? Diagnosed in China, prescribed Novolin 70/30 several newbie questions!

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sprout

sprout

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Hi, my kitty was recently diagnosed with diabetes (most likely induced by long-term topical prednisolone acetate to alleviate allergy-induced feline eosinophilic keratosis). Unfortunately we are in China, where the treatment options are more limited and the vets are very helpful but seem to practice a bit differently than the US information I can read online. For example it seems Lantus is not available to our vet.
Our vet prescribed Novolin 70/30 that the vet gave us in a penfill cartridge. Kitty's insulin dose is pretty low: 2 units (0.05mL) diluted to 12 units (0.6mL) with saline, then injected 4 units (0.2mL) at a time 3x/day, which seems very different from the dosages I read about online. The vet also instructed us to keep the penfill cartridge in the fridge between uses, yet online I read that when the penfill cartridge has been "opened" it should be kept at room temprature, yet below 86 degrees F. Given that we live in a tropical climate where our apartment is regularly above 86F, I'm not sure what the best course of action is.
I guess my question is: is any of this crazy? Should I just trust my vet or should I be seeking other options? Also, has anyone else had a cat possibly develop diabetes due to ophthalmic drop usage? We have taken kitty off of the drops for now, and are really hoping that the diabetes might subside once the pancreas has a chance to rest...how realistic is that?
 
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Welcome kitty and their dad! (What should we call you both? :))
I have not heard of diluting insulin in order to do TID (3x daily dosing) yet. This method is more difficult on the caregiver. There is another newer member in Singapore who is using Vetsulin. Is Lantus just not available to your Vet or can you not get it anywhere in China? If using an insulin pen cartridge, you can extend the life by refrigerating it :)

Can't verify if it's "crazy" but I will be honest, I'm not one to blindly trust Vet's or any doctor. If you can seek a second opinion, go for it. You have to do what's best for your kitty and not too difficult on yourself ;). I did some looking on the forum for your question :bookworm: about diabetic development due to ophthalmic drop usage and haven't come across a thread for it being the cause but it does raise BG numbers (blood glucose), which steroids are prone to doing. Would Zyrtec work well enough for kitty's allergy? Just a thought, I know some need stronger meds.

Are you home testing? It's the best tool in treating FD kitties (feline diabetes) and might be more vital if you stopped the eye drops and effect allows pancreas to start working again. This is our Spreadsheet template for recording home test results: HERE . As for how realistic, we have a saying here, Every Cat Is Different (ECID) so it is a possibility but no guarantee. Keep in mind if diabetes subsides, it's considered remission, kitty may become diabetic again. There are so many possibilities, sorry I can't provide a more positive answer for you.

Could you put some information about your kitty by setting up your Signature: http://www.felinediabetes.com/FDMB/threads/editing-your-signature-profile-and-preferences.130340/
Since kitty is on insulin TID and steroid eye drops have ceased, I'm going to leave you this just in case: http://www.felinediabetes.com/FDMB/threads/how-to-treat-hypos-they-can-kill-print-this-out.15887/
 
thanks for the information!! it turns out that glargine is available here, I was just having trouble with the translation into Chinese :). However we are going to give the Novolin 70/30 a shot since it seems to be working and he has already had his dose dialed in.
We have tried home blood monitoring, but our cat (sprout) is a bit skittish on the best days and these are certainly not his best. It is a struggle to even get him steady enough to do the insulin shots (although we are switching to shorter, smaller gauge needles to see if that helps - super jealous of all of these youtube videos of folks injecting cats who seem to not care at all about the poke!). We are doing daily urine testing as a surrogate, but of course like you said that won't help for determining remission. Luckily our vet makes house calls so we are going to try and have him tested at least once a week.
Interestingly enough after going cold-turkey on the eye drops, his FEK has not flared up again. He was diagnosed when we lived in the US, so possibly whatever he was allergic to is not present in China.
 
