2018-05-24 Conan Tresiba insulin degludic update

Discussion in 'Tresiba (degludec)' started by Jessica & Conan, May 24, 2018.

  1. Jessica & Conan

    Jessica & Conan Member

    Jan 16, 2016
    Previous post: http://www.felinediabetes.com/FDMB/...-insulin-degludic-update.194584/#post-2179735

    At the time of my last update, about a month ago, we were at 2.5U twice a day, and not having great results. I continued to increase Conan's dosage in .25U increments every 6 cycles or so, and gradually started seeing improvement, first some yellows and occasional blues, then some more blues, and then some greens (I have altered my spreadsheet so it shows green from 50-119, since I think this is accepted as an ideal range), until we were at 3.75U.

    At this point it was clear that the dosage was successfully lowering Conan's BG to a fairly good level - but that it was not lasting anywhere near a full 12 hours. By the time of PMPS (always very close to 12 hours), he was always well back into the 300s. And since it takes a solid 4 hours for the Tresiba to really take effect, he was spending about half the day out of an ideal range (about 1-2 hours before each shot and maybe 4 hours after). This is exactly what happened to him with Levemir - in terms of duration of action at least; the Levemir never had such a consistent effect for him.

    I decided to experiment for a few days and see what would happen if I dosed him every 9-10 hours. I only did this for two days or so. At 9 hours he was often still only in the yellows - but once he is in the yellows, it moften means he's on the upward slope, the insulin is wearing off. Dosing him at this point may be too late, because it's going to take 3-4 more hours for the shot to take effect, so he's going to keep going up, possibly even into the pinks, before he comes down again. It actually isn't quite that simple - also depends on how recently he's had his steroid, and other mysterious cat factors that I don't understand - but 9-10 hours did not lead to reliable control.

    So I gave up and accepted that I was going to have to push the doses even closer and go back to TID dosing. So since about May 10, Conan has been getting his insulin 3 times a day. I've experimented a little with the timing (I also bumped his dose up to 4U to see if that helped with duration). 3 times a day, equally spaced, is every 8 hours. But it seems like 8 hours is actually too long. The dose definitely lasts for 8 hours. But because of the delay of onset of action, he needs to get the next dose while the previous dose still has a solid period of effectiveness left, so there is a generous overlap. Otherwise, the next dose has to work to bring him back down, rather than simply maintaining him at a good level.

    As I understand it, humans generally dose Tresiba 1x/day, even though the duration of action is about 40 hours. So there's a really large overlap - each dose is well inside the effective period of the dose before. This I think is what is necessary for it to keep BG levels consistent all the time.

    So ideally, to keep him solidly in the greens and sometimes blues all the time, I believe Conan needs to be dosed more frequently. If the duration of action for him is about 10 hours, he needs to be dosed maybe every 7 hours, well before the first dose has even begun to lose its effectiveness. I suspect in that case he wouldn't need quite such a high dose either, because it wouldn't have to work to counteract rising BG levels, during the first part of every cycle.

    Of course, dosing every 7 hours is just about impossible to keep track of or maintain. I've thought about trying every 6 hours, which at least fits into a 24-hour day. The problem is that I simply can't do that every day - in fact there is almost no day in which he could get a shot in the AM and another shot 6 hours later. It's often hard to get his midday 8-hour shot. But I might play around with this when I have time, and to see what happens. Maybe 6 hours will turn out to be too much anyway.

    But from a larger perspective, all this is nitpicking. His current spreadsheet looks incredibly good, especially when compared to how it used to look. Mostly blue, but also lots of green, some yellow. An occasional pink here and there, or a red, usually on days when I'm gone all day and not able to do TID dosing at all. This is by far the best he's ever been controlled.

    So my thoughts about Tresiba at this point:
    - BG levels are very consistent, even with the steroid. No spiking, no plummeting BG (at least during its duration of action). Far fewer weird inexplicable numbers than the other insulins I've used.
    - It's more forgiving of "early" dosing than the other insulins I've used - but no more forgiving of "late" dosing (in the sense that once it wears off, it wears off).
    - Onset is delayed. It works best and BG levels stay most consistent when there is significant overlap in dosing cycles; i.e., the next dose is given well inside the duration of action of the previous dose - earlier is better (see previous point). This means that the dose must be given when BG levels are still quite low (and indeed, I've dosed when Conan has been as low as 81, with no issues).

    I really, really, *REALLY* wish that insulin didn't speed through Conan at such a rate- I was so hoping to at least be able to achieve BID dosing on the Tresiba, if not the once-a-day advertised for humans. That being said, I'm pretty pleased with the results we've been able to achieve so far. His spreadsheet has never looked even close to this in two and a half years of treatment.
  2. Stacy & Asia

    Stacy & Asia Well-Known Member

    Oct 2, 2017
    I like it! Wow! It’s unfortunate you didn’t get a longer duration with it, but it does seem very forgiving of how much is dosed and when as well as being stable. The fact you could get more insulin in him by giving him 4 units TID and it doesn’t bottom out when 3.5 BID took him to the 60s is amazing! I doubt you’d have the same luck with the L’s for that part. So maybe not all we hoped it would be for him, but he is looking pretty good!!!

