snoring pretty much point to a positive on something. I will have Xrays taken once his results are in.

I have to say that his coat has improved greatly as well, but I recently adopted him so his history is not known completely to me. I can't comment on how he ate before or what his coat has always been. He arrived here 3/20/10 and I switched him on 4/20/10.

If you need any info on either of the two, please do not hesitate in asking.

 

I received Oliver's result for IGF-1 - 325 so he's positive acro and can be added to your acro side of your list.

 

Here is the source of the information regarding the dose being 30% less Levemir than for Lantus : University of Queensland: http://www.uq.edu.au/ccah/docs/diabetesinfo/link4.pdf

 

Great info!

Thanks to all who have posted here.

 

If the cat is being tested, and a known acrocat, I would be leery of starting Levemir at 1/3 the dose. Could cause a very nasty backslide and induce ketones.

 

Understood. Experience usually trumps 'standard' advice, especially for acros. But just for the record, my math says it would be 2/3 the dose, not 1/3. Just saying...

 

Ahh you caught my typo Carolyn LOL, I stand corrected, and I meant to say 1/3 LESS a dose

 

Technically, it would be 70% of the dose, not 66%.

 

You know, after I posted, I figured that you probably had just left off a word and you might catch it later...

And I do think that stuff that is in the Univ. of Queensland pdf is really for 'regular' kitties (hahaha, what's that?) that are just beginning their treatments and it wouldn't necessarily translate well to kitties already in treatment and I can't imagine that it would apply to acros. Experienced advice is really a blessing for that, and thank goodness there are many acro and high dose moms on FDMB, seriously!

 

hey dr lisa! nice to see you, have missed talking to you...but as you know i've been out of the box pretty much 24/7 lately.

few things on this thread...
"My question to you guys is a pretty general one - have there been many cats that seem to be resistant to Lantus but do much better on Levemir?"
~not at that dose. not with what you are looking for, magic bullet as far as lev vs lantus for this cat. yeah sure can get slight temporary improvement when switching from one L to another (my cat was one of the first lantus to lev switch cats) but it doesn't last and you are not going to have a 10 units lantus cat turned into a 1.5 unit lev cat just cause of insulin switch. (sometimes the timing of a switch from lantus to lev for an acro corresponds with one of their many rev downs (GH fluctuations) and it could look like the switch was the cause rather than the GH levels).
why are mostly all the HD cats on lev? cause once they got over a certain dose back when we were getting the first HD cats in LL, i would start recommending the switch, my reasons being that very large doses of lantus *might* sting some cats (haha, and some of that was cause i *thought* it did in my own not low dosed cat, he was so bad for his lantus shots, turns out he is just as bad for his lev shots, dis cat just don't like needles, lol), and that when i originally started that recommendation we were under the impression from lack of data that lev lasted longer than lantus, was more 'fragile' which now vet med studies have proven the opposite (oops)and hence the HD cats could use lev vials rather than lantus carts for $$ savings, and...cause of the warning on lantus about rats and cancer and super super high mg/kg doses happening one in blue moon. eh i was being way over cautious, really have no worries about that nowadays. really either is fine, but if you are looking at an acro (which you prolly are) then i would go for lev just in case he ends up being an acro like say girlcat and her top doses of 60 something units bid and the possible sting thing. (most acros do not 'go there' with their doses though, there are plenty of "low-dose" acros around, meaning under 10-15 units). HD cats being on lev has just become part of FDMB culture rightly or wrongly i would not draw a firm medical opinion on (and what part i played in that i hope it ends up being rightly, lol). i havela been toying with idea lately of switching my cat back to lantus, it is a once a day insulin in humans vs. lev's twice a day in humans and i have to wonder if maybe lantus has a stronger shed than lev (longer overlap/better depo)? and cats that have switched the other way, from lev to lantus have noticed the same temporary improvement. push comes to shove the action is so similar in the end~ whichever as far as a choice for most cat, however if this cat is going to continue up the dosing scale with no end in sight, then go with lev for possible comfort reasons. last thing one needs is a larger dose cat that doesn't like his shots...trust me on that one. :roll:

~the IAA question, yes test for it, they can start off at first shot being resistant to whatever insulin they were injected with, after all they built up a resistance to their own natural insulin, right? and from what we have seen, which is very data poor being that IAA is truly rare and we do not have a large data base here (or anywhere! trust me i looked, there is crappus as far as feline IAA info out there anywhere :sad: ), IAA is crossover to all insulin, with the exception of one IAA cat that is (or was, i have not checked in quite some time) able to get R somewhat past the antibodies. the tx plan for IAA cats is very different than acrocat's.

"Come to think of it...I probably should post this in Levemir so I will put a link there also."
~the HD lev cats hang out here, don't know that you will get any hands on current experience posing question there.

you got all the info on all testing, nice job everyone.

as far as when/how to do the switch~ owner must be home for whole cycle. first shot big action has been seen on plenty of occasions among acros and reg diabetic cats when switching (like first shot of any L insulin this has been noticed, we like owner home and full hypo tool box. often total non-event but always like to err on side of caution). with the blue this cat has been getting i personally would drop a couple of units off first shot and then be prepared to go right back to the 10 unit prior dose immediately after if numbers call for such. SS looks like getting closer to needed dose there, maybe not too far away from getting the all blue acro curve that is desired, if this cat is an acro of course. getting the blue, just need to lose the pink, so nice job getting that close.
~jojo

(if you can....check your e-mail later, i have an FIV+ feral question for you, k?)

eta: man i type too slow, been 10 new posts since i started this? geez. gotta go out and feed my ferals, will be back to read...

