Vet won't prescribe Lantus pen

Because she's not comfortable with switching from the vial. Says that the pen doesn't measure half-units well (true) but I did explain (through her tech) that I planned on using a syringe.

Still will not prescribe the pen. So I sent her this great video:




I know that there's a nice video available here, but somehow I thought that when a Diplomate of the American Board of Veterinary Practitioners talks, like E.F. Hutton, people listen. Maybe.

 

The only problem is that this video is wrong - you do not inject air into the pens, that's what you do with vials. From the sticky on Lantus Info, Handling and Storage:

Do not inject air into cartridges or pens. Cartridges and pens are designed to work on a negative pressure principle.

One reason I like using the pens (or cartridges which I can get in Canada), is that I use it to the very last drop. Unless your cat is on a larger dose of insulin, you likely won't use all of a vial before it starts going off.

 

How odd if you're using a vial you're obviously using syringes already so how is the measurement of a half unit going to be any different??? and as far as I'm aware pens don't measure half units at all!

Sounds like there must be some crossed wires somewhere...

 

Wendy & Neko:

I know...did you read the comments? Someone brought that up. The clinic responds and they go ahead and quote the vial insert instead of the pen insert. Not something I expect my vet will have any idea about anyway.

Did you notice at the very end he also says to put it back in the refrigerator? I notice that the package says to store it at RT after the pen is opened (not the vial, the vial goes back in the refrigerator) and that once opened, it will last only 28 days unrefrigerated. But while the pen is unopened, it must be stored in the refrigerator.

So there exists this raging controversy. Mysteriously there is no real consistent information as to why it has to stay at RT even when the customer service line was called (I didnt' call..I'm just reading about it). I would put it back in the fridge myself, since it's 80 degrees here during the day.

Do you know what gives with that? What do you do?

 

Rumour has it that the pen can't dose consistently when the lantus is cold - not an issue when you're using a syringe. You definitely want to store it in the fridge because you want more than a month out of it. Refrigerated it can last six months after opening.

P.S. If you want to tag someone you do it like this @Wendy&Neko then they will get an alert to call them to the message.

 

I know, it's clear the vet has never held a Lantus pen in her hand. I think they still teach docs to "stick to your guns no matter what even if you're wrong" and I think in this day and age with the internet it's kind of a dummy tactic. You can and will be found out so why not just give patients/cat owners a little more credit. Just at least listen.

She told her tech she prescribed me a pen, but I called the pharmacy first instead of just running over there to pick it up, and they said the script was for a vial. And the vet didn't make a mistake...she prescribed a vial but told her tech to tell me it was a pen, because she later backpedaled and admitted she didn't want to order the pen. Sheesh.

Julie

 

I wonder if the pharmacy would be obliging enough to just give you the cartridges instead?

 

@Vyktors Mum Thanks!

Julie

 

Nope. It was the first thing I tried, before I even called the vet to change the script. It doesn't make much sense to me, but there it is.

Julie

 

Hmmm. How fond are you of this vet? I think I'd be looking for another (actually what I did when I couldn't get Cinco's vet to prescribe the pen).

I take Cinco to the University of California at Davis Veterinary Teaching Hospital, and one of the students that was on clinic duty in Internal Medicine told me they get exactly 5 hours of study on diabetes - which includes both cats and dogs! No wonder we are all so frustrated with our vets!

 

You might ask your vet what she thinks pediatricians suggest to parents with diabetic children since the dosing is not unlike that with a cat! They use syringes with the pens.

If you are anywhere near a vet school, they undoubtedly have a veterinary pharmacy. I'd call and talk to the pharmacist about this and get the person's name and phone #. Ask if you can have your vet call so the pharmacist can educate her.

 

his so reminds me of what I went through when I requested the script for the pens. I had to go and give them, the vet and the pharmacy, a demo! Crazy, but n the end they understood, and I got the pens,. Wishing you much luck.

 

Yeah, it's a little time consuming this back and forth with the vet. Luckily San Diego is full of vets, and a quick Google search pulls up one with a specialty in diabetic felines, so I may try her instead if I can't set up diabetes education from the pharmacist with this one.

Julie

 

wish I still had an old pen to send you to go show your vet.....
it works just like a vial....
just saves money in the long run.... especially if you don't use a whole vial.

anyone got an almost empty pen to illustrate to the vet?

 

This is a great idea. I'm thinking I can ask the pharmacy at the VCA nearby because they have a feline diabetes specialist on their roster. My vet is also at a VCA but a different location. Guess there's not much interaction between them.

