Problem with Lantus Injections

After many years since visiting the board, I'm here seeking advice. Our Cody, a male siamese, celebrated his 20th birthday last month and his 5th year with diabetes. My wife and I tried tight regulation initially and after a brief period of remission, had to resume giving lantus. He remains on a relatively low dose averaging 1.25 units twice a day. The problem we've had on an ongoing basis and that has become more of a problem lately is fur shots. We give the injection, wipe his fur and smell insulin. We can count on a glucose rise of about 200 in 12 hours, creating a stressful situation because we know we have to get the dose in the next time. It's very difficult because with such a low dose, it's risky to try to repeat a missed or partially missed dose. We are injecting in his flank, and are successful 90% of the time, but we seem to be having more difficulty lately, and have missed/partially missed the last 2 injections. We've watched videos and employed the technique, but with longer fur and the 5/16 needle, we are still having trouble. He is also difficult to regulate, remaining at 100-150 for a few days, then in 12 hours dropping to about 40 or going to 300+. Thanks in advance for any suggestions.

 

Oh, I feel for you as I went through a period of doing several in a row I watched some more videos on technique and I will share the one that helped me the most. Even though I did not shave my cat's fur like the vet in the video did the "triangle shaped tent" helped me with needle placement. Hope it helps you too. Also have you tried changing locations like around the shoulders of his side just to see if you will have better luck?

 

Poking my finger into the tent and finding the flat where I wanted the needle to go made a big difference for me. No fur shots since employing that technique.
Have you seen the "roll" technique, also? It's supposed to be better for kitties with longer fur. It's towards the bottom of the first post here

 

Shaving the injection site is an option. That way you remove the hair barrier and only deal with the skin.

 

Me too!

 

I had far less success with flank shots than shooting in the scruff. For what it's worth, there are longer needles available from BD.

 

Barb (my wife), Cody, and I thank each of you for the suggestions and for the quick responses. Each of you knows how much it means to be able to connect with somebody out there that has experience in caring for their diabetic cat. I remembered this board offered a wealth of experience and it was the first place I came today after taking him in to have the vet get him regulated. Vet visits are very hard for him. They had to sedate him, but he's home now and between my legs sleeping as I type. Sienne and Gabby, thank you for your post. We began injecting in the scruff, and it was easier to shoot him there, but we were told by one vet that insulin was not as well absorbed there, but your experience suggests that we need to go back to the scruff.

Bobbie and Bubba, do you inject into the scruff as well? Thank you for the video. When I shoot Cody, I lift the skin, slide needle in, and feel for the end of the syringe to be centered between and just below my fingers, angled slightly downward. I'm thinking now that this is too high after watching the video.

Andy, the roll technique lets me see the skin. I'll keep that option in mind.

AZ, if we continue to have trouble, we'll shave an area so that we can improve on technique.

Thank you all again for the quick replies and sharing your experience.

Kind regards,
Marion Davis (Dave)

 

I did last night because it is said that the scruff doesn't absorb as well or fast and I wanted to slow down the insulin last night. I indicated in on my Spread Sheet so I can look back and see if I think it did slow things down. Most of the time, I inject below his shoulders and I alternate from right to left. Hope the video helps you, it sure did me as most of my fur shots were the needle going all the way through the skin and out the other side. When I saw the video and the "Triangle shape" it helped me place the needle differently and really helped me.

 

I shoot a bit behind the scruff, over the ribs, where there is still loose skin. Right side AM, left side PM.

edit to add: sounds like the same spot as Bobbie

 

Hi Dave--
I have senior kittys as well.... one is thin and the other is "big boned"--
It is definitely easier to give a injection to my big guy--my other is 17 and he is non diabetic but he gets fluids, adequan and cerenia. I always give fluids before either of the other injections as he does not have as much "wiggle" room to shoot-
Not sure if your kitty gets SQ but being 20 I am thinking so..... If so, you want to spread out the fluids and the insulin by several hours.
my 2 cents

 

I shoot the flanks and I use the roll method. I find that the flank skin doesn't tent as well as the scruff (probably because there isn't as much loose skin there comparatively), plus I can see the skin if I roll just right to get the hair to part nicely.

