New. Senior cat dx with steroid induced diabetes

Hi everyone. I just stumbled on your forum. I got the call from our vet about an hour ago that our sweet cat, Jack, has diabetes. His diagnosis is almost assuredly from a regular steroid regimen he was on due to his asthma. We have to take him back to the vet tomorrow to figure out a plan. Per the vet, the options are glargene (through a pharmacy) or Prozinc. She said glargene has a slightly better remission rate than Prozinc but his chances of remission might be even greater given that we know the cause. He's 14, almost 15 years old.

Does anyone here have experience with a steroid-induced diagnosis in an asthmatic cat? If we can even get glargene (Lantus?) using the GoodRX discount, is that the better option? Unfortunately, the pharmacies can't tell us if the discount will work until they run the prescription, so if it doesn't, I think we're likely looking at going with Prozinc.

The vet also mentioned needing to come in to check his glucose levels (she used a word I can't recall) but that I may want to invest in a glucometer because having them do it is quite costly. Any advice this forum has there would be greatly appreciated.

I'm trying to not be overwhelmed by all of this, including the emotional realization of having to give my cat injections twice/day. Whether his behavior will change as a result, etc.

I did read the FAQs for new members and I hope I've done this right. Still a bit in shock and emotional.

 

Welcome to yourself and Jack,

The diabetes diagnosis is quite overwhelming but you've found a great place to learn about feline diabetes and its treatment, and also to get lots of practical help and support.

Lantus is indeed a brand name for insulin glargine. Many of our US members purchase it from Canada at a much better price:

Buying insulin from Canada

It does take a little while to order and receive it via this route so the above info may be of more help in the future. I think there are some places in the US who sell single Lantus pens. It might be worth checking with your local pharmacies if you wish to start treatment with this insulin.

WRT Prozinc, some members buy that from chewy.com (with a prescription from their vet). Again, there might be a few days delay before you'd receive insulin via that route but might be helpful to know for the future.

Your vet probably said that they would run a glucose curve or possibly do a blood draw for a fructosamine test. A glucose curve is essentially a series of readings at regular intervals to gauge how low the dose is taking blood glucose (BG) levels. This is needed for safety (to make sure BG doesn't go too low), to ascertain how effectively the current dose is working, and whether it needs to be adjusted. A fructosamine test result gives information on the average BG level over the previous 1-3 weeks but it does not throw any light on how high or how low blood glucose levels run day to day.

Assuming you're in the US, Relion Prime and Relion Premier glucometers from Walmart are popular choices among members here because they have the most reasonably priced test strips. (If you're not in the US, let us know which country you do live in and we should be able to make alternative meter suggestions.)

Home monitoring of BG works better because readings aren't stress-influenced. It's better for safety because you have better insight into how low any given dose takes BG levels. It also helps to optimise treatment because you get a clearer picture of how effectively any given dose is working and this better informs dose adjustments. Here are some links to help you get started:

Home testing tips and links

Testing and injection tips (good diagram of where to test on the ear in this post)

In addition to the above educational links you can post at any time for more practical and specific help if there's anything you're finding a bit tricky. We also have spreadsheet templates where you can record Jack's dosing and BG information. The spreadsheet makes it easier to interpret the readings and assess trends in response to treatment. Here are links to the how-to guides for when you're ready to set one up:

How to create a spreadsheet for your cat

How to use your cat's spreadsheet

Give a shout if you'd like a bit of assistance with the set-up and we'll find someone to help.

We regularly see cats with steroid-induced diabetes here. I'm going to tag a couple our members who have experience with treating asthma and who might be able to give you some pointers in this area:

@Aleluia Grugru & Minnie
@THH

The diagnosis is a big emotional hit, but as you learn more and establish a routine that works for you and Jack things will get better. We'll do all we can to help you both along the way.




Mogs
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Hello! I also have a cat with asthma, his name is Yato. Yato started having some concerning symptoms when he was on prednisolone--started drinking and urinating a LOT--so we started him on an inhaled steroid called Flovent and tapered him off the prednisolone. The main benefit to the inhaler steroid is minimal systemic effects (eg, raising blood glucose). We use the inhaler with a device called an AeroKat and it works great! Here's a link to a video of him getting his Flovent:
https://fb.watch/3SOK2APOGq/

We order the Flovent from Inhouse Pharmacy online since it's so expensive in US pharmacies; here's the exact one we order: https://www.inhousepharmacy.vu/p-398-flixotide-fluticasone-cfc-free-125mcg-inhaler.aspx

 

@THH - Thanks, T.