Julie

 

Thanks anyway. Also seems good to have an extra pen (or four) on hand in case one goes bad, and you waste less if one gets contaminated...makes sense all around to me!

I think rather than me demonstrating with a pen I like the idea of the pharmacist at the VCA Emergency Hospital doing a little tutorial with my vet (if she is OK with that).

The pharmacist will be back Monday and a DVM that is a feline diabetes specialist works at the same clinic and she will be back Wednesday so one way or another I will get to the bottom of this...annoyance.

 

What they do within VCA is send all the records from your current vet to the diabetes specialist @ VCA, and once the specialist sees the cat for a visit, she prescribes the Lantus pen and reports back to the current vet and they continue to follow together. The specialist is back from vacation tomorrow so I'll call my vet and have the records sent over. Seems pretty straightforward and routine at the VCA, once you get some good advice from FDMB, Google the heck out of "feline diabetes veterinarian san diego" and ask the right people. Isn't there an easier way?

What they told me at the pharmacy was, usually the vet that's uncomfortable prescribing the pen will refuse to do it no matter what, so just getting the script from the specialist is the end run around the reluctant vet. Within network (VCA) my current vet will send the paperwork over because it's not like she's losing a client. Good to know!

Julie

 

Update: the primary vet never sent the medical records over to the specialist (I guess I'm not surprised), so the other workaround they told me about was just to set up a consult with the specialist and then the specialist clinic will call the primary vet and get the medical records as is required prior to the consult. Takes the burden off me to keep after the primary vet.

It turns out this is the best way to handle things because the specialist is booked out a few weeks anyway. I wouldn't want to wait for my primary vet to send the records (whenever that ever is) and then set up an appointment with the specialist because it could take months for the stars to align properly for her appointment.

Julie

 

How frustrating. Good on you that you are keeping on top of it, though. I had to do the same with Cinco and UCD. I hope that Natasha is feeling okay.

I see you increased your dose and got a blue preshot. I hope you can get a test in tonight to see how low this dose takes her. You really do need to try to find out where she's nadiring.

 

Wow, what a hassle! Have you ever thought of taking a short vacation trip to Canada? You could go up there to buy your Lantus. One does not need a prescription if you buy Lantus (or Levemir) in Canada. Just go to the pharmacy counter and ask for it. (But if you are ordering online to one of the Canadian pharmacies you do need your vet's prescription.)
Just a thought.
Good luck!
Ella & Rusty

 

I've been the 2u dose route before, so yes I checked the nadir. 2u is usually too much and now it looks like 1.75u is too little, but I've never tried 2u with her meals broken up into 4 small meals q 6h before so I'm hoping this strategy will keep her from going too low.

I'm guessing from previous history with her that she will be in the 80-90 range by PMPS this evening (168 AMPS, but perhaps not with the +6 meal now). What I've done before is check her q half hour after her evening meal if she's in the green range at PMPS, and dose her once she gets closer to 200, but I knew with her recent history in the purples she wouldn't go too low last night so I just dosed her right away even though it was 115.

I'd be interested in other strategies besides the smaller more frequent meals because if this doesn't work I'm not sure what to try next.

 

Sometimes, you need to "fatten" or "skinny" a dose. This is a lot easier if you use digital calipers to aid in measuring. Whether you eyeball the dose or use calipers, it would be a dose that's between the 2.0u and 1.75u.

 

I can get Lantus OK, I just can't get the pen! If you mean go to Canada to get the pen vs vial, that would not be very cost effective unless I were planning a vacation there anyway (which I'm not, but now that you mention it, I could use a break from this heat). I used to live in Seattle and from there it might make more sense.

 

Leave it to my cat to need a dose between 2 and 1.75! 1.875u twice daily and 0.375 can of low carb food 4x daily. Thanks if she starts going too low I will use the calipers to skinny the dose.

I have seen the caliper demo video and it is amazing. I should also make sure these 0.5u increment syringes are printed consistently (although this does not seem to be a problem).

Julie

 

If you look closely at the markings on several syringes, the degree of variability is amazing. When you're cat's on a small dose, it can really make a difference.

Which brand of syringes are you using? The brand I've used for years, Terumo, has stopped making insulin syringes.

 

These are Sol-M syringes from CA Veterinary Supply.

Julie

 

Natasha as always is oblivious to everything. She is on the whole a very content happy cat. She will protest BG checks for a few seconds and then immediately starts purring before the stick (enjoying the attention). I don't think I would be this compliant!

