Question on regulation with Levemir

This is a two-part general question on how to regulate your cat on Levemir so I guess I'll just blurt it right out in my usual straightforward style:

As the doses are increasing and the numbers are starting to come down, how does one know what the right dose is? What should the caregiver be looking for to know they are going in the right direction?

This may be a dumb question, but sometimes I need things spelled out a little more plainly than the general modified tight regulation protocol guidelines. I guess I''m looking for other people's experiences: what worked, what didn't, etc. as I'm trying to evaluate Harley's patterns and see if he's responding the way most cats do or if he has his own rulebook. (OK, I know he has his own rulebook but my other kitty Princess is very stubborn about translating it for me. She keeps upping the bribery demands.)

Thanks in advance!

Laura and Harley said:

This is a two-part general question on how to regulate your cat on Levemir so I guess I'll just blurt it right out in my usual straightforward style:

As the doses are increasing and the numbers are starting to come down, how does one know what the right dose is? What should the caregiver be looking for to know they are going in the right direction?

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Harley is pretty much a poster kitty for showing what to look for when going in the right direction. His cycles got steadier and lower on each dose increase and that's what to look for. 1.75U is looking very good on Day 2!

As for how to know when you're there, that is probably something for an individual owner to decide. What I mean is - are you comfortable with your cat going down in to the 70s, 60s, 50s while on insulin? OTJ is dependent on maintaining BG below 120mg/dl as much of a cycle as possible or at least getting them to the point where their pancreas starts to take over. That's probably going to cause BGs to be in the 60s sometimes. And you must decide how low should the BG go before decreasing the dose.

My suggestion for a case like Harley's is too continue increasing his dose until he's going low enough over an average cycle and then stay with that dose. Low enough in my view would be blues and greens throughout a cycle. The object is to keep the BGs low enough to help heal the pancreas, ideally that is 120 or below.

Does that help?

Hi Vicky, Thank you so much for always being there to answer all my/our questions!

Vicky & Gandalf said:

Harley is pretty much a poster kitty for showing what to look for when going in the right direction. His cycles got steadier and lower on each dose increase and that's what to look for. 1.75U is looking very good on Day 2!

As for how to know when you're there, that is probably something for an individual owner to decide.

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I guess that's kind of where I am right now - trying to figure out what my goals are for Harley given his health conditions. How far I can take this and still keep the whole cat well.

The main reason for choosing Levemir for Harley was the hope and possibility to achieve a more flat cycle given his tendency to panic during periods of rise and fall of BGs. I want to try to find the right dose to keep him as flat as possible and as a result, as comfortable as possible. That is my main overriding goal above all else. If that means a flat blue cycle and no greens that'd be just fine with me. Even flat high blues or low yellows below the renal threshold would be good. It's the sharp drops like yesterday 6/4 from 290 at AMPS to 86 at +6 that Harley can not seem to stomach. They terrify him. He's fine once he's surfing along.

Based on the above, I'm curious to know at what point (if there is a point) at which the pre-shot BGs should start to flatten out and duration will improve? When his cycles were high, he didn't have much of a curve but I wasn't too worried then because I knew that was due to the dose being too low. While the overall BGs have come down, in most cases (save for a few cycles) the duration has not increased by much if at all, and if raising the dose continues to produce more of a drop without extending the duration, that could prove to be a problem for us. I know what I'm trying to say, but having trouble articulating - does this make sense?

Vicky & Gandalf said:

What I mean is - are you comfortable with your cat going down in to the 70s, 60s, 50s while on insulin? OTJ is dependent on maintaining BG below 120mg/dl as much of a cycle as possible or at least getting them to the point where their pancreas starts to take over. That's probably going to cause BGs to be in the 60s sometimes. And you must decide how low should the BG go before decreasing the dose.

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Ah, if only it were up to me. I'll have to take my cue from Harley's pancreas as to what number range it can handle. Since he still has pancreatitis which is only being held at bay with 5mg prednisolone daily, I'm honestly not sure whether or not it will be able to heal even by holding BGs in the normal range. Just before he got really sick while we were still on PZI, it seemed to sputter and throw nice beautiful low numbers in the 80-90 range on occasion and everyone including me thought that perhaps it meant he was getting ready to go OTJ. However, only after he got sick did I learn from Justin (Gator & H) that such pancreatic sputtering can also signify a pancreas that is getting ready to flare. If bringing his BGs low enough into a range that starts asking his pancreas to work again actually stresses it out so much that it flares again, that may be a limiting factor that will affect Harley's regulation and how far I can take him.

