Meet Warren (again)

I was trying to find my old post to update it, but just figured out the board updated software and it looks like old posts were lost.

Anyway, this board helped me regulate my 14yo DSH after he was diagnosed with diabetes. We were using Vetsulin and he did so well, we were able to take him off insulin completely after 4 months. Unfortunately he's had a relapse and the Vetsulin isn't lasting the 12 hours. I'm working up a curve on him now to see if it makes sense to dose more often or possibly switch. However after spending the past hour reading, it appears ProZinc is no longer what it used to be (and expensive) and Lantus even more expensive. Any recommended threads on pricing and best places to buy?

 

The four insulins which last roughly 12 hours in cats are as follow:
2 depot insulins
Lantus
Levemir
2 non-depot insulins
ProZinc
BCP PZI - your vet can get a free sample with this form.

 

Thanks, I'll certainly give the free sample a go, but assuming the vet agrees to send it in, I suspect it would take some time for the vet to get the free sample and I'd need a solution in the meantime.

Is there a thread you'd recommend re: cheapest places to purchase the above recommendations?

 

If you go with Lantus or Levemir and are in the USA, you'll find that Canadian pharmacies are much less expensive. Marks Marine is one of the pharmacies folks have had good luck using. Either of those should be purchased as the 5 pack of pens, as you'll be able to use all the insulin before it wimps out. You still use a syringe to withdraw the insulin from these.

 

Marks is definitely by far the cheapest I've seen, thanks a ton for that tip. I'm a bit curious though about shipping options.

Regular Air Mail 2-3 weeks - $14.75
Expedited 1-2 weeks - $19.95

Doesn't this stuff need to be kept refrigerated?

 

It is shipped with refrigerated packs to keep it cool.

 

I'm guessing then it only takes a day or two to arrive, it wouldn't stay chilled for longer than that. I'll talk to the vet tomorrow about a prescription, hopefully they won't have a problem writing one. They're running a battery of tests, so hopefully nothing else comes up and it's just a matter of getting his insulin switched. I'm very grateful for the lead on Marks. That's even more affordable than the vetsulin doing it that way, especially since it's 100U instead of 40U.

 

Hi Rob,
FYI, I think your original thread is here:
New to diabetic cat

 

Yep there it is, thanks!! I searched for all posts by robr and all posts I was watching and came up empty.

 

If you click on your user name and go to your profile page, there is an option to see all your content, or your posts.

 

Prescription in hand, U-100 syringes ordered, Lantus ordered, just awaiting confirmation of the order. In the meantime, after doing a curve, the Vetsulin is only lasting about 8 hours. I started doing 1.5 units 3x a day now and so far no more litter box accidents. Warren is however getting very sick of having his ear lanced and flattens them out as soon as I touch them, but his curve is looking much better. Sorry buddy! He can take comfort knowing I have to stay up until midnight for his next dose.

 

Very strange, I measured warren's glucose level before giving him his injection this morning and it was 160.
It had been 8 hours since his last shot and I actually reduced the dosage a little for that one (from 1.5 to about 1.25) since I'd be asleep and couldn't monitor him.

Yesterday after 8 hour intervals, he was at 337 and 320. (prior to switching to 8 hour intervals, his 12 hour readings were around 500).

Looks to me like he's going to be good for about 12 hours from this particular dose. Maybe I ordered the Lantus prematurely and his body needed some time to adapt to being back on the Vetsulin? It's been about a week since he went back on.

 

It'll be easier to see if it is on our grid to record your glucose tests which will help us give you better feedback. Instructions are here.

Understanding the spreadsheet/grid:

The colored headings at the top are the ranges of glucose values. They are color-coded to clue you in as to meaning.

Each day is 1 row. Each column stores different data for the day.

From left to right, you enter
the Date in the first column
the AMPS (morning pre-shot test) in the 2nd column
the Units given (turquoise column)

Then, there are 11 columns labeled +1 through +11
If you test at +5 (5 hours after the shot), you enter the test number in the +5 column
If you test at +7 (7 hours after the shot), you enter the test number in the +7 column
and so on.

Halfway across the page is the column for PMPS (evening pre-shot)
To the right is another turquoise column for Units given at the evening shot.