 

He was 205 at the vet's office about 4 hours ago and was 395 a bit ago. I opted to go with the flank with roll method. I could see the skin, he flinched when I inserted needle. I did not smell insulin on the first rub but clearly smelled it when I rubbed him again. Could I be pushing insulin back out as I rub over the site? I do like this method better because I can see where I'm injecting. Thanks for the suggestion.

I'll check him again in a couple of hours. I realize you folks are reluctant to give dosing advice, and I certainly would not hold anyone responsible, but I am interested in knowing what you do if you smell insulin after an injection.

Thank you for responding, Jayla. We had to give him fluids at home once after receiving I131 treatment for thyroid cancer. He's on a wet diet of Purina Classic and drinks well. The vet was concerned he might be dehydrated but he was not.

 

In the case of a possible fur shot, you should never try to correct it. There is no way to know how much, if any, insulin went in. Best thing to do is gather data on the cycle and wait for the next scheduled injection.

Could it be you have insulin left on the syringe needle, after adjusting the dose? Many folks here wipe the needle with a tissue before injecting. This way if you smell insulin you KNOW it didn't go in the cat.

I also think it is possible for a bit to squeeze back out the "hole". I used to "smell check" often and sometimes there is no odor initially, but then odor an hour later. Letting the skin relax before removing the needle seems to help with this.

ETA: I've come to the point myself where if it doesn't feel wet, I assume it was a successful injection. So my kittie smells like bandaids, oh well....

 

Feel the site with your hand also for wetness. As Andy said, sometimes there is insulin on the needle tip when you inject which you can smell but does not always mean you had a fur shot.
Can we get you to set up a Spread Sheet like the rest of us and then dosing advice would be easier to see your data.

How to create our spreadsheet

 

Thank you for the responses. I touch the tip of the needle to a tissue to dab off excess before injecting. We keep a written record of glucose, amount lantus given, and time. I can enter into an excel spreadsheet or enter manually in a reply. How much historical would you like and how would you like for me to provide it?

 

If you could put your data on our SS that would really help peeps here to offer advise to you. Here is an explanation of how to read the SS. if you click under my post on Bubba's SS it will allow you to see what it looks like. Below is an explanation on how to use it and/or read it.


AMPS is the AM Pre-shot test (always test before shooting to make sure they're high enough to give insulin)...then the U column is for "Units" (how much you gave)

The +1, +2, +3, etc are for how many hours since shooting...so +2 is 2 hours after the AM shot, +9 is 9 hour after, etc.....Since we're all over the world here, saying "he was at 148 at 8pm" doesn't tell us anything...we need to know how long since his last shot

At the end of a 12 hour cycle, it's PMPS time! (PM Pre-shot) and the whole thing starts over.

If you need help setting it up just ask and someone with help you ( needed help)

 

It would be best to enter the data you have into the spreadsheet that we use here....We really depend on it to help show us the "patterns" we look for before we give any advice on dose adjustments

 

How do I bring up a blank spreadsheet?

 

FDMB SPREADSHEET INSTRUCTIONS

 

Is the blank spreadsheet showing up now?

 

yep!

 

I see your dosing is all over the place. FYI, Lantus does not work like conventional insulins. Doses should not be adjusted for the pre-shot number. Lantus needs consistent dosing to work properly. One shot builds on the next, so to speak. It is a depot insulin, and every time the dose gets changed, the depot is disrupted. Learn about the depot here.
It's going to be tough to give dosing suggestions without any mid cycle tests. Lantus dosing is based on how low it takes kitty, not the pre-shot number.
You will also need to look at Tight Regulation Protocol and Start Low, Go Slow and see which "method" you would like to practice.

 

There is also much more useful information in the New to the Group Sticky


Please ask any questions!

 

You did good, but the first thing I notice is that you're changing the dose a lot....Lantus craves consistency so we need to find a dose that's safe to give both AM and PM

Next thing is that it looks like he's stuck in a "go low and then bounce high" mode which probably means the dose is too high....it's taking him too low, his liver is responding by dumping stored sugar and hormones to bring him up quickly and he ends up too high.

