Feline Diabetes Mellitus
In Part 1 of this article (IVC, Winter 2012), I covered the diagnosis of feline diabetes mellitus, and how early DM can be managed with diet, medication and herbs. Now Ill discuss insulin stabilization and home monitoring, the complications that can occur with the disease, and the reasons why some cats dont recover. Feline DM is treated with Rx insulin injections twice a day (BID) combined with home BG monitoring. Cats metabolize insulin twice as fast as dogs or humans, and ideally, a cat with DM should be eating a very low carbohydrate diet twice a day. Hence the ultra-long-acting human insulins, Glargine Lantus or Detemir Levemir, work best for these cats. Rx Glargine = Lantus: This acid pH insulin precipitates in the neutral pH of the body and is absorbed slowly. The initial dose is 1 to 2 IU/cat twice a day. It lasts 12 to 18 hours. The bottles are 10 ml and fairly expensive. Rx Detemir = Levemir: The Detemir insulin is strongly protein bound (that is, albumin bound) and slowly released. The initial dose is 1 to 2 IU/cat twice a day. It lasts 18 to 21 hours. One box contains 5 x 3 ml vials. Detemir appears to be better tolerated than Levemir in some cats, and may have less variability. As Detemir is strongly protein bound, there is the potential for drug interactions. Other drugs commonly used in cats that are also strongly protein bound include the injectable long-acting penicillins, long-acting cephalexin, and Rx Propofol, an injectable anesthetic. I now prefer Levemir insulin in my diabetic cats. I find the BG nadir occurs, on average, about three to six hours after injection, and there is a fairly flat BG curve. On Lantus and Levemir, over 80% of my newly diagnosed diabetic cats recover within three months. I purchase the box of Levemir and dispense the 3 ml vi Continue reading >>
Insulin Actions Times And Peak Times
A good way to improve your glucose levels is to track the peaks and drops in your glucose, so you can figure out why they happened and how to correct them. Once you identify glucose patterns (they ARE there!), you also want to understand when each of your insulins is active and when they typically stop lowering your glucose. This helps you adjust your doses or food intake to stop unwanted ups and downs in your readings. The table below shows the start, peak, and end times for various insulins with some explanations and typical uses for each. When Does My Insulin Peak and How Long Does It Last? Action Times for Insulins Insulin Starts Peaks Ends Low most likely at: Usage Hum/Nov/Apidra 10–20 m 1.5–2.5 h 4.5–6 h 2–5 h designed to peak, covers meals and lowers high BGs Regular 30–45 m 2–3.5 h 5–7 h 3–7 h NPH 1–3 h 4–9 h 14–20 h 4–16 h intermediate, less peaking, larger action Lantus 1–2 h 6 hr 18–26 h 5–10 h designed for flatter and longest action, background insulin action for keeping your BG flat when fasting Levemir 1–3 h 8–10 18–26 h 8–16 h Rapid Insulins Humalog, Novolog and Apidra insulins currently give the best coverage for meals and help keep the glucose lower afterward. Their glucose lowering activity starts to work about 20 minutes after they are taken, with a gradual rise in activity over the next 1.75 to 2.25 hours. Their activity gradually falls over the next 3 hours with about 5 to 6 hours of activity being common with these insulins. Although “insulin action times” are often quoted as 3-5 hours, the actual duration of insulin action is typically 5 hours or more. See our article Duration of Insulin Action for more information on this important topic. In general, "rapid" insulins are still too slow for many common mea Continue reading >>
Comparison Of Insulin Therapies
BACKGROUND: Insulin is a common therapy in the treatment of diabetes mellitus type 1 and 2. With the advent of intermediate-acting and long-acting insulin products, basal insulin therapy has become a common practice usually utilized to reduce the number of injections needed to administer or in combination with a short-acting insulin product in the basal–bolus insulin regimens. The original insulins created to have longer durations of action were the NPH insulins which utilized a crystalline complex between the insulin and protamine.2 In more recent years, newer basal insulins such as Levemir and Lantus have come onto the market which do not rely on the use of protamine-insulin complexes and also claim to last longer (possibly up to single dose a day administration) with no peak activity. The lack of peak activity promises to reduce hypoglycemia risk and to provide a more basal-like dosing.1,3 The original insulins used as bolus insulin therapy were isolated from either animal or human