2018-04-23 Conan Tresiba insulin degludic update:

Discussion in 'Tresiba (degludec)' started by Jessica & Conan, Apr 23, 2018.

  1. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    Previous posts:
    - http://www.felinediabetes.com/FDMB/threads/2018-04-16-conan-tresiba-insulin-degludec-update.194256/
    - 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/

    In my previous update I mentioned that Conan had lost his appetite. After about 3 days on metoclopramide (.2ml subcutaneous injection 3x/day), which brought us to last Thursday 4/19, he had improved significantly, at which time I stopped the medication. His appetite continued to improve steadily, and by yesterday was totally back to normal, as was his general demeanor. Since last Wednesday he has been eating his usual amount of food - though for a few days I had to feed him in multiple small meals. Now he's back to his usual voracious self and eating large meals again.

    Unfortunately, however, the Tresiba experiment seems to have stalled. For a few days while he was sick (and eating almost nothing), his daily numbers were in the blues and greens. As soon as he began eating normal amounts, though, he went back into the pinks - and pretty much stayed there constantly. There were a few occasional yellow readings, but mostly pink, pink, pink.

    Last Wednesday night, after my previous suppositions (discussed in prior updates) that the insulin was wearing off after 12 hours continued to be confirmed, I decided to go to BID dosing. I kept the same amount for each dose - I had been giving him 2U in his daily dose, and I switched to 2U twice a day. This was the approach that made sense to me (and it's what I did when I switched to TID dosing with Levemir). For Conan at least, the insulin is only lasting 12 hours or less, then after that, his numbers go back up to their baseline "un-medicated" state, and the insulin seems to be totally gone from his system. There's no sign of any depot effect (though I can't be certain there isn't at least a small one). So each dose is entirely independent of the one before. It would make no sense (at least or so my reasoning goes! :) ) to split his prior 2U dose and give him 1U twice a day, because a 1U dose is completely ineffective for him.

    So he's now been on BID dosing for 6 days, and I've been able to get some good curves, though the last two days I haven't been able to test much after the morning dose (I've tested much more regularly after the PM dose).

    And the results have been... TERRIBLE. It looks almost as if he's getting no insulin at all - so much so that I actually drew a dose and squirted it onto my fingers just to make sure I wasn't making a mistake drawing from a pen! (And I've actually been tempted to try a dose out of a different pen just to double check, though it seems highly unlikely this pen could have "deteriorated," since I've only had it a few weeks and have handled it carefully and kept it scrupulously refrigerated - as the Tresiba instructions call for).There's no bouncing around, no real spikes - just relatively consistent pinks, higher after meals, lower in the morning - which is what I think I'd get if he weren't getting any insulin at all! I am utterly baffled by this!

    Three days ago I increased his dose from 2U to 2.25U - and I thought maybe I was seeing a slight change, since I got a few readings in the high yellows, but they went right back to the pinks. Tonight after 3 days at 2.25 I've increased the dose yet again, to 2.5U, since I'll be around for the next few days to monitor.

    I have to admit to being somewhat discouraged, and perplexed, by the seeming ineffectiveness of the insulin - though at least its effect is certainly consistent! The difficult part, though, is that it's hard to be sure it's even having an effect, since this BG levels remain fairly consistent even at the end of the cycles, when the insulin has (presumably?) worn off.

    I'm not prepared to give up yet - if this increase doesn't work, I'll try at least a few more increases. It is true that for humans the Tresiba dose is often around 80% of the Lantus dose, and when I stopped Lantus at a 2.75U dose I had definitely not yet reached an effective dose. So perhaps it makes sense that this dose isn't high enough. But I'm not feeling quite as optimistic about the Tresiba as I was at the beginning!
     