Lantus dosing is based on how LOW it takes them, so it's also really important to try to start getting some mid-cycle tests on the AM cycle (around +5 to +7) and at least a "before bed" test on the PM cycle since most cats go lower at night

What are you feeding? And what type of meter are you using? It would help to go ahead and fill out the signature box so we don't have to keep asking the same questions over and over again. Most of us put things like name/cats name, age, date of diagnosis, type of insulin, type of meter, type of food, as well as any other health problems we know of.

 

Thank you, Andy. I'll look at the links tomorrow. We've known about "holding the dose" and there are instances where we did not adjust based on the result. Over time, we found the adjustments seemed to work, but we're certainly open to not changing the dose unless he goes low. As far as more frequent checks, we have found in the past he goes lowest at 12-13 hours. His left ear is very sensitive, so we move around on the right ear to get the 12 hour readings. There have been times when he's been hungry and we've found him to be low at +9. We'll try to get some additional checks in over the weekend. Thanks again for the input.

 

Thank you for the reply, Chris. The "wild card" seems to be inconsistent dosing and fur shots where he gets partial doses or none at all. I'll add additional info as time permits, and we'll work on holding the dose and intermediate checks. We're feeding Purina Classic turkey, beef, and mostly chicken, which he seems to prefer. We use a Bayer Contour meter.

We've been doing this for a while and have deviated from some of the lantus standards because they seemed to work. The big problem lately is getting the insulin in. My wife's a nurse and working tonight. She has a better track record than I do, so hopefully we can get him regulated soon. Thanks to each of you for caring enough to reply with suggestions. We'll keep you posted.

 

How are you shooting? Using the "tent" method all the video's show?

 

We always shot in the scruff because it seemed easiest - we had very few fur shots. I'd shoot where it works for you.

Others have mentioned the dose changes, and you guys have been doing this for years, so you may not feel like you need much advice.

The one thing I'd say is that with a preshot in the 40's, it's very possible he's going lower after the shot. Cats do change in how they respond to insulin. If he's going low, that could easily explain why you've got some high numbers (the red pmps for the past couple of days) thrown in there. You are probably familiar with bouncing? I think you've got some lows causing bouncing highs. If he were mine, I'd stick with the 1.0u and try to get a spot check now and then to see how low the dose is causing him to go. I don't see anything to suggest he needs more than 1.0u and I think he might flatten out some with holding the dose a little longer.

But as I said, you've been doing this for a long time, so take it for what it's worth. Best of luck to you!!

 

I need to leave for work in a bit but want to reply. Cody was (thankfully) 315 at 4 AM, down from 483 at 10 PM last night. I'm thankful to say he's between my legs purring again.

Yes, Chris, we've always used the tent method with about 90% success, but with lower success lately, which is one reason I'm here.

Thank you for your post, Julie, and for understanding old habits are hard to break. But I'm seeing good reason to make some changes and appreciate everyone sharing their experience. Years ago, I read a good article that I think originated in New Zealand. In a nutshell, hold the dose for 72 hours unless glucose drops to 45. If it does, immediately reduce the dose by .25 units if the dosage is below a certain number and .5 if dosage is higher. Cody fell in the .25 range. We tried holding the dose when he went higher, and when it continued to climb, we raised the dose because we've always been concerned about the long term effect blood sugar over 200 would have on his kidneys. From the depot article, obviously, we need to wait longer and will try to begin doing that. I agree that 1.0 unit might be his number. There was also a high that required an increase, but I don't remember what it was. At what glucose level should we raise the dosage?

We tried very hard to get him off insulin, and I still secretly hope it will happen, but I've read that after 5 years on it, it probably won't. Some of the odd numbers is the result of getting some or none of the insulin in him, so that's the first hurdle we have to cross since we can't regulate a dose when we don't know what he's getting.

Thanks again to all of you for your suggestions.

 

Thankfully, we've not had any fur shots since last post. Thanks again to each of you for posting suggestions. I have been giving flank shots for a long time and after pulling on him in various places, decided to stay with the flank and, as Andy suggested, feeling and looking at where I needed to inject. I found that I've been going high and likely going in and out. We also went to 1/2" needles, but I'm not sure if that really makes a difference, especially if I was going in and out.