sources. Today, the standard of isolated insulin therapies is regular human insulin. Like the long acting insulin products, recent years have seen the emergence of rapid acting insulin analogues. These rapid insulins promise to have higher efficacy and safety due to rapid onset (for meal time administration) and shorter duration of action.1,4,5 While the newer insulin products claim to have benefits of duration of action and less risk of hypoglycemia, they come at a higher cost than the regular human insulin and NPH insulin products. The average patient admitted to hospice care usually does not have insulin therapy related to the terminal diagnosis — with some obvious exceptions such as pancreatic cancer. The following is an analysis of the benefits and claimed convenience of the newer Continue reading >>
Levemir Dosing: Not Always Clear Cut
I asked about trying Levemir back in December, 2007. My PCP gave me some sample pens and said to take it twice a day. Later I saw another doctor who tried to tell me that it was a once a day insulin. Although in the beginning I did better on Levemir than I had on Lantus, I found that it just didn’t last long enough and I would run high before my 12 hours was up. The following spring, there was a discussion on a message board and several of us felt that Levemir was not lasting for 12 hours. I brought up trying it three times a day and I decided to give it a try. I actually found that worked a lot better for me. Right around when I tried that was when I also learned about doing basal testing. By doing basal testing, I know that my rates are set correctly and I can go 24 hours and have my blood sugar stay fairly stable. Another person on that message started taking Levemir three times a day also after I started. There is a third person on TuDiabetes that also takes her Levemir that way. I know that there are at least three of us taking Levemir three times a day successfully. A couple weeks ago, there was a discussion on TuDiabetes about Levemir. Someone has having trouble with it and I told her what I did. Every time I suggest that to someone, I also suggest doing basal testing and state that I know it works for me because of doing basal testing. Someone else immediately piped up and told her that she couldn’t do that. My response was why not. I have been doing it for 3 ½ years less the 8 months that I was on the pump. I get pretty good results from it. If you read the prescribing information for Levemir, under Pharmacodynamics, it states “The mean duration of action of insulin detemir ranged from 5.7 hours at the lowest dose to 23.2 hours at the highest dose (sampl Continue reading >>
![Levemir® (insulin Detemir [rdna Origin] Injection) Indications And Usage](https://diabetestalk.net/images/zILfBIRSAQsMnaxK.jpg)
Levemir® (insulin Detemir [rdna Origin] Injection) Indications And Usage
Levemir® is contraindicated in patients with hypersensitivity to Levemir® or any of its excipients. Never Share a Levemir® FlexTouch® Between Patients, even if the needle is changed. Sharing poses a risk for transmission of blood-borne pathogens. Dosage adjustment and monitoring: Monitor blood glucose in all patients treated with insulin. Insulin regimens should be modified cautiously and only under medical supervision. Changes in insulin strength, manufacturer, type, or method of administration may result in the need for a change in insulin dose or an adjustment of concomitant anti-diabetic treatment. Administration: Do not dilute or mix with any other insulin or solution. Do not administer subcutaneously via an insulin pump, intramuscularly, or intravenously because severe hypoglycemia can occur. Levemir® (insulin detemir [rDNA origin] injection) is indicated to improve glycemic control in adults and children with diabetes mellitus. Levemir® is not recommended for the treatment of diabetic ketoacidosis. Intravenous rapid-acting or short-acting insulin is the preferred treatment for this condition. Levemir® is contraindicated in patients with hypersensitivity to Levemir® or any of its excipients. Never Share a Levemir® FlexTouch® Between Patients, even if the needle is changed. Sharing poses a risk for transmission of blood-borne pathogens. Dosage adjustment and monitoring: Monitor blood glucose in all patients treated with insulin. Insulin regimens should be modified cautiously and only under medical supervision. Changes in insulin strength, manufacturer, type, or method of administration may result in the need for a change in the insulin dose or an adjustment of concomitant anti-diabetic treatment. Administration: Do not dilute or mix with any other insulin Continue reading >>
How Do You Use Basal Insulin?