  2. Stacy & Asia

    Stacy & Asia Well-Known Member

    Joined:
    Oct 2, 2017
    Maybe some glucose toxicity? It looks like you have to find your breakthrough dose all over again. :confused:

    I recently discovered the German FD forum (where they developed the TR protocol that we adapted here) had a handful of cats on Tresiba back in 2015. I’m assuming it was u100, but it was unclear. Anyway, none of the SS are available to see anymore, unfortunately. :( But from reading the threads regarding Tresiba I was able to gather that it did work as a once a day insulin...for one cat. The others had to dose BID. I feel like the general consensus was that it was flat and predictable but ultimately the benefits didn’t make it preferable to most due to the high cost compared to the L’s. They pulled Tresiba from the market in Germany I think in 2016. Don’t worry, it wasn’t a safety issue, it was a cost dispute, Germany wanted some proof that it was a better insulin over the L’s to justify the higher price and they were not satisfied. It became a stalemate and Novo Nordisk decided to pull out of the market there rather than lower the price.

    I know that’s not a super helpful chunk of information, but I thought you’d like to know that there were cats using Tresiba (doing TR even) and what the overall experience was. The forum is linked in our TR protocol sticky if you wanted to go read some of it for yourself. I had google translate the page and then did a forum search for “Tresiba”.

    I’m glad Conan is feeling better though. :cat: When they don’t feel great, it usually shows in the SS in either higher or lower than usual numbers. Always higher ones over here! :rolleyes:
     
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  3. Ter and Sally

    Ter and Sally Member

    Joined:
    Jan 9, 2018
    I was wondering about toxicity too. Glad he's feeling better and eating, sorry that this is so perplexing to say the least. I think FD is great for making you think one thing and then doing the opposite. There's no logic in this at all. Thank you for these updates.
     
  4. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    If I ever knew about glucose toxicity, I had completely forgotten, so thank you for mentioning it! It looks like that could very well be what Conan is experiencing, in which case it seems like I do need to just keep increasing his dose, and monitoring carefully, until he breaks through. That does make me more hopeful.

    Thanks also for the information about the German Tresiba cats. Cats are just so...difficult! determined to march to their own beat! - when it comes to drugs and medications. I have horses also, and it's so easy to mildly sedate a horse - give them a shot of something, and they reliably get calm and sleepy and let you do all sorts of (medical) things to them. I asked a vet once why you can't do that to cats, and she said, they have sedatives for cats, and they work on some small subset of cats, but for other cats they're completely ineffective, and on others cats they have the opposite effect and make them agitated and overstimulated. And you have no idea which category your cat will fall into - and it might differ depending on the day!

    As I think I said in an earlier post, the cost of Tresiba isn't actually enormously different from Levemir for us, especially considering that we were on TID dosing with Levemir - though of course that will depend on the dose we ultimately settle at. And the consistency of Tresiba's curve could be a big benefit. Inconsistency was a big issue for him on the Ls. He was wildly inconsistent his first time on Lantus (though our last brief attempt at Lantus had seemed to be less so); and Levemir, especially because of its short action with him, led to huge variations in his BG. If we ever get the Tresiba to a dose that works, it seems like it’s possible that his numbers might even out - though it does depend on whether it lasts the full 12 hours. If not, then because of how long it takes to kick in, we might end up with the same problem as Levemir, with 4-5 uncontrolled hours at the end of every cycle and beginning of the next.

    But that's a problem for the future - for now we'll keep plodding along, to see if it's possible to reach a dose that gets his numbers reasonably controlled!
     
    Last edited: Apr 24, 2018
    Reason for edit: Typos
  5. Stacy & Asia

    Stacy & Asia Well-Known Member

    Joined:
    Oct 2, 2017
    Sounds like a very cat thing to do! :p This is true with some humans as well. Took my daughter on a plane when she was a baby and I was so worried about her screaming and crying the whole way, my pediatrician suggested to give her some Benadryl...to make her calm and sleepy... it made her crazy and wired instead! :facepalm: I asked about this at her next visit and the ped said, yeah, it can have the opposite effect on a few! :eek:

    I would increase as often as is safe and see what happens when a good dose is reached. If numbers are largely staying over 300, you might consider a .5 increase instead of .25.

