HUMULIN N 3x a day

nailbite_smile Hi Everyone
I'm new to the group. I'm hoping there is someone out there that can help me. I have a Tonkenese 10 years old. He has had a very hard life. When we neutered him, he was allergic to the anestesia and died on the table but they revived him several times. Because of that problem, he became blind and couldn't walk. He had seizures frequently. But because of his determination and persistance, he taught himself how to walk, and a little eyesite came back, be he compensates just fine. He is a sweet boy. His name is Luga. We found out Luga had diabeties in May of 2009. He was drinking more and urinating frequently and gaining alot of weight. I suspected diabetes. One day there was urine and blood all over. He had a very bad bladder infection from the diabetes, so we took him to our regular vet and she confimed it. She told us to start him on Lantus - 1unit a day. I didn't know anything about home testing and it really wasn't explained how important it was. So we did that for about a month or so, brining him in frequently for tests, but his levels never went down. Unfortunatley he developed Diabetic Neuropothy. One day I came home and he was so low on his back legs he was having difficulty walking. The vet told me to rush him to emergency. She didn't know if it was neurological or something pertaining to the diabetes. When we got there, it was confirmed that it was the Diabetic Neuropothy. I was crushed to think I did this to my cat. The doctor suggested home testing and taught me how to do it. Luga was then put on Lantus 2 units twice a day. I started home testing and his numbers were all over the place. High - Low - in-between. I called the vet and he said that Luga was probaly having a smoji effect (new to me). He explained that when Luga's numbers go to low, the body compensated and released more insulin. That's the body's way of keeping you alive. A hight number is safer than a lower number. They also neglected to tell me that the Lantus doesn't have much of a shelf life. 4-6 weeks at the most. So we kept trying with the lantus and nothing was working. Even the specialist was perplexed. I suggesed PZI. We tried it and it did absolutely nothing for him, even adjusting doses. In fact, he was so high for that month, his neuropothy became so bad that on my wood floor, he was flopping around like a fish. Pathetic. So now the vet suggested Humulin N - the last choice. He told us to give him 2 units 8 hours apart. After reading some of the postings and learning that the Humulin N can be harsh, I decided to play it safe and only give him only 1 unit. When I took is bg before the shot at 8:30 it was 411. At 2:00 it was 82 (5 1/2 hours later). Because I'm not familiar with this insulin, I was afraid to give him another unit 2 1/2 hours later because I couldn't figure out how low it might have gotten but I tested him at 6:00 p.m. and it was very hight - 469. So I gave him another unit at 6:00 p.m and test again at Midnight and he was 128. I did read on the message board that you should wait a week for the body to get adjusted before you do a curve, so I'm kinda at a loss. I do feel that the 2 units my vet suggested would have been way too much so I think it was the right decision to only give the 1 unit. Can someone out there give me some direction. I really think my "specialist" is just learning along with me. It's been 10 months and Luga is still not regulated. I wouldn't really mind his numbers being a little elevated if it wasn't for his neuropothy. Poor thing can't jump, play or hardly walk. nailbite_smile Thank You, Linda


Edited by Venita and The Boyz to remove 911.

 

Hi Linda

Wow, what a journey you guys have been on!

Now, first, you've posted in think tank when you should be posting on the health board, feline diabetes forum. Link is viewforum.php?f=3

as to the battles you've been having, I think we need a bit more information before we can solve this puzzle. What food is he/was he on while on lantus? Has he had thorough tests for other issues? Has arthritis been ruled out?

I really wish you'd been hometesting on lantus (I am not being critical) because then we'd have the data to know why it didn't appear to work. Now you've been through lantus and PZI and are now on N and you guys must be stressed. However, I'm so glad that you are now testing so we can try to help. First thing to do, after answering questions above, is to start collecting data and we can see how the N is really working. It does look like he's getting big drops on it, so I'd suggest considering staying at 1 unit twice a day for a few days to see how things settle out. The only caveat to that is if you get a test at shot time (called a preshot test) that is 200 or less, do not shoot but rather test again in awhile and see if he's come back up and at that time consider a reduced shot.

Meanwhile, I will copy and paste both your initial post and my response over on the health forum so that you can get a better response, and hopefully one of our resident vet techs can take a look and maybe they'll have some ideas

Stay strong !