When the first long-lasting basal insulin analogs (insulin glargine [brand name Lantus] and insulin detemir [Levemir]) came out, they were supposed to last 24 hours. You injected once a day. That schedule clearly doesn’t work for everyone. Why is that, and what works for you? First of all, what is “basal” insulin? “Basal” insulin is that background level of insulin you need 24 hours a day. It’s not for the food you eat; it’s for everything else insulin has to do in your body. As I wrote here, insulin keeps glucose stored in the liver, fat stored in fat cells, and promotes cell reproduction, along with several other functions. People with Type 1 and many with Type 2 have very low or no basal insulin. Without basal insulin, your liver can pump out glucose all the time. Your sugars can go way up even if you don’t eat, like at night. So the invention of a 24-hour basal insulin was a great advance. It brought people’s A1C levels way down, but it doesn’t always work as advertised. Dr. Richard Bernstein, author of Diabetes Solution, says “In my opinion, there is no 24-hour basal insulin.” Larger insulin doses take longer to absorb. According to Dr. Bernstein, drug companies used larger-than-needed doses to make them last 24 hours. “The large basal doses needed to make ‘long-acting insulins’ last 24 hours,” he says, “[can cause] a number of undesirable consequences. These include hypoglycemic episodes [lows], weight gain, and possible [blood vessel] effects.” At the proper doses, basal insulin will frequently not last 24 hours. A study in Diabetes Care found a window of low insulin levels when the daily dose has worn off and the next day’s dose hasn’t yet kicked in. The authors suggested twice daily dosing would provide better coverage. O Continue reading >>
Insulin Detemir (rx)
Dosing & Uses Type I or II Diabetes Mellitus Once daily dosage: Administer SC with evening meal or at bedtime Twice daily dosage: Administer SC with morning meal and either with evening meal, at bedtime, or 12 hr after the morning dose Type 1 diabetes: Approximately one third of the total daily insulin requirements SC; rapid-acting or short-acting, premeal insulin should be used to satisfy the remainder of the daily insulin requirements; usual daily maintenance range is 0.5-1 unit/kg/day in divided doses; nonobese may require 0.4-0.6 unit/kg/day; obese may require 0.6-1.2 units/kg/day Type 2 diabetes inadequately controlled on oral medication: 10 units/day SC (or 0.1-0.2 unit/kg/day) in evening or divided q12hr Type 2 diabetes inadequately controlled on GLP-1 receptor agonist: 10 units/day SC given once daily in evening Subsequently adjust dose based on blood glucose measurements Conversion from other insulins If converting from insulin glargine: Change can be accomplished on a unit-to-unit basis If converting from NPH insulin: Change can be accomplished on a unit-to-unit basis; however, some patients with type 2 diabetes may require more insulin detemir than NPH insulin Closely monitor blood glucose during transition and in the initial weeks thereafter; concurrent rapid-acting or short-acting insulins or other concomitant antidiabetic treatment may require dose adjustment Dosing Considerations Dosage of human insulin, which is always expressed in USP units, must be based on the results of blood and urine glucose tests and must be carefully individualized to optimal effect Dose adjustments should be based on regular blood glucose testing Adjust to achieve appropriate glucose control Look for consistent pattern in blood sugars for >3 days Same time each day: Compare bloo Continue reading >>
Key Facts About Basaglar: A Less Expensive Long-acting Insulin
If you’ve been using a long-acting insulin like Lantus, you might have heard about a friendly competitor called Basaglar which is coming soon to pharmacies. Basaglar is insulin glargine known as a biosimilar (also called a follow-on biologic). Because of the manufacturing process it isn’t considered a generic, but there are no differences from Lantus in regard to safety, purity and potency. To get to know Basaglar better, here are some details you’ll want to be aware of. What is the difference between a biosimilar and a generic? Generic drugs are copies of a brand name drug, and their manufacturing process can be replicated exactly through chemical reactions. Biologics are made using manufacturing processes and living organisms that are unique to each manufacturer. Therefore, it is not really possible to make an exact copy of a biologic. For an in-depth look at the definition of biosimilar, see here. Is Basaglar less expensive than