There is second set of columns labeled +1 through +11
If you snag a before bed test at +3, you enter the test number in the +3 column.

We separate day and night numbers like that because many cats go lower at night.

It is merely a grid for storing the info; no math required.

 

Thanks, probably not much point in filling that out now since he's getting switched to Lantus on Monday, I'll just have to closely monitor over the weekend.
That one dose lasted longer than the others, (perhaps I gave him slightly more Vetsulin that time, it's hard to get exactly 1.5 units with .5cc U40 needles... I ordered 0.3cc U-100's for the Lantus) we're back to 8 hours or less really (8 hours after the last two doses he measured right around 400). Rather than putting him (and me) through continuing to map a curve when we're switching, I'm only measuring at about 7-8 hours. I'll be getting up at 3 or 4am until I get him on the new stuff.

But bottom line is he's once again doing much better. No litter box accidents since moving to 3x/day and he's grooming himself again.

 

Well, if you set it up now, it'll be ready to roll when you start the Lantus. Sometimes, folks have a few hitches in getting it done.

 

Warren's Lantus spreadsheet is up:
https://docs.google.com/spreadsheets/d/1S508KbqLlvVG3Ajq69o5ZfFJ6ENWA_CcZwHmSZAF8h0/edit?usp=sharing

I switched him from Vetsulin on Thursday night close to midnight. Haven't really collected enough data yet to figure out how he's reacting and to be sure all the vetsulin is out of his system. It's a bit odd to see his levels still dropping at +10 today (reading of 60), but yesterday at +10 he had an accident (reading of 415). Not sure there is anything to learn from this data yet, other than take more readings over the next few days and try to take them more often. I'm terrible at getting blood from his ear and sometimes it takes me 5 or 6 attempts. So he's not very cooperative as you might imagine and I don't want to traumatize the poor guy any more than necessary.

 

Going to have to skip his shot tonight and put him in the bathroom with a litter box. I need to go to bed and at almost +13 his blood sugar is 80. Gone from not lasting long enough with the vetsulin to lasting too long with the lantus.

 

When you have a chance, please add the spreadsheet link to your signature. That way it will show up for every post, making it easy to review.
Any time you get below 50 mg/dL on a human meter (or 68 mg/dL on a pet meter), you may take a 0.25 unit reduction. Lantus builds up in the body over 5-7 days starting out and 3-5 days on later dose changes.
So, tomorrow morning, eyeball and dose 0.75 units, if he is above 200 mg/dL on your meter at pre-shot.

 

Signature added. He was at 540 this morning and I gave him approx 0.75 dose.
I wish I could find smaller diameter syringes, it's hard enough to measure 1 unit, nevermind fractions. I'm using Ulticare Ulti-Fine U-100 Insulin Syringes - 29G 0.3cc 1/2" and they only have markings for full units. The distance between units is tiny.

 

They do make 3/10 (0.3cc) insulin syringes with 1/2 unit markings. That is all you can do

 

It can help to get magnifiers. If you wear glasses, Carson Clip and Flip work pretty well. A free standing magnifier works well, too.

Some folks use calipers to measure on the syringes, particularly when they notice that the lines aren't consistent from syringe batch to syringe batch.

Check the syringes at ADW; purchases there help support the board.

 

After the 0.75 dose, at +9 he was reading 364 and I had to give him his evening dose. I have him 1 unit. Hopefully it will last 14 hours like last time to get him though until I wake up.

 

Lantus works best using the same dose, every 12 hours. You already know that 1 unit can take him too low, so go down to 0.5 or 0.75 units in the morning and stick with it.

We have 2 protocols for this. Please review them and pick one
Tight Regulation
Start Low, Go Slow
Unless the glucose goes too low (under 50 mg/dL on a human glucometer), you hold the same dose for a minimum of 2 full days (high dose, Tight Regulation cats) to 2 weeks (Start Low, Go Slow protocol cats).

When the glucose drops swiftly and/or drops to an unfamiliar number, it triggers hormones which release stored glucose (glycogen). The glucose elevates for up to 3 days after this. He is currently bouncing; do NOT raise the insulin.