Jen

 

Hi Linda,

Welcome to FDMB. You've and Luga have really been through a hard time together. You all must love each other dearly.

How long ago did you purchase the PZI? Do you know what kind it is (PZI Idexx or a locally compounded version)?

My inclination would be to switch back to the PZI if it is Idexx and not too old. We can help you get better results from it, especially since you are already hometesting.

What does Luga eat?

Terri

 

Thanks Terry and Jen for answering be back so quickly. Sorry I will post to the correct board next time. I'm a little confused but I'll get it right.

Ok here we go - I was testing Luga on Lantus and PZI once I went to the specialist which was about 8 months ago. So this poor little guy has been tested a few times a day for about 8 months and I've done several curves on him and still got wacky numbers. At one point he went for a frucosamine test, and although his numbers were high, his diabetic symptoms had disapated, but the neuropathy never went away. I marked everything down and weekly I would send the report to the vet. His numbers were all over. Never once, in 8 or 9 months did I get a consisten 100-200 bg. He had the smoji effect at one point, so we had to adjust to that, so we played with the dosages. He was either to high or too low. We played with times we gave it to him and units.

Right after I found out he was diabetic, I took him off all hard food and went through the gamet of 95% EVO protein food and a few of the other companies out there that were high protien. He didn't like them at all. He does, however like the Purina Kitten and Fancy Feast Kitten food, I stay away from anything that says "GRAVEY". I read that the kitten foods were higher in protein and less carbs. He does get a treat everyday - We call them "the goodies" and he is addicted to them, as well as my other two Tonkenese. Yes, I have two other healthy young cats, which makes the feeding a nightmare, which I'm sure owners of multiple cats will tell you. I'm sure, once in a while he get's into their hard food - but it's a good hardfood Innova EVO, but we do try to keep him away from it.

I don't recall what kind of PZI we had him on. But he was on for only a month. It seems like we were giving him water because it didn't help a bit. Anyway the vet said they discontinued it.

He doesn't have arthritis, that was ruled out. Maybe we can figure it out. In the meantime, he had a shot at 7:00 a.m. He is due for another one at 3:00 p.m. I will test him and if he's too low then I'll wait, which throws off the directions my vet gave me of every 8 hours, but I have to do what's best for The Lug.
Thanks

Oh, from now on should I go on the Healh Board. Just in case I re-post in there and then we can contine our conversation.

 

3 different insulins in 8 months is a lot of changing around to do. Most cats take at least a month or more to get used to exogenous insulin and very few achieve tight regulation in that short of a time period.

Humulin N is unfairly labelled as a "harsh" insulin on this board, IMHO. It is a fast acting insulin though so you need to make sure he has a full belly before you give him a shot. Also, you will find that it will start acting within the first hour after a shot. It's really important that you get enough spot checks to determine how low the dose is taking him (called peak or nadir).

Also, shooting three times a day (abbreviated TID) can be very successful, but it can also backfire if you aren't testing frequently. When one dose is working before the previous dose has pooped out, it's called overlap. But sometimes the cat will get too much overlap and then you get rebound (somogyii effect). This is all much easier to handle with PZI than with Humulin N.

It sounds to me like your vet is prescribing a dose that is too high for your cat. On Lantus, the folks here like to start at 0.5 unit and increase the dose by .25 units every 5-7 days; and on PZI we like to start at 1.0 units and increase the dose by .5 units every 2-3 days. However, there are microdose cats whose PZI gets increased in .2 units doses.

As for the peripheral neuropathy, here's a great site that should help you a lot: http://www.laurieulrich.com/jasper/

Terri

 

Ok, so you were hometesting..that makes it even more puzzling!

Hopefully we get some other eyes here, as there must be something that we are missing....

 

Hi Terri

I agree with you - alot of insulins. Maybe we were too hasty in changing. I haven't kept too close of an eye on him because I read that it takes a few days for his system to adjust to the new insulin. The only reason I tested him yesterday is because I didn't want to shoot him if he was low (being that I don't know much about the effects of this new insul), and Thank God I did that yesterday or I would have given him a dose when he was 82 and ... Thank God I didn't give him the 2 units the vet told me to give him in the morning. Luga is a grazer. He is starving all day long. Everytime I move from my chair, he is right behind me wanting food, so I don't have to worry about his full belly :lol:
Should I just wait and see. I'm due to give him another shot today at 3:00. I'll check again, if it's low then no shot,but then how will I know when it's going to shoot up. It might be drastic and I can't keep taking his blood every 1/2 hour. When I was giving the numbers to the vet, he said that even though I was testing alot, I still might have missed is lowest bg level. I wish they made a chip to insert in people as well as animals that constantly took a reading. His poor little ears.