    I’m still very hopeful you’ll get better duration from Tresiba. I don’t know what they were charging for it in Germany, but I’m guessing much more compared to the L’s than here. Because a flatter action and better duration sounds like something I’d happily pay more for. :smuggrin: Of course, if your cat is flat and has tons of duration on the L’s, it wouldn’t be worth it. The takeaway from the German experiences and one of the reasons why I shared it, is at least you know the insulin is safe and does work to tightly regulate cats. :bighug:
     
  6. LizzieInTexas

    LizzieInTexas Well-Known Member

    Joined:
    Jul 25, 2016
    Wow. Those two greens came out of nowhere and were pretty low :eek:

    I hope that maybe it is the start of a breakthrough?

    How is Conan feeling? I hope he is better.
     
  7. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    Well I did increase his dose by .5U instead of .25 last night, which I’ve never done before! I’m not sure if it was a good move, because it inspired a breakthrough, or a bad move, because now he’s a little all over the place, not consistent at all. In any event, I dropped back down .25 this morning and will see if he balances out here or if I need to decrease him again. It would be nice to have some dark greens in there!

    Those numbers do look worrying, but I know Conan pretty well now, and he has never shown any reaction to numbers as low as 25. He’s never shown a hypo symptom, or any sign at all that things aren’t completely normal, and he’s been this low many times. I don’t take it lightly, and it’s certainly not ideal, but I don’t panic about it either. Last night, because it was the middle of the night, I did give him a small,high-carb cat treat with a light slick of Karo on it (I don’t like to do more than that, or it sends his BG flying up). Today I just gave him a small meal of his regular raw food, and then tested again.

    Happily, Conan is doing great now, eating voraciously and back to his normal personality, so I am very happy about that. And pleased that the Tresiba is finally doing something - but not yet what I want it to do. It’s never easy, is it?!
     
  8. LizzieInTexas

    LizzieInTexas Well-Known Member

    Joined:
    Jul 25, 2016
    Glad to hear that :bighug:

    I would hold the 2.75U for the full 6 cycles and see if he can stabilize. You went to 2x/day shooting and then the increase by 0.50U and then 2 really lows and HC/karo. That is a lot of changes in a very short time. Plus he was seeing low blues before the increase (few and far between, but still low blues).

    Thank you again for using Conan for this experiment. I don't post much because I don't feel like I have enough knowledge but I find it very interesting to follow.
     
  9. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    Well since I went to 2x/day, I held 2U for 6.5 cycles, 2.25U for 4 cycles, and 2.5U for 6 cycles, before I increased to 3. So the increase by .5U wasn’t immediately after going to BID dosing. But I definitely intend to keep him at 2.75U for at least 6, unless he keeps regularly going below 50 each cycle. If that continues, I may have to consider dropping back to 2.5 again for a while - it’s not good for him to have such low numbers.

    I hope my experience will ultimately be useful for someone else! The only problem with using Conan as an example, though, is that his use of steroids makes him a little atypical - he is unusually difficult to regulate. Insulin also seems to have an unusually short duration of action with him. But I guess all cats are unique in some way. :)
     
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  10. Tracey&Jones

    Tracey&Jones Well-Known Member

    Joined:
    Dec 12, 2016
    Jones is on 5mg of prednisolone per day and is steriod-induced as well.

    I had a hard time getting him to come back down after an increase in pred last fall. He is finally coming around though.

    Following your threads. I think you are doing great!
     
  11. LizzieInTexas

    LizzieInTexas Well-Known Member

    Joined:
    Jul 25, 2016
    Wasn't criticizing at all. You are doing amazing in uncharted territory :nailbiting::D.

    Why is he on the steroids?
     
  12. Stephanie & Quintus

    Stephanie & Quintus Well-Known Member

    Joined:
    Dec 9, 2017
    Hi! Just checked out your SS and wondering how things were doing. The numbers I see seem encouraging, but as my nose isn't right in there day after day, I'm not sure how you're seeing things!
     
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