Mogs
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@Critter Mom - Thank you for the quick responses to my post. Yes, I'm in the U.S. We found the pharmacy price for a vial of the Lantis is something like $340 here, which if I knew I could get it from Canada I might order once in the U.S. to get us started while waiting on the Canadian shipment. Talking to the vet again today, she said Lantis is the "gold standard" for potential remission cases, which is ideal for us. Prozinc will work, but I'm very much tempted to try the Lantis if there's 1. a better chance at remission and 2. we can indeed get it cheaper from Canada. The vet mentioned if we wanted to do that and wait for the shipment she could start us on Vetsilin (sp?) then switch but we'd have to recheck those glucose curves all over again if we switch.

ETA: So it seems on that insulin post, most recommend going with the pens rather than the vials. Is that because it's easier to store, or you lose less if it's dropped? Just curious. It seems I can get a single vial of the Lantus in the U.S. to "hold us over" until we can get the Canadian shipment.

Have you seen cases of remission in cats on Lantis?

@THH - Thank you! Jack was on prednisolone but has been off of a regular dosage for a while. We have a nebulizer with albuterol that we can also use. His triggers are spring and fall allergies, so right now his asthma is fine without any medication.

 

I personally saw at least 3 diabetic cats go into remission from Lantus in a rescue group-room setting... so not a low-stresss, ideal environment even! It's a great insulin to use.

 

Most of us buy the 5 pens from Canada rather then a vial because the pens will last you a year or longer.
They probably have expiration dates of 2022 and 2023 on them

They will last that long keeping them in the fridge middle shelf
You will want to also buy U-100 syringes with half unit markings if you choose to go with Lantus

You can shoot with the pens but can only increase by whole units
We increase by 0.25 units at a time
So that's why we buy the syringes and take the top off of the pen
You will see a little gray rubber stopper and you will stick your syringe in there to
draw out the insulin

My cat has just gone into remission using lantus

 

Thank you! Where do you get the syringes? Do I purchase those from the Canadian pharmacy or here in the U.S.?

 

No matter what you choose, you'll do glucose testing multiple times a day.

If you look at people's spreadsheets you'll see how frequently we test. And it's a lot.
You have great chances of remission by using lantus and the TR protocol.

 

Hi again. Is it OK to call you Ruby?

Absolutely! We've seen hundreds of cats here achieve remission when treated with Lantus (possibly more), one of whom was my own Saoirse. It should be noted that some cats can do well on other insulins and achieve remission on them, Vetsulin included, but the better choices are Lantus, Levemir and Prozinc because they have greater duration in cats, thus can keep them in better numbers for a greater part of the day. The longer a cat can be kept close to or within the normal feline BG reference range, the greater the chance of becoming a diet-controlled feline diabetic (not on insulin), hence the significantly greater statistical chance of achieving remission in cats treated with longer-acting insulins. I've attached the peer-reviewed study that provides the foundation for the Lantus dosing methods used at FDMB below for your information. (It also addresses use of human glucometers to monitor cats' blood glucose levels in case your vet may have any queries in this respect.)

Vetsulin (also branded Caninsulin in some countries) is an 'in-out' insulin: the dose goes in, does its work during a single 12-hour cycle, and is then gone from the system. Typically it hits quite hard and fast early in the cycle and peters out several hours before the next dose is due. Here's an 'ideal' example of a glucose curve for a cat on Vetsulin:



Because there's typically quite a significant drop from preshot to nadir BG on Vetsulin, it often results in getting to the point where preshot BGs may still be fairly high but any increase in the dose is likely to take the cat too low at nadir.

Conversely, Lantus is a 'depot' insulin: some of each dose gets used during the cycle in which it was administered but part of the dose goes towards building up a little 'tank' of insulin under the skin - the depot - which releases gradually over time. As each successive dose builds on the previous ones, duration of effect of this insulin is enhanced, thus helping the cat to stay in better numbers for longer on each cycle. Also, Lantus typically has a gentler mode of action and when an effective dose is arrived at (through small, gradual increments) Lantus curves can be more like wide, shallow smiles compared to the 'bucket-shaped' curves so typical of Vetsulin, and it is this characteristic that, with adequate testing, creates greater opportunity to give insulin safely at lower preshot levels and therefore more tightly regulate a cat's blood sugars.

Although not a depot insulin, Prozinc also has good duration in cats but, to the best of my knowledge, as BG levels get into tighter numbers, the preshots may not get down into quite as good a range as might be possible with Lantus in some cats.

Saoirse was treated initially with Vetsulin (a legal requirement at the time in the UK) but it became impossible to improve her numbers enough to get her into remission (dose could not be increased for safety reasons, poor duration). After switching to Lantus, Saoirse's overall blood glucose range improved greatly within a few weeks and she achieved remission in under 3 months.

