? Starting levemir - Vet is concerned.

Hello everyone,

I have convinced my vet to move Toby to a longer acting insulin, my preference was Levemir over Lantus but she is challenging me and I'd like to go back to her with a response and so would love you guys with experience to help me.

The vet said:

I am comfortable changing to a longer acting insulin. My usual choice would be glargine (lantus) and also last time we looked into use of determir we had trouble with accurate dosing in animals less than 10kg even with use of an insulin pen. There is more literature regarding glargine too. If you are aware of a way to get accurate dosing I have nothing against use of Determir. Otherwise I recommend we change him to Glargine 1 unit twice daily – this a conservative dose particularly as he is underweight. Be aware that the nadir with these longer acting insulins may be close to the time of the next injection. If we changed his insulin I would ask you to take occasional BG’s to monitor for hypoglycaemia but otherwise to wait 5-7 days before performing a full curve. Insulin dose would not be changed in that time unless he was going too low (<3.5mmol/l).

Is accurate dosing a problem with Lev?

I am keen to get started as his BG is way too high, do I need to be around for extra testing when I start? I work all day so do my curves at the weekend usually.

Thanks in advance.

@FurBabiesMama @MrWorfMen's Mom

 

Let your vet know that you will not be dispensing insulin directly out of the pen. You use the pens exactly as you would use a vial. You insert a U100 insulin pen into the rubber stopper at the top of the pen and draw off your cat's dose. Using a syringe is far more accurate than a pen (regardless of whether you are using Lantus or Lev) since the pens dispense in 1.0u only and cats typically need much less insulin than an adult human. You'll be doing exactly what is done when treating a child.

To the best of my knowledge, the only differences (except in the overall pharmacology) between Lantus and Lev is that onset and nadir occur later in the cycle with Lev. Otherwise, dosing should be equivalent. The Tight Regulation Protocol which was published in the Journal of Feline Veterinary Medicine several years ago by Roomp & Rand was researched using both Lantus and Lev.

 

Hi Kate! I also have a snowshoe siamese

Apologies if you already know the following: Have you read through the stickies on the Lantus/Lev forum? We have two methods here: Start Low Go Slow and Tight Regulation which is the Roomp and Rand researched protocol that Sienne mentioned. I would print out that article for your vet to read.

http://www.felinediabetes.com/FDMB/...-low-go-slow-slgs-tight-regulation-tr.210110/

And I also see that you're using the Alpha Trak. The dosing methods we use are based on human meters so using a human meter could be an option for you (it's more affordable too!).

Just remember that the way dose changes are determined with depot insulins is different from the way dose changes are determined with PZI and other shorter acting insulins. We change dose based on the nadir and only sometimes take into consideration PS numbers. That's one of the biggest changes you'll have to make in regards to how you think about insulin for Toby. I also switched from ProZinc to Lantus (and now Levemir).

Your vet said that nadir may be close to the time of next injection and while it may be true for some cats, that's more true for Levemir than Lantus. Lantus nadirs are generally at around +6 while Lev can be later. But ECID.

 

Thank you Sienne, your response was spot on and I have a Lev prescription! Whoop!!

 

Hi Crista,

Thank you for your reply, I have read and re-read the protocols and whilst I would love to go with TR I will have to go with SLGS due to my work and family commitments.

I had wondered about changing to a human meter, I guess now would be the time to do it so I don't have to compare, I can just start a fresh with new testing and new insulin. I am in the UK so not sure what is available so I will do some research.

I am very nervous about the change as I only just feel "I get it" with the Prozinc dosing and what is happening with Toby. So this will be like starting again for me.

Thank you again and its wonderful to hear another Lev advocate!

 

Only just saw your first line!! Another snowshoe!! Ahh yay! they are amazing!! Toby is very chatty and very needy, he sleeps on my pillow and is literally always by my side! I have only ever met one other! Ming is beautiful, and I love his name!

 

What I like about being on the depot insulin forum is that there are actual methods/protocols to follow and there are a lot of people here who can help! I miss the PZI forum and family too though! I wouldn't be here without them.

With the depot insulins, it's really important to be consistent with dosing. In the beginning, when you eventually run into a lower than what you're used to PS number, it's can be scary and I know my own reaction was to REDUCE REDUCE! But shooting lower numbers is what keeps numbers low: shoot low to stay low. I like that your vet has some sense that PS numbers might be lower than usual. I find that when some vets see a number lower than 200 or 150, they'll advise their clients to hold insulin which, while may work for some cats, it's not ideal. Shoot low numbers is something you will inevitably have to learn to do and probably one of the scariest parts.

And yay for snowshoes! Love their little white slippers. And yes, Ming is needy in his own peculiar way. While he doesn't very cuddly, Ming follows me everywhere and it's really weird when he's not in the same room as me. The odd times he's off alone, my family says that he's "growing up" and being a big boy off on his own ahha

eta: Of course, when you do come across a PS number that you're not used to, stall, don't feed, and post on the forum and get help.

 

Glad the vet is on board with changing insulin for Toby. I think it would be ideal to be able to monitor a little the first couple of days on the new insulin but if you don't want to wait till the weekend, grabbing a few more tests at night would also be an option.

