2018-04-07: Conan's first day on insulin degludec/Tresiba

At the request of the mods, since there is no forum dedicated to insulin degludec (Triseba), I'm posting periodic updates on Conan's & my experience with Tresiba (insulin degludec, the U100 formula) in this forum. I gave all the details here: http://www.felinediabetes.com/FDMB/threads/starting-insulin-degludec-tresiba.193769/

Obviously there isn't too much to report right now, but in the interest of completion and recording our trailblazing for posterity, I'll be more thorough rather than less. But if there's information anyone wants that I'm not providing, feel free to ask!

Also keep in mind that Conan is on (and has been for years, and is likely to be for his lifetime) prednisolone, which makes him atypical - and his BG extremely unpredictable and difficult to regulate.

Conan's first 1.5U dose was this morning. My suspicion is that 1.5U is going to be too low, but we (the vet & I) thought it best to be conservative.

I've done quite a bit of reading about Tresiba in humans - most of what I've read indicates it takes at least 3 days for a dose adjustment to settle out and for the adjustment's full effects (especially dose increases) to become apparent. I think this is partly because in humans, the duration of action can be up to 40 hours, so in 1x/day dosing, typical for humans, there can be a large overlap (which apparently is not a big deal with insulin degludec given its slow release and flat curve, and in fact the dosing flexibility, the fact that it doesn't need to be given at the same time each day, is one of its great appeals).

But in cats the duration of action is likely less. In the Clinic of Small Animal Internal Medicine (Zurich) study it ranged from 7-22 hours. That did involve only 6 cats, and they were non-diabetic, but it gives some indication.

Right now after less than a full day on the Tresiba my strong feeling is that Conan is not going to be anywhere near the high end of that range. For him anything below 400 is generally a sign that the insulin is working. Today he got no lower than 284, and was mostly in the 300s, but that was enough for me to know that it was "working." But he was at 470 by +13 and 570 by +15, which doesn't give me hope that he's ever going to approach 24 hours with one dose.

Obviously it hasn't been long enough for me to make any sort of judgment about duration. I'll stay at 1x/day for at least another day, to make sure the Lantus is totally out of his system and to get a clearer picture of the duration of action of the Tresiba. But I don't want him to be uncontrolled like this for too long, so I'm not sure I'm willing to let it go longer than another day. I'll see how tomorrow goes. My feeling is that it won't matter and that we are going to have to go to 2x/day dosing with the Tresiba - and truthfully I always feared this, as duration has been a huge problem for Conan (Levemir often didn't last longer than 7 hours, sometimes less).

But my hope is that, as in humans, there will be more flexibility in terms of overlap and dosing schedule (so eg it won't matter if the duration is 14 hours say, and it won't be imperative that I give shots exactly 12 hours apart).

(All the numbers are in Conan's spreadsheet! The only thing that can be bit difficult to figure out are the hour headings in the column - since I've been using the same 2018 the spreadsheet for 1x, 2x, and 3x/day dosing.)

 

Even though it lasts longer than 24 hours in humans, most of them dose Tresiba once a day for consistency. Apparently the overlap is not an issue. If you ended up having to do BID, it seems like you could get better duration than you experienced with the L’s. Conan was on 5.5 units a day (that you split BID) of Lantus right before this and you were looking to increase that before the switch, so 1.5 units is a safety starting dose, but still well under what he had daily for Lantus. As you increase and settle on a dose, you might find even shooting BID that you have more flexibility and can get to past 12 hours or even longer...this is assuming it lives up to the promise and you could shoot at 6:00 one morning and 10:00 the next with no noticeable downside, I’ll believe that when I see it.

I’m sure you’ve also come across that humans have different results depending on the time of day they shoot. I found, anecdotally, most had better results with morning shots (I would guess this is because they are trying to avoid going low at night, although with a peakless insulin it shouldn’t matter, I think most of us know better). Then again, humans are not cats and many cats are more active at night. It’s something to keep in mind that you could play around with and see if it makes any difference, eventually.

I don’t know what your experience has been with Lantus or Levemir, but for Asia, I have noticed the larger the dose, the better the duration (for her) often times. I’ve seen other cats on tiny drop doses that go well past 12 hours. Going off the theory that the difference is cats that are getting help from their own homegrown insulin vs ones that are not. I’m hopeful when you work up to something closer to his daily dose amount from Lantus, you will see some better duration. Paws crossed for that!

Thanks for sharing with all of us.

 

Yes to all of what you said! (Though I did come across many humans who dose Tresiba once a day.) Humans - more than cats - seem interested in the timing of dosing because of their own natural and habitual (eg, eating- and activity-based) variations in BG, and how those are affected by the (relative) flatness of Tresiba's curve, when they've been used to using the (relatively) more extreme ups-and-downs of Levemir & Lantus to counteract their own lows and highs.