Lantus? The cost of Basaglar is estimated to be about 20% cheaper than Lantus. It is manufactured by Eli Lilly as a KwikPen. Basaglar won’t be sold in a vial form. Will my insurance switch me to Basaglar? In some cases, yes. CVS Health has announced that Basaglar will be on formulary in place of Lantus. Is it really equivalent to Lantus? Yes, the onset, peak and duration of action are almost identical. Will my dose be the same as the insulin I’m currently taking? Your healthcare provider will tell you exactly how to make the switch. In general, Lantus and Basaglar can be interchanged unit for unit. If you were on Levemir, the conversion will also be unit for unit. If you were taking Levemir twice a day, the total number of units will likely be given as one Basaglar injection. If you are switching from Toujeo or NPH, your dose might Continue reading >>
(insulin Glargine Injection) 300 Units/ml
Toujeo® is a long-acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus. Limitations of Use: Toujeo® is not recommended for treating diabetic ketoacidosis. Contraindications Toujeo® is contraindicated during episodes of hypoglycemia and in patients hypersensitive to insulin glargine or any of its excipients. Warnings and Precautions Toujeo® contains the same active ingredient, insulin glargine, as Lantus®. The concentration of insulin glargine in Toujeo® is 300 Units per mL. Insulin pens and needles must never be shared between patients. Do NOT reuse needles. Monitor blood glucose in all patients treated with insulin. Modify insulin regimens cautiously and only under medical supervision. Changes in insulin strength, manufacturer, type, or method of administration may result in the need for a change in insulin dose or an adjustment in concomitant oral antidiabetic treatment. Changes in insulin regimen may result in hyperglycemia or hypoglycemia. Unit for unit, patients started on, or changed to, Toujeo® required a higher dose than patients controlled with Lantus®. When changing from another basal insulin to Toujeo®, patients experienced higher average fasting plasma glucose levels in the first few weeks of therapy until titrated to their individualized fasting plasma glucose targets. Higher doses were required in titrate-to-target studies to achieve glucose control similar to Lantus®. Hypoglycemia is the most common adverse reaction of insulin therapy, including Toujeo®, and may be life-threatening. Medication errors such as accidental mix-ups between basal insulin products and other insulins, particularly rapid-acting insulins, have been reported. Patients should be instructed to always verify the insulin label bef Continue reading >>
An Analysis Of Dosing Equivalence Of Insulin Detemir And Insulin Glargine: More Evidence?
Current guidelines for the management of type 2 diabetes call for the use of basal insulin when glycemic targets are not achieved, despite the use of oral antihyperglycemic medications.1,2 Controversy remains in the medical literature regarding the comparative efficacy of insulin detemir and insulin glargine, both of which have demonstrated superiority over neutral protamine Hagedorn insulin. While two published studies have demonstrated noninferiority of insulin detemir and insulin glargine, both studies were designed to dose insulin detemir twice daily if predinner glucose levels were elevated, whereas insulin glargine was only dosed once daily regardless of predinner glucose levels.3,4 A third study is underway with a similar design,5 but does not address the comparative efficacy of once-daily administration of these two basal insulins. In this issue of Journal of Diabetes Science and Technology, Dr. Allen King provides further important details of his previously published trial that provides important data in addressing this issue.6,7In this randomized, double-blinded, crossover trial, once-daily insulin detemir was compared with insulin glargine in 29 patients with type 2 diabetes under relatively good glycemic control (average hemoglobin A1c 7.1%). Several design features help provide new information about the use of both of these basal insulins. First, both insulins were restricted to once-daily use in the evening at 8 pm, whereas previous comparison trials allowed for twice-daily usage of insulin detemir. No mealtime insulins were administered in the trial. Second, the crossover design allowed for the patients to serve as their own controls, i.e., each patient used both forms of insulin in the trial. Third, continuous glucose monitoring (CGM) was used to more cl Continue reading >>
Levemir Side Effects Center