Vicky & Gandalf said:

My suggestion for a case like Harley's is too continue increasing his dose until he's going low enough over an average cycle and then stay with that dose. Low enough in my view would be blues and greens throughout a cycle. The object is to keep the BGs low enough to help heal the pancreas, ideally that is 120 or below.

Does that help?

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Thanks Vicky, it does help. Guess I'm going to have to keep my eyes open, take lots of deep breaths - and when in doubt administer chocolate. Chocolate for me, shrimp for Harley! :idea:

I didn't copy your post, but I wanted to reply to a couple points that after your explanations about Harley's p-titis are clearer, so change my original answers some.

If you need him to have flat curves, then that is the dose you should try to find. Since he seemed to react to the green, then maybe back off the 1.75U a drop or 2. That would be fine tuning the dose.

I just rec'd a book by Dr. Hodgkins. She is an expert on FD, although without going in to it, is persona non grata on FDMB. She is strictly a PZI advocate. Anyway, she says that diabetics are pretty much suffering a low grade pancreatitis. Not all cats need treated for it, but apparently Harley does.

I haven't addressed the pred use, but it is a factor in regulating his BGs, which I'm sure you're aware. The fact that he's done so well despite that is a testament to your efforts.

I'm familiar with Dr. Elizabeth Hodgkins and her views on diabetic regulation. Thanks to nosing around TT I'm also familiar with some of the reasons why she is persona non grata on FDMB as you so tactfully put it. Her theory about diabetics and p-titis kind of makes sense. I think I'll nose around and try to find that book.

I'm pretty much resigned that Harley will probably need the prednisolone indefinitely unless I can find the source/trigger of his p-flares. Funny how in 4 months my goals for him have changed so dramatically. OTJ is such a dream and even a luxury now. Keeping him healthy and free of pain while balancing regulation in order to prevent further organ damage have become the new daily priorities. I appreciate your recognizing my efforts! And Harley does too. cat_pet_icon

Forgive me if I drop out of sight for a few days - it looks like the p-flare I've been dreading ever since I saw the 86 seems to be starting. :cry: Hoping this one is short.

Thanks so much Vicky for your patience and help!

I'm not sure if I understand how having an 86 might mean his p-titis is flaring. Have you had bloodwork done when he's having one of these spells? I would expect either his amylase or lipase to be high if it's really a flare. Could just be IBD too. Honestly my experiences with p-tits have taught me that #1) it's diet related, #2) IBD can be a complicating factor and IBD is diet related and #3) the liver is not a silent partner and it needs support as well.

If you ask me, the key to keeping p-titis at bay is proper diet, which ideally would be raw food. And the more I read both Dr. Hodgkins and Dr. Lisa, the more I'm convinced that most feline problems have at their source diet. It may not even be what you're feeding now that is causing it, but what was previously fed (especially if dry, grain-filled foods) has damaged the system that it's still causing problems. But getting the cat back to its natural diet is the key to healing from the wrong diet.

Cats are said to have 9 Lives for a reason. They are remarkable healers if given the proper tools to heal. The answer is not always to throw another med at the problem.

My vet wanted me to give Gandalf's metronidazole because his ultrasound always comes back as IBD, yet he shows few typical symptoms like diarrhea, and this was right after his bloody stool. She says it's good for that. Well, I had stopped supplementing his canned food with a couple ounces of raw food each day. I knew as soon as the bloody stool happened I'd have to make sure he got his raw food. I filled the metronidazole anyway, but NEVER USED IT. He's been fine since back on the raw food.

Just my experience, but it's backed up by what those who are considered experts in feline diet say.

Laura, how do you treat the pancreatitis?

When Beau used to have flares (after I learned what the heck I was doing) I would give him a 1/4 tablet of pepcid ac about 20-30 mins before feeding him, followed with a few teaspoons of plain greek yogurt warmed to room temp. He would usually lick that up ok. Then I would feed him whatever he would eat, which was often ham baby food or boiled chicken breast. Sometimes I had to syringe feed him in which case it was baby food (ham, turkey or chicken) thinned with water. He had a couple of flares where he stopped eating all together and a few where his appetite was decreased. His BGs would go down and I would reduce the dose a bit until he started eating again.

I know that some folks give pain meds, but I never did that because I didn't know about it and my vet didn't "use" them until about a year ago.

