Switching insulin

confused_cat : Ok - been at this diabetes-thing with Ruby going on two years, now. She was regulated on Vetsulin from diagnosis. I knew about the Vetsulin issue since last October, but at the time we were dealing with "something" healthwise w/ Ruby. fPL was up, but U/S and further testing came back clean, so the IM specialist we are seeing isn't convinced it truly was pancreatitis. Anyway - going through some diet tweaking and getting her over her sick spell - both vets felt that since no definite product recalls were being made, changing insulin at that point would be rather counter-productive. Instead, we opted to give her a scheduled snack mid-day to counter any possible weirdness from the Vetsulin and watch her.

Fast forward to a week ago: Ruby's preshot sugars, even after two and a half months, are still alittle too wonky to suit me (running between 240 and 350 with no predictability, rhyme or reason), and didn't the Vetsulin issue make our local news? Tired of worrying if it's "Ruby" or the Vetsulin, I put in a call to our IM vet about switching insulins. After some preliminary discussion, she was thinking Lantus may be a very good choice for Ruby and told me to hang tight - she's trying to coordinate efforts with Ruby's new general practitioner vet so that alot of the monitoring can be done there. Seems like overkill....but I'm thinking maybe because of Ruby's health history and such, caution is a good thing. I'm game.

Ok....I'm cool. (chuckling) until this weekend. Ruby's not eatting normally, and her am BG this morning was 206. Gave her the 3units and resolved to test throughout the day, but I used my last Alpha-Trak strip at noon - when she tested 201 an hour after her snack. I do have a Precision-Xtra and the stips to monitor bloodketones....so I ran to Walmart to get some glucose strips for that meter to see me by until I can get to the vet office tomorrow. When the issue of insurance came up at checkout - i very calmly said it's for a cat....no insurance. At which point -to make a long story short - the pharmacist there questions me on Ruby's insulin and age, and starts telling me that I don't want to change Ruby to Glargine....NPH would be much cheaper and much better....yadda yadda yadda. He claims that people are being given bad information about Lantus - refigerated or room temp, it's only guaranteed effective for 28 days. The dude tells me to tell my vet that Ruby's age will kill her before the diabetes does....to put her on NPH and tells me to get it "there".

A Sell-job, I figure - but at this point I would like some "good " information, I know "this" is the place to get it. What can I expect with changing from Vetsulin to Lantus? Does she have to be off The Vetsulin for anylength of time before we start the Lantus? And, Last I read any where - despite what the literature from the manufacturer says, Lantus was good for 6 months to a year, as long as it was treated with kid gloves and kept in the refrigerator.......has that changed?

Lisa and Ruby

BTW: She tested 257 pm preshot and pre supper with the Precision Xtra. She's still not eatting like she usually does, but no vomitting and she seems to want to eat better once the insulin kicks in (eventually she ate all her breakfast and snack given previously today).- so got her 3 units......I gave her some famotidine for tonight and will test her again before bed......I am planning to take her in to be checked if it continues.

 

Nope, your pharmacist is wrong.

NPH (Humulin N, etc) is a fairly poor choice for cats ( see http://petdiabetes.wikia.com/wiki/Category:Insulins for more on all the insulins ) because its peak effectiveness in most cats is in about 3-5 hours, with duration about 6-8 hours. It will not last the full 12 needed for twice-daily shots. Plus it is very fast-acting at first and can easily lead either to a hypo situation or to a "rebound" where the cat releases stored sugar from the liver (see http://petdiabetes.wikia.com/wiki/Somogyi_rebound )

If you're able to get human insulins from the pharmacist, the best choices right now are the longest-acting -- either Lantus (your vet may call it 'glargine'), or Levemir (detemir).

If you spend a little time on the insulin study groups on this board, please try reading through their introductory materials and you'll see why Vetsulin and NPH are both not in the first- or even second- choice category.

 

A lot of people here buy Lantus cartridges or the pens. They come in a package of fire 3 ml cartridges/pens. You just insert the end of a syringe needle in the rubber port and draw out insulin just like a vial. A lot a people use up a 3 ml cartridge/pen before it goes bad. Thus, even though on a per ml basis the cartridges/pens cost more the cost per ml actually used and not thrown away is less.