My own cats are not at all active at night! They are most active whenever I come home from being out, and particularly in the evenings - when both of us are home. Also sometimes immediately after eating. In the past, Conan's numbers have been lower overnight - though admittedly after he was on Levemir for a while I stopped testing him overnight. This was a big issue when I began Lantus when he was first diagnosed, and at the time, the vet & I experimented with how to split his steroid dose (he gets three 1.25 mg tablets - usually 2 AM and 1 PM, but for a while we tried 1 AM and 2 PM, and I even tried splitting one of the pills to give him an equal dose AM & PM. Truthfully it made little difference). Interestingly, when I started him on the Lantus again a week or two ago, he was generally having higher numbers overnight. This is part of his general unpredictability - I'll never know how much of which is just him, and how much is caused by the steroid. Then again, it's unlikely he'd ever have been diabetic without the steroid, so I guess it doesn't matter.

I've been pondering how to juggle increasing his dose vs going to BID, since I don't want to do both at once. Yesterday I was thinking I'd go to BID on this (very low) dose. But now I'm not sure. It occurred to me too that increasing the dose might increase the duration. It never worked that way for Conan with the Levemir - increasing the dose lowered his nadirs without increasing the duration. But then again, I started Levemir with a dose that was high enough to get his BG to blues and greens. It seems logical that if the dose is significantly too low, it might simply be impossible for the insulin to reach the full duration potential.

Interestingly, after a reading of 570 at +15 yesterday, he was at 330 this morning at AMPS. I screwed up my alarms last night after a very long day, so he had no tests after +15, which is not what I intended! So I'm not quite sure what happened in there, when he started to drop again. And of course no idea why. It seems unlikely he'd have had any kind of bounce from going down only to the high 200s. But I'm just speculating, as I think it's really too early to draw any sort of conclusions - it's likely he still even had some Lantus affecting him yesterday.

So I think I need to give it a bit more time before making any changes, and see how things go with a little more time on just this dose of Tresiba. I need more information before I can make a decision about what changes to make - obviously, as it's barely been a day! It may be that the way to go is first to try increasing the dose, and then to move to BID. I'm really not sure!

 

Hi - your new spreadsheet link isn't working.

 

I thought I might have screwed something up! Let's see if this works....

 

Your SS link isn’t working so I can’t see, but wow if he came back down from going black? @Marje and Gracie could help you with your SS if you were interested to have one where the header bar (with the + numbers and units) stays glued to the top as you scroll so that when you scroll down, you know exactly where you are at in the cycle at one glance.

Just processing out loud to help you think through some options to discuss with your vet.

Going slow with the changes will definitely help keep things clear what is causing what. You don’t have the luxury of “tresiba usually does x...” because you’re the first. At the same time, it’s a similar long acting basal insulin, so some things should be obviously similar, like bouncing or depot.

If you increased the SID amount first, you could get the clearest picture on insulin duration, where the peaks and valleys are (I know they say it’s flat, but yeah right), nadir, etc. As the depot builds and stabalizes and Lantus gets out of the picture, those things will reveal themselves hopefully within 5 days or so of an increase. How long will it take to arrive at a good dose is the question. The risk is, obviously, you’re allowing the numbers to stay high or potentially much higher at the back end of the cycle in the meantime. As cool as experiments are, we are talking about your well loved boy, so we don’t want him to have a hard time of it.

If you swap to BID first, you’re dealing with the risky uncertainty of overlapping an insulin that supposedly lasts 100% longer than the one you used prior. I would be prepared for potentially low numbers and in theory for an extended period of time since the insulin has longer effect. If that doesn’t happen and all goes well, you’ll be able to see how it works as a 12 hour insulin, which for Conan may actually be 12 hours if not more! You won’t have a high back end of the cycle like you would in SID, but numbers may still remain high becuase you’re sacrificing a dose increase in favor of splitting the current dose in two. You would still, over a length of time, be able to see duration and the potential for 24 hours. Once you got him stabilized on a good dose BID, if you were up for the challenge and wacky around the clock shooting it would take for a bit, you could slowly push the BID times out to find when he starts losing steam at the end of a cycle. Start with 12/12, give a certain amount of time for depot to stabilize (3-5 days is my best guess), then move the shot times to shooting 13/13, 14/14, 15/15 etc. letting them each stay for another 3-5 for depot stabilization. Or you could do by a larger amount 12/12, 14/14, 16/16, 18/18 to get there a bit faster. If indeed the insulin doesn’t react poorly to moving shot times around, that may be useful. With this method, you could eventually stretch out to 24 hour dosing of find out how close you can get. With the other you would start at 24 and increase until things became clear, you may end up going BID anyway.

This is exciting! How was Conan’s first day? Is he acting the same? Is he bothered? Eating well and all that? The behavior report completes the picture, though I’m sure he’s going to be a bit out of sorts until his numbers come down. High five to you for being up for the challenge. Belly rubs (does he like those) and ear scratches for Conan, he’s a trooper.

Here is one of the human forums I lurk in a lot, they have some Tresiba users: https://www.diabetes.co.uk/forum/

 

Go with your gut, Jessica. You're absolutely right, it's been a day... only the second shot today! There's time to process options as you're evaluating and observing Conan's response as well as getting a feel for the insulin itself. Try not to become overwhelmed with all the possibilities at this point...