The data has been updated. It appears that 1.0 is too much and that .75, at least over the short term, is not enough. Trying to give .85 units is like splitting hairs. Any feedback will be appreciated.

He gets 5 mg of glipizide before PM feeding. It's easier for us to do intermediate checks during the day. For that reason, should the glipizide be given before the AM feeding? I don't know how long it influences his blood sugar over the 24 hour period.

He gets up to 1/2 tsp per day of clearlax for constipation. A small amount is sprinkled on his wet food each time he's fed, which is usually 3 times per day. It seems to work fairly well if we make sure he gets it consistently. What are you using for a laxative?

The extra checks seem to have his ears more sensitive and he often pulls away just as we try to stick him or when we touch the strip. Any suggestions on making him more comfortable? I'm trying to choose a different area each time. We use a heated rice bag to warm the ear well before the stick.

When we first found out he was diabetic, we read a lot about vets not knowing how to treat cats with it. I looked at the suggested questions to ask potential vets. We've lived here about 2 years and the vet we use seems knowledgeable enough. The problem is that while docile and gentle at home, Cody is vicious at the vets office. I watched them put a towel over him to handle him last visit. When I picked him up, I asked for, and got a sedative to give him before next visit. We are thinking of looking for a vet that specializes in cats with diabetes and also to ask how they handle aggressive cats. Any shared experiences will be appreciated.

 

Many of us use digital calipers to make sure our dosing is consistent. The lines on syringes are not always identical and the calipers both insure accuracy and allow you to fine tune the dose. I got my 4" calipers from Harbor Freight.

How long have you been using glipezide? Generally, the oral meds are not recommended since they will prevent a cat from getting into remission. This medication has a negative effect on the beta cells in the pancreas.

 

Thank you for that suggestion. I assume one blade goes on the end of the plunger. Where does the other end go for measurement? I have noticed that when pushed all the way in, the tip of the plunger is not always at 0, so we have adjusted the dosage accordingly. Yours is a more accurate method.

Our vet recommended it about a year ago.

 

It varies a bit from syringe to syringe, but the generic answer is "where the plunger touches when it's all the way in".

Check out DOSING WITH CALIPERS UPDATED W/VIDEOS

 

Dave, I have a long hair (in pic he was shaved) big cat 2 months shy of 18 yrs. I use roll technique and then part with the comb in the flank. Haven't had a fur shot in a long time. I don't rub the area after. I read somewhere the insulin could run out, don't know if that's true but I don't do it.

Good luck.

 

Dave

A couple things...I always did the roll technique on Gracie (short hair) and in +5 years only gave two fur shots. One was when we were new and her brother Headbutted her as I shot and the second time, a loud noise made her jump. Just be sure you are also not shooting too flat and that you are getting into the subq layer and not just barely under the skin. Don't rub the injection site when you are done.

I would definitely discuss with the vet stopping the glipizide. I'm surprised you haven't seen hypoglycemia because the glipizide alone can cause hypos much less adding insulin. As Sienne said, the glipizide can work against you as it actually causes beta cell loss in the pancreas in cats.

Shooting in the scruff can cause slower absorption but it could also increase duration so I don't think it's a bad thing. I rotated shots to keep from building up scar tissue or fat depoits from shooting the same place every time.

Pretty amazing he's 20 and has been FD for five years. Good job!!!

 

Thank you for your response. Was there a noticeable difference in regulation after you began using the technique? We are using Easy Touch syringes.

 

I will provide one response since I developed the technique after an idea from another member. Yes....it made a huge difference for my Gracie but she could see effects in small dose changes (0.1u). A syringe that might be off by almost 0.5u affected her regulation especially because the syringes in one box might be so variable.

The other thing it did was allow my husband and I both to very accurately and consistently dose the same. Two people can rarely consistently eyeball the same dose. Heck, even eyeballing it consistently was a challenge for me and I also had a tough time consistently using the drop method. My drops were never the same size. So it made a pretty big difference for Gracie.