Sorry I dropped out of sight for a little while, Harley did have a mini p-IBD flare and seems to be a little better now.

Thanks for changing the thread title. The general question I had in mind turned specific in a hurry.

Vicky & Gandalf said:

I'm not sure if I understand how having an 86 might mean his p-titis is flaring. Have you had bloodwork done when he's having one of these spells? I would expect either his amylase or lipase to be high if it's really a flare. Could just be IBD too.

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To clarify my meaning in my post above, an 86 in and of itself with no other symptoms other than Harley freaking out a little because he's afraid, would not be a cause to suspect a flare. But based on my experience, when I see a number lower than usual, which does not fit Harley's typical insulin response pattern for a given dose (or in the case with my PZI data, with no insulin at all) in conjunction with or followed by a soft runny stool, signs of pain, and an appetite fall-off then yes, that is cause to suspect a flare is coming. It may not be the case with every kitty with pancreatitis, but ECID. As for bloodwork, when his symptoms were at their worst, his spec-fPL was 20 the first time I had him tested and 40 the second time. The most recent spec-fPL is 6.1 which is down but still positive for pancreatitis.

I'm not sure what the exact relationship is between lowering BG preceding a flare (and neither are two vets that I see). Although his ultrasound was negative for anything in the pancreas or gut, the thought of an insulin producing tumor has crossed my mind. Or a diseased, overstressed pancreas which is trying to kick in but is too far gone and flares instead.

Sheila & Beau & Jeddie said:

Laura, how do you treat the pancreatitis?

When Beau used to have flares (after I learned what the heck I was doing) I would give him a 1/4 tablet of pepcid ac about 20-30 mins before feeding him, followed with a few teaspoons of plain greek yogurt warmed to room temp. He would usually lick that up ok. Then I would feed him whatever he would eat, which was often ham baby food or boiled chicken breast. Sometimes I had to syringe feed him in which case it was baby food (ham, turkey or chicken) thinned with water. He had a couple of flares where he stopped eating all together and a few where his appetite was decreased. His BGs would go down and I would reduce the dose a bit until he started eating again.

I know that some folks give pain meds, but I never did that because I didn't know about it and my vet didn't "use" them until about a year ago.

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For smaller flares where his appetite does not stop completely, I'll hand feed or spoon feed him anything he wants to eat and give him anti-nausea meds. and pain meds. His already on 2.5mg prednisolone BID, and Pepcid 2.5MG BID. So I add in Buprenex and if he seems to be nauseated or vomiting, the Anzemet. I don't use appetite stimulants. I had to push for both pain meds and anti-nausea meds. from the vets, but I got them and it saved Harley a feeding tube which he would have hated.

Odd for a dairy boy, Harley doesn't like yogurt, but LOVES cottage cheese and parmesan cheese. I add those to foods to entice him to eat. I also make boiled chicken breast on a regular basis as those are his testing treats. During his worst flare 3/31-4/6, I baked three chicken breasts and the aroma had my civie Princess dancing at my feet the while time I was cutting them up. But when I offered some to Harley he just looked at me, looked away, and let out a sigh/moan. I popped a little piece in his mouth and he spit it out. That is one sick cat who doesn't eat fresh baked chicken breast. After he recovered, he was swirling at my feet along with Princess when I cut up the next batch of baked chicken.

I've tried syringing him but gave that up as he would fight me so hard it was making his pain worse and stressing both of us out. I used to use baby food (nector of the gods and my secret weapon for many a CRF kitty) but he developed a food aversion to them because I was syringing them before I got any anti-nausea meds. ohmygod_smile

Thanks for taking the time to respond and explain your experience. Everything you said makes sense to me.

Is there any possibility that in the beginnings of a flare he's not eating as much, therefore it translates in to lower BGs? The first time Gandalf had a flare he had low BGs off and on, mostly due to not eating. The second time he had higher BGs, but still had inappetence. So I think BGs can go both ways with pancreatitis. You're using the additional symptoms to conclude he's having a flare, so that's the best indicator - multiple symptoms. I just don't want you to assume that every time his BGs go green he's about to have a flare.

Gandalf loves cooked chicken too - would not touch it when he came down the first time and I knew something was very wrong.

I don't know if I have any suggestions with the syringe feeding. I basically have to force Gandalf now after an apparently bad experience being syringe fed at the vet's. He was fine before that - would lick it off with little prompting. They really do develop an aversion if something about the situation with that food upset them.

Have you given anymore thought to trying raw food with him?