    Do you find the onset of Tresiba is even later than it was for him on Levemir or are they about the same?

    Asia seems to burn through the insulin too, I also wish I knew why. I started TID with Asia on Levemir and it’s working quite well for her too. It’s not even as annoying as I thought it would be, I find it easier to monitor the shorter cycles and there seems to be less surprises this way.
  3. Jessica & Conan

    Jessica & Conan Member

    Jan 16, 2016
    Yes, I think the onset is later than for Levemir by an hour or so - but the duration of the Tresiba is slightly longer for him, and while it lasts it's more stable (I'd say the duration of Tresiba is consistently at least 10 hours, though as I explained in the post, he needs to have the next shot well before that). And overall everything is much more predictable. With Levemir, I could never be entirely certain if his reading after 8 hours would be red or blue. I was constantly looking at his number feeling bewildered as to why his midday pre-shot value , 8 hours after the morning shot, was 90 today, whereas yesterday it was 380. His AMPS varied wildly, and his PMPS was typically too high. And I definitely did not feel I could dose him on the Levemir completely comfortably, even after 8 hours, if his pre-shot value was below about 120, if I wasn't going to be there to monitor him just in case. He was more prone to bounces, or rebounds, on Levemir - after a stretch of nice low numbers, he'd sometimes go super high. He doesn't seem to experience that at all with the Tresiba. He was also certainly far more sensitive to dose changes in the Levemir - he probably needed a higher dose when we stopped, but still, he was only at 1.75U. The problem was that as the dose went higher, he didn't necessarily have more consistency in his "good" low numbers, or even fewer spikes, but he did risk dropping into hypo ranges.

    I do have a feeling I am going to end up lowering his current Tresiba dose though, especially if I can figure out an ideal timing. I think this dose has the potential to be too much for him, if the timing is correct.

    To be fair, I had a hard time being consistent with TID dosing with the Levemir. I've slightly changed things this time - with the Levemir, I dosed and fed three times a day, but with the Tresiba, whereas I'm dosing 3x/day, I'm continuing to feed just twice a day, 12 hours apart (he gets his steroid with his meals). So his midday and PM shots are not with food. This has not been an issue as far as BG values, and it makes things easier for me, because meals are so time consuming. Each meal involves feeding not just Conan, but the other three cats as well (too difficult, logistically and psychologically, to routinely feed one of them separately). Plus, Conan's meals are quite large, since he's so thin, and he is a very slow eater, but since he gets raw food, I can't leave it out for him - I have to wait for him to finish, then clean up. I really can't feed in less than half an hour. I'm used to doing that in the morning and evening, but adding it to the middle of the day didn't always work. This way I still only have to do that twice a day, and all I have to do in the middle of the day is give a shot, which takes no time at all - and is even something my husband can do, if for example I'm out on a weekend day and he's here, and I leave him a syringe. So far I've been able to manage this better than I did the 3-meal Levemir schedule.

    (As a total aside, after reading the study cited somewhere on this site, I decided it was acceptable to draw up syringes up to a day or so in advance, despite the commonly-dispensed advice, and I do this routinely when necessary, as I think it's the only way to truly ensure that dosing is exactly the same. It's never caused any issues that I'm aware of. If I'm gone for a longer period I'm not willing to risk it, but for a day or two it's fine. I use digital calipers and a magnifying visor to measure out the dosages, but I still don't believe that any two people, even using the same equipment, will end up with the same dose - I doubt even my own are exactly the same each time; the tools just aren't that precise, but at least I am always doing it the same way so my own measurements are more likely to be close - and at such small dosages, even small variations can make a difference.)

    Still, there are days I simply can't come home in the middle of the day (I have horses too, and some days I have to haul them somewhere, which is an all-day affair.) This isn't ideal, but it appears from what I can tell that the consequences of an occasional BID dosing day are limited to that day; or at least, by the next day, his values are back in a good range.
  4. Cheryl and Yoda

    Cheryl and Yoda New Member

    Apr 12, 2017
    Jessica and Conan, I hope all is still well with your experience on Tresiba. Just wanted to let you know, my kitty Yoda is experiencing flat normal curves for the first time in over a year and a half , thanks to you and thanks to Sam and Esse. If it weren’t for your posts, I never would have known to suggest Tresiba to my vet to help my unstable kitty. Yoda started on Tresiba last month on July 16th, and it is already making a HUGE difference! Thank you for your posts!
    Jill & Alex (GA) likes this.

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