7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=270

Back on 7/11 I switched Chingis to Levemir from Lantus, where he had been bouncing for a bit. I started on 1U (was on 1.75U Lantus, which I thought may have been high). I held the dose for roughly 6 days before raising it, and then held it at 1.25 and held that for a week before raising that.

Problem: within two days he has "bounced" to higher, flatter numbers and seems to be staying there.

My dilemma is back to an old problem:

how to tell if this is chronic rebound from too high a dose (or otherwise reacting to too high a dose) or him settling to the right dose?

How long should I keep him at this dose, even if this bouncing pattern doesn't wear off? (should I then lower him back down to 1.25, or maybe even straightaway to 1U and start over?)

(note: there was one day on the 17th where I was gone all day for 15 hrs and had to put some dry out, which skewed things. I also raised the dose that am, maybe prematurely?)

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

It also could be meter variance.
Ignore the colors for a moment.
Multiply the lower number by 1.2 and the higher number by 0.8.
If the high vs low order switches, the numbers may be considered the same.

And glucose level is multifactorial - changes in food batches, activity levels, absorption rates, etc can affect it.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

when I look at his numbers now at the 1.5u Levemir he is getting, vs the 1U that he started on back on 7/11, it looks like he was getting better numbers back then.

Does this pattern over the past 4 days look like he is getting too much insulin?

One thing is that he has had ongoing spells of pancreatitis for the past 2 yrs, so could it be that there is a residual inflammation in his pancreas that is keeping him from getting low numbers? Or, since he has been high for long, maybe another factor keeping him from being low for long?

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

To me, it looks like he could use a dose increase of 0.25, as you've held the dose the minimum required before changing (3 full days after any initial dose which is held at least 5 full days in most cats).

His other medical conditions may be affecting his glucose, so you have to adjust around that. Have you considered B-12 injections - cyanocobalamin for pancreatitis prevention, not methylcobalamin which is good for diabetic neurapthy - in this case)

Those nadir/mid-cycle tests are your most important and Lev tends to nadir late, so +7 - +9 may be a time range where you want to get some tests when possible.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

i THINK IF YOU SUSPECT PTITIS, YOU DON'T WANT TO REDUCE THE DOSE (oops! Beau steeped on the caps lock) until you are seeing significant lows. Also, when they have been in higher numbers for a while, raising the dose to break through and then lowering it if there are lows below 50 is the way to go. Seems like it doesn't take much to get some insulin resistance starting up. So, that .25 increase sounds like a good idea to me too.

He did have some very nice numbers earlier in the year on lantus at 1.25u, but that doesn't seem to be holding lately.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

Hi, thanks, what did you mean by "Seems like it doesn't take much to get some insulin resistance starting up"?

Last night I seen that he was getting worse on 1.5U in the way of being high and flat.. I don't think that this would break even if I kept it up for a few more days. He wasn't even dipping at all the past weekend. So I dropped his dose to 1U, as I had some not bad numbers when I started him on it on 7/11 and held that for almost a week (mind you, that was a busy week with no opportunity to test him through the day. That has changed now and for the next few weeks I can get lots of data points on him, like the pattern I've been doing for the past 5 days or so)

One thing I worry about is that maybe the Levemir, for him, doesn't have the duration that Lantus did. His +3's are all a big, sudden jump, which suggests to me that the insulin poops out pretty fast.

Or could that be the opposite: that the overlap is so strong, if that his dose is too high, there are two shots working and putting him over into a high flat rebound? especially if something else that I suspect is happening -> that the Lev is stronger then Lantus. They say in a few threads that the "70%" Levemir dose vs Lantus is just a starting point, but I think that the 1.5U Lev he was getting for the past 5 days would be equal to 2.25U Lantus, and that, according to his history would tend to be too much.

When I look at the limited data points over the past 3 mos, he did the best on 1.5U Lantus, which would also likely be analogous to the 1U Lev he is getting now.