 

Well, that's the problem with jumping into a tight regulation approach without full background knowledge of how your cat responds to this particular insulin.

You shouldn't need to test him every 30 minutes, but in an 8 hour period, I would want to test at least every 2 hours. Yes, you might miss the lowest number, but you'll have it bracketed so you can extrapolate. I might test every 1/2 hour starting at hour 7 though. It's good to know how fast he is going up or if he's still going down before you give a shot.

Are you on east coast time?

 

Hi and welcome to FDMB -- you've come to the right place for help and hugs.

Great that you are home testing and feeding lower carb canned food.

One thing that caught my eye --- you said Luga GAINED weight when he became diabetic - MOST diabetics Lose weight, and the ones that GAIN may have a condition called Acromegaly -- excess growth hormone interferes with the insulin and causes weight gain.

Please confirm whether Luga gained weight and how much over what period of time. My Norton had Acromegaly, and he gained a pound per month for 4 months in a row in the early days of his diabetes treatment.


TID dosing can work, but you do need to test before every shot -- and you need to build up data on how Luga responds to insulin (curve) at different doses -- that way you can develop a Sliding Scale and adjust the dose to what Luga's BG is at shot time. The Sliding Scale is mainly only used with the shorter duration insulins like PZI or Humulin. NOT with Lantus or Levemir which really require steady dosing at 12 hours intervals to work properly.

 

I guess my first question is, should I do a curve now, or do I have to wait until his body settles into the new insulin. I don't want to do a curve if It's not going to be accurate.

Luga's weight gain has been gradual. He is getting older, he is 10 so he doesn't move around as much and he can't see that well, so the other cats won't play with him, he also is (I hate to say this) a little slow because of brain damage due to lack of oxygen when he was neutered.

Since we found out he was diabetic (8 or so months ago) Luga's weight has only fluctuated a couple of pounds +/- The vet said this was a good sign because if he was eating like a horse a lossing weight, that would be a problem. But he seems fine in that area.

It sure is puzzling. I'm not trying to keep him on a very "tight" bg. But I wish I could get him somewhat stabalized so that his neuropathy get's better. I've even tried the Vitamin B12, but nothing has helped because his bg is not stable.

Thanks so much.

 

My recommendation to get tests every 2 hours isn't really for a curve so much as to help you determine dosage. I'm a little bit confused on how much you are shooting. I think you shot 1 unit at 7 am this morning. Is that correct? What you need to know is how low that 1 unit took him. Testing every 2 hours will help you figure that out. You also need to know how fast (or if) the 1 unit has worn off by +8. That's why I suggested testing every 1/2 hour starting at hour 7.

As for the settling time, there's a lot of disagreement. I do think it's good to give the cats body time to acclimate to a new insulin though. Humulin N is quite different from PZI. So I'd want to find a dose that he does OK with, give him a couple of days on that dose, and then determine what adjustment needs to be made.

Good luck with the 3 pm shot. I'm off to a doctors appointment and won't be back by 3:00 pm. But hopefully Phoebe will be here to help you. She's a pro!

 

Agree... test every two hours to find out when the Humulin N has worn off. Maybe that is at 10 hours, maybe not.

Once you know the duration, then you can decide better if TID dosing will work and how much.

When we were doing TID dosing with Norton on PZI, due to our work schedules, we could not shoot 8 - 8- 8. We could shoot 8 - 10 - 6, so we developed a sliding scale and adjusted his dose based on his preshot BG, the scale and our knowledge of how Norton responded to the insulin. (if less than 8 hours from previous shot, the scale/dose was lower than if more than 12 hours). It was kind of syncopated TID, in that about every 2nd or third day, he would be in double digits at shot time -- :smile: so skip the shot

 

Hello...

Along with the advice yo have already received, understanding how your insulin works and tips designed to help use that insulin really can make the difference.

Here is the Humulin N primer, please have a good read through and ask any questions you like.
viewtopic.php?f=19&t=303

Kimmee

 

Do we know many people who've successfully done TID dosing with N? I'd think that unless you can work the overlap (can you with N?) that it would be quite a rollercoaster!