I am primary caregiver for my Dad who has dementia. Dealing with his pet's health (Natasha's his cat) is not trivial, but easy by comparison!

Julie

 

aw, you're a good daughter! That's a tough job, but I'm sure your dad is grateful - both for his care and for you taking care of Natasha.

You were spot on with the prediction he'd be green at pmps. Nice crystal ball! One of the first suggestions here is to "Know Thy Cat" because each cat is so different in how they respond to diabetes and insulin. Looks like you are on your way!

If you can't get a pen easily, I'd just get a vial. Punkin was a high dose cat so we used up vials, but they can last a really long time if you take care of them. There's info on the "Taking Care of Your Insulin" yellow sticky at the top of the main LantusLevLand (LLL) page that includes a video on how to draw up a dose while not contaminating the remaining insulin.

Are you able to get a +2 this evening? That can be a very telling test - in some cats, the +2 can act as a bit of a predictor on how the rest of the cycle might go. If it's higher than the preshot number (98) that can suggest a bounce is beginning - so you might not need to test much in the next few hours/cycles, depending on the cat. If it's lower than the preshot, that's a giant red flag that the cat is having a very active cycle and you may need to intervene in case of low numbers, or rapidly dropping numbers.

If the +2 is about the same as the preshot, then that can signal a normal "active" Lantus cycle, where the cat's blood sugar declines to somewhere mid-cycle and then rises to the next shot time. There is more on this on the "New to the Group?" sticky.

I'm just thinking because he was green at pmps, I'd want to monitor (test) to see what he's got up his sleeve. That's why I"d get the +2 if you can.

Glad to have you here - and welcome to the LLL group! The best place you never wanted to be.

 

I held off tonight b/c it's been longer since the purples, and checked her at PMPS +1.5 and dosed at +2. She will be mid-blues tomorrow AMPS most likely. I may be up frequently tonight b/c I'm taking a medication for a procedure tomorrow and it will disrupt my sleep so I can probably check her nadir at the very least at +6 or +7 since dosing.

For some reason she didn't notice the autofeeder had turned at AMPS +6 so she had a late lunch and I'm not too worried about her going too low. I'll have to re-record a message on the autofeeder to alert her: "Natasha! Dinnertime!" so she gets a clue. Without me around she tends to just sleep the day away, which is why I think she may run lower days vs nights. I really don't know but she does have an interesting trend of lower during the day while I'm gone, which scares me.

One thing I notice is that she eats a little less with 4 meals vs 2 (same amount of food doled out), so she must have been just scarfing it down before her appestat kicks in when she was eating 2 large meals. Even though it hardly makes a difference in her BG profile (hence the predictability) it's probably a lot easier on her system to have the smaller meals.

Her environment is very controlled so I'm not THAT surprised that I can guess the BG based on past performance. She is such a creature of habit and happiest when things are thus and so, so she's a good little patient.

My vial of Lantus is 6 months old in a few weeks. That's why I'm trying to get a pen, because I know it will go bad soon. I know it says I joined August 5 but Natasha got her first vial of Lantus in March.

Julie

 

I hate to bump up your thread since it's so old, but wanted to follow up with your comment here.

If I understand that correctly, it means that at +13.5 (13.5 hours since the morning shot) she was 93 and you waited 1/2 hr and shot her at +14 maybe at 156? I don't think I have this right - looking at the spreadsheet I'm pretty confused.

Just to clarify how to use the spreadsheet - the amps is whenever you give the morning shot and the pmps is whenever you give the pm shot. If you delay longer than 12 hours in a cycle, you'll want to stack up those tests in the pmps column so it shows the delay and that the cycle was longer than 12 hours long.

Here's an example:

12=60
12.5=75
13=95

All stacked up in the +12 column, manually colored green. That tells us that the person tested at +12 (usual shot time) and got a 60, delayed 30 minutes and got a 75, delayed another 30 minutes and got a 95, then shot the 95. So the pmps is 95. Let's say when you actually shot was 7pm, even though your normal shot time is 6pm.

Then if you tested at 8pm, it would be +1, because it's 1 hour after the actual shot was given. All the +hours count is counted from whenever the previous shot was given. So if you shoot at 7am, skip the pm shot (that would've normally be at 7pm) and just shoot at the regular time the next morning (7am) that would be +24. You can make notes about this kind of thing in the comments section, or you can fix it in the cells like I indicated above. Anytime there's a change in schedule it might end up being important, so it's good to take notes on that kind of thing.

Does that make sense?

