? Moose | 4/3 | AMBG = 271 | UPDATE FROM VET VISIT - Advice Needed

Hello all! It has been a while. I apologize for my absence, Moose and I have been very busy enjoying life off of insulin. I am sad to say that it was short lived, but it was great while it lasted

I noticed Moose drinking and urinating more, so I did a BG check (it was about time for his one month check anyway). It was 217 the other day, and 271 this morning (I'm sorry I have not had a chance to update his SS yet.)

I am taking him to the vet tonight as he needs to have his creatinine levels rechecked, and I will pick up a new bottle of insulin then. I'm not sure that I can start him back on the insulin until Saturday because I have many obligations this week and cannot monitor him closely. Obviously, I did know this was going to happen so I am not prepared schedule wise

According to the starting dose recommendations, he should start on ~ 1.5 U? I will get an updated weight at the vet and have a better idea of what his starting dose will be as I'm not sure if his weight has changed since I last checked it. I will resume TR protocol.

Nothing else has changed except I did start feeding him more. I had only been feeding him one 5-6 oz can a day, now I am feeding him 2 cans a day. I wasn't aware how low the calorie count was in some of the LC foods so I felt I was underfeeding him. We will see what his weight has done since then.

I also switched him from TIKI fish to TIKI chicken only. After rereading the blog written by Dr. Lisa, I saw that it is bad to to feed a lot of fish due to the mercury. He only eats TIKI chicken , Soulistic Chicken, and Friskies Pate (none of the fish varieties.) I wonder if this change affected anything with his BG. I didn't notice the excessive drinking/urinating until after I switched him, but maybe it was just coincidental.

Hugs & head bumps!

Edit: Edited to add that Moose did have a projectile vomiting episode the other night which is not normal for him. He does get a few hair balls here and there, but projectile vomiting is not the norm. I'm sure the vet will test for ketones tonight. If not, I have ketone testing sticks and I will test.

 

Aw, I'm sorry Moose fell off the wagon. Perhaps there is something temporary going on, like an infection that is causing this? Hope that's a possibility and if not, you have a lot of friends here and you'll get Moose back in line quickly.

 

Aw, I'm sorry to see you back for this reason. I don't know if I would start at 1.5u. 2 and 1 units were too much before. I would probably try 0.5u to start. Let's see what the experts say. Don't you have any insulin left from before? If you kept it refrigerated, then it should still be good.

 

Oh, bummer! Glad you're getting him checked out at the vet-- like Stacy says, it could just be a temporary blip due to an infection or something like that. Have them check his mouth for dental issues, too-- that's probably the #1 most common reason for dropping out of remission.

I don't know why the food change would have made a difference (assuming no formula changes by the company to increase carbs!) unless he's got an undiagnosed food allergy/intolerance. But, you know, brands like Friskies tend to contain a blend of all kinds of proteins (no matter what the "official" flavor on the outside of the can), so you'd think that any intolerances would have been apparent before.

Glad to see you back, but hope for both of your sakes that it's only a short visit away from the Falls!

 

That's a possibility! I had not thought of that. Hopefully the vet visit will give us more answers.

Thank you so much, I really appreciate it

 

Yeah the 1.5 U does seem a little steep, I would hate for a hypo episode right off the bat! I was only going by the recommendation that was on the TR protocol thread. But maybe that's for "new" diabetics?

I do! However, I was under the impression that it "expires" after 28 days. Honestly, when Moose was first diagnosed, I used the same bottle of Lantus for 2 years and it worked just fine. I was young and dumb and didn't realize that it had an expiration date until a pharmacist brought it to my attention. I was still skeptical though considering that the "expired" Lantus did regulate his blood sugar for those 2 years!

Thank you very much

 

Ok thank you, I definitely will have them check his mouth!

Hmm, that's a good point. It sounds like it was just coincidental then!

I am happy to be back, maybe not under these circumstances, but I did miss you all!

 

Additional thought on food intolerances: although it's probably not a protein problem for the reason stated above, it could be some other addition that's in the new food that wasn't in the old one. Grains/corn are common culprits, but if the food is low-carb that's probably not it. Hmm.

 

I should note that I didn't start him on the Friskies pate until after I had checked his BG last week (it was 217). I just picked up some Friskies Pate this weekend. I had switched him over to the Tiki Koolina and Tiki Puka Puka about...2-3 weeks ago? (from the Tiki & Soulistic LC fish versions.)