Levemir (insulin detemir [rDNA origin] injection) is a man-made form of a hormone that is produced in the body used to treat diabetes in adults and children. Common side effects of Levemir include: injection site reactions (e.g., pain, redness, irritation), swelling of the hands/feet, thickening of the skin where you inject Levemir, weight gain, headache, back pain, stomach pain, flu symptoms, or cold symptoms such as stuffy nose, sneezing, sore throat. Tell your doctor if you experience serious side effects of Levemir including: signs of low potassium level in the blood (such as muscle cramps, weakness, or irregular heartbeat). Levemir is for once- or twice-daily subcutaneous (under the skin) administration. Patients treated with Levemir once-daily should administer the dose with the evening meal or at bedtime. Patients requiring twice-daily dosing can administer the evening dose with the evening meal, at bedtime, or 12 hours after the morning dose. Levemir may interact with albuterol, clonidine, reserpine, guanethidine, or beta-blockers. Other medicines can increase or decrease the effects of insulin Levemir on lowering your blood sugar. Tell your doctor all prescription and over-the-counter medications you use. Tell your doctor if you are pregnant before using Levemir. Discuss a plan for managing your blood sugars with your doctor before you become pregnant. Your doctor may switch the type of insulin you use during pregnancy. It is not known if this medication passes into breast milk. Consult your doctor before breastfeeding. Insulin needs may change while breastfeeding. Our Levemir (insulin detemir [rDNA origin] injection) Side Effects Drug Center provides a comprehensive view of available drug information on the potential side effects when taking this medication. T Continue reading >>
A Review Of Insulins
Unlike the limited selection of insulins Dr. Elliott P. Joslin had to work with, today we have a range of alternatives to choose from. Instead of coming from pigs or cows, most of our insulin is made in the laboratory using recombinant DNA.(As an interesting aside, the insulins used for our pets with diabetes usually still come from the pancreas of animals) . The insulins we have today fit into one of three broad categories: basal, bolus, and mixed basal-bolus insulin. Basal insulins after being injected, dissociate slowly in the fatty tissue to provide a constant stream of insulin into the circulation throughout the day. They help reduce the amount of glucose secreted by the liver, thereby keeping glucose levels steady. The new basal insulins last approximately 24 hours and are given once or twice a day. Currently we have three basal insulins available in the United States: Lantus®, Levemir® and NPH. (Lantus® and Levemir® are brand names, NPH is a generic) Lantus® and Levemir® are categorized as long-acting insulins because they can be given once- a -day to cover a 24-hour period. (In people with type 1 diabetes, Levemir® and sometimes Lantus® is given twice per day to avoid reduction in efficacy in the waning hours before the next dose is due) Both are flat, peakless insulins. Peakless insulin works with the same intensity throughout the life of the dose. This has some advantages for people with diabetes because they can calculate approximately how much basal is working per hour by simply dividing their dose by 24. The advent of peakless basal insulins freed people from having to have fixed-snack times that match the insulin peak. Today most people use Lantus® or Levemir ®as their basal insulin. However, there are still some people who continue to use NPH. N Continue reading >>
Levemir Vs. Lantus: Similarities And Differences
Levemir and Lantus are both long-acting injectable insulins that can be used for long-term management of diabetes. Insulin is a hormone that is naturally produced in the body by the pancreas. It helps convert the glucose (sugar) in your bloodstream into energy. This energy is then distributed to cells throughout your body. With diabetes, your pancreas produces little or no insulin or your body is unable to use the insulin correctly. Without insulin, your body can’t use the sugars in your blood and can become starved for energy. The excess sugar in your blood can also damage different parts of your body, including your blood vessels and kidneys. Everyone with type 1 diabetes and many people with type 2 diabetes must use insulin to maintain healthy blood sugar levels. Levemir is a solution of insulin detemir, and Lantus is a solution of insulin glargine. Both are basal insulin formulas. That means that they work slowly to lower your blood sugar