 

After reading up on the tight regulation protocol, it sounds like I should have just waited the full 12 hours and stuck with the same .75 dosage and continued with that for 5 days or so and see where he's at. That's fine, he'll just have to live in the bathroom overnight in case he goes too high at the tail end and has an accident.

If you look at his chart, yesterday he had 1 unit, and he did not drop below 50. The only recorded incident I have of him dropping below 50 was actually after an approx .75 unit dosage the day prior. That was because I foolishly gave him his next dose at +12 even though he was reading 93 (my thought was that like Vetsulin, it would take a couple of hours to kick in and by then, the current dose would have worn off, but in hindsight, I don't have enough information on how he reacts to Lantus to try to overlap). So right now, before we've given things a week to stabilize, 1U is too high for 12 hour dosing, but .75 is too low for 12 hour dosing, and there is no good way to measure anything in between with any kind of accuracy.

I'll resume 0.75 in the AM and just hit him every 12 hours for the next 5 days and see where we're at.

 

On a single shot basis, you might think that 0.75 is too low. However, the effects build up over 3-5 days of the same dose at the same time.

Lantus forms small crystals under the skin. These dissolve and release the insulin to work. At the end of 12 hours, some crystals remain. We call this the depot or shed. It gives some overlap between shots when done consistently.

Think of a funnel. If you pour water in too fast, it will overflow. Pour it in too slowly and it runs right through. Get just the right speed and a small pool of water is created; that is what you are aiming for with the Lantus.

 

Got it to some degree..... we're at +6 today after 0.75 and he hasn't gotten below 344. (update: 293 at +8, 518 at +12) Will keep taking readings every 2 hours or so until bed and see how things look tomorrow. Getting better on taking blood. Last 3 times I did it in on the first try and he's being less fussy because I'm not stabbing him 50 times . Probably just jinxed myself.

 

He's still bouncing a bit; you just have to grit your teeth and hang in there.
So long as you you get the pre-shot tests and a test sometime in the +5 to +7 hour period, you don't need to test every 2 hours.
As you start getting down to low numbers near 50 mg/dL at the nadir, snagging a test before bed can be helpful in deciding if you need to get up later to test mid-cycle to make sure he's not too low. High glucose causes problems slowly; low glucose kills quickly.

 

Thanks for the advice, will test him once more at +4 before bed, but he will appreciate not being prodded every 2 hours.

 

If, and only if, he starts diving towards 50 mg/dL on a human glucometer, then you would need to follow our hypo protocol where you:
- feed 1-2 teaspoons of high carb
- wait 20-30 minutes
- re-test
- and repeat until past the nadir, with 2 or more rising number.

 

Hi BJM, I think we have a bit of a dilemma. Can you check out the spreadsheet please and let me know what I should do? It's time for his evening shot and we're at 90.

 

I just got home did you shoot yet?

I suspect he is heading off the juice. The bounce definitely broke! Wait 30 minutes without feeding (ie stall),re-test, and if rising, I think I would reduce the dose to 0.5 units or skip until tomorrow.

 

I haven't yet. Was going to check again in a bit. When it wears off he seems to climb quickly. Should I do 0.5 from now on or go back to 0.75 tomorrow am?

Thanks again for the help.

 

Re-test. Is the glucose rising? If yes, I'd go with a token dose - maybe only 0.25. If not rising, I'd skip.

 

It's on the rise, 130 at +13.5 hours. So you think 0.25 tonight and back to 0.75 tomorrow AM? Or 0.5 tomorrow AM and going forward?

 

I'm thinking 0.25 tonight, to keep it from rising too high, and depending on the morning pre-shot, 0.25-0.5 units.

 

Once you find a safe dose you can shoot every 12 hours, things should stabilize into a routine. Then you can get into the protocol that will work best for you.
The choices:
Tight Regulation
Start Low, Go Slow

 

My reading at +12 said "HI" and he peed on the floor last night (with a litter box 3 feet away). I retested again and it was 590. This meter may cap out at 600. So far it seems like the Lantus wears off more quickly at night. Going to dose him now with 0.5.

I also got up in the wee hours and measured him at +7 and he was up to 359.

 

I agree with the 1/2 units this morning.