 

Another thought is... you did double Moose's food intake so that in theory may be double the carb intake? I am just throwing it out there.

 

Oh no! I am sorry to hear this. I am sure the vet will check his teeth also as a bad tooth or gingivitis can take a cat out of remission. Sending

 

I'm sorry Moose is giving you high BG numbers. I hope it is something simple and he won't need to be on insulin very long. You should still be able to use any insulin you had from before as long as it was kept in the refrigerator. Furball was OTJ for 1 1/2 years and I was able to use the last pen she had been using when she went back on the juice because it had not expired. Sending prayers.

 

I had the same thought -- get any source of infection or inflammation ruled out including dental, UTI, pancreatitis, etc. For many cats, their BG levels will increase prior to their showing any symptoms that they're not feeling well.

Lantus does have an expiration date but most of us ignore it. I'd use it as long at it's working. I'd also suggest calling around to see if you can buy a single pen anywhere. The prices for Lantus are outrageous. If you can track down a single pen, you can then order out of Canada (Mark's Marine Pharmacy is very popular) for a fraction of the price that Lantus will cost in the US.

I also think that 1.5u is a big starting dose unless Moose is back up to his ideal weight. I'd probably start a bit lower -- you can always fast track his dose up if necessary.

 

Possibly! The Tiki Koolina and Puka Puka are "0" carbs, but maybe I AM overfeeding him now...the fish varieties of Tiki are very low cal, and that was what I was basing his previous feedings off of and was feeding him 2 cans a day.

But now looking at the food chart, the 6 oz cans of the Tiki Koolina and Puka Puka are higher cal...~ 200 cals per 6 oz can. He's been getting 2 a day, so that's about ~ 400 cals a day which I think is double what he should be getting??

Oh goodness, have I accidentally been fattening him back up which may have resulted in higher BG??? I need to go back to Dr. Lisa's blog and look at the recommended calorie intake per day, but I'm pretty sure it was around 200 - 250 cals A DAY...

 

Sorry to see those numbers for Moose. I hope it is as an easy fix not a total drop out of remission.

Calorie intake - ideal weight in lbs x 13.5 +70 = calories required.

eg 15 lbs x 13.5 +70 = 272. Good luck on the food!

 

Thank you Bobbie!

 

Thank you Carla! I really appreciate it.

I have kept it in the fridge but it has an expiration date of 28 days after it had been opened...which is total bogus in my opinion so maybe I will still give it a shot and see if it's effective! I read that the reason that they put an expiration date of 28 days is because they do not test the effectiveness of the insulin past the 28 days...

 

I absolutely will! He has seemed very under the weather and had a projectile vomiting episode last week...I thought maybe the high BG was causing him not to feel well but maybe the high BG is a symptom of something else going on. We will see.

The cost of the Lantus vial was the reason I switched to Glargine. The Glargine vial is much smaller, and I was able to get through a full vial within a month when Moose was on 2U twice a day. However, I will look into the Lantus pens if those end up being even more cost efficient. The Glargine vial costs $72, and lasts me a month usually.

I'm not sure what Moose's ideal weight should be, honestly. The vet originally wanted him to get down to 15 lbs and he has surpassed that (last checked he was 14.6). We will see what she says today about his weight. But I agree, better to start small and slow.

Thank you!

 

Thank you!

& yikes, looks like I have been overfeeding. I did not mean to...I will adjust accordingly. Looks like he only needs one 6 oz can a day instead of the two.

 

Wean him so he doesn't feel like you are starving him.

 

Haha, he already acts like I'm starving him, even with the two 6 oz cans But I will!

 

Lantus is glargine, one and the same. Note the name of this forum. One is the brand, the other is the drug name. It comes in vials, pens, and cartridges outside of the US. Where did you get the "glargine"? Wonder if it was a repackaged Lantus. We recommend not getting repackaged insulin.

 

I get it directly from my vet's office. How would I know if it has been repackaged?

 

Take a look at the manufacturer's website (or Google images) and see if what you're getting from the vet looks the same. Some vets will buy a vial, and repackage it in a smaller container and thereby increase the potential for both contamination and that due to the process of repackaging, the insulin is damaged and doesn't have the same shelf life. A pen (or cartridge) contains 3 ml. A vial contains 10 ml. A box of 5 pens is typically more economical.