 

First, you should be able to see Conan's spreadsheet now. The top rows are all fixed; I used the standard FMDB SS for human meters originally. I just made some modifications to it for 3x/day dosing etc (also added some columns to record food amounts and exact times of day and some other things - keeping track of how much I feed him is important, as it's very difficult for me to keep weight on him). The issue arises from the fact that where you are in a cycle depends on how long a cycle is. So for example, in 2x/day dosing a cycle is 12 hours, so there is a "+11" in one cycle. But in 3x/day dosing, a cycle is only 8 hours, so that +11 is actually +3 in the next cycle. And in 1x/day dosing, of course, with a 24 hour cycle, there will be a +13-+23! The headers in the standard FMDB SS, and its whole structure with AMPS/PMPS etc, are for BID. I added a section for "MDPS" (mid-day PS), and set up my headers and the placement of PMPS around an 8-hour cycle, but I also still have in parenthesis in the headers the numbers for BID dosing, and also still have a section for PMPS placed according to BID dosing - which I kept hidden when I was doing TID. You can see it all there on the spreadsheet now; I know what it all means but it could be confusing to someone else!

Stacy your points are all well taken and I appreciate your out-loud processing. It helps me with my own thought processing. I won't do much for the moment as I continue to get a feel for the insulin - as per Jill! - but it's useful to me to have all these thoughts percolating around in my mind, even if I won't do anything with them for a while, and even if I know that the answers will reveal themselves with time. It's how I operate, and I feel better having more ideas and thoughts and information than less. Then when it's time to "go with my gut," my gut has something backing it up - if that makes sense. So I welcome all ideas, input, and extrapolations (since none of us has actual experience with Tresiba) based on other people's knowledge and experience with other cats & insulins, and understanding of degludec in humans!

Conan meanwhile is doing just fine. He is one of those cats whose behavior does not change much regardless of his BG level. He does _tend_ to act hungrier when his BG is high, but he's hungry all the time anyway, so it's not a clear relationship. Perhaps the steroid effects overwhelm the effects of the BG? I don't know,, but generally I can't tell from his behavior whether he's at 27 or 590! He does seem to do better when his BG is more consistent even if it's high - less aggressively hungry - but it's a subtle difference. I haven't tested him so frequently in quite a while, though, so his poor ears are looking a little ratty. He has very thin pink skin, and his hair coat is very light colored and has become patchy and poor quality (an effect of the steroid), so the lancet-pricks are very visible! He's an extremely good natured, happy, and un-aggressive cat though, so is an excellent patient.

 

Yes, I'm seeing the SS now and following this with great interest.

 

Good morning, Jessica & Conan!

I'm sorry his ears are taking a beating. I know a lot of people use neosporin for that. I got a product that was recommended to me by someone else here that I like because it's made for cats, so I assume they realize it can be licked off and is non toxic. It's made by Halo and it's called Could Nine Herbal Healing Salve. Also, are you using finer lancets like 30 gauge? I've even used 33 before and that helps as well because it makes a smaller puncture.

I'm pretty impressed with the AMPS numbers so far, relative to the rest of the cycle, cautiously optimistic over here.

A few questions, you feed Conan 3 times a day? Roughly 3 oz. at AMPS, 3 oz. at +12 and 1 oz. around +21/+22? Pred is 2.5 mg in the am and 1.25 mg in the pm, is the pred given with the AMPS and +12 meals? Before? After? When you get the BG readings at food times, is that before he has eaten (non food influenced BGs)?

Not regarding with Tresiba, but in general, since diagnosis, what are you observations with Conan and food? Does he get food spikes (always/sometimes/never), big ones, little ones? What are your observations with the pred? Does it spike the BG? If so, is it at a particular time, 1 hour after, 2 hours after, etc.?

 

Looking better already...
good luck with the increased dose!

 

Thanks for trailblazing! I am close to trying Tresiba here as well so will follow your posts carefully

It took a week for my (human) daughter to stabilize on Tresiba. Even now, after using it for a year, its one weakness is 3+ (emphasis on the "plus") days it takes for adjustments to balance out/be noticeable. On other basal insulins, I could tweak daily. Not at all so with Tresiba.

Brie

 

A brief update - first, aside from the insulin, Conan isn’t doing so well. He has stopped eating and become very lethargic. We are heading to the vet today. Conan has many medical issues, and I fear one is catching up to him. Truthfully I’ve suspected something was changing for a few months, though his last checkup a month ago seemed clean.

I think it unlikely this is related to the Tresiba. I’ve been checking his levels regularly and they are actually as good as they’ve ever been - at least for the first 12 hours. I am starting to believe that its effect isn’t lasting much longer than that. The overnight numbers are remaining too consistent no matter the dose; I believe they are not being affected by the insulin at all.

So depending on what happens with Conan, I probably ultimately will attempt BID dosing. But first I will wait longer for the current 2U dose, which seems right now to be a good one, to continue to balance out, and continue watching the numbers.

 

Sending positive thoughts... please lets us know how he's doing when you can.

 

Sending Healing Vines and Eating Vines to Conan.

 

Thank you! I posted another update here: http://www.felinediabetes.com/FDMB/threads/2018-04-16-conan-tresiba-insulin-degludec-update.194256/