 

Hi,

I've been on this board for almost one year.

First off, may i suggest that you remove the 911 from your post. As that is reserved for emergencies - such as hypo situations, DKA, etc. This is not to negate the importance of your post, but just to not freak out people here about a possible emergency - OK.

You've been given a lot of advice so far and I'll add my 2 cents.

It seems that you are going backwards on the insulin spectrum - meaning you started on lantus which many of consider to be an excellent insulin, with terrific results in regulating our cats and even getting them into diet controlled remission. Now you are on a short acting insulin that quite frankly, may be very challenging to manage.

Also, I'd like to clear up a misconception that you were told about Lantus. While the manufacturer does claim that opened Lantus is good for 28 days, the reality is that many of us are able to use our opened Lantus for much longer than that (several months in fact).

Now there are simple actions you need to take to ensure the lantus lasts - Always keep opened and unopened lantus in the fridge. Doesn't matter what vessel it's in, must always be kept cold (not frozen). Do not shake, rattle, roll or re-inject the insulin.

If you follow those steps, Lantus should last a long time for you.

Also, please read the "starred" postings on the Lantus forum. It tells you everything you need to know about how lantus works, dosage and handling.

Lantus Forum

Without knowing how much lantus gave over that time and testing BG's on a regular basis, there is no way to tell if the lantus worked for your cat or not. Also, you may have skipped over the ideal dose.

You mentioned foods that you are feeding are these canned or dry foods? The EVO 95% canned is an excellent food that is low in carbs. There are many flavors of Fancy Feast canned that are low carb too - these are typically the pate style foods - without gravy or sauces.

Here is a link to Janet & Binky's Food chart. The idea is to feed 10% or less in carb foods.

Janet & Binky Food Chart

Yes, home testing is vital. You need to understand what the insulin is doing in the cat and if it is safe to shoot, etc. So, I'm glad you have learned. Do you need any further assistance in that area?

Such as tricks or tips to help the ears bleed? how to hold the lancet device? Not to reuse the lancet, etc? WE can help you with all that.

Neuropathy is a scary thing to see in a cat, Methylcobalamin B12 is a vitamin that is used to help slow and reverse the effects of the neuropathy. However, getting on the correct insulin and insulin dosage will go a long way in helping reverse the neuropathy.

Here is a link to the Methylcobalamin B12 I used and recommend to others:

http://www.vitacost.com/NSI-B12-Methylc ... 0-Capsules

Now you don't need to get this one, you can purchase it locally in a vitamin shop or supermarket, just make sure it contains Methylcobalamin and not another type of B12.

I would mix one capsule daily in Maui's low carb canned food.

I have not used N or PZI so I cannot offer insight into those insulins, but I have used Lantus and highly recommend it. You may want to reconsider using it and come to the Lantus board (link above) read and learn about it and post there.

Oh and if you have the data, would you start a spreadsheet and attach it to your signature, so that we can see what you have been shooting and the bg's etc.

Here are instructions on how to set it up and the template to follow:

Creating spreadsheet and attaching

 

Hi Linda--are you still with us? Just wondering how you're doing.......

 

Hi

Yes, I'm here. I did test Luga at 3:00 and his bg was 268. Not too bad. I thought that it would be much higher. Of course I don't know what his in-between numbers were because I haven't been testing every hour. I wanted him to settle into the N first. I did give him 1 unit at 3:00. He is due again at 11:00 p.m. I will test him before I dose him.

I know that it seems I took a step backward going from Lantus to N, but he was on the lantus for such a long time, with not very good results. His numbers were high. He has had several furcosomene tests done within the last 9 months and they determined that his bg had been at a steady high. Some of his readings were 350 and above. Sometimes reaching in the high 400's. We first thought he was insulin resistant, but as it turned out, he wasn't. The PZI was my idea. I suggested it to the vet after doing some research. Unfortunately Luga got worse on it. I have tried the 95% EVO wet and he didn't like it, but he does like the wet kitten food and the fancy feasts pate that are low carb. So I'm good with that.

Everyone says the Lantus is great because it works and it's long lasting, but I didn't get those results. If the N isn't working I'll go back to the lantus. I do know that it does bring his numbers down. It's the correct dose that's tricky. He's been on as little as 1/2 unit up to 3.5 units twice a day. It's either too much or not enough. Sometimes I wonder if my vet knows what he's doing or am I not understanding the whole process.