 

Hmm, none of the bottles appearing on the website/google images look like the bottle that the vet's office sells to me. The label is one that they print out at their office as it has Moose's name and dosing instructions on it. Sounds like I will no longer be purchasing insulin from them...

Thank you for the information. I really had no idea.

 

If the insulin you have is in the manufacturer's packaging, it will have an expiration date on it somewhere like if you buy something from the grocery store. It won't be 28 days.

 

Yeah it's definitely not the manufacturer's packaging.

 

That's sad your vet did that.

 

You can check out the sale forum on the main board. Sometimes individual pens can be bought there.

 

I'm pretty shocked. I had no idea and now I am pretty upset about it...

 

I will do that, thank you

 

Check your local Walmart. Mine sold me a single Lantus pen a few years ago.

 

Thank you! Definitely worth a shot, but they give me a hard time about buying the syringes so fingers crossed!

 

Just to help clarify, insulin vials do have an expiry date, as well as a lot number. Expiration dates should be well within the timeframe for use (i.e. My current vial expires 03/2020).

The second "label" is from the pharmacy, mine says to discard unused portion after 28 days. Because it is a human insulin, I believe the manufacturer only guarantees the stability and potency for 28 days, which is what the manufacturer submitted to the FDA as part of their drug approval.

 

Thank you Christie! I'm sorry, I did not mean to make it sound as though I don't believe that they expire at all, just that 28 days seems like such a short time, especially when throwing away a close to full bottle of $300 lantus...

I don't think that the insulin I am using now has an expiration date besides the "28 days from time of opening", but I will double check. From what others have stated above, it seems as though the vet's office I am buying it from is repackaging it and I don't think that they print the actual expiry date on their label with Moose's name, DOB, dosing instructions, etc.

 

You could always post a picture here of the "vial" and we'll help you figure out if it's repackaged. You are not alone, we've seen this before.

 

Oh gosh, no worries, that's not how I read your comment at all. Most human diabetics don't have to worry about using up a vial within 28 days! I agree it would be such a waste to throw out an almost full vial given we have relatively small doses for our kitties.

My pharmacist was concerned that I had been using the same vial for 4 months, I explained that I keep it in the fridge, and only take it out to draw the small dose, and I test often enough with my cat that I'll know very quickly if it is losing potency. They just have an obligation I think to clearly point out that the manufacturer doesn't guarantee potency after 28 days from opening. Funny enough, I went through a few cycles some months ago where I was sure it was the Lantus losing potency, but then discovered all that I needed was a dose increase to get Maverick's numbers back in line .

I'm sorry, I think I missed the part where you had mentioned it was repackaged by your vet, what I purchase from the pharmacy has the lot and expiry dates both on the cardboard package and stamped on the vial as well. That is troubling, I'd be looking for a different source of supply too .

 

Rae, if you end up having Moose back on the juice, send me a PM. I have pens .

 

My first vial of Glargine was through a local pharmacist and it had definitely been repackaged. It worked for the trial run of it, but I switched to Marks Marine after that.

 

I will do that, thank you.

 

Did that ease your pharmacist's worries after you told them that? How long did you continue to use the same vial of Lantus? Moose went into remission (the first time) while I was still using the same vial of Lantus. I had used it for 2 years...which probably was not the best but my old vet had not said anything about throwing it out after a certain time. But hey, obviously it was potent enough for him to go into remission!

I'm not 100% sure that it has been repackaged, but based on the comments here and a bit of googling, it would appear that it has been. We will see once I post a picture here. I'm sure the experts will be able to spot a repackage pretty quickly!

 

Thank you so very much! I feel kind of lost now that I probably won't be getting it from my vet. That means a lots!

 

They were actually really good about it. For me, I only had the original prescription from the vet, then I was able to get the refill from the pharmacy without going back to the vet. That's when they mentioned the 28 days, and more than likely because they were refilling without a script from the vet, they just wanted to make sure I understood that. They also suggested that if I started noticing that the insulin wasn't as effective, they could dispense the cartridge pens instead.

The first vial was about 5 months, it is likely still good, no floaties or particles, I keep it as back up in case my new vial gets damaged, I've seen horror stories of people dropping their vials and not being able to get insulin right away, and figured less potent is better than nothing! The current vial is just 3 months.