We can help with tips for home blood monitoring. HERE are some tips and don't be afraid/embarrassed about asking for help with a skittish kitty. You wouldn't be the first :). A couple members I know of had a semi-feral kitty. There is also the caturrito (burrito a kitty). The most important thing is just to make the experience a positive one.

For shorter needle, just make sure the needle goes all the way in so the insulin gets to subcutaneous level. Also, if it's urine glucose test strips, it's only going to show (I believe, there is some debate) if glucose is over 200 - 250, when it spills over. So if you get one that doesn't show any, Sprout's BG may still be higher than normal. I'm glad his FEK has not flared up again :cat:. Two of the great reasons for home testing (there are quite a few :smuggrin:): 1. You'll know Sprout is safe to receive his 2.0U dose of insulin. 2. If he drops too low and you notice him acting weird (like hypo symptoms) you'd know his numbers right away. :)

Feel free to look at some of the Spreadsheet links from other members. I apologize if I sound pushy for home testing but I remember the first month with my boy and dosing blindly had me in hawk mode 24/7 :(. We've had many situations where if I wasn't home testing him, I would have given him his usual dose on schedule, and probably sent him hypo.
 
Can't help you with the insulin issue. But if you start routine for testing eventually Sprout will be easier to test.

Pick the times and spot you are going to give the insulin. 5 minutes before giving get Sprout into the spot and just rub his ears and cuddle and talk to him with him. Do this each time, give a low carb treat after each time one you don't give any other time. He will start to associate the routine with a treat. You will know when he starts accepting (don't rush it) and soon you can move on to testing. If eating his treat he might not even realize you tested. Sometimes turning off any of the alarms on the meter and not using the lancet device because it clicks helps.

I used a throw rug on my table (made it easier and comfortable to position Smokey). Once Smokey saw the treat bag next to the rug he would lay right down. Once I got the test he would paw the treat bag as if to remind me to give him his treat for being good.
 
Yong said:
We can help with tips for home blood monitoring. HERE are some tips and don't be afraid/embarrassed about asking for help with a skittish kitty. You wouldn't be the first :). A couple members I know of had a semi-feral kitty. There is also the caturrito (burrito a kitty). The most important thing is just to make the experience a positive one.

For shorter needle, just make sure the needle goes all the way in so the insulin gets to subcutaneous level. Also, if it's urine glucose test strips, it's only going to show (I believe, there is some debate) if glucose is over 200 - 250, when it spills over. So if you get one that doesn't show any, Sprout's BG may still be higher than normal. I'm glad his FEK has not flared up again :cat:. Two of the great reasons for home testing (there are quite a few :smuggrin:): 1. You'll know Sprout is safe to receive his 2.0U dose of insulin. 2. If he drops too low and you notice him acting weird (like hypo symptoms) you'd know his numbers right away. :)

Feel free to look at some of the Spreadsheet links from other members. I apologize if I sound pushy for home testing but I remember the first month with my boy and dosing blindly had me in hawk mode 24/7 :(. We've had many situations where if I wasn't home testing him, I would have given him his usual dose on schedule, and probably sent him hypo.
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I use to shoot blindly. I did what my vet said to do. Learned how to test during a hypo event and a bad one at that. Smokey would not have made it through the night if I hadn't found this site and they talked me through it. Of course they said get to ER but I just moved didn't know where it was and I had no car that night. Learning to test during a crisis is not the time to learn. Never again will I shoot blind. People don't when it's themself, so why is it okay for any other live being.
 
If my math is correct, your vet has your cat on 0.67u of insulin three times daily. Given the type of insulin you are using, he may have prescribed three injections per day to ensure more even coverage across each 24 hour period. Novolin N (70/30) is considered an intermediate insulin and may not last a full 12 hours in cats due to their fast metabolism. If your cat requires that small a dose of insulin, your vet may not consider Lantus a good option because it cannot be diluted and it is a bit more problematic to give consistent micro doses. That said, Lantus doesn't drop the BG nearly so dramatically as Novolin N can and lasts a full 12 hours so you would only need to dose your cat twice daily. Syringes with half unit markings would be needed to give tiny doses of Lantus.

