9/27 Jenks - Let's talk about the future of Jenks' treatment

9/26

It's been about 6 months since we began the TR protocol on Lantus, and now it's time to reflect on our progress. We've made pretty significant strides in the last couple of months. 5.50U seems to be at or very near the sweet spot for Jenks, tending to give him nice blue/green evenings, even if he is still upside down during the days. No matter what we've done, we can't get the daytime numbers down. And, his nighttime numbers can sometimes be unpredictable. What's clear is that he doesn't seem to metabolize Lantus in an understandable way.

If he's going to ever achieve tight regulation, we need to find ways to flatten his curve out. Based on my research, there appears to be three options:

1) Switch to Levemir.

Advantages: As a depot insulin like Lantus, very little about the daily routine should change. It can benefit cats that are difficult to regulate on Lantus. Because the dose is roughly 70% of Lantus, a pen conceivably lasts longer and therefore confers an economic benefit. Can always jump right back to Lantus if it's not working out.

Disadvantages: Mentions of an even later nadir than Lantus, which could put Jenks at or beyond shot time. Not guaranteed to address daytime rise.

2) Add a booster insulin.

Advantages: A fast acting, short lived, insulin given alongside AMPS might be able to knock down the daytime rise, allowing for Lantus to have some measurable effect during the day. If that curve flattens out, then perhaps the nighttime drops wouldn't be so dramatic. Allows continued use of Lantus, which we know works to some degree.

Disadvantages: More advanced technique. Requires additional monitoring which would tax OH's patience. Added expense of a second insulin, more needles, and more testing supplies. Carries additional risk.

3) Add an additional daily dose (e.g. TID)

Advantages: Unknown

Disadvantages: Time, monitoring, expense, advanced technique requiring experimentation, cumulative effect of overlap during the night could be very risky for Jenks.

There's a little less than one week left in the current Lantus pen. So.....thoughts?

Re: 9/27 Jenks - Let's talk about the future of Jenks' treat

i think of things as Plan a, b, c, etc.

You've tried Plan A with Lantus. You've done a great job of following the protocol. You get enough testing in to see a pretty clear picture of how the insulin is working in Jenks body.

You've tried Plan B with Lantus - tinkering with feeding him to try to flatten him out.

Of the options you've offered, I think the first one would be the next step to try. You've given Lantus a good 6 months and have worked hard at tweaking things to get the best results.

We don't know how he would take to Levemir, but I wouldn't assume his nadir would be later than it is on Lantus. He has a later-than-normal nadir anyway - most cats on Lantus nadir around the middle of the cycle - his nadir typically falls near the end of the cycle. And yes, he typically has 2 different cycles each day, or should i say his curve has different nadirs with each cycle.

I'd try the Lev. If you're nearly out of the Lantus, it's an opportunity to switch with no waste. Perhaps you can get just one Lev pen to try it out. You would drop to 70% of the Lantus dose to start out, then increase if he needs more. Some cats have to go up to their Lantus dose, some are ok with the 70% or so dose. 70% of 5.5u would be 3.85u, so you could try 3.5u - 4.0u, depending on your preference. When you switch, you just give the last Lantus dose at one shot and the Lev at the next shot. There's nothing else you have to do. The Lantus depot will diminish as the Lev one builds.

I wouldn't be enthused about trying R for Jenks, mainly because he doesn't have a lot of really high BGs that you're trying to knock down. Some cats can be very sensitive to R and even a tiny dose can cause a plummet. It's not expensive, though - I think someone suggested to Peg/Toby that they could get it for about $35 at Walmart. You use the same syringes. It works best for helping bring down the high numbers so that the Lantus/Lev can "grab a hold" of the BGs and get to work. I think your Lantus is already doing that.

Another Lantus option you could try - which you could even do this week, is to try to increase his Lantus dose, perhaps just a quarter unit to try to pull down his remaining higher numbers. You have to raise his nadirs up to do that, by increasing his carbs to prevent him from going below 50. This requires a lot of monitoring, of course, because you are knowingly giving him a little more than just gets him into green nadirs. Sometimes just a few days of doing that can be enough additional insulin to bring down the higher BGs in the cycle.