 

We haven't had a very good day today with the 0.5 dose. I have to be honest, this is getting frustrating. With my inability to accurately measure his dose, I have no idea if it's dosage errors preventing us from finding a stable approach or if it's Warren. Any recommendations on how to move forward this evening?

PMP 590 / +2 490 / +4 310 / +6.5 460 / +9 359

 

Stick with the 0.5 units again. Lantus needs to build up to a stable consistency over 3-5 days.
You've got his spreadsheet up, so you're ready to start posting in the Lantus forum, following whichever of the 2 protocols you choose.

 

Ok, 0.5 it is. I expect him to be off the charts in the AM. Hopefully I'll be surprised. His PMPS tonight is 566.

 

Lantus is like climbing up a down escalator. Go too slowly and you're right back at the bottom. Go too fast and you get off at the top. Get up to a midpoint and maintain a constant pace and you'll stay close to one level.

 

I think the escalator is a better analogy than the funnel . I was pleasantly surprised this morning. Warren was in the low 400s instead of the high 500s.
Hopefully he has a better day and I can let him out of the bathroom for a while.

 

Different analogies work for different people. There's another one about turning a huge cruise ship
Keep hanging in for a total of 3 full days and then the a couple of mid-cycle tests between +5 to+7, or a curve (serial testing every 2 hours from pre-shot to pre-shot) will evaluate the dose.

 

Will stay the course. He was at 170 I think it was at +4 today so he's running around the house happy to be out of the bathroom. He didn't see the 100s at all yesterday.

 

So I thought Warren had a much better day today, after +4, he was in the high 100's all day (and still is at +11). I let him roam the house freely but he peed on the kitchen rug. My wife has had about enough and is starting to push me to get rid of him. There is nothing else wrong with him, I had a full blood and urine workup done 3 weeks ago. In 15 years he has not had behavioral issues, so I have to put this back on the diabetes. Does it take a while before they start reliably using their litter box again? Are his readings still high enough that it could cause this? He is still drinking a ton.

 

He's making progress! So long as he is not controlled, he is going to have accidents. Imagine having the need to go and not being able to control it. That can happen with diabetic neuropathy, nerve damage caused by excessive glucose levels in the body. High glucose also makes them more susceptible to bladder infections - did the vet check for that when you were last there?

And some inexpensive painters tarps will reduce the cleanup from the accidents and maybe the conflict with the wife.

 

I'm not sure if they checked for that, I'll call when they open. 282 AMPS today. Moving in the right direction still.

 

Hi BJM, would you mind taking a look at the past 2 days and see if you think I should continue with our current track? He hasn't really gotten under 300 in 48 hours, but the AMPS and PMPS did decrease on both days.

 

I would take it up to 0.75, which you will have to eyeball, as syringes don't measure quarter units. Ideally, you want to find a dose you can give safely every 12 hours.

Are you testing for urine ketones with either KetoStix, KetoDiaStix, or generic? That'd be really important to do.

 

Not closely, last time I measured was probably a week ago (it's noted in the spreadsheet). I gave him 0.5 about 15 minutes ago and since I can't measure another 0.25 accurately I'll start 0.75 tomorrow am. Warren and I thank you for all the help you've been.

 

If you'd like, you can start posting in the Lantus forum. There are many very experienced Lantus users there to give feedback when I'm not around.

 

Thanks. Btw which syringes here have 1/2 unit markings? Doesn't seem to mention that info.

http://www.adwdiabetes.com/catalog/insulin-syringes_178.htm

 

Generally, 3/10 mL syringes are more likely to have half unit markings (I get mine from WalMart and all their ReliOn 3/10 U-100 syringes have half unit markings - they also have online ordering). If you can't tell by the product descriptions ay ADW, call them and they'll help you out.

 

Ok thanks, my ulticare 3/10ths don't. I need some more relion test strips anyway so will give Walmart a shot.

 

Hi bjm, I'd really value your input. I'm unfortunately not getting very much support from the lantus board and my wife and I are now butting heads. She's tired of Warren using the kitchen as a litter box a couple of times a week when there is a real litter box in the bathroom a few feet away from where he is peeing. She wants him put to sleep. He still has not stabilized and he's been on lantus a month now. I'm afraid I may have very little time left before I'm given an ultimatum. I can do another curve if that might help but it seems we don't have another choice in dosage. He drops too low if I go up, but at .75 his readings are all over the place. Thanks.