If today I was looking to treat a newly diagnosed feline diabetic and could choose any of the available insulins I would go straight for Lantus without any hesitation.

That's a very good suggestion from your vet. It would let Jack get started on insulin ASAP, reducing risk of any complications from ketones (see FDMB ketone primer for more info) and buy you the time to get the Lantus Rx from Canada. WRT running curves again, that's no real biggie if you're testing at home because you'll be able to get real-time readings on how Jack is doing every day, regardless of the insulin he's being treated with, provide feedback to your vet, run any required curves at home. Data from daily readings and home-run curves can be used to safely and effectively manage his dosing. We can give you guidance on the difference in mode of action of the two insulins, particularly the best times to test to catch the lowest (nadir) BG level and make sure the dose is safe. Also, you don't need to take a step backwards when switching insulins because you'll be able to take into account his response to Vetsulin when setting the starting dose for Lantus.

On starting dose, for safety we very much recommend starting low and going slow with the dose adjustments. The latest manufacturer's dosing guidelines for Vetsulin base the starting dose on a snapshot BG level at start of treatment. From their website:



The trouble with this is that the baseline reading may be taken at the vets and may be temporarily elevated by stress, so if it's borderline the 2.0IU dose may be too high as a starting dose. The FDMB Vetsulin/Caninsulin guide generally recommends a starting dose of 1.0IU.

(Note: An older iteration of the Merck Vetsulin protocol took both the cat's weight and baseline BG into account when setting starting dose but, as noted above, the recommended starting dose is now per cat based solely on baseline BG.)

Lantus starting dose is based on the cat's weight (0.25IU per kg of actual weight OR per kg of ideal weight if the cat is overweight at time of diagnosis - an average 10lb cat would start on 1.0IU Lantus). Also, if a kitty has been on another insulin prior to starting Lantus treatment, the dose of the previous insulin is also taken into consideration.

NB: If you do decide to go with your vet's plan to treat briefly with Vetsulin and then move quickly onto Lantus, bear in mind that they have different concentrations and you need to use the insulin syringe type appropriate to the insulin you're using. Vetsulin is a U40 insulin (40 international units (IU) per ml) and is administered with U40 syringes, Lantus is a U100 insulin (100 international units per ml) and is administered with U100 syringes. If you know that you won't be treating with Vetsulin for long, then perhaps just buy enough syringes to cover you till the Lantus arrives.

As Diane notes above, you can use the Lantus pen as a 'mini vial' of insulin and draw up each dose using a U100 syringe. Walmart do carry the 0.3ml U100 syringes with 1/2 unit markings but, according to some members' reports, their staff sometimes don't actually realise they stock them so it's worth asking them to double-check if you have problems at your local store.

There are lots of information 'sticky' posts at the top of our Lantus support group's board to help you learn more about this insulin. I'd suggest starting with the following:

What is the insulin depot?

[Lantus] Dosing methods: 'start low, go slow' and 'tight regulation'

It is a bit of a steep learning curve at first, but so much of this will become second nature, and a lot sooner than you might think right now. We'll do all we can to support you as you learn. Ask away with any questions you have, we're only too happy to answer them.


Mogs
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I believe my kitty may have gotten D because of experimenting with steroids to help arthritis. Less than 5 months on Lantus, and she has been in remission for 14 months.

A friend's kitty came off insulin in just two months once steroids were removed.

What awesome help you have received - welcome to FDMB!

 

Just as an addendum to Diane's post and in answer to this question, most cats only need small doses of insulin and consequently the volume in a vial (10ml) won't get used up before it becomes non-viable. The pens contain just under 3ml of Lantus and can be used to the last drop within that time, therefore are less wasteful.


Mogs
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This is extremely helpful to know! I think I'm going to get a single vial of the Lantus from my local Walgreens (~$31 as opposed to the 10 vial pack over $300) until the Canadian shipment comes in. Would I be better off waiting to order from Canada if it's going to take a while to use up a 10ml vial?

 

Welcome! You are at the site with the greatest people on earth. I've gotten so much help here. Please focus on their information, it will help you a great deal.

I just want to put this out there. Please change your cat's food to the Fancy Feast classic pate that so many of us use. I say that because my cat was pushed over into a diabetic condition due to a steroid shot for a uti. (But I'm sure she was already experiencing D before that, I just didn't see the signs.) Emma does not take constant steroids so I was able to control her D by changing her food and some insulin injections when she registered high. I realize that your situation is different but I want to let you know that you too can do this. I KNOW you can manage this! You'll be able to do the testing and injections and whatever else is needed. The wonderful people here can help so very very much. I wish you the best and here's a hug cause I know how stressed you must be.