There is no reason to stop Vetsulin for any amount of time before starting Lantus. Just start the Lantus the next time a shot is due. I would proably start the Lantus at 1 unit bid.

 

Thanks, Steve....

I'd been reading good stuff about Lantus (glargine) while Ruby was on the Vetsulin. We, however, were able to eventually get her regulated on 1-2 units of Vetsulin twice daily for a year,( before she got so sick last fall), so with her response being a good one at that time.....we just kept her on it.

Now? Well - I'm not a happy camper. Too many factors to take into concideration when she's "off" and the BG's are going wonky. I have to go down the list of is it UA? (she has urolithiasis) Hyper-T? (she's concidered to be in the "grey zone") Pancreas attack? Infection?.......I just ain't happy wondering and worrying if it's the insulin and having to add that to the list, too OR if the vetsulin is going to add to the problem!

The IM vet told me, probably, the switch is going to be to Lantus. Ruby's due to go in this month for a re-work-up on all her bloodtests, general BP and glaucoma screening...... and the switch was going to be then....The IM vet wanted to get things coordinated with her reg. vet. If Ruby's eatting issue continues into tomorrow, though.....I'm going to have to bump that up - whether the two vets have everything coordinated or not.

Lisa and Ruby

 

THANK YOU LARRY!!!!!

Forwarned is forarmed.......and thank you for the tip about the cartridges. That is helpful!

( I knew this was the place to come!)

Lisa and Ruby

 

Hi Lisa,

Glad you came and asked. Yeah for the vet being up on Lantus, boo to the pharmacist.

Seriously, visit the Lantus forum - since 2008 there have been over 100 cats who have gone into remission, as a result of posting daily on the lantus board, following the Tilly protocol and guidance from the people on the Lantus board who know the insulin and our cats. (Maui is included in that 100 group).

Lantus is an excellent insulin choice. OK I'm biased, but either L (Lantus or Levemir) are excellent choices.

You are correct on the longevity of lantus. It used to be the party line that it only lasts a month - it's still the manufacturer's line. However, we've found that when stored and handled properly (in fridge, no shaking, rolling or reinjecting) it can last for much longer. How long, some people can get several months out of one container.

Some other things to know, especially if you return to same pharmacy - you need U100 syringes, the U40's you have WILL NOT work with the L's. Also, get them with 1/2 unit markings, it helps when microdosing, which is what tends to happen here. Short or long needle, your choice.

When buying the cartridges or solostar pens, the pharmacist may tell you must use the pen needles that go with it. Just tell them no, you will use the U100 syringes. There are pics to show you that you treat the pen/cartridge same as you would a vial.

Please be sure to read the starred posts on the Lantus group, as it will tell you everything you need to know about handling, storage and use of the L's and there's pics too!

Also, since this is a new insulin for you, you may want to become a regular here and post daily on the lantus forum. It is really helpful, as you will get great insight into the insulin and how it's working for Ruby, as well as any tweaks you need to make.

Would you mind telling us what kind of food your feeding her. This may also be helpful in determining if that's negatively affecting her BG's. And yes, we can provide you with alternative food choices if necessary. We've got an entire food chart.

Hope this is helpful and looking forward to hearing more about Ruby.

Oh one final thought - given the concerns you have with vestulin, not to mention the recall and issues with it - why not start Ruby on Lantus immediately and not wait a month? If the vet is willing to write the script - I say go for it.'

One more final thought - when starting on a new insulin, we typically recommend starting at 1 unit or 1/2 unit and hold this dose for 5-7 days (and lantus is given twice a day in 12 hour increments). Again, this is spelled out on the forum.

Also, you may wan to start a spreadsheet, as a way to track the Bg's and add it to your signature, so we can see and assist. instructions for spreadsheet are on the tech forum.

 

We were on Vetsulin 2 1/2 years, switching to Lantus in November 2009. I simply grew tired of mid-high stagnant numbers. I did not use the Vetsulin FDA warning as my reason to change; I was tired of being stagnant.