Tomorrow I am going to test him every hour and see how the new insulin is working.

 

Oh, I forgot.

I know that the lantus needs to be refrigerated. I never shook or mistreated it in any way. I gently mixed it by tilting it back and forth. My vet is the one that told me that it would only last 4-6 weeks. I only buy one bottle at a time so, of course it is opened in my frig and I never ever leave it out. I also make sure not to inject at the same site and not in the neck fold. I think I have followed all the rules.

 

Sounds like a good plan for moving forward. Please keep us posted on your progress.

 

So far so good today. Testing every hour on the hour until the last shot which will be at 4:30 (that would be 8 hours). So far he is in the low 200's and droping slowly. I gave him only 1 unit instead of the 2 recommended by the vet this morning at 7:30 a.m. I'm keeping my fingers crossed that he stays in the 100's until the dose at 4:30. That would be the best he has done in a very long time. I'll keep you posted.

 

good stuff! looking forward to seeing the final results!

 

Hi
I'm four hours into the testing and so far (on 1 unit)
9:30 291
10:30 234
11:30 214
12:30 266

I'm sorry to see that his number is going up now and probably will continue to do so.
I might have to go to 1.5 units in order to keep his sugar a bit lower so that
when he comes up, it doesn't get too high.

Thanks

 

welcome to N.....the good thing I see is that the action isn't steep, as is usually common. Increasing the dose a smidge will help bring the numbers down but won't help duration. But have a little patience and we'll see what you get today...

 

Yes, I'm happy its a slow decline. I'm ok with the duration. I'll just be happy if I can get it down a little more before it starts going back up. I think the 1.5 might do the trick. I have a feeling that he is a T.I.D. He has always been an unusual cat, with many disabilities. Hopefully we can get through this.

 

Here are the new numbers and they aren't so good.

at 2:30 461
at 3:30 477

He went up quick. I just fed him and gave him his insulin. Maybe 1.5 or 2.00 as the doctor recommended might be better. But I know it still won't change the duration, but maybe the numbers will be lower as he comes up.

Looks like I'm still on this rollercoaster.

 

ick...my only concern with raising the dose is if he bounces too much

a. he'll feel like crap
b. better chance of rebound which isn't good....

 

data gathering is a good thing, tho.
so you know he peaked at +3 and by +6 or so it was depleting quickly out of his system.
increasing the dose may actually increase the duration a little, tho i believe it tends to happen more as you approach the cat's ideal dose.

i'm not an N user (i've given only PZI and lantus), but based on the curve it looks like he can use more insulin. don't want him staying in high numbers too long, so i'd definitely check him on 1.5u with next dose.

re lantus: no need to gently mix lantus. so tilting/rolling are not advisable and may cause it to go bad faster. best just to draw up the dose, shoot kitty, then put right back in fridge.

 

This morning he started in the 200s and he ended in the upper 400s. What was different? Is he more active during the night than during the day? Could he be constipated or have gotten into some verboten food?

 

Totally off topic question here....Is that an english word (verboten)? I know it is a german word, I thought the english translation was vorbidden? Anyway just wondered if people use that in english as well.

 

See Webster's Dictionary for definition:
http://www.merriam-webster.com/dictionary/VERBOTEN

 

I've tried it and it's possible, barely, with a lot of monitoring. Not a recommended choice and it might well require 4x daily instead of 3 depending on cat.

Overlap is certainly possible and necessary to use.

On the bright side, these faster-acting insulins don't leave much around for the next shot, so there's no need to counsel waiting for 'depot' or for the body to adjust. It does what it does, so watch it every day until you can find a slower, gentler insulin again.

If you're interested, I can show you a "protocol" I thought up, that was tried successfully with Ruthe & Smokey, for transitioning from a fast insulin over to a slow one while keeping blood sugar reasonable.

 

thanks for the input Steve! I find that TID with N gets suggested every so often and I'm very leery of it but I've not tried it myself so my comments don't have the same validity...