Just to clarify, there is one difference between a vial and the pen. You do not need to inject air into the pen before withdrawing the dose of insulin with the syringe. Different mechanism than the vial and injecting air would eventually make withdrawing the insulin from the pen more difficult.

 

Sorry I did not see this sooner. It looks like you got your prescription though! My first thought after reading your post was that the vet must think you were going to use the pen to give the insulin. No way. I see that Sienna helped you get that straightened out.

It will take a few days to really be able to see the impact of the Levemir, so your vet is right about not changing the dosing. You will still want to test regularly to know what is going on though. I hope it works out for you.

 

Here's a good thread about drawing up insulin from the pen: http://www.felinediabetes.com/FDMB/...info-proper-handling-drawing-fine-dosing.151/

There's section about drawing up from a pen with links to videos

 

I see you got your lev script. Just want to point out some things.

Lev is a depot insulin and the reservoir will need to fill, usually about 6 cycles. So you might see some higher numbers. However, since ECID you could possibly see some result in the first 24 hrs. Some have, some have not.

It is said lev will have a later nadir, again ECID. Ollie does not. She still had nadir between +4-7.

Lev is suppose to help flatten out the curve. Only recently had this happened with Ollie, have been on lev over a yr now. BUT Ollie has acro and that controls her glucoses.

Remember, you base dose on the nadirs, NOT the preshot test.

Good luck, I think it's a smart move.

 

Everyone else has addressed the glargine issue, I'd like to talk about dose. Typically when people switch from other insulins to the long lasting ones, we consider the dose of the existing insulin. I think 1.5 units would be a better starting dose, and he'll likely need more. You will hold the initial dose 7 days on SLGS, unless he goes under 90 (5.0). The initial depot takes longer to build than 3 days.

I presume you'll ignore the vet's comment about not testing much. Preshots tests for sure and mid cycles as you can fit in. Doing the switch when you have a couple days you can monitor more is best. Every once in a while we get a cat that responds really well to the new insulin. Meaning, lots of monitoring and carbs needed.

There are advantages to having the nadir around shot time, like my girl often did. First, you are usually home for shot time and awake. So it's easier to spot the nadirs, which is what we dose on. Second, onset is later, typically around +4. So if a cat is off their food, you have four hours to get food in them after the shot. It's not such a rush as insulins that onset sooner.

My Neko also had acromegaly, and started flattenng out almost immediately. Her second dose of Levemir was flat blue. ECID.

Here is the link to your previous post here. We include those for continuity.

 

Hi Toby from Tina, a light snowshoe! She doesn't have those fancy markings like Toby (gorgeous boy), but she's sweet as they come, and quite vocal and expressive.
We love Crista's Ming because he reminds us of Tina's late brother and her current best bud (yes, Ming's markings are "better"!) I saw a black kitty club around a couple weeks ago; we can start a showshoe club, j/k
Welcome to this great place, Kate!

 

I'll share my thoughts on dosing just so you have different perspectives. Your vet is being cooperative and reasonable enough to give you a prescription to an insulin she apparently was not as familiar or comfortable with. So, if it was me, and she wanted me to start at 1 unit, I would. How is it going to impact your relationship with her if you disregard her dosing instructions after she agreed to the insulin you wanted? I'm in 100% agreement of doing what is best for your cat if you are in a situation where a vet is telling you to do something that you have enough knowledge to know is not the right thing (for example, I would never stop testing because a vet said to do so), but this does not seem like one of those situations to me. You don't know yet how your cat will react to Levemir, so what is the harm in starting at 1 unit and going up from there as needed? Your cat most likely will end up needing more than that since he consistently runs really high (to me, it looks like his dose of ProZinc has not been high enough), but you can build up to the right dose.

When I switched Mia, she was getting 2.50 units of ProZinc, and I was not comfortable switching over at the same dose though it was recommended to me here. I went with 1.50 units, and was glad I did. She never needed more than 1.50. It was not long before we started needing dose decreases.

 

Hey Tina! What a beauty. We shall be the snowshoe appreciation society! I know Toby's sister is still alive and well, she is also a house cat. I will dig out a picture of Toby as a kitten but he was as pale as Tina for about a year, he then went dark!

 

Thanks Wendy, really appreciate your input. Totally ignoring the point about not testing yes! She means well but she has been against me testing too much for months!

I'll be totally honest, I am quite worried about the change in insulin and how we will do, it's a new regime just when I feel like I'm getting to grips with what I'm doing, I feel like a newbie again! I will definitely go steady and monitor lots.

 

We also are able to microcode by using calipers.

 

Thank you so so much for putting my thoughts and feelings into words, this is exactly what I am feeling. I had to push the vet towards Levemir as i have read and read over and over the benefits, so she is already being brilliant, i really want and need to keep her on board, shes a endocrine specialist not my usual vet (the usual vet who incidentally said they had never heard of Levemir!), so I'm kind of at the best place I can be in terms of vet care and dont want to jeaopordise that.

Once again thanks, you got me!

 

Prozinc is a U40 insulin. Levemir is a U100 insulin. You will need to get new syringes.
When you switch to levemir, do give away or put in the attic the U40 syringes.