I would highly doubt that the topical steroid eye drops would be the cause of the diabetes. Steroid shots are the most common steroidal cause and oral steroids can have an effect on the amount of insulin required too but topical administration would have minimal impact as the amount being absorbed systemically would be tiny.

Like the others who responded, I would encourage you to try to get your cat accustomed to being tested at home. Knowing it is safe to give insulin and checking mid cycle to see how kitty is responding is the best way to get your cat regulated and keep kitty safe. It's a pretty safe bet that when those You Tube videos were made, the starring cat was a pretty seasoned veteran of testing and shots so don't give up. It may take a little bribery and a step by step approach but it is doable with most cats. Many of our cats actually come and get us at test time!
 
Thanks to all for the kind advice!! Sprout is currently doing pretty good accepting his insulin shots now. He always gets the shots around mealtime so he has a thing where he's alternately hungry and wary, but once the shot is over with he is back to normal in a minute or two. His attitude and personality seem to be 95% back to normal (pre-diagnosis), and his urine tests have been consistently clear, so it seems like everything is going smoothly so far.

I will try soon to get him adjusted to routine blood testing once he gets more accustomed to the insulin shots so I only have to fight one battle at a time. I have read several places that testing the paw pad can be a good alternate site to ear testing, and I'm thinking he may tolerate that better (just a guess based on his personality). Does anyone have any insight? If I use a spring loaded lancet, any suggestions on the depth to select (1-5 scale)?

regarding the eye drops, his was a particularly rough case of FEK. When he was in the US, at the beginning of his disease (first month or so) he was on ~5 drops daily per eye. That got ratcheted back to 2 drops daily per eye. When we moved to China it seemed to recede and we scaled back again to 1 drop daily each eye. But still, that is a lot of steroid drops over the course of 3.5-4 years. In humans, 1 drop per day can cause noticeable increases in blood glucose, so it's not unreasonable to consider that since sprout's dose was HIGHER than typical human doses, and his body is 10x smaller, the proportional increase in blood glucose levels might be enough to throw his system pretty out-of-balance.
 
Glad to hear Sprout is doing better with the shots but I am a little weary that his urine glucose tests are clear while receiving insulin. Usually, glucose only spills over to show in urine when BG is over 200 - 250 (I'll have to double check). For newer members home testing, we recommend NO SHOT under BG 200. Since he is getting dosed TID (3x a day) I would think reducing the dose is a plausible idea.

For testing in paw pad, I've only heard of two members doing it. If she's around, I think @Lisa and Smoky was one of them. Smoky crossed the bridge but Lisa does check in once in a while. Hopefully, I remembered correctly ;). For the spring loaded lancing device, you'd have to do some tests for your self with Sprout. I've seen people use setting 2-4.
 
Hmm that surprises me, what is the thinking beyond no shot for BG under 200? I'm not sure if everyone can access this article (I'm an academic so I my university affiliation gets me access to most academic publications), but this study: http://www.tandfonline.com/doi/full/10.1080/01652176.2014.924057 shows that in a study of 54 cats, more aggressive dosing ("near-euglycemic paradigm") leads to significantly higher likelihoods of achieving remission. Interestingly the study showed no significant difference between hypoglycemic events (defined as either "biochemical hypoglycemia" - low BG without symptoms; or "clinical hypoglycemia" - showing hypo symptoms). Obviously I am not a vet so I can't pretend to be truly informed, but my naive thinking was that maybe "riding the edge" was a better way to go.
 