One other question: when you reduce a dose, is it typical that the numbers can run higher for a few days, even though you eventually might confirm you are getting to the right dose? (what I mean is, is it possible that when the cat's dose is lowered, the shed fill dumps stored insulin into the mix, skewing the readings?)

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

for the last part- yes. Chingis 'shed' will be dumping the insulin into the bloodstream until it catches on to the fact that it wasn't a skipped shot but a reduced one. Give it at least 5 cycles to catch up- more if he takes a while to get in the dose.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

Thanks for this, I never looked at that from this angle - that the depot readjusts itself to the drop in dose thinking its a missed shot. I've put him back on back on Lantus as I am speculating that he had a better response to it.

The whole point about the shed/depot dumping stored insulin might even be trickier when you have it dumping one type of insulin, as another one gets started, with the two different mechanisms of action and everything..

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

Did I read correctly that you switched back to lantus? I don't think you gave the lev enough chance to work. And the dose was too low.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

Thanks Sheila.

I don't know if it wasn't that the dose was too high. If you look at when I started him on Lev back on the 11th, he seemed to do ok on 1U Lev, and then I held that for 6 days, and raised him to 1.25 and held that for 6 days. The first few days when I raised him to 1.5, he seemed to do ok, but I think what has happened here is a bounce.

If you look at some of the readings from the 26th to the 29th, I get the impression that Lev, in him, doesn't seem to work for at least 4-5 hrs so he climbs after his am shot and then the rapid drops on the 25/26, even though they weren't that low, seemed to trigger higher flatter numbers. Even though he isn't going down to greens, I think that it was more the speed of the drop several times over several days that triggered some sort of unresponsiveness with high flats.

I've seen this before in this cat, and that and the fact that the more raised the dose of Lev, the worse he got spooked me out of wanting to take a chance and bringing him up to 1.75. I lowered him 1U Lev and saw no response.

I really think that Lev somehow is stronger than Lantus and the comparison isn't a 1:1 ratio - and the onset and peak action in this cat is too different for me to gauge what's going on. It could be true that the dose equivalence of Lev vs Lantus is 70%. So, the 1.5U Lev would be equal to 2.25 Lantus, which I think would be too high for him, as he's never been up that high.

I thought that maybe its better to go with the devil I know and go back to Lantus. So after lowering him down to 1U Lev for three cycles and not seeing anything give, I put him on the last dose of Lantus that worked.

Now, its the morning of day 3 on that, and the last 2.5 days, all I have seen is high and flat again.

This am, I raised him up to 1.8 units of Lantus to see if he responds.

Question: have you (or anyone else) ever seen a case of a cat being high and flat from too much insulin - without ever getting into the green?

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

It does take Lev 4 to 5 hours to work- that is why you don't have to have the cat eat first. Nadir is usually around + 8 or +9 (Sneakers is +10) and then there is overlap of the one shot leaving and the other shot coming in.

Looking at the chart- 19 days isn't really enough time to give Lev a chance to work if you had not yet found his dose. The pinks around the 17th should be attributed to the dry food you needed to leave out as you were gone so long- these cats can hold onto it for days.

1.25 looks to have been close to the right dose, but it does look like he was starting to go high on the 1.5 almost immediately.

What is the carb count of the food you give? Do you mix up % numbers? I ask because Sneakers is very carb sensitive and will have a 50pt increase going from a 2% to a 4% food and it will take a few days to clear.

As always- Chingis might take longer to settle into his dose than a normal cat. Instead of 5 days you might want to give 7 or even 9. Without getting any other numbers but the PS's you really aren't getting a nadir # and it is difficult to dose by them alone.

Flat we call a pancake- they are at the IHOP- high- that can be too much or not enough. The last few days you've been getting lots of tests in but I don't think it is normal for him.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

Hi, thanks. With his food, I found that he is also very very sensitive. Eg, even though Wellness Chicken grain-free is 4%, he spikes high off of it.. so, I have been very fastidious about keeping him on FF Classic Chicken and Classic Savoury Salmon without any chance of him getting into anything else. So we can 100% rule out postprandial spikes etc..

