Sam's First Month on Tresiba

Discussion in 'Tresiba (degludec)' started by Sam & Esse, Jun 14, 2018.

  1. Sam & Esse

    Sam & Esse Member

    Joined:
    Oct 18, 2017
    Hello :joyful:

    June 13th marked Sammi's one month anniversary on Tresiba. I thought I'd post a bit on how he's doing; general impressions, worries and triumphs, along with a touch of past history for a bit of perspective.

    When Sam was first diagnosed he was put on ProZinc. That lasted just over 3 weeks. Although everything I read said a cat shouldn't feel ProZinc, Sam absolutely did. He fought the shots, and as the weeks went by the skin along his back started twitching violently for hours after shot time. I requested a Levemir prescription from my vet, since I figured if Sam was feeling the ProZinc that badly, Lantus was definitely out of the question. Although my vet had no previous experience with Lev, he agreed to the medication change as long as I brought Sam in for monthly fructosamine tests... Yeah, those didn't happen.

    Sam accepted the Lev better; shot time became easier. But while Lev had better duration than ProZinc, Sam was still metabolizing the insulin too quickly. And he bounced. Boy, did he bounce. Getting the flu in December derailed any plans of regulation; January started showing some promising numbers — but only mid-day. Preshots just about had me in tears. Then the dives started. Poor Sam was all over the place.

    I knew Sam had some bad teeth; when I took him in for his six-month follow up I asked the vet if he'd clear Sam for a dental (he'd previously wanted Sam regulated) and if he'd consider prescribing Tresiba. After enduring a bit of a rant over me not holding doses for six days and over-testing at home (which, lol! I'm not able to test near enough), the doctor cleared Sam for his dental — pending blood work, including fructosamine that I reluctantly agreed to — and a move to Tresiba after Sam's dental work.

    So... Sammi is now toothless. If the way he's started gnawing on me is any indication, he approves of the change. Otherwise, his only other health problem is being overweight. Got the Tresiba from Mark's in Canada after a small snafu (I have a feeling someone at the vet's office was "misplacing" the Rx request forms) and started Sam on a token dose in case of an immediate allergic reaction.

    Dose increases were far faster than any protocol would approve; I was getting panicky that the insulin wasn't working/had gotten too warm/was bactine-scented water... However, at 3.5u improvement became apparent. 3.75u had been Sam's tipping point on Lev, and it looks like that holds true with the Tresiba.

    Differences I've noticed with Tresiba?

    1. Sam's a lot more level on it. Less bouncing, not bouncing as high, and clearing bounces faster for the most part. The blue squares look so pretty on his SS.
    2. Dose increases likely take longer than 6 cycles to demonstrate full efficacy.
    3. I am clueless about the depot. How long does it take to fill? How long to deplete? Is there even a depot, and if there is, is it anything like Lantus or Lev? Right now I'm leaning towards Tresiba having an extended duration, but there's something other than a traditional depot in play. I do not have the knowledge or the testing info needed for any sound answers.
    4. Sam has no problem at all with the injection. Zero fussing, and a few times he's actually come into the kitchen when he's "Ready for your mojo?"
    5. When at a "good" dose, Tresiba can both pull down high BG numbers and keep them fairly level; ie, when I had to skip a dose, Sam came back down smoothly and relatively quickly.
    6. There are far less occurrences of bubbles when drawing the Tresiba dose from the pen, and when there is a bubble it's much, much easier to get out than it was with Lev.
    7. Tresiba may be more forgiving of rapid dose changes. For medical reasons PM testing isn't something I can do often; instead, I decrease dose to hopefully keep Sam safe. On Tresiba Sam's numbers may wobble a bit but still look okay; Lev, I could tell it had a negative impact.

    Questions it will take a larger user base to answer:

    1. When confronted with a low preshot #, traditionally the advice is to stall without feeding and retest in 20 or so minutes, repeatable for up to an hour. If Tresiba is holding numbers steady, and the duration extends several hours past preshot time, this method may not be applicable.
    2. Hypo treatment. If Tresiba does have a longer duration for particular cats, is there a possibility that the standard two hours of safe, non-food-influenced BG#s might not be long enough to predict if the cat is actually safe?
    3. Since Tresiba comes in a u200 as well as a u100 formulation, could it be an option for high dose cats? A regular u100 syringe could hold a total of 60u instead of the 30u we're used to.
    4. When used in cats, is Tresiba a depot insulin? Or should it be considered an extra-long lasting in-and-out insulin? Or will it prove to be another case of ECID?