I couldn't test smokys ears so did his paw pads. He didn't mind that too much. I used a 26 gauge lancet on a setting of 1 to 2. I tested his back paws having found out it hurt him to test his front paws.
 
sprout said:
Hmm that surprises me, what is the thinking beyond no shot for BG under 200? I'm not sure if everyone can access this article (I'm an academic so I my university affiliation gets me access to most academic publications), but this study: http://www.tandfonline.com/doi/full/10.1080/01652176.2014.924057 shows that in a study of 54 cats, more aggressive dosing ("near-euglycemic paradigm") leads to significantly higher likelihoods of achieving remission. Interestingly the study showed no significant difference between hypoglycemic events (defined as either "biochemical hypoglycemia" - low BG without symptoms; or "clinical hypoglycemia" - showing hypo symptoms). Obviously I am not a vet so I can't pretend to be truly informed, but my naive thinking was that maybe "riding the edge" was a better way to go.
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This is a well known study. HOWEVER, the insulin was glargine (Lantus is the brand name) which is a very different beast than Novolin. It's a depot insulin with a much slower onset and greater duration than Novolin. The depot acts to keep the BG level much more stable over the whole cycle and this effect is increased when the dose is optimal. That's why it's possible to allow a cat to run very close to the edge. You can't do this with an "in-and-out" insulin like Novolin that's known to cause fast drops to a low nadir even from high pre shot numbers.
 
The article you provided the link for is either based on the original German study or a subsequent study of the same/similar treatment protocol. The insulin used in both those studies was Lantus (aka Glargine). Roomp and Rand have done further research based on the German study and the Tight Regulation protocol (TR) used here with Lantus/Levemir (another human depot insulin) is based on their documentation.

Trying to do TR with an insulin like Novolin N would be more complicated/dangerous because it's duration is shorter than Lantus/Levemir and it can cause sudden more steep drops in BG making it is more difficult to safely maintain optimal BG levels that are "riding the edge" for long enough during each cycle. The suggestion of not shooting under 200 is advice given to folks new to feline diabetes. Once enough data has been collected, insulin can be given at lower pre-shot BG but it would not be advisable to shoot as low a pre-shot as you might with Lantus or Levemir. Lantus and Levemir are long acting so BG does not drop nearly as fast or as steeply giving both the cat's defence mechanisms and the caregiver much more time to take action should the cat be approaching BG levels that could lead to a clinical hypoglycemic episode.

If you want to try Tight Regulation, you can read about it HERE. We can help you do so but you'd have to change to a long acting insulin...either Lantus or Levemir.
 
Hi All - Thanks to everybody for their kind and informative comments. We decided to put on our big people pants in the house and have started to do home-testing for sprout. Our first successful blood draw (after a few false starts as we work out the kinks in doing the lancet pricks) showed him at 6.7mmol. Our vet advised us to skip this dose and test again tonight. We are thinking about transitioning to glargine but want to get the home testing down to a science first so that we can do a proper glucose curve for him at home. Also, we dose him 3x per day at very low doses (2/3u each time), which may keep the ups and downs of novolin 70/30 from being too severe. Anyway he seems to be responding well to Novolin 70/30 so we'd like to continue to evaluate before deciding to jump horses midstream.
 
Kudos for starting to home test. That is by far the best tool we have to keep our kitties safe and as regulated as possible.

The best insulin for your cat is the one that works for your cat and if you are getting decent results with the Novolin N, giving it more time is a good plan. While research suggests more cats reach remission on the longer lasting insulins, lots of cats do go into remission while being treated on less aggressive protocols using Lantus and other insulins. The chances of remission are not only related to the type of insulin and "riding the edge" but also how quickly the diagnosis was made, treatment started and how efficiently you can keep the BG in optimal ranges. And of course some of it is just luck of the draw. :)
 
Thanks for everyone's comments! It looks like we were lucky to start testing when we did. After the initial 6.7mmol, his BG dropped further to 5.4 and has hovered in the 5's without any insulin dosing for the past 4 days. His urine tests have also been consistently clear. We are continuing to discuss with the vet but we are cautiously hopeful!
 
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