By the way, go ahead and reply to me in a new thread. I'll look for it. One of the things on this particular insulin support group is that everyone starts a new thread each day - one thread per cat per day. Once a thread (we call them condos, for the place where cats live) is old, people will stop looking at it because the info is old and if they get long it takes too long to read through to find what's current. There's more on this in the "New to the Group?" sticky.

I hope your procedure went well today. I see a test for Natasha this afternoon, so am guessing you got home ok. Take care of yourself!

 

What I did was test her at her usual shot time of 7pm (+12) and it was too low in my opinion, 98, so I waited 1.75h and she was still only 156, but I gave her a shot at 9pm (+2 her normal time) so that's now her PMPS. I usually just write this in a note that's underneath each cell so I know what's going on. I'll change it to what you are saying since I'm guessing you can't read the notes underneath each cell from your comments.

So tomorrow I'll be dosing her at +10 and that will put her back on a +12 schedule.

Julie

 

Shooting 2 hours early is really significant. If you can adjust by 30 minutes a day, you won't see as much of an impact on her numbers. Most people either adjust 15 minutes per shot or 30 minutes once a day without noticing an impact on blood sugar.

When you shoot significantly early, you are increasing the overlap between the current cycle that's ending and the new cycle that's beginning. It can cause low numbers, depending on the situation.

From the Tight Regulation sticky (although this applies to dosing regardless of what dosing strategy you are using)

• KNOW THY CAT. Shooting early or late is a practice best reserved for those who have a full understanding of the insulin used and it's effects on their kitty.
  Because of the cumulative nature of Lantus and Levemir, please be aware: Shooting an hour or two early *could* act like a slight dose increase. Shooting an hour or two late *could* act like a slight dose reduction. How your cat will react has a lot to do with what kitty is doing that day. For instance, if a bounce is breaking shooting early probably isn't the best idea because you'll have a little extra action on the dose from both the early shot and the bounce breaking simultaneously. The next shot is due 12 hours after the time of the early or late shot if you're shooting twice a day. Oftentimes the effects of an early or late shot will not be seen until the next cycle. Please monitor carefully when shooting early. Ask for guidance if you're unsure.

​

 

Yes I'm aware of that, but I was having a medical procedure today and I didn't know when I would be dosing her till 9pm last night (too late to call the sitter). Normally also I would be at work so I have to get her back on track. I'm thinking this dose increase will not work out for us in the long run, so perhaps simpler just to reduce down to 1.875u.

Julie

 

You can always just skip a shot and shoot at the right time tomorrow night. One time I was off by about 3 hours with punkin, and after a day of working backwards and having him complain mightily about his meals being late, I just gave up, skipped the next shot and got back on track with the following one. That can be easier sometimes. It's up to you - I didn't know if you knew about the depot/overlap concern or not.

 

Technical issues: I made a new row (no need to manually color then), but I notice that others just expand the row. Which is going to be the least confusing, and then how do you do this on the spreadsheet? I'm reading the help for Google Sheets and I believe I lost some functionalities when I upgraded to Windows 10. Not sure I can wrap text within a cell for instance.

 

OK I might just do this tonight because as you can see she's way low anyway (also consider this is AlphaTrak). It will mess her up for about 3 days, but with all the dose adjustments she's going to be bouncing all over the place anyway.

Julie

 

Sometimes it's the easiest on everybody. That also allows you to sleep tonight without worrying. Some cats recover quickly from skipped shots too, so you never know.

 

I wouldn't do another row - to people who are experienced looking at spreadsheets, we look at color patterns as much as numbers, and each row represents a day. It makes it more difficult to "see" the patterns.

Another option is to put it in the comments section, although I prefer it in the cells. But whatever you can make work for you. And no, I couldn't see your comments.

I don't have Windows 10, but when I added to the cells I just put in a space and that would allow it to wrap around. I'm not super techy, but if you can't figure it out you can either edit your subject line and ask for help with the ss, or you can post the question in the Tech Forum.

 

I got it to wrap by inserting spaces, but how do you manually color it if one number is green and the other blue I wonder. Take an average and call it blue I guess.

 

My cat and boss both would complain mightily! My goodness I'm jealous of your flexible schedule. I have a cat sitter in the neighborhood who is great but you know I don't want to always be asking at the last minute, especially with all these dose and mealtime changes lately. Something's bound to go wrong.

 

I'm noticing that Lilly will be putting out a Lantus biosimilar so pretty soon this will be a moot point! But I will still have to deal with this vet (who may not be "comfortable" with Lantus biosimilars). So I think it's best just to take care of this now.