Take a look at our spread sheet and look at the almost immediate results on Lantus. We started having issues a few weeks ago with high numbers... come to find out there was a bladder infection, gingivitis, stomatitis, and unfortunately a positive diagnosis for Feline Leukemia. However, we've started on vitamins and ImmunoRegulin and Baytril for the infections and we have a new cat!

Just remember... when you make the switch from Vetsulin to Lantus (and I know you will!)... the dose is not based on pre-shot numbers; it is based on nadir. And that was extremely difficult for me to wrap my head around. I spent several weeks posting every single BG reading on the Lantus ISG because I was afraid to do anything without help. But once I finally wrapped my head around it all, we're on a roll!

 

Thank you Hillary and Sherri -

Your insights are really appreciated! Mmmmm - think I'll be a little bit more patient with regards to starting her on the lantus, so that everyone in my neck of the weeds is 'on board' so to speak. We ran into a snag last fall when we lost her regular vet(he moved out of state) and I know he would've been cool with it. The new one we chose at the same practice is a lovely lady - but I have yet to really get to know her . And if she's not familiar or comfortable with using lantus - I needs ta know.....all monitoring and phone contact will need to be done entirely through the IM vet, then.

Hmmmm - glad you told me the doses were based on nadir. Now I understand the IM vet's precautions. She worries more about hypoglycemia than I do. Also, being a "working mom" - my brain is now running to how I can schedule getting home and getting spot-checks in through the day.

As for diet? - Ruby's a confirmed kibble - addict. And at her age, with her issues, I'd just rather not fight her to eat canned. I tried the whole mixing-thing, and she'd walk away rather than deal with it and I am forever worried about hepatic-lipidosis. She's funny about her food. I've got her eatting Royal Canin Hi-Pro Calorie Control / EVO Salmon/herring / Wellness Cat and Kitten dry - mixed 1/4cp/1/4cp/1/8cp and portioned out into two main meals and a mid-day snack. My attempts at still trying to keep the carbs down, while trying to cut the fat/fiber in her diet down to moderate levels. The added kitten food is something the IM vet wants her on, and the %fat in wellness cat/kitten isn't too horrible. I do put out a half can low carb fancy feast for the day.......sometimes Ruby eats it, but most days I'm just throwing it away. I more or less put it down to make me feel better and she does nibble at it to self-regulate on days when her sugar's dropping.


I'll be checking out that Lantus forum, more, and although I do keep BG logs at home, here....will check out how to start a spreadsheet. Thanks!

Lisa and Ruby

 

Take a weekend (assuming that is when you do not work at TBP (The Bad Place) and run a curve. I would suggest a +3, +6, +9 so you can really see where nadir is on Lantus. And, Lantus kitties have a tendency to have lower numbers during the evening cycle.

You play the hand you're dealt, and in this case you work around the food. Just remember, no food 2 hours prior to shot so that you do not have a food spike when recording the PS (pre-shot) number.

 

Lantus/Feeding [was: Switching insulin]

You play the hand you're dealt, and in this case you work around the food. Just remember, no food 2 hours prior to shot so that you do not have a food spike when recording the PS (pre-shot) number.[/quote]

Oh.....good to know! Thank you. On vetsulin I had been testing, feeding.....then giving the insulin an hour later, to make sure she ate enough to get her shot. Truth be told, though......there are times Ruby doesn't eat everything at "mealtime" but munches as the insulin kicks in. The portions are more for calorie control and consistancy, rather than "meals" - and are left down 12hours. I don't know exactly when she stops munching the kibble/fancy feast? - particularly the last few days - her eatting seems to be off a bit. She's not eatting much when I put the food down and there's still a wee bit of kibble left in the dish come time for the next test/feeding....

It's just weird. After an am-ps of 267, she ate real good today( but not the fancyfeast). Tonight's pm-ps was 205 and she barely touched her supper yet. I'm starting to worry that her pancreas is flaring again.

Lisa and Ruby