 

Perhaps you should try posting in the main health forum with a title that better describes your current predicament. It may get more views than on here. Include links to this post and the one in the lantus forum. I hope you can work it out!

You could try adding another litter box somewhere else in the house.

 

For right now, pick up some tarps or medical bedpads to place where he has had accidents, to make clean up easier.
For cleaning, first remove all solids, then blot up all liquids. Use an enzyme based cleaner to treat all areas as directed on the packaging. I like Simple Solution.

 

Thanks guys, I'll try the other forum as you suggested. Cleaning is not an option, my wife will not entertain any further accidents. She has sentenced Warren to live in the bathroom but her patience is thin with that as well. That's where she does laundry. I added another litter box a month ago, it's literally 5 feet away from where he's been peeing. He uses the box fine when he is in the bathroom and has never had an accident in the bathroom. I already purchased enzyme based cleaner (bought some stuff with 4.5* with 2100 reviews on Amazon).

I just don't see what else I can possibly do with the Lantus. At what point is it time to say Lantus is never going to work properly and it's time to try Lenevir or something else?

 

Urinating outside the box can also be indicative of some other problem. Could he be over anxious? If so maybe a pheromone collar or defusers might help.

 

Other than his diabetes, the vet gave him a clean bill of health after full lab workups a month ago. He doesn't seem anxious at all, he seems his happy normal self. If it wasn't for the peeing, I'd think he was completely healthy. He bathes himself, he plays with toys, he purrs all the time, his coat is soft and shiny. But his blood sugar levels are all over the place from day to day. If not for my taking readings, I wouldn't even guess that was an issue. I'm willing to try anything though. I initially thought the peeing was because he was drinking so much he couldn't hold it, but with the litter box 5' away, that doesn't seem like it would be the case. He has never had any issues in his 15 years with behavior and marking his territory. I'll read up about pheromone collars, hopefully it won't freak out the other cats.

 

I'm just trying to think of any other possibility you may have overlooked.

 

I appreciate that. I'd hate to have Warren meet his maker for overlooking something obvious.

 

Did the vet do a cystocentesis to check the urine for crystals or an x-ray to look for stones?

 

I provided a fresh urine sample which was tested for various things. I'll see if they can provide me with specifics as to what was tested. My thought was that the peeing was related to the diabetes not being regulated and was hoping by now it would be regulated and either the peeing would stop or we could eliminate the possibility of it being the diabetes causing it.

 

It has to be cystocentesis. If you do a free catch at home, it can very easily get contaminated between the litter box and the lab. When they do cystocentesis, they are able to get a sterile sample so if bacteria shows up, they know it's from him and not from contamination.

 

and a few months ago test isn't indicative of what's necessarily going on now.... see Julie's explanation of how fast bacteria can grow
in your other thread.

 

Hi there,
I know I'm getting in on the end of the convo, but regarding kitty (Warren?) peeing outside the litter box, I have a 2 kitties who do similar things. For one of my kitties, the vet thinks it may be due to old age (arthritis) as well as a territory thing. The other one (my diabetic kitty), periodically sits on the litter box the opposite way (rear facing outside the litter box as opposed to rear facing in)...
Both kitties have been checked out. My diabetic kitty did have a UTI, however, he's always done this even before he was diagnosed with diabetes. And, his UTI is now gone. My non-diabetic kitty goes pee 1-3 feet outside the litter box. To address this issue, I put down those dog wee wee training pads around the litter box. These absorb up to 6 liters of fluid and work great as they have a plastic liner on the bottom. My other kitty also has a tendency (when using the litter box) to crouch on the edge of the litter box, with his rear facing outside of the litter box (thus he misses the litter box completely and pees just outside the litter box). Thus, these doggy wee wee pads come in handy. Perhaps they will help Warren as well!? Just a thought... BJM, Rhiannon and Shadow, Marje and Grace, and Elizabeth and Bertie et al., are the best ones to advise RE: insulin..Best Wishes!