levels. They’re both absorbed into your body over a 24-hour period. They keep blood sugar levels lowered for longer than short-acting insulins do. Although the formulations are slightly different, Levemir and Lantus are very similar drugs. There are only a few differences between them. Children and adults can use both Levemir and Lantus. Specifically, Levemir can be used by people who are 2 years or older. Lantus can be used by people who are 6 years or older. Levemir or Lantus can help with daily management of diabetes. However, you may still need to use short-acting insulin to treat spikes in your blood sugar levels and diabetic ketoacidosis (a dangerous buildup of acids in your blood). Learn more: All about diabetic ketoacidosis » Administration Both Levemir and Lantus are given through injection in the same way. You can gi Continue reading >>
When You Can't Afford The Insulin That You Need To Survive | How To Use The Cheap "old-school" Insulin
Note: BootCamp for Betics is not a medical center. Anything you read on this site should not be considered medical advice, and is for educational purposes only. Always consult with a physician or a diabetes nurse educator before starting or changing insulin doses. Did you know that all type 1 diabetics and some type 2 diabetics need injectable insulin in order to live? Put another way, if a diabetic needs insulin in order to live, and the diabetic does not get insulin, the diabetic will die. Diabetic death from Diabetic Ketoacidosis is a grisly process, during which acid starts running through your bloodstream, searing your vessels and organs while your body shrivels up in dehydration as it tries to push the acid out of your body through your urine and lungs, and, left untreated, the condition shuts down your organs one by one until you are dead. If you're lucky, your brain will be the first thing to swell itself into a coma and you'll be unconscious for the remainder of the organ failures. In some cases, this grisly diabetic death can take a few days or weeks to complete its process. Or, if you're one of the luckier less-resistant insulin-dependent type 2 diabetics, you may actually get away with staying alive for quite a few years and suffer only some heart disease, stroke, kidney damage/failure, neuropathy, limb amputations and blindness. (my intent in describing how lack of insulin leads to death is not to cause fear in people with diabetes or their loved ones; rather, my intent is to make clear the reality that injectable insulin is absolutely vital to diabetics who depend on injectable insulin to live) While I'd love to go off on a political rant about how insulin should be a basic human right for all insulin-dependent diabetics (and why the hell isn't it?), that' Continue reading >>
What Is Levemir (insulin Detemir)?
Levemir is the brand name for the prescription drug insulin detemir. It's used to treat type 1 and type 2 diabetes. Levemir is a long-acting insulin that lowers blood sugar by encouraging tissues to take excess glucose, discouraging the body from making more glucose, preventing the breakdown of fat and protein, and helping the body regulate levels of blood sugar. The Food and Drug Administration (FDA) approved Levemir in 2006. Novo Nordisk manufactures the drug. Levemir FlexTouch Levemir FlexTouch is an insulin pen syringe prefilled with Levemir. It's designed to make the drug easier to use. You should keep unopened Levemir FlexTouch in the refrigerator until you’re ready to use it. After opening, store it at room temperature no warmer than 86 degrees Fahrenheit. You should dispose of FlexTouch 42 days after opening, regardless of whether or not there is any left in the device. Levemir versus Lantus Levemir is similar to another man-made form of insulin, insuline glargine, which is sold under the brand name Lantus. Both drugs have similar side effects and have been to be effective at managing blood sugar levels in people with type 1 and type 2 diabetes. Talk to your doctor about which drug is better for you. Levemir Warnings You should not take Levemir if: You’re allergic to Levemir or any other ingredient in the drug Your blood sugar is low Talk to your doctor before taking Levemir if: You’re sick, stressed, or have an infection You have kidney or liver problems The potassium level in your blood is low Your doctor may lower your dose of Levemir if you are taking certain drugs, such as exenatide (Bydureon), liraglutide (Victoza), or albiglutide (Tanzeum). Levemir Storage You can store unopened vials of Levemir at room temperature or in the refrigerator, but toss a Continue reading >>