 

COmplete thread-jack alert: Dr. Lisa I can't reply to your PMs, it says that the user has turned off PM receipts or something

 

Hi Jojo,

Nice to see you! I sent you an email about a month ago asking how you were doing but never heard back from you. I am happy to see that you are still among the living!

Regarding dosage - I had already let Debbie know that we are planning on starting with 5 u and then go up from there. I am not of the mind to dilly dink around and crawl back up so I am glad to see that you would get right back up to 10 fairly quickly if the numbers show us that this is reasonable.

We will also pick a day when momma can be home.

Carolyn - I hear you about ketones and being too conservative. What a crappy balancing act!

We are definitely not thinking that Levemir is going to be a miracle rescue insulin, by any means, but do want to give it a try.

Regarding IAA....I have said this a million times - I don't get why that is not more of a problem. We are injecting a foreign substance into a cat's body so why in the world aren't they making ABs to the 'invader'????

That said, I would still think that we would at least get an initial response (for at least a few days) to an insulin while the body ramped up IAAs to the new 'enemy'.

More later....

 

Opps...that's what I get for being anti-social.

Can you email me at DrPierson at catinfo dot org?

 

Well...I think IAA is a fairly common condition, and ALL animals that recieve forgein insulin develop antibodies the determining factor is how much antibodies. The test for IAA is considered negative under a certain level (a value of zero is never found) but at lower levels those antibodies don't generally create a problem. I suppose some of the variablity in "breakthrough dose" amoung cats is related to thier individual insulin resistance and antibody response. Some cats who are not tested but get up to doses over 3U (not high dose here but less common than cats who max at 2U) likely have more antibodies than others.

As to switching insulins, there may be a slightly increased initial response but these antibodies are not 100% specific to a brand of insulin and the simularties in all synthetic human insulins probably are enough that the antibodies will recognize the new insulin just as quickly. In human cases of extreme insulin resistance often a switch to a completely different catagory of insulin is tried.

Of course if you are dealing with Acro here thats another story and the guilty party is the growth hormones which are not affecting the insulin itself but rather the receptors in the body have a higher affinity for those than the insulin.

 

oh shoot, missed that e-mail. i miss whole clumps of PM's and e-mails when i am having flare and then never ever can catch up. never saw it, sorry dr lisa.

"Well...I think IAA is a fairly common condition, and ALL animals that recieve forgein insulin develop antibodies the determining factor is how much antibodies. The test for IAA is considered negative under a certain level (a value of zero is never found)"

we have had plenty of felines get a value of zero for IAA test results. like here this was just first one i checked:
Kt and Buckwheat:
Endocrine Results from MSU 3/26/09
Insulin-like Growth Factor 1 196 H [Ref Range 12-92]
Insulin Autoantibody 0
and that was done on a cat that had been on first PZI for 3 years, than lantus/R for many many months prior to that testing and always large doses (over 3 units). maybe cats are different than humans in that respect? i have list somewhere in my notes of everyone's test results, but is too late here (eek, almost 4 am, gotta go!) to look for tonight, but i know i have seen lots of zeros for feline IAA results.

 

Hmmm.....I wonder how the IAA test is run in terms of specificity. You just mentioned 3 different insulins all with different antigenic properties which would then lead to different antibodies (on a structural level) being manufactured by the body.

When we test for herpes...or calici...or FIV...or etc....etc....etc....antibodies, we have to use a very specific test for the antibody in question. But when we order the IAA test, all we know is that it is an "IAA" test....with no specificity - in terms of which insulin the cat has been on - attached to it.

But I guess that makes sense because if the insulins were *that* different from one another, then they would not all be able to do the same job....so the structural variation in IAAs is probably minimal.

Don't mind me....I am just rambling.

 

There are several methods for testing antibodies of all types. Typical tests are ELISA, Radio-labeled binding, IFT, and Western blot. Each will report results in terms of different units. What is confusing is what is actually being measured here...IAA (Insulin AUTO antibodies) is generally a test to identify Type I DM, antibodies are being produced against endogenous (auto=self) insulin. IA (insulin antibody) is a test to determine if antibodies are present in response to exogenous insulin during insulin therapy.

"Regardless of purity and origin, therapeutic insulins continue to be immunogenic in humans. However, severe immunological complications occur rarely, and less severe events affect a small minority of patients."

I don't belive the antibody tests are sensitive enough to specify which insulin type they are aimed at. Specifically antibodies of the IgG class and occasionally IgM are found in the case of immune insulin resistance, Antibodies of the IgE type are typical in an allergic reation to the insulin.

"Most commonly, IAs that develop in response to exogenous bovine, porcine, or human insulins are cross-reactive with all three species. In rare cases, however, antibodies bind differentially to insulins from different species, correlating with clinical responses observed when switching insulin sources."-pertains to human studies but likely simular response can be found in other animals. I think there have been cats that were resistant to one insulin but for which another worked better, in other (most I think) cases the insulin antibodies were interferring regaurdless of what insulin type was used.

More interesting tidbits concerning IA (in humans)

A possible advantage for Lantus/Levemir?

A guidline for when to consider testing?

A very interesting article about testing, and ways to treat insulin resistance. Something we already know

Other possible interventions include in Type II diabetic actually stopping insulin therapy for a period of time (if possible) and attempting managing the glucose through diet or medications. Another possibility is using cotisone to supress the immune response.

http://edrv.endojournals.org/cgi/content/full/28/6/625

 

Hi there - it's Bryce's Mom....

I wanted to THANK all of you for your responses to Dr. Lisa's post on our behalf. My head is spinning a bit from all the information, but what an education!!

And, Dr. P -- there are no words to express my thanks....I will be referring back to the information in this post as we move forward.