 

So an all-canned food diet? We have two other healthy cats from the same litter that all eat the same food. Right now it's a combo of Natural Balance canned food and ProPac dry food. I can eliminate the dry but should we get the insulin regulated first then work on food? I don't want to freak him (or the other cats) out by drastically changing everything all at once unless absolutely necessary. The vet was less inclined to mess with food for the time being.

 

Am I right in understanding that you're able to get a single Lantus pen from Walgreen's? If yes, then that should provide plenty of cover while you take receipt of an insulin shipment from Canada (c. 3ml contains 300 units of insulin).

In comparison, a 10ml vial contains 1000ml insulin and would typically last months (and, as mentioned above, would likely become non-viable before all the insulin was used) but you'd be in a bit of a bind if anything were to happen to the vial. With the pack of pens you're covered in the event of a mishap. Just something to consider when making your decision.

I'm tagging @Chris & China (GA) to ask her if she can give you an idea of roughly how long it takes at this time of year for an insulin order from Marks Marine to arrive after they dispatch it.


Mogs
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Transitions to an exclusively low carb wet diet need to be undertaken with care, firstly because they can cause digestive upsets, undesirable for any cat but doubly so for a diabetic needing insulin treatment (both for safe administration of the insulin and also to avoid ketone complications - see link above). Secondly, when a cat has started insulin, reducing the carb load can often lead to a significant drop in overall BG levels in a short space of time so BG levels need to be closely monitored during the transition and the insulin dose reduced as required (to avoid the cat becoming hypoglycaemic). More on safely transitioning a feline diabetic to a lower carb diet at the following link:

catinfo.org - Feline diabetes page

Here's a link to the US food chart:

https://catinfo.org/docs/CatFoodProteinFatCarbPhosphorusChart.pdf

Foods with under 10% kilocalories from carbs are suitable for general feeding. You'd also need to grab a few cans of higher carb wet foods (c. 15% and c. 20%) for your hypo kit (used alongisde honey/karo to raise BG if numbers are low). More info:

Hypo toolkit

How to treat hypos (recommended to print out a copy of this and keep it with your hypo toolkit)


Mogs
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They will not ship it if the temperatures between them and you would risk the insulin freeze, but once shipped, it's usually within 7-10 days at most. I've ordered refills on a Monday afternoon and had it in my mailbox by Friday morning but with the current state of the post office, it's best to figure a little longer.

You will get a tracking number so you can watch it move through the postal system though.

 

So whoever I spoke to at Walgreens yesterday was mistaken. It was a vial and was definitely not $30. I ponied up anyway until I can order more from Canada. Jack is only on one unit twice/day to start. When I spoke to Mark's yesterday they said it should take 7-10 days on a new patient/prescription. The vet is also going to contact them about the inhaler Jack needs for his asthma.

 

Thank you! This is in line with what our vet indicated as well. She's not concerned about transitioning Jack's diet immediately (partially because he's on a primarily wet food diet already, although he will graze on *some* dry food during the day). She mentioned the Karo as well, so I'll pick that up at the grocery. Thank you so much for the information and links!!

 

@THH - where did you find the Aerokat device? I see it on Chewy but wondered if there are less expensive sites to order from?

On the Flovent, do you need an Rx to send to the InHouse pharmacy you linked? The vet wrote a paper Rx, but I don't see instructions for mailing.

Thanks!

 

I bought my AeroKat on amazon, but it doesn't seem to be listed currently... it was about $60 I when I bought it.

For Inhouse, you don't need to provide a prescription. Note it does take a few weeks to arrive, due to shipping. My experience is about 3 weeks from order to arrival, including mailing them a check.

 

@Critter Mom Should the vet fax the order in, then I create an account to order or do I call them? When I spoke to someone there yesterday he sent me an email with this list:

1. A piece of photo ID (can fax, text or email)
2. The prescription
3. Read below, if you have questions, let me know... otherwise - reply back saying "I agree" (ideally, replying back with I agree, and the two pieces of ID)

If I have a paper Rx from the vet, don't they have watermarks to prevent scanning/faxing/emailing? Does she need to write "care of (my name)" in order for them to associate the prescription with me? I'm sorry if this seems obvious, but I'm new to how this works!

 

@Rubyslens -

I'm assuming you're asking about ordering Lantus from Marks Marine here, so I'm going to tag @Chris & China (GA) again to see if she can answer your questions about the ordering process. (I'm in the UK so have never ordered insulin from Canada.)


Mogs
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I only scanned through your post and did not read every word, but if you bought a vial from Walgreens, that can last up to 6 months.
You may want to hold off on buying more Lantus from Mark's Marine, for a few months. The weather will be better for shipping in that time, and your kitty may go into remission in that time. Just my thoughts.