I am taking him into the vet in an hour to see what his bloodwork shows and check his urine etc.. But I think this is all caused by him overreacting to the 1.5U.. It could be that the high/flat is hanging around b/c I dropped him too low in panic to 1U and then maybe held that too long, so now although the high/flat was caused by too high a dose back on or around the 26th/27th, now it could be hanging around b/c of too low (and I changed him back to Lantus after three cycles at back down to 1U Lev). So, he could have almost no Lev left in him now and the Lantus might not have been built up enough to form a substantial depot yet, and the Lantus dose could have been too low.

(I started him back on 1.5U Lantus Tues am, as that was approx the last best dose of that which he was on back around July7th or so. And I am very suspicious that Lev is stronger in strength than Lantus. On that "Queensland Protocol" from Roomp and Rand, they note that the mean, med and max dose of Lev is 70% of Lantus, and then go on to give eg of 1.75 Lev = 2.5 Lantus.

Based on how Chingis reacted to the three different doses of Lev, I'd say that this is accurate. He started on 1u Lev, which is like 1.5 Lantus, then up to 1.25 which would be like 1.75 Lantus, and then up to 1.5 Lev, which would be more like 2.25U Lantus - a dosage which he had never been up to. If I couple that with Lev's slow onset, and strength when it did start to work (as evidenced on 25th/26th Jul), this could explain why he went high and flat, and *maybe* defied the conventional wisdom pointed out by so many others that he wasn't getting enough of a dosage - even though we never saw any low enough #'s).

This am I raised him from 1.5 to 1.8 (again back on Lantus) and will see if he reacts to this. I have a feeling that this would be equal to the 1.25 Lev he seemed to do not too to bad on.. If I could only get him back to where he was last week, mid-week.. I would love that for a few weeks to give his metabolism a rest.

Maybe the vet appt (in one hour) can find something else going on.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

I think you may be way over analyzing the lev vs lantus and the high flat numbers being rebound. While it theoretically is possible to have rebound with high flat numbers and without a drop to low numbers, I am not sure I have seen this happen. Because it is so hard to tell rebound from not enough insulin all you can do is to slowly raise the dose until you do have a drop. If you are doing it slowly and methodically, you aren't going to see a sudden drop to 30. I really didn't see any numbers with Chingis that told me you were near the best dose with lev - I mean, not within .25u to .5u of the best dose.

Yes, lev is approx 40% "stronger" than lantus, but that is only important when switching insulins and finding a starting dose. And lev does tend to nadir later than lantus. In order for the dosing to work with either insulin you have to find the dose where there is still some residual insulin from the last dose as the new dose begins to take effect. If there was a significant climb from PS then you didn't have that dose yet (weren't high enough).

Finding best doses does often cause temporary rebound, or a bounce, from a low number that is a safe low, but hasn't been experienced in a while for the cat. You just have to weather that until it clears. Sometimes you have to back off and raise more slowly, which is why it has been suggested on the lev ISG to raise/fine tune in 10-15% increments. There is less chance of setting off rebound in the first place.

Remember that best dose/insulin needs will change over time. There are so many factors and other health issues that contribute to the equation that we never "set it and forget it" when it comes to a dose.

Also, many (maybe most) cats have a stronger response to lev at the beginning and then seem to settle into a flatter response. This is why you start low, let it settle and then slowly raise until you are getting good nadirs.

 

Re: 7/27 Chingis PMPS=250 +3=326 +7=330 AMPS=324 +3=342 +7=2

I'd say don't give up on Lev all together as you really didn't give it any chance at all. If you still have it I would say give it another try for at least two months.

And as we say here- you are holding the syringe. Chingis is your kitty and you will do what you think is best for him.