 

i've done N tid/prn also, yes it can be done but it is really is not easy to do. you have to test all the time every single day. also need to feed at certain times to get the flattest curve you can with N. a lot of work. suggest getting the methyl-B asap for the neuropathy, it really helps. also suggest having a well stocked hypo tool box in house in case you get too much of a drop off the N, it does like to drop a cat out quick. you can control that with high carb fast acting food.

sounds like you did a lot of dose hopping when on lantus which does not work. it is a great insulin for cats and you might want to give it another try only with help this time from the people on lantus ISG that can explain why a number is what it is for you every day and help you get to right dose the right way (how you get to dose is as important as the dose itself with lantus). there is a phase of lantus use where numbers look like they are all over place, but really it is just body getting used to a normal range of numbers again and the phase ends, reacting by changing dose to higher or lower PS's doesn't work and doesn't let the cat work through that phase to get the nice low flat curve that lantus is famous for.

if you go to tech forum there is a sticky for spread sheets to put all your numbers on. that will help a lot, it is easy to see patterns on a spread sheet. just use a new line for each shot with the + hour from last shot before PS number when using the traditional bid spread sheet.

~jojo

 

Hi Linda--how's it going today?

 

Hi
Sorry I haven't been on this weekend, but I really wanted to look at Luga's numbers. I took his bg's alot this weekend.

After reading your posts, it seems to me that alot of people on this board are real advocates for lantus. I didn't realize that it took a long time for the lantus to level off. I think part of the problem was that since the numbers were all over the place, the doses changed as well. If he was too low, I would give him less, to high, more. I just figured to me that if he was too high, you needed to step up the dose. So there was alot of back and forth going on and my vet didn't just say - leave him at one does for 3 months no mater what. Instead I would give him a report every two weeks and we would adjust. Now I feel really badly about making him go through all this adjustment.

Getting back to the N. He definately Peaks +4. I get the lowest numbers - 67, 59 and then withing 2 hours, it's high 400's. So it is going down, not to fast, but shoots up +6, +7, +8. So then I give him another shot and we go through the same things. Here are some of my numbers:

Shot at 7 a.m. (1 unit) - don't know what BG was but I know it was high
9:30 BG 291
10:30 BG 234
11:30 BG 214
12:30 BG 266
2:30 BG 446
3:30 BG 471
4:00 )fed and gave 2 units)
5:00 BG 341
6:30 BG 156
8:00 BG 61
9:30 BG 143
11:00 BG 467

The reason I went to the two units is because that's what the vet recommended and I thought that it would make the duration longer. And you're right, there is no overlap.

So that's where I am now. It's hard giving him 3X a day, but I'll do anything to get this little guy back to normal.
I bought the B12 and am givig him 3MG in his food and he seems to eat it. He'll eat anything. He grazes all day.

Thanks

 

Glad to see you back. The good news is that he is responding positively to the N. The problem is that the drop is too steep. You might find that if you back off the dose a little bit and give him a more U-shaped curve that it will extend his duration (after a few days).

 

Honestly?

Given you are now understanding where we're coming from a bit more, I'd ditch the N and go back to lantus and start over. You can try and make the N work for you, but why? If jojo tried and found it difficult, and she's a vet tech, I see no reason to go through so much work when other options may work much better for both of you! N really isn't meant for cats, is showing in your cat that it is not the right insulin....Please consider :smile:

 

Hi Everyone

I just wanted to thank eveyone that responded. I can't beleive how many people have posted their ideas to help me. This has been so great. So thanks for taking out the time.

Linda

 

Hi Everyone

I have had Luga on the N now for over a week and I have to say he seems better. Maybe he is just a 3x a day kinda guy. The only drawback is the T.I.D. but I have to learn to work around it, and his BG does go up drastically before he's due for another shot. I'm still watching him but now I'm just taking numbers right before Shot and 4-5 hours after to see his peak. I guess I just have to watch and hope for the best. I'm giving him the B12 and hoping is neuropothy get's better.

Linda

 

Hi Linda,

Is there any reason why you would not be willing to try the lantus again? Honestly, it's much easier to work with, once you understand how it works and many, many cats do very well on it.

I'm glad you're able to home test and that's a half the battle. So, congrats.

how about giving lantus another try - give it a month and if you don't like it or the results, you can always go back the TID N.

What do you say?

 

Quick comment here... It's quite probable that by "mixing" the Lantus its life was shortened. The mixing is a misconception many vets have. Also, there is less waste with the 3ml pen cartridges than with the 10ml vials. (Just wanted to pass this along in case you should decide to go back to Lantus at some point.)