2018-04-11: Conan Tresiba/Insulin Degludec Update

Discussion in 'Tresiba (degludec)' started by Jessica & Conan, Apr 11, 2018.

  1. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    Previous thread: http://www.felinediabetes.com/FDMB/...first-day-on-insulin-degludec-tresiba.193815/

    An update on how Conan is doing on Tresiba - also some responses to Stacy's comment I somehow missed on the previous thread!

    FYI, all BG numbers at meal times are taken before meals.

    We are on Day 5 of Tresiba. On Day 3 I increased his dose from 1.5U to 1.75U (1x/day, dosed @5:45am). To the extent I've been able to notice a pattern so far, it appears that his BG is relatively consistent for roughly the 12 hours after his AM shot - though I don't have enough data in the +2-+5 range. Most mornings I have to leave right after the shot and am not back until 5-7 hours later; there are only 1-2 days a week I can be around during this time frame. Sometimes my husband is able to get a reading, but not every day, so this is the period where I have the biggest information gap.

    After +12 the numbers go up. I cannot be sure if this is an insulin curve issue or a post-meal spike, since I typically feed him dinner at +12. When I look back over his early spreadsheets, when I took many more BG readings, it does not appear that he ever had a big post-meal spike when I was giving him Levemir or Lantus,- but that doesn't necessarily mean he wouldn't with Tresiba. I don't think he's getting a post-meal spike with Tresiba after his AM meal, but he's just had his shot then and so is at a different point in the curve. So I need to experiment with putting off his dinner for a few hours and see what happens. I may end up doing this tomorrow - I have to bring some horses to the vet, an all day trip, and probably won't be back in time for dinner at +12 in any event, so it will be a perfect opportunity to see what happens after +12 if he doesn't get a meal!

    So after this spike, it appears that roughly in the +18-+19 range (+6-+7 after his evening meal), his BG starts going down again, until by AMPS it is back in the range it was in before dinner. Since there have been mornings where this number has been in the 200s, I believe, though I can't be 100% certain, that the downward slope must be attributable to the insulin. Again I can't be 100% certain, but I think it is very unlikely he'd come back down into the 200s on his own without the effect of outside insulin. I *think* this also supports the conclusion that the spike is meal-related. Would this post-spike reduction make any sense if the spike WASN'T meal related?

    Anyway, the downward slope and reduced AMPS suggest that the Tresiba may in fact be remaining active for 24 hours! I'll know for sure if his numbers keep getting lower with a higher dose - if the AMPS gets lower as well, I'll be able to be confident it's the insulin still working.

    This of course is excellent - but the post-dinner spike is problematic, because it is currently much higher than ideal, and so far at least, increasing the dose does not seem to have decreased the BG spike numbers compared to what they were on the lower dose. I am pretty certain I am going to have to raise his dose further (which I won't do until at least 1-2 more days at this level) - I'm hoping a higher dose will ultimately reduce those post-spike numbers to an acceptable, if higher than ideal, level. If not....I'm not sure.

    A few more relevant points: Conan gets 3.75mg Prednisolone per day. Currently he gets 2.5mg with his AM meal (at the same time as his insulin shot) and 1.25mg with his PM meal. In the past when he had very low numbers overnight I tried switching the higher amount (2.5) to PM, but I could never tell much difference. I've never been able to directly associate his BG levels with the amount or timing of his steroid dose (and indeed for a while we tried lowering his overall daily steroid dose to 2.5mg and it didn't change his BG values at all - eventually we had to go back up because his IBD started flaring). I could try giving him the larger steroid dose with his evening meal to see if that affects the post-meal spike, but it seems counterintuitive to think that more steroids would lower his BG levels.

    With regard to meal timing: Conan is extremely thin, and maintaining his weight is a big issue. My cats have eaten a homemade raw diet for years, and Conan eats at least 50% more than my other 3 cats, if not more, just to maintain a similar weight. With 2 meals a day, I can't get enough food in him - I've maxed out what he'll eat in a single meal. So for right now I am giving him 3oz food AM, 3 oz food PM, and another very small "snack" of .8-1 oz about 3-4 hours after dinner. This last small snack may not be ideal with respect to the BG spike but I'm a little at a loss as to what else to do. It might be better to give him the snack in the morning, but I'm seldom there to do it. There are some days I could give him the snack at midday or even split his total food amount into three equal meals, so each is smaller - but I couldn't do this every day (when he was on 3x/day Levemir, I split his meals into 3 whenever I could, but I was not always able to give him the midday dose & meal).

    But I could experiment with these at some point. For right now I'm probably going to keep these variables steady while I adjust dosage and continue to gather information.

    Last point: Stacy, thanks for the advice re: salve for the ears. I use 31g lancets. Never thought to try 32 - I will look into those next time I buy a batch!

    As always, all his numbers are on his spreadsheet! Always welcome thoughts/opinions/questions, but also I'm just keeping those who are interested updated on our journey. Conan is doing great - eating normally, happy, etc. - and his numbers are currently just about as good as they were on the Lantus, and vastly more consistent than they were on the Levemir (though the nadirs are not as low), and seeming to improve every day - so I feel no trepidation about proceeding with our experiment!
     
  2. Stacy & Asia

    Stacy & Asia Well-Known Member

    Joined:
    Oct 2, 2017
    Nice blue today, Conan!

    The protraction of this insulin is so unlike everything else, so it’s hard to understand what can affect when and how much of it is released. Lantus is in an acidic base so there are several annoyingly common things that can influence its release faster or slower than you would want, degludec doesn’t work that way, it’s closer to Levermir in the way it forms and diffuses, but the way tresiba goes about it seems much more stable. It’s utterly fascinating and frustratingly over my head! :p ...but if you want to nerd out over it:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399081/#!po=14.0625

    The +13 to +18 nonsense. To me, a food spike seems unlikely with the data thus far. Nothing so dramatic as this occurs after his am meal. It was there on the first day and Conan hadn’t eaten until +15, he was already in black by then and obviously came down not long after to arrive at the AMPS you saw the next day. He continues to rise after his +12 meal and goes down shortly after his +16 meal (which, granted, is smaller). It could just be where this insulin peaks with Conan. Like you said though, if he is at a good dose, hopefully that peak will be irritating but insignificant to the larger picture.

    Had you every tried splitting up his meals into smaller and more frequent portions? Since we are asking a basal insulin to do double duty as a bolus, consistently timed smaller meals makes lighter work of it. I know you can’t always be there to feed him, but you don’t have to be. There are timed feeders many of us use. I feed Asia raw food and that was my biggest concern “how do you leave raw food out for hours?”. You can freeze portions of food to thaw out slowly, you can add ice cubes to the food to thaw and add extra water (great for CKD cats), and some timed feeders have slots for ice packs.

    Are his weight issues related to his IBD? If you had a timed feeder you may be able to feed him more food so he can gain a little weight, since they are spaced out and more frequent? I agree, change one thing at a time, but some things to consider for the future. If he does get small food spikes at the hour after feeding, which is not uncommon, they would be smaller with smaller, more frequent meals.

    I’m glad the steroids have no predictable influence with timing on his BGs, that’s a plus since you have to give them anyway.

    Such an exciting thing to watch this unfold. I’m so glad Conan is feeling good, responding well, and having some elusive and long awaited duration with this insulin. :bighug:
     
    Stephanie & Quintus likes this.
  3. Jill & Alex (GA)

    Jill & Alex (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Took a peek at Conan's ss. Wow!
    Curious to see how this plays out. Will he bounce from the drop? If so, how long will it last? Will he go right back to green tomorrow?

    Watching with great interest...

     

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