2018-04-16 Conan Tresiba insulin degludec update

Discussion in 'Tresiba (degludec)' started by Jessica & Conan, Apr 16, 2018.

  1. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    Previous posts:
    - http://www.felinediabetes.com/FDMB/threads/2018-04-11-conan-tresiba-insulin-degludec-update.194017/
    - http://www.felinediabetes.com/FDMB/threads/2018-04-07-conans-first-day-on-insulin-degludec-tresiba.193815/#post-2172939

    As I mentioned at the end of one of the previous threads, entirely independent of his insulin/diabetes, Conan hasn't been doing very well. In the last 4-5 days his appetite has been greatly reduced and he's been extremely lethargic. We went to the vet today, and an ultrasound revealed that despite the fact that he's eaten very little, his stomach is full, suggesting his intestines aren't moving. It's not clear why, as there are no physical blockages. He has IBD, though, and his digestive system doesn't always work properly. It seems very plausible that the food in his stomach, increased stomach acid, and sluggishness of his system are causing him to feel generally ill, bloated, and certainly not hungry. We are trying metoclopramide injections (for gastric/intestinal motility) for the next few days to see if that helps.

    But neither the vet nor I feels that this is related to his insulin.

    With regard to the insulin, I increased him to 2U last Friday. My BG testing during the days hasn't always been consistent since then. However, I've been able to do enough testing to feel somewhat confident that this dose seems to be getting his numbers to a good place for much of the day, and keeping it there relatively evenly. The thing about Tresiba that is different from Lantus and Levemir - for Conan - is that there seems to be no jumping around, no spikes or dips and peaks. The insulin starts to take effect, his numbers drop, they stay dropped, then they gradually start to rise until the insulin (I believe) wears off. But even when he went fairly low, into the greens, for the first time, there was no real bounce, not like he experienced on the Levemir certainly, or on the Lantus when we used it for the first 6 months after his diagnosis.

    Also, it seems that it lasts for a good 10 hours or so, though it's hard to tell as 1) we haven't been on 2U long enough; and 2) I haven't been able to test consistently enough throughout the day.

    HOWEVER - it also seems clearer to me now that the insulin *is* in fact only lasting roughly 12 hours. After that his numbers go up, and they stay up throughout the next 12 hours. They don't "bounce" up to the high reds or blacks, and that's what was confusing me at first - they just politely go back to what I presume is his "normal" high level, generally ranging throughout the 300s (on a human meter; it would be higher than that in the lab). But I feel fairly certain that the insulin is having no or minimal effect during these hours, because even though his BG values for the 12 or so hours post-shot have gone down noticeably and unmistakably each time I've increased his dose, the overnight values in the +12-+24 range have not changed at all. They are the same at 2U as they were at 1.5U.

    It's true that he's slightly lower at AMPS than he is at, say +15 - but I am thinking now that this is just his natural cycle.

    So....once he's had a bit more time at 2U for me to get more readings, and for me to be sure that he's "settled out" at this dose and isn't continuing to go any lower (it definitely takes a few days on this insulin for that to happen!), and also once he, hopefully, improves his eating and his medication takes effect, I am going to take the plunge and move to BID dosing - at this dose. I am going to have to do that at a time when I can monitor him closely, since it could possibly result in some low levels. My hope is that there will be a little overlap so he will have no period in which the insulin "wears off" (as it is doing now in the +10-+12 range; also it seems to take until about +2 before it starts to bring his BG down again).

    In humans the duration of action is up to 40 hours, and yet most dose every 24 hours, and studies indicate that it doesn't really matter if it's exactly 24 hours, or instead 20 or 30. I'm hoping that will be the same for cats, so some overlap won't result in really low numbers, but instead it will all smooth out. And also - maybe it won't be as critical that the shots be *exactly* 12 hours apart, which is sometimes an issue for me.

    But as I said, I'm going to still wait a few more days to try that.

    So far I have to say though that I'm very pleased with the Tresiba! We aren't yet anywhere near working out a final dosage for Conan, but the curve appears to be by far the best of the insulins he's tried - the most smooth and consistent, and it keeps him controlled the most evenly for the longest time. So far. We've still got a ways to go though!
     
  2. Stephanie & Quintus

    Stephanie & Quintus Well-Known Member

    Joined:
    Dec 9, 2017
    Thanks so much for documenting this. Your reasoning makes perfect sense and I hope the BID works out as you expect it to!

    And before that, sending intestinal vines for things to start moving along.

    :bighug:
     
  3. Tracey&Jones

    Tracey&Jones Well-Known Member

    Joined:
    Dec 12, 2016
    Sending tummy vines for Conan. I hope when he starts eating again that too will help with numbers.
     