 

Thank you for your comment. I could not see how far the pointer finger was rolled under in the picture showing the roll technique, and I had trouble raising enough skin in the flank area to roll it as far as I thought I should so that I didn't actually stick my pointer finger. Once I lowered the insertion point a little using the tent method, I have not had a fur shot, but the roll method is still an option if I do. Thank you again.

 

This is good information that probably accounts for unexpected results following a dose that looked to be the same as the last dose. The caliper at HF is not that expensive and it would be worth getting it just to compare the variation of distance where the 1u mark is located on some of our syringes. I'll probably need something to magnify the syringe as well. Do you have the make and model number of the magnifier you use in the video? Thank you for the videos, by the way. They are nicely done.

 

I got the magnifying glass at HF as well. I got the light box through Amazon and it made a huge difference as I had light above and below.

You're welcome and thank you for the kudos. It was a little challenging for Mike to try and get the camera in close enough that you could see something!

 

Thank you for commenting.The roll technique seems to be popular and reliable. I need to look more closely at using it. I've had good luck in the 5 years I've been giving injections and it baffles me that I recently began having trouble. Obviously, the anxiety involved, over-thinking, and trying corrections is complicating the process. I could probably get more skin, but try to be real gentle with him. In doing so, I'm trying to make sure it's subq, but am concerned too about not getting too deep. I'm working on not rubbing over the site after injecting. Thankfully, no fur shots since going lower in the tent.

I've been seeing high blood sugar in the morning lately and will stop glipizide to see what effect it has. He might be going low during the night and rebounding. The only advantage we saw in using it is a slight decrease in insulin demand. It could be doing more harm than good with keeping him regulated.

The vet who diagnosed him taught us to shoot in the scruff. Because of our interest in using tight regulation to get him into remission, we went to another vet who had more lab equipment and experience with FD. She said on first visit, the first thing you need to do is begin injecting him in the right place and we went to the flank. The vet we currently use injects in the scruff, so obviously both sites work.

Thanks for the compliment. You've done a great job yourself in the 5+ years with Gracie's diabetes. Our Cody just endures. He's siamese, meows a lot, and meows louder now that he's nearly deaf. But he usually starts purring before his feet leave the floor when we pick him up, comes over to us when it's time to have his sugar checked, and has actually licked our hand as we were giving him insulin. He's gradually losing weight now, and is just over 7 lbs, but his blood work results last week were remarkably good for his age. Thanks again for your input.

 

Another fur shot this morning. My wife is going out of town to visit family on Thursday and I've got to get this down. You've all provided great advice. The problem is my resistance to change a technique I've been using for 5 years. I've been trying to tweak and not getting consistent results. It's the old adage of doing the same thing and expecting a different outcome. I've decided to go to the scruff and use the skin roll even though some say it's not absorbed as quickly. I asked about using saline solution earlier to practice with. What I actually meant was a couple of units of lactated ringers we've used for fluids before. I'll ask my vet about using that tomorrow since I'll probably need him to call it in anyway.

 

Dave, we only shot punkin in the scruff and it was fine. Do what works for you!

 

Thank you, Julie. We started out injecting in the scruff and it seemed easier. I appreciate you sharing that with me.

 

Using the roll technique and injecting in the scruff is much easier. Seeing where I'm injecting really helps. I'm 2 for 2 and believe I've got it down now. Thanks again and to all the others wh0 posted responses.

 

I started injecting in the scruff. No problems. Tried the flank -- fur shots. I used the scruff for 99% of Gabby's shots for 6.5 years. I did shoot on alternating sides.

 

Thank you for your response. It's encouraging to know that injecting in the scruff corrected your problem and that Gabby did so well. Kudos to you for taking such good care of Gabby during the 6.5 years of diabetes!

 

I picked up the calipers and magnifier from HF Saturday. Our syringes were the same type as those measured but from a different manufacturer. The measurement for 1 unit was within .02mm of your reading on several syringes I checked. These had 1/2 inch needles. When I began injecting in the scruff, I was more comfortable with the 5/16 needles that we still had on hand. I checked one of those tonight and found a difference of about .25u! Since I had not done a calibration chart, I could not confirm the actual difference, but was surprised that there would be such an apparent difference. This confirms for me the difference you wrote about. I initially assumed only that the plunger did not stop at the zero unit mark. We allowed for that difference on the syringe scale. But I found tonight that there can also be a difference between the distance between the graduations from one syringe to the next. Thank you for providing this info that makes a significance difference when trying to regulate lower dosage cats.