TID is really hard on people. I wouldn't encourage it, although if you want to, you could give it a try.

For lurkers - I'm talking specifically about Jenks - this is definitely not something a person should try before trying the more standard protocol approach and understanding how their cat works with the insulin. If you want help for your cat, please ask and we can take a look at what might help and make some suggestions for you to try. Each cat is different in what might help them.

Re: 9/27 Jenks - Let's talk about the future of Jenks' treat

I like the Lev option the best, too - simply because I've seen a lot of kitties recently make the switch and do so well on it. Of course, I'm not one of the most experienced members here, so take my thoughts for what they're worth! ;-)

Whatever you decide, paws are crossed that it will work to help get Jenks regulated!

Re: 9/27 Jenks - Let's talk about the future of Jenks' treat

I've been toying with lev myself but with my personal issues don't know if it would be possible right now. I have seen some very dramatic results lately and plan to discuss it with my vet. Max has been on lantus since November of last year, off in December and back on since January. He is a bouncy cat rather than as high as Jenks but neither is very encouraging. Good luck with whatever you decide to do. I know how you feel. :roll:

Re: 9/27 Jenks - Let's talk about the future of Jenks' treat

I also vote for a switch to lev because Jenks, like Max, reminds me of Gracie on lantus. Although Jenks and Gracie are more similar because Gracie also liked those late nadirs and loved to give me a dropping 50 something number at PS. While she is still bouncy on lev, it has been miraculous for her because she can have very, very long stretches of lovely flatness that she never got with lantus. In fact, there have been many times we thought she would go into remission on lev but just didn't quite get there. I think it is worth a try for Jenks.

As Julie said, the dose is only 70% of the lantus dose to start with. We had to go above our lantus dose and I bumped her up fairly quickly. It took a couple months to start seeing some progress so, if you switch, you will need to be patient. Sometimes it does take time and you can look back at Gracie's 2011 Lev SS to see. Her lantus SS is also tabbed. My point, as Julie's is, is you may or may not save money but lev is less expensive than lantus.

Yes, you can shoot at the same time but the nadir might be different. Since Jenks likes to nadir late on lantus, you might not see a big difference. What I saw with Gracie is, when the dose is right, she gets a lot of carryover/overlap and she can nadir at +15. Neko will sometimes do this as well. Gracie was on lantus a year when we switched so we were experienced but it still felt like learning things anew but it did not take long to catch up. There are many things I like about lev but one of them is the later onset which allows you to shoot lower (above 50).

I would not switch back to lantus right away. You need to give it a few months.

We can reevaluate as you go. It's possible to shoot a bolus R with lev as soon as a bounce starts if you are there to monitor and it can be a good tool if it's needed. It might not be needed. I also would discourage tid dosing with lantus or levemir. It's a lot of work.

Re: 9/27 Jenks - Let's talk about the future of Jenks' treat

I also vote for giving Lev a try. My kitty Neko on Lantus was like Jenks, daytime going up, night time going low. Check out her 2013 SS after February. It was very tiring. I tried a lot of things to try to break that pattern and finally switched to Levemir last September. Guess what, she still prefers going up during the day and down and night. :roll: However, she is flatter and now gives me some daytime greens. More importantly, the flatness at night means I'm getting a bit more sleep. Neko, as is Jenks, is a late nadir cat, although she does vary the times. On Lev the range of times is about two hours later than it was on Lantus. Like Marje, I like the fact that her nadir is often around preshot, because I'm awake and home then. I felt like a newbie for the first month on Lev, trying to figure out Neko's new patterns - so be prepared for that. Good luck if you decide to make the switch. I waited until I was done with a cartridge of Lantus and just switched over. Her dose has gone up and down a bit but is around the same as it was on Lantus.