No kidding?! 2 years...you may just hold the title for longest running use of an insulin vial .

sorry to see Moose is back into some higher than normal numbers, I really do hope it's something easily fixed.

 

Vet Update

Got back from the vet an hour ago. I'll do my best to summarize the visit. (To note, Moose ate 2 hours before the blood test/urine test).

Physical exam revealed that Moose had excessive tartar on his back teeth. The vet was able to remove the tartar. He weighed in at 13.4 lbs. This a 1.1 lb loss from his ER visit in January (he was 14.5 lbs.)

Took urine/blood. Urine was negative for ketones, and 1-2% (?) glucose. PH was 6.0. Blood test revealed elevated glucose (363 mg/dL), elevated creatinine (2.6 mg/dL), and elevated BUN (51 mg/dL). The vet said he has the beginning stages of kidney failure. We discussed that the food appropriate for kidney failure (low protein) is counter productive for diabetes. She didn't have any suggestions, besides sending me a home with a can of Purina DM wet food (which I didn't feel like arguing with her about...just a bit miffed that I spent close to $2 on a can of food that I won't use. Oh well, what's $2 on a $200 vet bill?)

The vet suggested starting him back on 1U of Glargine twice a day. She wanted me to buy a new Glargine vial while I was there. I declined, and told her that I would like to test the (almost) full bottle that I have at home and see if it's still effective. I promised I would get the new Glargine tomorrow if the current bottle proved to not be potent anymore.

Any thoughts/advice on the test results and/or dosing are greatly appreciated. I suppose I'm not sure if 1U is too high until I begin dosing, whether or not the current Glargine is effective. Also not sure if I should change what I'm feeding him to help the kidneys or keep feeding to lower the BG.

I have attached pictures of the blood test results. I have also attached a picture of the Glargine vial as some were curious to see if the vet's office that I purchase the Glargine from is repackaging insulin.

 

I still think 0.5u is a safe starting point.

That would explain why Moose ate so much, yet lost weight.

BUN isn't as important as Creatinine. I think that's Stage 2. I wouldn't worry too much about that right now and focus on getting the diabetes controlled again.

 

Asia has CKD as do other cats here in various stages. There is controversy on feeding kidney diets as they are on the lower side with protein and that can lead to muscle wasting while preserving kidney function.

I chose not to feed a low protein diet for Asia, I feed her raw and she had been stable kidney wise until the diabetes diagnosis (and a kidney infection) for a couple of years. Low phosphorous foods are absolutely important. There are lists on low p foods, you can use Dr Lisa’s list or you can look here, this is Tanya’s CKD site and it has more information than you want, you can get lost over there. However, they discuss diet and the like. Also, add water to his food as long as he will tolerate it.

https://www.felinecrf.org/

 

It's been a while since I've dealt with CKD, but I have a couple of suggestions.
Did they also happen to give you a urine specific gravity (USG) value? That will tell you if Moose is concentrating the urine.
I'm wondering since it may be a sudden increase inthe BUN and creatinine values, and the fact that Moose's BG have also suddenly started rising, whether there may actually be a kidney infection? I have no experience directly, but it may be something you can ask your vet about?
Incidentally, there are other reasons for elevated creatine and BUN. For example, if Moose is a larger, more muscular kitty, the creatinine can be higher. If he is dehydrated, the BUN can be elevated. That's why the SDMA test is better at confirming CKD. Also, did they get any phosphorus, potassium, sodium, calcium readings? If Moose has early stage CKD, you ideally want to feed a low phosphorus diet, I'm not certain of the value but somehow less than 300 mg/100kcals seems to pop in to my head...the lower the better.

That vial does seem repackaged. Mine definitely doesn't have a peel-away label.

 

I think it's weird that it says it's a compound drug. Doesn't that mean mixing ingredients? I would think repackaging is just the insulin being transferred from one vial to another.

 

Yes it's repackaged. We've seen that from Wedgewood before. If the current insulin doesn't work, get a paper prescription and see if you can get pens at a human pharmacy.

What's more important any in early stages of CKD is good quality protein that is low phosphorus. The Fancy Feast may have to come out of the rotation, it's phosphorus is higher.

Hoping it's just a short stay here.