 

Yep, calipers are the way to go!
I shoot Rusty in the scruff and have had no problems (although I still give my share of fur shots). He has long hair and I simply pull up on his scruff hair, find skin, and shoot into this "tent". After I fill the syringe I touch the base of the needle (where it joins the barrel) with the edge of a paper towel. This sops up all the insulin that might be lurking on the barrel after filling the syringe and that would otherwise get into the fur from the fur's contact with the barrel.

Good luck with all these changes!

Ella & Rusty

 

Just when we think we've found a good dose, he goes low. It seems that anything less than 1 isn't enough and 1 is too much. Thankfully, no fur shots lately.

 

I compared a couple different syringes and the volume in them for the same dose (e.g. 1u) was startling.

While absorption in the scruff might be slower, that might also allow for,longer duration.

 

you said he flinched.....
if you have the bevel upside down, that could be why.....







Use correct Position: Hold the syringe almost parallel to the cat's spine. You want the insulin to be injected just under the skin (subcutaneous) NOT into the muscle, which hurts! Make sure the bevel of the needle is UP. This ensures a clean, quick puncture instead of a drag through the skin.

 

Thank you for responding. I don't have a micropipette to do a calibration curve on the syringes we're using, but it seems that .25u difference is causing him to go low and high.

 

Thank you for the response. I'll pay closer attention to where the bevel is.

 

Different barrel sizes will change the measurements. Different brands all seem to measure different. That may be some of the problem with the difference in measurement.

 

Most people don't. A member of the board who is a friend and a Ph.D in a lab loaned me hers because, as noted, barrels can differ in size so that makes using the same caliper measurement from one syringe type to another a challenge.

Sorry to just get back to this. You're welcome for the input. Is he off the glipizide?

Thank you for your comments on Gracie doing well. She did do fairly well most of the time until she got ill the last week or so. She was a Lil Stinka but she taught me a lot.

 

Thank you for the response. Yes, I've stopped the glipizide. The vet offered it, saying that it's intended to help the pancreas "wring out" more insulin. Since stopping it about a week ago, there has been no increase in insulin demand, but there is still quite a bit of variation in glucose readings. I just realized that Gracie's time to go came recently. I'm sorry for your loss. It's apparent that she could not have had better caregivers.

 

I'm glad you stopped it. It will be better for his pancreas to not have it.

Thank you. The easiest thing in my entire life was to love and care for her...she was absolutely amazing.

 

I'm using a digital caliper to gradually adjust dosage in small increments. In spite of that, there was a sudden drop this morning. Any thoughts on why this might have occurred will be appreciated.

 

Hey Dave, I trust you gave Cody some HC food to bring that number up, right? Could you please test again and post what the number is.

 

Dave I hope you have steered Cody up with HC food. Since that drop was early in the cycle, you will need to continue checking for a while since the depot could still be in action. I hope you are seeing this post. You will need to reduce the amount of insulin next shot by .25 since Cody dropped below 50.

 

It looks like Cody was clearing a bounce. I think he may have had green numbers in the PM cycle of Feb 29, he was on a downward slide into that cycle and then you didn't get any tests. He could have gone low that night and cause another bounce (which broke today).

To put it bluntly I think you're missing lows in the night cycle and shouldn't have increased the dose yesterday. It would be really beneficial if you could get at least one test in every PM cycle.

 

Thank you all for responding. I've updated the spreadsheet.

 

Not a problem

I would reduce to 0.75 tonight

 

Finally! Thanks again to all who replied.

 

beautiful green cycle today!!! Cody's looking great!

Just a little housekeeping item - can you start a new thread with each new day? This thread has gotten really long and gone on for nearly a month, and on this group we ask everyone to start a new one each day. So glad to see Cody doing this well!