 

I wasn't working at the time - in between jobs, which was very convenient for learning how to take care of punkin's diabetes. When I went back to work it got a little more harried!

 

And the makers of Lantus have released their new Toujeo which is glargine only at a 300U per mL concentration ....it's being HEAVILY advertised around here on TV (for humans of course, not sugarcats...no way would I feel comfortable trying to measure the doses we do on an insulin that's 3 times as strong!)

They're really pushing it as the "new" Lantus and touting how much better it's supposed to be....gotta save those huge profits!!

 

They are making plenty of profits off U-100 raising the prices like they are. So unless you want to fund their patent cliff, I am going for the pen until "Basaglar" is available (and then we will be the Basaglar/Lantus (glargine)/Levemir(detemir) board!)

But besides the savings it's always better to dose from a smaller container rather than keep puncturing the same stopper 360 times I would think.

 

Yeah I might be in between jobs soon if I try to schedule my work around my cat. My boss is already aware that I have to be home at 7pm to dose which I found out is not a good thing. Once I told him, he scheduled 3 meetings last week on last minute notice at...you guessed it...7pm. When our normal work hours are 9-5pm. So I had to race home and inject the cat at 6:30pm and race back (20-30 min commute each way).

 

I found a free add-on that will do this automatically: "Merge Values".

 

Like I said, 3 days! But I think it was the best strategy to skip a shot since I was reducing the dose anyway. Any deviation in schedule and/or dose will throw her off for 3 days, but meals, looks like she recovers within the day. I think the meals timed to the nadir are helping (she gets 4 small meals at 6-h intervals). We'll see today when I collect a curve.

Excellent post/video. Some great information there. Some additional things I do, from someone nearing month #7 on the same vial of (still potent) Lantus:

1) Store the Lantus away from the freezer compartment.
2) Wash my hands prior to handling the vial.
3) Wipe down the stopper with a 70% alcohol sterile pad prior to piercing it.
4) Never touch the stopper with anything except a sterile needle.
5) I have never yet left it out overnight (knock on wood) and I minimize the amount of time it's outside the fridge.

(Full disclosure: I dose rodents for a living as an in vivo pharmacologist. Not saying I can't always learn more from dosing my own cat at all (I have learned quite a bit more!), but these things are just completely ingrained in how I handle a vial of sterile contents, and might contribute to its longevity. Since the Lantus formulation is so pH-dependent, you can never be too careful. It's why one day, one day, one day that's hopefully coming soon, when I get a Lantus pen, I will try to always have at least one backup pen in the fridge.)

 

Well, this is pretty amazing. Does the vet know what you do for a living? You probably know more about the packaging and use of insulin (or any drug, for that matter) than the vet.

 

I know drugs, but I don't know cats. Natasha isn't even my cat...she's my Dad's. I've never had a cat in my life. But I'm glad I do now, even with the extra care she requires. I know from my work, mice are not small rats. Likewise cats are not large rats! Each species has it's own quirks.

Also this issue of not being able to dilute a drug is a new one for me. Usually I have different formulation problems: the drug is not soluble, or I can't get it concentrated enough. If I'm trying to be precise with a dose, I just dilute it but I don't want to try this with Lantus (I know people have, but I really don't want to mess with something this expensive and pH-dependent). If I ever run into precision problems at work, I've learned a ton dosing Natasha.

And then this vet is not really even listening to me anymore, so there's that. I think it's time for a do-over with a diabetes specialist who is a little more confident and knowledgeable.

 

Are you familiar with calipers? If you feel like you need to be more precise with your dose, calipers will provide that accuracy for you. The insulin syringe markings are notoriously inaccurate - compare 10 of your syringes to each other and notice the placement of the dose markings.

There is a post called "Dosing With Calipers" in the "Where Can I Find?" link, in the second part. Some kitties are extremely sensitive to small dose changes.

 

Yes actually Ann & Tess mentioned this to me about a month ago, and then scroll up in this (probably too long) thread, Sienne & Gabby mentioned them again, so now they are...OMG! They just arrived in my mailbox!

I have been winging the 1.875u dose but no longer. Excuse me, I have some work to do.

Julie

 

hahaha too funny.

by the way, go ahead and start a new thread next time you post. As they get long they become unmanageable - people can't find the questions, etc., and people will stop looking at the thread if it's long and old like this.

 

I use the pen and it works great. My cat doesn't even notice it when i give him a shot. If I need half-doses I will go to a syringe but so far we are inching up units. My vet actually sells the pens in his office. CVS here sells them individually as well.