  4. Ter and Sally

    Ter and Sally Member

    Joined:
    Jan 9, 2018
    Hope your tummy feels better Conan! Thank you for the detailed postings, very interesting and I wish you both continued success!!!
     
  5. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    Update on Conan: he has gradually improved more and more until tonight he is eating almost normally again!is eating again, though not the way he used to. Actually he’s eating almost as much, but now in many more small mealshe red instead of 2-3 larger ones, and generally with less enthusiasm and requiring more coaxing. It has been 3 days and he is still on the metoclopramide, so hopefully he’ll continue to improve.

    Meanwhile, I decided to switch him to BID Tresiba starting yesterday. So yesterday he had a PM shot. I tested him throughout the night last night, and he was definitely lower than previous nights - spent the entire night, through AMPS, in the yellow. To some extent this surprised me, as I thought this 2U dose had been enough to get him to blues and greens.

    More troubling, or at least baffling, his numbers went back up to the pink after his morning shot and meal - and barely dropped throuhpghout the cycle, just into the yellow. No sign of the blues and greens from previous days at this dose. Even worse, as the dose wore off around +10, he went up into the reds, for the first time since almost his first day on the Tresiba. Which is where he still is now, at +2 after the evening dose.

    So what to make of all this? First, the anomalously high numbers (compared to the last few days on this dose). Could they have something to do with some reaction to switching to BID dosing? Some sort of weird bounce-ish thing caused by increasing the amount or timing of the insulin? Or is it something else? Maybe the metoclopramide? The listing for the drug does say it may affect blood sugar since food is absorbed more rapidly, and (for humans) insulin may need to be adjusted. But he’s been on it since Monday afternoon (he is getting a .2 ml subQ injection 3x/day), and while I don’t have a ton of daily readings from Tues and Wed, it doesn’t look like his number s went so high those days. Maybe its effect increases with time? Today is certainly the first day he really ate like normal. I just don’t know, but it’s weird, and I’m not happy about it. In any event, he’s had 3 days on the metoclopramide, and I’m going to try seeing how he does without it, so midday today was his last dose (unless he regresses in his eating). If his numbers start to get better, that might indicate the metoclopramide was the cause.

    The other thing these numbers *seem* to be showing more clearly about the Tresiba is that it is having less than 12 hour duration of action for Conan, so far from 24 hour effectiveness, Conan isn’t even getting any overlap on 12 hour dosing. It looks like it begins wearing off before +12, so the previous shot is just about gone by +12 and his numbers at shot time are either close to or at their “normal” (no insulin) levels. And then it appears to take at least 3-4 hours minimum for the next shot to take effect, during which his numbers remain at that elevated “normal” level - not affected by the previous shot.

    I can’t feel confident this is true until I have more data - more time BID dosing, more BG readings close to shot time (and without the metoclopramide), and possibly even seeing what happens with an increased dose if it proves to be necessary (though so far that hasn’t seems to affect duration of action very much). But right now that’s what I’m inferring from the limited data I have.

    If that ultimately proves to be the case I’m not sure what I’ll do. Try TID dosing of the Tresiba? Go back to Lantus - which did seem, I think, to last 12 hours, but at least when Conan was on it the first time, didn’t have anywhere near as smooth and predictable a curve? One step at a time I guess, and I’m not at that point yet, so I’ll keep going and see what happens next!
     
  6. Stacy & Asia

    Stacy & Asia Well-Known Member

    Joined:
    Oct 2, 2017
    I’m sorry it’s not working out as 24 hours, that is really disappointing. :( I hope Conan feels better soon as all that he has going on is bound to mess with things and not show the clearest picture of what is happening (case in point, Asia’s SS recently, UTI). Healing and motility vines for pioneer Conan. :bighug:

    Food for thought regarding switching to BID and the numbers you are seeing. You doubled your dose instead of splitting it, typically you would take the SID dose and cut it in half for BID, or 1 unit twice a day. I’m not saying it’s necessarily too much insulin for him as he was on more than that before you switched (and this assumes Tresiba is pound for pound with Lantus for cats, which who knows). But that could be the reason for the sudden high pinks and reds you are seeing, it’s bound to be quite an adjustment for his body to increase that much so suddenly, an extra heaping helping of new dose wonkiness.

    I’m glad to hear the action is smooth, that is one of the reasons I switched from Lantus to Levemir. It could be the hybrid of the 2, the duration of Lantus with the smoothness of Lev. Also, it’s bound to last longer for some kitties without some of the issues our cats are dealing with. Still following with interest, but I have to remind myself to come over here to check on you two. ;)
     

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