    I think that about covers everything I've thought about during the last month. Sam's SS should be viewed with the knowledge that I'm not following an established protocol, and that risks were taken that probably shouldn't have been. For people that have considered switching to Tresiba, I thought that being able to see how another cat is doing on it might be helpful. I hope it is, at least :)
     
  2. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    For a high-dose cat I would just use the pen w/pen needle. with a high dose one can easily dose in one-unit increments or two-unit increments if the U200 pen only does as small al 2 units increments. With my acromegaly MurrFee I just used the pen w/pen needles when I got a good deal for pens. After the deal I just used the vial since per unit the vial was less expensive than the pens
     
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  3. Sam & Esse

    Sam & Esse Member

    Joined:
    Oct 18, 2017
    Thank you, I hadn't thought about it quite that way. When dealing with higher doses, there's probably not much need to be able to measure half and quarter units. If I may ask, did you prime the pen needle when using it? I know the manufacturer recommends it in the instructions, but it seems to me a dose could be figured out taking a non-primed needle into consideration.
     
  4. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    With a dose of 30 units I did not waste the Levemir by priming. The slight reduction of insulin injected would not really make a difference
     
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  5. Jessica & Conan

    Jessica & Conan Member

    Joined:
    Jan 16, 2016
    I just saw this now! Conan has been on Tresiba for 2.5 months now, and at a stable dose of 4U for a little more than 2 months. It is the only insulin that has come close to regulating him (he's been on Lantus & Levemir) - by far the stablest and most effective. I agree with virtually all your points. (And just as a side note, Conan has had all his teeth removed as well, except his canines and most of his incisors!).

    Conan requires TID dosing, unfortunately, in order to stay decently regulated. There are days when this is impossible. Often for a single day at BID, he will maintain numbers in the blues/yellows - but more than one and he'll be back up into the pinks. This leads me to believe that there is some sort of depot action happening, but I can't figure it out (it's made more complicated in my case by Conan's steroid usage). As you say, as soon as I return to normal dosing, he immediately responds, coming back down smoothly and predictably. No weird inexplicable bounces or spikes.

    When he is on regular TID dosing, he stays entirely in blues and greens, with some yellows, especially at his midday shot (which I attribute to his morning steroid dose), quite consistently. It's like a miracle!

    With respect to your Question #1, I will offer that I have dosed Conan when he's been as low as 61, with no hypo incidents at all (I generally have tested quite regularly, though the last 2 weeks or so I've had some events that have not permitted such regular testing - and also have required more BID dosing than I generally like - and also I've backed off a little as I've grown to know his patterns). I have found that the Tresiba takes at least a few hours to start to take effect and actually works best if I dose him when he's below 100. When he's over 150, he's likely to go higher than I think is ideal in the 3-4 hours immediately after dosing, before the new dose starts having its effect. If I'm not going to be around, I generally don't dose if he's under 75-80 just in case, but I always dose if he's at 80 or over. So I basically ignore the usual advice about pre-shot numbers. The very few times I've tested him and gotten a hypo number (below 50), it has been late in his cycle, and has resolved definitively within an hour or so with a normal meal.

    I'm not sure whether Conan is a good test case or example to follow, but Tresiba has been great for him!
     
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  6. Sam & Esse

    Sam & Esse Member

    Joined:
    Oct 18, 2017
    Hi Jessica!

    The improvement on Conan's SS since you've begun Tresiba with him -- well, it looks incredible. Especially considering the daily Pred. I admit, I've followed his progress closely. It's because of your patience starting with once a day dosing that I knew to start Sam with BID. I had hoped you'd get better duration, but there's no arguing the amount of control you've gained.

    I wish I was able to test Sam more often, but what I do know is that most days (and for now) his nadir is right around the PS, and that his dose begins to actually take effect somewhere after +6 :facepalm: I'm not sure how long this will go on for. I'm just thrilled that it's held true for this past week, and I'm learning to work with it. I haven't been brave enough to shoot a full dose on a lower pre-shot. Instead, I've developed a tiny sliding scale for dosing of a quarter unit leeway, and when I am shooting a low number, I make sure that I wait to take my own night time meds until I know Sam's safe. I have no idea if it's the right thing to do, but it seems to be mostly working. So far. Knock on wood.

    Honestly, I'd started to really worry about Sam and the damage his bounces were doing. Since about week 2 on Tresiba, however, I've started to allow myself to hope that regulation might be possible. --And, Sam just gifted me with a mighty hairball, so it'll be interesting to see what his PMPS is in a few minutes :p
     
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